Ptosis

Ptosis case presentation

1. Case presentation DR.ANKITA MAHAPATRA DEPT. OF OPHTHALMOLOGY VSSIMSAR, BURLA

2. HISTORY 21 Yr /HM Sundargarh Student CHIEF COMPLAINT : Drooping of eyelid (LE) – since birth

3. History of present illness Patient has unilateral drooping of eye lid of Left eye since birth. Constant through out the day Not complaining of double vision

4. HISTORY OF PAST ILLNESS No aggravating or relieving factor No H/o trauma No h/o any previous surgery No h/o contact lens wear No h/o botox injection No h/o any drug intake or poisoning No h/o Myasthenia gravis , myotonia , Muscular dystrophy , Diabetes, HTN No h/o recurrent stye / chalazion / vernal keratoconjunctivitis

5. PERSONAL HISTORY From a middle socioeconomic background Normal bowel and bladder habit Normal non vegetarian Indian diet Allergic history not known Family history not suggestive

6. ON EXAMINATION Average body built, well nourished Conscious & Well oriented to time, place and person No cyanosis, icterus, pallor , clubbing , pedal oedema or lymphadenopathy Vitals PR- 78/min B.P -120/90 mm of Hg R.R- 14/min Temp- 98.4°F

7. SYSTEMIC EXAMINATION CNS :- Conscious, Oriented, GCS – 15 CVS:- S1, S2 normal, no murmur RS:- B/L VBS, No added sounds P/A :- Soft, Non tender, No organomegaly

8. OCULAR EXAMINATION Head is erect, slight back tilt present Drooping of Left upper eye lid Absence of Left upper eyelid crease Orthophoric EOM – free, full, painless in all directions of gaze BCVA :- RE- 6/6 LE – 6/6 (Upper eyelid uplifted) Near vision – N6 (BES)

9. OD OS Lid and adnexa Normal Drooping of upper eyelid Conjunctiva Normal Normal Cornea Clear Corneal sensation intact Clear Corneal sensation intact Ant. Chamber PACD = 1CT PACD = 1CT Iris and Pupil Normal in colour and pattern, Pupil- Circular, reacting to light Normal in colour and pattern, Pupil- Circular, reacting to light Lens Clear Clear

10. PTOSIS MEASUREMENTS TESTS DONE OD OS PALPEBRAL FISSURE HEIGHT 10 mm 6 mm MARGIN REFLEX D I S T A N C E ( M RD ) 1 5 mm -1 mm MARGIN REFLEX D I S T A N C E ( M RD ) 2 5mm 5mm MARGIN CREASE DISTANCE 9 mm Absent LPS FUNCTION (BERKE’S METHOD 12 mm 3 mm (poor) LPS FUNCTION (PUTTERMAN’S METHOD) 9 mm 6mm

11. Bell’s phenomenon- Good in both eyes No Lagophthalmos No Diplopia Marcus-Gunn jaw winking phenomenon absent Cogan lid twitch test- absent Shirmer’s test – normal No signs of any Keratopathy

12. OD OS Mydriasis Good Good Media clear Clear Optic Disc Normal Normal Macula FR+ FR+ Blood vessel Normal Normal Periphery Normal Normal

13. Provisional diagnosis SIMPLE CONGENITAL PTOSIS ( LEFT EYE )

14. THANK YOU