Makindo Medical Notes Comprehensive Medical Encyclopedia | Education for Healthcare Professionals

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Causes of Ptosis

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Important: Facial nerve (VII) weakness, such as in Bell's palsy, does not cause ptosis. Instead, the inability to close the eye is observed in such conditions. This is a common point of confusion for medical students and doctors.

About Ptosis

The eyelids are kept open by the levator palpebrae superioris (innervated by the oculomotor nerve (III)) and the superior tarsal muscle (innervated by sympathetic fibres).
The facial nerve (VII) controls the closing of the eyes and is unrelated to ptosis.
The frontalis muscle on the forehead elevates the eyebrows. Paralysis of this muscle can cause **eyebrow ptosis**, which can mimic eyelid ptosis but is not the same.

Causes of Ptosis

Cause	Clinical Presentation	Diagnostic Tests	Management
Third Nerve (Oculomotor) Palsy	Complete ptosis Eye positioned "down and out" Fixed and Pupil dilation (due to parasympathetic loss)	Clinical exam (eye position, pupil response) MRI/CT scan to check for aneurysm or tumour Angiography if aneurysm suspected	Treat underlying cause (e.g., aneurysm, tumour) Surgical repair in severe cases
Horner's Syndrome	Partial ptosis Miosis (small pupil) Anhidrosis (loss of sweating on affected side)	Pharmacological testing (e.g., apraclonidine or cocaine test) Chest X-ray or MRI to rule out Pancoast tumour Neuroimaging to find lesion along sympathetic pathway	Treat underlying cause (e.g., tumour, carotid artery dissection) Symptomatic management if no treatable cause
Myasthenia Gravis	Fluctuating ptosis (worsens with fatigue) Diplopia (double vision) Generalized muscle weakness	Acetylcholine receptor antibodies Tensilon (edrophonium) test Electromyography (EMG)	Anticholinesterase inhibitors (e.g., pyridostigmine) Immunosuppressants (e.g., corticosteroids, azathioprine) Thymectomy if thymoma is present
Botulism	Ptosis, blurred vision Facial weakness Respiratory muscle weakness in severe cases	Toxin assay in blood or stool Nerve conduction studies Clinical history (e.g., foodborne botulism, Botox overdose)	Administration of botulinum antitoxin Supportive care (ventilation if necessary) Monitoring for respiratory failure
Myotonic Dystrophy	Progressive muscle weakness Ptosis, facial muscle atrophy Difficulty releasing grip (myotonia)	Genetic testing (for DMPK gene mutation) Electromyography (EMG)	Symptomatic treatment Physical therapy to improve function Monitor for complications (e.g., cardiac involvement)
Congenital Ptosis	Present from birth Ptosis often unilateral Impaired vision if severe	Clinical evaluation Vision testing to assess impact on eyesight	Surgical correction if vision is impaired Regular follow-up for amblyopia prevention
Senile Ptosis	Age-related drooping of eyelids Gradual onset, often bilateral	Clinical evaluation	Surgical correction (blepharoplasty) for cosmetic or functional reasons

Common Causes of Ptosis

Third Nerve (III) Palsy: Presents with **complete ptosis**, **dilated pupil**, and the eye in a **down and out** position. Causes include aneurysms, trauma, or tumours.
Horner's Syndrome: Involves **partial ptosis**, **miosis** (small pupil), and **anhidrosis** due to disruption of sympathetic innervation. Often caused by a lesion along the sympathetic pathway (e.g., Pancoast tumour, carotid artery dissection).
Myasthenia Gravis: Autoimmune disease causing **fatigable ptosis** and **diplopia**. Symptoms worsen with use and improve with rest. Diagnosis confirmed by acetylcholine receptor antibodies or a positive response to edrophonium (Tensilon test).
Muscle Disorders: Includes conditions like:
- Myotonic Dystrophy: Progressive muscle weakness leading to **ptosis** and other systemic manifestations.
- Facioscapulohumeral Muscular Dystrophy: Weakness of facial and shoulder muscles leading to ptosis.
- Mitochondrial Myopathies: Causes **progressive external ophthalmoplegia**, leading to ptosis and difficulty with eye movements.
Botulism: Neurotoxin causing muscle paralysis, including ptosis. Can be caused by **botox overdose** or botulism infection.
Congenital Ptosis: Present at birth due to abnormal development of the levator muscle.
Senile Ptosis: Age-related weakening of the levator aponeurosis leading to drooping of the eyelids.

Clinical Findings in Horner's Syndrome

Slight ptosis due to loss of sympathetic tone in the superior tarsal muscle.
Miosis (constricted pupil) due to loss of sympathetic input to the dilator pupillae muscle.
Enophthalmos (sunken appearance of the eye) and conjunctival injection may also be present.
If the lesion is proximal to the superior cervical ganglion, there may also be anhidrosis (loss of sweating) on the affected side of the face.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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