Ptosis - Differential Diagnosis Framework



Ptosis (Greek- to fall) Drooping of the upper eyelid that usually results from a congenital or acquired abnormality of the muscles that elevate the eyelid.



When patients present with ptosis, it is important to think about three clinical diagnoses associated with ptosis:

1. CN III palsy

2. Horner’s syndrome

3. Myasthenia gravis



Neurogenic Ptosis - Neurologic disease affecting the muscle, neuromuscular junction, cranial nerve, and the brainstem may lead to ptosis and weakness of the levator muscle of the upper eyelid:

• Third nerve palsy

• Horner syndrome

• Myasthenia gravis

• Botulinum toxin

• Multiple sclerosis

• Cerebral ptosis - Supranuclear lesions

• Ophthalmoplegia migraine



Myogenic Ptosis:

• Mitochondrial myopathy

• Myotonic dystrophy

• Myasthenia gravis

• Ocular myopathy

• Oculopharyngeal muscular dystrophy

• Blepharophimosis syndrome



Aponeurotic Ptosis:

• Spontaneous disinsertion or dehiscence of the levator aponeurosis (the tendon connecting the levator to the tarsal plate)

• Involutional (senile) change

• Contact lens wearing

• Ocular surgery



Congenital Ptosis - Absence or reduction of striated levator palpebrae superioris muscle:

• Marcus Gunn jaw-winking syndrome



Traumatic Ptosis - Direct or indirect trauma to the eyelid leading to:

• Levator transection

• Cicatrization

• Eyelid laceration or orbital rooftop fracture with ischemia



Mechanical Ptosis - Levator function is impaired due to the mass effect of some abnormal external structure/excess weight on the upper lid:

• Neoplasm

• Chalazion

• Contact lens in the upper fornix

• Scarring

• Ocular pemphigoid

• Trachoma



Pseudoptosis:

• Microphthalmos

• Anophthalmos

• Enophthalmos

• Lid retraction of one eye causing ptosis in the contralateral eye

• Redundant eyelid skin and prolapse of the orbital fat (dermatochalasis)

• Lowering the ipsilateral eyebrow and raising the contralateral one

• Duanes Syndrome



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