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The Problem
“My child’s eyelid is droopy.”
Common Causes
Congenital ptosis
Other Causes
Myasthenia gravis
Horner syndrome
Third nerve palsy
Eyelid or orbital mass
Pseudoptosis
Eyelid retraction of opposite eye
Eyebrow skin overhanging normal eyelid
KEY FINDINGS
History
Congenital ptosis
Present from birth
Isolated, familial, or syndromic
Often worse with fatigue
Chin-up head posture
Myasthenia
Variable ptosis, worse with fatigue
Often have strabismus/diplopia
Horner syndrome
Congenital or acquired
Unequal pupils
Decreased sweating on affected side
Unequal iris colors (if congenital)
Third cranial nerve palsy
Strabismus/diplopia
Unequal pupils
Other symptoms depending on etiology
Eyelid or orbital mass
Eyelid lesion or proptosis
Possible limited eye movement
Other symptoms depending on etiology
Pseudoptosis
Mild appearance of ptosis due to excess skin overhanging eyelid
Squinting of eyelid due to other ocular disorder
History of light sensitivity
Foreign body sensation or ocular discomfort
Eyelid retraction on opposite side
Alternates between eyelid retraction of one eye and ptosis of the other
Proptosis of opposite eye
Other symptoms depending on etiology of proptosis
Examination
Congenital ptosis
Unilateral or bilateral drooping of eyelids
Varies from mild to almost complete occlusion
Decreased ability to elevate eyelid
Decreased eyelid crease
Brow lift and chin-up posture if marked ptosis
Myasthenia gravis
Variable ptosis
Eyelid twitch (Cogan’s sign)
Increased eyelid opening after rest, ice test
Often have strabismus
Horner syndrome
Usually mild-to-moderate ptosis
Pupil smaller on affected side
Decreased sweating/facial flushing on affected side
Third nerve palsy
Usually moderate to marked ptosis
Strabismus (eye out and down)
Unequal pupils (pupil larger on affected side, except may be smaller in congenital third nerve palsy)
Eyelid or orbital mass
Visible lesion on eyelid
Proptosis
Limited extraocular movements
Pseudoptosis
Extra eyebrow skin
Eyelid height and function normal
Strabismus
Appearance of ptosis due to strabismic eye being lower
Voluntary closure due to other ocular problems
Corneal foreign body, abrasion
Other ocular inflammatory disorders
Eyelid retraction on opposite side
If child fixes with retracted eye, opposite eye appears ptotic
If child fixes with normal eye, retraction worse in opposite eye
Possible proptosis on side with eyelid retraction
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Children with congenital ptosis may develop amblyopia, particularly if the ptosis is unilateral and occludes the pupil. These children should be referred to a pediatric ophthalmologist to determine whether surgical treatment is indicated. Mild-to-moderate ptosis usually is not an immediate threat to vision, but evaluation is important due to its possible association with systemic diseases. Children with new onset of acquired ptosis, particularly if associated with signs of third nerve palsy or orbital mass, should be referred promptly for further evaluation.

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What Shouldn’t Be Missed

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Acquired ptosis may be the initial sign of a serious underlying disorder, such as a third nerve palsy or an orbital tumor. Prompt diagnosis improves the outcome of most of these disorders (Table 14–1).

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Table 14–1. Causes of Ptosis with Potential Serious Systemic Implications...

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