From the Guidelines
The workup for a 59-year-old female with unilateral ptosis should begin with a thorough history and physical examination to determine the cause, including a comprehensive eye examination with particular attention to sensorimotor exam, evidence of ptosis and anisocoria, and pupillary responses in bright and dim illumination, as recommended by the adult strabismus preferred practice pattern 1. The physical exam should assess ptosis severity, pupillary responses, extraocular movements, and facial muscle strength. Key elements of the history include:
- Onset (acute vs. gradual)
- Associated symptoms (diplopia, pain, visual changes)
- Medical history (diabetes, hypertension, previous trauma, neurological disorders) Laboratory tests should include:
- Complete blood count
- Metabolic panel
- Thyroid function tests
- Erythrocyte sedimentation rate
- Anti-acetylcholine receptor antibodies to rule out myasthenia gravis Neuroimaging with MRI of the brain and orbits is essential to evaluate for structural lesions like stroke, tumor, or aneurysm, especially if the pupil is involved or if there is partial extraocular muscle involvement or incomplete ptosis, as this may indicate a compressive lesion 1. Additional tests may include the ice pack test or edrophonium (Tensilon) test for myasthenia gravis, and the fatigue test to assess for neuromuscular junction disorders. Referrals to neurology and ophthalmology are typically warranted for specialized evaluation, as unilateral ptosis in this age group could indicate serious conditions ranging from oculomotor nerve palsy to Horner's syndrome, myasthenia gravis, or even a cerebrovascular event requiring prompt diagnosis and management 1.
From the Research
Unilateral Upper Eyelid Ptosis Workup
The workup for a 59-year-old female presenting with unilateral ptosis (partial or complete drooping of the upper eyelid) involves a comprehensive evaluation to determine the underlying cause. Some possible causes of unilateral ptosis include:
- Diabetic oculomotor nerve palsy, which can present with ptosis and diplopia, but pupillary function is often spared 2
- Systemic lupus erythematosus (SLE), which can cause optic neuropathy and other ophthalmologic problems 3
- Guillain-Barre Syndrome (GBS) spectrum clinical variant, which can present with an initial isolated, unilateral third nerve palsy prior to development of areflexia and lower extremity weakness 4
- Discoid Lupus Erythematosus (DLE), which can present with upper eyelid edema and erythema 5
- Congenital aberrant lacrimal gland ductules, which can present as a nonhealing upper eyelid lesion 6
Diagnostic Evaluation
The diagnostic evaluation for unilateral ptosis may include:
- Neurological examination to assess for other signs of neurological dysfunction
- Ophthalmologic examination to assess for other signs of ocular disease
- Laboratory tests, such as blood glucose and inflammatory markers, to assess for underlying systemic disease
- Imaging studies, such as MRI or CT scans, to assess for structural abnormalities
Treatment
Treatment for unilateral ptosis depends on the underlying cause and may include:
- Aggressive control of blood sugar in patients with diabetic oculomotor nerve palsy 2
- High-dose intravenous corticosteroids for patients with SLE-related optic neuropathy 3
- Intravenous immunoglobulin for patients with GBS spectrum clinical variant 4
- Oral hydroxychloroquine for patients with DLE 5
- Surgical excision or redirection of aberrant ductules for patients with congenital aberrant lacrimal gland ductules 6