Patient Presentation
An 8-year-old female came to clinic with a 3 day history of painful left eyelid swelling with redness, swelling and one area that was somewhat painful. She denied problems seeing, walking or other activities. She had no eye problems previously. She had noted some crusting on the eyelids after awakening. The review of systems was negative.

The pertinent physical exam showed a well-appearing female with normal vital signs and growth parameters that were 10-25%. Visual acuity was 20:20 by Snellen chart. Extra ocular movements were intact. The left eyelid margin showed one 4-5 mm swelling in the center of the eyelid with an area that pointed outward that was slightly yellowish. There was mild erythema of the swelling and surrounding tissue. She had a notable localized ptosis, that came to the top of the pupil. There were no other lesions noted with eversion of the eyelid. Neurological examination was intact and she had normal head position. The rest of the examination was normal. The diagnosis of a simple external hordeolum was made. The family was instructed to do warm compresses for 15 minutes four times/day. They were to call if the swelling or pain increased, or if changes in vision or generalized symptoms such as fever developed. They were also to call if any neurological symptoms appeared or the hordeolum was not improving in about 3 days.

Discussion
Ptosis or blepharoptosis is the downward displacement of the upper eyelid. The eyelid aponeurosis, levator muscle and Muller muscle retain the proper position of the upper eyelid. Ptosis can be congenital or acquired. Some causes require immediate attention by an ophthalmologist for proper treatment to preserve eyesight including trauma, uveitis, orbital cellulitis, etc.. Other causes require additional subspecialty assistance such as a cerebrovascular accident, thyroid disease, myasthenia gravis, etc.

Mild ptosis can be a cosmetic problem, but proper function and position of the eyelid is essential to preserve eyesight. Ptosis may decrease the amount of light entering the eye and therefore decrease acuity. Abnormal structural relationships of the globe and eyelid may cause secondary eyelid and other visual problems.

For more information about styes, chalazions and hordeolums, click here.

Learning Point
The differential diagnosis for ptosis includes:

• Infection
  • Blepharochalsis
  • Conjunctival scarring including trachoma
  • Chalazion
  • Hordeolum
  • Preseptal cellulitis
  • Orbital cellulitis
  • Uveitis
• Neuromuscular
  • Benign essential blepharospasm
  • Botulism
  • Congenital ptosis
  • Congenital fibrosis syndrome
  • Cerebrovascular accident
  • Horner’s syndrome
  • Oculomotor (Third nerve) palsy
  • Ophthalmoplegic migraine
  • Myotonic dystrophy
  • Myasthenia gravis
  • Multiple sclerosis
• Pseudooptosis
  • Blepharospasm
  • Contralateral proptosis
  • Lid apraxia
  • Enophthalmosis
  • Hypotropia
  • Microophalmosis
  • Misalignment
• Trauma
  • Contact lens trauma
  • Eyelid foreign body
  • Eyelid laceration
  • Globe malposition
  • Orbital fracture
  • Previous eye surgery
  • Transection of the levator muscle or aponeurosis
• Tumor
  • Capillary hemangioma
  • Primary or secondary malignancy
• Other
  • Blephalophimosis syndrome
  • Drugs – vincristine
  • Genetic syndromes – Noonon, Leigh
  • Fabry disease
  • Marcus Gunn jaw-winking phenomenon
  • Porphyria
  • Thyroid disease

Questions for Further Discussion
1. How would you evaluate a child with ptosis?
2. When can a child’s visual acuity be evaluated in a health supervision visit?

Related Cases

Disease: Hordeolum | Eye Lid Disorders

Symptom/Presentation: Mass or Swelling

Specialty: General Pediatrics | Ophthalmology

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Eyelid Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:197.

Mulvihill A, O’Keefe M. Classification, assessment, and management of childhood ptosis. Ophthalmol Clin North Am. 2001 Sep;14(3):447-55.

Ahmadi AJ, Sires BS. Ptosis in infants and children. Int Ophthalmol Clin. 2002 Spring;42(2):15-29.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:2167,2363.

Sajja K, Putterman AM.Evaluation of Ptosis. ePocrates. Available from the Internet at https://online.epocrates.com/u/29111168/Evaluation+of+ptosis/Differential/Overview (rev. 11/08/2010, cited 5/16/2011).

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