Part 2 book “Neurological clinical examination” has contents: Ptosis, abnormalities of vision or eye movement, tremor and cerebellar signs, other abnormal involuntary movements, speech disturbance, higher function testing, higher function testing, psychogenic disorders. | 8 0 Ptosis Inspection 48 Distribution of weakness 49 Drooping of the eyelids is common in the elderly, and results from dehiscence of the levator aponeurosis. Otherwise, it usually results from weakness of the levator palpebrae superioris muscle. This is innervated by the oculomotor (IIIrd) nerve. The under-surface of the levator muscles is connected to the tarsus by smooth muscle fibres, Müller’s muscle, which is innervated by cervical sympathetic nerves. Ptosis results from damage to these nerves or to disorders of muscle or neuromuscular junction. Inspection Give yourself a moment to take in the overall appearance of the patient. There are some characteristic presentations: ● One eye closed, the other normal (oculomotor palsy or myasthenia gravis). ● Ptosis with lowering of the upper eyelid due to weakness of the levator palpebrae on one side with the pupil larger on the same side (oculomotor palsy; Fig. ). See Video 35: Third nerve palsy ● Partial ptosis with lowering of upper eyelid and elevation of the lower eyelid due to weakness of the Müller’s muscle on one side with the pupil smaller on the same side (Horner’s syndrome; Fig. ). Distribution of weakness (a) Normal (b) Horner's syndrome (c) Oculomotor palsy Figure The eyes in the primary position: (a) normal, (b) Horner’s syndrome, (c) oculomotor nerve palsy. ● Bilateral ptosis (myopathy, such as dystrophia myotonica [drooping mouth, thin neck and frontal balding] or Kearns–Sayre1 syndrome; or myasthenia gravis). ● Proptosis and ptosis in one eye (orbital tumour or vascular anomaly). Listen for a bruit over the eye. Distribution of weakness In the first place, you need to: ● test visual acuity; ● examine the lens and fundi; ● test pupillary response to light and accommodation; ● test visual fields; ● test eye movements; and ● examine for weakness of the facial muscles (especially orbicularis oculi). 1. Thomas P Kearns, Mayo Clinic neuro-ophthalmologist (1922–); George Pomeroy Sayre,
