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explain ptosis in opthalmology mbbs

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Ptosis (Blepharoptosis)

Ptosis means an abnormally low position of the upper eyelid in primary gaze. Normally, the upper lid covers about 2 mm of the superior cornea. It may be unilateral or bilateral, congenital or acquired.
Kanski's Clinical Ophthalmology, 10th ed., p. 75.
It can obstruct the visual axis, cause a compensatory chin-up posture, and in children may lead to amblyopia.

Basic anatomy

Upper-lid elevation depends on:
  1. Levator palpebrae superioris
    • Main elevator of the upper lid
    • Supplied by the superior division of oculomotor nerve (CN III)
  2. Müller muscle (superior tarsal muscle)
    • Gives an additional 1-2 mm elevation
    • Supplied by sympathetic nerves
Therefore:
  • CN III palsy produces marked ptosis.
  • Sympathetic interruption in Horner syndrome produces mild ptosis.

Classification and causes

1. Congenital ptosis

Usually due to congenital dysgenesis or fibrosis of the levator muscle.
Features
  • Present since birth or early childhood
  • Often unilateral
  • Poor levator action
  • Poorly developed or absent upper lid crease
  • Lid lag on downgaze may be seen
  • Child may elevate the chin to see beneath the lid
Associated conditions
  • Marcus Gunn jaw-winking syndrome
  • Blepharophimosis-ptosis-epicanthus inversus syndrome
  • Congenital third-nerve palsy
  • Congenital Horner syndrome

2. Acquired ptosis

TypeMechanismExamples / clues
Aponeurotic (involutional)Levator aponeurosis stretches, dehisces, or disinsertsMost common acquired cause. Elderly patient, high lid crease, good levator function
NeurogenicNerve supply defectCN III palsy, Horner syndrome
MyogenicLevator muscle diseaseMyotonic dystrophy, chronic progressive external ophthalmoplegia
Neuromuscular junctionImpaired transmissionMyasthenia gravis, botulism
MechanicalLid is weighed down or scarredLid tumor, edema, chalazion, dermatochalasis, cicatricial disease
Traumatic / iatrogenicDamage from trauma or surgeryFollowing eyelid surgery, cataract surgery, contact lens use
Kanski's Clinical Ophthalmology, 10th ed., p. 75.

Important clinical patterns

A. Third-nerve palsy

  • Complete or severe ptosis
  • Ophthalmoplegia: eye often "down and out"
  • Diplopia may occur
  • Pupil may be dilated in compressive lesions, such as aneurysm
Ptosis with headache, pain, diplopia, or a dilated pupil is an emergency.

B. Horner syndrome

Classical triad:
  • Mild ptosis, from paralysis of Müller muscle
  • Miosis
  • Facial anhidrosis, depending on lesion site
There may be reverse ptosis of the lower lid, causing narrowing of the palpebral fissure.

C. Myasthenia gravis

  • Fluctuating, fatigable ptosis
  • Worse late in the day or after sustained upgaze
  • May be unilateral or bilateral
  • Diplopia is common
  • Pupils remain normal

D. Aponeurotic ptosis

  • Common in older adults
  • Good levator function
  • High upper lid crease
  • Often worsens with age
  • Can occur after intraocular surgery or long-term contact lens wear

Pseudoptosis

This is an apparent drooping of the upper lid without true failure of lid elevation.
Causes include:
  • Enophthalmos or a small eye
  • Phthisis bulbi
  • Contralateral lid retraction
  • Ipsilateral hypotropia
  • Brow ptosis or excess upper-lid skin
In hypotropia, the lid follows the downward globe. The apparent ptosis improves when the affected eye fixes.
Kanski's Clinical Ophthalmology, 10th ed., p. 75.

Clinical examination

History

Ask about:
  • Onset: since birth or acquired?
  • Sudden or gradual onset?
  • Diurnal variation or fatigability
  • Diplopia
  • Headache or eye pain
  • Trauma, surgery, contact lens use
  • Systemic muscle weakness
  • Old photographs, to establish duration

Examination

  1. Visual acuity and refraction
    • Essential in children to assess amblyopia.
  2. Lid height
    • Measure MRD1: distance from corneal light reflex to upper lid margin.
    • Normal MRD1 is approximately 4-5 mm.
  3. Severity of ptosis
    • Mild: 1-2 mm
    • Moderate: 3-4 mm
    • Severe: more than 4 mm
  4. Levator function
    • Measure lid excursion from downgaze to upgaze while fixing the eyebrow to prevent frontalis action.
    • Poor: 0-4 mm
    • Fair: 5-7 mm
    • Good: 8 mm or more
  5. Upper lid crease
    • High crease suggests aponeurotic ptosis.
    • Poor or absent crease suggests congenital levator dysgenesis.
  6. Pupils, ocular movements, and diplopia
    • To detect third-nerve palsy or Horner syndrome.
  7. Fatigability tests
    • Sustained upgaze may worsen myasthenic ptosis.
  8. Bell phenomenon and corneal exposure
    • Important before surgery. A weak Bell phenomenon raises the risk of postoperative exposure keratopathy.
      Kanski's Clinical Ophthalmology, 10th ed., p. 75.
A focused acquired-ptosis assessment should include pupil size, ocular motility, facial sensation, lid height, palpebral fissure, and levator function, as also outlined by the American Academy of Ophthalmology.

Management

Management depends on the cause, visual impact, levator function, and corneal protection.

Treat the underlying disease

  • Myasthenia gravis: medical management by neurology/ophthalmology
  • Third-nerve palsy: urgent investigation when acute or pupil-involving
  • Horner syndrome: investigate the cause
  • Mechanical ptosis: treat mass, inflammation, edema, or scar

Congenital ptosis

Observe if:
  • Mild ptosis
  • No visual-axis obstruction
  • No amblyopia
  • No abnormal head posture
Surgery is indicated if:
  • Visual axis is obscured
  • Amblyopia develops or is likely
  • Significant chin-up posture occurs
  • Major cosmetic or psychosocial concern
Operations
  • Levator resection/advancement: for moderate or good levator function
  • Frontalis suspension (brow sling): for poor levator function, typically severe congenital ptosis

Aponeurotic ptosis

  • Usually treated by levator aponeurosis advancement or repair.
  • Müller muscle-conjunctival resection may be used in selected mild cases with good levator function.
After cataract surgery, mild ptosis often improves without intervention; corrective lid surgery is generally deferred for about a year. Kanski's Clinical Ophthalmology, 10th ed., p. 75.

MBBS exam summary

Ptosis is drooping of the upper eyelid due to congenital or acquired dysfunction of the levator muscle, its aponeurosis, its nerve supply, sympathetic supply to Müller muscle, or mechanical factors.
Examine lid height, levator function, lid crease, pupils, ocular movements, Bell phenomenon, and visual function.
Always exclude third-nerve palsy, Horner syndrome, and myasthenia gravis in acquired ptosis.
Treatment is cause-specific, with levator surgery for good function and frontalis sling for poor levator function.

Create a one-page ptosis revision PDF

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mkdir -p "/tmp/workspace/ptosis-revision-pdf/src" "/tmp/workspace/ptosis-revision-pdf/output" && python - <<'PY' from reportlab.lib.pagesizes import A4 from reportlab.pdfgen import canvas from reportlab.lib import colors from reportlab.lib.units import mm from reportlab.pdfbase.pdfmetrics import stringWidth from reportlab.pdfbase.ttfonts import TTFont from reportlab.pdfbase import pdfmetrics from reportlab.pdfbase.pdfmetrics import registerFontFamily from reportlab.pdfbase.ttfonts import TTFont import os out='/tmp/workspace/ptosis-revision-pdf/output/Ptosis_MBBS_One_Page_Revision.pdf' # Use built in Helvetica for compatibility W,H=A4 c=canvas.Canvas(out,pagesize=A4) c.setTitle('Ptosis - MBBS One-Page Revision') # palette navy=colors.HexColor('#11324D'); blue=colors.HexColor('#1676A8'); pale=colors.HexColor('#EAF4F9'); red=colors.HexColor('#A52A2A'); amber=colors.HexColor('#FFF4D6'); green=colors.HexColor('#EDF7F0'); dark=colors.HexColor('#17222B'); grey=colors.HexColor('#52616B') margin=12*mm; gap=5*mm; colw=(W-2*margin-gap)/2; left=margin; right=margin+colw+gap def rect(x,y,w,h,fill,stroke=None, radius=0): c.setFillColor(fill); c.setStrokeColor(stroke or fill) if radius: c.roundRect(x,y,w,h,radius,stroke=0,fill=1) else: c.rect(x,y,w,h,stroke=0,fill=1) def txt(x,y,s,size=8,font='Helvetica',color=dark): c.setFont(font,size); c.setFillColor(color); c.drawString(x,y,s) def wrapped(x,y,text,width,size=7.5,leading=9,font='Helvetica',color=dark, bullet=False): words=text.split(); line=''; yy=y for word in words: cand=(line+' '+word).strip() if stringWidth(cand,font,size)<=width: line=cand else: txt(x,yy,line,size,font,color); yy-=leading; line=word if line: txt(x,yy,line,size,font,color); yy-=leading return yy def section(x,y,w,title,body,fill=pale, titlecol=navy, size=7.35, leading=8.7): # calculate height temporary based on text wrapping words=body.split(); lines=[]; line='' for word in words: cand=(line+' '+word).strip() if stringWidth(cand,'Helvetica',size)<=w-10: line=cand else: lines.append(line); line=word if line: lines.append(line) h=14+len(lines)*leading+5 rect(x,y-h,w,h,fill,radius=3) txt(x+5,y-10,title,8.3,'Helvetica-Bold',titlecol) yy=y-21 for line in lines: txt(x+5,yy,line,size,'Helvetica',dark); yy-=leading return y-h-4 # Header rect(0,H-30*mm,W,30*mm,navy) txt(margin,H-13*mm,'PTOSIS',22,'Helvetica-Bold',colors.white) txt(margin,H-20*mm,'MBBS Ophthalmology - One-Page Revision',9.5,'Helvetica',colors.white) txt(W-margin-65*mm,H-13*mm,'UPPER-LID DROOP',8.5,'Helvetica-Bold',colors.HexColor('#B9E4F5')) txt(W-margin-65*mm,H-20*mm,'Classify • Examine • Do not miss red flags',7.5,'Helvetica',colors.white) y=H-35*mm # top definition strip rect(margin,y-15*mm,W-2*margin,15*mm,colors.HexColor('#DDF1FA'),radius=4) txt(margin+5,y-7*mm,'Definition:',8.5,'Helvetica-Bold',navy) txt(margin+28*mm,y-7*mm,'abnormally low upper eyelid in primary gaze.',8.5,'Helvetica',dark) txt(margin+5,y-12*mm,'Normal upper lid covers approximately 2 mm of superior cornea.',7.5,'Helvetica',grey) y-=20*mm # columns ly=y; ry=y ly=section(left,ly,colw,'1. ANATOMY', 'Levator palpebrae superioris is the main elevator and is supplied by CN III. Muller muscle adds 1-2 mm of elevation and is sympathetically supplied.', green) ly=section(left,ly,colw,'2. CLASSIFICATION', 'Congenital: levator dysgenesis, poor lid crease and poor levator action. Acquired: aponeurotic, neurogenic, myogenic/neuromuscular, mechanical, traumatic or iatrogenic.') # causes table mini rect(left,ly-54*mm,colw,54*mm,colors.HexColor('#F7F9FA'),radius=3) txt(left+5,ly-9,'HIGH-YIELD CAUSES',8.3,'Helvetica-Bold',navy) rows=[('Aponeurotic','Elderly; high crease; good levator function'),('CN III palsy','Severe ptosis + ophthalmoplegia +/- dilated pupil'),('Horner syndrome','Mild ptosis + miosis + reverse lower-lid ptosis'),('Myasthenia','Variable, fatigable ptosis; pupils normal'),('Mechanical','Mass, edema, scarring, dermatochalasis')] yy=ly-18 for a,b in rows: txt(left+5,yy,a,6.8,'Helvetica-Bold',blue); txt(left+34*mm,yy,b,6.5,'Helvetica',dark); yy-=7 ly=ly-58*mm ly=section(left,ly,colw,'3. PSEUDOPTOSIS', 'Apparent, not true, ptosis: enophthalmos or small globe, contralateral lid retraction, ipsilateral hypotropia, brow ptosis, or excess upper-lid skin.', colors.HexColor('#F4F0FA')) # right ry=section(right,ry,colw,'4. HISTORY', 'Onset and duration, old photographs, unilateral/bilateral, variability or fatigue, diplopia, pain/headache, trauma/surgery/contact lens use, and systemic weakness.', colors.HexColor('#EAF4F9')) # examination box rect(right,ry-69*mm,colw,69*mm,colors.HexColor('#F7F9FA'),radius=3) txt(right+5,ry-10,'5. EXAMINATION - WRITE THESE IN VIVA',8.3,'Helvetica-Bold',navy) exam=['Visual acuity and refraction: assess amblyopia in children.','MRD1: corneal light reflex to upper-lid margin.','Ptosis severity: mild 1-2 mm; moderate 3-4 mm; severe >4 mm.','Levator function: lid excursion in down to upgaze with brow fixed.','Lid crease: high in aponeurotic; poor/absent in congenital.','Pupils, ocular movements, cover test and diplopia.','Fatigability test, Bell phenomenon, lagophthalmos and corneal exposure.'] yy=ry-19 for item in exam: yy=wrapped(right+7,yy,u'• '+item,colw-13,6.9,8.0) ry=ry-73*mm # red flags rect(right,ry-34*mm,colw,34*mm,amber,radius=3) txt(right+5,ry-10,'RED FLAGS - URGENT ASSESSMENT',8.2,'Helvetica-Bold',red) redtext='Acute ptosis with severe headache, pain, diplopia, ophthalmoplegia, or anisocoria/dilated pupil: suspect compressive CN III palsy. New Horner syndrome also needs cause-directed evaluation.' wrapped(right+5,ry-20,redtext,colw-10,7.0,8.3,'Helvetica',dark) ry-=38*mm ry=section(right,ry,colw,'6. MANAGEMENT', 'Treat the cause first. Observe mild congenital ptosis if no visual-axis block, amblyopia or chin-up posture. Surgery: levator resection/advancement for fair-good function; frontalis sling for poor levator function. Check corneal protection before surgery.', green) # Bottom key lines bot=28*mm rect(margin,bot,W-2*margin,18*mm,navy,radius=3) txt(margin+5,bot+11,'EXAM PEARL:',8.4,'Helvetica-Bold',colors.white) txt(margin+31*mm,bot+11,'Acquired ptosis = examine pupils + ocular movements + fatigability before calling it involutional.',7.7,'Helvetica',colors.white) txt(margin+5,bot+5,'Memory aid:',7.7,'Helvetica-Bold',colors.HexColor('#B9E4F5')) txt(margin+27*mm,bot+5,'A N M M = Aponeurotic, Neurogenic, Myogenic, Mechanical.',7.7,'Helvetica',colors.white) # footer txt(margin,14*mm,'Based on Kanski’s Clinical Ophthalmology, 10th ed., p. 75, and Wills Eye Manual.',6.2,'Helvetica',grey) txt(W-margin-28*mm,14*mm,'For revision use',6.2,'Helvetica',grey) c.showPage(); c.save() print(out) PY python - <<'PY' from pypdf import PdfReader p='/tmp/workspace/ptosis-revision-pdf/output/Ptosis_MBBS_One_Page_Revision.pdf' r=PdfReader(p) print('pages=',len(r.pages)) print('chars=',len(r.pages[0].extract_text() or '')) print((r.pages[0].extract_text() or '')[:400]) PY

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CVS clinical history taking

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cardiovascular history taking AND systematic review

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cardiovascular clinical history taking chest pain dyspnea palpitations syncope NICE assessment

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https://cks.nice.org.uk/topics/breathlessness/diagnosis/asse…

CVS Clinical History Taking

1. Introduction and opening

  • Wash hands, introduce yourself, confirm patient identity.
  • Explain: “I would like to ask some questions about your heart-related symptoms and general health.”
  • Obtain consent and ensure comfort/privacy.
  • Start open-ended:
“What brought you to hospital today?”
“Can you tell me more about this problem?”
Then clarify the presenting complaint and its duration.

2. Presenting complaints in CVS

Ask specifically for:
  • Chest pain
  • Breathlessness
  • Palpitations
  • Syncope or presyncope
  • Leg swelling
  • Fatigue or reduced exercise tolerance
  • Cyanosis
  • Claudication
  • Symptoms of stroke/TIA

3. History of presenting complaint

A. Chest pain

Use SOCRATES:
  • Site: Central, left-sided, epigastric?
  • Onset: Sudden or gradual? At rest or exertion?
  • Character: Tightness, heaviness, pressure, burning, stabbing?
  • Radiation: Left arm, both arms, neck, jaw, back, epigastrium?
  • Associated symptoms: Sweating, nausea, vomiting, dyspnoea, palpitations, dizziness/syncope.
  • Timing: Duration, frequency, progression, episodic or continuous?
  • Exacerbating/relieving factors: Exercise, cold weather, emotional stress, meals; relieved by rest or GTN?
  • Severity: Score out of 10.

Typical angina history

  • Constricting discomfort in chest, neck, jaw, shoulder, or arm
  • Triggered by exertion or emotional stress
  • Relieved within minutes by rest or GTN
For chest pain, document its location, radiation, severity, duration, frequency, provoking/relieving factors, associated breathlessness, previous cardiovascular disease, and cardiovascular risk factors, as recommended in NICE chest-pain assessment.

B. Dyspnoea

Ask:
  • Is breathlessness at rest or only on exertion?
  • What level of activity causes it? For example, walking distance or number of flights of stairs.
  • Has exercise tolerance declined recently?
  • Is there orthopnoea? “How many pillows do you sleep with?”
  • Is there paroxysmal nocturnal dyspnoea (PND)? “Do you wake at night breathless and need to sit or stand up?”
  • Is there nocturnal cough, wheeze, frothy sputum, or haemoptysis?
  • Any ankle swelling, weight gain, abdominal distension, or reduced urine output?
Dyspnoea on exertion, orthopnoea, PND, and peripheral oedema suggest heart failure. The Washington Manual of Medical Therapeutics, History section.

C. Palpitations

Ask the patient to describe the sensation:
  • Racing, pounding, fluttering, missed beats, or irregular heartbeat?
  • Sudden or gradual onset and termination?
  • Regular or irregular?
  • Duration and frequency of attacks?
  • At rest, exertion, after caffeine, alcohol, smoking, stress, or drugs?
  • Can the patient tap out the rhythm?
  • Associated chest pain, dyspnoea, dizziness, presyncope, or syncope?
Palpitations should be defined by their duration, frequency, precipitating factors, and associated chest pain, dyspnoea, light-headedness, or syncope. Goldman-Cecil Medicine, Palpitations section.

D. Syncope or presyncope

Clarify whether it was true transient loss of consciousness.
Ask:

Before the episode

  • Posture: standing, sitting, or supine?
  • Trigger: prolonged standing, pain, fear, micturition, cough, exertion?
  • Warning symptoms: sweating, nausea, visual dimming, dizziness?
  • Palpitations, chest pain, dyspnoea?

During the episode

  • Witness account
  • Duration of unconsciousness
  • Injury, tongue bite, abnormal limb movements, incontinence?

After the episode

  • Rapid recovery or prolonged confusion?
  • Weakness or focal neurological symptoms?

Cardiac red flags

  • Syncope during exertion
  • Syncope while supine
  • No prodrome
  • Palpitations before syncope
  • Known structural heart disease
  • Family history of sudden cardiac death

E. Peripheral oedema

Ask:
  • Both legs or one leg?
  • Ankle swelling worse in evening?
  • Progression to legs, sacrum, scrotum, or abdominal swelling?
  • Associated dyspnoea, orthopnoea, PND, weight gain, or reduced urine output?

F. Claudication and peripheral vascular symptoms

Ask:
  • Pain in calf, thigh, or buttock while walking?
  • Walking distance before pain begins?
  • Does it improve with rest?
  • Rest pain, especially at night?
  • Non-healing ulcers, cold feet, colour change, numbness?
  • Symptoms in upper limbs, such as arm claudication?

4. Past medical history

Ask about:

Previous cardiovascular disease

  • Hypertension
  • Ischaemic heart disease, angina, myocardial infarction
  • Heart failure
  • Rheumatic fever or valvular disease
  • Arrhythmias, especially atrial fibrillation
  • Congenital heart disease
  • Cardiomyopathy
  • Peripheral arterial disease
  • Stroke or TIA
  • Venous thromboembolism

Previous interventions/investigations

  • ECG, echocardiography, stress test, coronary angiography
  • Angioplasty, stent, CABG
  • Valve surgery
  • Pacemaker, ICD, cardiac resynchronization therapy
  • Previous hospital admissions for cardiac illness

Relevant non-cardiac illnesses

  • Diabetes mellitus
  • Dyslipidaemia
  • Chronic kidney disease
  • Thyroid disease
  • Anaemia
  • COPD/asthma
  • Obstructive sleep apnoea

5. Drug history

Ask for prescribed, over-the-counter, herbal, and recreational drugs.
Important CVS medicines:
  • Antiplatelets: aspirin, clopidogrel
  • Anticoagulants: warfarin, DOACs
  • Statins
  • Beta-blockers
  • ACE inhibitors/ARBs/ARNI
  • Calcium-channel blockers
  • Nitrates
  • Diuretics
  • Digoxin
  • Antiarrhythmics
Also ask:
  • Compliance and missed doses
  • Side effects
  • GTN use and response
  • Drug allergies and reaction
Ask specifically about substances that may provoke cardiovascular symptoms:
  • Cocaine, amphetamines
  • Alcohol
  • Tobacco/nicotine
  • Excess caffeine or energy drinks

6. Family history

Ask about first-degree relatives with:
  • Premature coronary artery disease or MI
  • Hypertension, diabetes, dyslipidaemia
  • Sudden unexplained death, especially at a young age
  • Cardiomyopathy
  • Arrhythmia or pacemaker/ICD
  • Congenital heart disease
  • Marfan syndrome or familial hypercholesterolaemia

7. Social history and cardiovascular risk factors

Ask:
  • Smoking or vaping: pack-years
  • Alcohol intake
  • Recreational drugs
  • Diet, including salt and saturated-fat intake
  • Physical activity/exercise
  • Occupation and stress
  • Functional capacity and activities of daily living
  • Recent travel, immobilisation, or surgery if thromboembolism is possible

Major cardiovascular risk factors

  • Age and sex
  • Hypertension
  • Diabetes
  • Dyslipidaemia
  • Smoking
  • Obesity
  • Sedentary lifestyle
  • Family history of premature cardiovascular disease

8. Systems review

Briefly ask about:
  • Respiratory: cough, sputum, wheeze, haemoptysis
  • Neurological: weakness, facial droop, speech difficulty, transient visual loss
  • Renal: reduced urine output, frothy urine
  • Endocrine: weight change, tremor, heat intolerance, cold intolerance
  • GI: reflux, epigastric pain, nausea
  • General: fever, fatigue, weight loss

9. Example case presentation

“Mr X is a 62-year-old man with hypertension, diabetes, smoking history, and dyslipidaemia, presenting with 2 hours of central constricting chest pain radiating to the left arm. The pain began at rest and is associated with sweating, nausea, and shortness of breath. He has a background history of previous MI and is taking aspirin, atorvastatin, metoprolol, and ramipril. The history is concerning for acute coronary syndrome.”

10. OSCE checklist: do not miss

  • Characterise chest pain properly
  • Ask exercise tolerance, orthopnoea, PND, and oedema
  • Ask palpitations and syncope
  • Identify cardiovascular risk factors
  • Ask past cardiac events and procedures
  • Ask drug history and adherence
  • Ask family history of sudden cardiac death/cardiomyopathy
  • Ask smoking, alcohol, and recreational drugs
  • End with systems review and summarise

Urgent warning symptoms

Escalate urgently if there is:
  • Acute chest pain with sweating, vomiting, or breathlessness
  • Syncope with exertion or while supine
  • Palpitations with chest pain, syncope, or severe breathlessness
  • Sudden dyspnoea, haemoptysis, or hypotension
  • New focal neurological symptoms
For acute breathlessness, assess ABC, vital signs, oxygen saturation, onset, positional symptoms, exercise tolerance, and associated chest pain, palpitations, or syncope, as outlined in NICE breathlessness assessment.
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