Urgent considerations
See Differentials for more details
Uveitis
Uveitis may have an acute or insidious onset with recurrent exacerbations. Ocular inflammation may be caused by traumatic, infectious, autoimmune, and idiopathic factors.[7] Common symptoms include decreased vision, redness, ocular discomfort, and photophobia. Loss of vision can be significant with retinal and optic nerve involvement. Inflammation can be prolonged, and require topical or systemic immunosuppression. Topical cycloplegics may be used for ocular discomfort. Patients with significant symptoms, profoundly decreased vision, a relative afferent pupillary defect, or an unknown etiology that requires topical or systemic corticosteroids should receive prompt ophthalmologic evaluation.
Uveitis has no direct relation to the onset of ptosis, but ptosis may occur in people with this condition as a secondary response to ocular pain, photophobia, and eyelid edema.
Globe malposition
Globe malposition refers to any process that alters the normal anatomic position of the globe within the orbit, including volume changes of the globe. Alterations of this relationship result in eyelid malposition.
The cause of globe malposition is often elucidated by careful clinical history (e.g., congenital versus acquired, acute versus chronic, traumatic versus surgical). Inflammatory conditions, such as thyroid eye disease and orbital inflammatory syndrome, may result in soft-tissue fibrosis causing pseudoptosis. Facial trauma resulting in globe perforation or significant orbital fracture requires urgent surgical intervention.
Thyroid disease
Thyroid eye disease can result from restrictive extraocular myopathy or eyelid edema, although eyelid retraction with proptosis is characteristic. Severe extraocular muscle enlargement may result in loss of vision due to compressive optic neuropathy. Systemic corticosteroids, orbital radiation, or surgical decompression by a specialist may be indicated.[10]
Myasthenia gravis
Fluctuation and fatigability are hallmark features. Ptosis is the most common sign and >50% have ocular signs and symptoms at disease onset.[15]
Systemic disease associated with dysphagia and dyspnea may have life-threatening implications and necessitates prompt treatment with anticholinesterases and immunotherapy.[9]
Traumatic transection of levator muscle or aponeurosis
Direct trauma to the levator muscle or aponeurosis, or previous eyelid surgery, may cause disinsertion or dehiscence of the levator aponeurosis from its tarsal attachments. Salient wound characteristics, such as prolapse of orbital fat with or without decreased vision, are suspicious for levator transection or globe perforation. Determination of levator function may be difficult secondary to soft-tissue edema. Urgent surgical referral is necessary for primary wound evaluation and repair.
Orbital and facial fracture
Trauma to orbital and intracranial structures and adjacent paranasal sinuses may be associated with significant enophthalmos and ptosis, and diplopia. Pediatric orbital fractures may be associated with minimal swelling and other signs and symptoms of orbital injury. Prompt ophthalmologic evaluation is recommended.[16]
Eyelid laceration
Eyelid laceration with herniation of orbital fat requires evaluation for levator muscle and aponeurosis laceration, and for globe perforation. A laceration with extension medial to the lacrimal punctum suggests lacrimal canalicular injury. Any eyelid trauma with decreased vision or a relative afferent pupillary defect requires urgent ophthalmologic consultation with possible surgical repair.
Third nerve palsy
The presence of a relative afferent pupillary defect with partial or complete third nerve palsy should prompt neuroimaging, with urgent neurologic consultation for a compressive lesion or an aneurysm.[17] Third nerve palsy with headache and vision loss suggests giant cell (temporal) arteritis. Ophthalmologic evaluation with possible temporal artery biopsy by a specialist may be indicated.
A complete third nerve palsy in a patient with evidence of hypertension, diabetes mellitus, or atherosclerosclerotic disease, is most likely due to microvascular ischemic disease. Therefore, in this patient cohort, a complete third nerve palsy without pupillary abnormalities may be cautiously observed.[12]
Horner syndrome
Congenital Horner syndrome is associated with trauma to the brachial plexus during birth. Extraocular motility and levator function are preserved. Children with a new-onset Horner syndrome are evaluated for possible neuroblastoma. Acquired Horner syndrome in adults warrants a careful history for other symptoms that may aid in localization of the lesion (e.g., apical lung tumor compressing the sympathetic trunk). Ipsilateral head pain or temporary loss of vision suggests possible carotid dissection or aneurysm. Neuroimaging or arteriography with neurologic consultation are appropriate.[13][17][18]
Stroke
Acute onset of symptoms may correlate with route of circulation and region of ischemia. Urgent neurologic consultation for evaluation and treatment is mandatory.
Orbital cellulitis
Patients present with orbital pain and discomfort, decreased vision, proptosis, and diplopia. The history is significant for recent concurrent sinus infection, recent dental and facial surgery, trauma, preseptal cellulitis, or immunocompromised state. Orbital cellulitis represents a vision-threatening, potentially life-threatening, emergency requiring appropriate neuroimaging and broad-spectrum, intravenous antibiotics.[17] Ophthalmologic consultation is mandatory early in the clinical course. Poor initial response to antibiotics may require addition of antifungals or surgical intervention.[19][20]
Eyelid foreign body
An eyelid foreign body may reflect previous trauma or surgical intervention. Clinical history is contributory. Orbital imaging is indicated in traumatic forms of ptosis if eyelid laceration is associated with a deeply embedded foreign body or frank globe trauma.[17] Treatment includes surgical removal of the embedded foreign body from the eyelid.
Giant cell arteritis
Giant cell arteritis is an inflammatory condition that affects branches of the carotid artery. Patients are typically older adults, with a history of a temporal headache, vision loss, and variable ocular or orbital discomfort. Associated symptoms include jaw claudication, ptosis, fatigue, lethargy, loss of appetite, and weight loss. Associated signs include palpable tenderness along the course of the superficial temporal artery and lack of pulsation of this artery. Vision loss may be significant and symptoms may develop in the contralateral eye without urgent identification and appropriate intervention. Urgent ophthalmologic evaluation is necessary to prevent permanent loss of vision.
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