Ptosis — MCQs
Which surgery is indicated for ptosis in Horner's syndrome?
Surgery of choice in a patient with congenital ptosis with good levator action is:
Which is the most common ocular finding in myasthenia gravis?
All of the following are seen in the Horner's syndrome, Except
A 40-year-old man presents with muscle weakness, ptosis, and difficulty swallowing that worsens throughout the day. What is the best initial diagnostic test?
A 10-year-old girl child presents with ptosis of right eyelid. On movement of jaw there is retraction of ptotic eyelid. The image of the patient is shown below. This condition is known as:
A patient with ptosis has the upper 4 mm of cornea covered by the upper eyelid. What is the grade of ptosis?
Appropriate treatment for mild congenital ptosis?
Fasanella-Servat operation is done for:
Senile ptosis is:
Ptosis Indian Medical PG Practice Questions and MCQs
Question 1: Which surgery is indicated for ptosis in Horner's syndrome?
- A. Blaskovics operation
- B. Frontalis sling
- C. Levator resection
- D. Fasanella-Servat (Correct Answer)
Explanation: ***Fasanella - servat*** - This procedure involves resecting the **tarsus**, **Müller's muscle**, and conjunctiva, effectively shortening the posterior lamella of the eyelid. - It is particularly useful for **mild ptosis** with good levator function, often seen in cases secondary to sympathetic denervation like **Horner's syndrome**. *Blaskovics operation* - This is a more complex external approach that involves the resection of the **levator aponeurosis** and Müller's muscle, which is generally reserved for more severe ptosis. - It is typically indicated for patients with **poor levator function** or significant ptosis that cannot be corrected by less invasive methods. *Frontalis sling* - This procedure is used for severe ptosis with **very poor or absent levator function**, often seen in congenital ptosis or oculomotor nerve palsy. - It involves using a sling material to connect the eyelid to the **frontalis muscle**, allowing the eyebrow to lift the eyelid. *Levator resection* - This operation is performed when there is moderate to severe ptosis with **some levator function** present. - It involves shortening the **levator palpebrae superioris muscle** to elevate the eyelid margin.
Question 2: Surgery of choice in a patient with congenital ptosis with good levator action is:
- A. Fascia lata sling surgery
- B. Fasanella-Servat operation
- C. Müller's resection
- D. LPS resection (Correct Answer)
Explanation: ***LPS resection*** - **Levator palpebrae superioris (LPS) resection** is the surgery of choice for congenital ptosis with **good levator action** (typically defined as >8-10 mm of levator function). - This procedure directly shortens and strengthens the **levator muscle**, improving eyelid elevation. *Fascia lata sling surgery* - This procedure is indicated for patients with **poor or absent levator function** (typically <4 mm). - It involves suspending the eyelid to the **frontalis muscle** using a sling material, often **fascia lata**, to allow eyebrow elevation to lift the eyelid. *Fasanella-Servat operation* - This is a minimally invasive procedure used for **mild ptosis** with **excellent levator action** (>10 mm). - It involves resecting a small amount of **Müller's muscle**, **conjunctiva**, and occasionally the **tarsal plate**, but is less effective for moderate-to-severe ptosis. *Müller's resection* - **Müller's muscle resection** is generally reserved for **mild ptosis** (1-2 mm) that responds positively to the **phenylephrine test**. - It primarily addresses ptosis due to sympathetic denervation or mild aponeurotic disinsertion, not significant congenital ptosis with good levator function.
Question 3: Which is the most common ocular finding in myasthenia gravis?
- A. Ptosis (Correct Answer)
- B. Lagophthalmos
- C. Proptosis
- D. Enophthalmos
Explanation: ***Ptosis*** - **Ptosis**, or drooping of the eyelid, is the most common ocular manifestation of **myasthenia gravis**, affecting a large majority of patients. - It results from **weakness of the levator palpebrae superioris muscle**, which is responsible for lifting the eyelid. *Lagophthalmos* - **Lagophthalmos** is the inability to close the eyelids completely, often due to facial nerve palsy or severe proptosis. - While it can lead to exposure keratopathy, it is **not a primary or common finding** in myasthenia gravis. *Proptosis* - **Proptosis** (or exophthalmos) is the forward bulging of the eyeball, most commonly associated with **Graves' ophthalmopathy**. - It is **not a feature of myasthenia gravis**, which typically involves muscle weakness, not orbital mass effects. *Enophthalmos* - **Enophthalmos** refers to the posterior displacement of the eyeball within the orbit, often seen in conditions like **orbital fractures** or Horner's syndrome. - It is **not associated with the neuromuscular dysfunction** characteristic of myasthenia gravis.
Question 4: All of the following are seen in the Horner's syndrome, Except
- A. Dilated pupil (Correct Answer)
- B. Drooping of upper eyelid
- C. Enophthalmos
- D. Loss of sweating on same side of face
Explanation: ***Dilated pupil*** - **Horner's syndrome** results from damage to the sympathetic pathway, leading to **miosis** (constricted pupil) due to unopposed parasympathetic activity [2]. - A **dilated pupil** would be indicative of a different pathology, such as oculomotor nerve palsy [3]. *Drooping of upper eyelid* - This symptom, known as **ptosis**, is a classic feature of Horner's syndrome due to the paralysis of the **superior tarsal muscle** (Müller's muscle), which is innervated by the sympathetic nervous system [1], [2]. - The degree of ptosis is typically mild to moderate. *Enophthalmos* - **Enophthalmos**, or the apparent sinking of the eyeball into the orbit, is often seen in Horner's syndrome. - This is partly an illusion caused by the ptosis and sometimes attributed to a loss of tone in the **orbitalis muscle** (if present and sympathetically innervated). *Loss of sweating on same side of face* - This is known as **anhydrosis** and occurs on the **ipsilateral side of the face and neck** due to the disruption of sympathetic innervation to the sweat glands. - The extent of anhydrosis depends on the level of the lesion along the sympathetic pathway [4].
Question 5: A 40-year-old man presents with muscle weakness, ptosis, and difficulty swallowing that worsens throughout the day. What is the best initial diagnostic test?
- A. MRI of the brain
- B. Lumbar puncture
- C. CT angiography
- D. Acetylcholine receptor antibody test (Correct Answer)
Explanation: ***Acetylcholine receptor antibody test*** - The clinical presentation of **muscle weakness**, **ptosis**, and **dysphagia** that **worsens with activity** (fatigability) is highly suggestive of **myasthenia gravis** [1]. - Detecting **acetylcholine receptor antibodies** confirms the diagnosis of myasthenia gravis in the vast majority of patients [1]. *MRI of the brain* - An **MRI of the brain** would be more appropriate for suspected central nervous system disorders like **stroke**, **multiple sclerosis**, or **brain tumor**, which typically present differently. - While imaging may be considered to rule out other conditions, it is not the primary diagnostic test for myasthenia gravis given these specific symptoms [1]. *Lumbar puncture* - A **lumbar puncture** is used to analyze cerebrospinal fluid and is indicated for suspected **meningitis**, **encephalitis**, or **Guillain-Barré syndrome**. - It would not directly diagnose myasthenia gravis, as the pathology is at the neuromuscular junction, not within the CNS [2]. *CT angiography* - **CT angiography** is primarily used to visualize blood vessels, often to detect **aneurysms**, **stenosis**, or **vascular malformations**. - It would not address the symptoms of fluctuating muscle weakness and ptosis characteristic of myasthenia gravis.
Question 6: A 10-year-old girl child presents with ptosis of right eyelid. On movement of jaw there is retraction of ptotic eyelid. The image of the patient is shown below. This condition is known as:
- A. Marcus Gunn pupil
- B. Marcus Gunn syndrome (Correct Answer)
- C. Floppy eyelid syndrome
- D. Myasthenia gravis
Explanation: ***Marcus Gunn syndrome*** - This syndrome, also known as the **Marcus Gunn jaw-winking phenomenon**, is characterized by a unilateral congenital ptosis that retracts or elevates when the jaw is moved (e.g., chewing, sucking, jaw protrusion). - The image clearly shows **ptosis of the right eyelid** (Image A) and **retraction of the ptotic eyelid** when the mouth is open (jaw movement, Image B), which is the hallmark of this condition. *Marcus Gunn pupil* - This refers to an **afferent pupillary defect (APD)**, typically detected by the swinging flashlight test, where the pupil paradoxically dilates when light is shined into the affected eye. - It is a sign of **optic nerve damage** and is unrelated to eyelid ptosis or jaw movements affecting the eyelid. *Floppy eyelid syndrome* - This condition is characterized by **loose, elastic upper eyelids** that evert easily, often during sleep, and are associated with chronic papillary conjunctivitis. - It is commonly seen in **obese, middle-aged men** and does not involve jaw-winking phenomena or congenital ptosis. *Myasthenia gravis* - This is an **autoimmune neuromuscular disorder** causing fluctuating weakness of voluntary muscles, including the extraocular muscles and those responsible for eyelid elevation. - While it can cause **ptosis** and **diplopia**, the ptosis typically worsens with fatigue and does not exhibit the specific jaw-winking phenomenon.
Question 7: A patient with ptosis has the upper 4 mm of cornea covered by the upper eyelid. What is the grade of ptosis?
- A. Moderate (Correct Answer)
- B. Profound
- C. Severe
- D. Mild
Explanation: ***Moderate*** - **Moderate ptosis** is defined as **3-4 mm of lid drooping** below the normal position - In this case, the upper eyelid covers **4 mm of the cornea**, which falls into the moderate category - The lid margin is typically **at or slightly below the superior limbus** in moderate ptosis - This degree of ptosis is **functionally significant** and may warrant surgical correction *Mild* - **Mild ptosis** is defined as **2 mm or less** of lid drooping - The upper lid margin is **above the superior limbus** but below the normal position - This patient has 4 mm coverage, which **exceeds the mild category** *Severe* - **Severe ptosis** is defined as **5 mm or more** of lid drooping below the normal position - The upper lid typically **covers the pupillary axis significantly** and causes marked visual obstruction - This patient's 4 mm coverage **does not reach severe criteria** *Profound* - **"Profound"** is not a standard term in ptosis grading systems - The standard classification uses **mild, moderate, and severe** as the three grades - If used, it would refer to extreme cases where the lid almost completely covers the pupil
Question 8: Appropriate treatment for mild congenital ptosis?
- A. Frontalis sling procedure
- B. Antibiotics and hot compression
- C. LPS Resection (Correct Answer)
- D. Wedge resection of conjunctiva
Explanation: ***LPS Resection*** - **LPS (levator palpebrae superioris) resection/advancement** is the most common surgical treatment for congenital ptosis, especially in mild to moderate cases. - This procedure strengthens the levator muscle, improving eyelid position and is appropriate when the **levator function is good** (typically greater than 4mm). *Frontalis sling procedure* - The **frontalis sling procedure** is generally reserved for severe congenital ptosis with poor levator function (<4mm) or in cases where the levator muscle is absent or highly dysfunctional. - It uses the frontalis muscle to lift the eyelid indirectly, which is less ideal for mild ptosis. *Antibiotics and hot compression* - **Antibiotics and hot compression** are treatments for infectious or inflammatory conditions of the eyelid, such as a **hordeolum** (stye) or **chalazion**. - They are not effective treatments for anatomical defects like congenital ptosis, which requires surgical intervention. *Wedge resection of conjunctiva* - **Wedge resection of the conjunctiva** might be used in some cases of conjunctival prolapse or for correction of specific conjunctival lesions or abnormalities. - It is not a standard or appropriate treatment for congenital ptosis.
Question 9: Fasanella-Servat operation is done for:
- A. Myasthenia gravis
- B. Congenital ptosis (Correct Answer)
- C. Drug induced ptosis
- D. Horner syndrome
Explanation: ***Congenital ptosis*** - The **Fasanella-Servat operation** is indicated for **mild to moderate ptosis with good levator function** (levator function >10mm). - This includes cases of **mild congenital ptosis** where the levator muscle has adequate function. - The procedure involves resecting a portion of the **conjunctiva, Müller's muscle, and upper tarsus** to elevate the eyelid. - It provides approximately **2-3mm of lid elevation** and is particularly useful when levator function is preserved. *Horner syndrome* - Horner syndrome causes ptosis due to **denervation of Müller's muscle** (sympathetic dysfunction). - The Fasanella-Servat operation **resects Müller's muscle**, which would be counterproductive when this muscle is already dysfunctional. - Ptosis in Horner syndrome is typically managed with **levator resection** or observation, not Fasanella-Servat. *Myasthenia gravis* - Ocular manifestations of **myasthenia gravis** are treated with **acetylcholinesterase inhibitors** and immunomodulatory therapies. - The underlying **neuromuscular junction defect** causes variable ptosis that fluctuates throughout the day. - Surgical correction is not appropriate as the condition requires medical management of the autoimmune process. *Drug induced ptosis* - **Drug-induced ptosis** is a reversible condition that resolves with **discontinuation of the offending medication**. - Common culprits include topical prostaglandin analogs and certain systemic medications. - Surgical intervention like the Fasanella-Servat operation is not indicated as the cause is reversible.
Question 10: Senile ptosis is:
- A. Neurogenic
- B. Myogenic
- C. Aponeurotic (Correct Answer)
- D. Mechanical
Explanation: **Explanation:** **Senile ptosis** (also known as Involutional ptosis) is the most common form of acquired ptosis in the elderly. **Why Aponeurotic is correct:** The primary pathology in senile ptosis is the **disinsertion, dehiscence, or stretching of the Levator Palpebrae Superioris (LPS) aponeurosis** from its attachment to the tarsal plate. This occurs due to age-related degenerative changes. Characteristically, these patients present with a **high or absent upper eyelid crease** and good levator function, as the muscle itself is healthy, but its "tendon" (aponeurosis) has slipped. **Why other options are incorrect:** * **Neurogenic:** Caused by nerve defects, such as 3rd Nerve Palsy or Horner’s Syndrome. Senile ptosis does not involve nerve dysfunction. * **Myogenic:** Caused by primary muscle disorders (e.g., Myasthenia Gravis or Myotonic Dystrophy). In senile ptosis, the LPS muscle fibers are typically normal. * **Mechanical:** Caused by the weight of a mass (tumor, edema, or chalazion) pulling the lid down. Senile ptosis is due to structural laxity, not added weight. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Sign:** A "high skin crease" is the hallmark of aponeurotic ptosis. * **Thinning of the lid:** The eyelid may appear thin, sometimes allowing the iris to be visible through the skin (due to LPS dehiscence). * **Surgical Management:** The treatment of choice is **LPS Aponeurosis advancement or repair**. * **Differential:** If ptosis is associated with miosis, think Horner’s; if associated with ocular motility issues, think 3rd Nerve Palsy.
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