Blepharoptosis is one of the common clinical symptoms in neurology department. It is often accompanied by eye movement disorder and diplopia. It can be divided into unilateral blepharoptosis and bilateral blepharoptosis. The former can be seen in Horner syndrome, oculomotor nerve palsy and trauma, while the latter can be seen in Fisher syndrome and myasthenia gravis. The etiology of blepharoptosis is complicated. How to make a positioning and qualitative diagnosis is one of the basic skills of neurologists. Combined with my clinical experience, the clinical diagnosis ideas of blepharoptosis are summarized as follows.
Clinical diagnosis of blepharoptosis
The main cause of blepharoptosis is extraocular muscle paralysis, which may be accompanied by diplopia, ocular dyskinesia, orbital pain and other clinical manifestations. The location diagnosis of extraocular muscle paralysis can be divided into neurogenic, neuromuscular junction lesions, myogenic lesions and congenital lesions. Neurogenic disease is the most common, and can be divided into supranuclear, nuclear, inter nuclear and peripheral neuropathy. Myasthenia gravis is the most common cause of ptosis caused by neuromuscular junction lesions. Myogenic lesions are more common in thyroid myopathy, muscular dystrophy and mitochondrial myopathy. Congenital extraocular muscle paralysis is more common in congenital orbital fibrosis and senile degenerative changes.
The qualitative diagnosis of extraocular muscle paralysis can be divided into inflammatory, vascular, space occupying, traumatic, metabolic and so on. Extraocular muscle paralysis caused by inflammation is more common in painful ophthalmoplegia, cerebral neuritis, Guillain Barre syndrome, cavernous sinus thrombosis, orbital cellulitis, etc.; extraocular muscle paralysis caused by space occupying, common intracranial aneurysms, skull base tumors, etc.; extraocular muscle paralysis caused by vascular diseases can be seen in brainstem infarction and hemorrhage. Metabolically induced extraocular muscle paralysis is more common in diabetes, hyperthyroidism and cancerous peripheral neuropathy; there are some uncommon causes of extraocular muscle paralysis, which can not be ignored clinically, such as leakage of internal carotid cavernous sinus, multiple sclerosis, etc.; trauma is more common in orbital fracture and surgery, which can also lead to extraocular muscle paralysis; extraocular muscle paralysis with ipsilateral pupil narrowing is found in Horner’s syndrome Symptomatic, cervical sympathetic nerve damage.
What are the auxiliary examinations needed for differential diagnosis of extraocular muscle paralysis? Clinical diagnosis should first consider common diseases and frequently occurring diseases. Since I was engaged in clinical work, extraocular muscle paralysis is the most common in diabetic peripheral neuropathy (oculomotor nerve is most commonly involved), brainstem stroke, intracranial aneurysms, intracranial tumors. Diabetic oculomotor nerve paralysis is the most common, but some patients have no history of diabetes, fasting blood glucose is normal, need to monitor 2 hours postprandial blood glucose, glycosylated hemoglobin, if necessary, OGTT test to diagnose diabetes or abnormal glucose tolerance. Brain stem lesions or space occupying lesions of skull base can be excluded by MRI scan. The extraocular muscle paralysis caused by intracranial aneurysm compression of oculomotor nerve usually has mydriasis, which should be excluded by MRA / CTA as soon as possible. Suspected intracranial infection, extraocular muscle paralysis caused by Guillain Barre syndrome needs lumbar puncture for definite diagnosis; for extraocular muscle paralysis caused by other reasons, thyroid function, ENA, ANCA series, tumor markers, immunity, rheumatism series should be examined, and cerebrovascular angiography should be performed for differential diagnosis if necessary. Myasthenia gravis caused by extraocular muscle paralysis, mostly bilateral ptosis, no abnormal eye movement, mild morning and evening heavy phenomenon, fatigue test, neostigmine test positive, some patients with positive acetylcholine receptor antibody, patients with hyperthyroidism, thymoma and other autoimmune diseases. If the extraocular muscle paralysis caused by myogenic lesions is considered, electromyography can be performed, and muscle biopsy can be performed if necessary. In addition, there are a small number of extraocular muscle paralysis is unknown, but in clinical work, we should first consider common diseases, frequently occurring diseases and treatable diseases.
For the treatment of extraocular muscle paralysis, the first is etiological treatment, removing the cause is the basis of treatment, symptomatic treatment is mainly to nourish the nerve, reduce edema, improve microcirculation treatment, followed by acupuncture treatment, strengthen rehabilitation training.