Transient traumatic isolated neurogenic ptosis after a mild head trauma: a case report

Neurogenic Blepharoptosis After Medial Orbital Wall Reconstruction

ABSTRACT

Neurogenic blepharoptosis after orbital wall reconstruction is a rare complication. It can either present as an isolated blepharoptosis, or accompany with other ocular symptoms. The authors introduce 4 cases of post-operative neurogenic blepharoptosis after reconstruction of medial orbital wall via transcaruncular approach.Immediately after the surgery, 2 adolescent patients experienced unilateral islolated complete blepharoptosis with no other ocular symptoms. The other 2 adult patients presented unilateral complete blepharoptosis accompanied by lateral displacement of the globe and evident extraocular movement limitations. The 2 adolescent patients were observed with no particular treatment, whereas the other 2 adult patients were treated with intravenous systemic steroids. The blepharoptosis symptom began to improve at 2 weeks post-operatively and completely recovered within 3 to 4 months in all patients, while the globe displacement and extraocular movement limitation started to improve at 4 weeks after the surgery and fully recovered within 6 months.Although neurogenic blepharoptosis after medial orbital wall reconstruction is a very rare complication, it can be critical once it occurs. According to the author's experience, it fortunately shows a favorable clinical course of spontaneous recovery. Post-operative neurogenic blepharoptosis usually recovers between 2 weeks and 4 months and other ocular symptoms related to oculomotor nerve injury recovers within 6 months after the surgery.

A case of surgically treated traumatic ptosis caused by scratching by human hand

The patient was a 49-year-old woman. She had worked at a child welfare facility where she sustained a wound to the left side of her upper eyelid after it was scratched by a child facility resident's finger. One month had passed since the injury when she visited our hospital. The initial treatment was not appropriate, and her left eyelid could not be lifted at all. A secondary surgery was performed 2 months after the injury when the scar contracture was most strong. Such corrective surgery for posttraumatic eyelid is typically scheduled after at least 6 months when the scar tissue softens from the viewpoint of wound healing. However, this case indicated the importance of determining the appropriate timing of surgery in consideration of the patient's background and the scientific basis. Reports of sharp traumatic ptosis are rare, and this is the first reported case of traumatic ptosis resulting from a scratch caused by human hand.

Spontaneous resolution of isolated neurogenic blepharoptosis after blunt trauma: A case report and literature review

RATIONALE

Complete isolated neurogenic blepharoptosis caused by blunt trauma is a sporadically reported rare entity and there is no consensus regarding the optimal treatment. We would like to report a rare case of isolated neurogenic blepharoptosis secondary to eyelid trauma with spontaneous recovery occurring within 4 weeks.

PATIENT CONCERNS

A previously healthy 47-year-old man presented with blepharoptosis in the right eye after eyelid trauma.

DIAGNOSIS

At presentation, visual acuity in both eyes was 20/20, and intraocular pressure was within the normal limits. Physical examination showed unilateral ptosis; magnetic resonance imaging (MRI) showed hematoma in the right frontal sinus. No intracranial lesions were observed and the pupillary reactions were normal. The remainder of the examination was unremarkable with full ocular motility. He was diagnosed with an isolated neurogenic blepharoptosis.

INTERVENTION AND OUTCOMES

He was managed conservatively without any specific treatment. Four weeks later, the patient had normal, symmetric lid height, and levator function was completely restored.

LESSONS

Isolated neurogenic blepharoptosis can be caused by blunt trauma, which might cause injury to the terminal branch of the oculomotor nerve. In this case, no special treatment was required, and complete resolution was achieved within 4 weeks.

Traumatic Ptosis: Evaluation of Etiology, Management and Prognosis

Introduction:

To investigate whether a systematic approach to subgrouping traumatic ptosis according to etiology can allow for better tailoring of prognosis and treatment.

Methods:

Retrospective chart review of patients with trauma-related blepharoptosis managed by Oculoplastic surgery specialists at an academic medical center from January 1995 to November 2015. Injury mechanism, eyelid position and function, interventions, and outcomes were reviewed.

Results:

Of 648 patients treated for blepharoptosis, 55 (8.5%) were traumatic. Careful review revealed 4 subcategories of traumatic ptosis cases: aponeurotic (n = 16), myogenic (n = 18), neurogenic (n = 7), and mechanical (n = 14). Margin reflex distance (MRD1) at presentation was significantly worse for the myogenic subtype (-0.59 mm, SD ±2.09, P = 0.046). The aponeurotic subtype had the best average levator function at presentation (14.29 mm, SD ±2.05), while myogenic had the worst (8.41 mm, SD ±4.94) (P = 0.004). Thirty-five (63.6%) patients were managed surgically. Final MRD1 was significantly different for each subtype (P = 0.163), with aponeurotic 2.63 mm (SD ±1.01), myogenic 1.29 mm (SD ±2.24), neurogenic 1.79 mm (SD ±2.48), and mechanical 2.31 mm (SD ±1.18). There was a significant increase in MRD1 from presentation to final follow up across all groups (P < 0.05).

Conclusion:

Traumatic ptosis is heterogenous. Systematically evaluating traumatic ptosis cases by trauma mechanism can guide decisions about prognosis and management. Two-thirds of cases were treated surgically, with most patients responding well to conjunctiva-Müller resection or external levator advancement. While all subgroups demonstrated improvement in MRD1 at final follow up, aponeurotic cases had the best prognosis, while myogenic fared the worst and required the longest for maximal recovery.