bilateral ptosis

If you find bilateral ptosis in the patient examined
3 diagnosis must blink in your brain
1) GBS (guillain barre syndrome) if + complete opthalmoplegia then = Miller fischer
Check for ataxia and opthalmoplegia for miller fischer , areflexia for GBS
2) Myasternia grvis demonstrate eyelid fatigue, proximal myopathy fatigue and verbal fatigue(ask pt to count 1-50 continuously)
3) Dystrophy myotonica-demonstrate percussion myotonia at palmar and tongue.
or rare causes-oculopharyngeal dystrophy,
third nerve palsy caused by oculomotor nucleus lesion (rare), multiple sclerosis also may considered but normally presented with internuclear opthalmoplegia and optic atrophy.

Experience in exam:
a lady presented with weakness of bilateral lower limb. Please examine the lower limb.
surprisingly normal tone and power 5/5, reflex absent on jendrassic maneuver
request for gait , cerebellar sign , sensation and gait.
Examiner not keen.
Request to look at the face.
A lady with eyes closed, ask to open eyes demonstate eyes movement -complte opthalmoplegia
want to demonstrate ataxia. stopped by examiner
ask what else to consider -want to demonstrate fatigue of muscle-proceed no fatigue of muscle.
Final diagnosis- miller fischer
ask about feature of miller fischer?
give the famous three-opthalmoplegia, ataxia and areflexia.

Approach patient with unilateral ptosis

When You see patient with partial ptosis, One of the commonest patient found in neuro station. See whether it is unilateral or bilateral.
for unilateral
The second thing to do is look directly to pupil size,
If pupil size is small then you should enter Horner syndrome protocol which i will explain in my next explaination.
If pupil size is big then , it is third nerve palsy(a surgical third nerve palsy) most likely posterior communicating artery aneurysm.
If pupil size is normal then most likely (medical third nerve palsy) most likely diabetic or vasculitis cause and etc.
Third please demonstate the eye movement to see whether got other nerve involvement.etc 4th or 5th
If got 3rd ,4th and 5th, consider Graves disease(lid retraction )
cavernous sinus 3th 4th 6th and 5th may coexixst(demonstrate corneal reflex)
tolosa hunt (pain with no redness)