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Answers: 2009 Series -  August 11, 2009 Lecture 21 of 52  NEXT»

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This 3-year-old boy has had a droopy right upper lid since birth. His motor development has been normal otherwise. He does not have an abnormal head posture. Refraction is OD +2.50 and OS + 3.00. The eyes appear to be normal, but there is an obvious right hypotropia and right upper lid ptosis. The right upper lid is being held up by the mother because it remains ptotic. There is no history of trauma.

1. The most important test that can be done in the clinic is:

c -- observation of the right eye during forced lid closure

When a person forcefully closes the lids, a reflex upward movement of the eye normally occurs as a type of protective measure.  This is called the Bell phenomenon.  When present it means that the muscles that elevate the eye are innervated and that the defect is supranuclear.

2. A likely diagnosis in this boy is:

e -- none of the above

None of the answers given make much sense, so we will tell you -- if you have not already guessed.  This is a double elevator palsy.

3. If the Bell reaction were intact, this would be:

a -- supranuclear palsy

If the Bell reaction were intact it means that the elevating muscles are functioning in the right eye and that they respond on a reflex level. 

Double elevator palsy is a difficult type of strabismus to manage.  Depending on the amount of elevation remaining in the involved eye and the state of the inferior rectus, contracted or not, treatment is a vertical recess/resect or a transfer of the horizontal muscle to the superior rectus.  Any persisting ptosis is corrected at a second procedure with special care to under correct if the Bell is absent.

 


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