Chief Complaint: Drooping of the left upper lid.
History of Present Illness: A 7 month-old male patient was referred to the Oculoplastics Clinic at the University of Iowa by his pediatric ophthalmologist for evaluation of left upper eyelid ptosis. The mother stated that the eyelid had been "droopy" since birth and that it appeared to be getting progressively worse. She denied any alteration of eyelid position with feeding. He had been followed closely by his pediatric ophthalmologist and had previously shown no signs of amblyopia of the left eye. However, at his most recent visit he appeared to be favoring his right eye, which prompted the referral to the Oculoplastics service. The mother had also been advised to begin part time occlusion of the right eye to address the developing amblyopia.
Medical History: The patient was born full term after an uncomplicated pregnancy and delivery. There was no history of birth trauma. He had reached all of his developmental milestones.
Allergies: No known medication allergies.
Family history: There was no history of congenital ptosis in the family.
Social history: The patient lives and is cared for by both parents.
Visual Acuity (without correction): Fixes and follows OD, Fixes and follows OS. He had demonstrated a fixation preference for the right eye at his recent pediatric ophthalmology exam.
Pupils: No anisocoria and no relative afferent papillary defect.
Motility: Full OU.
External Exam: Ptosis of the left upper eyelid. There was no variability of eyelid position with feeding or in different gaze positions. There were no palpable masses in the upper eyelid (see Figure 1).
Normal excursion and velocity
Anterior segment exam: Normal conjunctiva, corneas, anterior chambers, irides and lenses OU.
Dilated funduscopic exam: Normal macula, vasculature and periphery OU.