general physical examination at age 15 years showed : height 113 cm ( <3 percentile ) , weight 10 kg ( <3 percentile ) , and head circumference 48 cm . he was apparently well up to the age of 18 months , later he developed failure to thrive , loss of hair , prominent eyes and joints , and senile appearance . systemic examination revealed craniofacial disproportion , mandibular and maxillary hypoplasia , prominent scalp veins ,  plucked bird appearance , thin lips , irregular and carious teeth , dental crowding , beaked nose , protruding ears with absent ear lobes , pyriform thorax , thin limbs , prominent and stiff joints , wide - based gait and shuffling , thin and high - pitch voice , incomplete sexual maturation , generalized alopecia , absence of subcutaneous fat , thin and wrinkled x - ray survey of the skeletal system showed radiolucent terminal phalanges ; coxa vulga , enlarged metaphysis of long bones , short dystrophic clavicle and osteoporosis [ fig . 4a and b ] . his best corrected visual acuity was 20/20 , n6 in both eyes ( be ) with -1.25 cylinders at 161 in right eye ( re ) and -0.50 cylinders at 41 in left eye ( le ) . external photograph of a 15-year - old hutchinson - guilford progeria male patient ( a ) showing disproportionately small face in comparison to the head , micrognathia , prominent eyes , both upper eyelids retraction , beaked nose , thin lips . ( b ) prominent scalp veins , alopecia with grey and sparse hairs , and protruding ears with absent earlobe ( a ) upper jaw dental crowding and dental caries ( b ) lower jaw dental crowding and dental caries prominent joints of hand ( red arrow : metacarpophalangeal joints , blue arrow : interphalangeal joints ) with loss of subcutaneous fat , nail dystrophy and sclerodematous skin ( a ) x - ray hand showing radiolucent terminal phalanges ( white arrow ) and osteoporotic changes ( black arrow ) . ( b ) x - ray shoulder joint showing dystrophic and short clavicle ( white arrow ) external ocular examination showed excessive wrinkling of forehead , superior sulcus deformity , inner canthal distance 20 mm , outer canthal distance 58 mm , inter - pupillary distance 40 mm , vertical palpebral fissure 12 mm , horizontal palpebral fissure 20 mm , lagophthalmos 2 mm , upper eyelid retraction 2.5 mm , upper lid lag in down gaze 5 mm , in be , nearly total loss of eyebrows and eyelashes , a few present eyelashes and eyebrows showed poliosis [ fig . thus , in view of the characteristic clinical presentation , imaging studies , and urine analysis , the child was diagnosed to have hgp syndrome . ( a ) both upper lids lag in down gaze , superior sulcus deformity , loss of eyelashes and eyebrows . the hgp syndrome is an extremely rare , fatal , genetic disorder of childhood with striking features resembling premature aging . the hgp syndrome has a slight male predilection ; the male - to - female ratio is 1.5:1 . the incidence of the hgp syndrome has been estimated at 1 in 4 - 8 million live births . the clinical diagnosis of the hgp syndrome is based on recognition of characteristic features and exclusion of other progeroid syndromes . children with progeria usually have a normal physical appearance in early infancy . at approximately one to two years of age , affected children develop severe growth retardation , resulting in short stature , low weight and delayed anterior fontanel closure . these children develop a distinctive facial appearance characterized by a disproportionately small face in comparison to the head , micrognathia , delayed dentitions , dental malformation and crowding , beaked nose , prominent eyes , nasolabial circumoral cyanosis and loss of scalp hair , eyebrows , and eyelashes . other characteristic features include generalized atherosclerosis , cardiovascular diseases and stroke , hip dislocations , prominent scalp veins , lipodystrophy , dystrophy of nails , joint stiffness , skeletal defects , and/or other abnormalities . the most common reported ocular features are prominent eyes , loss of eyebrows and eyelashes , and lagophthalmos . other rare ocular manifestations of the hgp syndrome are bands of skin running from the upper lid to the cornea , senile ectropion , ptosis with marcus - jaw - winking phenomenon , dry - eye syndrome , corneal dryness , keratopathy , iridocorneal adhesions , corneal opacities , corneal clouding , cataract , strabismus , irregular nystagmoid movements , myopia , hyperopia , retinal arteriolar narrowing and tortuosity , and retinal angiosclerosis.[468 ] many of these findings are based on individual case reports and are absent in the present case . the ophthalmic anthropometric measurements such as horizontal palpebral fissure length , interpupillary distance , inner canthal distance , outer canthal distance in our patient are less than aged - matched normal indian values . eyelid retractions , lagophthalmos , lid lag in down gaze , are due to inelastic and taut skin . poor pupillary dilatation may be due to ischemic changes in the iris muscles secondary to microvascular insufficiency induced by atherosclerosis , however , visible atrophic changes were absent on slit - lamp examination in our patient . in the hgp syndrome eyes looks prominent ( pseudoproptosis ) probably due to lid retraction , although there is no true proptosis . interestingly , patients with hgps do not develop other ocular features associated with aging , such as presbiopia , arcus senilis or age - related macular degeneration . the hgp syndrome should be differentiated from other progeroid syndromes such as werner 's syndrome ( adult progeria ) , wiedemann - rautenstrauch syndrome ( neonatal progeria ) , hallermann - streiff syndrome , mandibuloacral dysplasia , cockayne 's syndrome , rothmund - thomson syndrome , metageria and acrogeria . the average life expectancy is 13 years , with an age range of 7 - 27 years . the most common cause of death is myocardial infarction or congestive cardiac failure , secondary to widespread atherosclerosis . at present ophthalmic manifestations / signs / features / findings  ,  eye  ,  premature ageing syndrome  and various combinations thereof . all cross - references in citing literature were included in our search and referenced . to the best of our knowledge , lid retraction , lid lag in down gaze , superior sulcus deformity and poor pupillary dilatation