Management of Severe Bilateral Ptosis in a Patient With Midbrain Infarction: A Case Report
A 73-year-old woman with a previous history of hypertension and myocardial infarction was admitted to the neurosurgery department via the emergency room because she could not open her eyes and had altered consciousness. She was diagnosed as acute infarction on the bilateral paramedian midbrain including bilateral cerebral peduncle by magnetic resonance imaging ().\nAfter conservative management, her conscious level improved but she was still unable to open her eyes. Examination revealed pronounced bilateral ptosis, with left and right pupil diameter of 6 mm and 3 mm, respectively. The left pupil was not reactive to light. There was marked limitation of adduction, moderate limitation of depression and elevation in the movement of both eyeballs. Abduction was normal. There were no other findings of central nervous system disease that could cause ptosis from brain imaging, and no evidence of other orbital disease causing ptosis in an ophthalmologic examination. Muscle strength rated using the Medical Research Council Scale was grade 3/5 in both upper limbs and 4/5 in both lower limbs. She was transferred to the department of rehabilitation medicine for intensive rehabilitation management. Participation in the rehabilitation programs was difficult due to continuing inability to open her eyes.\nWe tried taping her lids with Micropore tape and used lubricants to prevent exposure keratopathy. However, this method was less efficient due to blinking. Eye-putti eyelash glue-mediated fixation of the upper eyelid to the supraorbital structures was ineffective. The patient became frustrated and depressed, and refused to participate in the rehabilitation programs.\nAfter about 6 months from the stroke attack, bilateral ptosis was not improved at all. Consultations were held with the department of plastic surgery with the aim of considering surgical treatment, with the thinking that it would be hard to anticipate spontaneous recovery. Plastic surgeons planned the surgical correction of bilateral ptosis and the Muller's muscle procedure was done, considering the benefits and losses.\nAfter surgical correction, the upper lid height was improved from 7.0 to 4.0 mm on the right side and from 7.0 to 4.5 mm on the left side. The palpebral fissure height was 3.5 mm on the right side and 3.0 mm on the left side (). The patient was quite contented with the effect of the operation and actively participated in the rehabilitation programs. She was able to perform activities of daily living and mobility with minimal assistance. The effect of surgical correction has persisted for at least 6 months.