Abstract
Purpose
This study reports two cases of malaria-induced ptosis with surgical resolution.
Observations
Case 1 is a 27-year-old female with a past medical history of bilateral ptosis following childhood malaria. Case 2 is a 63-year-old male with left-side ptosis following adult-onset malaria. Both patients required revision surgery but ultimately did well after surgical correction.
Conclusions and importance
Malaria-induced ptosis is a rare entity that should be suspected in patients presenting with ptosis following infection and treatment of malaria. It is unknown if the patients’ malaria results from malarial infection, antimalarial treatment, or a combination of both. Surgical correction is the mainstay of treatment.
1
Introduction
Blepharoptosis most commonly arises from myogenic, involutional, neurogenic, mechanical, traumatic, and congenital causes. Less commonly, ptosis has been documented to arise from infectious sources. This study presents two cases of patients with malaria-induced ptosis.
2
Case reports
2.1
Case 1
A 27-year-old female was referred for evaluation of painless bilateral ptosis that occurred following an episode of childhood malaria. Her eyelids were in a normal position before developing an acute episode of malaria during childhood. The ptosis was visually significant and required her to adopt a chin-up head position. She denied diplopia and systemic weakness. Her family history was negative for ptosis or other ocular or systemic disease. Ocular history included refractive amblyopia. Past medical history was negative for neurological disease, and a review of systems was negative.
An ophthalmologic exam revealed a visual acuity of 20/50 in the right eye (oculus dextrus – OD) and 20/60 in the left eye (oculus sinister – OS). Pupils were equally round, briskly reactive, and 4 mm in room lighting in both eyes (oculus uterque – OU). Extraocular movements revealed a −1 deficit in the superior temporal directions bilaterally. An external exam revealed bilateral ptosis with marginal reflex distance 1 (MRD1) of −2 mm right upper eyelid and −3 mm left upper eyelid ( Fig. 1 ). Eyelid excursion was 7 mm in the right upper lid and 8 mm in the left upper lid with normal fornices and no lagophthalmos of either eye. Each eyelid had an upper lid crease that was present but effaced. There was no response following the administration of 10% phenylephrine to the right eye. Eversion of the eyelids showed no scarring. A corneal exam revealed superior circular scars at the limbus with pitting OU. All other slit lamp exam (SLE) findings were unremarkable. The fundoscopic exam was unremarkable. The Humphrey visual field revealed obscuration of the superior visual fields that resolved when the lids were manually elevated to a normal position.
The patient elected to undergo bilateral upper eyelid external levator advancement four months later. Although this procedure improved the ptosis in both eyes, the patient had residual ptosis with a marginal reflex distance (MRD) of zero and elected to undergo bilateral silicone frontalis sling placement two years later. At her one-month surgical follow-up, she reported symptom improvement and denied any eye pain. Examination revealed a marginal reflex distance of +1, which increased to +4 with brow activation, good lid symmetry, and no lagophthalmos ( Fig. 1 ).
2.2
Case 2
A 63-year-old male was referred for severe ptosis of the left upper eyelid. The ptosis began in 2012 after a hospitalization for malaria in Cameroon, during which he was treated with chloroquine. He described needing restraints to prevent him from rubbing his left eye during his hospitalization. The patient denied diplopia, floaters, and orbital trauma.
Family history was negative for ptosis or other ocular or systemic disease. Ocular history was negative. Past medical history was positive for human immunodeficiency virus (HIV) and impaired glucose tolerance. The review of systems was negative.
An ophthalmologic exam revealed a visual acuity of 20/25 OU. Intraocular pressure was 15 mm Hg OD and 16 mm Hg OS. Pupils were equally round, prompt, and 3 mm in room lighting OU. Extraocular movements were full. Perimetry demonstrated a visual field defect inferior to the horizontal meridian with >50° improvement when the eyelid was manually raised to a normal position in the left eye.
An external examination revealed a 5 mm left upper eyelid ptosis with an MRD1 of −3 mm. Lid excursion was 10 mm right upper eyelid and 3 mm left upper eyelid with normal fornices and no lagophthalmos OU ( Fig. 2 ). Eyelid creases were present and symmetrical, but the left eyelid crease was effaced. The patient used his frontalis muscle to elevate the left eyelid. The remainder of the eye exam was unremarkable.
