Bilateral Ptosis: A Rare Presentation of Hydrocephalus
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To the Editor: Hydrocephalus is common in children and many varied causes are known to present with hydrocephalus ranging from congenital to infections, trauma, intraventricular bleed and tumors. In children it mainly manifests as bulging anterior fontanelle, macrocephaly, irritability, squinting of eyes, sun set sign, retraction of upper eyelids, vomiting, head-banging/ headache and in rare cases, as spastic paraplegia. Presentation as just ptosis is not very well known and there are only isolated case reports [1, 2, 3].
Bilateral ptosis as a presentation of hydrocephalus is not a well known described entity. Many pediatricians, pediatric surgeons, neurologists and neurosurgeons who deal with children suffering from hydrocephalus or are involved in following up of cases after shunt surgeries are not aware of this. In chronic hydrocephalus like in our case, a mild but sudden cerebrospinal fluid pressure change like that occurring at the time of minor head injury might induce functional impairment at the level of vulnerable periaqueductal structures and result in bilateral ptosis . The fibers for the levator palpebrae superioris are in the midline in front of the aqueduct, thereby making them more vulnerable. The other possibility is bending/stretching of the third nerve due to ventriculomegaly . Thus, it is important to realize that hydrocephalus can present as bilateral ptosis with or without weakness of ocular muscles.
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