Levator Palpebrae Superiorus Muscle

Part 1 anatomy

Origin: Sphenoid bone

Insertion: Tarsal plate, Upper eyelid
Action: Retracts (or elevates) eyelids
Nerve supply: Oculomotor nerve

Part 2: Disease

Horners syndrome

Horner's syndrome is a combination of symptoms that arises when a group of nerves known as the
sympathetic trunk is damaged. The signs and symptoms occur on the same side as the lesion of the
sympathetic trunk. It is characterized by miosis (a constricted pupil), partial ptosis (a weak, droopy
eyelid), apparent anhidrosis (decreased sweating), with or without enophthalmos (inset eyeball).

The nerves of the sympathetic trunk arise from the spinal cord in the chest, and from there ascend to
the neck and face. The nerves are part of the sympathetic nervous system, a part of the autonomic (or
involuntary) nervous system. Once the syndrome has been recognized, medical imaging and response to
particular eye drops may be required to identify the location of the problem and the underlying cause.
Pathophysiology

Horner syndrome is due to a deficiency of sympathetic activity. The site of lesion to the sympathetic
outflow is on the ipsilateral side of the symptoms. The following are examples of conditions that cause
the clinical appearance of Horner's syndrome:

First-order neuron disorder: Central lesions that involve the hypothalamospinal tract (e.g.
transection of the cervical spinal cord).

Second-order neuron disorder: Preganglionic lesions (e.g. compression of the sympathetic chain
by a lung tumor) that releases acetylcholine.

Third-order neuron disorder: Postganglionic lesions at the level of the internal carotid artery
(e.g. a tumor in the cavernous sinus or a carotid artery dissection) that releases norepinephrine.

Partial Horner's syndrome: In case of a third-neuron disorder, anhidrosis is limited to the middle
part of the forehead or can be absent, resulting in a partial Horner's syndrome.

If someone has impaired sweating above the waist affecting only one side of the body, yet they do not
have a clinically apparent Horner's syndrome, then the lesion is just below the stellate ganglion in the
sympathetic chain.

Part 3: How to diagnose the disease

Three tests are useful in confirming the presence and severity of Horner syndrome:

Cocaine drop test: Cocaine eyedrops block the reuptake of post-ganglionic norepinephrine
resulting in the dilation of a normal pupil from retention of norepinephrine in the synapse.
However, in Horner's syndrome the lack of norepinephrine in the synaptic cleft causes mydriatic
failure. A more recently introduced approach that is more dependable and obviates the
difficulties in obtaining cocaine is to apply the alpha-agonist apraclonidine to both eyes and
observe the increased mydriatic effect (due to hypersensitivity) on the affected side of Horner
syndrome (the opposite effect to what the cocaine test would produce in the presence of
Horner's).

Paredrine test: This test helps to localize the cause of the miosis. If the third order neuron (the
last of three neurons in the pathway which ultimately discharges norepinephrine into the
synaptic cleft) is intact, then the amphetamine causes neurotransmitter vesicle release, thus
releasing norepinephrine into the synaptic cleft and resulting in robust mydriasis of the affected
 pupil. If the lesion itself is of the third order neuron, then the amphetamine will have no effect
and the pupil remains constricted. There is no pharmacological test to differentiate between a
first and second order neuron lesion.

Dilation lag test

It is important to distinguish the ptosis caused by Horner's syndrome from the ptosis caused by a lesion
to the oculomotor nerve. In the former, the ptosis occurs with a constricted pupil (due to a loss of
sympathetics to the eye), whereas in the latter, the ptosis occurs with a dilated pupil (due to a loss of
innervation to the sphincter pupillae). In a clinical setting, these two ptoses are fairly easy to distinguish.
In addition to the blown pupil in a CNIII (oculomotor nerve) lesion, this ptosis is much more severe,
occasionally occluding the whole eye. The ptosis of Horner syndrome can be quite mild or barely
noticeable (partial ptosis).[citation needed]

When anisocoria occurs and the examiner is unsure whether the abnormal pupil is the constricted or
dilated one, if a one-sided ptosis is present then the abnormally sized pupil can be presumed to be on
the side of the ptosis.[citation needed]