Ptosis: Clinical stepwise approach for examining the lids

Hints for Your clinical step wise approach for examining the lids(with particular regard to Ptosis):

1. Shake hands to exclude myotonia (Note slow release of grip)
2. Observe:
3. Face for asymmetry

4. Brow for overactive forntalis

• Globes for position and asymmetry
• Lids for position, asymmetry or scars 
• Pupils anisocoria or heterochromia

5. Measure palpebral aperture
6. Measure upper margin reflex distance
7. Measure position of upper lid crease
8. Measure levator function:

• Inhibit frontalis by placing a thumb on the brow      

9. Measure any lagophthalmos:

• Ask patient to close eyes, gently at  first, and then to squeeze eyes shut      

10. Assess orbicularis function and Bell’s phenomenon

• Try to open patient’s eyes against resistance      

11. Assess fatiguability over 1 min  for worsening of ptosis

• Ask patient to keep looking upward at a target held superiorly      

12. Examine for Cogan’s twitch Any overshoot      

• Ask patient to look rapidly from downgaze to a target held in primary position      

13. Assess for jaw-winking For any change in ptosis

• Ask patient to simulate chewing and to move jaw from side to side      

14. Slit-lamp examination of lid and subtarsal conjunctiva  for Inflammation,masses or scars.
15. Check corneal sensation and Bell’s phenomena (Very Prognostic for any lid surgery)
16. Examine ocular motility  for:

• motility abnormality in 9 cardinal positions
• change in ptosis with ocular motility       

17. Examine pupils  for:

1. Anisocoria (in response to light and near)
2. Iris heterochromia

18. Consider: ice-pack test for MG
19. Full cranial nerves assessment

• Second, Third, Fourth, Fifth, Sixth, Seventh Cranial Nerve

20. Examination of fundus
21. Systemic review (myopathy, fatiguability).
22. Exclude pseudoptosis:  

• Excessive skin (dermato or blepharochalasis)
• Inadequate globe size (micropthalmos,phthisis)
• Incorrect globe position (hypo or hypertopia)
• Brow ptosis
• Contralateral lid retraction Contralateral large globe

23. Management :

Depends upon degree of ptosis and residual Levator function and the cause of ptosis

• Levator resection
• Levator advancement
• Frontalis sling

24. Normal lid measurements gift:

• Palpebral aperture 8-11 mm (Female > Male)
• Upper margin reflex distance 4–5 mm
• Upper lid excursion (levator function) 13–16 mm
• Upper lid crease position 8-10 mm from margin (Male > Female)

About the author : "Dr. Reda Gomah is a Consultant Ophthalmologist in Egypt.