Ptosis: Clinical stepwise approach for examining the lids

Hints for Your clinical stepwise 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 frontalis

• 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 the position of the upper lid crease
8. Measure the levator function:

• Inhibit frontalis by placing a thumb on the brow      

9. Measure any lagophthalmos:

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

10. Assess orbicularis function and Bell’s phenomenon

• Try to open the 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 the patient to look rapidly from downgaze to a target held in primary position      

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

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

14. Slit-lamp examination of the 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 (microphthalmos, phthisis)
• Incorrect globe position (hypo or hypertropia)
• Brow ptosis
• Contralateral lid retraction Contralateral large globe

23. Management :

Depends upon the 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 the margin (Male > Female)

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