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
ptosis examination
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.