1. Shake hands to exclude myotonia (Note slow release of grip)
2. Observe:
3. Face for asymmetry
- Globes for position and asymmetry
- Lids for position, asymmetry or scars
- Pupils anisocoria or heterochromia
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
- Ask patient to close eyes, gently at first, and then to squeeze eyes shut
- Try to open patient’s eyes against resistance
- Ask patient to keep looking upward at a target held superiorly
- Ask patient to look rapidly from downgaze to a target held in primary position
- Ask patient to simulate chewing and to move jaw from side to side
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
- Anisocoria (in response to light and near)
- Iris heterochromia
19. Full cranial nerves assessment
- Second, Third, Fourth, Fifth, Sixth, Seventh Cranial Nerve
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
- Levator resection
- Levator advancement
- Frontalis sling
- 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.