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:
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:
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:
- Anisocoria (in response to light and near)
- Iris heterochromia
18. Consider: ice-pack test for MG
19. Full cranial nerves assessment
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:
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.
