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HOW TO EVALUATE ITS CLINICALASPECT
Dr. Neeraj Agarwal
Blepharoptosis is derived from the greek word
blepharon=eyelid and ptosis= falling.
So blepharoptosis means drooping of upper
Blepharoptosis often abbreviated as ptosis.
Normally upper eyelid covers 1/6th of cornea
Therefore in ptosis it covers more than 2mm.
EVALUATION OF PTOSIS
When patient enters examination room,
observation of the head posture with chin
elevation and frontalis overaction indicate
Age of onset
Weather ptosis worsen through the day
previous ptosis surgery
Presence of any aberrant lid movements
Weather eye movements are impaired
Past medical history
Lid skin laxity
Telecanthus, epicanthus inversus
Importance in myogenic ptosis,
To R/O 3rd nerve palsy
presence of strabismus, especially vertical
strabismus entails that it be corrected prior to
the correction of the ptosis.
Best-corrected visual acuity should be
assessed to record any amblyopia if present,
especially in cases of congenital ptosis
Refraction- Cycloplegic test refraction is
indicated in all children with ptosis since it is
known that a significant number have
anisometropia primarily due to astigmatism on
the ptotic side.
Any significant refractive error should be
Margin reflex distance 1(MRD 1)- After
shining the torchlight in the patient eye, the
distance between the corneal light reflex to the
centre of the upper lid margin is measured.
Normal value is 4- 4.5mm.
Marginal reflex distance
• Distance between upper lid
margin and light reflex (MRD)
• Mild ptosis (2 mm of droop)
• Moderate ptosis (3 mm)
• Severe ptosis (4 mm or more)
Margin reflex distance 2 (MRD 2)- the
distance of corneal light reflex to the centre of
the lower eyelid margin in primary gaze.
Normal value is 5- 5.5mm
Margin reflex distance 3(MRD 3)- the
distance between the corneal light reflex and
the centre of upper eyelid margin in extreme
Palpebral fissure height (PFH)- MRD1 + MRD2.
Central palpebral fissure height is measured in
primary gaze and compared with the normal eye in
Also it is important to measure the PFH in
downgaze. As reduced ptosis/ lid lag is seen in
congenital ptosis as the dystrophic muscle
neither contracts nor relaxes.
Margin crease distance(MCD)- it is an
important anatomical landmark, which give
clue to levator action.
It is measured with patient looking down,
distance from the central eyelid margin to the
most prominent lid crease.
Normal value in Men 5-7mm, women 8-10mm
Crease is absent in congenital ptosis and
higher in aponeurotic ptosis.
An absent lid crease is often accompanied
by poor levator function.
If a lid crease is present, but higher than
normal and if there is a deeper upper lid
sulcus on that side these should be noted as
signs of levator disinsertion.
MARGIN LIMBAL DISTANCE- it gives the
degree of loss of Levator action.
It is measured as the distance between the
centre of upper lid margin to 6o’clock limbus
in extreme upgaze
Normally it is 9mm.
Levator function test- Excursion of
upper eyelid from extreme downgaze to
extreme upgaze is a measure of LPS
function, negating the action of frontalis
muscle (Berke’s method).
Grading of levator function-
>8 mm= good
5-7 mm= fair
<4 mm= poor
Used in children
Pt upper lid is everted in downgaze. On
looking up, the lid should return to normal
position if levator action is good.
Marcus gunn jaw winking
Marcus Gunn jaw-winking phenomenon is the most
common form of congenital synkinetic neurogenic
The unilaterally ptotic eyelid elevates with jaw
movements due to cross innervations between
oculomotor nerve and mandibular branch of
This synkinesis is best demonstrated by having the
patient move the jaw the opposite side.
The internal pterygoid may be involved, but rarely.
Grading of marcus gunn
Mild- maximum elevation of ptotic eyelid non-
Moderate- maximum elevation goes upto
Severe- maximum elevation beyond the
superior limbus with scleral show
BELL’S PHENOMENON- the eyes moves
generally upwards and outwards on eyelid
closure. It is extremely important in assessing
post-operative corneal complications.
Poor bells phenomenon invariably warrants
good= >2/3 of cornea disappears
fair= 1/3 – 2/3 of cornea disappears
poor= <1/3 of cornea disappears
Inverse- upward & inward
Reverse- downward & outward
Preverse- different directions
Corneal sensation- always check before
planning the surgery.
Schirmers test – to rule out dry eye disease
Pupillary abnormalities- miosis in horner’s
syndrome mydriasis in 3rd nerve palsy.
Look for any associated mass lesion causing
Cogan's lid twitch sign- may be seen when the
patient first looks down for a short period and
then look back to primary position.
The upper eyelid elevates excessively during
this upward movement.
This is interpreted as transient improvement in
lid strength after rest of the levator in
downgaze, followed by droop in the primary
position as the levator fatigues
Phenylephrine test- The function of muller’s is
tested by applying drops of 10% phenylephrine
to the eye on the side of blepharoptosis.
A rise in the MRDl of 1.5 mm or greater is
considered a positive test. This indicates that
Müller's muscle is viable. so operation to resect
muller’s muscle and conjunctiva can relieve
• Measure amount of ptosis or
diplopia before injection
• Inject i.v. atropine 0.5 mg
• Inject i.v. test dose of
edrophonium (0.2 ml-2 mg)
•inject remaining (0.8 ml-8mg)
if no hypersensitivity
Before injection Positive result
An ice pack is applied to the affected upper
eyelid for 5 minutes. A positive test is the
improvement of ptosis by > 2mm or more.
This transient improvement in ptosis is due to
the cold decreasing the acetylcholinesterase
break-down of acetylcholine at the
neuromuscular junction. More acetylcholine
collects in the junction and therefore increases
the muscle contraction.