This document discusses the examination of eyelids and ptosis. It outlines how to inspect eyelid position, eversion of the upper eyelid, and demonstration of ptosis evaluation and surgery. Examination of the eyelids involves inspection of position, palpebral fissure width, and skin. History should include onset, duration, laterality, worsening, diplopia, weakness and trauma. Examination evaluates head posture, scars, laxity, telecanthus and epicanthus. Ptosis is measured by marginal reflex distance, vertical fissure height, levator function and lid crease level. Levator function classifies ptosis as mild, good, fair or poor. Decision making depends on

1. Eye lid

2. ILOs
Inspect position of the eyelids (Normal lid position, lid retraction,
ptosis, Entropion, Ectropion, Lagophthalmos) Identify signs of previous
trachomatous infection.
Examine the lid by Penlight, including upper lid eversion.
Demonstrate Ptosis evaluation, surgery for good and poor Levator
function.
Review demonstrative videos for surgical correction of entropion,
ectropion, trichiasis and ptosis.

3. Examination Methods
The eyelids are examined by direct inspection under a bright light.
A slit lamp may be used for this purpose. Bilateral inspection of the
eyelids includes the following aspects:
Eyelid position: Normally the margins of the eyelids are in contact with
theeyeball and the puncta are submerged in the lacus lacrimalis.
 Width of the palpebral fissure: When the eye is open and looking
straightahead, the upper lid should cover the superior margin of the
cornea by about 2 mm.

4. Skin of the eyelid: The skin of the eyelid is thin with only a slight
amount ofsubcutaneous fatty tissue. Allergic reaction and inflammation
can rapidly cause extensive edema and swelling

7. History
• Age of onset
• Duration
• Unilateral/ bilateral
• Whether ptosis worsen through the day
• Diplopia
• Muscle weakness
• Trauma / surgery

8. Examination
• Head posture
• Scar marks
• Lid skin laxity
• Telecanthus, epicanthus inversus

9. Visual Acuity
 Best corrected visual acuity should be
assessed to record any amblyopia if
present, especially in cases of congenital
ptosis.
 Cycloplegic test refraction is indicated in
all children with ptosis since it is known
that a significant number have
anisometropia due to astigmatism on the
ptotic eye.

10. Pupil examination
• Horner syndrome
• Third nerve palsy
Ocular motility
• Importance in myogenic ptosis
• Third nerve palsy
• Presence of strabismus , that should be corrected
before the correction of the ptosis

11. Measurements
1. Marginal reflex distance
2. Vertical fissure height
3. LPS action
4. Lid crease level

12. Amount of ptosis = 4 – Marginal Reflex Distance ( MRD)

13. Vertical Fissure Height
Central palpebral fissure height is measured
in primary gaze and compared with the
normal eye in unilateral ptosis.

14. Levator Function Test
 Excursion of upper eyelid from extreme
downgaze to extreme upgaze is a measure of
LPS function, blocking the action of frontalis
muscle (Berkes method).
• Normal (15 mm)
• Good (12-15 mm)
• Fair (5-11 mm)
• Poor (4 mm or less)

15. Lid Crease Distance
• 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 5-7 mm
Women 8-10 mm
• Crease is absent in congenital ptosis and
higher in aponeurotic ptosis.

16. Bells phenomenon
 The eyes moves generally upwards and outwards
on eyelid closure.

17. Phenylephrine Test
• It is a useful test in patient with mild
ptosis or ptosis due to Horner syndrome.
• Instill 2.5 % phenylephrine drop and the
patient is reexamined after 5 minutes.
• A rise in the MRD 1 by 1.5 mm or
greater is considered a positive test.
• This indicates that Muller muscle is
viable so the operation to resect muller
muscle is beneficial.

19. Decision Making

20. Ptosis
Mild
Phenylephrine
+ve
Mullerectomy
Phenylephrine
-ve
Fasanella
Servat
Moderate
Levator
Resection
Severe
Frontalis
Sling