This document discusses examination of ptosis, or drooping of the upper eyelid. Examination includes evaluating the degree of ptosis, measuring the margin reflex distance, and assessing levator function. Ptosis is graded as mild, moderate, or severe depending on the amount the eyelid covers the cornea. Levator function is measured using Burke's method and graded as normal, good, fair, or poor based on eyelid excursion. Special tests like Tensilon or Phenylephrine may be used and photographic records should be taken.

1. 3rd year bsc optometry
NETHRADHAMA SCHOOL OF OPTO

2. Introduction
 Abnormal drooping of the upper eyelid is called Ptosis.
 Normally, upper eyelid covers about upper one sixth of
cornea, i.e., about 2mm. Therefore in ptosis it covers more
than 2mm.

3. Examination
 Examination include
 Evaluation
 Measurement of amount(degree) of ptosis
 Margin reflex distance
 Assessment of levator function
 Special investigation
 Photographic record

4. Evaluation
 Pseudoptosis (simulated ptosis) should be excluded
on inspection.
 Points to be observed:
 Whether ptosis is unilateral or bilateral.
 Function of orbicularis oculi muscle.
 Eyelid crease is present or absent.
 Jaw-winking phenomenon is present or not.
 Associated weakness of any extraocular muscle.
 Bell’s phenomenon( up and outrolling of the eyeball during
forceful closure) is present or absent.

5. Measurement of amount (degree) of
ptosis
 In unilateral cases, difference between the vertical
height of the palpebral fissures of the two sides
indicates the degree of ptosis.
 In bilateral cases it can be determined by
measuring the amount of cornea covered by the
upper lid and then subtracting 2mm.
 Ptosis is graded depending upon
its amount as :
 Mild ptosis: 2mm
 Moderate ptosis: 3mm
 Severe ptosis: 4mm

6. Margin reflex distance
 Margin reflex distance (MRD) refers to the
distance between the upper lid margins and
corneal light reflex .
 Normal value of MRD is 4-5 mm.

7. Assessment of levator function
 It is measured by the lid excursion caused by LPS
muscle (burke’s method).
 Patient is asked to look down, and thumb of one
hand is placed firmly against the eyebrow of the
patient by the examiner.
 Then the patient is asked to look up and the
amount of upper lid excursion is measured with a
ruler held in the other hand by the examiner
 Levator function is graded as follows:
 Normal: 15mm
 Good: 8mm or more
 Fair: 5-7 mm
 Poor: 4mm or less

9. Special investigation
 Tensilon test is performed when myasthenia is suspected.
 Phenylephrine test is carried out in patients suspected of
Horner’s syndrome.
 Neurological investigations may be required to find out the
cause in patient with neurogenic ptosis.

10. Photographic records
 Photographic records of the patient should be
maintained for comparison.
 Photographs should be taken in primary position
as well as in up and down gazes.