This document provides information on how to evaluate blepharoptosis (drooping of the upper eyelid) clinically. It discusses classifications of ptosis as congenital or acquired. Evaluation involves measuring eyelid positions, assessing levator function and other muscle movements. Tests like phenylephrine, ice and edrophonium help determine the cause. Thorough history, examination and documentation including photographs are needed before considering surgical management of ptosis.

1. HOW TO EVALUATE ITS CLINICALASPECT
Dr. Neeraj Agarwal
GMC, KOTA

2.  Blepharoptosis is derived from the greek word
blepharon=eyelid and ptosis= falling.
 So blepharoptosis means drooping of upper
eyelid.
 Blepharoptosis often abbreviated as ptosis.
 Normally upper eyelid covers 1/6th of cornea
i.e. 2mm
 Therefore in ptosis it covers more than 2mm.

3. CLASSIFICATION
 CONGENITAL
 ACQUIRED

4. CONGENITAL
 Simple ptosis
 With SR weakness
 With blepharophimosis syndrome
 Synkinetic ptosis – Marcus Gun Jaw Winking
ptosis, Misdirected third nerve syndrome

5. ACQUIRED PTOSIS
 Neurogenic- 3rd nerve palsy, horner syndrome.
 Myogenic- myasthenia gravis, Myotonic
dystrophy.
 Aponeurotic- involutional, post surgical
 Mechanical- tumour, swelling.

6. Pseudoptosis
 Ipsilateral hypotropia
 Enopthalmos
 Dermatochalasis
 Double elevator palsy
 Brow ptosis
 Blepharospasm
 Contralateral lid retraction
 Contralateral exopthalmos

7. EVALUATION OF PTOSIS
 When patient enters examination room,
observation of the head posture with chin
elevation and frontalis overaction indicate
severe ptosis.

8. HISTORY
 Age of onset
 Duration
 Unilateral/bilateral
 Weather ptosis worsen through the day
 Diplopia
 Muscle weakness
 trauma/ surgery
 lid edema
 previous ptosis surgery

9.  Presence of any aberrant lid movements
 Weather eye movements are impaired
 Past medical history
 Current medications
 Family history
 Old photographs

10. EXAMINATION
 Head posture
 Periocular fullness
 Frontalis overaction
 Scar mark
 Lid skin laxity
 Telecanthus, epicanthus inversus

11.  Ocular Motility:
 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.
 Visual acuity
 Best-corrected visual acuity should be
assessed to record any amblyopia if present,
especially in cases of congenital ptosis

12.  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
corrected

13. MEASUREMENTS
 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.

14. 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)

15.  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

16.  Margin reflex distance 3(MRD 3)- the
distance between the corneal light reflex and
the centre of upper eyelid margin in extreme
upgaze.

17.  Palpebral fissure height (PFH)- MRD1 + MRD2.
 Central palpebral fissure height is measured in
primary gaze and compared with the normal eye in
unilateral ptosis.

18.  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.

19. Upgaze accentuate ptosis
Downgaze  lid
lag

20.  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.

21.  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.

22.  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.

23. 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).

25.  Grading of levator function-
 >15mm= normal
 >8 mm= good
 5-7 mm= fair
 <4 mm= poor

26. ILLIF’s test
 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.

27. Marcus gunn jaw winking
phenomenon
 Marcus Gunn jaw-winking phenomenon is the most
common form of congenital synkinetic neurogenic
ptosis.
 The unilaterally ptotic eyelid elevates with jaw
movements due to cross innervations between
oculomotor nerve and mandibular branch of
trigeminal nerve
 This synkinesis is best demonstrated by having the
patient move the jaw the opposite side.
 The internal pterygoid may be involved, but rarely.

28. Grading of marcus gunn
phenomenon
 Mild- maximum elevation of ptotic eyelid non-
ptotic position
 Moderate- maximum elevation goes upto
superior limbus
 Severe- maximum elevation beyond the
superior limbus with scleral show

30.  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
under correction.

31. BELLS PHENOMENON
 GRADING-
good= >2/3 of cornea disappears
fair= 1/3 – 2/3 of cornea disappears
poor= <1/3 of cornea disappears
 VARIANT-
Inverse- upward & inward
Reverse- downward & outward
Preverse- different directions

32. BELLS PHENOMENON

33.  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.

34.  Look for any associated mass lesion causing
mechanical ptosis

35.  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

36.  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
blepharoptosis.

37. Edrophonium test
• 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

38. ICE TEST
 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.

39. Ice test

40.  Photographic documentation- it is the most
important aspect of ptosis evaluation. Review
of old photographs gives clue to the duration
and nature of ptosis.

41. So we should examine case of ptosis
carefully before proceeding for surgical
management, to avoid any post operative
surprise.

42. THANK YOU