This document provides a comprehensive evaluation of ptosis, detailing its definition, classifications (congenital and acquired), history taking, examination methods, measurement techniques, grading, and surgical treatments. Key aspects include differentiating between true ptosis and pseudoptosis, evaluating ptosis severity, and various diagnostic tests such as the ice test and tensilon test. The document concludes with references for further reading and documentation requirements for ptosis evaluations.

1. PTOSIS EVALUATION
DR. HUSSENI J. MJALIWA
RESIDENT OPHTHALMOLOGY-MUHAS

2. Layout
• Introduction
• Classification
• History taking
• Examination and measurement
• Grading of ptosis
• Treatment
• Reference

3. INTRODUCTION
• Ptosis – is the abnormal drooping of the upper eye lid in a primary position of
gaze
• Normally upper eyelid covers 1/6th of the cornea ,its about 1.5- 2mm
• In ptosis it covers more than 2mm

4. • Before counting to any thing you have to role out pseudoptosis on inspection
Pseudoptosis -Microphthalmia ,Phthisis bulbs, Enophthalmos, dermatochalasis ,
eyelid retraction

6. Classification of ptosis
Congenital
Acquired
• Neurologic
• Myogenic
• Mechanical
• Aponeurotic
• Traumatic
Pseudoptosis

7. Congenital
• Simple congenital ptosis- not associated with a any anomaly, congenital
associated with weakness of levator palpebral superior muscle(maldevelopment)
• Blepharophimosis syndrome – congenital
ptosis+blephrophimosis+telecanthus+epicathus inversus.
• Congenital synkinetic ptosis – Marcus Gunn jaw phenomenon,(condition of
misdirection of 3rd nerve)

8. Acquired
 Neurogenic
• 3rd nerve palsy
• 3rd nerve misdirection
• Horner’s syndrome
 Myogenic
• Myasthenia gravis
• Ocular myopathies
• Myotonic dystrophy
 Mechanical
• Excessive weight to upper lid –tumor, excess skin,
multiple chalazion, lid edema
 Traumatic
• Trauma or post surgery
 Aponeurotic
LPS function is good, but aponeurosis is stretched
or thinning due to repetitive stress and effect
gravity and aging causes drooping of lid

9. History taking
• Onset and duration of ptosis
• Variability
• Unilateral/bilateral
• Severity of ptosis - Whether the activities of daily living are affected
• Precipitating factors – history of trauma, eye surgeries, previous eye diseases such as dry
eye/thyroid eye disease, pregnancy, delivery, and medical conditions
• Associated conditions – Jaw winking, diplopia, dysphagia, tiredness
• Family history – Congenital or hereditary ptosis, ocular myopathies, blepharophimosis

10. Examination
• Head posture
• Frontalis overreaction
• Palpation of eyelid and orbital rim
• Features suggestive of BPES
• Proptosis or enophthalmos
• If squint present should be full
evaluated
• Bell’s phenomenon
• EOM
• BCVA
• Anterior segment examination-
especially pupil examination
• Posterior segment examination e.g.
abnormal retinal pigmentation in
Kearn-Syre syndrome

11. Ptosis measurement
Corneal light reflex test- you shine a light at the eyes and observe where the
reflex is located in reference to pupil.- central, eccentric, inward or outward

12. Marginal reflex distance 1- distance between central corneal reflex and upper lid
margin with primary position
• Normal is 4-5mm
Marginal reflex distance 2 – distance between the central corneal reflex to margin
of lower lid with eye in primary position
• Normal 5-5.5mm
Marginal reflex distance 3- distance from ocular light reflex to central of upper lid
margin when patient looks in extreme upward gaze

13. PFH- distance between the upper lid margin and lower lid margin at the pupil axis
• PFH=MRD1+MRD2

16. Levator palpebral superioris function- by Burke's method measuring the upper
eyelid excursion, from downgaze to upgaze with frontalis muscle function
negated. The amount of lid elevation is recorded in millimeters (mm) of levator
function.
• The classification of levator function:

17. • Iliff test- It is used to assess levator function in infants. Upper eyelid of the child is
everted as the child looks down. If the levator action is good, lid reverts on its
own

18. Margin crease distance- Upper eyelid crease position is the distance from the
upper eyelid crease to the eyelid margin in downward gaze.
• It is normally 7–8 mm in males and 9–10 mm in females.
pretarsal show- It is an important aspect of finding out the symmetry of eyelids. It
is the distance between the lid margin and the skin fold with the eyes in primary
position.

20. • Fatigue test-MRD1 should be measured first. Then the patient should be asked to
look up for 2 min after which the MRD 1 is to be measured again. Worsening of
ptosis is seen in myopathies, myasthenia as well as senile aponeurotic ptosis
• Ice test- Glove containing ice pack is applied on the closed ptotic eye for 2 min. If
the lid elevates by 2 mm or more, it is suggestive of myasthenia
• Phenylephrine test- Sympathomimetic agents, such as phenylephrine or
apraclonidine, can be instilled under the eyelid to test the function of Muller's
muscle

21. Tensilon test-In cases of suspected myasthenia, edrophonium is injected slowly ,if
myasthenia is the cause, ptosis improves after the injection
Corneal sensitivity should be tested in all cases

22. Grading of ptosis
In unilateral cases ,difference between the vertical height of palpebral fissure 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.
• Mild 2mm
• Moderate 3mm
• Severe 4mm

23. Complete ptosis- is the complete dysfunction of the somatic efferent supply from CN3 and
this associated with fully covering of the pupillary visual axis and closure of the eye.
Partial ptosis – is the paralysis of the superior tarsal muscle due to the dysfunction of the
sympathetic supply and this associated with partial covered pupil and eye is not full
closed.
Total ptosis – is the dysfunction of both somatic and autonomic efferent supply and
presented with full closure of the eye

25. Types of surgical treatment
• Fasanella –servant operation
• Levator resection
• Frontalis sling operation /brow suspension

26. Summary
 Documentation of any ptosis evaluation should include
1. Hb /CRL
2. Lid crease
3. MRD1&2
4. LPSF
5. PFH
6. Bell’s phenomenon
7. EOM
8. Corneal sensitivity test

28. References
• KANSKI’S clinical Ophthalmology Systametic Aproach 9th ED
• AAO- Acquired Ptosis: Evaluation and Management- By Carrie L. Morris, MD, and
David A
• Pauly M, Sruthi R. Ptosis: Evaluation and management. Kerala J Ophthalmol
2019;31:11-6.
• Internet