Clinical Hints for Your clinical stepwise approach for examining the lids (with particular regard to ptosis)

✍Observe

☝Face for asymmetry

☝Brow for overactive forntalis

☝Globes for position and asymmetry

☝Lids for position,asymmetry or scars

☝Pupils anisocoria or heterochromia

✍measure palpebral aperture

✍measure upper margin reflex distance

✍measure position of upper lid crease

✍measure levator function

☝Inhibit frontalis by placing a thumb on the brow

✍measure any lagophthalmos

☝Ask patient to close eyes, gently at first, and then to squeeze eyes shut

✍Assess orbicularis function and Bell’s phenomenon

☝Try to open patient’s eyes against resistance

✍Assess fatiguability over 1 min for worsening of ptosis

☝Ask patient to keep looking upward at a target held superiorly

✍examine for Cogan’s twitch Any overshoot

☝Ask patient to look rapidly from downgaze to a target held in 1ry position

✍Assess for jaw-winking For any change in ptosis

☝Ask patient to simulate chewing and to move jaw from side to side

☝Slitlamp examination of lid and subtarsal
conjunctiva for Inflammation,masses or scars

☝Check corneal sensation and Bell’s phenomena (very Prognostic for any lid surgery)

✍examine ocular motility for

☝motility abnormality in 9 cardinal positions

☝change in ptosis with ocular motility

✍examine pupils for

☝Anisocoria (in response to light and near)

☝reactivity

☝iris heterochromia

✍Consider ice-pack test for suspected MG

✍full cranial nerves assessment

☝( 2nd , 3rd ,4th ,5th ,6th and 7th )

✍examination of fundus

✍systemic review (myopathy, fatiguability).

✍exclude pseudoptosis

☝Excessive skin ( dermato- or blepharochalasis )

☝Inadequate globe size( micropthalmos,phthisis)

☝Incorrect globe position( hypo or hypertopia )

☝Brow ptosis

☝Contralateral lid retraction

☝Contralateral large globe

PtosisManagement

✍Depends upon degree of ptosis and residual Levator function and the cause of ptosis

☝Mulletectomy

☝Levator resection

☝Levator advancement

☝frontalis sling

PtosisNormal lid measurements gift

✍Palpebral aperture

☝8–11 mm (♀>♂)

✍Upper margin reflex distance

☝4–5 mm

✍Upper lid excursion (levator function)

☝13–16 mm

✍Upper lid crease position

☝8-10 mm from margin (♀>♂)

DD of acute dangerous ptosis

✍Horner

✍3rd cranial palsy ( partial or complete)

✍MG

✍CPEO

✍periorbital infection or malignancy