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

 Ptosis Management

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

☝ Mulletectomy

☝Levator resection

☝Levator advancement

☝frontalis sling

 Ptosis Normal 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