How to evaluate ptosis (drooping of the eyelid)?

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From the Guidelines

To evaluate eyelid drop (ptosis), begin with a thorough history and physical examination, considering the most recent and highest quality study from 2024 1. When evaluating eyelid drop, it is essential to ask about the onset, duration, and variability of symptoms throughout the day, as well as any associated symptoms like double vision or eye pain.

  • A comprehensive eye examination should include a sensorimotor exam, evidence of ptosis and anisocoria, and pupillary responses in bright and dim illumination, as recommended in the 2020 adult strabismus preferred practice pattern 1.
  • The examination should also include a fundus examination to evaluate for the presence of papilledema or optic atrophy.
  • Assessing levator function by measuring lid excursion from downgaze to upgaze (normal is 15mm or more) is crucial, as well as looking for accompanying signs like pupil abnormalities, extraocular movement limitations, or facial asymmetry.
  • Evaluating for fatigue by having the patient maintain upgaze for 1-2 minutes can help identify underlying causes, including neurological disorders (third nerve palsy, Horner's syndrome, myasthenia gravis), mechanical issues (dermatochalasis, blepharochalasis), aponeurotic ptosis (age-related), or congenital ptosis.
  • Diagnostic tests may include the ice pack test or Tensilon test for myasthenia gravis, imaging studies for neurological causes, and blood tests to rule out systemic conditions, as suggested in the 2020 adult strabismus preferred practice pattern 1.
  • Treatment depends on the underlying cause, ranging from observation to medical management or surgical correction, and should be guided by the most recent and highest quality evidence, such as the 2024 study on adult strabismus preferred practice pattern 1.

From the Research

Evaluating Eyelid Drop

To evaluate eyelid drop, also known as ptosis, several factors and tests should be considered:

  • A thorough clinical examination to identify characteristic findings such as fatigable ptosis and Cogan's lid twitch sign 2
  • Investigation of the patient's medical history to determine if they have experienced any symptoms of myasthenia gravis, such as diplopia or variable ptosis 3, 2
  • Examination of ocular motility and pupillary function to rule out other causes of ptosis, such as third nerve palsy or Horner's syndrome 4

Diagnostic Tests

Several diagnostic tests can be used to evaluate eyelid drop:

  • Ice test: a simple office-based procedure that can help confirm the diagnosis of myasthenia gravis 3, 2
  • Serum autoantibody testing: to detect the presence of autoantibodies against the acetylcholine receptor or other related targets 2
  • Electrophysiological testing: such as repetitive nerve stimulation and single-fibre electromyography, to confirm the diagnosis of myasthenia gravis 2
  • Neuroimaging: to rule out other causes of ptosis, such as a brain tumor 3

Considerations

When evaluating eyelid drop, it is essential to consider the following:

  • The probability of myasthenia gravis in patients presenting with isolated ptosis is low, and other causes of ptosis should be ruled out first 4
  • Patients with myasthenia gravis often present with fluctuating ptosis, diplopia, or a combination of both, and may have specific examination findings such as Cogan's lid twitch sign 2, 5
  • A thorough examination and investigation are necessary to determine the underlying cause of eyelid drop and to develop an appropriate treatment plan 6, 3, 2

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

5
Research

Ocular Myasthenia.

Neurologic clinics, 2018

6
Research

Pseudopartial Third Nerve Palsy as the Presenting Sign of Ocular Myasthenia Gravis.

Optometry and vision science : official publication of the American Academy of Optometry, 2020

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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