From the Guidelines
Ptosis is evaluated through a comprehensive eye examination that assesses the severity and cause of the drooping eyelid, including measuring the margin reflex distance, palpebral fissure height, and levator muscle function, as well as checking for fatiguability and performing a pupillary examination to rule out underlying conditions such as Horner's syndrome or myasthenia gravis 1. The evaluation of ptosis involves a thorough assessment of the patient's ocular and systemic health, including a comprehensive eye examination that consists of an evaluation of the physiological function and the anatomical status of the eye, visual system, and its related structures 1. This examination includes:
- Visual acuity with current correction at distance and near
- Refraction when indicated
- Visual fields by confrontation
- External examination, including eyelid position and character, lashes, lacrimal apparatus and tear function, globe position, and pertinent skin and facial features
- Pupillary function, including size and response to light, and relative afferent pupillary defect
- Ocular alignment and motility, including cover/uncover test, alternate cover test, ductions and versions
- Slit-lamp biomicroscopic examination of the eyelid margins and lashes, tear film, conjunctiva, sclera, cornea, anterior chamber, and assessment of central and peripheral anterior chamber depth, iris, lens, and anterior vitreous
- Intraocular pressure measurement, preferably using a contact applanation method
- Fundus examination of the mid and posterior vitreous, retina, vasculature, and optic nerve
- Assessment of relevant aspects of the patient's mental and physical status Additional tests may be performed to determine the cause of ptosis, including the ice pack test or tension test for myasthenia gravis, and imaging studies like MRI or CT scans if a neurological or mass-related cause is suspected 1. Some key points to consider in the evaluation of ptosis include:
- Measuring the margin reflex distance (MRD) and palpebral fissure height to assess the severity of ptosis
- Assessing levator muscle function by measuring the excursion of the upper eyelid from downgaze to upgaze while immobilizing the frontalis muscle
- Checking for fatiguability by having the patient maintain upgaze for several minutes to reveal myasthenic ptosis that worsens with sustained effort
- Performing a pupillary examination to rule out Horner's syndrome, characterized by ptosis with miosis and anhidrosis
- Assessing cranial nerve function, particularly the oculomotor nerve (CN III), to identify neurogenic causes
- Considering additional tests, such as the ice pack test or tension test, to diagnose myasthenia gravis or other underlying conditions 1.
From the Research
Evaluation of Ptosis
Ptosis evaluation involves a comprehensive assessment of the upper eyelid to determine the cause and severity of the condition. The evaluation process includes:
- Clinical examination to assess eyelid position, symmetry, and movement 2, 3
- Measurement of levator muscle function to determine the severity of ptosis 2, 4, 5
- Assessment of pupil diameter and extraocular muscle function to rule out underlying conditions 3
- Evaluation of onset, symptoms, and medical history to determine the cause of ptosis 3
Diagnostic Techniques
Various diagnostic techniques are used to evaluate ptosis, including:
- Levator force measurement to assess the strength of the levator muscle 5
- Eyelid excursion measurement to assess the range of motion of the upper eyelid 5
- Photograph review and patient questionnaire to assess the severity and symptoms of ptosis 3
- Surgical exploration to confirm the diagnosis and determine the best course of treatment 2, 6
Classification of Ptosis
Ptosis can be classified into different types based on the cause and severity of the condition, including:
- Neurogenic ptosis caused by nerve damage or dysfunction 2
- Myogenic ptosis caused by muscle weakness or dysfunction 2
- Aponeurotic ptosis caused by damage to the levator aponeurosis 2
- Mechanical ptosis caused by mechanical factors such as tumors or cysts 2
- Congenital ptosis present at birth 2, 6
- Acquired ptosis developing later in life 3, 4