Sports Clearance for a 13-Year-Old with Unilateral Ptosis
A 13-year-old with isolated unilateral ptosis can receive sports physical clearance unless the ptosis is associated with underlying neurological, cardiovascular, or vision-threatening conditions that would independently disqualify them from participation.
Primary Evaluation Requirements
The key determination is whether the ptosis represents an isolated benign condition versus a manifestation of a serious underlying disorder:
Rule out urgent neurological causes including third nerve palsy with pupillary involvement (suggesting posterior communicating artery aneurysm), Horner's syndrome (suggesting carotid dissection), or myasthenia gravis 1, 2, 3.
Perform pupillary examination in both bright and dim illumination to identify miosis (Horner's syndrome) or mydriasis (third nerve palsy with aneurysm risk) 2, 3.
Assess for associated symptoms including diplopia, ophthalmoplegia, daily variation in ptosis severity (myasthenia), or other neurological deficits that would warrant further workup 2, 3.
Evaluate visual function to determine if the ptosis causes visual field obstruction, amblyopia risk, or functional impairment that could affect sports performance or safety 4, 5.
Sports Clearance Decision Framework
For isolated benign ptosis (aponeurotic, congenital without complications):
Clearance can be provided as ptosis alone does not create significant risk of sudden death, serious injury to the athlete, or others during sports participation 4.
The American Heart Association/American College of Cardiology framework for sports clearance emphasizes that restrictions should be based on conditions creating "significant risk of sudden cardiac death or other serious injury" 4.
Isolated ptosis without underlying pathology does not meet criteria for medical disqualification from competitive sports 4.
For ptosis with concerning features requiring further evaluation:
Withhold clearance temporarily if pupillary abnormalities, variable/fatigable ptosis, or associated neurological symptoms are present until diagnostic workup is complete 2, 3.
The American Academy of Ophthalmology recommends comprehensive evaluation including fundus examination for papilledema or optic atrophy when ptosis is accompanied by other findings 2.
MRI brain and orbits with contrast is indicated when ptosis occurs with proptosis, other neurological symptoms, or suspected mass lesions 2.
Sport-Specific Considerations
Vision requirements and protective equipment:
Assess functional vision in both eyes, as the functionally one-eyed athlete requires extra precautions and appropriate protective eyewear 6.
If ptosis significantly obstructs the visual field (>4mm covering the pupil), this may impair sports performance and safety, particularly in sports requiring full visual fields like basketball, baseball, or racquet sports 6, 5.
Pre-participation vision screening should identify athletes not meeting minimum visual acuity requirements, though comprehensive eye examination provides more thorough assessment 7.
Contact/collision sport considerations:
For high-risk eye injury sports (basketball, baseball, racquet sports), ensure adequate protective eyewear if vision is compromised 6.
The American Society for Testing and Materials has established performance standards for protective eyewear that should be followed 6.
Common Pitfalls to Avoid
Do not assume all ptosis is benign without proper pupillary examination and assessment for associated symptoms, as missing pupil-involving third nerve palsy or Horner's syndrome from carotid dissection can have life-threatening consequences 1, 2, 3.
Do not order advanced neuroimaging (MRI, antibody testing) for isolated unilateral ptosis without other neurological symptoms, as this is not warranted as first-line investigation 2.
Do not miss myasthenia gravis due to variable presentation—perform ice test or rest test if ptosis worsens with fatigue throughout the day 2, 3.
Do not overlook amblyopia risk in younger patients with significant congenital ptosis, as this can lead to permanently poor vision if not addressed 4, 5.
Documentation and Legal Considerations
Document the clinical examination including pupillary responses, levator function, visual acuity, and absence of concerning associated findings 4.
Physicians have flexibility to make individualized clearance decisions based on medical judgment, and the legal framework supports both providing clearance for benign conditions and withholding it when reasonable medical basis exists for concern about athlete safety 4.
If providing clearance despite any residual concerns, inform the athlete and family of potential risks in writing, even if deemed medically reasonable 4.