What is the appropriate workup for ptosis (blepharoptosis)?

From the Guidelines

The workup for ptosis should begin with a comprehensive history and physical examination to determine the cause, including assessing the onset, severity, variability, and associated symptoms, and may involve laboratory tests and imaging studies like MRI of the brain and orbit, as recommended by the most recent guidelines 1.

Key Components of the Workup

• Assessing the onset (acute vs. chronic), severity, variability throughout the day, and associated symptoms like diplopia or pain
• Measuring the margin reflex distance (MRD1) and palpebral fissure height to quantify the degree of ptosis
• Evaluating levator function by measuring excursion of the eyelid from downgaze to upgaze
• Testing for Hering's law (looking for contralateral lid retraction), fatigue with sustained upgaze, and pupillary abnormalities
• Neurological examination, including cranial nerve assessment, particularly oculomotor function

Laboratory Tests and Imaging

• Laboratory tests may include acetylcholine receptor antibodies for myasthenia gravis, thyroid function tests, and glucose levels
• Imaging studies like MRI of the brain and orbit are indicated for suspected neurological causes or mass lesions, as suggested by recent studies 1

Specialized Tests

• The Tensilon test (edrophonium chloride) may be used to diagnose myasthenia gravis, though this is less commonly performed now
• Ice pack testing (improvement with cold application) is a simpler alternative for suspected myasthenic ptosis, as noted in the adult strabismus preferred practice pattern 1

Approach to Diagnosis

This systematic approach helps differentiate between congenital, aponeurotic (age-related), neurogenic, myogenic, mechanical, and traumatic causes of ptosis, guiding appropriate treatment, and is supported by the most recent and highest quality studies 1.

From the Research

Ptosis Workup

• Ptosis is defined as a drooping of the upper eyelid, often resulting in functional and/or aesthetic impairment 2
• A rigorous, systematic, and clinical examination is necessary to distinguish "benign ptosis" from "urgent ptosis" 2
• The history should attempt to detect a daily variation in the ptosis, suggesting myasthenia gravis 2
• Pupillary examination should rule out myosis, which would suggest Claude Bernard-Horner's syndrome, or mydriasis, suggesting an intracranial aneurism 2

Clinical Examination

• The clinical examination should assess the levator muscle strength, which is helpful for determining the underlying etiology 2
• The Bell's phenomenon should also be assessed, as the lack of it is predictive of postoperative corneal exposure 2
• The amount of ptosis is not related to its etiology 2
• The physician must be able to classify the ptosis as either pseudoptosis, aponeurotic ptosis, neurogenic ptosis, myogenic ptosis, or junctional ptosis (myasthenia) 2

Treatment Options

• Surgery is the mainstay of treatment for ptosis, except for "urgent ptosis", which requires multidisciplinary medical treatment 2
• The surgical technique is based on the etiology of the ptosis, the strength of the levator muscle, and the phenylephrine test 2
• For myasthenia gravis, treatment options include immune suppression with steroids, acetylcholinesterase inhibitors, and steroid-sparing agents 3
• Ptosis surgery can be a useful adjunct to medical therapy to improve lid height in patients with myasthenia gravis 4
• Apraclonidine eye drops may also be effective in alleviating ptosis secondary to myasthenia gravis 5

Diagnostic Considerations

• Myasthenia gravis rarely presents with ptosis as an isolated finding, and the yield of investigating patients with isolated ptosis for MG is exceedingly low 6
• Patients with isolated unilateral ptosis and otherwise normal examination are unlikely to have myasthenia gravis 6
• Diplopia or orbicularis weakness on examination are common findings in patients with myasthenia gravis 6