7. History
• History of present illness
• Associated history
• Past history
• Family history
8. History
• History of present illness :age of onset
• Associated history duration
• Past history one/both eye
• Family history variability
vision
9. History
• History of present illness
• Associated history : diplopia
• Past history odynophagia
• Family history muscle weakness
cardiac problem
night blindness
10. History
• History of present illness
• Associated history
• Past history : trauma/ surgery
• Family history contact lens
lid edema
allergy
dry eyes
previous ptosis surgery
11. History
• History of present illness
• Associated history
• Past history
• Family history
12. evaluation of ptosis
• head posture,Eyebrow position, eyelid
masses, inflammation, proptosis
• pupillary size, reaction, heterochromia
• Best corrected Visual Acuity: In
infants, make sure infant can fix and
follow light with each eye
• Cycloplegic Refraction
19. Measurements
• Vertical fissure height
• Margin reflex distance
• LPS action
• Lid crease level
• Lid level on down gaze
20. Vertical fissure height
• The distance between the upper and lower
eyelid in vertical alignment with the center of
the pupil in primary gaze, with the patient’s
brow relaxed.
• Normal – 9-10mm in primary gaze
• Should be seen in up gaze, down gaze and
primary gaze
• Amount of ptosis = difference in palpebral
apertures in unilateral ptosis or Difference
from normal in bilateral ptosis
21.
22. Grading of severity of ptosis
< or = 2mm : mild ptosis
= 3 mm : moderate ptosis
= or > 4 mm : severe ptosis
23. MRD
• Margin-to-reflex distance 1 (MRD1) : is the
distance from the central pupillary light
reflex to the upper eyelid margin with the eye
in primary gaze.
• A measurement of 4 - 5 mm is considered
normal.
• If the margin is above the light reflex the
MRD 1 is a +ve value.
• If the lid margin is below the corneal reflex
in cases of very severe ptosis the MRD 1
would be a –ve value.
24.
25. MRD
• Margin-to-reflex distance 2 (MRD2) : is
the distance from the central pupillary
light reflex to the lower eyelid margin
with the eye in primary gaze. .
• The MRD1 plus the MRD2 should equal
the palpebral fissure measurement
26. Levetor function
• is the distance the eyelid travel from
downgaze to upgaze while the frontalis muscle
is held inactive at the brow.
• The normal levator function is between 13-
17mm
27. • Lid excursion is a measure of the levator
function. The frontalis action is blocked by
keeping the thumb tightly over the upper
brow and asking the patient to look up from
down gaze and measuring the amount of upper
lid excursion at the center of the lid.
29. Grading of levator action
< 4mm – poor levator function
5-7 mm – fair levator function
8-12 mm – good levtor function
30. Lid crease
• Position is the distance from the crease to lid
margin
• Normal – 8 to 10mm in primary gaze
• An absent lid crease is often accompanied by
poor levator function.
• If a lid crease is present but is higher than
normal and if a deeper upper lid sulcus is
found on that side, note these as signs of a
levator aponeurosis disinsertion.
31.
32. Phenyl ephrine test
• Patients with minimal ptosis (2 mm or less) should
have a phenylephrine test performed in the involved
eye or eyes
• Either 2.5 or 10% phenylephrine is instilled in the
affected eye or eyes. Usually two drops are placed
and the patient is reexamined 5 minutes later.
• The MRD1 is rechecked in the affected and
unaffected eyes .
• A rise in the MRDl of 1.5 mm or greater is
considered a positive test. This indicates that
Müller's muscle is viable
38. Case 1
• A 25 year old man is seen in OPD 2 months
after blunt trauma to right orbit. Examination
is normal except for blepharoptosis in RE.
Levator function is normal on bothsides and
the patient states the eyelid positions were
equal on both sides prior to injury. There is
no enophthalmous, and the patient does not
complain of diplopia.
39. Case 1
• CT scan to rule out orbital fracture
• Tensilon test to rule out myasthenia
• Surgical exploration and repair of aponeurosis
• Close observation
40. Case 2
EYE VITALS RE LE
VERTICAL FISSURE 10 7.5
MRD 1 +4 +1.5
LEVATOR FUNCTION 14 15
EYELID CREASE 8 12
SCHRIMER’S 10mm 10mm
42. Case 3
• A 10 year old girl has bulging and
blepharoptosis of both upper eyelids and
recurrent episodes of eyelid inflammation and
swelling. The diagnosis is
• Dermatochalasis
• Blepharochalasis
• Steatoblepharon
• blepharospasm
