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Blepharoptosis refers to the inferodisplacement or drooping of the upper eyelids.The condition can be congenital associated with the presence of a dystrophic levator muscle or acquired due to a myogenic, neurogenic, mechanical, aponeurotic or traumatic cause. We aim to provide certain general guidelines to the management of a patient with ptosis.

In assessment of long case of ptosis the clinical examination should start with History as with any other case.


Obtain a thorough medical and ophthalmic history.

  1. The onset of ptosis,
  2. Alleviating or aggravating factors,
  3. Family history of ptosis
  4. Whether increasing, decreasing, or constant since the time of manifestation
  5. Association with
    1. Jaw movements
    2. Abnormal ocular movements
    3. Abnormal head posture
  6. History of
    1. Trauma or previous surgery
    2. Poisoning
    3. Use of steroid drops
    4. Any reaction with anesthesia
    5. Bleeding tendency
  1. Previous photographs may prove to be of great help.

Ocular Examination:

  1. Head Posture: A significant head posture (usually chin elevation as the ptosis is minimum in downgaze in a patient with congenital ptosis) is also one of the indications for surgery especially in the pediatric age group. Abnormal brow position also indicates the functional fall-outs of this condition.
  2. Ocular Motility: Ocular motility assessment is of utmost importance. It not only is of importance in causes of myogenic ptosis, but the presence of strabismus, especially vertical strabismus entails that it be corrected prior to the correction of the ptosis.
  1. Visual acuity – Best-corrected visual acuity should be assessed to record any amblyopia if present, especially in cases of congenital ptosis.
  1. Pupillary Examination: Examination of the pupils is of utmost importance as they are of both diagnostic and therapeutic significance. Diagnosis of conditions like Horner’s syndrome are dependent on the pupillary examination while the presence of pupillary involvement in a case of third nerve palsy can have great prognostic importance for the appropriate management of the case.
  2. The palpebral fissure - the distance between the upper and lower eyelid in vertical alignment with the center of the pupil.

    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


Fig. 1a                                                             Fig. 1b


  1. The marginal reflex distance-1 (MRD-1) - the distance between the center of the pupillary light reflex and the upper eyelid margin with the eye in primary gaze. A measurement of 4 - 5 mm is considered normal. It is important to crosscheck the amount of measured ptosis lest the palpebral aperture may be giving false value due to abnormal positioning of the lower lid.


Fig 2

The difference in MRD 1 of the two sides in unilateral cases or the difference from normal in bilateral cases gives the amount of ptosis.

Hold the light source directly in front of the patient looking straight ahead. The distance between the center of the lid margin of the upper lid and the light reflex on the cornea would give the MRD 1. If the margin is above the light reflex the M RD 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. The latter would be calculated by keeping the scale at the middle of upper lid margin and elevating the lid till the corneal light reflex is visible. The distance between the reflex and the marked original upper lid margin in –ve sign would be the MRD 1.

< or = 2mm : mild ptosis
= 3 mm : moderate ptosis
= or > 4 mm : severe ptosis

It must be remembered that ptotic lid in unilateral ptosis is usually higher in down gaze due to failure of levator to relax.

The ptotic lid in acquired ptosis is invariably lower than normal lid in down gaze.
  1. The marginal reflex distance-2 (MRD-2) - the distance between the center of the pupillary light reflex and the lower eyelid margin with the eye in primary gaze. A measurement greater than 5 mm is considered normal.
  1. The margin crease distance (MCD) is the distance from the upper eyelid margin to the lid crease measured in down gaze. In women, a central measurement of 8 - 10 mm is considered normal, and in men, 5 - 7 mm is considered normal.

It helps in planning the surgical incision. In some cases where more than one lid creases are present, the most prominent one should be considered. (Fig. 3)


Fig 3

  1. Levator function is the distance the eyelid travel from downgaze to upgaze while the frontalis muscle is held inactive at the brow.

Berke’s Method (lid excursion):

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. (Fig. 4a,b)


 Fig.4a                                                    Fig. 4b

< 4mm – poor levator function
5-7 mm – fair levator function
8-12 mm – good levtor function
The normal levator function is between 13-17mm


Putterman’s method

This is carried out by the measurement of distance between the middle of upper lid margin to the 6’o clock limbus in extreme up gaze. This is also known as the Margin limbal distance (MLD).

Normal is about 9.0 mm

The difference in MLD of two sides in unilateral cases or the difference with normal in bilateral cases multiplied by three would give the amount of levetor resection required.

Assessment in Children

Measurement of levator function in small children is a difficult task, as the child allows no formal evaluation.  The presence of lid fold and increase or decrease on its size on movement of the eyelid gives us a clue to the levator action.  Presence of anomalous head posture like the child throwing his head back suggests a poor levator action.

Iliff Test

This is another indicator of levator action.  It is applicable in first year of life.  The upper eyelid of the child is everted as the child looks down.  If the levator action is good lid reverts on its own.