Ptosis (Blepharoptosis) in Adults Workup

Updated: Jul 10, 2020
  • Author: Adam J Cohen, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Laboratory Studies

If myasthenia gravis is suspected in a patient with ptosis, perform a serum assay for acetylcholine receptor antibodies and antistriated muscle antibody. Muscle-specific tyrosine kinase (MUSK) levels can be obtained when acetylcholine receptor antibodies levels are negative and the suspicion for generalized myasthenia is high.

The ice test has been shown to improve ptosis in patients with myasthenia. [5]

An edrophonium chloride (Tensilon) test or single-fiber electromyography may be needed to definitely exclude the diagnosis.

CSF analysis can aid in the diagnosis of multiple sclerosis. Mild lymphocytosis or increased protein levels in the CSF levels may be present. In addition, elevated immunoglobulin G (IgG) levels and oligoclonal bands often are found.

In patients with chronic progressive external ophthalmoplegia, an electrocardiogram, electroretinogram, electromyography, and mitochondrial assay should be considered.

Patients with suspected thyroid abnormalities should undergo thyroid function studies.


Imaging Studies

If ptosis is present with other neurologic deficits, imaging of the brain, orbits, or cerebrovascular system should be performed. An emergent CT angiography of the brain is necessary when ptosis is accompanied by other signs of a third nerve palsy. MRI of the brain with and without gadolinium is the imaging modality of choice to exclude structural cerebral etiologies, including middle cranial fossa neoplasia and demyelinating disorders.

CT scanning without contrast can be used to exclude dysthyroid orbitopathy and intraorbital neoplasia.

In acquired Horner syndrome, MRI or CT scan of the brain, MRA of neck, CT scan or X-ray of the spine, and CT scan or X-ray of the chest (especially of the apex of the lung) are needed to exclude a structural lesion along the sympathetic pathway.


Other Tests

Sympathomimetic agents can be used to stimulate the Mueller muscle, as follows:

  • 2.5% phenylephrine
  • 0.5% apraclonidine (Iopidine)
  • 1.0% apraclonidine (Iopidine)

Ten percent phenylephrine has not be shown to have increased clinical efficacy in predicting the outcome of Muller muscle–conjunctival resection. Therefore, the authors do not feel the use of 10% phenylephrine is necessary. [6]

Instill 2 drops on the eye under the eyelid (have the patient look down), wait 5 minutes, and assess any change in the palpebral fissure and the marginal reflex distance. If no response is observed or if elevation is not adequate, external levator resection or advancement may be needed to correct the ptosis. If a good response is observed, the ptosis can be repaired by advancing the internal levator (Mueller muscle–conjunctival resection).