Ptosis Blepharoplasty Workup

CT scanning of orbits should be considered in patients with acute ptosis or if any suspicion of an orbital process, sulcus filling, or exophthalmos exists.

See the list below:

• Visual acuity: Careful vision testing is performed using an age-appropriate method. In the past, ptosis alone was not considered to produce amblyopia, and other associated factors (eg, anisometropia, strabismus) were always thought to be the cause. However, recent studies have documented that amblyopia is possible with an isolated ptosis. This problem should be searched for and treated as necessary.

• Orthoptic evaluation: Look for associated problems (eg, double elevator palsy) or other more common forms of strabismus. If indicated, muscle surgery can be performed at the same time as ptosis surgery.

• Visual field: Obtain visual field tests in patients who are able to cooperate in order to document peripheral and superior visual field restriction.

• Slit lamp examination: Include slit lamp examination, intraocular pressure measurement, and fundus examination in the preoperative evaluation.

• Refraction: A cycloplegic refraction is indicated in all children with ptosis, since a significant number of them have anisometropia primarily due to astigmatism on the ptotic side. Correct any significant refractive error.

• Tear function testing: In adults, obtain a measure of basal tear secretion by performing a Schirmer test of the anesthetized eye. In addition, evaluate the corneal tear film for evidence of abnormal debris or tear breakup.

• Ptosis measurements

  • Simple observation: Begin with simple inspection of the patient. Observe the lid level relative to the globe and to the other lid. The presence or absence of a lid fold or lid crease gives a significant clue to the degree of levator function. An absent lid crease is often accompanied by poor levator function. If a lid crease is present but is higher than normal (a normal lid crease is 8-10 mm from the lid margin measured above the pupil) and if a deeper upper lid sulcus is found on that side, note these as signs of a levator aponeurosis disinsertion. When the patient is asked to look up, both the sulcus and the lid crease may move superiorly slightly before the lid moves. This is caused by a delay in levator action due to the attenuation or stretching of the normal aponeurotic attachments to the tarsus. Measure and record the position of both upper lid creases.

  • Upper lid height

    • This is a measure of the amount of ptosis in the primary position with the patient's brows relaxed. The upper limbus can be used as a baseline from which to estimate the amount of ptosis. The upper lid normally crosses the cornea approximately 0.5-2 mm below the upper limbus, and under normal situations, it maintains this approximate relation in upward and downward gaze. The cornea is about 11 mm in height; therefore, in a patient with 3.5 mm of ptosis, the lid margin splits the visual axis, assuming the measurement from the visual axis to the upper limbus is 5.5 mm (2 mm below the upper limbus normal position + 3.5 mm ptosis = 5.5 mm).

    • Employing the corneal light reflex and its distance to the lid margin, keeping the above relationships in mind, also can provide a relatively precise estimation. For instance, if the lid margin appears to be approximately 1.5 mm above the corneal light reflex, 2-3 mm of ptosis is present. Ptosis is considered mild if 1-2 mm, moderate if 2-3 mm, and severe if 4 mm or more.

    • Levator function: Evaluation of the levator function is extremely important and begins with evaluation of the lid crease, as noted above. Presence of a crease suggests that some levator function exists even if the lid moves poorly. If the examiner everts the lid and it does not flip back to its normal position when the patient is asked to look up (known as Iliff sign), poor levator action is certain. With the exception of patients of Asian ancestry, in whom the lid crease may not be present, an absent lid crease usually indicates absent levator function.

    • In patients with abnormal levator function, the amplitude of action of the muscle is diminished and the lid fails to elevate and depress normally, producing a lid lag in downgaze. The involved lid may be higher than the uninvolved one in downgaze. This lid lag is exaggerated by ptosis surgery and hence must be discussed in advance with the patient or parents.

    • In a patient with ptosis due to a dehiscence of the levator aponeurosis, the levator muscle is normal, its function generally is quite good, and the amount of ptosis remains the same in both upgaze and downgaze. This simple relationship allows the surgeon to readily differentiate true congenital ptosis from early-acquired ptosis, congenital ptosis associated with birth injury, and other forms of ptosis in which the levator muscle is normal. Although aponeurotic defects have been reported in congenital ptosis, these are not typical.

    • The levator function is determined by holding the brow immobile, placing a millimeter ruler over the lid in the plane of the pupil, and measuring the levator excursion from extreme downgaze to extreme upgaze. Levator function may be classified as poor levator function (≤ 4 mm), fair levator function (5-7 mm), and good levator function (>8 mm). Generally, in patients with congenital ptosis, mild ptosis usually is accompanied by good levator function, and moderate-to-marked ptosis is associated with fair-to-poor levator function. The measurements of the degree of ptosis and degree of levator function require the cooperation of the patient; usually a child must be aged 2-3 years before this cooperation can be obtained.

• Additional observations: The lid contour, lashes, and skin are also evaluated. The presence of jaw winking (Marcus Gunn phenomenon) can be assessed by asking the child to move the jaw from side to side or to chew or by allowing the infant to nurse under observation. In adults, redundant skin and ptosis of the brow may mask a true ptosis or produce ptosis due to mechanical factors. Test orbicularis oculi muscle function, corneal sensation, and Bell phenomenon. Palpation of the lids and orbits is important because it may reveal a mass not otherwise appreciable as the cause of acquired ptosis.