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Clinical Examination

  • Medical history: Photos? Fluctuations during the day?
  • Marginal reflex distance (MRD1)
  • Palpebral Aperture
  • Levator function
  • Lid crease
  • Simpson test
  • Bell’s phenomenon
  • Motility
  • Pupils

Red Flags

  • Anisocoria
  • Motility disorders
  • Proptosis
  • Double vision
  • Head/neck pain


  • Aponeurotic: high or absent lid crease, good levator function
  • Myogenic: usually congenital with poor levator function and absent or subtle lid crease, superior rectus weakness common, acquired form is rare (e.g. muscular dystrophy, CPEO)
  • Neurogenic: e.g. Horner syndrome, third nerve palsy, myasthenia gravis (varying)
  • Mechanical: contact lenses, inflammation (e.g. chalazion), scarring, neoplasia
  • Traumatic
  • Pseudoptosis

Important Differential Diagnosis

  • Myasthenia gravis: fluctuating findings, symptoms not always the same, Simpson test and ice test, consider chest CT (thymoma?)
  • Horner syndrome: carotid dissection? CT/CTA or MR/MRA head/neck
  • Third Nerve Palsy: pupil involvement? partial? intracranial aneurysm? CTA head
  • Neoplasia of the eyelids or orbit: consider CT/MRI orbit
  • CPEO (chronic progressive external ophthalmoplegia): e.g. Kearns-Sayre (cardiac work-up, ECG: cardiac arrhythmia?)


  • EyeWiki Blepharoptosis
  • The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7. Edition (2016)
  • Kanski’s Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8. Edition (2015)