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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
Aetiology
- 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?)
Sources
- 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)