Monday, February 22, 2010

Ptosis Evaluation

:: bismillahirrahmanirrahim ::

Mind you, the term "ptosis" which means "droopy" does not merely refer to "droopy eyelid" as we can have something else droopy as well, not just our eyelid. As you know, the exact term for "droopy eyelid" is actually "blepharoptosis" (blepharo=eyelid, ptosis=droopy). But in our field of optometry, we are just comfortable to use "ptosis" rather than "blepharoptosis" in referring to "droopy eyelid"... and so will I do in this article as I'm lacking of time to type the whole lengthy word again and again.

Straight to the point requested by Br Muziman (my PBL group instructor), here are some of the popularly used ways in evaluating ptosis, and you can add them up if you have known another way that is not mentioned here. For any of the pictures below, you can get a clearer view simply by clicking it.

1) Levator Function

- Levator function is measured as the extent of eyelid movement on maximum down and up gaze. Method:

i. The thumb of one hand is placed at the eyebrow (don't press, just gently place) - this is to block the effect of forehead on the elevation of the eyelid.

ii. With another hand, hold a ruler near the patient's upper eyelid (with zero-point at the central upper lid margin) while the patient is looking downward (Pic. A & C)

iii. Then have the patient look upward as high as possible without any head movement, and take the measurement on the ruler at which the upper lid margin is now positioned (Pic. B & D).

- Classification of levator function: Good (8 mm), Fair (5-7 mm), Poor (≤4 mm)
- An accurate measurement of levator function may be used to determine the type of ptosis and also the best surgical approach to repair it. For instance in cases of involutional ptosis, the patient has a quite normal levator function despite the droopy eyelid.

2) Palpebral Fissure (labelled as PF in Pic. XYZ)

- a.k.a PAS (Palpebral Aperture Size) in our CL clinic

- Measured as distance between upper lid margin to lower lid margin passing through the center of pupil in primary gaze.

- Normal measurement: 9-10 mm

3) Crease Height (labelled as VCD in Pic. XYZ)

- a.k.a Margin Crease Distance (MCD) / Vertical Crease Distance (VCD)

- Crease height is the distance from the upper eyelid margin to the upper eyelid crease in downward gaze.

- Normal measurement: 5-10 mm

4) Marginal Reflex Distance #1 (labelled as MRD1 in Pic. XYZ)

- MRD is the distance from the upper eyelid margin to the corneal reflex in primary gaze.

- Normal measurement: 4-5 mm

- MRD 1 +ve: if upper lid margin is higher than the level of corneal reflex.

- MRD 1 -ve: if upper lid margin is lower than the level of corneal reflex.

5) Margin Reflex Distance #2 (labelled as MRD2 in Pic. XYZ)

- MRD 2 is a distance between corneal reflex and lower lid margin in primary gaze.

- Measurement greater than 5 mm is considered normal.

Picture XYZ:


- Bilateral ptosis: the amount of ptosis is measured as difference from the normal value (as given above), with larger difference indicates more severe ptosis.

- Unilateral ptosis: the amount of ptosis is taken as difference in PF / VCD / MRD 1 between RE and LE. Classification of ptosis based on difference between the 2 eyes: mild (2 mm), moderate (3 mm), severe (4 mm)


:: wallahu a'lam ::


  1. PBL (trigger 5)
    case: Marcus gunn jaw-winking syndrome assoc. with marcus gunn pupil.

    i have the video on ptosis examination a.k.a abnormal eye position. same like what have been explained here. bezanyer yang tuh lam bentuk video. but i dont know how to upload here.. (huuhu).. nanti k, nak kener mintak tolong orang expert ajarkan.

  2. salam.

    to: Lara

    may b ko leh bg kt k dil@aku@zane@moon utk upload.

    skian, trimas.

    may the peace be with you.

    p/s: apsal cm bnyk? ari 2 kt pbl cm simple je....

  3. We think the tables that shown in PBL were more simple and easier to understand

  4. The information posted here seems to be very complicated because of the quite-detailed-explanation on how-about of each method.

    But FYI, this post is already a simplified version from the original sources... I struggled a lot to find the simplest yet informative explanation regarding this matter.

    But I'll try to simplify them even more whichever possible. Or maybe Rara's video may help us to digest everything more easily.

    To zul :---

    Tolong uploadkan video Rara tu... Aku tau ko pun lagi suka explanation through video rather than words kan... Tapi aku rasa la, orang yang rajin membaca will find that my explanation is very direct with no unrelated verbiage/wordiness.

    Adakah ko termasuk dalam golongan yang tidak rajin membaca? Hu.. jangan terasa, aku tau ko rajin membaca, sure u read a lot~~~ Rasanya Ain seorang je kot yang faham kenapa aku cakap camni kat ko. Will tell u later if, and if only u interested to know.

  5. To Adilah,

    We are glad on this posting and it is a big effort from in order to share knowledge with us.

    To other editors.

    Perhaps, if you have free time, could you rearrange the value of classification for each test in table form. So, the classification will be easier to see.

  6. that's rite bro Muzi,

    I can then 'copy and paste' the table and give it to my colleagues!

  7. Salam guys~

    I've uploaded a simple table as an image at the bottom of this post.
    Again ---> U can have a clearer and sharper view by just a click on the image.

    Note that in the table, I just use the acronym of the methods without any explanation as I believe that U are already familiar with those acronyms. If U aren't, U can just refer back to my older text in this post, including Picture XYZ. And if U still couldn't understand, U can click on the link of the references given at the end of the post for more detailed and comprehensive elaboration.

    Any question is cordially welcome. I'll try my best to answer your queries regarding the evaluation of ptosis. U're also welcome to answer any question arises regarding this topic.

    May Allah bless our efforts in gaining knowledge to benefit the Ummah.

    Wallahu a'lam

  8. terima kasih k.dil for your effort of explaining ptosis (blepharoptosis) knowledge..

    one thing to ask, in real clinic, do we really measure all those measurement, if yes, for what purpose?sorry for asking this 'nonsense' question..just curious to know its application...

    ||Cahaya Yang Menerangi|| =)

  9. Muni... now only I know why did U ask me about "n*n**n*" in our YM chat this morning. One more thing, is ||Cahaya Yang Menerangi|| the tagline of ur newly-created blog??? Don't forget to invite us eh, (especially me)...

    To answer the Q:
    I think this measurement is really important only when we want to consider for surgery, particularly when we are working with ophthalmologist ---> this is just my very own point of view, I myself do not sure on the extent of usefulness of all these measurements for us as an optometrist.

    But, just take that every knowledge is beneficial, if not now, maybe one time we would still see the benefits. Talking about this, I'd like to share an article which I read in the latest Solusi #16 (magazine) entitled Semua Ilmu Penting:
    "Bahawa semua ilmu penting dipelajari sebab kita tidak pernah tahu apa kesulitan yang sedang menunggu kita pada masa depan. Boleh jadi, ilmu yang tidak kita sukai itu sangat diperlukan dalam kerjaya kita pada masa akan datang" (Umar MN, Solusi #16, 2010, page 28)
    I'll summarize the story written by Umar MN in this article, and will make a new post for this topic in this blog.

    Nonetheless, we can still apply this knowledge in our clinic to specify our diagnosis. Maybe before this, when there is a patient with droopy eyelid, we just put "ptosis"/"blepharoptosis" as the diagnosis. But now with this knowledge, we can put the diagnosis as "Mild bilateral ptosis with good levator function", or "Moderate ptosis on LE with poor levator function", for instance.

    wallahu a'lam

  10. To Adilah & Munirah

    'I think this measurement is really important only when we want to consider for surgery, particularly when we are working with ophthalmologist' by Adilah
    From Admin (We are totally agreed with it.)

    'I myself do not sure on the extent of usefulness of all these measurements for us as an optometrist'. by Adilah

    From Admin (For optometrist, It is important for prognosis of curing from amblyopia n is the ptosis should be referred to oftal or not. With the knowledge of this classification, it will help us in diagnosing severity of the ptosis.Meaning to say, we have a clear guideline to classify the ptosis as mild and so on rather than use estimation or by our experience.)

    Thank you to Adilah, Rara n team..We are really appreciate this post. Very Useful for us.




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