Ptosis

	Other signs
Neurogenic	Usually poor LF
Sympathetic nerve lesion/Horner syndrome	Meiosis Anhydrosis Cervical lymphadenopathy
CN3 palsy	Other EOM weakness Mydriasis Other cranial nerve or brainstem signs
NM Junction
Myasthenia gravis	Variable/fatigable - Improves with ice test Normal pupils Weakness of EOM/eyelid closure Systemic weakness/ dysphagia
Congenital myasthenia syndrome
Myogenic	Usually very poor LF
CPEO (and other mitochondrial disease)	Associated global reduced EOM function
Myotonic dystrophy	Reduced eyelid closure strength
Muscular dystrophy (FSH, oculopharyngeal)
Myositis	Pain
Infiltration	Exophthalmos
Thyroid eye disease
Mechanical	Generally good LF
Aponeurotic dysfunction (stretch/dehiscence)
Mechanical obstruction	Lid abnormality (e.g. chalazion)
Pseudoptosis
Contralateral lid retraction
Enophthalmosis
Duane syndrome
Hemifacial spasm
Brow ptosis
Hypertropia

Examination

· Bilateral or unilateral ptosis

· Measure:

o Height of eyelid crease/lid fold

o Palpebral aperture/fissure (NR 9-12mm)

o Marginal reflex distance 1 (upper) (NR 4-5mm)

o Marginal reflex distance 2 (lower)

o Levator function (LF) - (upper eyelid excursion from full downgaze to full upgaze)

§ Normal >10-12mm

§ Moderate 5-10mm

§ Poor <5mm

· Eye movements

· Prolonged upgaze (look for change in PA/MRD)

Special test

Progressive