Lid/ ptosis examination

Question 1

What are 12 parts of lid/ptosis examination?

Answer 1

1. Shake hands to check for myotonia
2. Observe: face, brow, globes, lids, pupils
3. Measure: palpebrale aperture, upper margin reflex distance, position of upper lid crease, levator function
4. Measure any lagophthalmos
5. Assess orbicularis function and Bell’s phenomenon
6. Assess fatiguability over 1 min
7. Examine for Cogan’s twitch
8. Assess for jaw-winking
9. Biomicroscope examine of lid and subtarsal conjucntiva
10. Check corneal sensation
11. Examine ocular motility
12. Examine pupils

Question 2

What is a sign to look for when shaking hands?

Answer 2

to note slow release of grip

Question 3

What are 5 things to observe as part of the lids/ptosis examination?

Answer 3

1. Face
2. Brow
3. Globes
4. Lids
5. Pupils

Question 4

What are 4 things to measure in the measurement stage of the lid/ptosis examination?

Answer 4

1. Palpebral aperture
2. Upper margin reflex distance
3. Position of upper lid crease
4. Measure levator function

Question 5

How can levator function be measured?

Answer 5

inhibit frontalis by placing a thumb on the brow

Question 6

What is lagophthalmos?

Answer 6

incomplete or abnormal closure of the eyelids

Question 7

How can lagophthalmos be assessed?

Answer 7

ask pt to close eyes, gently at first, then ask to squeeze eyes shut

Question 8

How can orbicularis function and Bell’s phenomenon?

Answer 8

try to open patient’s eyes against resistance

Question 9

How can fatiguability be assessed and what should you look for?

Answer 9

pt to keep looking upward at a target held superiorly for 1 min, assess for any worsening of ptosis - assess for lid drifting down, reassess palpebral aperture in primary position at the end

Question 10

How do you examine for Cogan’s twitch?

Answer 10

ask patient to look down and then to look at a target held directly in front of them

Question 11

What is Cogan’s twitch?

Answer 11

overshoot of the eyelid which occurs on rapid elevation of the eyes from downgaze to the primary position

Question 12

What condition may Cogan’s twitch be seen in?

Answer 12

myasthenia

Question 13

Wha is jaw-winking?

Answer 13

lid can be elevated by movement of the jaw e.g. chewing, side to side movement of jaw

Question 14

What can cause jaw-winking?

Answer 14

synkinesis (mis-wiring), resulting in ptosis which varies with use of other facial muscles (pterygoids) - form of congenital ptosis

Question 15

What are 2 ways to assess for anisocoria?

Answer 15

response to light and near

Question 16

What should be the next step if fatiguability is demonstrated on examination?

Answer 16

examine for associated fatiguability of ocular motility and general musculature - usually a sign of myasthenia

Question 17

What specific test can be considered for myasthenia?

Answer 17

ice pack test (and further investigation)

Question 18

What specific test can be considered for myasthenia?

Answer 18

ice pack test (and further investigation)

Question 19

What is the normal range for palpebral aperture measurement?

Answer 19

8-11mm

Question 20

Which gender tends to have greater palpebral aperture?

Answer 20

female

Question 21

What is the normal range for upper margin reflex distance?

Answer 21

4-5mm

Question 22

What is the normal range for upper lid excursion (levator function)?

Answer 22

13-16mm

Question 23

What is the normal range for upper lid crease position?

Answer 23

8-10mm from margin

Question 24

Which gender tends to have a higher upper lid crease position?

Answer 24

female

Question 25

What is the upper margin reflex distance?

Answer 25

measurement in millimeters from the light reflex on the patient’s cornea to the level of the center of the upper-eyelid margin, with the patient gazing in the primary position

Question 26

What is the upper lid excursion (levator function)?

Answer 26

distance from the upper eyelid margin in downgaze to upgaze, with frontalis muscle function neutralized