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4 Rules to consider for ptosis examination

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Andrew R. Harrison

WAIKOLOA, Hawaii — In ptosis cases, four “rules of the road” can help steer the clinician away from management complications, a speaker here said.

The first rule when presented with a case is to examine the pupils, Andrew R. Harrison, MD, told colleagues at Hawaiian Eye 2019.

“A patient comes in with ptosis and asymmetric pupils. If the large pupil is on the side of the ptosis, you have to worry about a third nerve palsy. That’s something that can kill the patient,” Harrison said.

In his practice, Harrison said the protocol for patients with a droopy lid and a small pupil is to undergo an MRI and MRA from the hypothalamus to the lung apex to determine whether there is an arterial cause.

The second rule is to check extraocular motility in any patient who presents with ptosis, he said.

“The triad of ptosis, pupils and motility always run together,” Harrison said. “If you have a patient with an abnormality in one, then you need to check the other two.”

For example, a patient with ptosis and abnormal motility but symmetric pupils could have a pupil-sparing third nerve palsy, myasthenia gravis, chronic progressive external ophthalmoplegia, muscular dystrophy or thyroid eye disease, he said.

Harrison’s third rule is to evert the eyelids. Causes seen beneath the lids are retained contact lens, giant papillary conjunctivitis, conjunctival mass and floppy eyelid syndrome.

“[Floppy eyelid syndrome] does make levator surgery more difficult, because the tarsus is unstable, so the first thing I do is tighten the upper eyelid,” which can correct the ptosis in the majority of patients, he said.

The fourth rule is to check levator function, which determines which surgical procedures is appropriate, he said. While levator surgery is “a great operation,” Harrison said he has come to be a “Müller surgeon.”

Müller’s muscle conjunctival resection has a high success rate. “At least in my hands, it is faster and more predictable than levator surgery,” he said.

Harrison won Speaker of the Day for his talk. – by Patricia Nale, ELS

Reference: Harrison AR. Ptosis: Rules of the road. Presented at: Hawaiian Eye; Jan. 19-25, 2019; Waikoloa, Hawaii.

Disclosures: Harrison reports no relevant financial disclosures.