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Blepharoptosis, ‘the fallen eyelid’, is a clinical sign that neurologists encounter regularly. Knowledge of the anatomy and the normal physiology of the eyelid makes it easier to understand the various ways in which ptosis may present. The aetiology of ptosis can be divided into structural abnormalities affecting the eyelid muscles and/or surrounding tissues in the orbit, myogenic causes, neurogenic causes, disorders of the neuromuscular junction and central causes. Differentiating between these causes can often be achieved by a carefully directed history and examination. Investigation depends on the clinical assessment and hence the likely underlying cause. Treatment is usually directed at the underlying pathology but occasionally oculoplastic surgery is appropriate. This review summarises these aspects and provides a guide to the clinical assessment of ptosis.
Ptosis is a lowering of the eyelid to below its normal position. The word ‘ptosis’ derives from the Greek ‘πτωσις’, which translates as ‘to fall’. It is an abbreviation of ‘blepharoptosis’—a fallen eyelid—but this longer version is now almost never used. The normal palpebral fissure measures 12–15 mm. The distance between the corneal light reflex and the upper eyelid margin is termed the upper marginal reflex distance. These two measurements are used for objective assessment of ptosis (figure 1). The official definition of ptosis is an upper marginal reflex distance below 2 mm or an asymmetry of more than 2 mm between the eyes. Ptosis has many causes and is a presenting symptom in both emergency and outpatient settings. While most ptosis presents to ophthalmologists, neurologists often see cases in day to day practice. Ptosis may point towards something as dramatic as a leaking aneurysm or something as mundane as a soft …
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