CHAPTER 11
The Patient With Eyelid or Facial Abnormalities
Eyelid abnormalities and facial movement disorders are frequently encountered in ophthalmology. Many such problems are neurologic in origin and therefore require careful evaluation. A thorough history of the presenting complaints is essential, as is documentation of concomitant medical conditions. Although most patients are aware of an abnormality in the position or function of the eyelid, some may present instead with a chief concern of visual difficulties (eg, visual loss from ptosis) or pain (eg, exposure keratopathy from facial palsy). Occasionally, patients will attribute the problem to the wrong eye, mistaking ptosis for contralateral lid retraction, for example, or widening of the palpebral fissure for contralateral ptosis. The clinician should ask about onset and duration of symptoms, as well as associated symptoms. A careful evaluation of eyelid function and facial movements along with a thorough ophthalmic examination should be performed. Diagnosis and management of eyelid disorders are discussed at greater length in BCSC Section 7, Orbit, Eyelids, and Lacrimal System.
Examination Techniques
An examination of the eyelids begins by observing their general shape and appearance (eg, an S shape may indicate neurofibromatosis [Fig 11-1; see also Chapter 14] or pathology affecting the lacrimal gland) and blink rate (eg, low in Parkinson disease and high in blepharospasm), and by noting abnormal movements (eg, synkinesis with other facial muscles). If the ptosis is unilateral, the clinician should verify that it is not an artifact of vertical strabismus (eg, hypotropia; Fig 11-2) or contralateral lid retraction. The eyelids should be everted for examination to rule out a local cause of ptosis, such as retained contact lens or giant papillary conjunctivitis. If the ptosis is asymmetric—and especially if the higher eyelid appears retracted—the clinician should manually raise the ptotic eyelid to see if the higher eyelid drops to a new position (Fig 11-3).
Figure 11-1 Ptosis in a 2-year-old with neurofibromatosis; the S-shaped eyelid margin results from the presence of a
plexiform neurofibroma. (Courtesy of Steven A. Newman, MD.)
Figure 11-2 A, Patient with pseudoptosis from a large left hypotropia. B, Occlusion of the right eye revealed markedly improved upper eyelid position. (Courtesy of Tariq Bhatti, MD.)
Figure 11-3 A, Patient with myasthenia gravis and left-sided ptosis that is greater than that on the right. B, Manual opening of the left eyelid results in greater rightsided ptosis (enhanced ptosis). This sign, although often present with myasthenia gravis, is not specific. It may occur with other disorders producing asymmetric ptosis and is a manifestation of Hering’s
law of equal innervation. (Courtesy of Rod Foroozan, MD.)
Four important clinical measurements to obtain when evaluating a patient with ptosis include
1.margin reflex distance
2.vertical palpebral fissure height
3.upper eyelid crease position
4.levator function
Descriptions of these measurements are provided in BCSC Section 7, Orbit, Eyelids, and Lacrimal System, Chapter 11.
In addition, eyelid movement during target pursuit from upgaze to downgaze should be observed. Normally, such movement is smoothly accomplished, but eyelid lag may occur in patients with thyroid eye disease (Fig 11-4; see also Chapter 14) or as a result of aberrant regeneration of the third cranial nerve (CN III) (see also Chapter 8).
Figure 11-4 Eyelid retraction from thyroid eye disease (Graves ophthalmopathy). This 73-year-old woman presented with a 6-month history of foreign-body sensation (previously treated as “dry eye syndrome”). Eyelid retraction on the left side is