Evaluation of ptosis requires assessment of the upper eyelid crease, the amount of ptosis, and the function of the levator muscle. In severe congenital ptosis, the eyelid crease is usually absent. The clinician can determine the amount of ptosis by measuring the palpebral fissure height and the margin–reflex distance (MRD). The MRD is the distance from the margin of the upper eyelid to the corneal light reflex when the eye is in primary gaze. The examiner can determine levator muscle function by applying finger pressure on the brow to block the frontalis muscle and then measuring the distance that the upper eyelid moves when the patient shifts from downgaze to upgaze. Tear function and corneal sensitivity should be evaluated because exposure may occur after surgical repair. If the Bell phenomenon is poor, the cornea can decompensate after ptosis repair. The clinician should also determine whether the globe is microphthalmic or whether a hypotropia is present, as either of these conditions may produce pseudoptosis.

Correction of mild or moderate ptosis can usually be delayed until the patient is several years old, although a compensatory chin-up head posture may justify earlier surgery. Marked ptosis that obstructs vision must be corrected early in infancy to prevent deprivation amblyopia. Surgical techniques include external levator muscle resection, levator aponeurosis tuck, and frontalis suspension. When levator muscle function is less than 4 mm, frontalis suspension is usually performed. Materials for suspension include autologous fascia lata, human donor fascia lata, and synthetic material such as silicone rods. Autologous fascia cannot be obtained until the patient is 3 or 4 years old. Use of synthetic material or donor fascia lata may lead to higher recurrence rates.

Marcus Gunn Jaw-Winking Syndrome

Marcus Gunn jaw-winking syndrome (co-contractive retraction with jaw–eyelid synkinesis syndrome [CCRS], type 5) results from congenital synkinesis of the jaw and levator muscles. The ptotic eyelid elevates with opening of the mouth or movement of the jaw to the contralateral side. The clinician may test an infant for this condition by having the child suck on a bottle or pacifier. Treatment may involve simple ptosis repair or a combination of disinsertion of the levator muscle and frontalis suspension. Frontalis suspension may also be performed on the normal eyelid to achieve a more symmetric appearance.

Demirci H, Frueh BR, Nelson CC. Marcus Gunn jaw-winking synkinesis: clinical features and management. Ophthalmology. 2010;117(7):1447–1452.

Infectious and Inflammatory Eyelid Disorders

Inflammatory masses of the eyelids are much more common than neoplasms (Table 17-2). Chalazia are caused by blockage of the meibomian glands, and hordeola arise from blocked eccrine or apocrine glands. Treatment of both includes warm compresses and management of associated blepharitis; surgical treatment is reserved for large, painful, or chronic lesions. Pyogenic granuloma is a pedunculated, fleshy pink growth of granulation tissue that develops, sometimes rapidly and exuberantly, from the conjunctiva overlying a chalazion or site of trauma. Eyelid and epibulbar lesions can develop in juvenile xanthogranuloma (see Chapter 20).