Ptosis Evaluation & Diagnosis

Part of our complete guide to Ptosis (Droopy Eyelid) — this page covers ptosis evaluation and diagnosis in depth.

Evaluation of Ptosis

Careful measurement is the foundation of ptosis surgery planning. Your oculoplastic surgeon records the following at every ptosis evaluation:

Video: What a Ptosis Evaluation Looks Like

• Margin-reflex distance (MRD-1): the distance from the corneal light reflex to the upper lid margin in primary gaze. Normal ≈ 4–5 mm; ptosis is present when MRD-1 is < 2 mm
• Levator function: total lid excursion from full downgaze to full upgaze with the brow held still. Excellent ≥ 10 mm; fair 5–9 mm; poor ≤ 4 mm — this single measurement largely determines the surgical approach
• Lid crease height: the distance from the lash margin to the skin crease, which guides the incision level
• Phenylephrine test: a drop of 2.5% phenylephrine behind the upper lid stimulates Müller’s muscle; elevation of ≥ 1 mm predicts a favorable response to internal ptosis repair (MMCR)

Hering’s Law of Equal Innervation

When ptosis affects only one eye — or is much worse on one side — Hering’s law becomes critical to surgical planning. Both levators receive equal central drive from the brain. In unilateral ptosis, the brain increases drive to both sides to keep the ptotic lid open. If surgery elevates the ptotic lid, that extra drive drops — and the fellow lid may fall.

This “see-saw” effect means apparent unilateral ptosis can unmask bilateral ptosis after surgery on one side. The interactive animation below demonstrates this phenomenon.

The Phenylephrine (Neo-Synephrine) Test

Instilling 2.5% phenylephrine (Neo-Synephrine) drops stimulates Müller’s muscle. If the eyelid then lifts to a good height, the patient is an excellent candidate for an internal (Müller’s muscle–conjunctival resection) repair. This quick in-office test directly guides the choice of operation.

Key Measurements

• Margin reflex distance (MRD-1): the distance from the corneal light reflex to the upper-lid margin (normal ~4–5 mm); a reduced MRD-1 quantifies the ptosis.
• Levator function: upper-lid excursion from down-gaze to up-gaze (good ≥ 10 mm; fair 5–9 mm; poor ≤ 4 mm) — the single most important measurement for selecting the operation.
• Palpebral fissure height and lid-crease position: a high or absent upper-lid crease points to aponeurotic dehiscence.

Ptosis vs. Blepharoplasty

Two distinct upper eyelid conditions are often confused. Understanding the difference determines which operation is appropriate — and whether insurance will cover it.

Both conditions can be present simultaneously. Ptosis repair and blepharoplasty are frequently combined in a single operation through the same eyelid crease incision.