Download Eyelid Anatomy and Evaluation

Lip Teh
December 2005
Eyelid Anatomy and Evaluation
Embryology
 eyelids develop from mesenchymal folds above and below the optic cup
beginning during the 4 - 5 week
 week 10 – eyelids make contact along their margin and temporarily fuse by
desmosomes, thus isolating the eyes from amniotic fluid
 begin to separate at 20 weeks
 Failure of complete separation results clinically in varying degrees of
ankyloblepharon
 Levator develops late in the 3rd month
 Initially, the levator and superior rectus are blended as one common muscle.
 When the fetus reaches 60 mm in length, the levator muscle separates.
 This unique two-stage embryogenesis may explain why the levator muscle is
the eye muscle most prone to defects.
Anatomy
Lip Teh
December 2005
Eyelid skin
 thinnest in human body (0.7mm), upper thicker than lower.
 dense sweat glands
 least sebaceous glands
Blood supply
 marginal arcade - superior and inferior marginal palpebral arcades
 peripheral arcade – at proximal end of tarsal plate
 contibutors:
1. superomedial - dorsal nasal artery, supraorbital artery, supratrochlea artery
2. superolateral - frontal branch of superficial temporal artery
(Zygomaticoorbital – branch of middle temporal artery), lacrimal artery
3. inferomedial - angular artery, infraorbital artery
4. inferolateral - zygomaticofacial artery, transverse facial artery
Lip Teh
December 2005
Nerve supply
 superomedial - supraorbital nerve, supratrochlea nerve, infratrochlea nerve
(V1)
 superolateral – lacrimal (v1)
 inferomedial - infraorbital nerve(v2), infratrochlea nerve
 inferolateral - zygomaticofacial nerve (v2)
Lymphatics
 preauricular nodes – upper lid, lateral canthus, lateral ½ of lower lid
 submandibular nodes (via lymphatics of facial vein) – medial canthus, medial
½ lower lid
layers
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anterior lamellae - skin and orbicularis
middle lamellae - septum
posterior lamellae – tarsus, retractors and conjunctiva
Lip Teh
December 2005
Orbicularis oculi
 palpebral (preseptal, pretarsal) and orbital parts
 gentle blink - pretarsal and preseptal
 hard blink –orbital part
 Riolan's muscle - at lid margin, forms gray line
 orbicularis oculi has a direct muscle attachment to the inferior orbital rim from
the anterior lacrimal crest out to approximately the level of the medial
corneoscleral limbus above the origin of the levator labii superioris. Lateral to
this point, the attachment of the orbicularis to the rim is indirect through the
orbicularis retaining ligament
 Nerve suppy (on deep surface):
o Superior - temporal and zygomatic branches
o Inferior – segmental supply from buccal and zygomatic branches
o Relevance is that subciliary skin/muscle flaps will not denervate the
muscle
Lip Teh
December 2005
Orbicularis retaining ligament (orbito-malar ligament)PRS Sept 2002
 bilaminar septum-like structure attaching the orbicularis oculi to the inferior
orbital rim.
 The attachment of the retaining ligament is broader and stronger
inferolaterally than centrally.
 Aging changes of the retaining ligament are associated with distension,
elongation, and thinning.
Lip Teh
December 2005
ORL is negligible medially, increases to a maximum centrally, and then diminishes laterally. Its laxity creates a V-shaped
deformity
Levator palpebrae
 Lie deep to the preaponeurotic fat
 55mm (40mm muscle), 10-15mm excursion
 origin – lesser wing of sphenoid
 changes direction from horizontal to vertical at Whitnall’s ligament (superior
to muscle)
 insertion
 anterior fibres – orbital septum/skin forming supratarsal fold
 posterior fibres – anterior surface of tarsus 3-4mm below superior
border
 medial horn – posterior limb of medial canthal ligament
 lateral horn – superior edge of lateral canthal ligament, dividing
lacrimal gland into orbital and palpebral parts
 Alternative theory (R Siegel)
 Dynamic fusion between levator aponeurosis and septum with
intervening fat (zipper or conjoint fascia). Eyelid folds at the superior
end of the fusion
 Take too much fat and the fusion point will move superiorly giving the
impression of ptosis.
Lip Teh
December 2005
Mullers muscle
 nonstriated smooth muscle (10mm long, 15mm wide)
 2-3mm of excursion
 inserts superior border of tarsal plate
 nerve supply: sympathetic (T1) via internal carotid artery
Inferior Oblique muscle
 originates on the orbital floor, 5.14 ± 1.21 mm posterior to the inferior orbital
rim, on a line extending from the infraorbital foramen to 10 ± 0.9 mm medial
to the supraorbital notch along the supramedial orbital rim.
Lip Teh
December 2005
Capsulopalpebral ligament
 Condenses from Lockwood’s ligament (inferior oblique)
 5mm length
 Equivalent to levator for lower lid
 Some fibres insert into dermis to contribute to lower eyelid crease
 Deep to the fascia lies the inferior tarsal muscle, which is analogous to
Mueller's muscle.
Tarsus
 firm, dense fibrous tissue, contains Meibomian glands
 extends from lateral canthus to punctum
 superior 30mm long, 1mm thick, 10mm wide
 attachments – pretarsal obicularis, levator (anterior), Mullers(superior),
conjunctiva (posterior), canthal tendons
 inferior 25mm long, 1mm thick, 5mm wide
 attachments – pretarsal obicularis, capsulopalpebral ligament,
conjunctiva, canthal tendons
Medial canthal tendon
 anterior limb – anterior lacrimal crest (anterior to lacrimal sac)
 posterior limb – posterior lacrimal crest
 vertical limb – directed superoposteriorly.
 Unlike lateral tendon, this inserts strongly into bone (Sharpys fibers)
 medial retinaculum – formed by
1. deep head of pretarsal orbicularis
2. medial horn of levator
3. medial part of Lockwoods ligament
Lip Teh
December 2005
4. medial rectus check ligaments
5. orbital septum
6. Whitnall’s ligament
Lateral canthal tendon
 inserts into periosteum (not to bone) around Whitnalls tubercle (2mm deep to
lateral orbital rim, 10mm below ZF suture)
 has superficial and deep (or anterior and posterior), and superior and inferior,
attachments to the orbital rim

 lateral retinaculum – formed by
1. lateral canthal tendon
2. preseptal and pretarsal orbicularis
3. lateral horn of levator
4. Lockwood’s ligament
5. lateral check ligaments
 lateral palpebral raphe lies superficial - joining the upper and lower
preseptal orbicularis muscle
Septum orbitale
 arcus marginalis is where periosteum meets the septum
Lip Teh
December 2005
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Upper lid – inserts into levator aponeurosis 10-15mm above tarsus
Lower lid – insers into capsulopalpebral fascia 5mm below tarsus
Laterally, the septum is attached to the orbital margin, 1.5 mm in front of the
Whitnall’s tubercle attachment of the lateral canthal tendon. The Eisler fat
pocket separates the lateral canthal tendon from the orbital septum. From
there, the septum continues along the superior orbital rim at the arcus
marginalis. Superomedially, the septum bridges the supraorbital groove,
passes inferomedially anterior to the trochlea, and then follows the posterior
lacrimal crest. As it runs down the posterior lacrimal crest, it lies anterior to
the medial check ligament and posterior to the Horner muscle (and hence
behind the lacrimal sac). The line of attachment crosses the lacrimal sac fascia
to reach the anterior lacrimal crest at the level of the lacrimal tubercle. From
there, it passes inferiorly down the anterior lacrimal crest and laterally along
the inferior orbital rim. A few millimeters lateral to the zygomaticomaxillary
suture, the attachment leaves the rim and lies several millimeters from it on the
facial aspect of the zygomatic bone, thus forming the fat-filled premarginal
recess of Eisler. The line of attachment then continues to again reach the
lateral orbital rim just below the level of the Whitnall ligament.
Lip Teh
December 2005
The orbicularis muscle fibers, together with skin (anterior lamella) insert
anteriorly on the outer edge of the lateral orbital rim. The tarsoligamentous sling
(posterior lamella) inserts as the lateral canthal tendon inside the lateral rim on the
lateral orbital tubercle.
Postseptal/preaponerotic fat pads
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acts as a cushion to the eyelid and divides the septum from the levator
aponeurosis,
this fat remains relatively constant regardless of obesity or weight loss.
There is a greater amount of connective tissue and blood vessels in white fat
(medial compartments); the yellow fat (lateral) has a greater amount of
carotenoids.
Lip Teh
December 2005

Upper eyelid: 2 fat pads
1. long thin central fat pocket, preaponeurotic fat, yellow
2. globular medial fat pad – derived from intraconal orbital fat, white
3. Separated by superior oblique
4. medial fat pad is associated with the infratrochlear nerve and the
terminal branch of the ophthalmic artery
 Lower eye lid 3 fat pads (nasal, middle, and temporal)
5. The medial and central fat pads are separated by the inferior oblique
proper
6. Lateral fat pad sits in Eisler’s recess, separated by arcuate expansion
of inferior oblique
Lacrimal glands
 Basic secretors
1. goblet cells(conjuctival, tarsal and limbal) – inner layer mucin
2. accessory glands of Krause and Wolfring (fornices) - aqueous
3. meibomian glands (tarsal plate) - oil
 Reflex secretors – main lacrimal gland
o Lateral horn of the levator palpebrae superioris divides the lacrimal
gland into an orbital(66%) and a palpebral lobe (33%)
o lateral palpebral lobe is prone to prolapse and may be visible
externally.
o Ducts from orbital lobe pass through palpebral lobe. which in turn
empties into the superolateral conjunctival fornix via six to twelve tear
ductules. Extirpation of palpebral lobe equals total excision of glands
o
 Pilosebaceous(sweat) glands of Zeiss and the apocrine glands of Moll are
located anterior to the meibomian glands within the distal eyelid margin (at the
cilia)
1. infected meibomian gland leads to internal hordeolum
2. infected Zeiss or Moll gland leads to external hordeolum
 Tear = 3 layers
1. Innermost – mucous layer from goblet cells. Thinnest layer (0.05 m
thick)
2. Middle – aqueous layer from Krause and Wolfring (7.0 m thick)
3. Outermost – lipid layer from Meibomian-stabilise and reduce
evaporation (0.11 m thick) – also reduces surface tension so tears
don’t form doplets on cornea
 Needs presence of intact neural system
o Afferent fibres from the cornea (ophthalmic division of the trigeminal
nerve, V1) synapse in the nucleus of the spinal tract of V. Within the
brainstem, secondary axons from this nucleus synapse in the reticular
formation. This initiates bilateral contact with the facial nerve (VII)
motor nuclei which, in turn, innervate both orbicular muscles resulting
in eyelid closure.
o stimulation of the cornea gives rise to stimulation of the
parasympathetic facial nerve fibres via the salivary nucleus through to
the greater petrosal nerve.
o From the pterygopalatine ganglion, the post-synaptic fibres follow the
zygomatic nerve via the lacrimal nerve to the gland itself
Lip Teh
December 2005

o normal or basal tear flow is predominantly under sympathetic
control by regulating the gland’s blood supply, whereas reflex tear
secretion is under parasympathetic control as a result of
trigeminal nerve stimulation.
Drainage system
1. Evaporative 15%
2. Canaliculi 85% (lower 80%, upper 20%)
3. Punctum Lacrimale - Each is a small round or oval orifice (~0.3mm in
diameter) at the summit of papillae lacrimalis, situated at the junction
of the ciliary & lacrimal portion of lid margin medially. It is in line
with the openings of tarsal glands.
4. Each canaliculi has 2 mm vertical component and a 7-8 mm horizontal
component
5. Upper horizontal limb is directed medially & inferiorly while the lower
limb is directed medially & superiorly, both piercing lacrimal fascia &
unite (>90%) forming a small diverticulum ( sinus of Maier ) prior of
entering lateral wall of lacrimal sac ~ 2.5 mm below its apex, at the
level of the lower border of medial canthal tendon. Valve of
Rosenmuller within diverticulum prevents reflux.
6. Lacrimal sac - 12-15mm in vertical length. Portion above entrance of
common canaliculus is the fundus ~3-4mm in height & is normally
compressed by the medial canthal tendon. Anterior ethmoidal sinus lies
medially.
Lip Teh
December 2005
Lip Teh
December 2005
Tear composition
1. proteins/enzymes
a. protein composition of the closed-eye tear(immediately
upon waking) is significantly different from that of the open
and reflex-eye tear.
b. protein constituents of human tears maintain the surface
integrity of the cornea and conjunctiva, protect the eye from
microbial invasion, maintain the stability of the tear film
and also act as a lubricant between the eye and eyelids
c. Secretory IgA, lactoferrin, lipocalin(tear-specific prealbumin) and lysozyme
d. predominant proteins in reflex and open-eye tears are
lactoferrin, lipocalin and lysozyme
e. closed-eye tear is characterised by an increase in sIgA,
albumin and decrease in lactoferrin, lipocalin and
lysozyme.
2. electrolytes
a. 297 mEq/l
b. Na 132 mmol/L, K 24 mmol/L, HCO2 32.8mmol/L, Ca
0.8 mmol/L, Mg 0.61 mmol/L
3.
Superior Transverse Ligament (Whitnall’s ligament)
 extends from the lacrimal gland fossa to the trochlea
 acts as a fulcrum to allow for the change in direction of the levator and as a
Lip Teh
December 2005
check ligament for the levator muscle
Inferior Suspensory Ligament (Lockwood’s ligament)
 originates as a fibroelastic tissue from the inferior oblique muscle as two
sheets.
 Anteriorly these sheets fuse to form Lockwood’s ligament.
 Anterior to Lockwood’s ligament is the capsulopalpebral fascia.
Preseptal Fat
 Submuscular areolar tissue deep to the orbicularis oculi muscle.
 The lid may be split into anterior and posterior portions through this potential
plane, which is reached by division at the gray line of the lid margin.
 In the upper lid, this plane is traversed by fibers of the levator aponeurosis,
some of which pass through the orbicularis to attach to the skin to form the lid
crease.
 In the lower eyelid, this plane is traversed by fibers of the orbitomalar
ligament.
Lip Teh
December 2005
 Superior continuance in this submuscular plane arrives at the retro-orbicularis
oculi fat (ROOF), which is best developed in the eyebrow region.
 Suborbicularis oculi fat (SOOF) is found in the lower lid in a continuance of
this plane. Ramirez believes that ptosis of SOOF forms the malar fat pad
which is anterior to zygomaticus major and levator labii superioris
Evaluation
History
1) aesthetic concerns – wrinkles/forehead/eyelids/bulges
2) functional concerns – blocking vision
3) ocular history - dry eyes, contact lenses
4) systemic diseases – bleeding disorders, thyroid disease, myasthenia gravis
5) medications –aspirin
Surface assessment
1. Brow position
 Hairline 5-6cm
 Midpupil to bottom of brow >23mm
 With brow elevated, check eyes can still close—if not brow lift is
limited
 Get patient to close eyes in relaxed posture, then have patient open
eyes—measure automatic brow elevation=compensated brow
ptosis = this compensation will be lost if brow-only ptosis done
 Close eyes and totally relax forehead—press thumbs against brow to
obstruct elevation by frontalis—now open eyes—this is resting
brow posture and position of brow if bleph-only procedure is
performed
Lip Teh
December 2005
2. Globe
 Visual acuity
 Visual fields especially with ptosis
 Proptosis vs exopthalmos
o Exopthalmos defined as protusion secondary to endocrine dysfunction
and proptosis as due to nonendocrine causes
 Shallow anterior chamber - glaucoma
 Bells Phenomenon
 Reflex between facial and oculomotor nuclei
 Corneal reflex
 Reflex between V1 and Facial nerve
3. Lid aesthetics
 Palpebral fissure is 1/5 of facial width
 intercanthal distance
 28-32mm in female 32-34mm male (1/2 interpupillary distance)
 hyperteloric vs telecanthus
 Supratarsal crease (margin-crease distance)
 results from a fusion of the levator aponeurosis, orbital septum, and
fascia of the orbicularis oculi into the dermis.
 8-10mm above lid margin in Caucasians males, 10-11 in females
 Siegel believes that the height shoud be determined by the
balance of levator vs orbicularis (zipper fascia). Slightly
lower fold if levator is weak.
 2-3mm in most Asians
 Palpebral fissure distance 10-11mm
 upper lid margin overlaps limbus 1-2mm (limbus usually 11mm)
 lower lid crease
 4-6mm below lid margin
 margin touches limbus
 lateral commissure more mobile and more acute angle
 lateral canthus higher than medial (0-2mm male, 2-4mm female)
 mongoloid if this exaggerated
 reverse slant - Treacher Collins
 Visible pretarsal skin 3-6mm
 Factors determining amount of visualised pre-tarsal skin
1. Posture of brow at rest—the lower the brow the more lid overhang
2. Amount of skin redundancy
3. Level at which levator aponeurosis joins septum—ie level of fold
4. Lid fat—more fat=less pretarsal skin
Lip Teh
December 2005
The mean height of the eye fissure measured from the upper lid (P s) to
lower lid (P i) margin at the midpupil was 10.8 ± 1.2 mm. The mean
length of the eye fissure measured from medial to lateral canthus was
30.7. The mean inclination of the eye fissure was 4.1 degrees ± 2.2
degrees
4. Eyelid Bags
 Consider
1. excess skin
a. loss of skin elasticity - leading to rhytides, color and texture
changes, and festoon formation. The thin skin unveils
underlying irregularities including orbicularis, orbital fat,
and the tear trough.
2. excess fat – orbital fat prolapse
a. upper lid – reduced pretarsal skin show or lower crease
b. lower lid – eyelid bags defined below by the junction of the
septum at the orbital rim. fat compartments may be
visualised
c. may also be due to SOOF or malar fat pads
d. Unlike oedema, orbital fat is ballotable.
3. excess fluid
a. eyelid accumulates fluid preferentially in systemic edema
or local edema such as facial allergy
b. worse after a salty meal or in the morning.
c. Purplish color
d. Limited inferiorly by the orbital rim because of the
cutaneous ligaments, but it does not show the orbital
compartmentalization of orbital fat.
4. excess muscle
a. combines with loss of skin elasticity to contribute to
dynamic and static rhytides
b. Festoons of hypotonic muscle are diagnosed by the squinch
test, in which the patient tightly contracts the orbicularis
and the fold disappears.
5. tear trough depression
a. feature of eyelid and midface aging
b. more likely in those with maxillary hypoplasia
c. due to loss of subcutaneous fat with thinning of the skin
over the orbital rim ligaments combined with cheek descent
Lip Teh
December 2005
5. Lid ptosis
 Elevated position of tarsal crease suggests levator dehiscence
 Differentiate from pseudoptosis (excess skin)
 ptosis measurements (in primary gaze)
 Upper lid to limbus overlap
1. 1-2mm
mild
2. 3
moderate
3. >4mm
severe
 Marginal reflex distance -1 (light reflex to upper lid margin)
1. >2.5mm normal
 Marginal reflex distance -2 (light reflex to lower lid margin)
1. >5mm
normal
 eyelid excursion (levator function)
1. 0-4mm
poor
(severe >4mm ptosis)
2. 5-7
fair
(3mm ptosis)
3. 8-10
good
(1-2mm ptosis)
4. >11
mm
excellent
6. Lid support (lower lid)
 Distraction test
 pull lid away from globe
 >7mm abnormal
 Snap back test
 pulls lid away and inferiorly and allow to retract
 Grade 0 - normal lid that returns to position immediately on release
 Grade I - approximately 2-3 sec
 Grade II - 4-5 sec
 Grade III - >5 sec but does return to position with blinking
 Grade IV - never returns to position and continues to hang down in
frank ectropion after the snap-back test
 Cheek lift
o Assess for cicatricial ectropion
o If lid margin reaches level of upper limbus, no problem
 Intraoperative (Codner)
 Pull the incised lower lid laterally
 Distance the lower lid stretches to the orbital rim represents the amount
of redundancy.
 <3mm overlap – canthopexy, otherwise canthoplasty
7. Canthal laxity tests
 Lateral canthal tendon
 Pull lower lid medially away from lateral canthus and measure
displacement of lateral canthal corner; the greater the distance the more
the laxity
 Grade 0 - <2mm (normal)
 Grade I - 2-4 mm
 Grade II - 4-6 mm
 Grade III - > 6 mm
 Grade IV - >6mm and does not return to baseline even after blinking
Lip Teh
December 2005
 Medial canthal tendon
 distract the lower lid laterally.
 Grade 0 – <2mm (normal)
 Grade I - 2 mm displacement
 Grade II - 3 mm
 Grade III - >3 mm
 Grade IV - does not return to baseline
8. Lacrimal apparatus
 Look for
 Prolapsed gland
 Everted puncta
 Canalicular test
 involves injection of saline into the lower canaliculus through a
lacrimal cannula.
o If the saline comes out the upper canaliculus, the test is considered
positive; ie, the ducts are patent at least as far as their union with each
other or with the lacrimal sac.
Lip Teh
December 2005
 Primary dye test
 Checks for intranasal staining after 1 drop fluorescein application in
the eye
 If dye is seen, the test is said to be positive, meaning there is no
obstruction in the lacrimal passages and the epiphora is due to
hypersecretion.
 Secondary dye test
 Follows the primary test – saline is flushed via a lacrimal canula.
Staining in the nose implies a partial obstruction.
 Slit lamp examination
 Stains: Rose bengal stains not only dead and devitalized cells but also
healthy cells that are protected inadequately by a mucin coating.
Fluorescein pools in epithelial erosions and stains exposed basement
membrane.
 Decreased tear meniscus
 Increased debris in the tear film
 Superficial punctate keratopathy
 Tear film breakup time (BUT)
 Looks at stability of the tear film
 Measure the average time for the first small hole to appear in the tear
film when the fluorescent stained cornea is viewed using a cobalt blue
filter on a slit lamp
 Abnormal if <10s
 Schirmer test 1
 Measures basal and reflex production
 5x35mm Whatman no 41
 5mm is placed on lateral third of lower lid
 Left for 5mins
 Normal is 15mm, abnormal <10mm, very abnormal <5 mm
 Schirmer test 2 (perform if above is abnormal)
 Measures basic secretion
 Instill LA drops then dry with cotton tip applicator
 Normal is 10mm, abnormal <5mm, <3mm is very abnormal.
 Note: in ophthalmology literature, Schirmers 2 refers to a reflex
secretion test
o Perform by irritating the nasal mucosa with a cotton-tipped applicator
prior to measuring tear production filter paper. Wetting <15 mm after 5
min is considered abnormal.
9. Cheek aesthetics
 malar hypoplasia – globe vector
 relationship on lateral view between the anteriormost projection of the
globe and the malar eminence.
 Negative = angles posteriorly, indicates an absence of support for the
lower lid.
Lip Teh
December 2005
the cheek mass should lie an average of 1.5 mm anterior to the
cornea(positive vector)
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superior sulcus deformity
central/medial fullness – fatpad herniation
lateral fullness – prolapse of lacrimal gland
deepening – fat atrophy, orbital fracture, enucleation
hypertrophy of orbicularis – patients who squint a lot
lower lid aging
o orbital malar weakens – descend of malar fat pad
o malar crescent – hollowing of infraorbital region and sagging cheek
o increased distance between lower lid and check junction
o nasolabial folds deepen
Tests for myasthenia gravis
 edrophonium (Tensilon) test has remained the first-line test for diagnosis of
MG. The Tensilon test consists of injecting a small amount of the medication
edrophonium intravenously. If the patient has MG the ocular muscle weakness,
the ptosis, the general muscle weakness and/or nystagmus will improve
dramatically for a short period of time.
 acetylcholine receptor antibody titer (AChR Ab)
 peek test – attempt to forcibly open closed eyes, fatigue results in one or both
eyes opening, and the patient appears to “peek” at the examiner.
 fatigue test - This consists of having the patient look at an object held up by
the examiner in front of the patient. After a short period of time the eyelid(s)
will droop in the person with ocular MG.
 sleep test, which is based on the tendency for MG symptoms to improve
following rest, may be especially useful in cases where a Tensilon test is
technically difficult. This may be used in small children, patients with poor
veins, or allergy or sensitivity to anticholinesterase drugs such as Tensilon.
 morning/evening comparison test is similar in concept to the sleep test. The
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December 2005
patient is photographed, and the ptosis and ocular motility are compared at
different times during the day. Old photographs are very helpful to determine
how long the patient has drooping the of the upper eyelids.
 ice test is a simple test for ocular MG in patients who have ptosis. A surgical
glove filled with ice is held against the droopy eyelid for several minutes. In
ocular myasthenia the patient can open his/her eyelid normally for a short
period of time after the ice is removed.