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Page 8 of 23 Farber et al. Plast Aesthet Res 2020;7:20 I http://dx.doi.org/10.20517/2347-9264.2020.05

Figure 11. Large male with the hallmark appearance of floppy upper lid syndrome and ptosis

eyelid fatigability when the patient is instructed to close his or her eyes tightly, fatiguing the orbicularis and
inhibiting the levator, and to open them rapidly. A positive test is defined by immediate upward movement
of the lid secondary to the levator muscle, followed by downward drift. An adult with new onset signs and
symptoms, including the ones just mentioned, should have a neuro-ophthalmologic evaluation including a
Tensilon test.

Another important consideration is the presence of xerophthalmia, or dry eye syndrome. This syndrome is
characterized by a disruption in the tear film either due to decreased production or increased evaporation.
Symptoms such as burning, itching, foreign body sensation or other types of eye discomfort should be
elucidated. Risk factors for dry eye syndrome include laser eye surgery, smoking, and certain medications.
These risk factors should be mitigated prior to surgery and eye lubricating drops and ointments may also
[3]
be used as adjuncts .

Importantly, ptosis can be a key presenting sign in patients with the onset of neurological conditions.
Therefore, in an adult presenting with ptosis, the absence of levator dehiscence, and the presence of other
red flag symptoms such as diplopia, abnormal pupillary reflexes and difficulty with speech or swallowing,
[1]
neurological evaluation is critical to rule out other potentially life-threatening conditions .

Physical examination
Any ocular and periorbital examination should begin with an assessment of the globe, including visual
acuity, extraocular movements, and pupillary response. Additionally, Bell’s phenomenon should be
[5]
documented to ensure that the patient’s cornea will be protected postoperatively [Figure 12] .