An adequate history will typically provide important clues to the cause of the eyelid malposition and may also suggest the need for further evaluation before any surgery. In some cases, the history may make immediate surgical intervention unwise.

The time of onset of the eyelid abnormality may be congenital,¹ or acquired later in life. In the case of blepharoptosis, a careful birth history will uncover the possible use of forceps during delivery or the occurrence of other birth trauma. Similar abnormal eyelids in other family members should alert the observer to the possibility of a familial disorder, such as blepharophimosis syndrome or craniosynostosis syndrome. The presence of other congenital anatomical deformities or especially neurologic deficiencies may indicate a more serious genetic syndrome, congenital oculomotor nerve palsy, or a central mechanism for the eyelid disorder.

The time course of onset should be evaluated in all patients. Acute-onset ptosis in an adult may be the result of a metabolic disturbance or a compressive orbital lesion. Hemorrhage into a preexisting, unsuspected eyelid or orbital mass can result in sudden-onset ptosis, especially in children, often associated with some degree of proptosis or ocular motility disturbance. A history of recent trauma with new-onset eyelid malposition should raise suspicion not only of scarring or levator transection but also for a retained foreign body. Blunt trauma without eyelid laceration is more likely to result in a contusive injury to the levator muscle or the oculomotor nerve. These types of injuries have a high probability of spontaneous recovery over time. Unsuspected orbital fractures can be associated with eyelid malpositions. Ptosis that evolves over several days following eyelid trauma may indicate an enlarging hematoma or abscess.

Gradual onset of an eyelid malposition is more typically indicative of involutional disease but may also occur with a paralytic or cicatricial process. Eyelid changes occurring with other extraocular muscle dysfunction or loss of vision demands immediate imaging investigation of the orbital apex and cavernous sinus. History of decreased facial movement with associated ocular surface irritation, tearing, or blurred vision may accompany lagophthalmos or paralytic ectropion. A history of changes in the eyelid skin might suggest a chronic inflammatory process, infection, or dermatosis that has led to cicatricial changes in the anterior eyelid lamella. Chronic ocular surface
disease may result in tarsus or conjunctiva scarring, shortening of the conjunctival fornices, or symblepharon formation.

A history of slow progression is not uncommon with most involutional eyelid changes, but this usually occurs over several years.² Almost all patients with ptosis or dermatochalasis will report variable fissure height, with some increase in droopiness late in the day or when tired. This does not usually indicate myasthenia gravis. The occurrence of an eyelid malposition with orbital pain is always worrisome and demands an investigation to rule out neoplasm or inflamation. Any such association requires radiographic study.

A history of previous eye, eyelid, or sinus surgery is important. Eyelid malpositions are not uncommon sequelae of retinal detachment surgery, strabismus surgery, or cataract extraction.³,⁴ Ptosis is reported to occur following cataract surgery in 7% to 8% of cases. Other surgery, especially intracranial or thoracic procedures, may result in central third nerve palsy or Horner syndrome, respectively.⁵

The patient should be questioned carefully about previous episodes of eyelid edema, as with allergic angioneurotic edema or blepharochalasis syndrome, which can affect eyelid position.⁶ This is particularly true in younger patients. A past or present history of systemic diseases that commonly affect the eyelid and orbit, such as thyroid ophthalmopathy, should be noted. Symptoms of thyroid hormone imbalance should be reviewed since the eyelid manifestations of Graves disease may precede the diagnosis of systemic thyroid dysfunction.

A thorough ocular history should be obtained to attempt to uncover the presence of chronic conjunctivitis or uveitis, or a past or present history of cicatricial diseases, such as ocular pemphigoid or Stevens-Johnson syndrome. A history of morning ocular irritation and spontaneous eyelid eversion during sleep, particularly in an obese male, should lead to careful examination of the conjunctiva for papillary conjunctivitis, and of the tarsus for possible floppy eyelid syndrome.

Any prior malignancy should raise the possibility of a mechanical etiology for a malpositioned eyelid from metastatic disease. The previous excision of an eyelid or periocular tumor should alert the observer to the possibility of deep orbital recurrence resulting in distortion of eyelid position.