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Ptosis

Essentials

  • Drooping of the upper eyelids can be caused by blepharochalasis (dermatochalasis), ptosis or a combination of these.
  • A patient with acutely developed ptosis should be referred for further treatment on an emergency basis, primarily to a neurologist.
  • Congenital ptosis should be observed during the first visits to the child health clinic at the latest, and the infant should be promptly referred to an ophthalmologist for assessment.
  • It is important to distinguish ptosis from blepharochalasis which often is a cosmetic problem only and does not require immediate treatment.

Aetiology and clinical features

  • Blepharochalasis refers to the extra, loose skin and subcutaneous tissue of the upper eyelids that develop as the eyelid tissue loosens with ageing.
  • Ptosis refers to the entire upper eyelid descending. Sometimes the forehead and brow level can also descend (brow ptosis).
  • Ptosis can be uni- or bilateral.
  • The upper lid becomes ptotic if the muscles elevating the upper lid (m. levator palpebrae, m. tarsalis) do not function properly. The ptosis may be associated with paralysis of the ocular muscles. It can be an independent disease or part of a syndrome.
  • Congenital ptosis
    • It is usually unilateral and constantly present from birth.
    • The severity of the condition varies from hardly detectable to ptosis totally obscuring the pupilla. If the pupilla is covered, visual ability does not develop normally and the eye becomes amblyopic.
  • Secondary ptosis
    • May be a symptom of a muscle disease (myasthenia gravis Myasthenia Gravis, ophthalmoplegia externa progressiva, myotonia dystrophica Hereditary Myopathies, polyradiculitis Guillain-Barré Syndrome (Polyradiculitis)).
    • The symptom may be associated with paresis of the oculomotor nerve. In this case the patient always has, in addition to the ptosis, an eye movement disorder and potentially disturbance in the pupillary reflex.
    • In Horner's syndrome the sympathetic tract is damaged.
    • Various surgical interventions to the eye may also cause secondary ptosis.

Examining the patient

  • The asymmetry is usually easily visible. The difference between the eyes should be measured by using the margin to reflex (MRD) measurement (picture 1). When the patient looks up, a ptotic upper lid does not rise normally and the cornea stays under the lid.
    • Normal MRD is 4-5 mm.
  • Examine the pupillar reaction.
    • Mydriasis, i.e. dilation of the pupil, is observed in oculomotor palsy.
    • Horner's syndrome is a disorder of the sympathetic innervation where the patient has at the same time both ptosis and miosis, i.e. constriction of the pupil.
      • One possible rare cause of Horner's syndrome is dissection of a large blood vessel in the neck area which may be completely painless.
  • Examine eye movements.
    • Oculomotor palsy usually involves external strabismus as well as restricted eye movements in other orthogonal gaze directions.

Treatment

  • Acutely developed ptosis warrants emergency consultation with a neurologist.
  • Mild ptosis needs no treatment.
  • Surgical indications for ptosis
    • Functional impairment related to vision
    • More than 3 mm asymmetry in MRD
    • Almost total eye closure when reading
  • In congenital ptosis, if the pupillar opening is free, allowing vision to develop normally, the operation should be postponed until school age. If the pupillar opening is covered, the operation should be performed in early infancy to prevent amblyopia.
  • It is important to distinguish ptosis from blepharochalasis. The latter often is a cosmetic problem only and does not require immediate treatment. Blepharochalasis may also be associated with functional impairment, e.g. visual field restriction, in which case the patient may be referred to an ophthalmologist for an assessment.

    References

    • Rasiah S, Hardy TG, Elder JE, et al. Aetiology of acquired blepharoptosis in young adults. Orbit 2018;37(1):59-64. [PubMed]
    • Latting MW, Huggins AB, Marx DP, et al. Clinical Evaluation of Blepharoptosis: Distinguishing Age-Related Ptosis from Masquerade Conditions. Semin Plast Surg 2017;31(1):5-16. [PubMed]
    • Marenco M, Macchi I, Macchi I, et al. Clinical presentation and management of congenital ptosis. Clin Ophthalmol 2017;11():453-463. [PubMed]
    • Yadegari S. Approach to a patient with blepharoptosis. Neurol Sci. 2016 Oct;37(10):1589-96.