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Ptosis, Adult: Differential Diagnoses & Workup

Author: Adam J Cohen, MD, Assistant Professor, Department of Ophthalmology, Northwestern University Feinberg School of Medicine; Consulting Surgeon, Myers Wyse Center for the Eye; Director, Center for Facial Rejuvenation
Coauthor(s): Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota
Contributor Information and Disclosures

Updated: Aug 29, 2008

Differential Diagnoses

Anophthalmos
Hemangioma, Capillary
Apraxia of Lid Opening
Horner Syndrome
Bell Palsy
Laceration, Eyelid
Blepharospasm, Benign Essential
Lyme Disease
Cellulitis, Orbital
Marcus Gunn Jaw-winking Syndrome
Cellulitis, Preseptal
Multiple Sclerosis
Chalazion
Myasthenia Gravis
Chronic Progressive External Ophthalmoplegia
Neuro-ophthalmic History
Conjunctivitis, Giant Papillary
Neurofibromatosis-1
Corneal Abrasion
Oculomotor Nerve Palsy
Corneal Foreign Body
Orbital Fracture, Apex
Dermatitis, Atopic
Orbital Fracture, Floor
Duane Syndrome
Ptosis, Congenital
Exophthalmos
Thyroid Ophthalmopathy

Other Problems to Be Considered

Craniofacial syndromes
Socket contraction
Poor-fitting ocular prosthesis
Hemifacial spasm
Blepharophimosis
Blepharochalasia
Double elevator palsy
Orbital and lid tumors
Cavernous sinus syndrome
Superior orbital fissure syndrome
Malingering

Workup

Laboratory Studies

  • If myasthenia gravis is suspected, a serum assay for acetylcholine receptor antibodies and an edrophonium chloride (Tensilon) test or single-fiber electromyography may be needed.
  • CSF analysis can aid in the diagnosis of multiple sclerosis. Mild lymphocytosis or increased protein levels in the CSF levels may be present. In addition, elevated immunoglobulin G (IgG) levels and oligoclonal bands often are found.
  • In patients with chronic progressive external ophthalmoplegia, an electrocardiogram, electroretinogram, electromyography, and mitochondrial assay should be considered.
  • Patients with suspected thyroid abnormalities should undergo tests for thyroid function, including triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH).

Imaging Studies

  • MRI of the brain with gadolinium enhancement is the imaging modality of choice if multiple sclerosis is suspected.
  • If blepharoptosis is present with other neurologic deficits, imaging of the brain, orbits, or cerebrovascular system should be performed.
  • CT scanning can be used to evaluate dysthyroid orbitopathy.
  • In acquired Horner syndrome, MRI or CT of the brain, CT or radiography of the spine, and CT or radiography of the chest (especially of the apex of the lung) are warranted.

Other Tests

  • Sympathomimetic agents can be used to stimulate the Mueller muscle, as follows:
    • 2.5% phenylephrine
    • 10% phenylephrine: Be aware of cardiac complications.
    • 0.5% apraclonidine (Iopidine): This is an alpha-adrenergic agonist.
    • 1.0% apraclonidine (Iopidine): This is an alpha-adrenergic agonist.
  • Instill 2 drops on the eye under the eyelid (have the patient look down), wait 5 minutes, and assess any change in the palpebral fissure and the marginal reflex distance.
    • If no response is observed or if elevation is not adequate, external levator resection or advancement may be needed to correct the blepharoptosis.
    • If a good response is observed, the ptosis can be repaired by advancing the internal levator (Mueller muscle–conjunctival resection).

More on Ptosis, Adult

Overview: Ptosis, Adult
Differential Diagnoses & Workup: Ptosis, Adult
Treatment & Medication: Ptosis, Adult
Follow-up: Ptosis, Adult
Multimedia: Ptosis, Adult
References
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References

  1. Arslan E, Demirkan F, Unal S, et al. Enhanced frontalis sling with double-fixed, solvent-dehydrated cadaveric fascia lata allograft in the management of eye ptosis. J Craniofac Surg. Nov 2004;15(6):960-4; discussion 965-6. [Medline].

  2. Beard C. Types of ptosis. In: Beard C, ed. Ptosis. 3rd ed. St. Louis: Mosby; 1981:39-76.

  3. Carter SR, Meecham WJ, Seiff SR. Silicone frontalis slings for the correction of blepharoptosis: indications and efficacy. Ophthalmology. Apr 1996;103(4):623-30. [Medline].

  4. Collin JRO. Ptosis. In: Manual of Systematic Eyelid Surgery. Oxford, England: Butterworth-Heinemann; 1999:41-72.

  5. Dinges WL, Witherspoon SR, Itani KM, Garg A, Peterson DM. Blepharoptosis and external ophthalmoplegia associated with long-term antiretroviral therapy. Clin Infect Dis. Sep 15 2008;47(6):845-52. [Medline].

  6. Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. Philadelphia: WB Saunders; 1994:120-5.

  7. Emsen IM. A new ptosis correction technique: a modification of levator aponeurosis advancement. J Craniofac Surg. May 2008;19(3):669-74. [Medline].

  8. Frueh BR, Musch DC, McDonald H. Efficacy and efficiency of a new involutional ptosis correction procedure compared to a traditional aponeurotic approach. Trans Am Ophthalmol Soc. 2004;102:199-206; discussion 206-7. [Medline].

  9. Frueh BR, Musch DC, McDonald HM. Efficacy and efficiency of a small-incision, minimal dissection procedure versus a traditional approach for correcting aponeurotic ptosis. Ophthalmology. Dec 2004;111(12):2158-63. [Medline].

  10. Goldey SH, Baylis HI, Goldberg RA, et al. Frontalis muscle flap advancement for correction of blepharoptosis. Ophthal Plast Reconstr Surg. Mar 2000;16(2):83-93. [Medline].

  11. Levine MR. Manual of Oculoplastic Surgery. Oxford, England: Butterworth-Heinemann; 1996:75-105.

  12. Park DH, Baik BS. Advancement of the Müller muscle-levator aponeurosis composite flap for correction of blepharoptosis. Plast Reconstr Surg. Jul 2008;122(1):140-2. [Medline].

  13. Putterman AM. Cosmetic Oculoplastic Surgery Eyelid, Forehead, and Facial Techniques. London: WB Saunders; 1999:137-59.

  14. Sakol PJ, Mannor G, Massaro BM. Congenital and acquired blepharoptosis. Curr Opin Ophthalmol. Oct 1999;10(5):335-9. [Medline].

  15. Tsa CC, Li TM, La CS, et al. Use of orbicularis oculi muscle flap for undercorrected blepharoptosis with previous frontalis suspension. Br J Plast Surg. Sep 2000;53(6):473-6. [Medline].

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Further Reading

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Keywords

adult ptosis, blepharoptosis, droopy lid, droopy eyelid, drooping eyelid, upper eyelid ptosis, lazy eye, bedroom eyes

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Contributor Information and Disclosures

Author

Adam J Cohen, MD, Assistant Professor, Department of Ophthalmology, Northwestern University Feinberg School of Medicine; Consulting Surgeon, Myers Wyse Center for the Eye; Director, Center for Facial Rejuvenation
Adam J Cohen, MD is a member of the following medical societies: American Academy of Ophthalmology and American College of Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota
Michael Mercandetti, MD, MBA, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Ophthalmology, American College of Surgeons, American Society for Laser Medicine and Surgery, American Society of Ophthalmic Plastic and Reconstructive Surgery, Association of Military Surgeons of the US, and Sarasota County Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Ron W Pelton, MD, PhD, Private Practice, Colorado Springs, Colorado
Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society, Utah Medical Association, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

J James Rowsey, MD, Former Director of Corneal Services, St Luke's Cataract and Laser Institute, Florida
J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Pan-American Association of Ophthalmology, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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