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Adult Ptosis

  • Author: Adam J Cohen, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Sep 01, 2015
 

Background

Blepharoptosis, also referred to as ptosis, is defined as an abnormal low-lying upper eyelid margin with the eye in primary gaze. The normal adult upper lid lies 1.5 mm below the superior corneal limbus and is highest just nasal to the pupil.[1] See the images below.

Left ptosis. Lid crease is absent on the left. The Left ptosis. Lid crease is absent on the left. The crease is up in the sulcus. Superior sulcus deformity is present on the left and right, and the patient is elevating her brows. The right upper lid should be checked for an underlying or masked ptosis. If the right lid is ptotic, lifting the left lid causes the right lid to droop.
Visual field shows functional blockage of superior Visual field shows functional blockage of superior visual field due to a ptotic lid. Hashed line represents the superior extent of the seen visual field with the lid lifted. Solid line is with the lid in its natural, ptotic position.

Blepharoptosis can be classified as congenital, as shown below, or acquired.[2] This differentiation is based on age. A more comprehensive classification is based on etiology and includes myogenic, aponeurotic, neurogenic, mechanical, traumatic, and pseudoptotic. The most common cause of congenital ptosis is myogenic due to the improper development of the levator muscle.[3]

Congenital ptosis on right. Note the presence of a Congenital ptosis on right. Note the presence of a lid crease.

Most cases of acquired blepharoptosis are secondary to aponeurotic causes, such as involutional changes, a disinsertion, or a dehiscence. Identification of the underlying pathophysiologic mechanism is paramount to institute proper treatment.

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Pathophysiology

Blepharoptosis is the result of dysfunctioning of one or both upper eyelid elevator muscles. These elevator muscles are the levator palpebrae superioris and the Mueller muscle.

The levator palpebrae superioris is a striated muscle innervated by the superior division of the oculomotor nerve (cranial nerve III). This muscle is about 40 mm long and originates from the lesser wing of the sphenoid. It continues anteriorly, and at the Whitnall ligament, it travels inferiorly as an aponeurosis. The aponeurosis is 14-20 mm long and inserts into the anterior aspect of the tarsal plate. It also sends attachments to the skin, forming the upper eyelid crease. The levator muscle and aponeurosis is the major elevator of the upper eyelid.

The Mueller muscle, a sympathetically innervated smooth muscle, originates from the undersurface of the levator superioris. Approximately 12 mm long, it inserts superiorly on the tarsal border and elevates the upper eyelid by approximately 2 mm.

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Epidemiology

Mortality/Morbidity

The associated mortality is usually due to anesthetic complications from surgery. Kearns-Sayre disease, a subtype of chronic progressive external ophthalmoplegia, is a syndrome with associated myogenic ptosis, retinal pigmentary changes, and cardiac conduction abnormalities that can cause death.

Morbidity is associated with blockage of the visual axis in the severely ptotic eyelid. Congenital cases can obstruct vision and lead to amblyopia. Even without visual axis obstruction, the eyelid may induce refractive errors, especially astigmatism resulting in amblyopia.

In adults, the morbidity is associated with constriction of the superior visual fields. Patients may complain that they tire easily when reading and experience frontal headaches as they lift their eyebrows in an effort to keep the eyelids open. Patients may be dissatisfied with their appearance.

Race

No racial predilection has been described.

Sex

No sexual predilection has been described.

Age

Acquired ptosis can occur at any age, but it is commonly seen in older adults. Congenital ptosis occurs at birth.

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Contributor Information and Disclosures
Author

Adam J Cohen, MD Assistant Professor of Ophthalmology, Section Director of Oculoplastic and Reconstructive Surgery, Rush Medical College of Rush University Medical Center

Adam J Cohen, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, American College of Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: BioD, Poferious<br/>Serve(d) as a speaker or a member of a speakers bureau for: IOP<br/>Received income in an amount equal to or greater than $250 from: IOP for speaking.

Coauthor(s)

Michael Mercandetti, MD, MBA, FACS Private Practice

Michael Mercandetti, MD, MBA, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, Sarasota County Medical Society, 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

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

J James Rowsey, MD Former Director of Corneal Services, St Luke's Cataract and Laser Institute

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, Sigma Xi, Southern Medical Association, Pan-American Association of Ophthalmology

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

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 College of Surgeons, AO Foundation, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society

Disclosure: Nothing to disclose.

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

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

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

  4. Cohen AJ, Weinberg DA, eds. Evaluation and Management of Blepharoptosis. 1st. New York, NY: Springer-Verlag; 2010.

  5. Golnik KC, Pena R, Lee AG, Eggenberger ER. An ice test for the diagnosis of myasthenia gravis. Ophthalmology. 1999 Jul. 106(7):1282-6. [Medline].

  6. Glatt HJ, Fett DR, Putterman AM. Comparison of 2.5% and 10% phenylephrine in the elevation of upper eyelids with ptosis. Ophthalmic Surg. 1990 Mar. 21(3):173-6. [Medline].

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

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

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

  10. 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].

  11. 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. 2004 Dec. 111(12):2158-63. [Medline].

  12. 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. 2000 Sep. 53(6):473-6. [Medline].

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

  14. 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. 2004 Nov. 15(6):960-4; discussion 965-6. [Medline].

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

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

  17. Waqar S, McMurray C, Madge SN. Transcutaneous blepharoptosis surgery - advancement of levator aponeurosis. Open Ophthalmol J. Dec 2010. 14:4:76-80. [Medline].

  18. Baroody M, Holds JB, Sakamoto DK, Vick VL, Hartstein ME. Small incision transcutaneous levator aponeurotic repair for blepharoptosis. Ann Plast Surg. jun 2004. 52(6):558-561. [Medline].

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

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

 
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Patient with bilateral ptosis before surgery. Note the high lid creases.
Same patient as in the previous image after bilateral internal levator advancement. No skin incision was made, and no crease reformation was performed.
Anterior approach to the levator. White band is the levator aponeurosis (arrow).
Left ptosis. Lid crease is absent on the left. The crease is up in the sulcus. Superior sulcus deformity is present on the left and right, and the patient is elevating her brows. The right upper lid should be checked for an underlying or masked ptosis. If the right lid is ptotic, lifting the left lid causes the right lid to droop.
Visual field shows functional blockage of superior visual field due to a ptotic lid. Hashed line represents the superior extent of the seen visual field with the lid lifted. Solid line is with the lid in its natural, ptotic position.
Congenital ptosis on right. Note the presence of a lid crease.
Glasses with a crutch attached (arrow) that can be used to lift the lid if the patient does not desire surgery.
Patient with myasthenia gravis. Right lid is more ptotic than the left lid.
Same patient as in the previous image, 3 months later. Note how the ptosis has changed and is more on the left than the right.
Patient with bilateral ptosis before surgery.
Same patient as in the previous image after internal levator advancement. Patient has excessive skin (dermatochalasia) after the lid was lifted, with a pseudoptotic effect more on the left than the right. The dermatochalasia was present before surgery but is more significant afterward. Patient also has brow ptosis.
 
 
 
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