- Author: Adam J Cohen, MD; Chief Editor: Hampton Roy, Sr, MD more...
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. See the images below.
Blepharoptosis can be classified as congenital, as shown below, or acquired. 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.
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.
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.
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.
No racial predilection has been described.
No sexual predilection has been described.
Acquired ptosis can occur at any age, but it is commonly seen in older adults. Congenital ptosis occurs at birth.
Collin JRO. Ptosis. Manual of Systematic Eyelid Surgery. Oxford, England: Butterworth-Heinemann; 1999. 41-72.
Sakol PJ, Mannor G, Massaro BM. Congenital and acquired blepharoptosis. Curr Opin Ophthalmol. 1999 Oct. 10(5):335-9. [Medline].
Beard C. Types of ptosis. Beard C, ed. Ptosis. 3rd ed. St. Louis: Mosby; 1981. 39-76.
Cohen AJ, Weinberg DA, eds. Evaluation and Management of Blepharoptosis. 1st. New York, NY: Springer-Verlag; 2010.
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].
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].
Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. Philadelphia: WB Saunders; 1994. 120-5.
Levine MR. Manual of Oculoplastic Surgery. Oxford, England: Butterworth-Heinemann; 1996. 75-105.
Putterman AM. Cosmetic Oculoplastic Surgery Eyelid, Forehead, and Facial Techniques. London: WB Saunders; 1999. 137-59.
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].
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].
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].
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].
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].
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].
Emsen IM. A new ptosis correction technique: a modification of levator aponeurosis advancement. J Craniofac Surg. 2008 May. 19(3):669-74. [Medline].
Waqar S, McMurray C, Madge SN. Transcutaneous blepharoptosis surgery - advancement of levator aponeurosis. Open Ophthalmol J. Dec 2010. 14:4:76-80. [Medline].
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].
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].
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].