eMedicine Specialties > Ophthalmology > Lid

Ptosis, Adult: Treatment & Medication

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

Treatment

Medical Care

If myasthenia gravis is diagnosed, treatment may involve the use of pyridostigmine (Mestinon).

In certain cases, a patient may not want to undergo surgery. Glasses can be made with a crutch attachment that can hold up the lid.

Surgical Care

Many surgical techniques have been well described for blepharoptosis correction. A surgeon may prefer one technique to another. This brief discussion is merely a guide and not dogma for approaching ptosis correction.

  • If levator function is poor (<4 mm) or absent, the use of frontalis slings can achieve desirable postoperative results.
    • Many materials, both autogeneic and allogeneic, have been used with great success.
    • Fascia lata and frontalis muscle flaps are examples of autogeneic tissue, whereas Gore-Tex suture, frozen dura mater, silicone, and Alloderm are useful allogeneic materials.
    • Whether autogeneic or allogeneic material is chosen, the goal is to suspend the upper eyelid from the eyebrow or frontalis muscle.
    • With elevation of the eyebrow, the eye opens, and the orbicularis is used to close the eye.
  • A levator advancement or resection is a technique that results in shortening of the levator aponeurosis and muscle, depending on the amount of correction needed. The levator can be approached from an anterior or posterior direction.
    • In the anterior approach, an external eyelid incision is made by using the natural lid crease, if present, to allow for direct visualization of the aponeurosis. Once the levator aponeurosis is identified, it is disinserted from the tarsus, advanced and/or resected, and reattached. The amount of advancement depends on the degree of blepharoptosis being treated. The aponeurosis also is attached to the skin to reform the crease.
    • In posterior levator resection, the eyelid is everted, and the conjunctiva is separated from the Mueller muscle and the levator aponeurosis. Double-armed sutures are placed in the conjunctiva. The Mueller muscle and levator are separated from the septum and clamped. Then, the preplaced sutures in the conjunctiva are passed through the levator, and the excess tissue is excised. The sutures are passed through the skin with 1 arm of the double-armed suture taken a bit through the tarsus, and these sutures are tied reforming the eyelid crease.
  • If the levator is disinserted or dehisced, the anterior or posterior approach can be used, and the dehiscence or disinsertion repaired.
  • In the Fasanella-Servat ptosis procedure, the conjunctiva and tarsus and the Mueller muscle are resected. Two hemostats are placed across the superior tarsal border. The tissue below the hemostats is sutured, and then the tissue is resected.
  • The internal levator advancement, known more commonly as the Mueller muscle–conjunctival resection, is performed on the underside of the lid, as in a Fasanella-Servat procedure.
    • This surgery is chosen if the eyelid has had a good response to phenylephrine.
    • The conjunctiva and the Mueller muscle are marked off, clamped with a specialized clamp, sutured, the tissues are resected.
    • The conjunctival layer is then closed.
    • This procedure is believed to advance the levator aponeurosis, thereby elevating the ptotic lid.

Consultations

If a specific etiology of blepharoptosis is identified and has related systemic manifestations, consultation with other specialists is necessary.

  • If myasthenia gravis or multiple sclerosis is diagnosed, appropriate follow-up care with a neurologist is warranted.
  • If dysthyroid orbitopathy is found, an endocrinologist should be consulted to address the thyroidopathy.
  • Patients with Kearns-Sayre disease can have cardiac conduction abnormalities that should be managed by an internist or a cardiologist.
  • If the etiology of the ptosis is unclear and associated with ophthalmoplegia, consultation with a neuro-ophthalmic specialist is prudent.

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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