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Adult Ptosis Treatment & Management

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

Medical Care

If myasthenia gravis is diagnosed, treatment should be initiated by a neurologist.

Patient with myasthenia gravis. Right lid is more Patient with myasthenia gravis. Right lid is more ptotic than the left lid.
Same patient as in the previous image, 3 months laSame patient as in the previous image, 3 months later. Note how the ptosis has changed and is more on the left than the right.

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.

Glasses with a crutch attached (arrow) that can beGlasses with a crutch attached (arrow) that can be used to lift the lid if the patient does not desire surgery.
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Surgical Care

Many surgical techniques have been described for blepharoptosis correction.[7, 8, 9, 4] A surgeon may prefer one technique to another.

This brief discussion is a guide for approaching ptosis correction using the most common surgical techniques.[10, 11, 12]

  • If levator function is poor (< 4 mm) or absent, the use of frontalis slings can achieve desirable postoperative results.[13, 14, 15]
    • 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 frontalis muscle.
    • With elevation of the eyebrow, the eye opens, and the orbicularis oculi is used to close the eye.
  • A levator advancement or resection results in shortening of the levator aponeurosis and muscle. The levator can be approached from an anterior or posterior direction.[16, 17]
    • In the anterior approach (see the image below), 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.
    • Small paracentral incision techniques to access the levator and/or aponeurosis have also been used. This minimally invasive approach allows for less disruption of the fascia attachments but also provides less visualization. Often, a single-suture technique is used to reestablish the connection between the levator and tarsus.[18]
      Anterior approach to the levator. White band is thAnterior approach to the levator. White band is the levator aponeurosis (arrow).
    • 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, 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 (see the images below), known more commonly as the Mueller muscle–conjunctival resection, is performed on the underside of the lid, as in a Fasanella-Servat procedure.[19]
    • 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.
      Patient with bilateral ptosis before surgery. NotePatient with bilateral ptosis before surgery. Note the high lid creases.
      Same patient as in the previous image after bilateSame patient as in the previous image after bilateral internal levator advancement. No skin incision was made, and no crease reformation was performed.
      Patient with bilateral ptosis before surgery. Patient with bilateral ptosis before surgery.
      Same patient as in the previous image after internSame 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.
  • A full thickness resection can be used in combination with an external levator advancement. After a bleparotomy is performed, the superior tarsus can be resected for the length of the eyelid. Remember that aggressive tarsal resection can result in eyelid instability. Therefore, the resection should be limited to a height of 4 mm.
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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.[20]
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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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