eMedicine Specialties > Ophthalmology > Lid
Ptosis, Adult: Treatment & Medication
Updated: Nov 18, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
If myasthenia gravis is diagnosed, treatment may involve the use of pyridostigmine (Mestinon).
Patient with myasthenia gravis. Right lid is more ptotic than the left lid.
Same patient as in Media file 8, 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 be used to lift the lid if the patient does not desire surgery.
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.
Anterior 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 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.
Patient with bilateral ptosis before surgery. Note the high lid creases.
Same patient as in Media file 1 after bilateral internal levator advancement. No skin incision was made, and no crease reformation was performed.
Patient with bilateral ptosis before surgery.
Same patient as in Media file 10 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.
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
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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].
Levine MR. Manual of Oculoplastic Surgery. Oxford, England: Butterworth-Heinemann; 1996:75-105.
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].
Putterman AM. Cosmetic Oculoplastic Surgery Eyelid, Forehead, and Facial Techniques. London: WB Saunders; 1999:137-59.
Sakol PJ, Mannor G, Massaro BM. Congenital and acquired blepharoptosis. Curr Opin Ophthalmol. Oct 1999;10(5):335-9. [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. Sep 2000;53(6):473-6. [Medline].
Further Reading
Keywords
adult ptosis, blepharoptosis, droopy lid, droopy eyelid, drooping eyelid, upper eyelid ptosis, lazy eye, bedroom eyes
