Adult Ptosis Workup

  • Author: Adam J Cohen, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Aug 15, 2011
 

Laboratory Studies

  • If myasthenia gravis is suspected, perform a serum assay for acetylcholine receptor antibodies, antistriated muscle antibody. Muscle-specific tyrosine kinase (MUSK) levels can be obtained when acetylcholine receptor antibodies levels are negative and the suspicion for myasthenia is high.
  • The ice test has been shown to improve blepharoptosis in patients with myasthenia.[5]
  • An edrophonium chloride (Tensilon) test or single-fiber electromyography may be needed to definitely exclude the diagnosis.
  • CSF analysis can aid in the diagnosis of multiple sclerosis. Mild lymphocytosis or increased protein levels in the CSF levels may be present. In addition, elevated immunoglobulin G (IgG) levels and oligoclonal bands often are found.
  • In patients with chronic progressive external ophthalmoplegia, an electrocardiogram, electroretinogram, electromyography, and mitochondrial assay should be considered.
  • Patients with suspected thyroid abnormalities should undergo thyroid function studies.
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Imaging Studies

  • MRI of the brain with gadolinium is the imaging modality of choice if demyelination is suspected.
  • If blepharoptosis is present with other neurologic deficits, imaging of the brain, orbits, or cerebrovascular system should be performed. An emergent CT angiography of the brain is necessary when ptosis is accompanied by other signs of a third nerve palsy.
  • CT scanning without contrast can be used to evaluate dysthyroid orbitopathy.
  • In acquired Horner syndrome, MRI or CT scan of the brain, MRA of neck, CT scan or X-ray of the spine, and CT scan or X-ray of the chest (especially of the apex of the lung) are needed to exclude a structural lesion along the symphathetic pathway.
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Other Tests

  • Sympathomimetic agents can be used to stimulate the Mueller muscle, as follows:
    • 2.5% phenylephrine
    • 10% phenylephrine
    • 0.5% apraclonidine (Iopidine):
    • 1.0% apraclonidine (Iopidine):
  • Ten percent phenylephrine has not be shown to have increased clinical efficacy in predicting the outcome of Muller muscle–conjunctival resection. Therefore, the authors do not feel the use of 10% phenylephrine is necessary.[6]
  • Instill 2 drops on the eye under the eyelid (have the patient look down), wait 5 minutes, and assess any change in the palpebral fissure and the marginal reflex distance.
    • If no response is observed or if elevation is not adequate, external levator resection or advancement may be needed to correct the blepharoptosis.
    • If a good response is observed, the ptosis can be repaired by advancing the internal levator (Mueller muscle–conjunctival resection).
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Contributor Information and Disclosures
Author

Adam J Cohen, MD  Eyelid and Facial Aesthetic and Reconstructive Surgery, Diseases and Surgery of the Orbit and Lacrimal System, Cosmetic Laser Surgery

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

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.

Specialty Editor Board

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

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor 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, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

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

Disclosure: Nothing to disclose.

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.

References

  1. Collin JRO. Ptosis. In: 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. Oct 1999;10(5):335-9. [Medline].

  3. Beard C. Types of ptosis. In: 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. Jul 1999;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. Mar 1990;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. Dec 2004;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. Sep 2000;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. Mar 2000;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. Nov 2004;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. Apr 1996;103(4):623-30. [Medline].

  16. Emsen IM. A new ptosis correction technique: a modification of levator aponeurosis advancement. J Craniofac Surg. May 2008;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. Jul 2008;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. Sep 15 2008;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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