Ptosis (Blepharoptosis) in Adults Treatment & Management

In July 2020, the FDA approved oxymetazoline ophthalmic solution for the treatment of acquired blepharoptosis in adults. Approval was based on results from two phase 3 randomized trials showing statistically significant improvement from baseline compared with placebo for visual field and data point visualization, as measured with the Leicester Peripheral Field Test (LPFT) on day 1 (hour 6) and day 14 (hour 2) (P< 0.01). Eyelid lift was also improved, as measured with pupillary light reflex and the upper eyelid margin (P< 0.01). ^[7]

If myasthenia gravis is diagnosed in a patient with ptosis, treatment should be initiated by a neurologist.

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.

Many surgical techniques have been described for ptosis correction. ^{[8, 9, 10, 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. ^{[11, 12, 13]}

Frontalis sling

If levator function is poor (< 4 mm) or absent, the use of frontalis slings can achieve desirable postoperative results. ^{[14, 15, 16]}

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.

Levator advancement

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. ^{[17, 18]}

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 ptosis 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. ^[19]

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.

Fasanella-Servat ptosis procedure

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.

Mueller muscle–conjunctival resection

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. ^[20]

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.

Full-thickness resection

A full-thickness resection can be used in combination with an external levator advancement. After a blepharotomy 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.

If a specific etiology of ptosis 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. ^[21]

If ptosis correction is performed, the patient should be followed closely in the post-operative period.

After ptosis surgery, a topical antibiotic ointment (with or without a steroid) can be applied twice daily for 5-7 days. The authors do not routinely use ointments to dress wounds.

Perioperative IV antibiotics can be given or an oral antibiotic prescribed for 5-7 days as well. The authors do not routinely prescribe antibiotics.

Pain is usual minimal in the post-operative period but Tylenol #3 or Vicodin can be prescribed if necessary.