Blepharoptosis involves abnormal lowering or drooping of the upper lid due to structural abnormalities (muscular or aponeurotic) or neurogenic problems.
There are several categories of ptosis depending on the following:
Blepharoptosis is most commonly differentiated based on the age of onset (congenital or acquired) and etiologies (myogenic, neurogenic, aponeurotic, or mechanical). In children, isolated congenital ptosis is the most frequent subtype, but aponeurotic involutional ptosis is the most prevalent variety in adults. Congenital ptosis has a myogenic origin and is caused by dysgenesis in the levator palpebrae muscle.
1. Myogenic: A levator muscle dysfunction causes myogenic ptosis or disruption of impulse transmission at the neuromuscular junction (neuromyopathic). Myasthenia gravis, myotonic dystrophy, and progressive external ophthalmoplegia make up acquired myogenic ptosis.
● 3rd CN palsy contains a classical triad of ptosis, exotropia, and mydriasis. It can manifest in children through viral infections and in adults through ischemic mononeuropathy associated with diabetes mellitus and hypertension.
● Horner’s Syndrome is an oculosympathetic palsy characterized by an association of ptosis, anhidrosis, and miosis. It can manifest in both congenital and acquired forms. Acquired forms are preganglionic lesions at the first-order cervical neurons (occlusion of the vertebral artery), second-order thoracic neuron lesions (Pancoast tumor or aortic aneurysm) and third-order neuron lesions in the head and neck region.
● Progressive external ophthalmoplegia is characterized by bilateral ptosis and progressive ophthalmoplegia affecting extrinsic muscles of the eye. The underlying mechanism involves progressive mitochondrial myopathy.
● Blepharophimosis Syndrome: It has an autosomal dominant inheritance pattern and is characterized by ptosis, epicanthus invertus, and telecanthus.
● Marcus Gun Jaw Winking: It is caused by an aberrant connection between the fifth and superior branches of the third cranial nerve fibers, which innervates the levator muscle. It manifests as ptosis that disappears with the movement of the jaw.
● Myasthenia Gravis: Myasthenia Gravis presents as variable asymmetrical ptosis with associated diplopia and oculomotor paresis. The symptoms tend to increase at the end of the day and resolve with rest. Ophthalmologists can confirm the diagnosis with the cold test by applying an ice pack to the eyelids for 5 minutes, settling the drooping.
3 Aponeurotic ptosis is the most common acquired ptosis, typically developing after age 60. Detachment, dehiscence, or thinning of the levator aponeurosis causes this condition. A prominent eyelid crease and effective levator muscle activity distinguish aponeurotic ptosis.
4. Mechanical ptosis contains several underlying etiologies, including inflammation, infection, scarring, or tumor. It can also be accompanied by aponeurotic type as the early mechanical ptosis causes aponeurotic detachment causing the development of that type.
● Misaligned eye
● Diplopia or double vision
● Head Tilting to correct diplopia
● Eye Fatigue
● Problems in closing the eyes completely
● Irritation and dry eyes
● Mode of onset (Sudden or Progressive)
● Progression and Variation
● Personal, Family, and Ocular history
● Old photographs to determine type and progression
1. Gross Vision and retinoscopy
2. Give distant targets to fixate
3. Inspection with torch
● Compensatory Head posture
● Symmetry of face
● Position of globe
● Pupils- to check RAPD
4. Measurement with torch and scale
● Palpebral Fissure Height
● Marginal Reflex Distance
● Upper Lid Crease
● Levator Muscle Function
● Extraocular movements
● Check for Lid Lag
● Check for Marcus Gunn's jaw wink
● Check Bells phenomenon
Indications: Indications for ptosis treatment are both functional and esthetic. There is no definite optimal age for surgical intervention. In the absence of amblyopia, surgery can wait until 4-5 years of age (preschool). In neurogenic or traumatic ptosis, a wait of at least 6 to 9 months is advised before surgery.
● Severity of ptosis by MRD
● Levator function
1. Type of surgery: Depends upon Levator Function and Severity of Ptosis (MRD)
● Levator function good (> 10 mm) — Fasanella-Servat procedure/Muller Resection
● Levator function moderate (4 to 10 mm) — Levator resection/Advancement
● Levator function poor (< 4 mm) — Brow suspension
● Ptosis severe (> 2 mm) — aponeurotic repair
● Ptosis mild (< 2 mm) — Fasanella-Servat (tarsomullerectomy)
● 1st Post-Op day: Look for hematoma. If there is a risk of exposure, treat it with lubricants.
● One week: Remove Sutures
● Three weeks: Look for over and under correction
Author: Dr. Muhammad Saad, Resident Ophthalmologist at Al-Shifa Trust Eye Hospital in Rawalpindi, Pakistan