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Upper Eyelid Ptosis Revisited Padmaja Sudhakar, MBBS, DNB (Ophthalmology) Qui Vu, BS, M3 Omofolasade Kosoko-Lasaki, MD, MSPH, MBA Millicent Palmer, MD

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Upper Eyelid Ptosis Revisited Padmaja Sudhakar, MBBS, DNB (Ophthalmology) Qui Vu, BS, M3 Omofolasade Kosoko-Lasaki, MD, MSPH, MBA Millicent Palmer, MD ® AmericAn JournAl of clinicAl medicine • Summer 2009 • Volume Six, number Three 5 Upper Eyelid Ptosis Revisited Padmaja Sudhakar, MBBS, DNB (Ophthalmology) Qui Vu, BS, M3 Omofolasade Kosoko-Lasaki, MD, MSPH, MBA Millicent Palmer, MD Abstract Epidemiology of Ptosis Blepharoptosis, commonly referred to as ptosis is an abnormal Although ptosis is commonly encountered in patients of all drooping of the upper eyelid. This condition has multiple eti- ages, there are insufficient statistics regarding the prevalence ologies and is seen in all age groups. Ptosis results from a con- and incidence of ptosis in the United States and globally.2 genital or acquired weakness of the levator palpebrae superioris There is no known ethnic or sexual predilection.2 However, and the Muller’s muscle responsible for raising the eyelid, dam- there have been few isolated studies on the epidemiology of age to the nerves which control those muscles, or laxity of the ptosis. A study conducted by Baiyeroju et al, in a school and a skin of the upper eyelids. Ptosis may be found isolated, or may private clinic in Nigeria, examined 25 cases of blepharoptosis signal the presence of a more serious underlying neurological and found during a five-year period that 52% of patients were disorder. Treatment depends on the underlying etiology. This less than 16 years of age, while only 8% were over 50 years review attempts to give an overview of ptosis for the primary of age. There was a 1:1 male to female ratio in the study with healthcare provider with particular emphasis on the classifica- the majority (68%) having only one eye affected. The most tion, salient features of each of the subtypes, clinical evalua- common cause of blepharoptosis in the study was congenital tion, and treatment. (56% of patients). The prevalence rate in the school survey was found to be 1.2%.4 Ptosis has been increasingly recognized in the elderly population, particularly after cataract extraction or Introduction lens replacement.5 This is probably due to the stretching or dis- Blepharoptosis or ptosis (pronounced “toe-sis”) is one of the ruption of the levator muscle or its aponeurosis when the eyelid most common eyelid disorders encountered in ophthalmolo- is retracted with a speculum during surgery.6 gy. It refers to the unilateral or bilateral abnormal drooping of the upper eyelid. It usually occurs from a partial or complete dysfunction of the muscles that elevate the upper eyelid: the Anatomy levator palpebrae superioris and the Muller’s muscle.1 Ptosis The closure of the eyelids is facilitated by the protractors of can be classified as congenital or acquired. The most common the eyelids: circumferential orbicularis oculi muscle, which is cause of congenital ptosis is myogenic due to the improper innervated by the facial (seventh cranial) nerve. The eleva- development of the levator muscle. A more comprehensive tors of the upper eyelid are the levator palpebrae superioris and classification of ptosis is based on etiology and includes myo- the Muller’s muscle. The levator palpebrae superioris is the genic, aponeurotic, neurogenic, neuromuscular, mechanical, main upper eyelid elevator and is innervated by the oculomotor neurotoxic, traumatic, and pseudoptotic. Ptosis that obstructs (third cranial) nerve. The Muller’s muscle is a smooth muscle the pupil may interfere with the normal development of vision, that arises from the undersurface of the levator and inserts into resulting in amblyopia in children.2 In adults it may impair the the superior tarsus. The Muller’s muscle is innervated by the field of vision and interfere with activities of daily living. 2, 3 sympathetic nervous system. The muscle is responsible for the Thus, the early diagnosis and treatment of ptosis is an impor- over-elevation of the eyelid when a patient becomes excited or tant prognostic factor in its management. fearful and leads to mild ptosis with fatigue or inattention. Upper Eyelid Ptosis Revisited ® 6 AmericAn JournAl of clinicAl medicine • Summer 2009 • Volume Six, number Three Clinical Presentation • Best corrected visual acuity and cycloplegic refraction should be done. This helps to identify refractive errors and The presence of ptosis is usually an isolated finding; howev- amblyopia. In infants, note if baby can fixate, maintain, er, it can be part of a group of presenting symptoms of other and follow light. medical conditions. • Pupillary examination is important. Pupillary size and iris History color differences between the two eyes should be exam- ined to rule out Horner’s syndrome. A detailed history of present illness includes asking about the onset, duration, variability, progression, and severity of ptosis. • Extraocular muscle movement should be evaluated with Also investigate whether there is involvement of one eye or a note of diplopia - in chronic progressive external oph- both eyes simultaneously. In the past ocular history it is vi- thalmoplegia, there may be extraocular muscle weakness tal to elicit a history of eye trauma, previous eye surgeries, together with ptosis. contact lens use, and previous eye diseases, such as dry eyes and thyroid eye disease. One should also ask about associated • Evaluation of strabismus if present. symptoms, such as diplopia, odynophagia, peripheral muscle weakness, and symptoms of cardiac conduction abnormalities, • Slit lamp examination should note the presence of any an- which may give a clue to the diagnosis of associated systemic terior segment pathology, such as dry eyes, corneal expo- diseases, such as myasthenia gravis, myotonic dystrophy, and sure, or exposure keratopathy. Kearns Sayre’s. A complete medical history is important for the • Dilated fundus examination should rule out any posterior diagnosis of associated systemic diseases and surgical planning. segment pathology, such as abnormal retinal pigmentation Inspecting old photographs and eliciting information regarding seen in Kearn Sayre’s syndrome. familial predisposition for ptosis is helpful in the assessment of the severity of ptosis. Eyelid measurements Symptoms To quantify the severity of ptosis, various eyelid measurements should be taken with the face held in the frontal plane and with Most patients present with drooping eyelids, giving a sleepy or frontalis muscle relaxed.2 Frontalis contracture should be neu- tired appearance. The patients may complain of blurred vision, tralized by holding the brows in their relaxed position. If the increased tearing,2 and diminished upper visual fields. There is droopy lid obscures the lid margin, the examiner should lift the increased difficulty with activities of daily living, such as driv- brows to observe the lid level for measurement. The examiner ing, reading, and climbing stairs, affecting the patient’s quality should note the following: of life.7 They may complain about frontal tension headache from overuse of the forehead muscles in attempts to elevate the • The palpebrae fissure height (PF) is the distance between 2 eyelids indirectly by elevating the eyebrows. the upper and lower eyelid margins at the axis of the pupil. Undiagnosed congenital ptosis may result in amblyopia.2 On Normal measurement is 9 to 12 mm. inspection, the patients, especially children may assume a head- • Marginal reflex distance (MRD) is the distance between 2 tilt backwards and chin-up position. The individual may be the central corneal light reflex and upper eyelid margin seen lifting the eyelid with a finger or using multiple fingers with eyes in primary position. The severity of ptosis is bet- to raise the entire eyebrow in an effort to view from under the ter determined with MRD than PF measurements as lower 2 drooping eyelids. Symptoms of diplopia may be seen in ptosis lid malpositions are eliminated. Normal MRD is 4-5 mm. associated with myasthenia gravis or third nerve palsy. • Levator function should be evaluated in all cases. The pa- Signs tient looks downward as a measuring device is positioned with a mark adjacent to the upper lid margin. With the ex- A comprehensive ophthalmic examination should be done in aminer’s hand eliminating any brow action by the patient, all cases. the patient looks upward as far as possible without chang- • The examination begins with careful external examina- ing his/her head position. The amount of lid elevation is tion along with palpation of the eyelids and the orbital recorded in millimeters (mm) of levator function. rim. Evaluate any clinical evidence of relative proptosis or Classification of levator function: enophthalmos in each eye. Poor: 0 – 5 mm lid elevation • Inspection of eyebrows at baseline should be done, since Fair: 6 – 11 mm lid elevation patient may compensate by lifting eyebrows with the fron- Good: > 12 mm lid elevation talis muscle. • Upper eyelid crease position is the distance from the up- • The patient’s head posture should be noted; document per eyelid crease to the eyelid margin. It is normally 7-8 chin-up position. mm in males and 9-10 mm in females. Upper Eyelid Ptosis Revisited ® AmericAn JournAl of clinicAl medicine • Summer 2009 • Volume Six, number Three 7 The position of the ptotic eyelid in down-gaze should be as- • Sympathomimetic agents, such as phenylephrine or apr- sessed, as it helps in differentiating congenital from acquired aclonidine,10 can be instilled under the eyelid to test the ptosis. Congenital ptotic eyelid remains higher in down-gaze function of Muller’s muscle. due to lid lag. Discussion Ancillary testing • Corneal sensitivity should be tested in all cases. This is im- Types of Ptosis portant because of the potential for incomplete lid closure Ptosis is broadly classified into congenital and acquired, based on and exposure keratopathy after surgical correction. age of onset of the ptosis. Ptosis that is present at birth or within • Bell’s phenomenon should be tested to evaluate the risk of the first year of life is called congenital ptosis. This is usually exposure keratopathy if surgery is being planned.
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