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Ptosis - Causes, Symptoms & Treatment

Ptosis refers to the drooping of the upper eyelid and can affect one or both eyes. It may be congenital or acquired.

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Things worth knowing about "Ptosis"

Ptosis refers to the drooping of the upper eyelid and can affect one or both eyes. It may be congenital or acquired.

What is Ptosis?

Ptosis (also called blepharoptosis) is a medical condition characterized by the abnormal drooping of the upper eyelid below its normal resting position. Under normal circumstances, the upper eyelid covers only a small portion of the iris (the colored part of the eye). In ptosis, the eyelid descends further than normal and may, in severe cases, partially or fully cover the pupil, significantly impairing vision. The condition may affect one eye (unilateral) or both eyes (bilateral).

Causes

The causes of ptosis vary depending on whether it is present from birth (congenital) or develops during life (acquired).

Congenital Ptosis

Underdevelopment or dysfunction of the levator palpebrae superioris muscle, which is the primary muscle responsible for lifting the eyelid
Genetic factors or developmental anomalies occurring before birth

Acquired Ptosis

Neurogenic: Damage to the oculomotor nerve (cranial nerve III), for example due to a brain tumor, aneurysm, or stroke; or Horner syndrome
Myogenic: Muscle disorders such as myasthenia gravis or oculopharyngeal muscular dystrophy
Aponeurotic: Stretching or detachment of the levator aponeurosis, commonly seen with aging or following eye surgery
Mechanical: Tumors, scar tissue, or severe eyelid inflammation that weighs down the lid
Traumatic: Injuries to the eye or eyelid area

Symptoms

Visible drooping of one or both upper eyelids
Reduced field of vision, particularly in the upper visual area
A tired or sleepy appearance of the eyes
Headaches caused by compensatory eyebrow raising
In children: backward tilting of the head to improve vision
In severe cases in children: amblyopia (lazy eye) if the pupil is obstructed

Diagnosis

Ptosis is primarily diagnosed through a clinical examination by an ophthalmologist. The following assessments are commonly performed:

Palpebral fissure measurement: The distance between the upper and lower eyelids in millimeters
Margin-reflex distance (MRD1): The distance between the corneal light reflex and the upper eyelid margin
Levator function testing: Assessment of eyelid movement during upgaze and downgaze
Slit-lamp examination and general eye assessment
Neurological tests if a systemic condition is suspected (e.g., the edrophonium test for myasthenia gravis)
Imaging studies (MRI, CT scan) if an intracranial cause is suspected

Treatment

Treatment depends on the underlying cause, the severity of the condition, and the age of the patient.

Conservative Approaches

Ptosis crutches: Specially designed eyeglass frames with a support attachment that mechanically holds the eyelid open (primarily used in adults with neuromuscular conditions)
Treatment of the underlying condition, for example medication for myasthenia gravis

Surgical Treatment

Levator resection: Shortening of the levator muscle to improve eyelid elevation
Frontalis suspension: Connecting the eyelid to the frontalis (forehead) muscle using a suture or silicone band, used when levator function is severely reduced
In children with amblyogenic ptosis, early surgical intervention is essential to prevent permanent visual impairment

References

Griepentrog GJ, Diehl NN, Mohney BG. - Incidence and Trends of Pediatric Blepharoptosis. - Ophthalmology, 2011.
Bhatti MT, Schmalfuss IM. - Ptosis. - StatPearls, National Library of Medicine (NCBI/PubMed), 2023. Available at: https://www.ncbi.nlm.nih.gov/books/NBK585069/
Kanski JJ, Bowling B. - Clinical Ophthalmology: A Systematic Approach. 8th Edition, Elsevier, 2020.

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