Ptosis


WHAT IS PTOSIS (BLEPHAROPTOSIS)?

Blepharoptosis (ptosis) refers to drooping of the upper eyelid. Severe ptosis may disturb vision, while mild drooping may not cause any visual problems. Ptosis may be inherited in families, may occur in one or both eyes, and may be present at birth or occur later in life.

WHAT CAUSES CONGENITAL PTOSIS?

Ptosis which is present at birth (congenital) is often caused by poor development of the eyelid-lifting muscle (levator muscle). It usually is an isolated problem, but children with ptosis may also have eye movement abnormalities, muscular diseases, lid tumors or neurological disorders causing the ptosis. Trauma in children can cause ptosis. Congenital ptosis usually does not improve with time.

WHAT ARE THE SIGNS AND SYMPTOMS OF CONGENITAL PTOSIS?

Many children are born with a slight drooping of one lid (1/2 to 2 mm). This slight ptosis may occur in other family members and usually does not require any treatment. Moderate ptosis can give 3-4 mm drooping of the lid. More severe ptosis may occur in one or both eyes where the lid partially or completely covers the pupil. This can block normal visual development and lead to amblyopia ("lazy eye"). Children with ptosis will often tip their heads back and develop a chin-up posture to see past their eyelids, or raise their eyebrows in an effort to raise their lids.

WHAT PROBLEMS CAN OCCUR IN CHILDHOOD PTOSIS?

The most serious problem associated with childhood ptosis is amblyopia. Amblyopia is poor vision in an eye that did not develop normal sight in early childhood. It is a serious but treatable condition that begins in childhood and persists throughout life. Amblyopia may occur in a child with ptosis if the lid is drooping severely and blocking vision, or if the ptosis causes a focusing problem (astigmatism) by distortion of the roundness of the eye. Ptosis can also mask a misalignment of the eyes which can also cause amblyopia.

HOW IS CONGENITAL PTOSIS TREATED?

The treatment of ptosis depends on the age of the patient, whether the ptosis involves one or both sides, and the cause and severity of the condition. Almost all types of ptosis can be treated surgically, although there are rare disorders that may respond to medical treatment. Severe congenital ptosis may require early treatment to lift the eyelids to avoid amblyopia and to allow proper visual development. Mild or moderate ptosis in children usually does not require early surgical correction, but periodic eye exams should be performed to monitor visual development and check the need for glasses. For these reasons any child suffering from ptosis should be examined by an ophthalmologist to identify possible associated conditions that may cause amblyopia. Whether or not ptosis surgery is performed in preschool children, annual vision check-ups should be performed. As the eyes grow and change shape after surgery, focusing problems may occur and glasses may become necessary.

Measurement of the eyelid heights, strength of the eyelid lifting muscles, movement of the eyes, and eyelid closure are all part of the evaluation to determine the surgical procedure. Many techniques are available to treat patients with ptosis surgically. They usually improve the eyelid opening by tightening the eyelid muscles. In severe ptosis, where the levator muscle is extremely weak, the lids can be suspended from the brow so that the forehead muscles lift the lid.

ADULT PTOSIS

WHAT ARE THE SIGNS AND SYMPTOMS OF ADULT PTOSIS?

Signs and symptoms of adult ptosis usually are loss of some of the upper field of vision from the drooping eyelid, or fatigue from attempting to elevate a drooping lid. Adults with ptosis will often tip their heads back to see past their eyelids, or raise their eyebrows in an effort to raise their lids.

WHAT CAUSES ADULT PTOSIS?

Adult ptosis can result from many different causes. An adult who had ptosis as a child and did not have it treated will still have the condition. Congenital ptosis in an adult is treated as it is in children, although if there is amblyopia, it is no longer treatable.

The most common type of adult ptosis is due to a separation of the levator muscle or tendon (aponeurosis) from the lid. This can occur spontaneously or after cataract or other eye surgery. Repair involves reattaching the separated tendon to the lid.

Adult ptosis may occur because of acquired injuries or diseases involving the levator muscle or its nerve supply. Any type of nerve injury to the muscle, as in a stroke or with other necrologic disease can result in ptosis. Ptosis may be due to muscular disease such as muscular dystrophy. Traumatic injuries may cause ptosis due to damage to the nerves, muscles, or the eyelid itself. Ptosis may also be caused by mechanical impairment of the levator muscle to open the eyelid normally, as may happen with eyelid tumors.

Because of the many different causes of ptosis in adults, blood tests, X-rays or other tests may be required to determine the cause of the ptosis and plan the best treatment.

HOW IS ADULT PTOSIS TREATED?

The best treatment of ptosis depends on the cause of the ptosis, the amount of the ptosis and the strength of the levator muscle. Consultation with an ophthalmologist provides the patient with a comprehensive assessment of their ptosis, a discussion of the methods of treatment available, and of the possible risks and complications. Once the patient or parent has a thorough understanding of the situation an intelligent and informed decision can be reached regarding desired treatment. In adult ptosis where the levator tendon has separated from the lid, reattachment of the muscle can correct the ptosis. In mild ptosis in adults a small tuck in the lifting muscle and eyelid can lift the lid sufficiently. With more severe ptosis or in childhood ptosis which has not been corrected a tightening of the levator muscle is often performed. General anesthesia can be used for ptosis surgery, but in cooperative children and adults topical or local anesthesia to the lids can be used and allow for adjustment of the lid height during surgery.

ARE THERE RISKS IN PTOSIS SURGERY?

As with any surgery there are small risks with ptosis surgery. If general anesthesia is needed there is always a small risk of complications from the anesthetic. Complications from infection, bleeding or problems than can affect vision are small risks. Inability to fully close the eye after ptosis surgery is common and lubricant drops and ointments are frequently useful.

SUMMARY

Ptosis in both children and adults can be successfully treated with surgery to improve visual function as well as cosmetic appearance. Early treatment in children is important to prevent amblyopia and ensure normal visual development.