Ptosis is abnormally low positioned upper eyelid, also called blepharoptosis, which can decrease or even occlude the vision completely. It may be congenital or acquired in origin. Proper management requires recognizing the exact etiology and treat it accordingly, whether surgically or medically, to improve patient outcome.[1]
Ptosis is classified into congenital or acquired based on the age of presentation; the latter is usually further categorized into five types based on etiology[2]:
Among all cases of ptosis, congenital ptosis is the most common type which seems to be more prevalent in males. Simple congenital ptosis is the most prevalent form of congenital ptosis.[3] Among acquired cases, aponeurotic ptosis is the most common type which usually presents in late adulthood.[4] Enough data is not available yet, about the incidence of ptosis.[5] However, the prevalence of ptosis does not seem to be affected by other epidemiological factors such as race, etc.
Levator palpebrae superioris (LPS) and Muller's muscle are two muscles of upper eyelid responsible for its elevation. LPS is the main elevator which is supplied by the oculomotor nerve. The levator palpebrae superioris muscle origin is the lesser wing of the sphenoid bone, it travels anteriorly above the superior rectus muscle, and attaches in multiple insertions: anteriorly into the upper eyelid skin, inferiorly on the anterior surface of the upper tarsal plate and to the superior conjunctival fornix. Muller's muscle is a smooth muscle also attached to the superior tarsal plate with sympathetic innervation, which is defective in ptosis of Horner syndrome.[1] Loss of innervation of LPS and Muller's muscle causes neurogenic ptosis.
Levator muscle dystrophy causes simple congenital ptosis. On the other hand, involutional changes in the eyelid are the most common pathogenesis in adult ptosis. Deceasing tone and thinning of the levator muscle, due to aging, results in abnormal position of the eyelid. Disinsertion of the levator aponeurosis, or its dehiscence, after any trauma or surgery, can also lead to ptosis.[5]
Presentation:
Main presenting complain of patients with ptosis is the visual disturbance ranging from mild to severe, which can be unilateral or bilateral along with cosmetic disfigurement. Ptosis may accompany with some other problems depending upon the etiology.
History:
Age of onset and duration of symptoms is important to differentiate congenital from acquired cases. There also may be other symptoms of associated etiologies, such as diurnal variability, diplopia, eyeball deviation, body fatigability, etc. The patient should be asked about any previous history of trauma, surgery, or medical treatment.[6]
Clinical Evaluation
In the case of ptosis, the upper lid margin covers more than 2 mm of the cornea, making palpebral fissure narrower than normal. The examiner should observe both eyes and the general appearance of the patient. Backward tilted head, wrinkled skin of the forehead, and elevated eyebrows may present as compensatory changes.[2] Any scar, swelling, or abnormal structure near eyelids should not be missed. It may present with eyeball deviation, shrinking or bulging. Following clinical signs should also be examined:
Myasthenia gravis can manifest as generalized or solely ocular disease with pupil sparing ptosis. It can be assessed by edrophonium test which contains edrophonium, a short-acting acetylcholinesterase inhibitor. A positive test is the eyelid elevation in 2 to 5 minutes after administration of edrophonium.[9] It has relatively low sensitivity, and the ice test has superseded it; in which an ice pack is placed over the ptotic lid for 2 to 5 minutes and then improvement is noticed.[10]
Proper diagnosis and management of blepharoptosis require assessment by the following measurements:
If myasthenia gravis is suspected, blood serum is tested for acetylcholine receptor antibodies which are responsible for this autoimmune disorder. However, these are positive only in 50% of patients with solely ocular myasthenia.[9] Antistriated muscle antibodies and muscle-specific tyrosine kinase levels are also checked when myasthenia is highly suspected.
Thyroid studies are not needed usually, but myasthenia often correlates with thyroid disorders and rarely ptosis may present in hypothyroidism.[12] Thus, whenever thyroid involvement is suspected, thyroid functions must be assessed.
Imaging studies such as X-ray or brain and orbit CT/MRI scans are needed by ophthalmologists and neurologists when any pathology is suspected in these regions such as a tumor in orbit or skull, nerve defects, multiple sclerosis, trauma, etc. Thorax radiography is used to assess the thymus in case of myasthenia.
Treatment of ptosis depends upon the underlying etiology, the degree of ptosis, and the function of the levator muscle. In mechanical ptosis, removal of the abnormal structure, i.e., a chalazion, is all that is needed. However, surgical correction is the mainstay of treatment as well as some nonsurgical options available for specific conditions.
Pseudoptosis is the false perception of the ptosis, which may result from the following[1][2][6]:
Prognosis depends upon the type and treatment of ptosis. The appropriate surgical procedure applied according to the preoperative evaluation shows very good prognosis. For example, ptosis with poor levator function corrected with the levator resection instead of fascia lata sling procedure will show poor results. Proper preoperative assessment and postoperative care with close monitoring fairly improve the outcome of surgical repair in any form of ptosis.
Complications that can occur after ptosis repair can subdivide into:
Patient education regarding the cause of ptosis and long-term complications it can cause if untreated is necessary. All treatment options, surgical and nonsurgical, including the best one according to assessment, should be discussed. The clinician must explain likely postoperative complications to the patient that can occur earlier or later on and their management.
Ptosis is one of the most commonly presenting cases in ophthalmology clinics, which requires management with coordination between the ophthalmologist, optician, nurse, and the surgeon for proper management. The majority of patients with ptosis first present in primary care clinics, and it is important to refer these patients to a neurologist and/or ophthalmologist for further workup.
This teamwork is vital for the preoperative assessment and choosing the best treatment option for a particular case of ptosis. Surgical correction of ptosis should be carried out by an oculoplastic surgeon along with a plastic surgeon for the best visual as well as the cosmetic outcome. Specialty-trained nursing will prep the patient, assist during the surgery, and provide post-surgical care and counsel to the patient and/or family, reporting any concerns to the surgeon or other physicians managing the case. Knowledge and evaluation of the case are crucial for the surgeons to perform a procedure in the best interest of the patient. This type of interprofessional collaboration is vital to achieving optimal patient outcomes in ptosis cases. [Level 5]
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[13] | Hejsek H,Veliká V,Stepanov A,Rozsíval P, [Surgical treatment of severe degree of ptosis of the upper eyelid using a Fronto-tarsal sling of biocompatible PVC]. Ceska a slovenska oftalmologie : casopis Ceske oftalmologicke spolecnosti a Slovenske oftalmologicke spolecnosti. 2014 Jun; [PubMed PMID: 25032796] |
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