Ptosis is a condition characterized by a drooping or falling of the upper Eyelid, also referred to as droopy eyelid, caused by weakness of the muscle responsible for lifting it up It can affect one or both eyes and is a fairly common condition seen by ophthalmologists. Read on for a detailed guide to understanding the causes, symptoms, diagnosis, and treatment for ptosis.
What Is Ptosis?
Ptosis refers to the abnormal drooping or falling of the upper eyelid, also called blepharoptosis. The normal upper lid covers about 1-2 mm of the upper part of the iris, but in ptosis, it covers a larger part of the iris and pupil.
The levator palpebrae superioris is the muscle responsible for lifting the upper eyelid. Ptosis occurs when this muscle is weak or develops an abnormal attachment to the eyelid. This can happen due to age-related changes, an injury, or a disease affecting the muscle or nerve supplying it.
Ptosis can vary from mild to severe based on how low the eyelid droops and how much of the pupil it covers. The condition can affect one eye or both eyes. Ptosis usually progresses slowly, and the drooping may worsen over time. Fortunately, numerous treatment options—like ptosis correction Singapore—are commonly performed to treat significant cases of ptosis.
Causes Of Ptosis
There are several causes for ptosis, ranging from genetic to acquired conditions:
- Age-Related Ptosis
Also called involutional ptosis, this is the most common cause occurring in older adults. Over time, the levator muscle stretches and thins out, becoming weaker. Aging also causes the eyelid skin and other supporting structures to weaken, leading to sagging. Age-related ptosis tends to develop slowly over many years.
- Congenital Ptosis
Some children are born with ptosis due to underdevelopment or absence of the levator muscle. It can range from mild to severe. Amblyopia or lazy eye may develop if severe ptosis blocks vision in one eye during childhood.
- Neurogenic Ptosis
This refers to ptosis caused by damage or dysfunction of the nerve supplying the levator muscle, called the oculomotor nerve. It can be due to:
- Oculomotor nerve palsy
- Horner’s syndrome
- Myasthenia gravis
- III, IV, or VI cranial nerve palsies
- Brain tumor, aneurysm, or stroke
Neurogenic ptosis comes on suddenly and can affect one or both eyelids.
- Mechanical Ptosis
Any structural defects along the eyelid margin or levator complex can mechanically weigh down the eyelid, resulting in ptosis. Examples include:
- Chalazion: Chronic lipogranulomatous inflammation of the eyelid.
- Dermatochalasis: Excess or sagging eyelid skin.
- Infection: Eyelid swelling due to cellulitis.
- Tumors: Like neurofibroma, hemangioma.
- Trauma Or Surgery: Scarring along the eyelid or levator muscle.
Identifying and treating these underlying causes is key to addressing this type of ptosis.
- Myogenic Ptosis
Defects in the levator muscle itself, such as dehiscence or disinsertion of the muscle or blepharophimosis, can also cause ptosis. Levator disinsertion is the separation of the levator muscle from the upper eyelid margin.
- Aponeurotic Ptosis
This is when the connective tissue that attaches the levator muscle to the tarsal plate becomes weakened or detached. It is also called levator aponeurosis disinsertion. It usually occurs after the age of 50 years.
Symptoms Of Ptosis
The most noticeable sign of ptosis is a droopy upper eyelid. Other symptoms may include:
- The eyelid covers more of the iris and pupil than normal
- Vision may be blocked or obscured by the drooping eyelid
- There may be a narrowed vertical eyelid opening
- Fellow eye may adopt a higher-than-normal position to compensate
- Raising the eyebrows or excessive backward head tilt is required to see under the eyelid
- Frontalis overaction, or the increased contraction of the frontalis muscle to lift the eyelid
- Fatigue in the eyelid or forehead muscles with sustained activity
- Difficulty lifting the droopy eyelid
- Poor vision or amblyopia in children if ptosis blocks vision in one eye during visual development
- Double vision or strabismus may occur if both eyelids are not at the same level
A droopy upper eyelid is the hallmark of ptosis. But it can also cause visual obstruction, eye strain, and amblyopia if severe. Recognizing the symptoms early and getting prompt evaluation is advised.
An ophthalmologist examines the eyes in detail to determine the cause and extent of ptosis. The exam includes:
- External Examination: Excess skin, inflammation, and structural defects are looked for. The palpebral fissure height is measured in the primary gaze with the patient relaxed. A marginal reflex distance of less than 2 mm from the light reflex to the upper lid margin indicates ptosis.
- Levator Function: The patient looks up maximally, and the amount of eyelid excursion is measured. Less than 8 mm is considered poor function.
- Eye Motility: Any restriction of eye movements, like double vision, is noted, which may indicate neurogenic ptosis.
- Eyelid Crease: A high or absent crease may suggest levator dehiscence.
- Vision Assessment: Visual acuity and amblyopia are tested.
- Bell’s Phenomenon: Eyelid closing and upward rotation of the eyeball on attempted closure are tested. This protects the cornea if lagophthalmos or incomplete eyelid closure is present.
- Manual Eyelid Elevation: The upper lid is manually lifted to assess improvement in vision.
- Photography: Standardized photos may document the degree of ptosis for follow-up.
- Imaging: CT or MRI scans may be done sometimes to look for underlying neurological causes.
A combination of external examination, levator function tests, eyelid measurements, and imaging help diagnose ptosis and reveal its underlying cause and severity. This facilitates planning and appropriate management.
Treatment Options For Ptosis
The treatment options for ptosis include:
- Eyelid Crutches
These provide external mechanical support to lift the eyelid. Various crutches are available, such as:
- Temporary eyelid tape that is helpful for mild ptosis with levator function ≥ 4 mm
- Transparent eyelid splints
- Custom-designed external eyelid support devices
The tape or crutches are applied and removed daily by the patient. They can provide temporary relief in mild cases and help prevent amblyopia in children until surgery can be performed.
- Ptosis Surgery
This is the mainstay of treatment for most patients with moderate to severe acquired ptosis. Several surgical techniques exist, including:
- Levator Resection: Shortening and reattachment of the levator muscle to the upper tarsal border. It effectively tightens and lifts the eyelid.
- Frontalis Suspension: Fascia lata or other autologous slings are used to suspend the eyelid from the frontalis muscle and brow. It is preferred for severe congenital ptosis cases.
- Levator Advancement: The levator muscle is detached from the eyelid, advanced superiorly, and reattached to give a better eyelid lift.
- Muller’s Muscle-Conjunctival Resection: Conjunctiva and Muller’s smooth muscle are resected from the upper tarsal border, which helps lift the lid.
Ptosis surgery is typically performed under local anesthesia as an outpatient procedure. Recovery takes around 2-3 weeks, during which the operated eye needs to be protected from rubbing and pressure. The sutures are removed in 5-7 days.
- Treating Underlying Conditions
If there is an underlying neurological or mechanical cause like achalasia, myasthenia gravis, tumor, etc., those need to be treated first. This may help improve the ptosis in some cases.
Recovery Period After Ptosis Surgery
The recovery period after ptosis surgery usually lasts 2-3 weeks, during which the eyes appear bruised and swollen. Here are a few tips for recovery care:
- Keep the head elevated on 2-3 pillows for the first 2-3 nights to reduce swelling.
- Apply cold compresses gently on the eyes for the first 48 hours to reduce inflammation.
- Use lubricating eye drops as prescribed to prevent dryness.
- Avoid rubbing or putting any pressure on the eyes until healed.
- Wear goggles or eye protection while sleeping to prevent accidental injury.
- The operated eye may appear bloodshot or bruised initially.
- Strenuous activity should be avoided for two weeks. Reading and television can be done with moderation.
- Vision improvement can take a few weeks as the swelling subsides.
- Follow up with your ophthalmologist as scheduled for wound inspection, suture removal, and vision checks.
- Perform simple eyelid stretching exercises daily after two weeks to strengthen the lid muscle.
With proper pre-op guidance, good surgical technique, and post-op recovery care, successful results can be achieved in most ptosis patients.
Prevention Of Ptosis
While involutional and congenital causes cannot be prevented, here are some tips to reduce the risk of acquired ptosis:
- Protect the eye region from blunt injuries by using safety goggles during sports or activities with projectile hazards.
- Seek prompt treatment for any infections, inflammation, or cysts around the eyes to reduce mechanical drooping.
- Manage chronic health conditions like myasthenia gravis, III nerve palsy, and thyroid eye disease that can cause ptosis.
- Do eyelid stretching exercises to maintain good levator strength. Gently lift the eyebrows up and close the eyes tightly for 5 seconds, and repeat ten times, twice daily.
- Maintain a healthy diet and sleep routine to prevent eyelid muscle fatigue.
- Wear UV protection outdoors to prevent skin sagging around the lids.
- Have regular eye check-ups to treat any condition early before it worsens.
While one cannot prevent age-related or congenital ptosis, you can take measures to avoid acquired causes like infections, injury, and nerve damage. This includes eye protection, managing chronic conditions, and regular eye check-ups. Being proactive helps reduce ptosis risk.
Ptosis has a wide range of causes but is highly treatable in most cases with timely intervention. Mild cases can be managed conservatively, while surgical repair is the mainstay for moderate-to-severe ptosis. With proper pre and post-op care, the procedure has good success rates. Eyelid position and visual function can greatly improve after ptosis correction.
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