Generality
The eyelid ptosis consists in a complete or partial lowering of the upper or lower eyelids. The condition may be present from birth ( congenital palpebral ptosis ) or occur during life ( acquired eyelid ptosis ).
Surgical correction can be an effective treatment for eyelid ptosis, useful for improving vision and aesthetic appearance.
Note . When ptosis affects the upper eyelid, it is called blepharoptosis .
Symptoms
The most obvious sign of ptosis is the lowering of one or both eyelids. The appearance of a drooping eyelid can remain stable over time, develop gradually over decades (progressive ptosis) or follow an intermittent pattern. Eyelid ptosis can be barely perceptible or completely cover the pupil, iris and other parts of the eye. In some cases, blepharoptosis can limit and even prevent normal vision. When the condition is unilateral, it can be easy to highlight a difference by comparing the two eyelids, while ptosis can be difficult to identify when it affects both sides of the face or in the presence of minimal disturbance.
Sometimes, a drooping eyelid is an isolated problem that changes a person's appearance without compromising their vision or health. In other cases, it may be a warning sign for a more serious disorder involving muscles, nerves, eyes or the brain. Eyelid ptosis occurring over a period of days or hours can be a sign of a serious medical problem.
Other symptoms include:
- Difficulty closing or opening the eyes;
- Slight sagging or severe laxity of the skin on or around the eyelid;
- Fatigue and pain around the eyes, especially during the day;
- Change in the appearance of the face.
Ptosis can be associated with strabismus or another disorder affecting the position of the eyes or their movement. Often, children with eyelid ptosis tilt their head back or raise their eyebrows in an attempt to see better. This behavior, over time, can lead to headaches (due to hyperactivity of the frontal muscle) and to "ocular torticollis", which can cause, in turn, neck problems and / or developmental delay.
Amblyopia (generic weakness of eyesight not due to an overt disease of the eyeball) can derive directly from the obscuring of vision or indirectly from the development of refractive errors, such as astigmatism. The development of amblyopia is an indication for immediate surgical correction of eyelid ptosis.
Causes
The condition can affect people of all ages: it can be present in children as well as in adults.
The causes of drooping eyelids are different.
Congenital ptosis in one or both eyelids is present since birth. Usually, the condition is due to the poor development of the muscles that lift or close the eyelid (levator, orbicularis of the eye and upper tarsal). Some cases of congenital blepharoptosis may result from genetic or chromosomal defects or neurological dysfunction. Pediatric ptosis requires a detailed examination of the eyelids and treatment generally depends on the functionality of the eyelid muscles.
Although it is usually an isolated problem, a child born with one or two drooping eyelids may present with eye movement abnormalities, muscle diseases, tumors, neurological disorders or refractive errors. Congenital ptosis usually does not improve with time.
Most acquired eyelid ptosis occurs with aging, as the eyelid muscles weaken. In adults, the most common cause of ptosis is the separation or stretching of the elevator muscle tendon.
Sometimes, palpebral ptosis can result from injuries or side effects of corrective eye surgery (eg cataract surgery). Palpebral ptosis can arise in the course of life even if the muscles normally responsible for the movement of the eyelid are affected by injuries or diseases such as eye tumors, neurological disorders or systemic diseases, such as diabetes. High doses of opioid drugs (morphine, oxycodone or hydrocodone) can cause eyelid ptosis. Furthermore, the condition is a side effect commonly found in drug abuse, such as diacetylmorphine (heroin).
Depending on the cause, the eyelid ptosis can be classified as:
- Myogenic ptosis (or myogenic): it is due to a weakening of the levator, orbicularis of the eye and of the superior tarsal muscle. Myogenic ptosis is common in patients with myasthenia gravis or myotonic dystrophy.
- Neurogenic ptosis : it is caused by the involvement of the nerves that control the levator muscle that lifts the eyelid. Some examples include the paralysis of the oculomotor nerve and the ..
- Aponeurotic ptosis : refers to the involution effect (due to anatomical changes related to age) or to the weakening of the eyelid muscle connections due to a post-operative outcome.
- Mechanical ptosis : it can be consequent to a condition in which the weighting of the eyelid prevents its correct movement. Mechanical ptosis can result from the presence of a mass, such as a neurofibroma, a hemangioma or secondary scarring due to inflammation or surgery. Other conditions underlying mechanical ptosis may include edema, infections and eyelid tumors.
- Traumatic ptosis : may represent the outcome of a laceration of the eyelid with excision of the elevator of the upper eyelid or interruption of the neural pathway
- Neurotoxic ptosis : it is a classic symptom of poisoning, usually accompanied by diplopia, dysphagia and / or progressive muscle paralysis, respiratory failure and possible suffocation. It is therefore a medical emergency, which requires immediate treatment.
Eyelid ptosis in children
The most serious problem associated with eyelid ptosis in children is amblyopia (lazy eye), which consists of poor vision in an eye due to a failure to develop the normal visual system during early childhood. As a consequence, the disorder tends to induce the constant blurring of visual images, causing astigmatism or other refraction errors. If the eyelid ptosis is not corrected, significant vision loss can occur.
Ptosis can also hide a misalignment of the visual axis ( strabismus ), which, in turn, can cause amblyopia.
The contraction of the frontal muscle to help elevate the eyelid is a very common compensation mechanism, found in children with eyelid ptosis. Mild cases are usually regularly observed to monitor the occurrence of visual problems. For children who are born with moderate to severe ptosis, on the other hand, early treatment reduces the risk of permanent visual impairment. Surgery may also be indicated during pre-school years in cases where the maturation of the face does not improve eyelid ptosis sufficiently.
Risk factors and associated diseases
A wide variety of factors and diseases can increase the risk of developing eyelid ptosis:
- Aging (senile or age-related ptosis);
- Genetic predisposition;
- Diabetes;
- Horner syndrome;
- Myasthenia gravis;
- Stroke;
- Trauma at birth;
- Brain tumor or other neoplasms that can affect nerve or muscle reactions;
- Paralysis or lesion of the 3rd cranial nerve (oculomotor nerve);
- Trauma to the head or eyelids;
- Bell's palsy (compression / damage of the facial nerve);
- Muscular dystrophy.
Diagnosis
The ophthalmologist can diagnose ptosis by examining the eyelids with particular attention, by palpation of the same and the ocular orbit.
Before proceeding with the evaluation of visual acuity and using topical eye-drops, the following measurements are carried out precisely:
- Eyelid fissure: distance between the upper part and the lower eyelid in vertical alignment with the pupil center;
- Reflex marginal distance 1 (MRD-1): distance between the center of the pupillary reflex to light and the upper eyelid margin;
- MRD-2: distance between the center of the pupillary reflex to light and the lower eyelid margin;
- Function of the levator muscle;
- Distance of the skin fold from the upper eyelid margin (MFD).
Other features that can help determine the cause of the eyelid ptosis are:
- Eyelid height;
- Force of levator muscle;
- Eye movements;
- Tear production anomalies;
- Lagophthalmos (incomplete closure of the eyelid rim, above the eyeball);
- Eyelid retraction, to rule out thyroid orbitopathy;
- Presence / absence of double vision, muscle fatigue or weakness, difficulty speaking or swallowing, headache, tingling or numbness in any part of the body.
During the examination, the doctor is able to distinguish whether drooping eyelids are caused by ptosis or a similar condition, dermatocalase. The latter is an excess of skin in the upper or lower part of the eyelid due to the loss of elasticity of the connective tissue.
Further specific investigations are conducted to determine the cause of acquired ptosis and to plan the best treatment. For example, if the patient shows signs of a neurological problem or if the eye exam shows a mass (or swelling) inside the eye socket, a computerized tomography (CT) or magnetic resonance imaging (MRI) may be required.
Treatment
Specific treatment is directed to the underlying cause.
- Medical observation is generally sufficient in mild cases of congenital ptosis not accompanied by amblyopia, strabismus or altered posture of the head.
- If symptoms of ptosis are mild, medical intervention may not be necessary and treatment should be limited to eye exercises to strengthen weak muscles and correct the problem. Alternatively, non-surgical solutions can be used, such as the use of crutch glasses or special scleral contact lenses to support the eyelid.
- When blepharoptosis is a sign of systemic, muscular or neurological disease, the patient must be referred to the specialist physician responsible for appropriate management. The only valid option to correct a severe case of eyelid ptosis is surgery. The surgery reattaches and strengthens the elevator muscles, raising the eyelids and improving vision. In addition, surgical correction allows the appearance to be improved.
If the levator muscles are extremely weak to do their job properly, the surgeon may decide to attach the eyelid under the eyebrow, so as to allow the forehead muscles to take on the task of lifting it.
Immediately after surgery, it may be difficult for the patient to close the eye completely, but this effect is only temporary. Generally, bruising and swelling persist for about 2-3 weeks. In some cases, lubricating eye drops, antibiotics or painkillers may be prescribed. Healing should take place within six weeks of the operation.
Although surgery usually improves the height of the eyelids, these may not yet be perfectly symmetrical after the operation. Sometimes, more interventions may be needed to correct the problem. The expected result depends on the cause of ptosis, but in most cases the outlook is good. Surgery is usually able to restore the appearance and ocular function in children with congenital ptosis and adults with age-related ptosis. Complications that may occur after blepharoplasty include excessive bleeding, surgical site infection, scarring and damage to nerves or facial muscles. Patients suffering from eyelid ptosis, whether or not subjected to surgery, must be regularly examined by an ophthalmologist to monitor amblyopia, refraction disorders and related conditions.
