• Drooping of the upper eyelid
– May be congenital or acquired
– May cause blurred vision or loss of visual field
• Most commonly idiopathic
• May be inherited as autosomal dominant trait
• Familial occurrences suggest that genetic or chromosomal defects are likely, although yet unknown.
• Aponeurotic: levator stretching or dehiscence (1)
• Myogenic: primary or secondary levator and/or Muller’s muscle abnormality
• Neurogenic: damage to nerves innervating the levator and/or Muller’s muscle
• Traumatic: damage to eyelid retractors
– Myogenic: levator dysgenesis
– Neurogenic: synkinetic, Horner’s syndrome, cranial nerve (CN) III palsy
– Aponeurotic: normal aging changes, repetitive trauma in patients who rub eyes, contact lens wearers, patients with previous intraocular surgery
– Myogenic: myasthenia gravis, chronic progressive external ophthalmoplegia (CPEO), myotonic dystrophy, oculopharyngeal dystrophy
– Neurogenic: CN III palsy, Horner’s syndrome
– Traumatic: history of eyelid laceration with levator transection, contusion injury to the levator
– Reactive: due to ocular or orbital inflammation
COMMONLY ASSOCIATED CONDITIONS
• CN III palsy
– Congenital, compressive, vasculopathic, traumatic
• Horner’s syndrome
• Myasthenia gravis
• Other: Marcus Gunn jaw winking syndrome, ophthalmoplegic migraine, multiple sclerosis
• Determine the onset and duration of ptosis.
• History of surgery in either eye?
• Symptoms of ocular irritation?
• Orbital or eyelid trauma?
• Variability with fatigue?
• Associated with headache or neck pain?
• Associated diplopia?
• History of autoimmune disease (lupus, Sjögren’s syndrome)?
• Visual acuity
– Position of upper and lower eyelid margins (primary, up and down gaze)
– Levator function
– Presence and position of eyelid crease
– Amount of dermatochalasis, position of eyebrows
– Preexisting eyelid scars
– Evert upper eyelid
– Orbital exam: palpable masses or proptosis?
– Irregular, miosis or mydriasis
– Ductions and versions
– Bell’s phenomenon
– Strabismus or diplopia
• Anterior segment
– Conjunctival inflammation, filtering blebs
– Tear film
– Anterior segment inflammation
• Pigmentary changes
DIAGNOSTIC TESTS & INTERPRETATION
Acetylcholine receptor antibody testing and/or edrophonium chloride (Tensilon) testing under monitored conditions are recommended in cases of suspected myasthenia gravis.
• Suspected orbital mass: orbital CT or MRI
• Painful Horner’s syndrome: rule out carotid artery dissection with emergent CT/CT angiography (CTA) or MRI/magnetic resonance angiography (MRA) of the head/neck.
• CN III palsy (partial or pupil involving): rule out intracranial aneurysm with emergent CT/CTA, MRI/MRA, or angiography.
• Visual fields to determine functional impact
• Clinical photographs
• Ice test
– Improvement of ptosis with ice suggests myasthenia gravis.
• Cocaine and/or hydroxyamphetamine tests
– In cases of suspected Horner’s syndrome
• Single fiber electromyography (EMG)
– In cases of suspected myasthenia gravis
• Congenital ptosis
– Underdeveloped levator muscle, may be infiltrated by fatty tissue
• Aponeurotic ptosis
– Thinning, lengthening, and/or disinsertion of the levator aponeurosis from the tarsal plate
• Myogenic ptosis
– Ragged red fibers in CPEO
• Contralateral upper lid retraction
• Ipsilateral exophthalmos
• Small globe: microphthalmos, phthisis bulbi
• Brow ptosis
• Eyelid edema
• Myasthenia gravis: treatment of primary disorder will improve ocular symptoms
– Pyridostigmine, prednisone, intravenous immunoglobulin (IVIG), steroid-sparing agents
• Management of chalazion and eyelid and/or orbital neoplasms with excision
• Treatment of ocular irritation in reactive ptosis
• Traumatic ptosis should be observed for spontaneous improvement for at least 6 months.
Issues for Referral
• Congenital ptosis
– Referral to pediatric ophthalmologist for monitoring/management of possible amblyopia and/or strabismus
• Neurogenic ptosis
– Referral to neuro-ophthalmologist, neurologist, and/or neurosurgeon
COMPLEMENTARY & ALTERNATIVE THERAPIES
Taping and eyelid crutches attached to glasses
• External levator resection/advancement
• Internal levator resection
• Frontalis sling procedure: for patients with poor levator function
See issues for referral.
Congenital ptosis: see issues for referral.
Dependent of etiology
• After surgical repair:
– Orbital hemorrhage
– Eyelid asymmetry
– Dry eye syndrome
– Corneal exposure/lagophthalmos
1. Frueh BR. The mechanistic classification of ptosis. Ophthalmology 1980;87:1019–1021.