Types of ptosis
Normally, the edge of the upper eyelid slightly covers the upper part of the iris. With ptosis, it drops lower, and the degree is determined by how closed the pupil is. Congenital ptosis is usually associated with underdevelopment of the levator palpebral muscle and can be unilateral or bilateral. Among the acquired ones, the most common is aponeurotic, when with age the muscle tendon stretches and peels off. Neurogenic ptosis occurs when the oculomotor nerve or sympathetic fibers are damaged, myogenic - with muscle diseases and myasthenia, mechanical - due to the severity of the tumor or swelling of the eyelid.
- Congenital - muscle underdevelopment
- Aponeurotic - age-related, most common in adults
- Neurogenic - nerve damage, Horner's syndrome
- Myogenic – myasthenia gravis, muscular dystrophies
- Mechanical - swelling, scars, edema
- False ptosis - overhanging excess skin
Causes and risk factors
Congenital ptosis often occurs sporadically, sometimes it is inherited or combined with disorders of eye movements. In adults, the main cause is age-related tissue changes, and tendon stretching can be accelerated by long-term wearing of hard contact lenses, frequent eye rubbing, and eye surgery, including cataract removal. Diabetes mellitus and hypertension increase the risk of oculomotor nerve damage. Ptosis that changes throughout the day is characteristic of myasthenia gravis. Slight ptosis with constriction of the pupil occurs with Horner's syndrome. Temporary drooping of the eyelid is possible after botulinum toxin injections into the forehead.
- Age-related muscle tendon strain
- Long-term wearing of hard contact lenses
- Eye surgeries and injuries
- Diabetes mellitus and hypertension
- Myasthenia gravis
- Aneurysms and tumors in the nerve area
- Botulinum toxin injections - temporary
Symptoms
The main symptom is a visible drooping of one or both upper eyelids, which causes the eyes to appear different in size and a tired look. To see better, a person raises his eyebrows and tenses his forehead, which leads to headaches and wrinkles, or throws his head back. The upper field of vision is limited, especially noticeable when reading and driving. Children with congenital ptosis often raise their chin. With myasthenia gravis, ptosis is less pronounced in the morning, but increases in the evening and after exercise, and may be accompanied by double vision. Sudden ptosis with double vision indicates nerve damage.
- Drooping of the upper eyelid
- Eye asymmetry
- Forehead tension and eyebrow raising
- Throwing back the head
- Narrowing of the upper visual field
- Eye fatigue and headache
- Double vision with neurogenic and myogenic ptosis
Diagnostics
The ophthalmologist measures the distance from the edge of the eyelid to the center of the pupil, the height of the fold and the function of the muscle that lifts the eyelid - the choice of operation depends on this. The doctor distinguishes true ptosis from sagging skin, drooping eyebrows and eye asymmetry. Perimetry with raised and lowered eyelids objectively shows how limited the field of vision is. Check pupil size, eye movements and eyelid closure. If myasthenia gravis is suspected, cold and rest tests are performed, an antibody test is performed, and a referral is made to a neurologist. Sudden neurogenic ptosis requires urgent MRI or CT of the head vessels. Children must have their vision and refraction checked.
- Measuring eyelid position and muscle function
- Computer perimetry
- Assessment of pupils and eye movements
- Testing vision and refraction in children
- Test for myasthenia gravis and consultation with a neurologist
- MRI or CT for neurogenic ptosis
Treatment
The main treatment method for severe ptosis is surgery. In case of age-related aponeurotic ptosis, the surgeon sutures and shortens the stretched tendon of the muscle; if the muscle function is good, the operation can be performed through an incision in the crease of the eyelid. In congenital ptosis with a weak muscle, the eyelid is suspended from the frontalis muscle. If there is excess skin, correction is combined with blepharoplasty, but blepharoplasty itself does not eliminate ptosis. Children at risk of amblyopia undergo surgery earlier and receive vision treatment at the same time. For myasthenia gravis and neurological causes, the underlying disease is treated first. Exercises and creams do not lift a drooping eyelid.
- Shortening or suturing of the muscle aponeurosis
- Resection of the levator palpebral muscle
- Suspension of the eyelid to the frontalis muscle
- Combination with blepharoplasty for excess skin
- Treatment of amblyopia in children
- Treatment of myasthenia gravis and neurological diseases
- Special glasses with eyelid support - if surgery is not possible
