Generality
Eyelid ptosis consists of a complete or partial lowering of the upper or lower eyelids. The condition may be present from birth (congenital eyelid ptosis) or occur later in life (acquired eyelid ptosis).
.jpg)
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 "drooping of one or both eyelids. The appearance of a drooping eyelid may remain stable over time, develop gradually over decades (progressive ptosis), or follow an intermittent pattern." Eyelid ptosis may be barely noticeable 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 one-sided, it can be easy to spot a difference by comparing the two eyelids, while ptosis can be difficult to identify when it affects both sides of the face or when there is minimal disturbance.
Sometimes, a drooping eyelid is an isolated problem that changes a person's appearance without affecting their vision or health. In other cases, it can be a warning sign of a more serious disorder, affecting muscles, nerves, eyes or brain Ptosis that occurs 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
- Mild sagging or severe laxity of the skin on or around the eyelid
- Tiredness and pains around the eyes, especially during the day
- Change in the appearance of the face.
Ptosis can be associated with strabismus or another disorder that affects 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. Over time, this behavior can lead to headaches (due to hyperactivity of the frontal muscle) and "ocular stiff neck", which in turn, it can cause neck problems and / or developmental delays.
Amblyopia (generic weakness of vision not due to an overt disease of the eyeball) can result directly from the darkening of vision or indirectly from the development of refractive errors, such as astigmatism. The development of amblyopia represents an indication for the immediate surgical correction of eyelid ptosis.
Causes
The condition can affect people of all ages: it can be present in children as well as adults.
The causes of droopy eyelids are different.
Congenital ptosis in one or both eyelids is present from birth. Usually, the condition is due to poor development of the muscles that lift or close the eyelid (levator, orbicularis of the eye and superior tarsal). Some cases of congenital blepharoptosis can result from genetic or chromosomal defects or neurological dysfunctions. in pediatric age it requires a detailed examination of the eyelids and treatment usually depends on the functionality of the eyelid muscles.
Although it is usually an isolated problem, a baby born with one or two drooping eyelids can have eye movement abnormalities, muscle disease, cancer, neurological disorders, or refractive errors. Congenital ptosis does not usually improve over time.
Most acquired eyelid ptosis occurs with aging, as the muscles of the eyelids weaken. In adults, the most common cause of ptosis is separation or stretching of the levator muscle tendon.
Sometimes, eyelid ptosis can result from injury or side effects of corrective eye surgery (example: cataract surgery). Eyelid 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. Taking high doses of opioid drugs (morphine, oxycodone, or hydrocodone) can cause eyelid ptosis. In addition, the condition is a commonly seen side effect of drug abuse, such as diacetylmorphine (heroin).
Depending on the cause, eyelid ptosis can be classified as:
- Myogenic (or myogenic) ptosis: is due to a weakening of the levator, orbicularis muscle of the eye and of the superior tarsal muscle. Myogenic ptosis is common in patients with myasthenia gravis or myotonic dystrophy.
- Neurogenic ptosis: is caused by the involvement of the nerves that control the levator muscle that lifts the eyelid. Some examples include oculomotor nerve palsy and ...
- Aponeurotic ptosis: refers to the involutionary effect (due to anatomical changes related to age) or to the weakening of the muscular connections of the eyelid due to a post-operative outcome.
- Mechanical ptosis: can result from a condition in which the heavy eyelid prevents correct movement. Mechanical ptosis can result from the presence of a mass, such as a neurofibroma, hemangioma or scarring secondary to inflammation or surgery. Other conditions underlying mechanical ptosis may include edema, infections and tumors of the eyelid.
- Traumatic ptosis: can represent the outcome of a laceration of the eyelid with excision of the levator upper eyelid or interruption of the neural path.
- 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 is poor vision in one eye due to a failure to develop the normal visual system during early childhood. constant blurring of visual images, causing astigmatism or other refractive 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.
Contraction of the frontal muscle to help elevate the eyelid is a very common compensatory mechanism found in children with eyelid ptosis. Mild cases are usually observed regularly to monitor for any vision problems. For children born with moderate to severe ptosis, early treatment reduces the risk of permanent vision impairment. Surgery can also be indicated during the preschool years in cases where the maturation of the face does not sufficiently improve the eyelid ptosis.
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's syndrome;
- Myasthenia gravis;
- Stroke;
- Birth trauma;
- Brain cancer or other malignancies that can affect nerve or muscle reactions
- Paralysis or injury of the 3rd cranial nerve (oculomotor nerve);
- Trauma to the head or eyelids;
- Bell's palsy (compression / damage to the facial nerve);
- Muscular dystrophy.
Diagnosis
The ophthalmologist can diagnose ptosis by examining the eyelids with particular attention, by palpating them and the eye socket.
Before proceeding with the assessment of visual acuity and using topical eye drops, the following measurements are carried out precisely:
- Eyelid fissure: distance between the upper and lower eyelids in vertical alignment with the center of the pupil;
- Reflected marginal distance 1 (MRD-1): distance between the center of the pupillary reflex in light and the upper lid margin;
- MRD-2: distance between the center of the pupillary light reflex and the lower lid margin;
- Levator muscle function;
- Distance of the skin fold from the upper lid margin (MFD).
Other features that can help determine the cause of eyelid ptosis are:
- Height of the eyelids;
- Levator muscle strength;
- Movements of the eye;
- Abnormalities in the production of tears
- Lagophthalmos (incomplete closure of the eyelid rim above the eyeball);
- Eyelid retraction, to rule out thyroid orbitopathy;
- Presence / absence of double vision, muscle tiredness 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 droopy eyelids are caused by ptosis or a similar condition, dermatochalase. The latter is excess skin on the upper or lower part of the eyelid due to loss of elasticity of the connective tissue.
Further specific investigations are conducted to determine the cause of the acquired ptosis and plan the best treatment. For example, if the patient has signs of a neurological problem or if the eye exam shows a mass (or swelling) inside the eye socket, computed tomography (CT) or magnetic resonance imaging (MRI) may be needed.
Treatment
Specific treatment is directed at the underlying cause.
- Medical observation is generally sufficient in mild cases of congenital ptosis not accompanied by amblyopia, strabismus or altered head posture.
- If symptoms of ptosis are mild, "medical intervention may not be necessary and treatment may be limited to eye exercises to strengthen weak muscles and correct the problem. Alternatively, non-surgical solutions, such as" wearing glasses "may be used. crutch "or special scleral contact lenses to support the eyelid.
- When blepharoptosis represents a sign of systemic, muscular or neurological disease, the patient must be referred to the competent medical specialist for appropriate management. The only viable option to correct a severe case of eyelid ptosis is surgery. The surgery reattaches and strengthens the levator muscles, lifting the eyelids and improving vision. Furthermore, the surgical correction allows to improve the aesthetic aspect.
If the levator muscles are extremely weak to do their job correctly, the surgeon may decide to connect the eyelid under the eyebrow to allow the forehead muscles to take over the task of lifting it.
Immediately following surgery, it may be difficult for the patient to close their eyes completely, but this effect is only temporary. Typically, bruising and swelling persist for about 2-3 weeks. In some cases, lubricating eye drops, antibiotics, or pain relievers may be prescribed. Healing should occur within six weeks of the operation.
Although surgery usually improves the height of the eyelids, they may still not be perfectly symmetrical after the operation. Sometimes, multiple actions may be required to correct the problem. The expected outcome depends on the cause of the ptosis, but in most cases the outlook is good. Surgery is usually able to restore ocular appearance and function in children with congenital ptosis and adults with age-related ptosis. Complications that can occur after blepharoplasty include excessive bleeding, surgical site infection, scarring, and damage to the nerves or facial muscles. Patients with eyelid ptosis, whether or not undergoing surgery, should be regularly examined by an ophthalmologist to monitor amblyopia, refractive disorders and related conditions.
.jpg)
