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Ptosis, also known as blepharoptosis, is a drooping or falling of the upper
eyelid An eyelid is a thin fold of skin that covers and protects an eye. The levator palpebrae superioris muscle retracts the eyelid, exposing the cornea to the outside, giving vision. This can be either voluntarily or involuntarily. The human eyel ...
. The drooping may be worse after being awake longer when the individual's muscles are tired. This condition is sometimes called "lazy eye", but that term normally refers to the condition
amblyopia Amblyopia, also called lazy eye, is a disorder of sight in which the brain fails to fully process input from one eye and over time favors the other eye. It results in decreased vision in an eye that typically appears normal in other aspects. Amb ...
. If severe enough and left untreated, the drooping eyelid can cause other conditions, such as amblyopia or
astigmatism Astigmatism is a type of refractive error due to rotational asymmetry in the eye's refractive power. This results in distorted or blurred vision at any distance. Other symptoms can include eyestrain, headaches, and trouble driving at nig ...
. This is why it is especially important for this disorder to be treated in children at a young age, before it can interfere with vision development. The term is from
Greek Greek may refer to: Greece Anything of, from, or related to Greece, a country in Southern Europe: *Greeks, an ethnic group. *Greek language, a branch of the Indo-European language family. **Proto-Greek language, the assumed last common ancestor ...
'fall, falling'.


Signs and symptoms

Signs and symptoms typically seen in this condition include: * The eyelid(s) may appear to droop. * Droopy eyelids can give the face a false appearance of being
fatigue Fatigue describes a state of tiredness that does not resolve with rest or sleep. In general usage, fatigue is synonymous with extreme tiredness or exhaustion that normally follows prolonged physical or mental activity. When it does not resolve ...
d, disinterested, or even sinister. * The eyelid may not protect the eye as effectively, allowing it to dry out. * Sagging upper eyelids can partially block the person's field of view. * Obstructed vision may cause a person to tilt their head back to speak. * The areas around the eyes may become tired and achy. * Eyebrows may be constantly lifted to see properly. Some of the risk factors for ptosis include: * Eye tumor. * Diabetes. * History of stroke. * Cancer. * Neurological disorder. * Age. Eye muscles weaken as they age, increasing the chance of the eyelids drooping.


Causes

Ptosis occurs due to dysfunction of the muscles that raise the eyelid or their nerve supply (
oculomotor nerve The oculomotor nerve, also known as the third cranial nerve, cranial nerve III, or simply CN III, is a cranial nerve that enters the orbit through the superior orbital fissure and innervates extraocular muscles that enable most movements of ...
for
levator palpebrae superioris The levator palpebrae superioris ( la, elevating muscle of upper eyelid) is the muscle in the orbit that elevates the upper eyelid. Structure The levator palpebrae superioris originates from inferior surface of the lesser wing of the sphenoid bo ...
and sympathetic nerves for
superior tarsal muscle The superior tarsal muscle is a smooth muscle adjoining the levator palpebrae superioris muscle that helps to raise the upper eyelid. Structure The superior tarsal muscle originates on the underside of levator palpebrae superioris and inser ...
). It can affect one eye or both eyes and is more common in the elderly, as muscles in the eyelids may begin to deteriorate. One can, however, be born with ptosis. This is due to improper development of the infant's levator muscle while still in the mother's womb. Congenital ptosis is hereditary in three main forms. Causes of congenital ptosis remain unknown. Ptosis may be caused by damage to the muscle which raises the eyelid, damage to the superior cervical sympathetic ganglion or damage to the
nerve A nerve is an enclosed, cable-like bundle of nerve fibers (called axons) in the peripheral nervous system. A nerve transmits electrical impulses. It is the basic unit of the peripheral nervous system. A nerve provides a common pathway for the e ...
(3rd cranial nerve (oculomotor nerve)) which controls this muscle. Such damage could be a sign or symptom of an underlying disease such as
diabetes mellitus Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ap ...
, a
brain tumor A brain tumor occurs when abnormal cells form within the brain. There are two main types of tumors: malignant tumors and benign (non-cancerous) tumors. These can be further classified as primary tumors, which start within the brain, and seconda ...
, a
pancoast tumor A Pancoast tumor is a tumor of the apex of the lung. It is a type of lung cancer defined primarily by its location situated at the top end of either the right or left lung. It typically spreads to nearby tissues such as the ribs and vertebrae. Mos ...
(apex of lung) and diseases which may cause weakness in muscles or nerve damage, such as
myasthenia gravis Myasthenia gravis (MG) is a long-term neuromuscular junction disease that leads to varying degrees of skeletal muscle weakness. The most commonly affected muscles are those of the eyes, face, and swallowing. It can result in double vision, dro ...
or
oculopharyngeal muscular dystrophy Oculopharyngeal muscular dystrophy (OPMD) is a rare form of muscular dystrophy with symptoms generally starting when an individual is 40 to 50 years old. It can be autosomal dominant neuromuscular disease or autosomal recessive. The most common i ...
. Exposure to the toxins in some snake venoms, such as that of the black mamba, may also cause this effect. Ptosis can be caused by the aponeurosis of the levator muscle, nerve abnormalities,
trauma Trauma most often refers to: * Major trauma, in physical medicine, severe physical injury caused by an external source * Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event *Traumatic i ...
,
inflammation Inflammation (from la, wikt:en:inflammatio#Latin, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or Irritation, irritants, and is a protective response involving im ...
or lesions of the lid or orbit. Dysfunctions of the levators may occur as a result of autoimmune antibodies attacking and eliminating the
neurotransmitter A neurotransmitter is a signaling molecule secreted by a neuron to affect another cell across a synapse. The cell receiving the signal, any main body part or target cell, may be another neuron, but could also be a gland or muscle cell. Neuro ...
. Ptosis may be due to a
myogenic The myogenic mechanism is how arteries and arterioles react to an increase or decrease of blood pressure to keep the blood flow constant within the blood vessel. Myogenic response refers to a contraction initiated by the myocyte itself instead of ...
,
neurogenic In biology, the nervous system is the highly complex part of an animal that coordinates its actions and sensory information by transmitting signals to and from different parts of its body. The nervous system detects environmental changes ...
,
aponeurotic An aponeurosis (; plural: ''aponeuroses'') is a type or a variant of the deep fascia, in the form of a sheet of pearly-white fibrous tissue that attaches sheet-like muscles needing a wide area of attachment. Their primary function is to join muscl ...
, mechanical or traumatic cause, and it usually occurs isolated, but may be associated with various other conditions, like immunological, degenerative, or hereditary disorders,
tumor A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
s or infections. Acquired ptosis is most commonly caused by aponeurotic ptosis. This can occur as a result of senescence, dehiscence or disinsertion of the levator aponeurosis. Moreover, chronic inflammation or intraocular surgery can lead to the same effect. Also, wearing
contact lenses Contact lenses, or simply contacts, are thin lenses placed directly on the surface of the eyes. Contact lenses are ocular prosthetic devices used by over 150 million people worldwide, and they can be worn to correct vision or for cosmetic ...
for long periods of time is thought to have a certain impact on the development of this condition. Congenital neurogenic ptosis is believed to be caused by
Horner's syndrome Horner's syndrome, also known as oculosympathetic paresis, is a combination of symptoms that arises when a group of nerves known as the sympathetic trunk is damaged. The signs and symptoms occur on the same side (ipsilateral) as it is a lesion ...
. In this case, a mild ptosis may be associated with ipsilateral ptosis,
iris Iris most often refers to: *Iris (anatomy), part of the eye *Iris (mythology), a Greek goddess * ''Iris'' (plant), a genus of flowering plants * Iris (color), an ambiguous color term Iris or IRIS may also refer to: Arts and media Fictional ent ...
and areola hypopigmentation and anhidrosis due to paresis of the
superior tarsal muscle The superior tarsal muscle is a smooth muscle adjoining the levator palpebrae superioris muscle that helps to raise the upper eyelid. Structure The superior tarsal muscle originates on the underside of levator palpebrae superioris and inser ...
. Acquired Horner syndrome may result after trauma, neoplastic insult, or even
vascular disease Vascular disease is a class of diseases of the blood vessels – the arteries and veins of the circulatory system of the body. Vascular disease is a subgroup of cardiovascular disease. Disorders in this vast network of blood vessels can cause ...
. Ptosis due to trauma can ensue after an eyelid laceration with transection of the upper eyelid elevators or disruption of the neural input. Other causes of ptosis include eyelid neoplasms,
neurofibromas A neurofibroma is a benign nerve-sheath tumor in the peripheral nervous system. In 90% of cases, they are found as stand-alone tumors (solitary neurofibroma, solitary nerve sheath tumor or sporadic neurofibroma), while the remainder are found in p ...
or the cicatrization after inflammation or surgery. Mild ptosis may occur with aging. A drooping eyelid can be one of the first signals of a third nerve palsy due to a cerebral aneurysm, that otherwise is asymptomatic and referred to as an oculomotor nerve palsy.


Drugs

Use of high doses of
opioid Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid us ...
drugs such as
morphine Morphine is a strong opiate that is found naturally in opium, a dark brown resin in poppies (''Papaver somniferum''). It is mainly used as a analgesic, pain medication, and is also commonly used recreational drug, recreationally, or to make ...
,
oxycodone Oxycodone, sold under various brand names such as Roxicodone and OxyContin (which is the extended release form), is a strong, semi-synthetic opioid used medically for treatment of moderate to severe pain. It is highly addictive and a commonly ...
,
heroin Heroin, also known as diacetylmorphine and diamorphine among other names, is a potent opioid mainly used as a recreational drug for its euphoric effects. Medical grade diamorphine is used as a pure hydrochloride salt. Various white and brow ...
, or
hydrocodone Hydrocodone, also known as dihydrocodeinone, is an opioid used to treat pain and as a cough suppressant. It is taken by mouth. Typically it is dispensed as the combination acetaminophen/hydrocodone or ibuprofen/hydrocodone for pain severe en ...
can cause ptosis.
Pregabalin Pregabalin, sold under the brand name Lyrica among others, is an anticonvulsant, analgesic and anxiolytic medication used to treat epilepsy, neuropathic pain, fibromyalgia, restless leg syndrome, opioid withdrawal and generalized anxiety disord ...
, an anticonvulsant drug, has also been known to cause mild ptosis.


Mechanism

Different trauma can cause and induce many different mechanisms. For example, myogenic ptosis results from a direct injury to the levator muscle and/or Müller's muscle. On the other hand, neurogenic ptosis is caused by closed head injuries, or traumatically-introduced neurotoxin (wasp/bee/snake venom) or botulinum toxin, due to the effect of those factors on the CNIII or the sympathetic pathway. Mechanical ptosis can also occur due to scarring tissue restricting the patient's eyelid excursion or weighing down the patient's lid. Another mechanism is the disturbance of the oculomotor nerve causing the levator palpebrae to weaken, resulting in the eyelid drooping. Ptosis can also occur in a patient with brain tumors due to pressure on the third nerve, also known as the sympathetic nerve, on the brainstem.


Pathology

Myasthenia gravis Myasthenia gravis (MG) is a long-term neuromuscular junction disease that leads to varying degrees of skeletal muscle weakness. The most commonly affected muscles are those of the eyes, face, and swallowing. It can result in double vision, dro ...
is a common neurogenic ptosis which could be also classified as neuromuscular ptosis because the site of pathology is at the neuromuscular junction. Studies have shown that up to 70% of myasthenia gravis patients present with ptosis, and 90% of these patients will eventually develop ptosis. In this case, ptosis can be unilateral or bilateral and its severity tends to be oscillating during the day, because of factors such as
fatigue Fatigue describes a state of tiredness that does not resolve with rest or sleep. In general usage, fatigue is synonymous with extreme tiredness or exhaustion that normally follows prolonged physical or mental activity. When it does not resolve ...
or drug effect. This particular type of ptosis is distinguished from the others with the help of a Tensilon test and
blood tests A blood test is a laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a hypodermic needle, or via fingerprick. Multiple tests for specific blood components, such as a glucose test or a cholester ...
. Also, specific to myasthenia gravis is the fact that coldness inhibits the activity of
cholinesterase The enzyme cholinesterase (EC 3.1.1.8, choline esterase; systematic name acylcholine acylhydrolase) catalyses the hydrolysis of choline-based esters: : an acylcholine + H2O = choline + a carboxylate Several of these serve as neurotransmitters ...
, which makes possible differentiating this type of ptosis by applying
ice Ice is water frozen into a solid state, typically forming at or below temperatures of 0 degrees Celsius or Depending on the presence of impurities such as particles of soil or bubbles of air, it can appear transparent or a more or less opaq ...
onto the eyelids. Patients with myasthenic ptosis are very likely to still experience a variation of the drooping of the eyelid at different hours of the day. Ptosis caused by oculomotor palsy can be unilateral or bilateral, as the subnucleus to the levator muscle is a shared, midline structure in the brainstem. In cases in which the palsy is caused by the compression of the
nerve A nerve is an enclosed, cable-like bundle of nerve fibers (called axons) in the peripheral nervous system. A nerve transmits electrical impulses. It is the basic unit of the peripheral nervous system. A nerve provides a common pathway for the e ...
by a tumor or aneurysm, it is highly likely to result in an abnormal ipsilateral papillary response and a larger pupil. Surgical third nerve palsy is characterized by a sudden onset of unilateral ptosis and an enlarged or sluggish pupil to the light. In this case, imaging tests such as CTs or MRIs should be considered. Medical third nerve palsy, contrary to surgical third nerve palsy, usually does not affect the pupil and it tends to slowly improve in several weeks. Surgery to correct ptosis due to medical third nerve palsy is normally considered only if the improvement of ptosis and ocular motility are unsatisfactory after half a year. Patients with third nerve palsy tend to have diminished or absent function of the levator. When caused by
Horner's syndrome Horner's syndrome, also known as oculosympathetic paresis, is a combination of symptoms that arises when a group of nerves known as the sympathetic trunk is damaged. The signs and symptoms occur on the same side (ipsilateral) as it is a lesion ...
, ptosis is usually accompanied by
miosis Miosis, or myosis (), is excessive constriction of the pupil.Farlex medical dictionary
citing: ...
and
anhidrosis Hypohidrosis is a disorder in which a person exhibits diminished sweating in response to appropriate stimuli. In contrast with hyp''er''hidrosis, which is a socially troubling yet often benign condition, the consequences of untreated hypohidrosi ...
. In this case, the ptosis is due to the result of interruption innervations to the sympathetic, autonomic Muller's muscle rather than the somatic levator palpebrae superioris muscle. The lid position and pupil size are typically affected by this condition and the ptosis is generally mild, no more than 2 mm. The pupil might be smaller on the affected side. While 4%
cocaine Cocaine (from , from , ultimately from Quechuan languages, Quechua: ''kúka'') is a central nervous system (CNS) stimulant mainly recreational drug use, used recreationally for its euphoria, euphoric effects. It is primarily obtained from t ...
instilled to the eyes can confirm the diagnosis of Horner's syndrome, Hydroxyamphetamine eye drops can differentiate the location of the
lesion A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals. Types There is no designated classifi ...
. Chronic progressive external ophthalmoplegia is a systemic condition which usually affects only the lid position and the external eye movement, without involving the movement of the pupil. This condition accounts for nearly 45% of myogenic ptosis cases. Most patients develop ptosis due to this disease in their
adulthood An adult is a human or other animal that has reached full growth. In human context, the term ''adult'' has meanings associated with social and legal concepts. In contrast to a " minor", a legal adult is a person who has attained the age of major ...
. Characteristic to ptosis caused by this condition is the fact that the protective up rolling of the
eyeball Eyes are organs of the visual system. They provide living organisms with vision, the ability to receive and process visual detail, as well as enabling several photo response functions that are independent of vision. Eyes detect light and conve ...
when the eyelids are closed is very poor.


Diagnosis

A doctor will first perform a physical exam with questions about the patient's medical history to distinguish whether the condition may be hereditary. A slit lamp exam is performed with a high-intensity light that allows a close look at the patient's eyes. The doctor can also perform a test in which
edrophonium Edrophonium is a readily reversible acetylcholinesterase inhibitor. It prevents breakdown of the neurotransmitter acetylcholine and acts by competitively inhibiting the enzyme acetylcholinesterase, mainly at the neuromuscular junction. It is so ...
is injected into a vein and the eyelids are monitored for resulting signs of improvement. A visual field test, which assesses the degree to which the ptosis affects the superior vision, may be performed. Because nerve damage is among the possible causes for ptosis, the ophthalmologist will check the patient's pupil for abnormalities. The doctor will also check muscle function. The ophthalmologist may also measure the degree of the eyelid droop by measuring the marginal reflex distance, which is the distance between the center of the pupil and the edge of the upper lid, as well as the strength and function of the patient's levator muscle. This test entails holding the
frontalis muscle The frontalis muscle () is a muscle which covers parts of the forehead of the skull. Some sources consider the frontalis muscle to be a distinct muscle. However, Terminologia Anatomica currently classifies it as part of the occipitofrontalis muscle ...
to measure how far the eyelid travels when the patient is gazing downward. Through these tests, the ophthalmologist may properly diagnose ptosis and identify its classification, and a determination may be made regarding the course of treatment, which may involve surgery.


Classification

Depending upon the cause, ptosis may be classified into: * ''Neurogenic ptosis'', which includes
oculomotor nerve palsy Oculomotor nerve palsy or oculomotor neuropathy is an eye condition resulting from damage to the third cranial nerve or a branch thereof. As the name suggests, the oculomotor nerve supplies the majority of the muscles controlling eye movements (fou ...
,
Horner's syndrome Horner's syndrome, also known as oculosympathetic paresis, is a combination of symptoms that arises when a group of nerves known as the sympathetic trunk is damaged. The signs and symptoms occur on the same side (ipsilateral) as it is a lesion ...
, Marcus Gunn jaw winking syndrome and third cranial nerve misdirection. * ''Myogenic ptosis'', which includes
oculopharyngeal muscular dystrophy Oculopharyngeal muscular dystrophy (OPMD) is a rare form of muscular dystrophy with symptoms generally starting when an individual is 40 to 50 years old. It can be autosomal dominant neuromuscular disease or autosomal recessive. The most common i ...
,
myasthenia gravis Myasthenia gravis (MG) is a long-term neuromuscular junction disease that leads to varying degrees of skeletal muscle weakness. The most commonly affected muscles are those of the eyes, face, and swallowing. It can result in double vision, dro ...
,
myotonic dystrophy Myotonic dystrophy (DM) is a type of muscular dystrophy, a group of genetic disorders that cause progressive muscle loss and weakness. In DM, muscles are often unable to relax after contraction. Other manifestations may include cataracts, intel ...
, ocular myopathy, simple congenital ptosis and
blepharophimosis Blepharophimosis is a congenital anomaly in which the eyelids are underdeveloped such that they cannot open as far as usual and permanently cover part of the eyes. Both the vertical and horizontal palpebral fissures (eyelid openings) are shortene ...
syndrome. * ''Aponeurotic ptosis'', which may be involutional or postoperative. * ''Mechanical ptosis'', which is the result of
edema Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's Tissue (biology), tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels t ...
or tumors of the upper lid. * ''Neurotoxic ptosis'', which is a classic symptom of
envenomation Envenomation is the process by which venom is injected by the bite or sting of a venomous animal. Many kinds of animals, including mammals (e.g., the northern short-tailed shrew, ''Blarina brevicauda''), reptiles (e.g., the king cobra), spiders ...
by
elapid Elapidae (, commonly known as elapids ; grc, ἔλλοψ ''éllops'' "sea-fish") is a family of snakes characterized by their permanently erect fangs at the front of the mouth. Most elapids are venomous, with the exception of the genus Emydoce ...
snakes such as cobras,
krait ''Bungarus'' is a genus of venomous elapid snakes, the kraits ("krait" is pronounced , rhyming with "kite"), found in South and Southeast Asia. The genus ''Bungarus'' has 16 species. Distribution Kraits are found in tropical Asia, from near Ira ...
s,
mamba Mambas are fast moving highly venomous snakes of the genus ''Dendroaspis'' (which literally means "tree Asp (reptile), asp") in the family Elapidae. Four Neontology, extant species are recognised currently; three of those four species are essen ...
s and
taipan Taipans are snakes of the genus ''Oxyuranus'' in the elapid family. They are large, fast-moving, highly venomous, and endemic to Australia and New Guinea. Three species are recognised, one of which, the coastal taipan, has two subspecies. Taipan ...
s. Bilateral ptosis is usually accompanied by
diplopia Diplopia is the simultaneous perception of two images of a single object that may be displaced horizontally or vertically in relation to each other. Also called double vision, it is a loss of visual focus under regular conditions, and is often v ...
,
dysphagia Dysphagia is difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, in some contexts it is classified as a disease#Terminology, condition in its own right. It may be a sensation that suggests difficulty in the passag ...
and/or progressive muscular paralysis.
Neurotoxic Neurotoxicity is a form of toxicity in which a biological, chemical, or physical agent produces an adverse effect on the structure or function of the central and/or peripheral nervous system. It occurs when exposure to a substance – specificall ...
ptosis is a precursor to
respiratory failure Respiratory failure results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels. A drop in the oxygen carried in the blood is known as hypoxemia; a rise ...
and eventual
suffocation Asphyxia or asphyxiation is a condition of deficient supply of oxygen to the body which arises from abnormal breathing. Asphyxia causes generalized hypoxia, which affects primarily the tissues and organs. There are many circumstances that can i ...
caused by complete
paralysis Paralysis (also known as plegia) is a loss of motor function in one or more muscles. Paralysis can also be accompanied by a loss of feeling (sensory loss) in the affected area if there is sensory damage. In the United States, roughly 1 in 50 ...
of the
thoracic diaphragm The thoracic diaphragm, or simply the diaphragm ( grc, διάφραγμα, diáphragma, partition), is a sheet of internal Skeletal striated muscle, skeletal muscle in humans and other mammals that extends across the bottom of the thoracic cavit ...
. It is therefore a
medical emergency A medical emergency is an acute injury or illness that poses an immediate risk to a person's life or long-term health, sometimes referred to as a situation risking "life or limb". These emergencies may require assistance from another, qualified p ...
and immediate treatment is required. Similarly, ptosis may occur in victims of
botulism Botulism is a rare and potentially fatal illness caused by a toxin produced by the bacterium ''Clostridium botulinum''. The disease begins with weakness, blurred vision, feeling tired, and trouble speaking. This may then be followed by weaknes ...
(caused by
botulinum toxin Botulinum toxin, or botulinum neurotoxin (BoNT), is a neurotoxic protein produced by the bacterium ''Clostridium botulinum'' and related species. It prevents the release of the neurotransmitter acetylcholine from axon endings at the neuromusc ...
), and this is also regarded as a life-threatening symptom. * ''Pseudoptosis'' resulting from lack of lid support (empty socket or atrophic globe) or a higher lid position on the other side, as in lid retraction.


Treatment

Aponeurotic and congenital ptosis may require surgical correction if severe enough to interfere with the vision or if appearance is a concern. Treatment depends on the type of ptosis, and is usually performed by an ophthalmic plastic surgeon or a reconstructive surgeon who specializes in diseases and problems of the eyelid. If the condition occurs in a child, then the doctor will delay the surgery until the patient is 4 or 5 years old. If the patient is under the recommended age for surgery, then the doctor will test if occlusion therapy can compensate for the patient's impeded vision. The reason for delaying the surgery until the patient is at least 4–5 years of age is the necessity of delay for the frontonasal and upper face to complete their complex growth. After this complex growth is complete, the doctors will be able to obtain a more accurate measurement of the conditions. However, if the patient's vision impediment worsens or proves unresponsive to the occlusion therapy, then surgery will be needed sooner. Surgical procedures include: * Levator resection * Müller muscle resection * Frontalis sling operation (preferred option for
oculopharyngeal muscular dystrophy Oculopharyngeal muscular dystrophy (OPMD) is a rare form of muscular dystrophy with symptoms generally starting when an individual is 40 to 50 years old. It can be autosomal dominant neuromuscular disease or autosomal recessive. The most common i ...
) * Whitnall sling The frontalis sling surgery can only be done if the patient's ptosis condition is due to diseased or stretched-out muscles. The stretching-out of muscle is due to age. The frontalis sling surgery is done to either tighten or shorten the affected muscles, thereby allowing the process to raise the patient's lid's resting position. The procedure is done with the doctor using the sling to loop the material, then threading it underneath the patient's eyebrows and above the lashes. Once the sling has been tightened, this allows the patient's forehead's muscle to aid in lifting the lid. The sling can be looped in a pentagon shape, triangle (singular or double) shape. Many different types of slings in the market today include monofilament nylon, silicone rods, polyester, silk, collagen, stainless steel or polypropylene. Frontalis sling surgery is considered the most effective surgical treatment for moderate to severe congenital ptosis. Many different materials can be used for the surgery, though it is currently unclear which material has the highest success rate. The levator resection and advancement surgery should only be considered for patients who are experiencing a levator function less than or equal to 5 mm. The levator function is a measurement of the distance that the eyelid travels starting with the downgaze moving to the upgaze without moving the frontalis muscle. Although this procedure can be completed through two different approaches, the internal and the external, the external approach allows the surgeons to obtain a better view of the surgical site during the procedure. The surgeon will begin with an incision on the eyelid. Once the levator has been exposed, the surgeon either fold it or cut it off before suturing it to the tarsal plate. During this procedure, it is up to the surgeon to decide the height and the contour of the patient's eyelid, with input from the patient. The Whitnall sling procedure is done with an incision from the levator to the Whitnall ligament. Then the surgeon will suture the Whitnall's ligament connecting it to the superior tarsal edge. This procedure most likely is done if the patients are concerned about cosmetic appearance. The Whitnall sling procedure is able to provide a better cosmetic result because the procedure is able to keep the Whitnall's ligament intact. This allows the support of the lacrimal gland and temporal eyelid to be maintained. Despite the gains that the patient can obtain from the surgeries, there are risk factors. After the surgery, the patient may experience asymmetrical (uneven) eyelids. If the surgery was not done carefully, the patient may experience dry eyes owing to the eye no longer fully closing. The patient may also experience bleeding after the surgery and infections, if the surgical site is not taken care of properly. On rare occasions, the patient will experience a loss in eyelid movement. Non-surgical modalities like the use of "crutch" glasses or ptosis crutches or special scleral contact lenses to support the eyelid may also be used. Ptosis that is caused by a disease may improve if the disease is treated successfully, although some related diseases, such as
oculopharyngeal muscular dystrophy Oculopharyngeal muscular dystrophy (OPMD) is a rare form of muscular dystrophy with symptoms generally starting when an individual is 40 to 50 years old. It can be autosomal dominant neuromuscular disease or autosomal recessive. The most common i ...
, currently have no cures.


Prognosis

If the ptosis is left untreated, then patients may experience amblyopia, also known as lazy eye, which can permanently damage the patient's vision. After careful observation and planning from specialists, ptosis can be successfully treated. Treatment like surgery will allow the patient to begin experiencing improvement in vision as well as cosmetic results. In a study of patients who were previously treated for ptosis, half required additional surgery within 8 to 10 years of the first surgery. If the ptosis is not related to major health issues (such as cancerous tumours or traumatic injuries), then the condition will not shorten the patient's life expectancy.   


Epidemiology

According to ophthalmology studies done on ptosis patients, occurrence rates are as follows. The average age for females experiencing aponeurotic ptosis is 67.83 years and the corresponding male average age is 68.19. The average age for congenital ptosis is 12.27 years for females and 8.57 years for males. The average age for mechanical ptosis is 49.41 years in females and 43.30 years in males. The average age for myogenic ptosis is 53.45 for females and 43.30 for males. The average age for neurogenic ptosis is 43.6 years in females and 32.62 years in males. Lastly, the average age for traumatic ptosis is 35.12 years in females and 33.4 years in males. Ptosis was not found to have any overall gender or racial preference.


Research directions

Current studies have indicated that previous methods such as occlusion therapy and surgery are considered to be the most appropriate for treating this condition. Further studies are encouraged to be able to determine the optimal surgical indications. Any discoveries on approaches with dry eye will help further the oculoplastic surgeries.


Etymology

Ptosis is derived from the
Greek Greek may refer to: Greece Anything of, from, or related to Greece, a country in Southern Europe: *Greeks, an ethnic group. *Greek language, a branch of the Indo-European language family. **Proto-Greek language, the assumed last common ancestor ...
word πτῶσις (''ptōsis'', "fall"), and is defined as the "abnormal lowering or prolapse of an organ or body part".


See also

* Apraxia of lid opening *
Blepharophimosis Blepharophimosis is a congenital anomaly in which the eyelids are underdeveloped such that they cannot open as far as usual and permanently cover part of the eyes. Both the vertical and horizontal palpebral fissures (eyelid openings) are shortene ...


References


Further reading

* The AMA Medical Guide, Random House, Inc. New York, 1997 ed.


External links

{{Authority control Congenital disorders of eyes Disorders of eyelid, lacrimal system and orbit it:Ptosi