What is it?

Eyelid ptosis is defined as an excessive descent of the upper eyelid. That is, the upper eyelid falls below its normal height. The eyelid descent can be so great that it covers the pupil (apple of the eye), and can limit or even completely block normal vision.
Ptosis can be present in children: Congenital ptosis. You have to be very aware to this possibility, as it can cause amblyopia.

Causes

In children, ptosis can be the result of problems with the “levator superior eyelid” muscle (the one that lifts the eyelid). Sometimes a child born with ptosis can have other eye-related problems, including movement problems, eye muscle disease, tumors (on the eyelid or elsewhere), and other problems.
In adults, ptosis can be due to various problems that affect the neuromuscular system of the eyelid, such as:

·         Neurogenic causes (depend on nerve problems): common ocular motor paralysis, Horner’s syndrome, synkinesis, ophthalmoplegic migraine, etc.

·         Myogenic causes (muscle dependent): myasthenia gravis, myotonic dystrophy, ocular myopathy, oropharyngeal muscular dystrophy.

·         Alterations of the aponeurosis (fibrous membrane that covers the muscles): involutive linked to age, postoperative, post-traumatic, post-inflammatory, pregnancy.

·         Mechanics: By weight on the eyelid (dermatochalasis, blepharochalasia, tumors), restrictive (symblepharon).

Symptoms

In adults, the main symptom is a narrowing of the visual field (not seen from the top). In the most severe cases, it can even cover the pupil causing loss of vision.

In children, the picture can become more serious, since it can cause amblyopia (insufficient development of visual acuity in the affected eye). In addition, in children, ptosis can be associated with other problems, such as tumors, eye muscle disease, and even mobility problems.

Diagnosis

Diagnosis is mainly clinical, by assessing the patient’s medical history to evaluate the mode of presentation, the moment of onset of the picture, as well as concomitant signs and symptoms (it allows to identify the cause and choose the indicated treatment). An examination focused on the analysis of palpebral dynamics and a neurological study is indicated. In addition, the function of the levator muscle of the upper eyelid must be evaluated in detail. Depending on whether the function is good, deficient or bad, one therapeutic strategy or another will be considered.

Prognosis

It depends fundamentally on two factors: The cause that originates the ptosis and the type of surgical approach required. The main problem associated with the treatment of ptosis is the possibility of generating a lagophthalmos due to hypercorrection. If the cause is aponeurotic, most cases recover without sequelae. On the contrary, in congenital ptosis, it may be necessary to perform several surgeries throughout the growth of the child.

Treatment

The treatment of congenital ptosis and adult ptosis will be discussed separately.

Congenital ptosis

There are different parameters to take into account when selecting the therapeutic strategy:

·         The age of the child.

·         Bilateral or unilateral involvement (both eyelids or just one).

·         The height of the eyelid.

·         The strength of the levator muscle of the upper eyelid.

·         Eye movements.

In some cases, the treatment of choice is surgery. In the most severe cases, the child can develop amblyopia. Amblyopia treatment will be indicated in each case.
Children with ptosis, whether or not they have undergone surgery, require frequent visits to the ophthalmologist (mainly to detect the presence of amblyopia or other ocular pathologies).

Ptosis in the adult

In some patients, depending on their characteristics, medical treatment may be considered. The administration of oxymetazoline eye drops (a powerful sympathomimetic that causes strong local vasoconstriction) has been shown to improve the condition. This treatment should be used daily. This treatment is not indicated in those cases where ptosis is due to neurological problems.

In most patients, the treatment of choice is surgery. This is done on an outpatient basis and under local anesthesia. Although it is a safe procedure, it is not without complications. The patient must warn the ophthalmologist about the different treatments that he or she is taking or has recently taken, mainly those that facilitate bleeding, such as aspirin or similar.

The surgical technique to be performed depends, to a great extent, on the particularities of the case, the patient’s characteristics, and the surgeon’s preferences.