American Academy of Ophthalmology Web Site: www.aao.org
Clinical Update: Oculoplastics
Assessing and Correcting Ptosis
Ptosis has a reputation as a cosmetic problem, but ophthalmologists who treat it say that it is more often a functional deficit that can have real impact on patients’ lives. Ptosis results from the dysfunction of one or both of the upper eyelid retractors and often blocks peripheral vision. In some cases, ptosis may block central vision as well. Such visual loss carries associated dangers for the elderly patients who are most often affected by ptosis—namely, they risk injuring themselves in falls.
Ptosis can be congenital, but usually it is a condition of aging. Gradually, involutional changes occur in the eyelid. The aponeurosis connector muscle, for instance, attenuates and stretches so that the lid drops down.
Ptosis can also occur with poor levator function, either through the infiltration of fibrous or adipose tissue in aging, or, in congenital ptosis, though maldevelopment. “Often in congenital ptosis the levator muscle doesn’t develop, so the eyelid loses its lifting power,” said Bryan S. Sires, MD, PhD, in private practice in Kirkland, Wash. Ptosis can also result from cataract surgery, long-term contact lens wear, chronic inflammation or trauma, and it presents with various findings that can range from subtle cosmetic defects to significant visual deficits.1
Evaluating the Eyelids
The skin of the eyelid is unique, with one of the thinnest layers on the human body and no subcutaneous fat. It’s a pliable, dynamic structure that serves a protective purpose as well as a topographic function—helping to delineate the muscles that surround the eye. So when things go wrong with the eyelid, repair is often vital.
In evaluating a patient with ptosis, a detailed history as well as an examination is especially important. Sometimes patients can have a hard time providing an accurate estimate of when the ptosis started. To evaluate patients, it’s helpful to encourage them to bring in old driver’s licenses or photographs to explain the history. Many patients also report a worsening of the ptosis when fatigued.1
Watch for mimics. However, a marked fluctuation in symptoms of fatigue throughout the day may indicate myasthenia gravis. In these cases, patients should also be asked about their use of statin medications. There have been recent reports of myasthenialike syndromes that resulted in ptosis with the use of statins, which are common treatments for hypercholesterolemia.1
Patients should also be asked about dry eye because ptosis surgery can exacerbate this condition.
In treating congenital ptosis, the levator muscle can be shortened and strengthened, based on the amount of preexisting ptosis and levator function. In age-related or acquired ptosis, the levator may be reattached or slightly shortened to correct the lid position. If levator function is poor, the eyelid may be lifted by using a frontalis suspension sling to connect the frontalis to the eyelid. “By using this technique, the lifting power is greater and the eyelid margin may be lifted as well,” said Deborah D. Sherman, MD, oculoplastic chief and surgeon at the Sherman Aesthetic Center in Nashville, Tenn.
In rare cases, surgery is unnecessary. In spastic ptosis, the patient exhibits uncontrolled blinking of the eyelid, and surgery is usually not needed. “It’s as if the orbicularis oculi or closing muscle of the eyelid is stuck in overdrive,” said Dr. Sherman. “In these cases, using small doses of botulinum toxin type A (Botox) is the answer. It enables the orbicularis oculi muscle to relax, but patients should be warned that it can be as much as two weeks before the medication takes effect, and dry eye can occur with treatment.”
New surgical technique. Most of the treatments for ptosis are time-tested and have been used for years. However, one new development in surgical technique has attracted attention: small-incision surgery for aponeurotic ptosis, the most common type. In aponeurotic ptosis the levator muscle is normal but the levator aponeurosis muscle is stretched and thin, along with an elevated lid crease and deep upper lid sulcus. The result is that the lid drops to an abnormal position.
In an efficacy trial published in 2004, a small anterior, minimal dissection procedure was compared with a traditional, anterior aponeurotic approach (49 eyelids in both groups), and results of the less invasive surgery were as efficacious as the traditional approach.2 The small-incision procedure uses a surgical opening of about 4 mm, in contrast to the traditional 10 mm. In the study, those in the small-incision group also experienced better eyelid contour outcome.
Moreover, with the minimal dissection technique, operating time was significantly less—about half that for the traditional dissection group (25 minutes vs. 55 minutes for the traditional incision surgery).
However, the researchers note that the minimal dissection technique should only be used in eyelids that have not had previous surgery or trauma.
When results are not optimal. Complications of ptosis surgery can include overcorrection or undercorrection. In some cases, surgery can result in a contour abnormality that results in a “peaked” appearance of the eyelid. Repeat surgery may be necessary. However, overcorrection can sometimes be treated with repeated massage or suture adjustments.1
Postoperative keratitis is not unexpected after surgery for ptosis. The treatment for this is usually a combination of artificial tears and ointments that lubricate the eye.
Who’s Paying for This?
Surgery for ptosis is usually covered by insurance when it can be established that it is a functional problem. But how is that distinguished from an aesthetic problem? In order to meet insurance requirements, the drooping eyelid must create a 20 degree—or about 30 percent—loss of vision, according to Dr. Sires. This loss can usually be established through photographs and an exam. In cases where ptosis is purely an aesthetic problem, the surgery can range from $3,000 to $6,000, depending on the surgeon.
Ptotic Tots and Teens
Children and adolescents may be especially sensitive to self-esteem problems because of ptosis, especially if they are teased by schoolmates.
For the doctors who treat it, however, repairing ptosis in children can be especially challenging. The younger the child, the more difficult the ptosis repair. In children, general anesthesia must be used, and it becomes more difficult to adjust the sutures correctly, according to Dr. Sires. “Since children have to be asleep during the surgery, they can’t follow instructions like an adult. So you can’t ask them to look up or down to test how tight the sutures should be. In the end, you have to make an educated guess.”
Droopy at birth. Ptosis repair on very young patients may be necessary. Generally, it’s safest to wait until a child is at least 1 or 2 years of age to perform ptosis surgery, according to Christine C. Nelson, MD, associate professor of ophthalmology at the University of Michigan in Ann Arbor. General anesthesia is safer at this age than in infancy, she said.
In severe cases, surgery may be considered in the very young. Dr. Nelson recalls the interesting but rare case of a 3-week-old infant who had severe Marcus Gunn jaw-winking syndrome. Upon reevaluation at 2 months of age, the infant was found to be at risk for amblyopia, which is associated with the syndrome. The pupil was not exposed unless the child opened her mouth widely, Dr. Nelson writes in a case report.3
The baby was scheduled for surgery. Then, upon further examination, the researchers noted elevation of the left eyelid with occlusion of the unaffected side or with stimuli provided by the mother. The baby had already learned to habituate—to maintain an altered jaw position to reduce the full degree of ptosis.
Dr. Nelson noted that this case was the youngest patient she had seen who exhibited habituation in Marcus Gunn jaw-winking syndrome. She and a colleague note in their paper, “This topic (habituation at a young age) remains controversial. Experienced oculoplastics specialists have reported not seeing this habituation in their subset of patients, and it is generally thought to occur after infancy. It would be interesting to attempt part-time occlusion of the unaffected eye to encourage development of this adaptive technique.”
Surgery for the infant was delayed until it was safer.
2 Frueh, B. R. et al. Trans Am Ophthalmol Soc 2004;102:199–207.
3 Lelli, G. J. and C. C. Nelson. J Pediatr Ophthalmol Strabismus 2006;43:38–40.