- Traumatic ptosis can be neurogenic, aponeurotic, myogenic, or mechanical in nature.
- Pseudoptosis can mimic these phenomena.
- Iatrogenic causes account for roughly 50% of traumatic blepharoptosis (Crawford, Can J Ophthalmol 1974).
- Multiple possible factors have been suggested for ptosis after cataract surgery.
- Classically, felt to be associated with levator dehiscence
- Bridle suture placement
- Myotoxicity from anesthesia (Song, Korean J Ophthalmol 1996)
- After oculoplastic surgical procedures
- Postoperative edema or hematoma can create a mechanical ptosis.
- Trauma to levator muscle, particularly during blepharoplasty (Bernardino, Semin Ophthalmol 2002)
- Full-thickness resection can cause direct damage to levator muscle or Muller muscle (Altieri, Ophthalmologica 2005).
- Resection of conjunctival tumors can create a symblepharon, dragging the eyelid into a ptotic position (Bosniak, 1990).
- After administration of botulinum toxin
- Can create a self-limited ptosis with impaired levator function
- Incidence reported to be 5.4% (Henderson, Dev Ophthalmol 2008).
- After strabismus surgery
- Superior rectus advancements can result in ptosis.
- Classically, avoided with meticulous dissection (Altieri, Ophthalmologica 2005)
- Birth trauma
- Classically, thought to be related to levator dehiscence (Carruthers, J Am Acad Dermatol 2002)
- Blunt trauma (Figure 1)
- Edema of levator
- Dehiscence of levator
- Generally, self-limited (Altieri, Ophthalmologica 2005)
Figure 1. Blunt trauma. Courtesy Evan H. Black, MD.
- Penetrating/lacerating trauma (Figure 2)
- Occurs in setting of direct injury to the levator muscle
- Classically, immediate exploration with restoration of appropriate anatomy facilitates resolution of ptosis (Putnam, 1995)
Figure 2. Lacerating trauma. Courtesy Evan H. Black, MD.
- Associated with facial fractures
- Facial fractures can result in enophthalmos, creating the appearance of ptosis (Altieri, Ophthalmologica 2005).
- With orbital roof fractures, pieces of bone can abut levator muscle, resulting in ptosis and necessitating surgical repair (Berke, Am J Ophthalmol 1971).
- Neurogenic causes
- Cranial nerve III palsy
- Typically, associated with blunt trauma to the head, most commonly due to motor vehicle accident (Fulcher, Ophthal Plast Reconstr Surg 2003)
- Generally, complete ptosis
- Ptosis often resolves after one year, although aberrant regeneration occurs in roughly 50% of cases (Lin, J Neurosurg 2013).
- Superior orbital fissure syndrome
- Involves cranial nerves III, IV, V, and VI
- Rare finding in setting of craniofacial fractures (0.3%) (Krohel, Am J Ophthalmol 1979)
- Can be associated with Lefort II or III fractures and with zygomatic complex and frontobasal skull fractures (Chen, Craniomaxillofac Trauma Reconstr 2010)
Figure 3. Courtesy Anne Barmettler, MD.
- Traumatic ptosis has been reported to account for 11.2% of blepharoptosis in a tertiary care oculoplastic surgery setting (Lim, Orbit 2013).
- Intraocular surgery
- 4–12% after cataract surgery procedures (Mehat, Orbit 2012, Altieri, Ophthalmologica 2005, Boyle, 2011)
- Extracapsular cataract extraction is associated with a greater incidence of postoperative ptosis than phacoemulsification (Puvanachandra, Orbit 2010).
- 10.7% rate of ptosis after trabeculectomy alone and 12.7% rate after combined trabeculectomy/phacoemulsification (Song, Korean J Ophthalmol 1996)
- Mechanism of injury
- Intraocular or adnexal surgery
- Decreased upper eyelid marginal reflex distance
- In mechanical ptosis, evidence of eyelid edema or ecchymosis
- Neurogenic causes are associated with abnormalities of eyelid motility.
- Levator function can be decreased or normal (depending on etiology).
- Possible symblepharon
- Possible enophthalmos
- Possible entry wound or scar tissue
- Complete ophthalmic examination, ruling out evidence of intraocular trauma and ruptured globe
- Complete review of appropriate orbital and intracranial imaging
- Assess marginal reflex distance, motility, and levator function
- Check eyelid crease presence and height.
- In cases of acute trauma, assess for prolapsed orbital fat.