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Thursday / May 30.

Ptosis 101

Ptosis is a common complaint that can be successfully treated. But Sydney ophthalmologist Dr. Peter Martin told mivision eye health professionals must be aware that drooping eyelids – in children and adults – are sometimes a “red flag” for serious neurological disorders and should never be ignored.

The good news about ptosis, or drooping of the eyelid, is that it is a condition that can be successfully treated with a straightforward surgical procedure.

The bad news? Ptosis that comes on suddenly, particularly in an adult, can be a symptom – sometimes the only symptom – of a serious neurological or systemic condition.

Optometrists may be the first to see a patient presenting with ptosis, but Dr. Peter Martin, who is often referred to as ‘The Eyelid Man’ by his peers, believes there’s insufficient awareness about the causes and treatments of the condition – among eye health professionals and in the general community.

We need education to the community to inform them that it (ptosis) may be a simple problem, particularly if it has been present for a long period of time. If it is acute, it must be investigated immediately…

Optometry, he said, is on a “rapid learning curve” in relation to ptosis, and more upskilling and information is needed.

“There also needs to be more education in the wider community. Many people think that if they have ptosis, there’s no treatment available and they need to live with the deformity. But many times something can be done to correct it – there is a surgical procedure. I wouldn’t call it a simple procedure, but it is straightforward if you understand the principles.

A small group of ophthalmologists have been trained in the sub-discipline of oculoplastic surgery and are experts in assessing and managing patients with ptosis.

“We need education to the community to inform them that it (ptosis) may be a simple problem, particularly if it has been present for a long period of time. If it is acute, it must be investigated immediately,” Dr. Martin said.

Ptosis Symptoms

The foremost sign of ptosis in children and adults is an eyelid that sags or droops. Patients will often tilt their heads back or lift their eyebrows, in an expression of surprise, in order to see, especially if bilateral ptosis is present. In childhood, if the ptosis involves one side and a child tries to raise their eyebrow, it is generally a sign they are binocular and wanting to use both eyes. In children, it is essential to check their vision, to avoid them developing a lazy eye (amblyopia).

Among other symptoms, lax eyelids may cause headaches and brow aches, obscure vision or irritate the eye.

Children and Ptosis

Ptosis can be congenital or acquired. If it is present at birth, is it usually due to poor development of the muscle that lifts the upper eyelid (the levator muscle). If the ptosis is severe and fully or partially covers the pupil of the eye, it can lead to vision problems such as amblyopia (lazy eye) or strabismus (eyes that are not properly aligned or straight).

Dr. Martin said when a child presents with ptosis, it is often a congenital ptosis that was either not diagnosed at birth, or has developed over time. But he said there are instances where neurological conditions – such as myasthenia gravis, tumours and third nerve palsy – need to be considered.

Ptosis in children, he said, should be referred to a paediatric ophthalmologist or an oculoplastic surgeon who specialises in eyelid problems.

“If a child develops ptosis, it needs to be investigated. This sometimes may involve CT or MRI by a neurologist and blood tests to pinpoint conditions such as myasthenia gravis, which is not a common condition.”

He said another interesting condition seen in children with ptosis was the Marcus Gunn phenomenon or “jaw winking”.

“This is a misdirection of a nerve from the muscles in the jaw to the eyelid. When children present with this form of ptosis, you may notice the eyelid move up and down while they are eating and move their jaw.”

Dr. Martin said trauma can also cause ptosis – both in adults and children – and health professionals need to consider battered child syndrome if a child presents with acute or late onset ptosis, and no other cause is found.

“Another rare syndrome is Blepharophimosis syndrome, which is an inherited condition. It may present as a sporadic case but generally there is a family member with the same features.”

Adult Ptosis

Ptosis, though, is far more common in adult patients than children, with most patients in the 50 and 60+ age groups, although age-

related ptosis can occur in people as young as 40.

Most cases of acquired ptosis are characterised on the basis of the history. The most common form of ptosis in adults is the aponeurotic ptosis, which accounts for 90 per cent of cases.

‘Neurogenic’ ptosis is caused by a partial or complete third nerve palsy involving the levator muscle. Horner’s syndrome involves the sympathic supply causing a partial ptosis. ‘Myogenic’ ptosis can be caused by weakness of the extraocular muscles due to disturbance of the fine muscle fibres. ‘Traumatic’ ptosis can be induced by trauma to the eyelid. In ‘mechanical’ ptosis, the upper eyelid may be prevented from opening completely because of, for example, an eyelid tumour, which restricts the action of the levator. ‘Dermatochalasis’ is a form of mechanical ptosis due to excess eyelid skin and is almost always progressive with ageing.

Ptosis is also linked to the use of hard contact lenses due to the technique used to remove the lens over many years.

“In the past, most adults presenting with ptosis were neurologically investigated with lumbar puncture and myelograms, which was not without risk. We are now wiser and recognise that approximately 90 per cent of adult ptosis is aponeurotic ptosis, which is due to the aponeurosis of the levator muscle being stretched or separated from its insertion.

“With routine ptosis examination, aponeurotic ptosis has characteristic features to aid in diagnosis and direct appropriate tests. By inserting a drop that stimulates Muller’s muscle, it is possible to identify that there is an anatomical defect, rather than a neurological basis for the ptosis.”

Dr. Martin said demonstrating this to the patient is both reassuring and helps show that problems can be surgically corrected.

Treatment

The treatment of ptosis is largely surgical. Dr. Martin said “Ptosis surgery is designed to tighten the levator muscle by shortening it to allow the muscle to sufficiently elevate the eyelid.

“The surgery is usually completed under general anaesthesia in infants and children, and under local anaesthesia with sedation in adults so that the patient can open and close the eyelid for the surgeon.”

Dr. Martin said 95 per cent of patients have a good surgical outcome.

The most important message to allied health professionals and the wider community is that “ptosis may be a simple problem, particularly if it has been present for a long period of time. Ptosis is a highly correctable problem and oculoplastic surgeons are trained specifically to deal with both simple and complex ptosis issues.

Most patients expect perfect symmetry from surgical correction, he said.

“This is achievable in a large percentage of cases, but may require more than one procedure.

“Acute ptosis, however, must always be investigated further, and a multidisciplin


ary approach involving neurologists, may be necessary. Some cases of ptosis may resolve spontaneously, however some may require surgical intervention” Dr. Martin said.