Overview of ptosis
- Michael S Lee, MD
Michael S Lee, MD
- Departments of Ophthalmology and Visual Neurosciences
- University of Minnesota
Blepharoptosis, or ptosis of the eyelid, refers to drooping of the upper eyelid that usually results from a congenital or acquired abnormality of the muscles that elevate the eyelid. Ptosis may be the presenting sign or symptom of serious neurologic disease. Regardless of the etiology, when ptosis obstructs vision, it is disabling. The appropriate management requires recognition of the underlying cause.
The facial or seventh nerve innervates the circumferential orbicularis oculi to close the upper and lower eyelids. The oculomotor or third cranial nerve innervates the levator palpebrae superioris to elevate the upper eyelid. The levator palpebrae superioris becomes a tendinous aponeurosis, which fuses with the anterior superior portion of the superior tarsal plate and possibly the pretarsal skin (figure 1). This junction of the aponeurosis to the tarsus and orbicularis oculi forms the eyelid crease .
An additional accessory smooth muscle, Müller's muscle, is innervated by the sympathetic nervous system. It arises from the undersurface of the levator palpebrae superioris and inserts into the superior tarsus. It contributes approximately 1 to 2 mm to the elevation of the upper eyelid (figure 1) . Müller's muscle contributes to the over-elevation of the eyelid when a patient becomes excited or fearful and leads to mild ptosis with fatigue or inattention.
Landmarks — The normal eyelid crease is 6 to 7 mm away from the eyelid margin in adults. This crease is not appreciable in most Asian eyelids . The upper eyelid normally covers the top 1 mm of the cornea, and the lower eyelid typically lies at the junction of the cornea and sclera (picture 1) .
The palpebral fissure (PF) represents the distance between the upper and lower eyelid margins at the axis of the pupil. The normal PF measures 9 to 12 mm.
- Collin JR, Beard C, Wood I. Experimental and clinical data on the insertion of the levator palpebrae superioris muscle. Am J Ophthalmol 1978; 85:792.
- Beard C. Müller's superior tarsal muscle: anatomy, physiology, and clinical significance. Ann Plast Surg 1985; 14:324.
- Jeong S, Lemke BN, Dortzbach RK, et al. The Asian upper eyelid: an anatomical study with comparison to the Caucasian eyelid. Arch Ophthalmol 1999; 117:907.
- Dortzbach RK, Gausas RA, Sherman D. Blepharoptosis. In: Ophthalmic Plastic Surgery: Prevention and Management of Complications, Raven Press, New York 1993. p.65.
- Cartwright MJ, Kurumety UR, Nelson CC, et al. Measurements of upper eyelid and eyebrow dimensions in healthy white individuals. Am J Ophthalmol 1994; 117:231.
- Boboridis K, Assi A, Indar A, et al. Repeatability and reproducibility of upper eyelid measurements. Br J Ophthalmol 2001; 85:99.
- Toyka KV. Ptosis in myasthenia gravis: extended fatigue and recovery bedside test. Neurology 2006; 67:1524.
- Baldwin HC, Manners RM. Congenital blepharoptosis: a literature review of the histology of levator palpebrae superioris muscle. Ophthal Plast Reconstr Surg 2002; 18:301.
- BERKE RN, WADSWORTH JA. Histology of levator muscle in congenital and acquired ptosis. AMA Arch Ophthalmol 1955; 53:413.
- Johnson CC. Congenital ptosis. In: Principles and Practice of Ophthamology, Jakobiec FA, Albert DM. (Eds), WB Saunders Co, Philadelphia 1994. p.2839.
- Ahmadi AJ, Sires BS. Ptosis in infants and children. Int Ophthalmol Clin 2002; 42:15.
- Smith B, McCord CD, Baylis H. Surgical treatment of blepharoptosis. Am J Ophthalmol 1969; 68:92.
- Anderson RL, Baumgartner SA. Strabismus in ptosis. Arch Ophthalmol 1980; 98:1062.
- Sevel D. Ptosis and underaction of the superior rectus muscle. Ophthalmology 1984; 91:1080.
- Freedman HL, Kushner BJ. Congenital ocular aberrant innervation--new concepts. J Pediatr Ophthalmol Strabismus 1997; 34:10.
- Dortzbach RK, Sutula FC. Involutional blepharoptosis. A histopathological study. Arch Ophthalmol 1980; 98:2045.
- Kersten RC, de Conciliis C, Kulwin DR. Acquired ptosis in the young and middle-aged adult population. Ophthalmology 1995; 102:924.
- van den Bosch WA, Lemij HG. Blepharoptosis induced by prolonged hard contact lens wear. Ophthalmology 1992; 99:1759.
- Bernardino CR, Rubin PA. Ptosis after cataract surgery. Semin Ophthalmol 2002; 17:144.
- Feibel RM, Custer PL, Gordon MO. Postcataract ptosis. A randomized, double-masked comparison of peribulbar and retrobulbar anesthesia. Ophthalmology 1993; 100:660.
- Linberg JV, McDonald MB, Safir A, Googe JM. Ptosis following radial keratotomy. Performed using a rigid eyelid speculum. Ophthalmology 1986; 93:1509.
- Fujiwara T, Matsuo K, Kondoh S, Yuzuriha S. Etiology and pathogenesis of aponeurotic blepharoptosis. Ann Plast Surg 2001; 46:29.
- Walton KA, Buono LM. Horner syndrome. Curr Opin Ophthalmol 2003; 14:357.
- Burns TM, Russell JA, LaChance DH, Jones HR. Oculobulbar involvement is typical with Lambert-Eaton myasthenic syndrome. Ann Neurol 2003; 53:270.
- Elrod RD, Weinberg DA. Ocular myasthenia gravis. Ophthalmol Clin North Am 2004; 17:275.
- Abe K, Matsuo Y, Kadekawa J, et al. Measurement of tissue oxygen consumption in patients with mitochondrial myopathy by noninvasive tissue oximetry. Neurology 1997; 49:837.
- Taivassalo T, Jensen TD, Kennaway N, et al. The spectrum of exercise tolerance in mitochondrial myopathies: a study of 40 patients. Brain 2003; 126:413.
- Schmiedel J, Jackson S, Schäfer J, Reichmann H. Mitochondrial cytopathies. J Neurol 2003; 250:267.
- Perry JD, Kadakia A, Foster JA. A new algorithm for ptosis repair using conjunctival Müllerectomy with or without tarsectomy. Ophthal Plast Reconstr Surg 2002; 18:426.
- Frueh BR, Musch DC, McDonald HM. Efficacy and efficiency of a small-incision, minimal dissection procedure versus a traditional approach for correcting aponeurotic ptosis. Ophthalmology 2004; 111:2158.
- Finsterer J. Ptosis: causes, presentation, and management. Aesthetic Plast Surg 2003; 27:193.
- Erb MH, Kersten RC, Yip CC, et al. Effect of unilateral blepharoptosis repair on contralateral eyelid position. Ophthal Plast Reconstr Surg 2004; 20:418.
- CLINICAL APPROACH
- ETIOLOGY AND DIAGNOSIS
- Congenital ptosis
- - Third nerve palsy
- - Horner syndrome
- - Neuromuscular junction disorders
- Myasthenia gravis
- Botulinum toxin
- - Myogenic
- Mitochondrial myopathy
- Oculopharyngeal muscular dystrophy
- Myotonic dystrophy
- Nonsurgical therapy
- - Timing
- - Complications
- SUMMARY AND RECOMMENDATIONS