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.
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- 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