Ptosis
Ptosis (drooping of the upper eyelid) may be congenital or acquired, unilateral or
bilateral, and constant or intermittent. Severe ptosis usually responds well to treatment; slight ptosis may require no treatment at all.
Causes and incidence
Congenital ptosis is transmitted as an autosomal dominant trait or results from a congenital anomaly in which the levator muscles of the eyelids fail to develop. This condition is usually unilateral.
Acquired ptosis may result from any of the following:
❑ advanced age (involutional ptosis, the most common form, usually seen in older patients following cataract surgery)
❑ mechanical factors that make the eyelid heavy, such as swelling caused by a foreign body on the palpebral surface of the eyelid or by edema, inflammation produced by a tumor or pseudotumor, or an extra fatty fold
❑ myogenic factors, such as muscular dystrophy or myasthenia gravis (in which the defect appears to be in humoral transmission at the myoneural junction)
❑ neurogenic (paralytic) factors from interference in innervation of the eyelid by the oculomotor nerve (cranial nerve III), most commonly due to trauma, diabetes, or carotid aneurysm
❑ nutritional factors, such as thiamine deficiency in chronic alcoholism, hyperemesis gravidarum, and other malnutrition-producing states.
Risk factors for ptosis include aging, diabetes, stroke, Horner’s syndrome, myasthenia gravis, and cancer that affects nerve or muscle response.
Signs and symptoms
An infant with congenital ptosis has a smooth, flat upper eyelid, without the eyelid fold normally caused by the pull of the levator muscle; associated weakness of the superior rectus muscle isn’t uncommon.
The child with unilateral ptosis that covers the pupil can develop an amblyopic eye from disuse or lack of eye stimulation. In bilateral ptosis, the child may elevate his brow in an attempt to compensate, wrinkling his forehead in an effort to raise the upper lid. Also, the child may tilt his head backward to see.
In myasthenia gravis, ptosis results from fatigue and characteristically appears in the evening, but is relieved by rest.
Ptosis due to oculomotor nerve damage produces a fixed, dilated pupil; divergent strabismus; and slight depression of the eyeball.
Diagnosis
A physical examination reveals upper lid retraction, and examination with the Hertel exophthalmometer reveals the degree of proptosis. Diagnosis also includes these tests to determine the underlying cause:
❑ digital subtraction angiography or magnetic resonance imaging — aneurysm
❑ glucose tolerance test — diabetes
❑ ophthalmologic examination — foreign bodies
❑ patient history — chronic alcoholism
❑ Tensilon test — myasthenia gravis (in acquired ptosis with no history of trauma).
Treatment
Slight ptosis that doesn’t produce deformity or loss of vision requires no treatment. Severe ptosis that interferes with vision or is cosmetically undesirable usually necessitates resection of the weak levator muscles. Surgery to correct congenital ptosis is usually performed at age 3 or 4, but it may be done earlier if ptosis is unilateral because the completely occluded pupil may cause an amblyopic eye. If surgery is undesirable, special glasses with an attached suspended crutch on the frames may elevate the eyelid.
Effective treatment for ptosis also requires treatment for the underlying cause. For example, in patients with myasthenia gravis, neostigmine or steroids may be prescribed to increase the effect of acetylcholine and aid transmission of nerve impulses to muscles.
Special considerations
❑ Report any bleeding immediately. After surgery to correct ptosis, watch for blood on the pressure patch. (Some surgical procedures may not require a patch.) Apply ointment to the sutures as prescribed.
❑ Emphasize to the patient and his family the need to prevent accidental trauma to the surgical site until healing is complete (6 weeks). Suture line damage can precipitate recurrence of ptosis.
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
Other Book Chapters Related to Droopy eye-lid
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- "Differential Diagnosis in Primary Care" (2007)
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Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Droopy eye-lid
» Next page: Ptosis (Professional Guide to Signs & Symptoms (Fifth Edition))
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