Ptosis (eyelid)
Encyclopedia
Ptosis is a drooping of the upper or lower eyelid
. The drooping may be worse after being awake longer, when the individual's muscles are tired. This condition is sometimes called "lazy eye", but that term normally refers to amblyopia
. If severe enough and left untreated, the drooping eyelid can cause other conditions, such as amblyopia or astigmatism
. This is why it is especially important for this disorder to be treated in children at a young age, before it can interfere with vision development.
s that raise the eyelid (levator
and Müller's
muscles) are not strong enough to do so properly. It can affect one eye or both eyes and is more common in the elderly, as muscles in the eyelids may begin to deteriorate. One can, however, be born with ptosis. Congenital ptosis is hereditary in three main forms. Causes of congenital ptosis remain unknown. Ptosis may be caused by damage/trauma to the muscle which raises the eyelid, damage to the superior cervical sympathetic ganglion or damage to the nerve
(3rd cranial nerve (oculomotor nerve)) which controls this muscle. Such damage could be a sign or symptom of an underlying disease
such as diabetes mellitus
, a brain tumor
, a pancoast tumor
(apex of lung) and diseases which may cause weakness in muscles or nerve damage, such as myasthenia gravis
. Exposure to the toxins in some snake venoms, such as that of the black mamba
, may also cause this effect.
Ptosis can be caused by the aponeurosis of the levator muscle
, nerve abnormalities, trauma
, inflammation
or lesions of the lid or orbit. Dysfunctions of the levators may occur as a result of a lack of nerve communication being sent to the receptors due to antibodies needlessly attacking and eliminating the neurotransmitter
.
Ptosis may be due to a myogenic
, neurogenic, aponeurotic, mechanical or traumatic cause and it usually occurs isolated, but may be associated with various other conditions, like immunological, degenerative, or hereditary disorders, tumor
s, or infections
Acquired ptosis is most commonly caused by aponeurotic ptosis. This can occur as a result of senescence, dehiscence or disinsertion of the levator aponeurosis. Moreover, chronic inflammation or intraocular surgery can lead to the same effect. Also, wearing contact lenses for long periods of time is thought to have a certain impact on the development of this condition.
Congenital neurogenic ptosis is believed to be caused by the Horner syndrome. In this case, a mild ptosis may be associated with ipsilateral ptosis, iris
and areola hypopigmentation and anhidrosis due to the paresis of the Mueller muscle. Acquired Horner syndrome may result after trauma, neoplastic insult, or even vascular disease
.
Ptosis due to trauma can ensue after an eyelid laceration with transection of the upper eyelid elevators or disruption of the neural input.
Other causes of ptosis include eyelid neoplasms, neurofibromas or the cicatrization
after inflammation or surgery. Mild ptosis may occur with aging.
drugs such as morphine
, oxycodone
or hydrocodone
can cause ptosis, and it is a side effect commonly seen in the abuse of drugs such as diacetylmorphine (heroin). Pregabalin
(Lyrica) has also been known to cause mild ptosis.
is a common neurogenic ptosis which could be also classified as neuromuscular ptosis because the site of pathology is at the neuromuscular junction. Studies have shown that up to 70% of myasthenia gravis patients present with ptosis, and 90% of these patients will eventually develop ptosis. In this case, ptosis can be unilateral or bilateral and its severity tends to be oscillating during the day, because of factors such as fatigue or drug effect. This particular type of ptosis is distinguished from the others with the help of a Tensilon challenge test and blood tests. Also, specific to myasthenia gravis is the fact that coldness inhibits the activity of cholinesterase
, which makes possible differentiating this type of ptosis by applying ice
onto the eyelids. Patients with myasthenic ptosis are very likely to still experience a variation of the drooping of the eyelid at different hours of the day.
The ptosis caused by the oculomotor palsy can be unilateral or bilateral, as the subnucleus to the levator muscle is a shared, midline structure in the brainstem. In cases in which the palsy is caused by the compression of the nerve
by a tumor or aneurysm, it is highly likely to result into an abnormal ipsilateral papillary response and a larger pupil. Surgical third nerve palsy is characterized by a sudden onset of unilateral ptosis and an enlarged or sluggish pupil to the light. In this case, imaging tests such as CTs or MRIs should be considered. Medical third nerve palsy, contrary to surgical third nerve palsy, usually does not affect the pupil and it tends to slowly improve in several weeks. Surgery to correct ptosis due to medical third nerve palsy is normally considered only if the improvement of ptosis and ocular motility are unsatisfactory after half a year. Patients with third nerve palsy tend to have diminished or absent function of the levator.
When caused by Horner's syndrome, ptosis is usually accompanied by miosis
and anhidrosis
. In this case, the ptosis is due to the result of interruption innervations to the sympathetic, autonomic Muller's muscle rather than the somatic levator palpebrae superioris muscle. The lid position and pupil size are typically affected by this condition and the ptosis is generally mild, no more than 2 mm. The pupil might be smaller on the affected side. While 4% cocaine
instilled to the eyes can confirm the diagnosis of Horner's syndrome, Hydroxyamphetamine eye drops can differentiate the location of the lesion
.
Chronic progressive external ophthalmoplegia is a systemic condition that occurs suddenly and which usually affects only the lid position and the external eye movement, without involving the movement of the pupil. This condition accounts for nearly 45% of myogenic ptosis cases. Most patients develop ptosis due to this disease in their adulthood. Characteristic to ptosis caused by this condition is the fact that the protective up rolling of the eyeball when the eyelids are closed is very poor.
Treatment depends on the type of ptosis and is usually performed by an ophthalmic plastic and reconstructive surgeon, specializing in diseases and problems of the eyelid.
Surgical procedures include:
Non-surgical modalities like the use of "crutch" glasses or special Scleral contact lenses to support the eyelid may also be used.
Ptosis that is caused by a disease will improve if the disease is treated successfully.
Eyelid
An eyelid is a thin fold of skin that covers and protects an eye. With the exception of the prepuce and the labia minora, it has the thinnest skin of the whole body. The levator palpebrae superioris muscle retracts the eyelid to "open" the eye. This can be either voluntarily or involuntarily...
. The drooping may be worse after being awake longer, when the individual's muscles are tired. This condition is sometimes called "lazy eye", but that term normally refers to amblyopia
Amblyopia
Amblyopia, also known as lazy eye, is a disorder of the visual system that is characterized by a vision deficiency in an eye that is otherwise physically normal, or out of proportion to associated structural abnormalities of the eye...
. If severe enough and left untreated, the drooping eyelid can cause other conditions, such as amblyopia or astigmatism
Astigmatism (eye)
Astigmatism is an optical defect in which vision is blurred due to the inability of the optics of the eye to focus a point object into a sharp focused image on the retina. This may be due to an irregular or toric curvature of the cornea or lens. There are two types of astigmatism: regular and...
. This is why it is especially important for this disorder to be treated in children at a young age, before it can interfere with vision development.
Etymology
Ptosis is derived from the Greek wording (πτῶσις) “fall,” and is defined as the “abnormal lowering or prolapse of an organ or body part."Causes
Ptosis occurs when the muscleMuscle
Muscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...
s that raise the eyelid (levator
Levator palpebrae superioris muscle
The levator palpebrae superioris is the muscle in the orbit that elevates the superior eyelid.-Structure:...
and Müller's
Superior tarsal muscle
The superior tarsal muscle is a smooth muscle adjoining the levator palpebrae superioris muscle that helps to raise the upper eyelid.-Structure:...
muscles) are not strong enough to do so properly. It can affect one eye or both eyes and is more common in the elderly, as muscles in the eyelids may begin to deteriorate. One can, however, be born with ptosis. Congenital ptosis is hereditary in three main forms. Causes of congenital ptosis remain unknown. Ptosis may be caused by damage/trauma to the muscle which raises the eyelid, damage to the superior cervical sympathetic ganglion or damage to the nerve
Nerve
A peripheral nerve, or simply nerve, is an enclosed, cable-like bundle of peripheral axons . A nerve provides a common pathway for the electrochemical nerve impulses that are transmitted along each of the axons. Nerves are found only in the peripheral nervous system...
(3rd cranial nerve (oculomotor nerve)) which controls this muscle. Such damage could be a sign or symptom of an underlying disease
Disease
A disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune...
such as diabetes mellitus
Diabetes mellitus
Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced...
, a brain tumor
Brain tumor
A brain tumor is an intracranial solid neoplasm, a tumor within the brain or the central spinal canal.Brain tumors include all tumors inside the cranium or in the central spinal canal...
, a pancoast tumor
Pancoast tumor
A Pancoast tumor, also called a pulmonary sulcus tumor or superior sulcus tumor, is a tumor of the pulmonary apex. It is a type of lung cancer defined primarily by its location situated at the top end of either the right or left lung. It typically spreads to nearby tissues such as the ribs and...
(apex of lung) and diseases which may cause weakness in muscles or nerve damage, such as myasthenia gravis
Myasthenia gravis
Myasthenia gravis is an autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatiguability...
. Exposure to the toxins in some snake venoms, such as that of the black mamba
Black mamba
The black mamba , also called the common black mamba or black-mouthed mamba, is the longest venomous snake in Africa, averaging around in length, and sometimes growing to lengths of...
, may also cause this effect.
Ptosis can be caused by the aponeurosis of the levator muscle
Levator palpebrae superioris muscle
The levator palpebrae superioris is the muscle in the orbit that elevates the superior eyelid.-Structure:...
, nerve abnormalities, trauma
Physical trauma
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
, inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
or lesions of the lid or orbit. Dysfunctions of the levators may occur as a result of a lack of nerve communication being sent to the receptors due to antibodies needlessly attacking and eliminating the neurotransmitter
Neurotransmitter
Neurotransmitters are endogenous chemicals that transmit signals from a neuron to a target cell across a synapse. Neurotransmitters are packaged into synaptic vesicles clustered beneath the membrane on the presynaptic side of a synapse, and are released into the synaptic cleft, where they bind to...
.
Ptosis may be due to a myogenic
Myogenic
Myogenic contraction refers to a contraction initiated by the myocyte cell itself instead of an outside occurrence or stimulus such as nerve innervation.- Unstable Membrane Potentials :...
, neurogenic, aponeurotic, mechanical or traumatic cause and it usually occurs isolated, but may be associated with various other conditions, like immunological, degenerative, or hereditary disorders, tumor
Tumor
A tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...
s, or infections
Acquired ptosis is most commonly caused by aponeurotic ptosis. This can occur as a result of senescence, dehiscence or disinsertion of the levator aponeurosis. Moreover, chronic inflammation or intraocular surgery can lead to the same effect. Also, wearing contact lenses for long periods of time is thought to have a certain impact on the development of this condition.
Congenital neurogenic ptosis is believed to be caused by the Horner syndrome. In this case, a mild ptosis may be associated with ipsilateral ptosis, iris
Iris (anatomy)
The iris is a thin, circular structure in the eye, responsible for controlling the diameter and size of the pupils and thus the amount of light reaching the retina. "Eye color" is the color of the iris, which can be green, blue, or brown. In some cases it can be hazel , grey, violet, or even pink...
and areola hypopigmentation and anhidrosis due to the paresis of the Mueller muscle. Acquired Horner syndrome may result after trauma, neoplastic insult, or even vascular disease
Vascular disease
Vascular disease is a form of cardiovascular disease primarily affecting the blood vessels.Some conditions, such as angina and myocardial ischemia, can be considered both vascular diseases and heart diseases .Cigarette smoking is the major risk factor....
.
Ptosis due to trauma can ensue after an eyelid laceration with transection of the upper eyelid elevators or disruption of the neural input.
Other causes of ptosis include eyelid neoplasms, neurofibromas or the cicatrization
Cicatrization
Cicatrization can mean:* the process of a wound healing to produce scar tissue* scarification, a form of body modification that uses cicatrization to create patterns on the skin....
after inflammation or surgery. Mild ptosis may occur with aging.
Drugs
Use of high doses of opioidOpioid
An opioid is a psychoactive chemical that works by binding to opioid receptors, which are found principally in the central and peripheral nervous system and the gastrointestinal tract...
drugs such as morphine
Morphine
Morphine is a potent opiate analgesic medication and is considered to be the prototypical opioid. It was first isolated in 1804 by Friedrich Sertürner, first distributed by same in 1817, and first commercially sold by Merck in 1827, which at the time was a single small chemists' shop. It was more...
, oxycodone
Oxycodone
Oxycodone is an opioid analgesic medication synthesized from opium-derived thebaine. It was developed in 1916 in Germany, as one of several new semi-synthetic opioids in an attempt to improve on the existing opioids: morphine, diacetylmorphine , and codeine.Oxycodone oral medications are generally...
or hydrocodone
Hydrocodone
Hydrocodone or dihydrocodeinone is a semi-synthetic opioid derived from either of two naturally occurring opiates: codeine and thebaine. It is an orally active narcotic analgesic and antitussive...
can cause ptosis, and it is a side effect commonly seen in the abuse of drugs such as diacetylmorphine (heroin). Pregabalin
Pregabalin
Pregabalin is an anticonvulsant drug used for neuropathic pain and as an adjunct therapy for partial seizures with or without secondary generalization in adults. It has also been found effective for generalized anxiety disorder and is approved for this use in the European Union. It was designed...
(Lyrica) has also been known to cause mild ptosis.
Classification
Depending upon the cause it can be classified into:- Neurogenic ptosis which includes oculomotor nerve palsyOculomotor nerve palsyOculomotor nerve palsy is an eye condition resulting from damage to the third cranial nerve or a branch thereof. As the name suggests, the oculomotor nerve supplies the majority of the muscles controlling eye movements. Thus, damage to this nerve will result in the affected individual being unable...
, Horner's SyndromeHorner's syndromeHorner's syndrome is the combination of drooping of the eyelid and constriction of the pupil , sometimes accompanied by decreased sweating of the face on the same side; redness of the conjunctiva of the eye is often also present...
, Marcus Gunn jaw winking syndrome, IIIrd cranial nerve misdirection. - Myogenic ptosis which includes myasthenia gravisMyasthenia gravisMyasthenia gravis is an autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatiguability...
, myotonic dystrophyMyotonic dystrophyMyotonic dystrophy is a chronic, slowly progressing, highly variable inherited multisystemic disease. It is characterized by wasting of the muscles , cataracts, heart conduction defects, endocrine changes, and myotonia. Myotonic dystrophy can occur in patients of any age...
, ocular myopathy, simple congenital ptosis, blepharophimosisBlepharophimosisBlepharophimosis is a condition where the patient has bilateral ptosis with reduced lid size, vertically and horizontally. The nasal bridge is flat and there is hypoplastic orbital rim...
syndrome - Aponeurotic ptosis which may be involutional or post-operative.
- Mechanical ptosis which occurs due to edema or tumors of the upper lid
- Neurotoxic ptosis which is a classic symptom of envenomationEnvenomationEnvenomation is the process by which venom is injected into some animal by the bite of a venomous animal. Many kinds of animals, including mammals , reptiles , spiders , insects , employ venom for hunting and for self defense...
by elapids such as cobras, or kraits. Bilateral ptosis is usually accompanied by diplopiaDiplopiaDiplopia, commonly known as double vision, is the simultaneous perception of two images of a single object that may be displaced horizontally, vertically, or diagonally in relation to each other...
, dysphagiaDysphagiaDysphagia is the medical term for the symptom of difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, the term is sometimes used as a condition in its own right. Sufferers are sometimes unaware of their dysphagia....
and/or progressive muscular paralysis. Regardless, neurotoxic ptosis is a precursor to respiratory failureRespiratory failureThe term respiratory failure, in medicine, is used to describe inadequate gas exchange by the respiratory system, with the result that arterial oxygen and/or carbon dioxide levels cannot be maintained within their normal ranges. A drop in blood oxygenation is known as hypoxemia; a rise in arterial...
and eventual suffocationSuffocationSuffocation is the process of Asphyxia.Suffocation may also refer to:* Suffocation , an American death metal band* "Suffocation", a song on Morbid Angel's debut album, Altars of Madness...
caused by complete paralysisParalysisParalysis is loss of muscle function for one or more muscles. Paralysis can be accompanied by a loss of feeling in the affected area if there is sensory damage as well as motor. A study conducted by the Christopher & Dana Reeve Foundation, suggests that about 1 in 50 people have been diagnosed...
of the thoracic diaphragmThoracic diaphragmIn the anatomy of mammals, the thoracic diaphragm, or simply the diaphragm , is a sheet of internal skeletal muscle that extends across the bottom of the rib cage. The diaphragm separates the thoracic cavity from the abdominal cavity and performs an important function in respiration...
. It is therefore a medical emergencyMedical emergencyA medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...
and immediate treatment is required. - pseudo ptosis due to:1-Lack of lid support:Empty socket or atrophic globe. 2-Higher lid position on the other side: As in lid retraction
Pathology
Myasthenia gravisMyasthenia gravis
Myasthenia gravis is an autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatiguability...
is a common neurogenic ptosis which could be also classified as neuromuscular ptosis because the site of pathology is at the neuromuscular junction. Studies have shown that up to 70% of myasthenia gravis patients present with ptosis, and 90% of these patients will eventually develop ptosis. In this case, ptosis can be unilateral or bilateral and its severity tends to be oscillating during the day, because of factors such as fatigue or drug effect. This particular type of ptosis is distinguished from the others with the help of a Tensilon challenge test and blood tests. Also, specific to myasthenia gravis is the fact that coldness inhibits the activity of cholinesterase
Cholinesterase
In biochemistry, cholinesterase is a family of enzymes that catalyze the hydrolysis of the neurotransmitter acetylcholine into choline and acetic acid, a reaction necessary to allow a cholinergic neuron to return to its resting state after activation.-Types:...
, which makes possible differentiating this type of ptosis by applying ice
Ice
Ice is water frozen into the solid state. Usually ice is the phase known as ice Ih, which is the most abundant of the varying solid phases on the Earth's surface. It can appear transparent or opaque bluish-white color, depending on the presence of impurities or air inclusions...
onto the eyelids. Patients with myasthenic ptosis are very likely to still experience a variation of the drooping of the eyelid at different hours of the day.
The ptosis caused by the oculomotor palsy can be unilateral or bilateral, as the subnucleus to the levator muscle is a shared, midline structure in the brainstem. In cases in which the palsy is caused by the compression of the nerve
Nerve
A peripheral nerve, or simply nerve, is an enclosed, cable-like bundle of peripheral axons . A nerve provides a common pathway for the electrochemical nerve impulses that are transmitted along each of the axons. Nerves are found only in the peripheral nervous system...
by a tumor or aneurysm, it is highly likely to result into an abnormal ipsilateral papillary response and a larger pupil. Surgical third nerve palsy is characterized by a sudden onset of unilateral ptosis and an enlarged or sluggish pupil to the light. In this case, imaging tests such as CTs or MRIs should be considered. Medical third nerve palsy, contrary to surgical third nerve palsy, usually does not affect the pupil and it tends to slowly improve in several weeks. Surgery to correct ptosis due to medical third nerve palsy is normally considered only if the improvement of ptosis and ocular motility are unsatisfactory after half a year. Patients with third nerve palsy tend to have diminished or absent function of the levator.
When caused by Horner's syndrome, ptosis is usually accompanied by miosis
Miosis
Miosis is the constriction of the pupil of the eye to two millimeters or less...
and anhidrosis
Anhidrosis
Anhidrosis means lack of sweating. It is also known by a number of other names including Adiaphoresis, Ischidrosis, Hypohidrosis, Oligidria, Oligohidrosis and Sweating deficiency.-Causes:...
. In this case, the ptosis is due to the result of interruption innervations to the sympathetic, autonomic Muller's muscle rather than the somatic levator palpebrae superioris muscle. The lid position and pupil size are typically affected by this condition and the ptosis is generally mild, no more than 2 mm. The pupil might be smaller on the affected side. While 4% cocaine
Cocaine
Cocaine is a crystalline tropane alkaloid that is obtained from the leaves of the coca plant. The name comes from "coca" in addition to the alkaloid suffix -ine, forming cocaine. It is a stimulant of the central nervous system, an appetite suppressant, and a topical anesthetic...
instilled to the eyes can confirm the diagnosis of Horner's syndrome, Hydroxyamphetamine eye drops can differentiate the location of the lesion
Lesion
A lesion is any abnormality in the tissue of an organism , usually caused by disease or trauma. Lesion is derived from the Latin word laesio which means injury.- Types :...
.
Chronic progressive external ophthalmoplegia is a systemic condition that occurs suddenly and which usually affects only the lid position and the external eye movement, without involving the movement of the pupil. This condition accounts for nearly 45% of myogenic ptosis cases. Most patients develop ptosis due to this disease in their adulthood. Characteristic to ptosis caused by this condition is the fact that the protective up rolling of the eyeball when the eyelids are closed is very poor.
Treatment
Aponeurotic and congenital ptosis may require surgical correction if severe enough to interfere with vision or if cosmesis is a concern.Treatment depends on the type of ptosis and is usually performed by an ophthalmic plastic and reconstructive surgeon, specializing in diseases and problems of the eyelid.
Surgical procedures include:
- Levator resection
- Müller muscleSuperior tarsal muscleThe superior tarsal muscle is a smooth muscle adjoining the levator palpebrae superioris muscle that helps to raise the upper eyelid.-Structure:...
resection - Frontalis sling operation
Non-surgical modalities like the use of "crutch" glasses or special Scleral contact lenses to support the eyelid may also be used.
Ptosis that is caused by a disease will improve if the disease is treated successfully.
See also
- DermatochalasisDermatochalasisDermatochalasis is a medical condition. It is defined as an excess of skin in the upper or lower eyelid. It may be either an acquired or a congenital condition. It is generally treated with blepharoplasty....
- Iris sphincter muscleIris sphincter muscleThe iris sphincter muscle is a muscle in the part of the eye called the iris...
- Cosmetic surgery
- Maxillofacial surgeryOral and maxillofacial surgeryOral and maxillofacial surgery is surgery to correct a wide spectrum of diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral and maxillofacial region. It is an internationally recognized surgical specialty...
- OtolaryngologyOtolaryngologyOtolaryngology or ENT is the branch of medicine and surgery that specializes in the diagnosis and treatment of ear, nose, throat, and head and neck disorders....
- Plastic surgeryPlastic surgeryPlastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...