Ptosis (eyelid)

Definition:-
Ptosis is an abnormally low position (drooping) of the upper 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, like 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.

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Ptosis refers to the drooping of an eyelid, and it affects only the upper eyelid of one or both eyes. The droop may be barely noticeable, or the lid can descend over the entire pupil. Ptosis can occur in both children and adults, but usually happens because of aging.

Causes:-
Ptosis (pronounced toe’ sis), or drooping of the upper eyelid, may occur for several reasons such as: disease, injury, birth defect, previous eye surgery and age. In most cases, it is caused by either a weakness of the levator muscle (muscle that raises the lid), or a problem with the nerve that sends messages to the muscle.

Children born with ptosis may require surgical correction of the lid if it covers the pupil. In some cases, it may be associated with a crossed or misaligned eye (strabismus). Left untreated, ptosis may prevent vision from developing properly, resulting in amblyopia, or lazy eye.

Patients with ptosis often have difficult blinking, which may lead to irritation, infection and eyestrain. If a sudden and obvious lid droop is developed, an ophthalmologist should be consulted immediately.

Ptosis occurs when the muscles 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, 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, and diseases which may cause weakness in muscles or nerve damage, such as myasthenia gravis.

Classification:-
Depending upon the cause it can be classified into:

*Neurogenic ptosis which includes oculomotor nerve palsy, Horner’s Syndrome, Marcus Gunn jaw winking syndrome, IIIrd cranial nerve misdirection.

*Myogenic ptosis which includes myasthenia gravis, myotonic dystrophy, ocular myopathy, simple congenital ptosis, blepharophimosis 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 envenomation by elapids such as cobras, or kraits. Bilateral ptosis is usually accompanied by diplopia, dysphagia and/or progressive muscular paralysis. Neurotoxic ptosis is a precursor to respiratory failure and eventual suffocation caused by complete paralysis of the thoracic diaphragm. It is therefore a medical emergency 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

Signs and Symptoms:-
The causes of ptosis are quite diverse. The symptoms are dependent on the underlying problem and may include:

*Drooping lid (may affect one or both eyes)

*Irritation

*Difficulty closing the eye completely

*Eye fatigue from straining to keep eye(s) open

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*Children may tilt head backward in order to lift the lid

*Crossed or misaligned eye

*Double vision

Detection and Diagnosis:-
When examining a patient with a droopy lid, one of the first concerns is to determine the underlying cause. The doctor will measure the height of the eyelid, strength of the eyelid muscles, and evaluate eye movements and alignment. Children may require additional vision testing for amblyopia.

Treatment:-
Ptosis does not usually improve with time, and nearly always requires corrective surgery by an ophthalmologist specializing in plastic and reconstructive surgery. In most cases, surgery is performed to strengthen or tighten the levator muscle and lift the eyelid. If the levator muscle is especially weak, the lid and eyebrow may be lifted. Ptosis can usually be performed with local anesthesia except with young children.

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 ophthamolic plastic and reconstructive surgeon, specializing in diseases and problems of the eyelid.

Surgery is usually the best treatment for drooping eyelids. The surgeon tightens the levator muscles, and you come away with improved vision and appearance. In very severe cases involving weakened levator muscles, the surgeon attaches the eyelid under the eyebrow to allow the forehead muscles to substitute for the levator muscles in lifting the eyelid. Eyelid surgery is also known as blepharoplasty.

After surgery, the eyelids may not appear symmetrical, even though the lids are higher than before surgery. Very rarely, eyelid movement may be lost.

It is important to choose your surgeon carefully, since poorly done surgery could result in an undesirable appearance or in dry eyes from lifted eyelids not closing completely.

Before agreeing to ptosis surgery, ask how many procedures your surgeon has done. Also ask to see before-and-after photos of previous patients, and ask if you can talk to any of them about the experience.

Surgical procedures include:
———————————–
*Levator resection

*Müller muscle resection

*Frontalis sling operation

Non-surgical modalities like the use of “crutch” glasses to support the eyelid may also be used.

Ptosis that is caused by a disease will improve if the disease is treated successfully.

Ptosis Strips:
Ptosis strips from FCI Ophthalmics have been developed to treat frontalis suspension in patients with significant ptosis and poor levator functioning. FCI Ptose-Up strips are easy to place and adjust, and they provide an excellent eyelid contour. The strips are made of a biocompatible, porous, inert, biointegratable, non-toxic, ready to use, non-allergenic material. FCI ptosis strips can be removed in the case of overcorrection, or if the patient experiences dry eye problems as a result of treatment.

Ptosis in Children:
Children born with moderate or severe ptosis require treatment in order for proper vision to develop. Failure to treat ptosis can result in amblyopia (diminished vision in one eye) and a lifetime of poor vision.

All children with ptosis, even mild cases, should visit their eyecare practitioner every year. The eyes change shape as they grow, and sometimes focusing and visual problems develop, all because of the worsening ptosis.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.


Resources
:
http://en.wikipedia.org/wiki/Ptosis_(eyelid)
http://www.stlukeseye.com/conditions/Ptosis.asp
http://www.allaboutvision.com/conditions/droopinglids.htm
http://www.fci-ophthalmics.com/html/lid.html

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