| disease | Drooping of Upper Eyelid (Blepharoptosis) |
| alias | Ptosis |
Drooping of the upper eyelid (blepharoptosis)(ptosis) is an abnormal condition where the upper eyelid partially or completely droops. In mild cases, it partially covers the pupil, while in severe cases, the pupil is entirely obscured, affecting both appearance and vision. Congenital cases may even lead to amblyopia. Patients with unilateral ptosis often raise their eyebrows to improve vision, causing the opposite eyelid fissure to widen, while those with bilateral ptosis tend to tilt their heads back to see.
bubble_chart Clinical Manifestations
Drooping of upper eyelid (blepharoptosis) can be broadly categorized into congenital and acquired types. Based on the degree of drooping, it can be classified as complete, incomplete, or pseudoptosis. Recent studies have demonstrated that the lack of strength in the levator palpebrae muscle membrane is the primary cause, leading to the development of a mechanical classification system for ptosis. The current classification is as follows:
1. Neurogenic drooping of upper eyelid (blepharoptosis) This results from defects in neural innervation, often due to: ① Oculomotor nerve palsy, usually accompanied by other symptoms of cranial nerve III palsy; ② Ophthalmoplegic migraine, a rare condition characterized by ipsilateral oculomotor nerve palsy following migraine; ③ Horner syndrome caused by sympathetic nerve injury; ④ Synkinetic ptosis (Marcus Gunn syndrome).
2. Myogenic drooping of upper eyelid (blepharoptosis) Caused by defects in the levator palpebrae muscle, such as congenital dysplasia, myasthenia gravis, muscular atrophy, oculopharyngeal muscular dystrophy, or trauma affecting the muscle's contraction. This type of ptosis can be classified as mild (1–2 mm), moderate (3–4 mm), or severe (5–6 mm). Levator muscle function can be described as: good (>8 mm), fair (5–7 mm), or poor (4 mm or less). This classification is primarily used for estimating congenital ptosis, as applying the same surgical correction for acquired ptosis may result in overcorrection.
3. Aponeurotic ptosis Caused by impaired transmission of levator palpebrae muscle function due to defects or tears in the aponeurosis, leading to weakness. The aponeurosis may also become infiltrated or replaced by fatty tissue. Aponeurotic ptosis can occur after various eye surgeries, possibly due to postoperative eyelid edema or excessive stretching of the weakened aponeurosis when the patient forcefully opens their eyes during recovery. A typical sign of aponeurotic defects is an excessively high or indistinct eyelid crease (double eyelid), with the eyelid over the tarsal plate being very thin—sometimes even revealing the pupil when the patient closes their eyes.4. Mechanical ptosis Often caused by eyelid tumors, eyelid laxity, or other conditions. It may also result from eyelid scarring that restricts the movement of the levator palpebrae muscle.
For the purpose of selecting treatment methods, it is essential to carefully examine and differentiate the type of drooping of upper eyelid (blepharoptosis), disease cause, degree of ptosis, levator muscle function, and its relationship with systemic and other neuromuscular conditions.
1. Congenital drooping of upper eyelid (blepharoptosis), acquired drooping of upper eyelid (blepharoptosis), and generalized drooping of upper eyelid (blepharoptosis) often differ significantly in treatment. Overcorrection is more common in acquired ptosis than in congenital cases, so clear differentiation before treatment is crucial. A thorough medical and family history, as well as the age of onset, should be obtained. Congenital drooping of upper eyelid (blepharoptosis) in children is often associated with amblyopia and anisometropia. Generalized drooping of upper eyelid (blepharoptosis) appears as ptosis but with preserved levator function, and it resolves once the underlying disease cause is eliminated. Factors causing pseudoptosis include: ① Ocular abnormalities such as anophthalmos, microphthalmos, or phthisis bulbi; ② Eyelid displacement due to tumors (e.g., eyelid or lacrimal gland tumors), chalazion, elephant hide disease, eyelid edema, trauma-related adhesions, or scars; ③ Eyelid skin laxity; ④ Duane retraction syndrome; ⑤ Horner syndrome; ⑥ Blepharospasm, etc.
3. Assessment of levator muscle function: The patient is instructed to gaze forward, upward, and downward while measuring the palpebral fissure height and observing its relationship with the eyeball. The duration of upper eyelid elevation is recorded to evaluate levator function. To minimize interference from the frontalis and corrugator muscles during eyelid opening, the examiner should firmly press the patient’s brow with both thumbs before instructing the patient to gaze in different directions, recording the palpebral fissure height. Complete inability to elevate the upper eyelid indicates complete ptosis, while partial elevation (grade I) suggests incomplete ptosis. Preoperative photographs of the patient gazing in various directions should be taken for reference.
4. If myasthenia gravis is suspected, a Tensilon test should be performed. If ptosis worsens toward the end of the day and the patient is elderly, senile ptosis with concurrent myasthenia may be present.
5. For adult patients undergoing ptosis surgery, a neurological consultation should be obtained beforehand.
bubble_chart Treatment Measures
Congenital drooping of the upper eyelid (blepharoptosis) is often ineffective with drug treatment, and surgical correction yields better results. For acquired drooping of the upper eyelid (blepharoptosis), treatment should target the underlying disease cause. Early-stage drooping of the upper eyelid (blepharoptosis) should first rule out myasthenia gravis. If it is due to nerve palsy, the type should be identified to determine the disease cause for treatment. Before identifying the disease cause, oral or injectable vitamin B group medications, as well as ATP, cAMP, and CTP, may be administered. For cases with no improvement after long-term treatment, surgical correction should be considered, with the procedure selected based on the actual condition.
