Eyelid Ptosis, also known as blepharoptosis is a disorder of the upper eyelid that causes it to droop lower than its normal location. In adults, the normal location of the upper eyelid is 0.5 to 2 mm beneath the upper margin of the cornea1, but in eyelid ptosis, the location is well below these ranges.
- How Significantly Does Eyelid Ptosis Impact Aesthetic Appearance?
- What Causes Eyelid Ptosis?
- How Can Blepharoptosis Be Diagnosed?
- Can Eyelid Ptosis Be Prevented?
- Is It Essential to Treat Upper Eyelid Ptosis?
- What Are the Treatment Options for Eyelid Ptosis?
- What is the Outcome of Surgical Correction of Eyelid Ptosis?
Figure 1 – Patient with unilateral ptosis. Tucker, S.M., Verhulst, S.J., 1999
How Significantly Does Eyelid Ptosis Impact Aesthetic Appearance?
The degree of visibility and exposure of cornea, iris, and pupil is a major determining factor in eyelid aesthetics.4 An abnormally lowered eyelid can significantly alter a person’s facial features by covering a large portion of the cornea thereby narrowing the cornea’s area of visibility, resulting in an aesthetically undesirable appearance. A study by Knoll Et al 2008 reported the significant role played by upper eyelid exposure in determining how an onlooker perceives your mood as well as intellect.2
For instance, people with an unnaturally droopy eyelid can be stereotyped as being less intelligent than those with normal eyelid exposure. Vaca Et al 2019 concluded that the attractiveness of an eye was mainly determined by the degree of pretarsal show. Aesthetically, the ideal amount of pretarsal show considered to be attractive was 2-4 mm.3 The symmetry of the tarsal platform show in both eyes is even more important for eye aesthetics, with asymmetry indicating abnormalities such as eyelid ptosis.
What Causes Eyelid Ptosis?
Eyelid Ptosis, which can affect one or both eyes is caused by a wide range of underlying pathological conditions. The underlying mechanism of ptosis is attributed to a dysfunction of the ocular muscles or can occur due to damage to the nerves supplying these muscles. This condition can occur at birth, but it is more commonly an acquired condition affecting the elderly, due to progressive weakening of eye muscles with age.
The exact mechanism of congenital eyelid ptosis is not well understood but is thought to be due to abnormal fetal development of levator muscles.5 Histopathological analysis of ocular muscles in congenital ptosis found dystrophic levator muscles with the replacement of myocytes by a combination of adipocyte and fibrous tissue. Microscopic examination of tissue samples obtained from patients with severe ptosis revealed an almost complete absence of striated muscle. The findings suggest congenital ptosis to be a consequence of abnormal development in ocular muscles at a histological level. Additionally, the increased incidence of blepharoptosis in family members indicates an inherited pathophysiology.
New-onset eyelid ptosis in elderly individuals can be due to neurogenic, myogenic, traumatic, or aponeurotic etiology.6 It often occurs as an isolated condition but may also be associated with an autoimmune disorder such as lupus, malignant tumors, or infectious diseases. Ptosis that occurs due to a neurogenic cause can be an indication of an underlying more serious condition such as diabetes, metastatic cancer, or myasthenia gravis. Myasthenia Gravis is an autoimmune condition that results in musle weakness, and predominantly affects the eyes. Rarely, ptosis can be seen in botulism, which is an enteric infection caused by the consumption of bacterial toxin from improperly canned food contaminated with the bacteria responsible for releasing botulin toxin.
Usage of drugs containing opium such as morphine, heroin, oxycodone, and certain anticonvulsant drugs including pregabalin can also cause a mild form of eyelid ptosis. 7
How Can Blepharoptosis Be Diagnosed?
This condition can be easily diagnosed by a primary care physician by simply observing the close proximity between the margin of the upper eyelid and the central corneal light reflex. 1 Corneal light reflex test is a fairly easy test that can be conducted in an outpatient basis. In this procedure, an opthalmologist shines a beam of light above the nose or on the forehead as the patient stares ahead. The opthalmologist then examines the point where the light is reflected within the pupil, and this point is the central corneal light reflex. Measurement of the distance between the upper eyelid’s margin and this point of reflection can be easily done to confirm the presence of eyelid ptosis. Once the diagnosis of blepharoptosis is confirmed, further investigations, family history, and personal medical history will be obtained by the physician to determine the etiology and design a suitable treatment plan.
Can Eyelid Ptosis Be Prevented?
Although there is no possible way to prevent congenital eyelid ptosis, adult onset ptosis may be prevented in cases where the etiology is an underlying condition such as diabetes. In patients who already have a mild form of eyelid ptosis, identification of the causative agent of ptosis, whether it be drugs, autoimmune diseases, or infections is central to prevent worsening of eyelid ptosis.
Figure 2 – Intraoperative conjunctival view. Buried-suture blepharoplasty for double eyelid was applied to point A, E and F. At points B, C, and D, the blepharoptosis correction by transconjunctival approach was performed. Hyejeong Lee et al 2015
Is It Essential to Treat Upper Eyelid Ptosis?
Older patients often avoid corrective surgery for mild eyelid ptosis, as they refrain from going under the knife for aesthetic reasons alone. Milder forms of eyelid ptosis are often not corrected surgically, as the risk of complications arising from surgery often outweighs the benefits. In congenital cases of ptosis, observing the patient for the development of amblyopia is crucial to prevent permanent vision loss. If a child with eyelid ptosis fails to receive the timely surgical correction of eyelid ptosis, the potential of losing their vision rises exponentially once amblyopia develops. 7However, in adults with severe eyelid ptosis, the treatment of upper eyelid ptosis is essential not just for aesthetic reasons but also due to its detrimental impact on the patient’s lifestyle. Eyelid Ptosis can obscure up to one-fifth of the cornea9 or even more in severe cases, which can seriously impair the patient’s ability to read, drive, and walk up or down the stairs.
What Are the Treatment Options for Eyelid Ptosis?
Treatment options for eyelid ptosis depend on the severity of the condition, the underlying etiology, and the degree of impairment in visual functions. Surgical correction is done in severe forms of eyelid ptosis, in cases where the patient, as well as the surgeon, decides surgery to be essential and unavoidable. Blepharoplasty, also popularly known as Asian double eyelid surgery is the most commonly performed procedure in the field of plastic surgery. Double eyelid surgery is a type of surgery that surgically creates a crease on the eyelid, and is done mainly for aesthetic reasons. Often plastic surgeons may push a patient with mongoloid eyelids i.e, slanted eyelids to get a blepharoplasty to enhance their aesthetic appeal. In fact, blepharoplasty is an extremely common procedure in Asian countries, with many women opting for this invasive surgery immediately after completing high school. In the western world, blepharoplasty is usually done only in patients with pathological conditions such as upper eyelid ptosis. But worldwide, elective surgery for blepharoplasty is increasing day by day, as people voluntarily seek plastic surgeons with a desire to improve their scale of attractiveness.
Figure 3 – A 20-year-old woman with bilateral mild blepharoptosis: left, preoperative appearance; right, postoperative appearance 1 month later. Hyejeong Lee et al 2015
What are the Outcomes of Surgical Correction for Eyelid Ptosis?
Surgical repair of eyelid ptosis can satisfy the patient in terms of both functionality and facial aesthetics. But, patients may often require repeat surgeries as the condition can recur with time.
There is also a risk of complications with eyelid surgery that can in rare cases worsen facial aesthetics due to the formation of granulomas, asymmetry in eyelids due to overcorrection or under correction, and infections. 10
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- Avdagic and P.O. Phelps, Eyelid ptosis (Blepharoptosis) for the primary care practitioner, Disease-a-Month, https://doi.org/10.1016/j.disamonth.2020.101040
- Knoll, Bianca & Attkiss, Keith & Persing, John. (2008). The Influence of Forehead, Brow, and Periorbital Aesthetics on Perceived Expression in the Youthful Face. Plastic and reconstructive surgery. 121. 1793-802.
- Vaca EE., Bricker JT., Helenowski I., Park ED., Alghoul MS. Identifying Aesthetically Appealing Upper Eyelid Topographic Proportions, Aesthetic Surgery Journal, Volume 39, Issue 8, August 2019, Pages 824–834
- Lee, Hyejeong, Munjae Lee, and Sangmo Bae. “Blepharoptosis correction transconjunctivally using buried suture method: A prospective cohort study.” International Journal of Surgery 25.(2016): 9-16.
- Wabbels B, Schroeder JA, Voll B, Siegmund H, Lorenz B. Electron microscopic findings in levator muscle biopsies of patients with isolated congenital or acquired ptosis. Graefes Arch Clin Exp Ophthalmol. Oct 2007;245(10):1533-41.
- Finsterer, J (2003). “Ptosis: causes, presentation, and management”.Aesthetic Plastic Surgery. 27 (3): 193–204.
- Iqbal N (2002).”Ptosis, convergence disorder and heroin” (PDF). Annals of Saudi Medicine. 22 (5–6): 369–71
- Lin LK, Uzcategui N, Chang EL. Effect of surgical correction of congenital ptosis on amblyopia. Ophthal Plast Reconstr Surg. Nov-Dec 2008;24(6):434-6
- M. EmsenA new ptosis correction technique: a modification of levator aponeurosis advancement J. Craniofacial Surg., 19 (3) (2008), pp. 669-674
- R. Collin Complication of ptosis surgery and their management: a review J. R. Soc. Med., 72 (1979), pp. 25-26