Drowning

Disease Description (Causes and Symptoms)

• Definition: A condition in which the upper eyelid droops, reducing the opening between the eyelids (ptosis). It is caused by weakness or dysfunction of the muscle that lifts the upper eyelid (levator palpebrae superioris, upper eyelid elevator) or of its nerves/function.
• Causes
  • Congenital: Developmental abnormality of the upper eyelid elevator present from birth (muscle hypoplasia).
  • Acquired: Trauma (muscle or tendon rupture), nerve damage, neuromuscular disease (e.g., myasthenia gravis), senile changes (laxity of the levator ligament or tendon), tumors, or systemic diseases.
• Pathophysiology summary: Reduced lifting force of the upper eyelid due to decreased function of the elevator muscle or its supporting structures, causing more of the upper part of the cornea (the black part of the eye) to be covered. Normally, the upper part of the cornea is covered by about 1–2 mm. Levator function is assessed by the maximum movement of the eyelid (normally approximately ≥14 mm).
• Main symptoms: Drooping eyelid, eyes appearing small or sleepy, habit of straining the forehead (forehead wrinkles), amblyopia when visual function is impaired (especially in children), and a difference in the size of the two eyes (asymmetry).

Treatment Methods

• Treatment goals: Securing the visual field, preventing amblyopia (in children), and improving appearance and function. Treatment of the underlying cause is also performed as needed (e.g., testing and treatment for myasthenia gravis).
• Conservative and nonsurgical treatment
  • Children: Initially, tape may be used to lift the eyelid (temporary fixation), or the normal eye may be partially covered so that the eye on the ptosis side is used (for amblyopia prevention).
  • Adults: Temporary correction with an ophthalmic prosthetic device (ptosis crutch) attached to eyeglasses.
  • Protection from exposure: Use of artificial tears and ointment before and after surgery to prevent dryness and corneal damage.
• Surgical treatment (selected according to the degree of upper eyelid drooping and levator function)
  • Levator resection or levator advancement (advancement/resection) — when some levator function remains.
  • Levator aponeurosis plication (shortening) — mainly for senile ptosis (correction of a stretched levator ligament).
  • Frontalis sling (frontalis muscle suspension) — when levator function is absent or very weak. The forehead muscle and eyelid are connected using fascia (autologous fascia, e.g., fascia lata) or an artificial material.
  • Suturing and reconstruction in cases of traumatic rupture.
• Timing of surgery
  • Children: Early surgery is necessary for severe congenital ptosis with a risk of amblyopia (to prevent delayed visual development). When the risk of amblyopia is low, surgery is generally considered at 3–5 years of age.
  • Adults: Planned according to symptoms, appearance, and function. Local or general anesthesia may be used (general anesthesia for children).
• Postoperative care and precautions
  • Surgical results do not guarantee completely natural movement (the upper eyelid may not descend well, especially when looking downward).
  • Temporary or persistent incomplete eye closure (lagophthalmos) after surgery can cause corneal dryness and damage, so protect the eye with artificial tears, ointment, nighttime tape, and other measures.
  • When an underlying disease such as myasthenia gravis is present, treatment of that disease must also be continued.
• Possible complications: Infection, overcorrection/undercorrection (requiring revision surgery), exposure keratitis and corneal ulcer, cosmetic asymmetry, suture-related problems, and recurrence.

Outpatient Visit Checklist (Preparation, Examination Information, and Example Questions)

• Items and materials to bring
  • List of currently taken medications (including English and Korean names) and health supplements
  • History of previous ophthalmic or plastic surgery and information about any trauma
  • Previous ophthalmic examination results (visual acuity, intraocular pressure, previous photographs, etc.)
  • The time symptoms began and how they have progressed (e.g., whether they were congenital/present immediately after birth or have gradually worsened)
  • Whether symptoms worsen with fatigue (a clue suggesting myasthenia gravis)
  • Sleep and tear status (dryness, foreign-body sensation) and whether double vision is present
• Materials useful to show the doctor during the outpatient visit
  • Frontal and side-view facial photographs (for comparing the degree of eye opening when looking straight ahead)
  • Records of changes in visual acuity in both eyes; for children, visual acuity test results or whether the eye that is not being seen with is being used
• Examinations and measurements
  • Measurement of levator function (maximum up-and-down eyelid movement; normal ≈ ≥14 mm)
  • Measurement of MRD1 (the distance from the upper eyelid margin to the centerline of the pupil) is recommended (performed by a specialist)
  • If necessary, blood tests and neurophysiological tests related to neuromuscular diseases (e.g., myasthenia gravis) may be recommended

Examples of General Questions to Ask the Doctor

• "How much will this surgery improve the function of my eyes (visual field)? What is the prognosis?"
• "Which side effects or complications of the surgery are the greatest concern? How would they be treated if they occur?"
• "When can I resume daily activities (driving, returning to work, exercising) after surgery?"

Examples of Disease-Specific Questions

• "What is my (or the child's) levator function (e.g., the measurement in mm), and which surgical method do you recommend based on this value?"
• "In children, I am concerned about the risk of amblyopia. Is surgery needed right away to prevent amblyopia, or are observation and conservative treatment sufficient?"
• "There are signs suggesting myasthenia gravis (worsening with fatigue). What additional tests do you recommend (e.g., antibody tests or electrophysiological tests)?"