Disease Description (Causes and Symptoms)
Ptosis of eyelid is a condition in which the upper eyelid droops below its normal position, narrowing the opening of the eye. The main pathophysiology is reduced function of the muscle that elevates the upper eyelid (levator palpebrae superioris) or of the nervous system that innervates that muscle.
Main causes:
- Congenital: developmental abnormality of the levator muscle present from birth (most common).
- Acquired: age-related (degeneration of the muscle and tendon), trauma, neurogenic (third cranial nerve palsy), neuromuscular junction disorders (myasthenia gravis), involvement due to tumors or infection, etc.
Main symptoms: - Drooping of the upper eyelid (on one or both sides), with an appearance of always looking sleepy
- Development of forehead wrinkles and tilting the head backward (raising the chin) due to overuse of the forehead muscles
- In severe cases, amblyopia due to obstruction of the visual field (especially in children) or secondary increased blinking
Simple diagnostic indicators: Levator function (the maximum upward movement of the eyelid) is normally approximately 14 mm or more (12–15 mm in the literature); a marked decrease is assessed as reduced function. MRD1 (margin-reflex distance 1) is normally approximately 4–5 mm, and a lower value suggests significant ptosis.
Treatment Methods and Precautions
Treatment principles: Individualized treatment is provided according to the cause and severity of symptoms (visual field obstruction, risk of amblyopia, levator function, etc.).
Nonsurgical treatment/supportive care:
- Temporary taping (a temporary measure in infants or before surgery), artificial tears (for corneal protection before and after surgery)
- In children at risk of amblyopia, covering the normal eye (patching) to promote visual development
- Treatment of the underlying condition (e.g., for myasthenia gravis, anticholinesterase agents such as pyridostigmine and immunotherapy; for neurogenic causes, neurologic or tumor treatment)
Surgical treatment (main treatments):
- Levator resection/advancement: used when some levator function remains
- Muller's muscle procedures (e.g., mullerectomy): considered for mild ptosis
- Frontalis sling (connection to the frontalis muscle using fascia or an artificial material): used when levator function is nearly absent, connecting the eyelid to the frontalis muscle so that the eyelid can be raised
- Levator tuck/pleat, etc. (in age-related cases, the muscle is shortened through a folding procedure)
Timing of surgery: In children, if there is no risk of amblyopia, surgery is generally considered between 3 and 5 years of age. However, early surgery is necessary in severe cases (visual field obstruction or risk of amblyopia).
Precautions and complications:
- It may be difficult to expect completely normal movement after surgery (especially limitation when looking downward).
- Risk of corneal dryness and ulceration due to inability to completely close the eyes → artificial tears, ointment at night, and taping may be necessary.
- Postoperative asymmetry, overcorrection/undercorrection, scarring, infection, and recurrence are possible.
- When systemic diseases (such as myasthenia gravis) are present, treatment and evaluation of the condition are necessary before surgery.
Self-care points:
- Inform the doctor about medications, allergies, and previous surgical history before and after surgery
- Use artificial tears and ointment after surgery and maintain eyelid hygiene
- Use protective eye patches if the eyes do not close completely at night
Checklist Before an Outpatient Visit (Items to Prepare and Example Questions)
Items and information to prepare:
- A list of all medications currently being taken (including prescription drugs, over-the-counter drugs, and supplements)
- Results of previous ophthalmic or plastic-surgery-related examinations (vision tests, visual field tests, photographs, etc.)
- When the symptoms began, whether they affect one or both sides, and how the symptoms change (variation by time of day)
- Relationship to sleep and fatigue (important when myasthenia gravis is suspected)
- For children, information related to visual development (optometry records and whether corrective glasses are worn)
What to show the doctor during the visit:
- Recently taken photographs of the face and eyes (looking straight ahead, up, and down)
Simple examples of outpatient questions (self-check):
- Is your visual field obstructed by the drooping eyelid?
- Do the symptoms change during the day (difference between morning and evening)?
- Have other people noticed that the way you open your eyes has changed?
- Have you recently experienced symptoms such as headache, facial paralysis, trauma, or generalized muscle weakness?
General Examples of Questions to Ask the Doctor
- What do you think is the cause of this condition? Are additional tests needed?
- If surgery is recommended, which method do you recommend, and what are the expected results and risks?
- Are there any medications or lifestyle habits that should be avoided before or after surgery?
- Can surgery improve vision (restore amblyopia)?
- What should be done if complications such as corneal dryness or infection occur?
Examples of condition-specific questions
- (For a child's guardian) My child is at risk of amblyopia. When is the most appropriate time for surgery? What are the advantages and disadvantages of early surgery?
- Myasthenia gravis is suspected. What tests (ice test, antibody testing, nerve conduction studies/electromyography) are needed to determine whether the ptosis is caused by this condition?