How to identify ptosis in clinical practice

Upper eyelid and/or ptosis evaluation should be routinely assessed in examinations, particularly of older patients. These simple examinations can lead to earlier intervention, as well as the identification of more serious underlying conditions or pseudoptosis.

Blepharoptosis (or simply “ptosis”) can present in a variety of ways in clinical practice. In some cases, ptosis—a unilateral or bilateral drooping of the upper eyelid— is pronounced and is proactively mentioned by a patient seeking treatment. In many cases, however, presentation may be more subtle, or the practitioner is hesitant to initiate discussions that invariably involve surgery.

An active approach to identifying ptosis and discussing its implications with patients, however, is an important part of optometric practice. The asymmetric or “sleepy” appearance characteristic of ptosis can impact patients’ well-being, with study data revealing increasing anxiety and appearance-related distress in patients with ptosis.^1,2

Further, the potential impacts of ptosis go beyond factors related to appearance—even mild cases of ptosis can lead to detectable visual-field deficits,^3-5 which, in turn, can affect patients’ normal daily activities and health-related quality of life.^1,6-8

ODs also know that many patients are likely to develop ptosis as they age. Studies examining ptosis prevalence have consistently shown that incidence increases with age in the adult population.^9-11 Consistent with this, aponeurotic ptosis, caused by stretching or dehiscence of the levator aponeurosis, and typically associated with aging, is the most common form of the condition.¹²

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Other known causes include contact lens wear (both rigid and soft lenses),^13-17 ocular surgery (such as glaucoma, cataract, or strabismus procedures, which can lead to transient or more persistent forms of ptosis),18,19 and various underlying conditions.²⁰

Importance of evaluation

There are several good clinical reasons to include upper eyelid and/or ptosis evaluation in practice.

First, ptosis may be caused by a more serious underlying condition. It is therefore important to conduct a differential diagnosis to identify or rule out such conditions so that appropriate intervention can be initiated (Table 1).

Potential underlying neurologic or muscular causes of ptosis include third cranial nerve (oculomotor nerve) palsy, myasthenia gravis, Horner’s syndrome, and chronic progressive external ophthalmoplegia (CPEO), all of which can be readily identified via a relatively brief clinical examination.

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For example, Horner’s syndrome is characterized by a mild unilateral ptosis accompanied by ipsilateral pupil constriction and facial anhidrosis.^20-22 From an upper eyelid perspective, the ptosis is mild, but the condition may be secondary to trauma or stroke, for example, which makes an accurate diagnosis essential.

Similarly, ptosis caused by third cranial nerve palsy is identifiable by its unilateral nature and characteristic accompanying features: a “down and out” position of the affected eye, diplopia, and pupil dilation.^20-22 This condition can be secondary to ischemia and aneurysm, and, depending on whether the underlying oculomotor nerve palsy is judged to be partial or complete, close monitoring or immediate referral for neuroimaging is required.^20-22

Clinical examination can also identify conditions that might at first appear to be ptosis but involve no pathology of the upper eyelid retractor muscles or aponeurosis (such as pseudoptosis). These conditions include mechanical causes, such as dermatochalasis, brow ptosis, or floppy eyelid syndrome; neurogenic causes such as hemifacial spasm; and anatomical causes such as microphthalmos or superior sulcus deformity.^20-22

Interventions targeting the upper eyelid muscles may not be effective in cases of pseudoptosis, so differentiating these conditions from upper eyelid ptosis is essential in helping to select appropriate treatment.

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Identification and evaluation

From a clinical practice perspective, ptosis can be quickly and effectively identified and evaluated as part of a patient’s routine comprehensive examination. While a measure like the palpebral fissure distance (PFD) assesses the relative position of both the upper and lower eyelid, and therefore may be an indicator of dysfunction of either or both eyelids, the marginal reflex distance-1 (MRD-1), which is a measurement of the distance from the central pupillary light reflex to the central margin of the upper eyelid, helps identify drooping of the upper eyelid specifically.

Normal MRD-1 is typically 4 to 5 mm, and a decrease in MRD-1 is an indicator of the presence, as well as the severity, of ptosis.^20,21,23 MRD-1 is also an easy measure to help track ptosis progression with the help of photographs taken in-office. Similarly, measuring eyelid crease height, the distance from the upper eyelid crease to the eyelid margin, can be a helpful diagnostic tool. Normal eyelid crease height is approximately 7 to 8 mm in males and 9 to 10 mm in females, and an increase in this measure can be suggestive of aponeurotic dysfunction.²³

An assessment of levator function is likewise an important part of diagnosing ptosis. Levator function is assessed by negating frontalis muscle function (by holding the brow with the thumb) and measuring upper eyelid excursion when the patient shifts from downward to upward gaze.

The degree of levator function is based on this measurement, with 0 to 4 mm of lid elevation classified as poor function, 5 to 11 mm of lid elevation classified as fair function, 12 to 14 mm of elevation classified as good function, and >15 mm of elevation classified as normal.²³

Finally, visual field testing (such as Humphrey visual field test, Goldmann visual field test, or Leicester peripheral field test), when available, can be useful in assessing functional deficits caused by ptosis.^1,3,57 Unfortunately, the utility of visual field testing is primarily limited to establishing, for payer purposes, a functional need for surgical intervention.

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Similarly, cases of pseudoptosis can often be quickly and easily identified. Dermatochalasis, for example, can be identified by gently lifting excess eyelid skin and performing eyelid evaluation to ascertain normal upper eyelid function.²¹

Importantly, there is no need for a separate consult to perform any of these diagnostic tests, and the additional chair time required is minimal when the evaluation is incorporated into the routine comprehensive exam.

Treatment

Current treatment for ptosis exclusively consists of a range of surgical approaches, with the exact technique selected based on the specific pathology. Common surgical targets are the levator, Müller’s muscle, and levator aponeurosis.^7,24-26

Surgical intervention is generally effective, improving upper eyelid elevation, the superior visual field, and patients’ health-related quality of life.^6-8

So, while it might seem difficult to raise the topic of ptosis with patients, the benefits are evident: keeping patients informed, demonstrating a commitment to their overall eye health, and, when needed, directing them to treatment that can be truly impactful.

As new non-surgical therapies to treat ptosis become available, the potential options for patients, whether their ptosis is mild, moderate, or severe, will only grow, making identification and characterization an important part of clinical practice. As practitioners, ODs owe it to patients to look for ptosis, and not wait for it to look for them.

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References

1. McKean-Cowdin R, Varma R, Wu J, Hays RD, Azen SP, Los Angeles Latino Eye Study Group. Severity of visual field loss and health-related quality of life. Am J Ophthalmol. 2007 Jun;143(6):1013-23.

2. Richards HS, Jenkinson E, Rumsey N, White P, Garrott H, Herbert H, Kalapesi F, Harrad RA. The psychological wellbeing and appearance concerns of patients presenting with ptosis. Eye (Lond). 2014 Mar;28(3):296-302.

3. Alniemi ST, Pang NK, Woog JJ, Bradley EA. Comparison of automated and manual perimetry in patients with blepharoptosis. Ophthalmic Plast Reconstr Surg. 2013 SepOct;29(5):361-363.

4. Ho SF, Morawski A, Sampath R, burns J. Modified visual field test for ptosis surgery (Leicester Peripheral Field Test). Eye (Lond). 2011 Mar;25(3):365-369.

5. Meyer DR, Stern JH, Jarvis JM, Lininger LL. Evaluating the visual field effects of blepharoptosis using automated static perimetry. Ophthalmology. 1993 May;100(5):651-658.

6. Battu VK, Meyer DR, Wobig JL. Improvement in subjective visual function and quality of life outcome measures after blepharoptopsis surgery. Am J Ophthalmol. 1996 Jun;121(6):677-686.

7. Cahill KV, Bradley EA, Meyer DR, Custer PL, Holck DE, Marcet MM, Mawn LA. Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology. Ophthalmology. 2011 Dec;118(12):2510-2517.

8. Federici TJ, Meyer DR, Lininger LL. Correlation of the visionrelated functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. Ophthalmology. 1999 Sep;106(9):1705-1712.

9. Sridharan GV, Tallis RC, Leatherbarrow B, Forman WM. A community survey of ptosis of the eyelid and pupil size of elderly people. Age Ageing. 1995 Jan;24(1):21-24.

10. Hashemi H, Khabazkhoob M, Emamian MH, Yekta A, Jafari A, Nabovati P, Fotouhi A. The prevalence of ptosis in an Iranian adult population. J Curr Ophthalmol. 2016 Jun 11;28(3):142- 145.

11. Kim MH, Cho J, Zhao D, Woo KI, Kim YD, Kim S, Yang SW. Prevalence and associated factors of blepharoptosis in Korean adult population: the Korea National Health and Nutrition Examination Survey 2008–2011. Eye (Lond). 2017 Jun;31(6):940-946.

12. Lim JM, Hou JH, Singa RM, Aakalu VK, Setabutr P. Relative incidence of blepharoptosis subtypes in an oculoplastics practice at a tertiary care center. Orbit. 2013 Aug;32(4):231-234.

13. Hwang K, Kim JH. The risk of blepharoptosis in contact lens wearers. J Craniofac Surg. 2015 Jul;26(5):e373-e374.

14. Kitazawa T. Hard contact lens wear and the risk of acquired blepharoptosis: a case-control study. Eplasty. 2013 Jun 19;13:e30.

15. Thean JHJ, McNab AA. Blepharoptosis in RGP and PMMA hard contact lens wearers. Clin Exp Optom. 2004 Jan;87(1):11- 14.

16. Bleyen I, Hiemstra CA, Devogelaere T, van den Bosch WA, Wubbels RJ, Paridaens DA. Not only hard contact lens wear but also soft contact lens wear may be associated with blepharoptosis. Can J Ophthalmol. 2011 Aug;46(4):333-336.

17. Satariano N, Brown MS, Zwiebel S, Guyruon. Environmental factors that contribute to upper eyelid ptosis: a study of identical twins. Aesthet Surg J. 2015 Mar;35(3):235-241.

18. Godfrey KJ, Korn BS, Kikkawa DO. Blepharoptosis following ocular surgery: identifying risk factors. Curr Opin Ophthalmol. 2016 Jan;27(1):31-37.

19. Wang Y, Lou L, Liu Z, Ye J. Incidence and risk of ptosis following ocular surgery: a systematic review and meta-analysis. Graefes Arch Clin Exp Ophthalmol. 2019 Feb;257(2):397-404.

20. Finsterer J. Ptosis: causes, presentation, and management. Aesthetic Plast Surg. 2003 May-Jun;27(3):193-204.

21. Latting MW, Huggins AB, Marx DP, Giacometti JN. Clinical evaluation of blepharoptosis: distinguishing age-related ptosis from masquerade conditions. Semin Plast Surg. 2017 Feb;31(1):5-16.

22. Reinhard E, Spampinato H. The OD’s guide to ptosis workup. Rev. Optom. 2020;April 15. Available at: https://www. reviewofoptometry.com/article/the-ods-guide-to-ptosisworkup. Accessed 10/29/20.

23. Pauly M, Sruthi R. Ptosis: evaluation and management. Kerala J Ophthalmol. 2019;31(1):11-16.

24. Fasanella RM, Servat J. Levator resection for minimal ptosis: another simplified operation. Arch Ophthalmol. 1961 Apr;65:493-496.

25. Putterman AM, Fett DR. Müller’s muscle in the treatment of upper eyelid ptosis: a ten-year study. Ophthalmic Surg. 1986 Jun;17(6):354-360.

26. Putterman AM, Urist MJ. Müller muscle-conjunctiva resection. Technique for treatment of blepharoptosis. Arch Ophthalmol. 1975 Aug;93(8):619-623.