Taking a closer look at acquired blepharoptosis

What do people see when they look at you? What is the first thing they notice? If you said the eyes, you’re correct! Didn’t we choose the right profession?! What is it, though, that makes the eyes look good, different, or natural? How do you know what is ideal? The golden ratio is 1:1.618 and is found everywhere in nature, including our faces.

As an OD, how much do you pay attention to the periocular area? Do you study the patient when greeting them? Do you notice head tilts and head positions? Do you look at what is happening with the eyelids?

What story are the eyelids telling you about the patient? Do they say, “I’m well rested and lead a balanced life,” or do they say, “I’m tired and worn out?” Are they telling an accurate story? Maybe they say, “I’m sad and droopy,” when nothing could be further from the truth. Are they begging for someone to have a well-timed conversation about them?

ODs have such a unique opportunity to assess patients and their eyelids. I encourage you to take a moment and study the characteristics of each patient’s eyelids before diving behind the slit lamp.

Speaking of—when you get behind the slit lamp, do you pause and have the patient close their eyes to admire that beautiful structure that keeps the front of the eye healthy and seeing well? Yes, we are still talking about the eyelids. Or do you blow right past it in your haste to assess the cornea, lens, iris, and retina and optic nerve?

Completely bypassing one of the most integral structures that maintain homeostasis of the ocular surface. Acquired blepharoptosis is the condition named for droopy lids. Ptosis can affect not only visual quality and function but also quality of life. Patients don’t usually come in complaining about their eyelids. Typically, it’s a slow progression of change, and they may not know of the solutions we have to help them.

As for quality of life, there is the sometimes obvious psychological impact that can cause undue anxiety, depression, and overall concerns about appearance. There are also the less obvious negative quality of life experiences, such as physical discomfort, eye strain, and struggle to perform day-today activities.

“Doc, my eyes are just so tired,” is a common complaint I hear in my clinic. Or the proverbial, “I have trouble seeing at night.” As practitioners going through our differentials for these patients’, cataracts tend to be at the top. However, ptosis should also be at the top of that list.

There are several possible etiologies that can cause ptosis, such as aging, contact lens wear, ocular surgery (using a speculum), periocular neurotoxin that migrates to undesired locations, and trauma. Underlying diseases can also be the culprit. If a patient presents with a new onset ptosis, be sure to look for pupil involvement.

Horner syndrome, third nerve palsy, myasthenia gravis, thyroid eye disease, and chronic progressive external ophthalmoplegia could be sight or life threating and need to be treated as an ocular emergency. Given ptosis’ prevalence,^1-4 I have found it is great to screen every patient who makes an appointment in my clinic. We utilize a patient questionnaire that contains the question: Would you like your eyes to be more open? If the patient selects yes, this allows us to easily segue into options. I have created standing orders for my technicians that empowers them to first offer a new therapy (Upneeq; RVL Pharmaceuticals) indicated for adults who have acquired blepharoptosis. The drop contains oxymetazoline hydrochloride ophthalmic solution 0.1%, which is a direct-acting α-adrenergic receptor agonist. Mueller muscle contains these target receptors; contraction of this muscle occurs raising the eyelid.

If there are no health issues, my technician takes a picture of the patient with our iPad, then doses the worst eye with oxymetazoline hydrochloride ophthalmic solution 0.1%. The technician finishes pretesting, and by the time I enter the exam room—between 5 and 15 minutes— the drop has had time to take effect.

The technician then takes another photo and I review the results with the patient. We have found this to be an effective use of time to identify qualified patients, achieve results, and get patients excited about eyelid discussions.

When the patient has a result they love, we dose the other eye and write a prescription for the medication. The results can be quite dramatic. In the related studies, the average lift was 1 mm, but can be as much as 3.5 mm.

We also offer radiofrequency to patients. The TempSure by Cynosure is indicated for periorbital rhytids and works by building collagen, therefore tightening skin. This treatment is performed in a series. For most patients,

I perform the treatments in a series of 4 that are 4 weeks apart, spread over 4 months. This is a noninvasive treatment with no downtime that heats the dermal layer of the skin, causing targeted injury that results in the formation of collagen and elastin. When skin is tightened, the resulting effects may include a raised forehead and upper eyelids by as much as a few mm.

Some patients are also surgical candidates and can have comorbidities, such as dermatochalasis and brow ptosis.

With those patients, we discuss an upper eyelid blepharoplasty and browpexy with them and make an appropriate consult if the patient desires to do so. New technology is part of our practice culture and our patients reap the benefits. We want to offer solutions to patients that are customized to them.

Many people have ptosis and are not ready for surgery or may not be good surgical candidates. Such patients appreciate the noninvasive option of oxymetazoline hydrochloride ophthalmic solution 0.1% and are grateful we are able to provide a solution for them. Remember when it comes to blepharoptosis, don’t be shy:

» Ask the patient about their lids.

» Look at the patients’ eyelids.

» Ask the question “Would you like your eyes to be more open?” If they answer no and you notice a potential issue, then ask more questions, such as the following:

• Have you noticed your eyelids feeling heavy?

• Do you feel tired at night/end of the day?

• Do you see better if you lift your eyelids?

• Is there anything about your eyelids you would want to change?

Incorporating this knowledge into your clinic has been incredibly rewarding for both me and my patients. Don’t hesitate to talk about eyelids.

References

1. 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;24(1):21-24. doi:10.1093/ ageing/24.1.21

2. Hashemi H, Khabazkhoob M, Emamian MH, et al. The prevalence of ptosis in an Iranian adult population. J Curr Ophthalmol. 2016;28(3):142-145. doi:10.1016/j.joco.2016.04.005

3. Kim MH, Cho J, Zhao D, et al. Prevalence and associated factors of blepharoptosis in Korean adult population: The Korea National Health and Nutrition Examination Survey. Eye (Lond). 2017;31(6):940-946. doi:10.1038/eye.2017.43

4. United States Census Bureau. 2017 National Population Projections Tables: Main Series. Accessed September 1, 2020. https://www.census.gov/data/tables/2017/demo/popproj/2017- summary-tables.html