chirurgia i laseroterapia surgery and lasertherapy

artykuł przeglądowy review article

DOI: 10.24292/01.OT.310322.5

Ptosis – diagnostics and treatment

Mateusz Jacuński, Dominika Białas, Radosław Różycki

Military Institute of Aviation Medicine, Warsaw
Head of Clinic: Radosław Różycki, MD, PhD

Highlights
The low position of the upper
eyelid affects a lots of patients.
Effective ptosis correction,
which enables the improvement
of the appearance of the eyes
and visual acuity, is a complex
Abstract
process. The most important
parts of this process are thorough It is estimated that the low position of the upper eyelid affects over 1 million
diagnostics and selection of the patients in Poland. Ptosis limits the visual field, causes compensatory head po-
right treatment method. sitions and the feeling of visual deterioration. The unaesthetic appearance of
the eyes additionally contributes to low self-esteem. The aim of this article is
to review modern diagnostic algorithms used in the case of a dropped eyelid.
The paper also discusses the surgical techniques that are used in the case of
ptosis and the guidelines for the correct qualification of the patient to a given
surgical method.

Key words: ptosis, surgical techniques, müllerectomy, levator advancement,

frontalis sling eyelid suspension

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 Ptosis – diagnostics and treatment
M. Jacuński, D. Białas, R. Różycki

Introduction Drooping of the upper eyelids should not be confused with

Ptosis (from the Greek ptosis – I fall) is a term that refers dermatochalasis of the upper eyelids, which in most cases
to an incorrectly low position of the eyelid edge. In case of is only an aesthetic problem.
the upper eyelid, the main criterion of clinical diagnosis of
ptosis is the lowering of the free edge by 1–2 mm in relation
to the upper edge of the corneal limbus in the original gaze Ptosis diagnostics
direction (straight ahead). Drooping eyelids are one of the The examination of a patient with ptosis consists of a thor-
most common disorders in ophthalmic practice, but data ough ophthalmological and general medical history, physi-
from large-population studies are limited. Estimates of the cal examination with measurements of the protective appa-
incidence of ptosis depending on the region vary between ratus of the eye and additional diagnostic tests.
4.7% and 13.5% in the adult population and confirm the The examination begins as soon as the patient enters the
universal nature of the disease. Women suffer more often office. The ophthalmologist should pay attention to the po-
(13.2% compared to 9.0% of men) [1, 2]. In the UK, ptosis af- sition of the patient’s head. The chin is raised to compen-
fects 11.5% of the adult population over the age of 50. With sate for the upper visual field defect. As a result, patients
age, the frequency of this disease increases – in individual often complain of pain in the cervical spine. Also, the po-
age groups and amounts to, respectively: 50–59 years: 2.4%, sition of the eyebrows and the number of forehead wrin-
60–69 years: 8.9%, 70–79 years: 12.5%, and in the group of kles can be a clue in the diagnostic process. Drooping of
≥ 80 years: 42.9% [1]. Ptosis is not only a cosmetic defect, the upper eyelids is accompanied by hyperfunction of the
but mainly a functional one, limiting the visual field in the frontal muscle, which patients try to correct the position
upper part. Due to the reduced amount of light entering of the drooping eyelids. Patients with ptosis may report
the eye, it reduces visual acuity, especially at night. Patients a feeling of heaviness in the eyelids, a “tired” appearance
with ptosis report difficulty reading as the drooping eyelid of the face, headaches associated with an overactive fron-
worsens when looking down. There are neck pains resulting tal muscle, but most of all a limitation of the visual field in
from the compensatory head positioning. The lowering of the upper quadrants, which makes it difficult to read, drive
the edge of the upper eyelids also has social consequences. a car, reach for objects and many other daily activities. In
It has been shown that people with ptosis are perceived as the ophthalmological history, it is important to ask about
less attractive, sad, depressive [1], which often leads to anx- the dynamics of ptosis progression and the occurrence of
iety and alienation. In children, untreated ptosis can lead its daily fluctuations. The ptosis that worsens in the evening
to amblyopia as well as have adverse psychological effects. may indicate myasthenia gravis, especially if there is addi-
Ptosis can be congenital (diagnosed up to the first year of tionally diplopia. Sudden ptosis may suggest the presence
life) or acquired (manifesting itself after the first year of life). of posterior communicating artery aneurysm [3]. The pa-
Among acquired ptosis, the isolated form is distinguished – tient should be asked about the history of ophthalmologic
not related to systemic diseases, and the non-isolated form, procedures, injuries, use of contact lenses, habitual rubbing
which is at least one of the symptoms of systemic diseases. of the eyes, smoking, medications used (these are risk fac-
The most common type of isolated ptosis is involutional tors for ptosis), but also to deepen the internal medical his-
ptosis resulting from disturbed activity or position of the tory by asking about metabolic diseases such as diabetes or
levator aponeurosis. We divide the acquired non-isolated thyroid diseases.
ptosis into: During the ophthalmic physical examination visual acu-
• neurogenic (resulting from paralysis of the oculomotor ity, pupillary responses to light (attention to Horner’s
nerve, Horner’s syndrome or, less frequently, defects of syndrome, 3rd paralysis), and globe mobility (disturbed in
the central nervous system) chronic progressive external ophthalmoplegia, myasthenia
• neuromuscular (included in the autoimmune diseases gravis, III nerve paralysis) is assessed. The eyelids and bone
such as myasthenia gravis) margins of orbita should be palpated. It is important to as-
• neurotoxic (caused by paralysis of neuromuscular con- sess the protective mechanisms of the eyeball – Bell’s reflex,
nections, e.g. after bites by snakes, arachnids, or after the condition of the surface of the eyeball and the sensation
incorrect administration of botulinum toxin) of the cornea – needed after the repair of ptosis. If these
• myopathic disease (caused by a disorder of the levator mechanisms fail, the risk of exposure keratopathy increas-
eyelid muscle) es significantly. In doubtful situations, such as exophthal-
• mechanical (in the course of local growth within the mia or enophthalmia, a Hertel exophthalmometer should
eyelid, such as chalazion, tumors, cysts or neurofibro- be used, excluding pseudoptosis. Other causes of apparent
mas, making the eyelid too heavy for the levator muscle) ptosis are retraction of the eyelid on the other side, hypo-
• traumatic (resulting from direct injury to the eyelid trophy, and ptosis. It should also be mentioned the excess
muscles). skin of the eyelids (dermatochalasis), which apparently re-

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 Ptosis – diagnostics and treatment
M. Jacuński, D. Białas, R. Różycki

sembles ptosis and is not the same medical indication for • The function of the levator palpebrae superioris muscle
the procedure [3]. – it is measured when the frontal muscle is eliminat-
Important measures in the evaluation of ptosis include: ed (by pressing it with the thumb) (fig. 3). The range of
• MRD1 (margin reflex distance 1) – the distance of the movement of the upper eyelid is assessed by measur-
upper eyelid edge from the corneal reflex measured in ing with a ruler the distance that the edge of the eye-
the primary position straight ahead, the correct value is lid travels from the maximum looking down position
4–5 mm. The relationship between MRD1 and the se- to the maximum looking up position. The correct value
verity of ptosis is presented in figure 1. of the levator muscle activity is > 12 mm. According to
• MRD2 (margin reflex distance 2) – the distance of the Berk’s classification: very good when the levator func-
lower eyelid edge from the corneal reflex measured in tion is ≥ 13 mm, good when 8–12 mm, medium when
the primary position straight ahead, the correct value is 5–7 mm, poor when < 4 mm [2].
5–5.5 mm. Figure 2 shows how MRD1 and MRD2 are • MCD (margin crease distance) – the vertical distance
assessed. of the upper eyelid crease from the upper eyelid edge
measured looking downwards in the center of the eye-

FIGURE 1
The relationship between the MRD1 value and the severity of ptosis (own drawing).

Normal condition – 4 – 5 mm

Mild degree – 2 mm

Moderate degree – 3 mm

Severe degree ≥ 4 mm

FIGURE 2 FIGURE 3
Assessment of MRD1 and MRD1 (own material). Assessment of the activity of the levator palpebrae superioris
muscle.

• Palpebral fissure height – is the vertical distance in the

pupil axis between the edge of the upper and lower eye-
lids. The sum of MRD1 and MRD2 gives the value of the
palpebral fissure.

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 Ptosis – diagnostics and treatment
M. Jacuński, D. Białas, R. Różycki

lid. Normal values are 9–10 mm in women and 7–8 mm duction in ptosis observed immediately after ice remov-
in men. It should be noted that the absence of a crease al supports the diagnosis of myasthenia gravis. The test
indicates a congenital etiology of ptosis. Increased is characterized by a sensitivity of 77–89% and a high
MCD may indicate damage to the levator tendon [4–6]. specificity of approx. 98–100% [7, 8].
• Tensilon test – is performed when myasthenia gravis is
The tests used in the diagnosis of ptosis are: suspected. It consists in a slow (approx. 30 s) intrave-
• Phenylephrine test – it is based on MRD1 assessment nous administration of 2 mg of edrophonium (a revers-
before administration and 5 minutes after administra- ible acetylcholinesterase inhibitor). A 1 minute later,
tion of 10% phenylephrine (some authors use 2.5%). another 8 mg is administered. If the edges of the eyelids
Phenylephrine as an adrenergic factor stimulates α re- rise, then myasthenia gravis is diagnosed [6].
ceptors in the sympathetically innervated Müller mus-
cle. The test is considered positive if the eyelid margin
rises to a clinically significant extent, or otherwise if the Treatment
MRD1 increases by 2–3 mm. In this case, it is recom- Treatment of ptosis depends on the etiology of the disease.
mended to perform a Müller muscle transconjunctival Effective therapy includes the correct diagnosis of the caus-
resection (müllerectomy). If the test result is negative, es of the disorder and the planning of an appropriate sur-
it is recommended to perform a repair surgery on the gical method for a given patient. The severity and type of
levator aponeurosis. However, there are exceptions to eyelid droop, as well as the degree of preservation of the
this rule - recent reports indicate the possibility of mod- levator eyelid muscle function, are the main factors influ-
ifying a classic müllerectomy (e.g. in combination with encing the choice of the operating procedure.
a tarsectomy, according to nomograms other than that Depending on its severity, ptosis is divided into: minimal
proposed by Dresner). (1–2 mm), moderate (3–4 mm) and severe (> 4 mm) (fig. 4).
• Fatigue test – consists in measuring MRD1 in the orig- Due to the existence of three upper eyelid retractors (le-
inal position, then the patient looks maximally up for vator palpebrae superioris muscle, the Müller muscle, the
two minutes, trying to blink as rarely as possible. After frontal muscle) and depending on the severity of ptosis, the
this time, MRD1 is re-measured. A decrease in MRD1 surgical methods of correction of ptosis are generally divid-
value on one or both sides indicates myasthenia gravis, ed into three categories:
but also acquired aponeurotic ptosis. • external/percutaneous repair of the levator palpebrae
• Ice test – a glove filled with ice (or other clean cold superioris muscle complex
object) is placed over the closed eyelid with ptosis for • internal/transconjunctival repair of the levator palpe-
2 minutes. Low temperature reduces the activity of ace- brae superioris muscle complex/Müller muscle/Müller
tylcholinesterase, thereby increasing the concentration muscle and the tarsus
of acetylcholine in the neuromuscular junction. The re- • eyelid suspension on the frontal muscle.

FIGURE 4
Decision diagram for the surgical treatment of upper eyelid ptosis.

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M. Jacuński, D. Białas, R. Różycki

There is controversy about their relative indications, advan- related to with age, chronic use of contact lenses or epi-
tages and disadvantages, and the occurrense of new surgi- prostheses), Horner’s syndrome, survived ptosis after ante-
cal techniques and modifications has further complicated rior approach surgery, congenital ptosis with good levator
the traditional algorithms that lead the surgeon to select muscle function. In patients with mild (0.5–1.5 mm) and
a method. In patients with good levator function, surgi- moderate (2–3 mm) ptosis, with good function of the le-
cal repair can be performed from both the posterior and vator eyelid muscle (> 10 mm), müllerectomy is the proce-
anterior surgical approaches. Patients who want to obtain dure of choice [12]. However, classical müllerectomy is not
a more aesthetic and younger appearance (cosmetic indi- recommended in the case of: myogenic ptosis, ptosis with
cations) as well as patients who require improved comfort a negative phenylephrine test (although there are excep-
of functioning – widening visual field (medical indications) tions), ptosis with poor levator muscle function (< 10 mm)
are eligible for ptosis correction. and ptosis with sudden appearance [13].
Surgical correction of ptosis has been performed for centu- The most popular algorithm determining the scope of
ries, with reports dating back to ancient Arabia and ancient Müller muscle resection is a semi-linear nomogram devel-
Rome. Since then, hundreds of surgical techniques and oped in 1991 by Dresner, which makes the scope of resec-
their modifications have been described. The most signif- tion dependent on the degree of eyelid droop and the de-
icant changes in eyelid ptosis repair techniques come from gree of eyelid lift (in mm) in response to 10% phenylephrine
a better understanding of eyelid anatomy and physiology. administered to the conjunctival sac (some authors use it at
The key moment was the 1970s, when the proponents of a concentration of 2.5% or alternatively 0.5% apraclonidine)
anterior access techniques (such as Jones, Anderson and [8]. If the free edge of the upper eyelid rises by ≥ 2 mm after
Dixon) gained the advantage [9, 10]. It was the so-called 5 minutes, the test is considered positive (phenylephrine
“The Age of Aponeurotic Awareness”, in which the repair is an agonist of the α-adrenergic receptor, and the Müller
of the levator aponeurosis “from the outside” was recom- muscle is sympathetic). According to Dresner’s algorithm,
mended to the majority of patients with ptosis while main- for the 1 mm eyelid edge lift, 4 mm of the Müller muscle
taining the levator muscle function [11]. In recent years, and the conjunctiva are excised. In order to obtain the de-
posterior approach techniques have experienced a renais- sired eyelid elevation by 1.5 mm, 2 mm and 3 mm, 6 mm,
sance, such as müllerectomy, and they are characterized 8 mm and 10 mm of the Müller muscle and the conjunc-
by shorter procedure times, shorter convalescence, no scar tiva should be cut analogously [13] (tab. 1). It is not rec-
visibility, better predictability of the effects and a lower de- ommended to correct ptosis larger than 3 mm with this
gree of difficulty in performing the procedure compared to method.
levator muscle procedures [12, 13]. In the external – percutaneous repair of the levator muscle
The approach to surgical techniques of ptosis from a poste- complex of the upper eyelid, plastic surgery of the aponeu-
rior approach has evolved over the past 60 years. The oldest rosis and the so-called “Whitnall loop” (with modifica-
technique, which was the starting point for later ones, was tions). The use of these methods is recommended in pa-
described by Fasanella and Servat in 1961 [14] and involved tients with levator muscle function > 4 mm, with a minimal
the use of two pairs of curved forceps to secure the upper and moderate degree of advancement of ptosis. In patients
3 mm of the tarsus and 3 mm of the conjunctiva and the with ptosis of 3–4 mm, it is the method of choice, also when
Müller muscle on the inverted upper eyelid [3]. In 1966, müllerectomy is not indicated, eg when the phenylephrine
Beard popularized this method by adding to it the use of test is negative. The individual stages of the levator aponeu-
a zigzag catgut suture with an outward knot [15]. Another rosis repair surgery are as follows: linear incision in the area
modification of the method was carried out by Putterman
in 1972. The Putterman brace, also called clamp, in addi-
tion to ensuring haemostasis, improves the post-operative
TABLE 1
shape of the tarsus [16]. In 1973, Crawford introduced the
Desmarres lid retractor in order to better visualize the le- Nomogram for transconjunctival Müller’s muscle – conjunctiva
vator eyelid complex and the Müller muscle [17]. In 1975, resection according to Dresner [13].
Putterman and Urist proposed a prototype of the now Desired amount of eyelid
Scope of the müllerectomy
well-known classic Müller muscle-conjunctival resection lift (mm)
(MMCR) [18]. It should be noted, however, that improve- 1.0 mm 4.0 mm
ments to this surgical method, such as the use of tension
1.5 mm 6.0 mm
sutures, other suturing techniques, and the development of
nomograms, took place in the following years. Over time, 2.0 mm 8.0 mm
the indications for müllerectomy have also been extended.
3.0 mm 10 mm
Currently, these are: acquired involutional ptosis (changes

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 Ptosis – diagnostics and treatment
M. Jacuński, D. Białas, R. Różycki

of the eyelid sulcus, dissection and opening of the orbital FIGURE 5

septum, removal of the preseptal fat in order to visualize
the levator muscle aponeurosis, cutting the aponeurosis On the left, Wright’s fascia needle with a threaded silicone
from the tarsus and separation from the Müller’s mus- strap. On the right, a silicone strip arranged in a pentagonal
cle, suturing the aponeurosis (or a reduction of its certain shape, reflecting its position after the operation of
height depending on the degree of ptosis). After the eyelid suspending the upper eyelid on the frontal muscle (source:
is positioned at the desired height, which is performed after own materials).
the patient is seated on the operating table, the sutures are
tied. The procedure ends with suturing the skin wound with
the formation of an eyelid crease [6].
The Whitnall Loop is a procedure for maximum forward
advancement of the levator tendon in which the aponeuro-
sis is cut to the height of the Whitnall ligament and the tar-
sus is sutured directly to the ligament. One of the main indi-
cations of this procedure is congenital ptosis with a levator
function of 4–5 mm. The limitations of the above methods
are too low or too high eyelid positioning, exposure kera-
topathy, irregular eyelid margin, and asymmetry in the po-
sition of the eyelid crease [6]. Compared to müllerectomy,
anterior approach methods are more difficult to perform,
more time-consuming, may leave not aesthetic scar, and
the recovery period takes longer [12].
The frontal muscle suspension is used in patients with poor
levator muscle function (< 4 mm) and good frontal muscle
function. The indication for the use of this method is con-
genital, neurogenic and myopathic ptosis, including mito-
chondrial diseases. The method involves the use of strips
of fascia (e.g. wide thigh or temporal), silicone, gore-tex (or ptosis, while non-surgical approaches are extremely limit-
other non-autogenous materials) and inserting them with ed in both number and efficiency. Since surgical treatment
a needle or guide into the pre-septal space of the eyelid, is limited and effective only in some patients, finding ways
and then through the eyebrows to the end point on the to introduce novel non-surgical therapeutic options into
frontal muscle. Two incisions are made in the upper eye- practice makes it possible to treat a much wider group of
lid and eyebrow, and one in the area of the frontal muscle patients. Evidence of a newly approved pharmacological
(the place where the stripes are bonded), thanks to which agent for the treatment of acquired eyelid ptosis – 0.1%
the strips hanging the eyelid form a characteristic pentagon oxymetazoline hydrochloride is encouraging and provide
(fox pentagon, see fig. 5). The limitations of the method are the opportunity to offer patients effective non-surgical
the risk of infection, erosion of non-autogenous materials, treatment. For ophthalmologists, the availability of an ap-
granuloma, lagophthalmos [6]. proved pharmacological option can help them move from
a detection-and-referral approach to a diagnosis-and-treat-
ment approach, with referral to surgery when appropriate.
Conclusion Moreover, expanding treatment options may improve the
The frequency of occurrence and the wide clinical and patient’s focus on treatment by allowing both surgical and
functional consequences of acquired ptosis make early and nonsurgical approaches, depending on the underlying
accurate diagnosis and appropriate treatment extremely cause of ptosis, its severity, and the patient’s preferences.
important issues in the daily practice of ophthalmologists. While advances in the treatment of ptosis are encouraging,
Acquired ptosis is most often caused by age-related chang- they remain only part of the clinical equation. In order to
es in the upper eyelid retractor muscles, however, causes successfully treat ptosis, prompt and correct diagnosis is
vary and many practices and interventions common in essential.
ophthalmology today, such as wearing contact lenses and In particular, a comprehensive clinical examination and
cataract and glaucoma treatments, may also be the cause. differential diagnosis is critical to understanding whether
Along with the other etiologies discussed in this article, drooping eyelid is due to a primary pathology of the eyelid
they all require full investigation and evaluation of treat- retractor muscles – and therefore can be effectively treated
ment options. Surgery is an effective treatment option for with surgical or pharmacological measures targeting the

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 Ptosis – diagnostics and treatment
M. Jacuński, D. Białas, R. Różycki

upper eyelid, or whether an underlying cause at the root be relatively easily included in a comprehensive eye exam-
of the disease is, for example, a serious underlying neuro- ination. With a focus on awareness and diagnosis, clinical
logical disease that requires other, often urgent, interven- evidence-based targeted surgical or nonsurgical treatment
tion. While in many cases ptosis can only be assessed and offers hope to improve ptosis treatment for more patients.
treated when its onset is sudden or severe, upper eyelid ex-
amination for mild to moderate or progressive cases can Figures: from the author’s own materials.

Correspondence
Mateusz Jacuński , MD
Ophthalmology Clinic, Military Institute of Aviation Medicine
01-755 Warszawa, ul. Krasińskiego 54/56 ORCID
e-mail: [email protected] Mateusz Jacuński – ID – http://orcid.org/0000-0002-5554-6161

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M. Jacuński, D. Białas, R. Różycki

Authors’ contributions:
Mateusz Jacuński: 50%; Dominika Białas: 30%; Radosław Różycki: 20%.
Conflict of interest:
None.
Financial support:
None.
Ethics:
The content presented in the article complies with the principles of the Helsinki
Declaration, EU directives and harmonized requirements for biomedical journals.

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