Eyelid ptosis

Colin W. McInnes; Matthew Lee-Wing

doi:10.1503/cmaj.140579

Eyelid ptosis can obscure vision and impair activities of daily living

Eyelid ptosis (descent of the eyelid margin) is common (Figure 1; video available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.140579/-/DC1).1 The condition can obstruct vision and interfere with daily activities, such as driving and reading.1 Associated complaints include fatigue of the muscles in the forehead from continuous eyebrow elevation in an effort to raise the eyelids, neck soreness from tilting the head back to see, and appearing sad or tired.

Figure 1:

Eyelid ptosis in a 12-year-old boy.

Many conditions can cause ptosis

Ptosis is most commonly the result of age-related stretching and dehiscence of the levator aponeurosis (60%). Other causes may be neurogenic (e.g., third-nerve palsy, myasthenia gravis, Horner syndrome; 6%), traumatic (11%), congenital (10%), mechanical (e.g., eyelid tumours; 9%) or myogenic (4%).2 Pseudoptosis can be caused by dermatochalasis (excess eyelid skin that may hang over the margin). The underlying cause will affect the type and urgency of referral.

Physical examination is usually sufficient to determine the diagnosis

The examination includes assessing the patient’s visual acuity, extraocular movements and pupillary light reflex, marginal reflex distance (distance from the corneal light reflex to the upper eyelid margin, about 4–5 mm), upper eyelid crease (often absent in congenital and age-related ptosis, and in people of Asian descent), palpebral fissure distance (about 9 mm), and eyelid excursion (about 15 mm; may be 0 mm in congenital cases).3

Surgical treatment is highly effective

Ptosis is typically corrected by outpatient surgery performed under local anesthetic, in which the position of the eyelid is adjusted and scars are hidden. Postoperative satisfaction is high, and many patients experience substantial improvement in functional status and appearance.4

Some treatments are covered by public health insurance in Canada

Treatments for cases in which aging has resulted in a substantial defect in the visual field (e.g., moderate to severe ptosis or dermatochalasis) or is caused by non–aging-related conditions are typically covered. Eligibility criteria vary by province, but formal visual field testing by an optometrist is usually required.

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See the following video online: Physical examination of eyelid ptosis. www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.140579/-/DC1

Footnotes

Competing interests: None declared.
This article has been peer reviewed.
The authors have obtained patient consent.

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