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REPORT FOR HEALTH CARE PROFESSIONALS DELIVERING EYE CARE

PTOSIS IN CHILDREN AND ADULTS

Ptosis (pronounced "toe-sis") refers to a drooping of the upper eyelid. The lid may droop only slightly or it may droop enough to partially or completely cover the pupil, restricting or obscuring vision.

Ptosis may be inherited. It can affect one or both eyelids, be present at birth or occur later in life. Ptosis which is present at birth is called Congenital Ptosis. If the ptosis develops with age it is referred to as Aquired Ptosis.

What causes Congenital ptosis?

Congenital ptosis is most often due to an under-development of the eyelid lifting muscle - "the levator". Although usually occuring as an isolated problem, children born with ptosis may also have eye movement abnormalities, muscular diseases, lid tumors or neurological disorders. Congenital ptosis does not improve with time unless it was caused traumatically at the time of birth.

What are the Signs and Symptoms of Congenital Ptosis?

Children with ptosis will often tilt their heads back into a chin-up posture to see underneath their lids, or raise their eyebrows in an effort to raise their lids. When the lid droop is bilateral and severe, the child may be bumping into things and have a delayed development as a result of the drooping lids causing some visual restriction.

What Problems can occur as a result of childhood Ptosis?

If the lid covers a part of the visual axis, the child's visual development can be affected which could lead to amblyopia. Amblyopia is poor vision in an eye that failed to develop normal sight in the early years of life. This may occur in a child with ptosis if the lid is drooping severely enough to block vision or cause astigmatism. Ptosis can also hide a misalignment or crossing of the eyes which can also cause amblyopia. If not treated early in childhood the child’s vision will be permanently reduced as a result.

How is it treated?

The treatment for congenital ptosis is surgical in the overwhelming majority of patients. In determining whether surgery is advisable, an ophthalmologist specialized in treating droopy eyelids considers the individual’s age, the severity of the ptosis and whether one or both eyelids are involved. Measurement of the lid height, evaluation of the eyelids lifting and closing muscle strength and observation of the eye movements determine which surgical procedure is more appropriate.

The most common procedure involves advancing the under-developed levator muscle while the child is under general anesthesia. If the levator muscle has little or no function, the lid has to be attached or suspended to the brow so that the forehead muscle does the lifting (Brow Suspension).

Adult Ptosis


The most common type of adult onset ptosis is due to a weaking of the attachments between the levator muscle and the lid. This may occur as a result of the aging process, after cataract surgery or from an injury. Adult ptosis may also occur as a complication of other diseases involving the levator muscle or its nerve supply such as diabetes or myasthenia, or it may occur when movement of the levator muscle is restricted as may happen in the case of an eyelid tumor.

What are the Signs and Symptoms of Adult Ptosis?

The most obvious sign is a droopy upper lid. The patient may complain of peripheral visual loss or fatigue from attempting to elevate the droopy lid. Reading may be difficult as the ptotic lid tends to block the visual axis when the eye is looking down. Adults with ptosis will often tip their heads back to see past their eyelids or raise their eyebrows in an effort to raise their lids. If the ptosis is severe they may bump into things at a forehead level (cupboard doors).  

How is Adult Ptosis Treated?

Treatment when necessary is usually surgical and is done as an outpatient under local anesthesia. It is important to do the surgery under local anesthesia when the patient is old enough to co-operate (usually over the age of 12). This gives the surgeon a better idea of how much to raise the eyelids. Postoperatively there is usually some mild lid swelling which settles over the first 2 weeks or so. The patients are generally quite relieved to have the visual obstruction removed.

What are the Risks of ptosis surgery?

Bleeding and infection are possible but extremely rare. Patients on Aspirin and anti-arthritic medication may be asked to stop these for a few days prior and post surgery to reduce the chance of bleeding and bruising.

Under or over correction can occasionally occur and if obvious, a suture adjustment may be required in the first to two weeks.

A temporary inability to fully close the eye after ptosis surgery is not uncommon and resolves in most over a few weeks. The eyelids do not remain "stuck open". During this time period when the lids are not fully closing it is important to use lubricating drops and ointment to keep the cornea moist.

Summary

Ptosis in children and adults can be successfully treated with surgery to improve visual function as well as improve cosmetic appearance.
The drooping lid can affect visual development in an infant and if the lid is encroaching in the visual axis, an ophthalmic assessment is important to avoid the development of amblyopia.

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Patients should discuss all medical information with their personal physician. | E-mail any corrections to drjordan@magma.ca