Clinical Evaluation of Blepharoptosis: Distinguishing Age-Related Ptosis from Masquerade Conditions

Abstract

Aponeurotic ptosis accounts for the majority of acquired ptosis encountered in clinical practice. Other types of ptosis include traumatic, mechanical, neurogenic, and myogenic. In addition to true ptosis, some patients present with pseudoptosis caused by globe dystopia, globe asymmetry, ocular misalignment, or retraction of the contralateral lid. It is particularly important for the clinician to rule out neurologic causes of ptosis such as dysfunction of the third cranial nerve, Horner's syndrome, and myasthenia gravis, as these conditions can be associated with significant systemic morbidity and mortality. A thorough history and physical examination is necessary to evaluate each patient presenting with a complaint of ptosis. Correctly identifying the cause of the patient's complaint allows the ptosis surgeon to plan for appropriate surgical repair when indicated and to defer surgery when observation or additional clinical evaluation is warranted.

A review of acquired blepharoptosis: prevalence, diagnosis, and current treatment options

“…This insertion is absent or poorly formed in some Asian individuals. The levator is innervated by the superior division of the oculomotor nerve (cranial nerve III), and its contraction provides the majority (~80%) of upper eyelid elevation [ 5 , 14 – 16 ]. Müller’s muscle arises from the underside of the levator, at the level of the distal aponeurosis, and inserts onto the superior tarsal plate [ 5 , 14 , 15 ].…”

“…The smooth Müller’s muscle arises from the underside of the levator and inserts on the superior tarsal plate. It is innervated by sympathetic fibres from the superior cervical ganglion [ 5 , 14 – 16 ]. …”

“…Acquired ptosis, the predominant form of ptosis (Table 2 ), can be classified by aetiology, with cases typically defined as having an aponeurotic, myogenic, neurogenic, mechanical, or traumatic origin. Aponeurotic ptosis, the most common acquired form of the condition [ 24 ], is caused by stretching, dehiscence, or detachment of the levator aponeurosis from its insertion on the tarsus, and is typically associated with aging [ 5 , 16 , 24 ]. Myogenic ptosis is caused by primary or secondary myopathy of the levator muscle, due for example to chronic progressive external ophthalmoplegia (CPEO), oculopharyngeal muscular dystrophy (OPMD), or myotonic dystrophy [ 5 , 16 , 22 ].…”

Isolated left upper eyelid ptosis with pansinusitis and contralateral otitis media in a 9-year-old boy

“…Acquired upper eyelid ptosis can have many different etiologies, including traumatic, mechanical, neurogenic, and myogenic. 1 The most common cause of ptosis in the older population is aponeurotic due to levator dehiscence. 1 In the pediatric population, common causes include congenital ptosis, Cranial Nerve (CN) III palsy, Horner's syndrome, and mechanical ptosis due to a space-occupying lesion or orbital cellulitis.…”

“… 1 The most common cause of ptosis in the older population is aponeurotic due to levator dehiscence. 1 In the pediatric population, common causes include congenital ptosis, Cranial Nerve (CN) III palsy, Horner's syndrome, and mechanical ptosis due to a space-occupying lesion or orbital cellulitis. It is exceedingly rare for orbital cellulitis to cause isolated upper lid ptosis without any other associated neuro-ophthalmological findings or orbital signs such as chemosis, limited motility, proptosis, or afferent pupillary defect.…”