Ptosis

Synonyms in a broader sense

Drooping upper eyelid;
Greek: sinking, falling down

definition

Taken in isolation, ptosis is not a disease in itself, but a symptom that can have various causes. It can be recognized by the fact that the upper eyelid of one or both eyes, despite the patient's attempt to open the eyes wide, protrudes so far down that the upper iris and pupil are completely or partially covered.

Doctors differentiate between congenital and acquired ptosis.

General

Congenital ptosis congenita is inherited and is based on a genetic defect that restricts the function of the muscle that lifts the upper part of the body. This defect is usually limited to only one eye and means that the person concerned is limited in their spatial perception. This is because the drooping lid prevents seeing with both eyes (so-called binocular vision). If left untreated, the covered eye will become weaker and weaker over the years and permanent weak vision will develop (Amblyopia)that can progress to blindness. A prominent example of a one-sided, congenital ptosis is the entertainer Karl Dall.

Acquired ptoses are usually the result of accidents, age-related tissue weaknesses or other diseases that have affected the eyelid elevator muscle. The clinical picture is in principle analogous to congenital ptosis, but the drooping lid often occurs on both sides. Direct nerve lesions can also result in ptosis. This is the case with sympathetic ptosis. While this is only expressed by a slight lowering of the eyelid, the pupil is also restricted in its opening function. As a result, the eye seems to be a little deeper in the eye socket overall. The trigger is often a stroke or meningitis.

Various systemic muscle diseases (myasthenia gravis is an example) as well as intoxication with snake venom or dangerous chemicals can paralyze the muscles and attack the nerves.

The ptosis must be differentiated from the sham ptosis (Pseudoptosis) and the sunken eye (Enophthalmos). The sham ptosis can be the expression of decreasing connective tissue tension in the skin with age. The sunken eye describes that Sinking back of the eyeball into the eye socket due to a break in the floor of the eye socket.

Other causes of ptosis can be:

Also read: Drooping eyelid

frequency

Congenital ptosis is very rare and usually one-sided, but not further quantified in the literature. Forms of ptosis from other causes are based in their frequency on the disease causing them (ptosis)

Causes of Ptosis

There are many causes of ptosis.
They can be innate or have emerged in the course of life, which is known as acquired.
In the following, the congenital and acquired causes are presented.

Congenital causes of ptosis (ptosis congenita) can be caused either by the nervous system or by the muscles.
There may be a lack of structures in the core area of ​​the nerve that innervates the eyelid elevator muscle.
On the other hand, the eyelid lifter muscle itself can have a malformation that causes ptosis.

The acquired causes outweigh the innate ones.
Here it can happen that the nerve that supplies the eyelid elevator muscle is slightly paralyzed.
As a result, the muscle is not stimulated enough, which affects the lifting of the eyelid.
Age-related tissue changes can also occur, which can also weaken the eyelid lifter muscle.
Furthermore, there are also neuromuscular diseases, such as myasthenia gravis or myotonia, which can trigger the clinical picture of ptosis.
In myasthenia gravis, the switching point between muscle and nerve is disturbed.
Myotonia describe a delayed relaxation of the muscles, which leads to the fact that the muscle tension is pathologically prolonged.
In addition, the ptosis can also be caused traumatically, such as after violence or accidents.

The ptosis is also a symptom in the symptom complex of the so-called Horners syndrome: Here there is damage to the sympathetic region, which is part of the autonomic nervous system.

Read more about the causes of ptosis in our separate article:
These are the causes of ptosis

Detecting ptosis

What are the symptoms of ptosis?

Since ptosis is the actual symptom behind which a variety of disorders and diseases can be concealed, the question arises at this point about symptoms that occur together, which in their combination and after anamnestic questioning of the patient provide information about the cause. In addition to the external appearance of the drooping eyelid (ptosis), the patient may have an annoying feeling due to the eyelid resting on the eyeball. Vision may be partially or completely impaired in one eye. The danger of the development of a weak-sightedness due to a ptosis existing from birth has already been mentioned. Ultimately, the cosmetic impairment of the patient is also a significant consequence of the disease.

How is ptosis diagnosed?

As a further diagnosis of ptosis, a blood test can be carried out to clarify an autoimmune or genetic cause, as well as to detect tumor markers. Ultrasound, for example from the thyroid gland, can clarify its enlargement or show a dissection in the carotid artery. X-rays of the spine and chest provide information about a possible vertebral body fracture or a tumor of the tip of the lung (Pancoast tumor). Computed tomography or magnetic resonance tomography can be used to find skull fractures, infarct events, bleeding or even soft tissue processes such as inflammation.

Treating ptosis

How is ptosis treated?

Treatment of ptosis must primarily be based on its cause and the extent to which the patient is impaired. Congenital ptosis congenita, in which the eyelid elevator muscle is not fully functional from birth, can only be repaired surgically. The position of the lid must be corrected in a short surgical procedure and the defective muscle may be shortened slightly. This will improve the drooping of the eyelid and thus impaired vision. This type of operation is also necessary if the muscle has been permanently damaged by other processes and the situation cannot improve on its own. During the operation there is a risk of shortening the eyelid or the eyelid lifter muscle too much, so that afterwards a complete eyelid closure is no longer possible and the eye always remains a small gap open. Since this can lead to increased dehydration of the eyes and thus to damage to the cornea in the long term, a second corrective intervention is often unavoidable. In the case of systemic diseases such as myasthenia gravis, it is also possible to use drugs to influence the disease process and thus combat ptosis. However, this is only promising if the nerve of the eye lifter muscle has not yet been irreversibly damaged in its course.

Read more on this topic at: Treatment options for ptosis

Can ptosis be operated on?

Surgical correction of ptosis becomes necessary when the affected lid obscures the eye so much that seeing with both eyes at the same time (so-called binocular vision) is no longer possible or only possible to a very limited extent. This is mostly the case with congenital ptosis or with ptosis, where a traumatic event, for example, has resulted in a complete failure of the eyelid elevator muscle. The procedure itself can be carried out either under general or local anesthesia. The aim of the operation is to move the lid back to its original position and thus widen the gap between the eyelids. Depending on the patient's findings, various methods are available to the doctor. If the problem is only slight ptosis, it is sufficient to cut out a narrow strip in the area of ​​the rear upper eyelid and then sew up the wound again. In this way, the lid is shortened as a whole, but the lid lifter muscle itself remains untouched. However, if there is more severe ptosis, a small piece of the muscle must also be removed, usually between 10 and 22 millimeters. In very serious cases, the surgeon can attach the eyelid lifter muscle to one of the forehead muscles (a so-called frontalis suspension). After the procedure, the patient can lift the lid by moving the forehead.

Read more on this topic at: OP of a ptosis

Can ptosis be operated on in babies?

If ptosis already occurs in infancy or toddlerhood, research should first be carried out into the possible causes. If, as in most cases, it is congenital ptosis congenita, a specialist must assess how severe it is and how severely the child's vision is impaired. The rule of thumb here is: if more than two thirds of the pupil is covered, binocular vision is no longer sufficient and the child would inevitably develop ambylopia over time. Therefore, in such cases it is necessary to surgically correct the ptosis at an early stage so as not to impair the development of the child's eyes. It is of course also conceivable that other space-consuming processes, such as an intracranial tumor or the like, press on the eyelid elevator muscle or the nerves supplying it and thus lead to failure. Surgical intervention is also recommended here. However, if the ptosis is not so pronounced and the child is no longer affected by it in their everyday life, it is sufficient to observe the eye and wait to see whether the ptosis may worsen over time.

Read more about eye diseases in babies under conjunctivitis in babies.

Can acupuncture help with ptosis?

The principle of acupuncture is based on the fact that certain energy currents, invisible to the eye, run in lines, the so-called meridians, in the body. If the flow of energy along these lines is disturbed, illnesses occur. Accordingly, acupuncture suggests that a drooping eyelid is due to a faulty flow of energy in the facial area. By inserting small, fine acupuncture needles, an attempt is now made to direct the flow of energy back into its correct path. There is no guarantee of success for this procedure (which is why it is not paid for by the health insurances), but in individual cases an improvement in the symptoms has been reported.

Read more about acupuncture and meridians here.

Which doctor treats ptosis?

As explained in the section “Treating Ptosis”, ptosis is treated either with drugs or surgically.
The medication is prescribed by the ophthalmologist.
However, if the doctor determines that the medication is not bringing any improvement or that an operation is unavoidable from the outset, then an eye surgeon must perform the operation. The responsible ophthalmologist is responsible for the follow-up treatment and follow-up checks.

Course of ptosis

How long is the duration of ptosis?

Since ptosis in the majority of cases is based on damage to either the eye lifter muscle or the nerve supplying it, and this damage is usually irreversible, it can be assumed that once ptosis has occurred, it will not improve on its own. If the patient's vision is no longer impaired by the drooping eyelid, then the problem is merely cosmetic and does not require further medical treatment. However, it is imperative that a specialist clarify what the cause of a new and longer-standing ptosis is, as this can often be seen as a symptom of an underlying, more serious illness. If this is the case, the ptosis may also go away with treatment of the underlying disease.

For more on the underlying disease, see Mysthenia Gravis.