Eyelid ptosis

One of the most common oculoplastic problems that we see in our consultation room is eyelid ptosis, which is the abnormal position of one or both upper eyelids, whereby they appear to have fallen. 

Adults and children may suffer from this pathology, but it normally manifests itself during childhood, if it is a congenital issue, i.e. already present at birth.

The symptoms of eyelid ptosis vary depending on its degree, which can be mild, moderate or serious.  

In cases of mild eyelid ptosis, in which a droopy eyelid partially covers the upper part of the pupil, there may be a reduction in the visual field, or just cosmetic asymmetry, without a clinical translation. 

However, in moderate/severe cases, the eyelid may cover a large part of the pupil or even completely, compromising visual acuity enormously, which could be a serious problem for a child. For this reason, we have to treat it to avoid a lazy eye or amblyopia. 

Therefore, it is important that a newborn with eyelid ptosis (be it in one eyelid or both), sees an oculoplastic ophthlamologist as soon as possible to assess the degree of affectation and the type of eyelid ptosis, find out the treatment and the guidelines to follow as determined by a specialist.

The most common type of ptosis among children is simple congenital ptosis, which usually becomes bilateral and is due to a dysgensis, i.e. an abnormal formation isolated from the levator muscle of the upper eyelid, which the main muscle in charge of opening the eye. This pathology is sometimes associated with strabismus (a loss of parallelism of the eyes), a high astigamatism (cornea irregularity) or ansiometropia (a difference in the size of the eyes). 

Other times, this pathology is associated with an abnormality or weakness of the rectus superior muscle, the muscle that allows the eyeball to look up, although it is infrequent (5%). 

There are other types of congenital eyelid ptoses with a much lower rate of incidence, particularly blepharophimosis syndrome, a pathology which, in addition to eyelid ptosis, shows other eyelid signs, such as very small eyes, with a different nasal fold (inverse epicanthal fold) and telecanthus (increase of distance between one eye and another). This syndrome has a hereditary component, i.e one of the parents suffers from it. 

Another congenital palpebral ptosis with a lower rate of incidence is caused by a problem in the nerve that provides mobility to the muscle and means it won't work properly. In children, this occurs more commonly because of third cranial nerve palsy, the nerve that gives mobility to the levator muscle of the upper eyelid. The cause of this pathology is unknown, but its appears that there is a problem in the development of this cranial nerve and this causes a malfunction in the muscles innervated by it, like the levator muscle of the eyelid and some of the eye muscles. In this pathology, we may notice a loss of parellelism (strabismus) as well as ptosis in the examination of the child.  

Another type is Marcus-Gunn syndrome. It is a ptosis caused by an abnormal connection between the fifth cranial nerves and the pterygoid muscles in charge of chewing. The eyelids of children affected by this syndrome lift when the muscle responsible for chewing moves. It can be clearly seen when a baby sucks their dummy or bottle or when it opens its mouth. This is why the first people to notice it are usually the parents. 

Another rare cause of ptosis in childhood is Horner's Syndrome. There is a paralysis caused by neurological damage and we will usually observe eyelid ptosis, myosis (small pupil) and anhidrosis (facial dryness) in the examination.

Mechanical ptsosis are those ptoses that are caused by the fact that the eyelid has a weight on it that makes it fall or lower beyond its normal height. We see it, for example, in palpebral oedema or haematoma, or for example, in lesions that cause a stye-like weight or a tumour that impede correct opening and eyelid elevation. 

Traumatic ptosis are those with a trauma that damages the levator muscle, meaning it stops it from completely or partially doing its job properly.

Treatment for ptosis will depend on the cause and above all the degree of affectation of the child's visual acuity. 

In simple congenital ptsosis that impedes correct vision, with a visual acuity that does not improve despite conservative treatment for amblyopia, corrective surgery is indicated. Depending on the degree of muscle function and degree of ptosis, a specific technique will be chosen over another to repair this muscle. 

In cases where there is sufficient residual function of the elevator muscle of the upper eyelid, it will be operated on. However, in cases where this function is inexistent of very deficient, action will be taken on the the frontal muscle, which will help to lift the eyelid. 

These procedures are performed under general anasthetic and the patient must be admitted for one day. Postoperative treatment is simple and the child feels practically no pain at all after surgery. The sutures we use for the skin are sutures that dissolve after a few days. There's no need to have them removed.

When it is ptosis caused by something mechanical (tumour, oedema with a lot of fluid, a stye, haematoma), or by a trauma, action will be taken on the specific cause of the ptosis, be it conservative or surgical treatment.