Ptosis, or blepharoptosis, is the drooping of the upper eyelid caused by a congenital or acquired abnormality of the muscles that elevate the eyelid (Lee, 2021). Ptosis can affect normal vision, but more importantly, it may be a sign of a serious neurologic condition.
 

Patient History (Lee, 2021)

Upon initial evaluation of ptosis, the history and physical exam can typically identify the cause. Important questions to ask your patient include:

• Has the ptosis been present since birth (congenital)?
• Did the ptosis appear suddenly or progress slowly over time?
• Does the degree of ptosis change over the course of the day or with fatigue?
• Do you have other symptoms with the ptosis such as headache or diplopia?
• Do you have a history of ocular surgery or trauma (including birth trauma)?
• Do you wear contact lenses?
• Is there a family history of ptosis?

Classifications of Ptosis (Lee, 2021; Shahzad & Siccardi, 2022)

Ptosis is classified into congenital or acquired which is further subcategorized into the following:

• Neurogenic (nerve): results from defective oculomotor (III) cranial nerve innervation by of the levator muscle which lifts the upper eyelid. Associated with conditions such as third nerve palsy, Horner syndrome, Marcs Gunn jaw-winking syndrome, and multiple sclerosis.
  • Unilateral ptosis with impaired eye movement and/or a dilated pupil suggests a compressed third cranial nerve palsy. Causes can range in severity from benign to immediately life-threatening. Therefore, emergent neuroimaging is required to exclude an aneurysm.
• Myogenic (muscle): associated with mitochondrial disease, oculopharyngeal dystrophy, and myotonic dystrophy.
• Neuromuscular junction disorders: caused by myasthenia gravis (MG), botulinum toxin, and infectious botulism.
  • Myasthenia gravis is an autoimmune disorder often presenting initially with unilateral or bilateral ptosis with or without diplopia and ocular motor deficits. Patients with this disorder should be closely monitored as a rapid clinical worsening of MG could result in respiratory distress requiring intubation.
• Aponeurotic: disorder of the thin connective tissue (tendon) caused by aging, trauma, or postoperative complication.
• Mechanical: levator muscle function is impaired by an abnormal external structure such as a neoplasm, chalazion (eyelid cyst that develops from a blocked oil gland), contact lens in the upper fornix, or scarring.
• Traumatic: direct or indirect trauma to the eyelid.

Treatment (Shahzad & Siccardi, 2022)

Choice of treatment will depend on the underlying cause, the severity of ptosis, and the function of the levator muscle. Nonsurgical treatments are employed in myogenic and neurogenic ptosis and include eyedrops, taping the upper eyelid open and eyelid crutches attached to glasses. Surgery is required for congenital ptosis, when ptosis causes vision issues, and when nonsurgical treatment is ineffective. If ptosis is diagnosed in a primary care clinic, the patient should be referred to a neurologist and/or an ophthalmologist for further workup.
 

References:
 
Lee, M.S. (2021, March 17). Overview of ptosis. UpToDate.  https://www.uptodate.com/contents/overview-of-ptosis
 
Shahzad, B. & Siccardi, M.A. (2022, August 8). Ptosis. StatPearls. National Institutes of Health, National Library of Medicine, National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK546705/