Blepharoptosis or ptosis of the upper eyelid

Sergei Khaustov, MD, PhD, plastic surgeon of the highest category, current member of the European Academy of Facial Plastic Surgery (EAFPS), the International Confederation of Plastic, Reconstructive and Aesthetic Surgeons (IPRAS), the All-Ukrainian Society of Plastic, Reconstructive and Aesthetic Surgeons (VAPRAS) ( Ukraine)

Blepharoptosis (ptosis, from the Greek Ptōsis - fall) is a drooping of the upper eyelid, partially compensated by tension of the frontal muscle. Smoothness of the orbitopalpebral fold is noted. With a significant degree, there is a forced tilting of the head, wrinkling of the forehead - a symptom of “stargazer's head”. Normally, the edge of the upper eyelid covers up to one third of the pupil or covers the cornea by 2 mm when looking straight ahead.

There are three degrees of ptosis:

• I degree (partial ptosis): the upper eyelid covers the upper third of the pupil;
• II degree (incomplete ptosis): the upper eyelid covers up to half the pupil;
• III degree (complete ptosis): the upper eyelid covers the entire pupil.

DIAGNOSIS OF BLEPHAROPTOSIS
Ptosis is diagnosed using various medical tests. There are several ways to diagnose blepharoptosis:

• differential diagnosis: it includes assessment of the functional state of the upper eyelid and eye muscles. The assessment is carried out as a result of five sessions of electrical stimulation of the nerve of the blink reflex system and laser infrared stimulation of the protection of the lower third of the gyrus of the brain on both sides;
• assessment of the difference in the position of both eyelids: if the eyelids are at different levels, then the functional viability of the levator of the upper eyelid is diagnosed;
• measurement in millimeters of the distance of the eyelid from the cornea of the eye, from the edge of the eyelid and eyelashes; The position of the fold of the upper eyelid is also examined.
  

ETIOLOGY AND PATHOGENESIS OF PTOSIS

Ptosis can be congenital (blepharoptosis is one of the first among congenital eye diseases) and acquired, complete or partial, and can also develop in individuals with a family history. Acquired ptosis is usually unilateral and develops with a significant decrease in vision, after injury and due to damage to the oculomotor nerve, which innervates the muscle that lifts the upper eyelid (Fig. 1). Partial ptosis is also observed with damage to the cervical sympathetic plexus. Bilateral ptosis (sometimes asymmetrical) is observed in a systemic disease of an autoimmune nature - myasthenia gravis (photo 1). Neurogenic causes include paresis of the oculomotor nerve, Horner's syndrome, Marcus-Hun sign, and ophthalmoplegic migraine. Congenital ptosis occurs due to underdevelopment of the muscle that lifts the upper eyelid (levator) or a violation of innervation. May be complete or partial. If ptosis is not congenital, but acquired, then the reasons due to which it develops may be different. Among them are the following:

• the tone of the muscles that regulate the activity of the eyelids decreases, and they become weak and function poorly (senile blepharoptosis); in elderly people, lacrimation can also serve as a signal of the development of blepharoptosis;
• injuries to athletes: often as a result of eye injuries received during sports, various eye diseases develop, including ptosis of the upper eyelid. It can develop if the muscle responsible for the mobility of the upper eyelid is damaged;
• any injury to the eye if the muscle that regulates the upper eyelid is affected;
• involuntary and uncontrolled contraction of the muscles of the eyelid or blepharospasm, in which the upper eyelid itself lowers and rises.

Acquired blepharoptosis, in turn, can be divided into temporary and permanent.

Temporary ptosis of the upper eyelid can be encountered in patients who have undergone incorrectly performed botulinum toxin injections. It is associated with the diffusion of botulinum toxin into the muscle that lifts the upper eyelid. Fortunately, this type of blepharoptosis goes away with time.

For patients with persistent blepharoptosis, the only treatment option is surgical correction (blepharoplasty). The procedure is performed under both local and general anesthesia. Its task is to restore the muscle that lifts the upper eyelid. In more severe cases, reconstructive blepharoplasty is required.

An example is patient K., 36 years old, who underwent several corrective blepharoplasty operations that did not give a satisfactory result. The temporalis fascia was used and sutured to the frontalis muscle site. As a result, using facial expressions of surprise (tension of the frontal muscle) it was possible to achieve a lasting result in the correction of blepharoptosis.

TREATMENT OF BLEPHAROPTOSIS

The main treatment for upper eyelid ptosis is blepharoplasty. Its essence is that the upper eyelid is corrected through surgical intervention.
The operation itself is carried out in several stages:

• The first stage: the doctor conducts a full examination of the eyelids and eyes, studies the medical history, and talks with the patient. Before the operation itself, two mandatory consultations must be held;
• in the second stage: the operation is performed. Before surgery, a preoperative drawing is applied to the eyelids using a special medical skin marker. The operation is performed under anesthesia;
• third stage: postoperative adaptation of the patient. The result of the operation itself can only be assessed 3–6 weeks later. During this period, the sutures dissolve and tissue flexibility is restored.
• For blepharospasms, medications are often used. Solutions for injection are prepared from them. The action of the injection is aimed at restoring the neuromuscular system as a result of the appearance of new nerve endings. Typically, the effect of the drug lasts from three to five months.

Thus, blepharoptosis is an aesthetic problem that can be successfully solved by modern methods of plastic surgery.

An ophthalmologist always refers you for blepharoplasty. Contraindications to surgery are paralysis of the superior rectus muscle of the eye, external ophthalmoplegia, absence or decreased sensitivity of the cornea.

First published: "Les Nouvells Esthetiques Ukraine" 2/2016