Ptosis of the Century: Causes, Symptoms, Diagnosis, Treatment

Ptosis of the upper eyelid (blue blepharoptosis) is an abnormally low position of the upper eyelid, which can be congenital or acquired.

[1], [2]

Classification of ptosis of the eyelid

1. Neurogenic
   • paresis of the oculomotor nerve
   • Horner syndrome
   • Marcus Gunn syndrome
   • a syndrome of the oculomotor nerve
2. Myogenic
   • myasthenia gravis
   • muscular dystrophy
   • ophthalmoplegic myopathy
   • simple congenital
   • blepharopathy syndrome
3. Aponeurotic
   • involutionary
   • postoperative
4. Mechanical
   • dermatochalasis
   • tumors
   • edema
   • forward orbital damage
   • scarring

[3]

Indispensable ptosis of the century

An indispensable ptosis of the century is caused by a violation of innervation of the third pair of black nerves and paralysis of the nerve n. Oenlosympathetic.

Syndrome of aplasia of the third pair of cranial nerves

Syndrome of aplasia of the third pair of cranial nerves can be congenital or acquired due to paresis of the oculomotor nerve, the latter cause is more common.

Symptoms of Aplasia III syndrome of cranial nerves

Pathological movements of the upper eyelid. Accompanying the movement of the eyeball.

Treatment of aplasia syndrome of the third pair of cranial nerves

Resection of the leftist tendon and suspension to the eyebrow.

Myogenic ptosis of the eyelid

Myogenic ptosis of the century occurs on the basis of myopathy of the left-handed eyelid or worsening of neuromuscular transmission (neuromyopathy). Acquired myogenic ptosis occurs in myasthenia gravis, myotonic dystrophy and ocular myopathies.

Aponeurotic ptosis

Aponeurotic ptosis is caused by stratification, tendon rupture, or stretching of the aponeurosis leftover, which limits the transfer of effort from the normal levator muscle to the upper eyelid. At the heart of this pathology are often age-related degenerative changes.

[4], [5], [6], [7], [8],

Symptoms of aponeurotic ptosis of the eyelid

• 1. Usually bilateral ptosis of different severity with a good function of the levator.
  
  
  2. High fold of the upper eyelid (12 mm or more). Since the posterior attachment of the aponeurosis to the tarsal cartilage is disrupted, while the front attachment to the skin remains intact and pulls the fold of the skin upward.
  3. In severe cases, the upper fold of the eyelid may be absent, the eyelid above the tarsal plate is thinned, the upper groove is recessed.

Treatment of aponeurotic ptosis of the eyelid includes resection of the levator, refraction or restoration of the aponeurosis of the anterior left-hander.

Mechanical ptosis of the eyelid

Mechanical ptosis occurs as a result of impaired mobility of the upper eyelid. Among the reasons: dermatochalasis, large tumors of the century, for example, neurofibromas, scarring, severe swelling of the eyelids and damage to the anterior part of the orbit.

Causes of mechanical ptosis of the eyelid

Dermatochalasis

Dermatochalasis is a common, usually bilateral disease, found mainly in elderly patients and is characterized by "excess" skin of the upper eyelid, sometimes combined with a hernia of the cellulose through a weakened orbital septum. Observe the sack-shaped sagging of the skin of the eyelids with atrophic folds.

Treatment in severe cases is to remove the "excess" skin (blepharoplasty).

Blepharhalasis

Blepharhalasia is a rare disease caused by recurrent, painless, dense edema of the upper eyelids, which usually spontaneously subside after a few days. The disease begins during puberty with the occurrence of edema, the frequency of which decreases with age. In severe cases, stretching, sagging and thinning of the skin of the upper eyelid occurs like tissue paper. In other cases, weakening of the orbital septum leads to the formation of a hernia of cellulose.

Syndrome of Atonic Age

Syndrome of atonic ("clapping") century - a rare, one- or two-sided disease, which is often not diagnosed. This disorder occurs in very obese people suffering from snoring and sleep apnea.

Symptoms of the atonic ("clapping") century

• Soft and flaccid upper eyelids.
• Eversion of the eyelids during sleep leads to damage to the undisguised tarsal conjunctiva and chronic papillary conjunctivitis.

Treatment of the atonic ("clapping") century in mild cases involves the use of an eye protective ointment or bandages for eyelids at night. In severe cases, a horizontal shortening of the eyelid is required.

[9], [10], [11], [12], [13], [14]

Principles of surgical treatment of mechanical ptosis

The Fasanella-Servat technique

• Indications. Moderate ptosis with a Levator function of at least 10 mm. Applied in most cases with Horner syndrome and moderately expressed congenital ptosis.
• Equipment. The upper edge of the tarsal cartilage is excised together with the lower edge of the muscle of the muller and the conjunctiva lying above it.

Levator resection

• Indications. Ptosis of various degrees with a function of a levator not less than 5 mm. The volume of resection depends on the function of the levator and the severity of ptosis.
• Equipment. Shortening of the levator through the anterior (skin) or posterior (conjunctiva) approach.

Suspension to the frontal muscle

Indications

• Pronounced ptosis (> 4 mm) with very low left-handed function (<4 mm).
• Marcus Gunn Syndrome.
• Aberrant regeneration of the oculomotor nerve.
• Syndrome of blepharophimosis.
• Full paresis of the oculomotor nerve.
• Unsatisfactory result of previous resection of the leftist.

Equipment. Suspension of the tarsal cartilage to the frontal muscle with a ligature from its own wide fascia or a non-absorbable synthetic material such as proline or silicone.

Recovery of aponeurosis

1. Indications. Aponeurotic ptosis with high levator function.
2. Equipment. Moving and stitching of intact aponeurosis to the tarsal cartilage through the anterior or posterior approach.

Congenital ptosis of the eyelid

Congenital ptosis of the century is a disease with an autosomal dominant type of inheritance, in which an isolated dystrophy of the muscle that lifts the upper eyelid (myogenic) develops, or there is aplasia of the nucleus of the oculomotor nerve (neurogenic). There are congenital ptosis with normal function of the upper rectus of the eye (the most frequent type of congenital ptosis) and ptosis with weakness of this muscle. Ptosis is often one-sided, but can manifest itself on two eyes. With partial ptosis, the child lifts his eyelids, using the frontal muscles, and throws back his head (pose "astrologer"). The upper palpebral groove is usually weak or absent. At a sight directly the upper eyelid is pubescent, and at a sight downwards it is located above the opposite.

[15], [16], [17], [18]

Symptoms of congenital ptosis

1. Unilateral or bilateral ptosis of different severity.
2. Absence of anterior palpebral fold and reduced function of the levator.
3. When looking down, the eyelid with ptosis is located above the healthy one due to insufficient relaxation of the levator muscle; with acquired ptosis, the affected eyelid is located at or below the healthy level.

Treatment of congenital ptosis

Treatment should be conducted at preschool age after all necessary diagnostic procedures are carried out. However, in severe cases, it is recommended to begin treatment at an earlier age to prevent amblyopia. In most cases, resection of the levator is required.

Palpebromandibular syndrome (Gunn syndrome) is a rarely observed congenital, as a rule, one-sided ptosis, associated with the synkinetic retraction of the lowered upper eyelid with pterygoid pectoral pacing. Involuntary lifting of the lowered upper eyelid occurs with chewing, opening of the mouth or yawning, and the extraction of the lower jaw in the opposite direction to ptosis can also be accompanied by retraction of the upper eyelid. In this syndrome, the muscle lifting the upper eyelid receives innervation from the motor branches of the trigeminal nerve. Pathological synkinesis of this species is caused by lesions of the brainstem, often complicated by amblyopia or strabismus.

Marcus Gunn Syndrome

Marcus Gunn syndrome (palpebromandibular) is found in about 5% of cases of congenital ptosis, in most cases it is unilateral. Despite the fact that the etiology of the disease is not clear, the pathological innervation of the left-handed century is assumed to be a motor branch of the trigeminal nerve.

Symptoms of Marcus Gunn syndrome

1. Retraction of the lower eyelid with irritation of the ipsilateral pterygoid muscle during chewing, opening of the mouth, separation of the jaw in the opposite ptosis side.
2. Of the less common stimulations, it is possible to highlight the pushing of the jaw, the smile, the swallowing and clenching of the teeth.
3. The Marcus Gunn syndrome does not disappear with age, but patients are able to mask it.

Treatment of Marcus Gunn syndrome

It is necessary to decide whether the syndrome and associated ptosis are a significant functional or cosmetic defect. Despite the fact that surgical treatment does not always achieve satisfactory results, the following methods are used.

1. One-sided resection of the levator in moderate cases with a function of a levator 5 mm or higher.
2. One-sided separation and resection of the tendon of the leftist with an incilatory suspension to the eyebrow (frontal muscle) in more severe cases.
3. Two-sided separation and resection of the leftist tendon with an inclusive suspension to the eyebrow (frontal muscle) to achieve a symmetrical result.

Blepharophimosis

Blepharophimosis is a rare anomaly of development caused by shortening and narrowing of the ophthalmic neck, bilateral ptosis, with an autosomal dominant type of inheritance. It is characterized by a weak function of the muscle that lifts the upper eyelid, epicanthus and inversion of the lower eyelid.

Symptoms of blepharophimosis

1. Symmetrical ptosis of different severity with insufficient function of the levator.
2. Shortening of the eye gap in the horizontal direction.
3. Telecanthus and inverted epicanthus.
4. Lateral ectropion of lower eyelids.
5. Underdeveloped nose and hypoplasia of the upper orbital margin.

Treatment of blepharophimosis

Treatment of blepharophimosis includes the initial correction of epicanthus and telecanthus, after several months perform a bilateral frontal fixation. It is also important to treat amblyopia, which can be in about 50% of cases.

[19], [20], [21], [22], [23], [24], [25],

Acquired ptosis of the century

Acquired ptosis of the eyelid is observed much more often than congenital. Depending on the origin, the neurogenic, myogenic, aponeurotic and mechanical acquired ptosis are distinguished.

Neurogenic ptosis of the century with paralysis of the oculomotor nerve is usually one-sided and full, most often caused by diabetic neuropathy and intracranial aneurysms, tumors, trauma and inflammation. With complete paralysis of the oculomotor nerve, the pathology of the extraocular muscles and the clinical manifestations of internal ophthalmoplegia are determined: loss of accommodation and pupillary reflexes, mydriasis. Thus, an aneurysm of the internal carotid artery inside the cavernous sinus can lead to complete external ophthalmoplegia with anesthesia of the innervation of the eye and the infraorbital branch of the trigeminal nerve.

Ptosis of the eyelid can be caused with a protective purpose in the treatment of ulcers of the cornea, which do not heal because of the uncovered eye gap with the lagophthalmus. The effect of chemical denervation of botulinum toxin muscle lifting the upper eyelid is temporary (about 3 months), and usually it is enough to stop the corneal process. This method of treatment is an alternative to blepharophrenia (eyelid cross-linking).

The ptosis of the century with Horner's syndrome (usually acquired, but can also be congenital) is caused by a violation of the sympathetic innervation of the smooth muscle of Muller. This syndrome is characterized by a certain narrowing of the eye gap due to pubescence of the upper eyelid by 1-2 mm and a slight uplift of the lower eyelid, miosis, a violation of sweating on the corresponding half of the face or eyelids.

Myogenic ptosis of the eyelid occurs with myasthenia gravis, often bilateral, may be asymmetric. The severity of ptosis varies from day to day, it is provoked at a load and can be combined with doubling. Endorphin test temporarily removes muscle weakness, corrects ptosis, confirms the diagnosis of myasthenia gravis.

Aponeurotic ptosis is a very common type of age-related ptosis; characterized by the fact that the tendon of the muscle that lifts the upper eyelid is partially detached from the tarsal (cartilaginous) plate. Aponeurotic ptosis may be post-traumatic; it is believed that in a large number of cases, postoperative ptosis has such a development mechanism.

Mechanical ptosis of the eyelid arises with horizontal shortening of the tumor or cicatricial age, as well as in the absence of the eyeball.

In children of preschool age, ptosis leads to a persistent decrease in vision. Early surgical treatment of pronounced ptosis can prevent the development of amblyopia. With poor mobility of the upper eyelid (0-5 mm), it is advisable to hang it to the frontal muscle. In the presence of a moderately expressed excursion of the eyelid (6-10 mm), ptosis is corrected by resection of the muscle lifting the upper eyelid. When the congenital ptosis is combined with a violation of the function of the upper rectus muscle, the resection of the levator tendon produces a larger volume. A high excursion of the century (more than 10 mm) allows the resection (duplication) of the aponeurosis of the leftist or Muller muscle.

Treatment of acquired pathology depends on the etiology and magnitude of ptosis, as well as on the mobility of the eyelid. A large number of methods have been proposed, but the principles of treatment remain unchanged. With neurogenic ptosis in adults, early conservative treatment is required. In all other cases surgical treatment is advisable.

With the lowering of the eyelid by 1-3 mm and its good mobility, the Müller's muscle is resected transconjunctively.

In the case of a moderate ptosis (3-4 mm) and good or satisfactory mobility of the eyelid, operations on the muscle lifting the upper eyelid (plastic tendon, re-fixation, resection or duplication) are indicated.

With minimal mobility of the eyelid, it is suspended from the frontal muscle, which provides a mechanical lifting of the eyelid when the eyebrow is raised. The cosmetic and functional results of this operation are worse than the effect of interventions on left-leavers of the upper eyelid, but in this category of patients there is no alternative to hanging.

For the mechanical lifting of the eyelid, it is possible to use special arches fixed to the spectacle frames, the use of special contact lenses. Typically, these devices are poorly tolerated, so they are very rarely used.

With good mobility of the century, the effect of surgical treatment is high, stable.

[26], [27], [28]

Clinical Features of Ptosis

Congenital and acquired ptosis differ in the age of the patient, when pathology was indicated, and the duration of its course. In doubtful cases, old photos of the patient may be useful. It is also important to know about possible manifestations of systemic diseases, for example, associated diplopia, "the difference in degree of ptosis during the day or against the background of fatigue.

[29], [30], [31], [32]

Pseudoptosis

For ptosis can be mistaken for the following pathologies.

• Inadequate eyelid support due to a decrease in the volume of the contents of the orbit (artificial eye, microphthalmos, enophthalmos, phthisis of the eyeball).
• Contralateral retraction of the eyelid is revealed by comparing the levels of the upper eyelids, given that the upper eyelid normally covers the cornea by 2 mm.
• Ipsilateral hypotrophy, in which the upper eyelid descends downwards, behind the eyeball. Pseudoptosis disappears if the patient fixes the gyotrophic eye with closed healthy.
• Ptosis of the eyebrows due to the "excess" skin of the eyebrow, or with paralysis of the facial nerve, which can be identified by raising an eyebrow.
• Dermatochalysis. In which the "excess" skin of the upper eyelids is the cause of the formation of ordinary or pseudoptosis.

Measurements

• Distance edge of the century - a reflex. This is the distance between the upper edge of the eyelid and the corneal reflection of the beam of the flashlight, which the patient is looking at.
• The height of the eye gap is the distance between the upper and lower edges of the eyelid, measured in the meridian passing through the pupil. The margin of the upper eyelid is usually located about 2 mm below the upper limb, the lower eyelid - 1 mm or less above the lower limb. In men, the height is less (7-10 mm) than for women (8-12 mm). One-sided ptosis is assessed but the height difference with the coitalateral side. Ptosis is classified as light (up to 2 mm), moderate (3 mm) and heavy (4 mm or more).
• Function of the leftist (tour of the upper eyelid). Measured by holding the thumb of the patient's eyebrow when the patient looks down to exclude the action of the frontal muscle. Then the patient looks maximum up, the eyelid excursion is measured with a ruler. Normal function is 15 mm or more, good - 12-14 mm, sufficient - 5-11 mm and insufficient - 4 mm or less.
• The upper palpebral groove is the vertical distance between the edge of the eyelid and the fold of the eyelid when viewed from below. In women, it is approximately 10 mm. In men - 8 mm. Absence of a fold in a patient with congenital ptosis is an indirect sign of a lack of function of the levator, while a high fold indicates a defect in the aponeurosis. The skin fold serves as a marker for the initial incision.
• Pttarsal distance is the distance between the edge of the eyelid and the fold of the skin when the far object is fixed.

Associative traits

1. Strengthening the innervation can affect the levator on the side of ptosis, especially when looking up. The combined intensification of the innervation of the contralateral intact levator leads to a pulling of the eyelid upward. It is necessary to raise a finger with a ptotic eyelid and trace the descent of the intact eyelid. In this case, the patient should be warned that surgical correction of ptosis can stimulate the lowering of the contralateral eyelid.
2. The study of fatigue is carried out for 30 seconds, the patient does not blink at the same time. The progressive lowering of one or both eyelids or the inability to direct the gaze downward are pathognomonic signs of myasthenia gravis. With myasthenic ptosis, the deviation of the upper eyelid on the saccades is seen from the look down to the view directly (the symptom of Cogan twitching) or the "leap" when looking to the side.
3. Disturbance of mobility of the eye (especially dysfunction of the upper rectus muscle) should be established in patients with congenital ptosis. Correction of ipsilateral malnutrition may decrease ptosis.
4. Palpebromandibular syndrome is detected if the patient makes chewing movements or rolls the jaw to the side.
5. The Bell phenomenon is examined by holding the patient's open eyelids with his hands, while watching the ascending movement of the eyeball while trying to close his eyes. If the phenomenon is not expressed, there is a risk of postoperative keratopathy, especially after large resections of the levator or suspension techniques.