We may not always pay enough attention to conditions for which we do not have good treatment options — especially when the patient does not initiate the conversation. For many of us, mild to moderate blepharoptosis is one of those conditions. This has now changed with the introduction of an FDA-approved pharmaceutical indicated for acquired blepharoptosis or a low-lying upper eyelid margin when the eye is in primary gaze.

Here, I provide an introduction to blepharoptosis and explain the changes in my approach.

CAUSE OF ‘ABNORMAL DROOP’

The levator and Müller’s muscle work together to lift the eyelid. More commonly known as ptosis, blepharoptosis results from a dysfunction in one or both of the muscles. It is an abnormal drooping of the upper eyelid — which can affect one or both eyes — with the eye in primary gaze. Ptosis is classified as either congenital or acquired, with the latter being the predominant form.^1,2 Acquired ptosis can be either aponeurotic, myogenic, neurogenic, mechanical, or traumatic in origin. Acquired aponeurotic ptosis, typically associated with aging, results from stretching, dehiscence, or detachment of the levator.^1,2

Ptosis is among the most common eyelid disorders found in the eye clinic, with a prevalence of around 13.5% in the adult population, and increasing with age to exceed 20% among patients aged 70 years and older.^1,2 Besides age, other causative factors that could be involved are previous ocular surgery, contact lens wear, ocular trauma, underlying disease, and periocular neurotoxin injection.^1,2

CONCERNS: APPEARANCE AND VISION

Patients with ptosis often have appearance-related concerns, and they complain that they look sleepy or tired and that the eyelids appear different or asymmetrical.² This can have a pronounced impact on a patients’ well-being, with ptosis patients reporting increased appearance-related distress, anxiety, and depression compared with the general population and similar to levels previously reported in patients with other appearance-altering ophthalmic conditions, such as strabismus.^1,3

Functionally, even mild pupillary obstruction as a result of ptosis can cause detectable deficits in the superior visual field, decreased contrast sensitivity, and an increase in higher order aberrations.^1-5 Patients may have blurry vision and difficulty with visual tasks.^1,6 They can experience physical discomfort like neck pain, brow ache, headaches, and eye strain as a result of compensating for droopy lids.^1,4 All of this adds up to negative effects on health-related quality of life measures.^1,3

EARLY EDUCATION

One of the first steps in managing ptosis is educating patients on the importance of the eyelids, a process that starts even before the exam room. For example, we have informational brochures and posters about ptosis and its treatment in the waiting area, and our technicians and students ask patients about their ocular health and if they have any concerns about their eyes or eyelids. Once in the exam room, I make a point of asking patients about their eyes and specifically their eyelids. Broaching the subject kicks off the conversation, helping patients feel more comfortable discussing something they might think is merely a cosmetic issue.

KNOW YOUR MRD-1

In my practice, we are redoubling our efforts to be proactive when evaluating the eyelid, from looking for lumps and bumps to evaluating the resting position of the eyelids. We measure marginal reflex distance 1 (MRD-1) — which is the distance from the central pupillary light reflex to the central margin of the upper eyelid — the traditional measure used to evaluate lid position.¹ A normal MRD-1 is 4.0 to 5.0 mm.⁴ As that number gets smaller, the more pronounced the droop and risk for visual impairment. For example, an unobstructed superior visual field measures about 50°.⁴

A 10% loss of visual field has been shown to cause an 8% increase in the odds of falling in patients over 65.⁷ A patient with an MRD-1 of 2 mm has a 24% to 30% impairment of their superior visual field, with detectable defects evident even in mild cases.⁴ Patients with an MRD-1 of 2 mm or less report having trouble performing daily tasks like reading, watching TV, doing fine manual work, hanging or reaching objects above eye level, performing their work, and walking without assistance.^3,8

BEYOND MRD-1

Along with MRD-1, we may also measure levator function to differentiate a true ptosis from pseudoptosis and evaluate the lid platform show or the distance between the eyelid margin and the lid fold. When I have identified ptosis, I will tell patients that the drooping likely will impede the superior part of their vision. Whether they are interested in contact lenses, glasses, or premium IOLS, low-lying lids can impair those optics. To put patients at ease and help them recognize that this is a common problem, I might even make light of the lid droop, telling patients it’s “a birthday problem” — the more birthdays we have, the likelier it is.

It is important, however, to rule out other causes. Although age-related ptosis is the most common cause of a droopy eyelid, a more serious neurogenic ptosis, like a third nerve palsy or Horner’s syndrome, must be considered, as well as a myogenic ptosis which is a muscle problem often from myasthenia gravis (see sidebar: Acquired Ptosis). Pupillary testing, extraocular motility testing, and eyelid fatigue testing (e.g., having the patient look up and down for 1 minute and reassessing the MRD-1) all can help to rule in or rule out other more serious causes of acquired ptosis, which may require surgery.

Common Types of Acquired Ptosis

APONEUROTIC (INVOLUTIONAL)

Caused by stretching, dehiscence, or detachment of the levator aponeurosis; typically associated with aging

 

MYOGENIC

Caused by primary or secondary myopathy of the levator muscle

 

NEUROGENIC

Relatively rare type of ptosis, caused by central nervous system abnormality or underlying neurological condition affecting the oculomotor or sympathetic nerves

 

MECHANICAL

Caused by excess weight on the upper eyelid, usually due to benign or malignant neoplasm

Can also be a pseudoptosis

 

TRAUMATIC

Caused by trauma to the eyelid retractor muscles, aponeurosis, or neural inputs to the eyelid

 

Source: Bacharach J, Lee WW, Harrison AR, Freddo TF. A review of acquired blepharoptosis: prevalence, diagnosis, and current treatment options. Eye (Lond). 2021;35(9): 2468-2481.

TREATMENT: SHOW PATIENTS THE DIFFERENCE

When I have confirmed age-related ptosis, I let the patient know we now have good news — a new eyedrop, oxymetazoline hydrochloride 0.1% (Upneeq; RVL Pharmaceuticals, Inc), has been developed that helps to raise the lid by a millimeter to a millimeter and a half and it can bring that eyelid back into a more normal position. I usually offer them an in-office trial in just one eye, so they can see the difference between the two lids; the drop usually takes effect in a matter of minutes. The drop is safe, efficacious, and can give them portions of their visual field back. Of course, the cosmetic improvement patients enjoy is important, but the impact from a functional perspective is just as big, if not bigger.

I tell my patients that I will work very hard at finding them the best solution for their visual needs, but they must also work hard with me. This means continually educating them to stay motivated and adherent to the treatments I provide and prescribe. I am sure to discuss all of the available options with patients and provide that extra dose of TLC and attention. OM

REFERENCES

1. Bacharach J, Lee WW, Harrison AR, Freddo TF. A review of acquired blepharoptosis: prevalence, diagnosis, and current treatment options. Eye (Lond). 2021;35(9):2468-2481.
2. Finsterer J. Ptosis: causes, presentation, and management. Aesthetic Plast Surg. 2003;27:193-204.
3. Richards HS, Jenkinson E, Rumsey N, et al. The psychological well-being and appearance concerns of patients presenting with ptosis. Eye. 2014;28:296-302.
4. Cahill KV, Bradley EA, Meyer DR, et al. Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology. Ophthalmology. 2011;118:2510-2517.
5. An SH, Jin SW, Kwon YH, et al. Effects of upper lid blepharoplasty on visual quality in patients with lash ptosis and dermatochalasis. Int J Ophthalmol. 2016;9:1320-1324.
6. Battu VK, Meyer DR, Wobig JL. Improvement in subjective visual function and quality of life outcome measures after blepharoptosis surgery. Am J Ophthalmol. 1996;121:677–686.
7. Freeman EE, Muñoz B, Rubin G, West SK. Visual field loss increases the risk of falls in older adults: the Salisbury eye evaluation. Invest Ophthalmol Vis Sci. 2007;48:4445-4450.
8. Federici TJ, Meyer DR, Lininger LL. Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. Ophthalmology. 1999;106:1705-1712.

DR. NATE LIGHTHIZER is a professor and associate dean at the Oklahoma College of Optometry at Northeastern State University, Tahlequah, Okla. He is also director of Continuing Education and chief of Specialty Care Clinics. Contact: lighthiz@nsuok.edu. Financial disclosure: Speaker for RVL Pharmaceuticals