What is eyelid ptosis?
Eyelid ptosis means drooping of the eyelid (upper) only, as there is a lift for it called (levator palpebrae muscle) that lifts the eyelid upwards.
Under normal conditions, the upper eyelid covers only about 2 millimeters or one-fifth of the cornea when a person looks forward. If the upper eyelid covers more than that, this is evidence that the eyelid is not in a normal condition. In some cases, the upper eyelid may droop until it covers the eye (pupil), blocking vision and the affected person cannot see unless he lifts his eyelid with his hand.
Simple eyelid drooping covers about 4 millimeters of the cornea, and (moderate) drooping covers more than 6 millimeters, i.e. it covers more than 8 millimeters, i.e. it covers the entire pupil. Eyelid drooping may affect both eyes, especially in children, and it may affect only one eye.
Causes and types of eyelid ptosis:
There are several types of eyelid ptosis, depending on the cause of the ptosis, which are:
First: Congenital ptosis:
It is the most common type, and occurs from birth, meaning that the child is born with it. Its causes are due to the absence, weakness, or paralysis of the levator palpebrae muscle responsible for lifting the eyelid. It is usually simple and hereditary, as heredity plays a secondary role in its occurrence. Also, the mother’s infection with some fevers or taking some medications during pregnancy may help it occur. This type often occurs accompanied by other ailments such as the inability to move the eye upwards or the presence of excess skin folds above the median bridge of the eyelids. It is usual in these cases for the ptosis to be in both eyelids, not in one eyelid.
Second: Paralytic ptosis:
It occurs as a result of the third cranial nerve being affected, which is the nerve that drives the eye and supplies the levator palpebrae muscle. There is a general disease that weakens the muscles of the body, including the levator palpebrae muscle. This disease is called general muscle weakness, and one of the most important signs of this disease is eyelid drooping.
In addition, paralysis of the (sympathetic) nerve leads to weakness of one of the muscles of the upper eyelid, called the Müller muscle, and the injury occurs after inflammation or surgery
Third: Mechanical relaxation:
It results from heaviness and swelling in the size of the eyelid, so the muscle that lifts the eyelid cannot perform its function. The most important reasons for this are: the presence of swelling in the eyelid tissues, which results from chronic inflammation, including: multiple fatty cysts, trachoma, trachoma, or vernal conjunctivitis, as well as the presence of tumors in the eyelid, especially congenital tumors, or the presence of bleeding under the skin as a result of injuries or inflammations behind the eyeball.
Fourth: Traumatic relaxation:
This results from cuts or damage to the levator palpebrae muscle or the third cranial nerve that supplies it as a result of injury from sharp objects such as stab wounds, shrapnel, gunpowder, or burns of all kinds, or injury from a chemical substance.
Complications of eyelid ptosis:
In some cases, ptosis of the upper eyelid may lead to poor vision in the affected eye, due to the severity of the degree of ptosis in the eyelid, which covers the pupil in children, resulting in the eye becoming lazy, which is known as (functional lazy eye) or astigmatism, and in both cases this leads to severe visual impairment.
Causes of eyelid ptosis in the elderly:
The condition of the upper eyelid drooping, which partially or completely covers the eye, is known as eyelid ptosis. This condition is due to the weakness of the muscle that lifts the eyelid. This condition may be present from birth, but it can arise at any stage of life if the nerve that controls the eyelid muscle or the muscle itself is damaged. This disease is common among the elderly due to some diseases such as diabetes and cases of aneurysms inside the skull. Muscular diseases such as myasthenia gravis can also damage the muscle. In all of these cases, eyelid drooping may occur in one or both eyes, and its severity varies during the day. Finally, eyelid drooping may occur due to aging when the muscles of one or both upper eyelids weaken. It is noted that the eyelid condition is an aesthetically unacceptable appearance and can block the vision of the affected eye in severe cases.
Treatment of eyelid ptosis:
Eyelid ptosis has multiple causes, many of which can be remedied with early treatment. Therefore, the affected patient should be referred to an ophthalmologist as soon as possible to diagnose the cause and then decide on the treatment.
Treatment depends on the age of the affected child and the cause of the disease…
If the ptosis is complete, surgical intervention must be performed immediately before the child reaches the age of six months.
If the ptosis is partial, it is possible to wait until the child reaches the age of five years, and the condition may improve with the growth of the eyelid muscles… In both cases, surgical intervention is necessary by shortening the levator palpebrae muscle, i.e. until its strength increases in lifting the sagging skin.
In the case of complete paralysis of the levator muscle, another surgery is performed in which the upper eyelid is (suspended) by special threads in the forehead muscle above the eyebrow… so that whenever the child raises his eyebrow, he can lift the eyelid.
In cases of eyelid heaviness due to the presence of fatty cysts, vernal conjunctivitis, tumors, etc., a layered removal of the eyelid cartilage is performed to remove the cause and reduce the weight of the eyelid.
What are the signs and symptoms of ptosis?
The most common symptoms of ptosis in children are drooping and falling eyelids. This can be seen by the lack of symmetry in the extent of drooping between the eyelids. In some cases, children may have to tilt their heads back or lift their eyelids up to make room for vision. This condition indicates that the child is trying to see using both eyes. In addition, over time (several years), this abnormal position of the head and neck may lead to deformities in them.
What are the problems caused by drooping eyelids in children?
The most common serious problem associated with drooping eyelids is amblyopia. Drooping eyelids can lead to amblyopia for two reasons:
An obstacle that blocks vision in cases of severe drooping eyelids.
Astigmatism and blurred vision resulting from it
In addition, drooping eyelids may hide a squint (if present) that may later lead to amblyopia.
How is ptosis treated?
In most cases, ptosis in children is treated surgically. If it is accompanied by amblyopia, it may be necessary to bandage the healthy eye and use glasses and eye drops. Determining whether surgery is necessary and choosing the appropriate method depends on the following factors:
- Age of the child
- Affliction of one or both eyes
- The severity of the ptosis
- The strength of the eyelid levator muscles
- The position of eye movements
There is no need to perform surgery for mild and moderate ptosis in early age. On the other hand, these cases and severe cases that have undergone surgery should undergo regular periodic examinations in order to detect amblyopia, refractive errors, and other conditions related to the disease early and treat them.
What are the risks of ptosis surgery?
The risks of ptosis surgery include infection, bleeding, and poor vision, but these complications are rare. The patient may suffer from incomplete eye closure immediately after the operation, but this condition is usually temporary, and eye drops and ointments can be used to protect the eye during this period. Although the appearance of the eye will improve significantly after the operation, some disparity between the eyelids may remain that prevents a complete comparison between them. The affected eyelid will usually remain slightly higher than the healthy eyelid after the operation when looking down, and it will also remain slightly open during sleep, but neither condition is a complication that poses a problem for the patient. In rare cases, there may be a lack of eyelid movements after the operation, and in some other cases, the eye may need more than one surgery to complete the treatment.
Conclusion
Blepharoptosis, whether in children or adults, is treated surgically. This treatment also helps improve the patient’s vision level in addition to modifying the external appearance of the eye. It is also very important to conduct periodic examinations for children to prevent amblyopia and treat it if it occurs.
Congenital ptosis means the drooping of the upper eyelid only, which accompanies the child at birth.
The reason for this condition is that the levator muscle of the eyelid suffers from a congenital weakness in the ability to raise the eyelid.
In normal conditions, when a person looks forward, the upper eyelid covers only about 2 millimeters or one-fifth of the cornea. If the upper eyelid covers more than that, this is evidence that the eyelid is not in a normal condition.
In some cases, the drooping of the upper eyelid may be so severe that the eyelid covers the axis of vision, and the child cannot see unless he raises his eyelid with his hand or uses the forehead muscle to raise the eyelid or raises his head to be able to see properly.
This condition in children may lead to lazy eye, which is one of the serious complications of this disease and may be difficult to treat. This condition also leads to psychological damage to the child due to the effect of his appearance on this condition.
Diagnosis method and evaluation of the degree of eyelid ptosis:
Using a ruler, the area of the affected eye opening is compared to that of the healthy eye.
Thus, the degree of ptosis is calculated (pictured below).
Also, evaluating the function of the levator palpebrae muscle gives an idea of the degree of weakness of this muscle and the nature of the appropriate operation for each case (picture below).
Treatment depends on several factors:
1. The extent of relaxation.
2. The strength of the levator muscle.
Treatment:
These cases require surgical intervention after choosing the appropriate time, when there is coverage of the visual axis by the eyelid,
This case requires early surgical intervention to save the child’s vision.
The muscle is either strengthened by removing part of it and tightening the remaining part (picture below).
Muscle tightening operation:
Before the operation
After the operation
أو في حالات الفقد الكلي لعمل العضلة الرافعة للجفن يتم أيصال عضلة الجفن في عضلة الجبهة ليستخدمها المصاب لرفع الجفن (الصوره أدناه).
عملية ربط عضلة الجفن بالحاجب:
بعد العملية
قبل العملية
أما عندما يكون الهدول بسيط فانه يفضل أن تجرى العمليه تحت البنج الموضعي عندما يصبح الطفل في عمر مناسب ما أمكن وذلك كي يتم تقييم أرتفاع الجفن المناسب بمعاونه من المريض والذي يطلب منه فتح عينيه أثناء العمليه للتأكد من أنه تم اختيار الارتفاع المناسب.