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Ophthalmology

Ptosis (Blepharoptosis) in Adults Differential Diagnoses

Updated: Aug 14, 2017
  • Author: Adam J Cohen, MD; Chief Editor: Hampton Roy, Sr, MD  more…
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Sections
Ptosis (Blepharoptosis) in Adults
  • Sections
    Ptosis (Blepharoptosis) in Adults
  • Overview
    • Background
    • Pathophysiology
    • Epidemiology
    • Show All
  • Presentation
    • History
    • Physical
    • Causes
    • Show All
  • DDx
  • Workup
    • Laboratory Studies
    • Imaging Studies
    • Other Tests
    • Show All
  • Treatment
    • Medical Care
    • Surgical Care
    • Consultations
    • Show All
  • Follow-up
    • Further Outpatient Care
    • Inpatient & Outpatient Medications
    • Complications
    • Patient Education
    • Show All
  • Media Gallery
  • References

DDx

Differential Diagnoses

  • Anophthalmos

  • Apex Orbital Fracture

  • Apraxia of Lid Opening

  • Atopic Dermatitis in Emergency Medicine

  • Bell Palsy

  • Benign Essential Blepharospasm

  • Capillary Hemangioma

  • Chalazion

  • Chronic Progressive External Ophthalmoplegia (CPEO)

  • Congenital Ptosis

  • Corneal Foreign Body

  • Duane Syndrome

  • Emergency Care of Corneal Abrasion

  • Emergent Management of Myasthenia Gravis

  • Exophthalmos (Proptosis)

  • Eyelid Laceration

  • Orbital Floor Fractures (Blowout Fractures)

  • Giant Papillary Conjunctivitis

  • Horner Syndrome

  • Lyme Disease

  • Marcus Gunn Jaw-winking Syndrome

  • Multiple Sclerosis

  • Neuro-ophthalmic History

  • Third Nerve Palsy (Oculomotor Nerve Palsy)

  • Ophthalmologic Manifestations of Neurofibromatosis Type 1 (NF-1)

  • Orbital Cellulitis

  • Preseptal Cellulitis

  • Thyroid Ophthalmopathy

Workup

 
References

  1. Collin JRO. Ptosis. Manual of Systematic Eyelid Surgery. Oxford, England: Butterworth-Heinemann; 1999. 41-72.

  2. Sakol PJ, Mannor G, Massaro BM. Congenital and acquired blepharoptosis. Curr Opin Ophthalmol. 1999 Oct. 10(5):335-9. [Medline] .

  3. Beard C. Types of ptosis. Beard C, ed. Ptosis. 3rd ed. St. Louis: Mosby; 1981. 39-76.

  4. Cohen AJ, Weinberg DA, eds. Evaluation and Management of Blepharoptosis. 1st. New York, NY: Springer-Verlag; 2010.

  5. Golnik KC, Pena R, Lee AG, Eggenberger ER. An ice test for the diagnosis of myasthenia gravis. Ophthalmology. 1999 Jul. 106(7):1282-6. [Medline] .

  6. Glatt HJ, Fett DR, Putterman AM. Comparison of 2.5% and 10% phenylephrine in the elevation of upper eyelids with ptosis. Ophthalmic Surg. 1990 Mar. 21(3):173-6. [Medline] .

  7. Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. Philadelphia: WB Saunders; 1994. 120-5.

  8. Levine MR. Manual of Oculoplastic Surgery. Oxford, England: Butterworth-Heinemann; 1996. 75-105.

  9. Putterman AM. Cosmetic Oculoplastic Surgery Eyelid, Forehead, and Facial Techniques. London: WB Saunders; 1999. 137-59.

  10. Frueh BR, Musch DC, McDonald H. Efficacy and efficiency of a new involutional ptosis correction procedure compared to a traditional aponeurotic approach. Trans Am Ophthalmol Soc. 2004. 102:199-206; discussion 206-7. [Medline] .

  11. Frueh BR, Musch DC, McDonald HM. Efficacy and efficiency of a small-incision, minimal dissection procedure versus a traditional approach for correcting aponeurotic ptosis. Ophthalmology. 2004 Dec. 111(12):2158-63. [Medline] .

  12. Tsa CC, Li TM, La CS, et al. Use of orbicularis oculi muscle flap for undercorrected blepharoptosis with previous frontalis suspension. Br J Plast Surg. 2000 Sep. 53(6):473-6. [Medline] .

  13. Goldey SH, Baylis HI, Goldberg RA, et al. Frontalis muscle flap advancement for correction of blepharoptosis. Ophthal Plast Reconstr Surg. 2000 Mar. 16(2):83-93. [Medline] .

  14. Arslan E, Demirkan F, Unal S, et al. Enhanced frontalis sling with double-fixed, solvent-dehydrated cadaveric fascia lata allograft in the management of eye ptosis. J Craniofac Surg. 2004 Nov. 15(6):960-4; discussion 965-6. [Medline] .

  15. Carter SR, Meecham WJ, Seiff SR. Silicone frontalis slings for the correction of blepharoptosis: indications and efficacy. Ophthalmology. 1996 Apr. 103(4):623-30. [Medline] .

  16. Emsen IM. A new ptosis correction technique: a modification of levator aponeurosis advancement. J Craniofac Surg. 2008 May. 19(3):669-74. [Medline] .

  17. Waqar S, McMurray C, Madge SN. Transcutaneous blepharoptosis surgery – advancement of levator aponeurosis. Open Ophthalmol J. Dec 2010. 14:4:76-80. [Medline] .

  18. Baroody M, Holds JB, Sakamoto DK, Vick VL, Hartstein ME. Small incision transcutaneous levator aponeurotic repair for blepharoptosis. Ann Plast Surg. jun 2004. 52(6):558-561. [Medline] .

  19. Park DH, Baik BS. Advancement of the Müller muscle-levator aponeurosis composite flap for correction of blepharoptosis. Plast Reconstr Surg. 2008 Jul. 122(1):140-2. [Medline] .

  20. Dinges WL, Witherspoon SR, Itani KM, Garg A, Peterson DM. Blepharoptosis and external ophthalmoplegia associated with long-term antiretroviral therapy. Clin Infect Dis. 2008 Sep 15. 47(6):845-52. [Medline] .

Media Gallery
  • Patient with bilateral ptosis before surgery. Note the high lid creases.
  • Same patient as in the previous image after bilateral internal levator advancement. No skin incision was made, and no crease reformation was performed.
  • Anterior approach to the levator. White band is the levator aponeurosis (arrow).
  • Left ptosis. Lid crease is absent on the left. The crease is up in the sulcus. Superior sulcus deformity is present on the left and right, and the patient is elevating her brows. The right upper lid should be checked for an underlying or masked ptosis. If the right lid is ptotic, lifting the left lid causes the right lid to droop.
  • Visual field shows functional blockage of superior visual field due to a ptotic lid. Hashed line represents the superior extent of the seen visual field with the lid lifted. Solid line is with the lid in its natural, ptotic position.
  • Congenital ptosis on right. Note the presence of a lid crease.
  • Glasses with a crutch attached (arrow) that can be used to lift the lid if the patient does not desire surgery.
  • Patient with myasthenia gravis. Right lid is more ptotic than the left lid.
  • Same patient as in the previous image, 3 months later. Note how the ptosis has changed and is more on the left than the right.
  • Patient with bilateral ptosis before surgery.
  • Same patient as in the previous image after internal levator advancement. Patient has excessive skin (dermatochalasia) after the lid was lifted, with a pseudoptotic effect more on the left than the right. The dermatochalasia was present before surgery but is more significant afterward. Patient also has brow ptosis.

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    Contributor Information and Disclosures

    Author

    Adam J Cohen, MD Physician/CEO, Eyelid and Facial Plastic Surgery and MediSpa

    Adam J Cohen, MD is a member of the following medical societies: American Academy of Ophthalmology , American Society of Ophthalmic Plastic and Reconstructive Surgery

    Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Mimedx.

    Coauthor(s)

    Michael Mercandetti, MD, MBA, FACS Private Practice

    Michael Mercandetti, MD, MBA, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery , Sarasota County Medical Society , American Academy of Ophthalmology , American College of Surgeons , American Society for Laser Medicine and Surgery , American Society of Ophthalmic Plastic and Reconstructive Surgery , Association of Military Surgeons of the US

    Disclosure: Nothing to disclose.

    Specialty Editor Board

    Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

    Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology , Association for Research in Vision and Ophthalmology , American Glaucoma Society

    Disclosure: Nothing to disclose.

    J James Rowsey, MD Former Director of Corneal Services, St Luke’s Cataract and Laser Institute

    J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology , American Association for the Advancement of Science , American Medical Association , Association for Research in Vision and Ophthalmology , Florida Medical Association , Sigma Xi , Southern Medical Association , Pan-American Association of Ophthalmology

    Disclosure: Nothing to disclose.

    Chief Editor

    Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

    Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology , American College of Surgeons , Pan-American Association of Ophthalmology

    Disclosure: Nothing to disclose.

    Additional Contributors

    Ron W Pelton, MD, PhD Private Practice, Colorado Springs, Colorado

    Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology , American College of Surgeons , AO Foundation , American Society of Ophthalmic Plastic and Reconstructive Surgery , Colorado Medical Society

    Disclosure: Nothing to disclose.

    Close
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    • Sections
      Ptosis (Blepharoptosis) in Adults
    • Overview
      • Background
      • Pathophysiology
      • Epidemiology
      • Show All
    • Presentation
      • History
      • Physical
      • Causes
      • Show All
    • DDx
    • Workup
      • Laboratory Studies
      • Imaging Studies
      • Other Tests
      • Show All
    • Treatment
      • Medical Care
      • Surgical Care
      • Consultations
      • Show All
    • Follow-up
      • Further Outpatient Care
      • Inpatient & Outpatient Medications
      • Complications
      • Patient Education
      • Show All
    • Media Gallery
    • References

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