Topical Review: An Update of Diagnostic and Management Algorithms for Acquired Blepharoptosis

Abstract

SIGNIFICANCE:Acquired ptosis is a condition of the upper eyelid that has negative cosmetic and functional effects but is likely underdiagnosed and undertreated. Given the evolving understanding of the condition and expanding therapeutic options, this review reappraised published evidence and clinical experience regarding diagnosis and treatment of acquired ptosis.The authors met over two structured virtual working sessions to review current evidence and develop timely recommendations for acquired ptosis identification, differential diagnosis, characterization, and treatment selection. Diagnostic algorithms, plus management and referral guidelines, are presented. Eyelid evaluation and, when needed, ptosis diagnostic workup are essential in the comprehensive eye examination. Acquired ptosis can be efficiently identified via patient questionnaire, history, and photograph review combined with assessment of eyelid position and symmetry using established methods. When ptosis is present, it is essential to evaluate onset, symptoms, pupil diameter, and extraocular muscle function to identify or rule out serious underlying conditions. If signs of serious underlying etiology are present, immediate referral/follow-up testing is required. After ruling out serious underlying causes, masquerade conditions, and pseudoptosis, pharmacologic or surgical treatment should be selected based on the clinical evidence. Effectively managing acquired ptosis requires practice-wide commitment to thorough eyelid evaluation, accurate diagnosis, and adoption of new treatment modalities. Aided by evolving pharmacologic therapeutic options, shifting from a "detect and refer" to a "diagnose and manage" approach can support identification and treatment of more patients with acquired ptosis, particularly mild-to-moderate cases.

The Prevalence and Severity of Acquired Blepharoptosis in US Eye Care Clinic Patients and Their Receptivity to Treatment

“…Acquired ptosis is a condition of the upper eyelid that has negative cosmetic and functional effects and may affect patient well-being, including increased appearance-related anxiety and depression; 1 however, it is likely underdiagnosed and undertreated. 1 , 6 Acquired ptosis is most commonly caused by a progressive, age-related stretching, dehiscence, or detachment of the levator muscle complex known as aponeurotic ptosis. 6 , 8 The underlying etiology can also be myogenic, neurogenic, mechanical, or traumatic.…”

“… 1 , 6 Acquired ptosis is most commonly caused by a progressive, age-related stretching, dehiscence, or detachment of the levator muscle complex known as aponeurotic ptosis. 6 , 8 The underlying etiology can also be myogenic, neurogenic, mechanical, or traumatic. Ocular surgery can also contribute to the development of transient or more persistent forms of ptosis.…”

“…For example, in Horner syndrome, ptosis is typically mild but can be secondary to trauma, tumor, or carotid dissection. 6 Increased patient awareness about ptosis is expected to enable early identification and subsequent treatment. As such, evaluation of the eyelid position should be a standard part of the comprehensive eye examination.…”

“…As such, evaluation of the eyelid position should be a standard part of the comprehensive eye examination. 6 …”

“… 5 Despite its negative impact on patients’ vision as well as physical appearance, ptosis is likely underdiagnosed and underreported since treatments were historically limited to a surgical correction, with intervention only at more severe stages and for functional indications. 6 , 7 Moreover, eyelid measurements for ptosis are not routinely performed as part of the comprehensive eye examination.…”