Ptosis: the disease of drooping of the upper eyelids
Also called palpebral ptosis or blepharoptosis, the ptosis corresponds to the sagging of the upper eyelids. “The upper eyelid is mobile and is raised by the action of the upper eyelid muscle and innervated by nerve III” (note 3rd cranial nerve or common oculomotor nerve), recalls Dr. Mahjoub.
Dr. Donia Mahjoub, neurologist: Ptosis therefore corresponds to functional impotence, more or less significant, of the levator muscle of the eyelid which can be linked to a lesion of the muscle, its aponeurosis or nerve connections.
He can touch one eye or bothand be congenital or acquired.
What are the different neurological causes of droopy eyelids?
When he is congenitalthe ptosis is related to the impotence of its levator muscle, generally consecutive to its dystrophy.
When it occurs during life, it can have different causes.
A carotid dissection
Carotid artery dissection refers to a tear in the wall of this artery, which carries blood to the brain. It is usually caused by an extension of the neck, following a choc or to a sudden movement when practicing a sport. “This tear causes ptosis, which is associated oculomotor muscle paralysisand lack of accommodation of the pupil and neck pain”, describes the neurologist.
A stroke
The cerebrovascular accident (CVA) corresponds to a sudden neurological deficit of vascular origin. It can cause eye symptoms of several types, including Claude Bernard-Horner syndrome. It is observed mainly in strokes by carotid dissection, and is characterized by ptosis, which is associated with a narrowing of the pupils (miosis) and a sinking of the eyes into the sockets called enophthalmos.
Diabetes
The ptosis caused by diabetes is peripheral and painful, linked to a nerve III mononeuropathy. It then occurs suddenly, in a few hours, on the ground type 2 diabetic often light, even unrecognized. It is then indicative of diabetes.
Progressive external ophthalmoplegia
Progressive external ophthalmoplegia is a mitochondrial disease which affects the muscles, causing muscle weakness, pain and fatigue. Ptosis is one of the common symptoms. “This ptosis is usually bilateral, and is often accompanied byother paralyzes sometimes with a heart damagea epilepsy and an laryngeal involvement“, explains Dr. Mahjoub.
A myasthenia gravis
Myasthenia gravis is a rare autoimmune diseasescharacterized by a dysfunction of the neuromuscular transmission at the origin of a ptosis and a diplopia (split vision) of fluctuating evolution during the day.
“No myasthenic ptosis can appear with the slightest muscular effort or an effort of attention. It can be unilateral, bilateral or rocking”, indicates the neurologist. This disease presents risks of attack of the respiratory muscles and therefore requires a follow-up with the neurologist.
Aging: dermatochalasis
Finally, damage to the levator muscle can be caused by the agingto which is added the loss of skin elasticity : We are talking regarding dermatochalasis. It is a common pathology that affects a large part of the population. It can be responsible for visual discomfort, by limiting the upper visual field.
Steinert’s disease
Steinert’s disease is caused by a genetic abnormality located on the chromosome 19. This is the high quantity repetition of a small DNA sequence (triplet of CTG nucleotides) at the level of the DMPK gene. It usually starts around 30 years oldbut may occur earlier from adolescence. It manifests as muscle damage with muscle weakness and muscle atrophy.
Why do I have one eye smaller than the other because of a heavy eyelid?
When the drooping of the upper eyelid is unilateral and sudden onsetit is usually secondary to thedamage to nerve III. The two main causes are then stroke and the diabetes.
“A unilateral ptosis and sudden onset is to be treated urgently, because it can reveal a CVA. It is absolutely necessary to do an imaging examination (IRM of the skull and the vessels of the neck) to make the diagnosis”, insists the neurologist. The neurologist and the ophthalmologist will make a joint assessment to determine the cause of the ptosis.
If the stroke is ruled out and the ptosis is linked to diabetes, the patient should be reassured: this ptosis is unsightly but not serious. It will normally regress spontaneously once the diabetes is regulated.
How to cure ptosis?
The management of ptosis of course depends on underlying cause. Very often, the treatment of the cause allows a spontaneous regression of the ptosis.
- “When she is following a strokethe patient is treated in a vascular unit and it is the treatment of the CVA that will make the symptomatology regress, if the care was taken early”, explains Dr. Mahjoub. Otherwise, a surgical intervention may later prove to be necessary.
- The diabetic ptosis tends to regress spontaneously with diabetes treatment, when blood sugar is regulated.
- In case of myasthenia gravis, management must be urgent to avoid damage to the respiratory muscles. Treatment is with anticholinesterases.
- During a carotid dissection : Antithrombotic treatment is necessary to prevent stroke or recurrence. This treatment includes anticoagulants or antiplatelets.
- “Alone ptosis linked to a genetic mitochondrial diseaseor to agingare finally surgically treated without any other specific treatment”, concludes the neurologist.
Operation: how to raise and enhance droopy eyelids?
When the ptosis is disabling and results in a significant upper visual field deficit or reading difficulties, surgery is recommended. It is then decided jointly between the doctor and the patient.
Three types of surgery are offered:
- the shortening or kinking : which consists of repositioning the levator muscle via an external transcutaneous route,
- the suspension au muscle frontal externally,
- the conjunctivo-Mullerian resection internally transconjunctivally, for the lightest ptosis.
One or the other of these techniques will be proposed according to the type and degree of ptosis as well as the more or less good functionality of the levator muscle of the eyelid.
The intervention takes place on an outpatient basis under thorough local anesthesia and in the operating room,