Traumatic Ptosis

Etiology

• Traumatic ptosis can be neurogenic, aponeurotic, myogenic, or mechanical in nature.
• Pseudoptosis can mimic these phenomena.
• Iatrogenic causes account for roughly 50% of traumatic blepharoptosis (Crawford, Can J Ophthalmol 1974).
• Multiple possible factors have been suggested for ptosis after cataract surgery.
• Classically, felt to be associated with levator dehiscence
• Bridle suture placement
• Myotoxicity from anesthesia (Song, Korean J Ophthalmol 1996)
• After oculoplastic surgical procedures
• Postoperative edema or hematoma can create a mechanical ptosis.
• Trauma to levator muscle, particularly during blepharoplasty (Bernardino, Semin Ophthalmol 2002)
• Full-thickness resection can cause direct damage to levator muscle or Muller muscle (Altieri, Ophthalmologica 2005).
• Resection of conjunctival tumors can create a symblepharon, dragging the eyelid into a ptotic position (Bosniak, 1990).
• After administration of botulinum toxin
• Can create a self-limited ptosis with impaired levator function
• Incidence reported to be 5.4% (Henderson, Dev Ophthalmol 2008).
• After strabismus surgery
• Superior rectus advancements can result in ptosis.
• Classically, avoided with meticulous dissection (Altieri, Ophthalmologica 2005)
• Birth trauma
• Classically, thought to be related to levator dehiscence (Carruthers, J Am Acad Dermatol 2002)
• Blunt trauma (Figure 1)
• Edema of levator
• Dehiscence of levator
• Generally, self-limited (Altieri, Ophthalmologica 2005)

Figure 1. Blunt trauma. Courtesy Evan H. Black, MD.

• Penetrating/lacerating trauma (Figure 2)
• Occurs in setting of direct injury to the levator muscle
• Classically, immediate exploration with restoration of appropriate anatomy facilitates resolution of ptosis (Putnam, 1995)

Figure 2. Lacerating trauma. Courtesy Evan H. Black, MD.

• Associated with facial fractures
• Facial fractures can result in enophthalmos, creating the appearance of ptosis (Altieri, Ophthalmologica 2005).
• With orbital roof fractures, pieces of bone can abut levator muscle, resulting in ptosis and necessitating surgical repair (Berke, Am J Ophthalmol 1971).
• Neurogenic causes
• Cranial nerve III palsy
• Typically, associated with blunt trauma to the head, most commonly due to motor vehicle accident (Fulcher, Ophthal Plast Reconstr Surg 2003)
• Generally, complete ptosis
• Ptosis often resolves after one year, although aberrant regeneration occurs in roughly 50% of cases (Lin, J Neurosurg 2013).
• Superior orbital fissure syndrome
• Involves cranial nerves III, IV, V, and VI
• Rare finding in setting of craniofacial fractures (0.3%) (Krohel, Am J Ophthalmol 1979)
• Can be associated with Lefort II or III fractures and with zygomatic complex and frontobasal skull fractures (Chen, Craniomaxillofac Trauma Reconstr 2010)

Figure 3. Courtesy Anne Barmettler, MD.

Epidemiology

• Traumatic ptosis has been reported to account for 11.2% of blepharoptosis in a tertiary care oculoplastic surgery setting (Lim, Orbit 2013).
• Intraocular surgery
• 4–12% after cataract surgery procedures (Mehat, Orbit 2012, Altieri, Ophthalmologica 2005, Boyle, 2011)
• Extracapsular cataract extraction is associated with a greater incidence of postoperative ptosis than phacoemulsification (Puvanachandra, Orbit 2010).
• 10.7% rate of ptosis after trabeculectomy alone and 12.7% rate after combined trabeculectomy/phacoemulsification (Song, Korean J Ophthalmol 1996)

History

• Mechanism of injury
• Intraocular or adnexal surgery

Clinical features

• Decreased upper eyelid marginal reflex distance
• In mechanical ptosis, evidence of eyelid edema or ecchymosis
• Neurogenic causes are associated with abnormalities of eyelid motility.
• Levator function can be decreased or normal (depending on etiology).
• Possible symblepharon
• Possible enophthalmos
• Possible entry wound or scar tissue

Testing

• Complete ophthalmic examination, ruling out evidence of intraocular trauma and ruptured globe
• Complete review of appropriate orbital and intracranial imaging
• Assess marginal reflex distance, motility, and levator function
• Check eyelid crease presence and height.
• In cases of acute trauma, assess for prolapsed orbital fat.

Depends on etiology

Nontraumatic ptosis

Pseudoptosis

Natural history

• The management depends critically on the etiology and clinical findings, making meticulous evaluation critical.

Medical therapy

• None

Radiation

• None

Surgery

• Cases related to upper eyelid lacerations necessitate immediate exploration and reapproximation of the levator muscle, when possible (Natl J Maxillofac Surg 2012).
• Prolapsed orbital fat indicates that the septum has been violated.
• In cases of muscle slippage or difficulty identifying the muscle, surgeons should identify Whitnall’s ligament because the levator muscle should be directly adjacent.
• Severe edema can make delineation of the muscle difficult.
• Once suspected levator muscle is identified, the tissue can be grasped with a forceps.
• By asking the patient to look up, tension on the grasped tissue strongly suggests that the surgeon has located the levator muscle.
• Classically, delayed repair is associated with scarring, making such interventions more difficult; surgeons should attempt repair at the time of the initial trauma (Silkiss, Adv Ophthalmic Plast Reconstr Surg 1987).
• Ptosis that is related to mechanical causes (i.e., edema) should be observed until the underlying etiology has resolved; cases of mechanical ptosis from blunt trauma recover without intervention in the majority of cases.
• Many authorities advocate waiting at least 3 to 6 months for resolution of postoperative ptosis prior to repair; the outcomes of postoperative ptosis repair are generally favorable and are generally consistent with involutional ptosis repair.
• Neurogenic ptosis
• Typically, many of these patients experience spontaneous resolution (Lin, J Neurosurg 2013).
• Consequently, surgical repair is generally delayed for one year.

Other management considerations

• None

Common treatment responses, follow-up strategies

• In cases of poor levator function (less than 5 mm), consider frontalis sling procedure.
• With better levator function, consider levator advancement.

1. Altieri M, Truscott E, Kingston AE. Ptosis secondary to anterior segment surgery and its repair in a two-year follow-up study. Ophthalmologica. 219(3):129-35, 2005.
2. Berke RN. Surgical treatment of traumatic blepharoptosis. Am J Ophthalmol, 72: 691-8, 1971.
3. Bernardino CR and Rubin PAA. Ptosis after cataract surgery. Semin Ophthalmol, 17: 144-8, 2002.
4. Bosniak SL. Complications: diagnosis and treatment. Cosmetic blepharoplasty. New York: Raven, 1990.
5. Boyle NS and Chang EL. Traumatic blepharoptosis. In: Cohen AJ and Weinberg DA (eds), Evaluation and Management of Blepharoptosis, New York: Springer, 2011.
6. Carruthers JA, Lowe NJ, Menter MA, et al. A multicenter, double-blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines. J Am Acad Dermatol, 46: 840-9, 2002.
7. Chen C, Chen Y. Traumatic superior orbital fissure syndrome: Current management. Craniomaxillofac Trauma Reconstr, 3:9–16, 2010.
8. Crawford JS. Ptosis as a result of trauma. Can J Ophthalmol, 9: 244-8, 1974.
9. Fulcher TP and Sullivan TJ. Orbital roof fractures: management of ophthalmic complications. Ophthal Plast Reconstr Surg, 19: 359-63, 2003.