Blepharoptosis (or ptosis) is an abnormal drooping of the upper eyelid that may be unilateral or bilateral. Ptosis affects approximately 13.5% of adults, and the risk of developing the condition increases with age; it occurs in as many as 32.8% of individuals older than 70 years of age.1-4 Although common, the condition is widely underdiagnosed and underappreciated by eye care practitioners, largely owing to a lack of treatment options. That may change with the availability of a noninvasive pharmaceutical option that can make a substantial difference for many patients.
HOW PTOSIS AFFECTS PATIENTS
Ptosis can make patients look older than they are and give them a sleepy appearance.5,6 Some eye care specialists dismiss the condition as an unimportant cosmetic concern, but ptosis can have a significant effect on patients’ well-being (see Assessing the Lid, Talking to Patients). Individuals with ptosis often report increased levels of distress, anxiety, and depression related to their appearance.7,8 Perhaps more important is that a droopy lid can obstruct the pupil, thereby reducing quality of vision by creating a deficit of the superior visual field, reducing contrast sensitivity, and increasing higher-order aberrations. Increased higher-order aberrations is of particular importance with regard to presbyopia-correcting IOLs.9-11 Compromised vision can significantly reduce patients’ health-related quality of life.7 Among individuals older than 65 years of age, every 10% loss of visual field equates to an 8% greater risk of falling.12
WHAT CAUSES PTOSIS?
Two muscles are responsible for elevating the upper eyelid: the levator and the superior tarsal, or Müller muscle. Ptosis is either congenital or acquired; the latter being the predominant form. Acquired ptosis is further classified by its etiology, which is aponeurotic, myogenic, neurogenic, mechanical, or traumatic in origin. Acquired aponeurotic ptosis results from stretching, dehiscence, or detachment of the levator muscle and is typically associated with aging.5,13,14 Ptosis, however, can also be a sign of a serious underlying condition, which is another reason why eye care specialists should not dismiss the condition.
Patients with ptosis typically have a reduced marginal reflex distance (MRD-1), a high upper eyelid crease, nearly normal levator function, and a decreased palpebral fissure distance.14 The MRD-1 measures the distance between the central pupillary light reflex and the upper lid margin in primary gaze (see Do Not Overlook the Pupil). Some physicians measure levator function in their evaluation of ptosis. Visual field testing can also be conducted. An average MRD-1 is 4 mm to 5 mm. The upper lid margin should touch the top edge of the iris or cover maybe 1 mm of the top iris. A visual field defect or impairment can occur when the MRD-1 is less than 4 mm. A patient who has an MRD-1 of 2 mm, for example, is experiencing a 24% to 30% impairment of the superior visual field.15
TOPICAL DROPS STIMULATE ALPHA-ADRENERGIC RECEPTORS
Oxymetazoline 0.1% (Upneeq, RVL Pharmaceuticals) was approved in 2020 as the first and only pharmaceutical to treat acquired blepharoptosis in adults. Ocular application of oxymetazoline is thought to stimulate the alpha-adrenergic receptors on Müller muscle, resulting in contraction and eyelid elevation. Treatment can also whiten the eye by constricting the vessels in the conjunctiva.
There were two randomized, double-masked, placebo-controlled multicentered phase 3 clinical trials evaluating the efficacy of oxymetazoline for treating acquired ptosis. Both studies demonstrated a significant improvement in superior visual field defects and upper eyelid elevation (MRD-1) compared to baseline. The safety of oxymetazoline 0.1% and the vehicle was comparable.16
A MEDICAL OPTION FOR THE WIN
When the problems that ptosis causes are addressed, patients experience a significant improvement in overall quality of life and vision, including peripheral vision.17 The advent of a pharmaceutical medication to treat acquired blepharoptosis in adults gives providers an opportunity to intervene earlier in a patient’s life and potentially restore quality of vision without surgery.
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