A decade ago, the only option for patients with blepharoptosis—or drooping eyelids—was surgery. Today, oxymetazoline 0.1% offers solutions that help patients improve their vision without surgery.
Currently, about 13 million people in the U.S. suffer from ptosis, which equates to about one in every 10 patients you might see in your practice. But rather than make diagnosing ptosis another thing you need to add to your list, Selina McGee, OD, FAAO, Dipl ABO, and founder of Precision Vision of Edmond, believes that addressing ptosis is about thinking differently—and understanding how patients will best receive information about a potential ptosis diagnosis.
Ptosis can have a huge impact to a patient’s visual field. Typically, ptosis is measured with a Marginal Reflex Distance (MRD)1, which is the space between the upper eyelid margin and the corneal light reflex indicating the center of the pupil. When the MRD1 is less than 4mm, it can indicate a problem. Typically, every 2mm loss of MRD1 equates to a 24-30% reduction (or 12-15 degrees) in superior visual field loss. In patients older than 65, peripheral vision is more highly associated with falls than visual acuity, highlighting the importance of a healthy visual field.
“When we look at ptosis, our concern as optometrists is that it affects their vision, but that’s not all,” said Dr. McGee. “Ptosis can also impact their mental state and how they feel about themselves. A patient with ptosis might have an increased risk for falls, but they might also have appearance distress related to the fact that they don’t look the way they want to or the way they used to. We can’t overlook how important the psychosocial impact of ptosis is.”
Dr. McGee added that a patient with ptosis doesn’t only suffer physically from visual impairments. “Patients with ptosis tend to adopt coping mechanisms that can lead to bigger problems with headaches and neck issues because they have to tilt their chins to be able to see underneath their lids,” said Dr. McGee. “It’s our job to walk into the room, look at a patient, and notice the subtleties of where their lids sit, what their posture is like, and how their gait seems to you. I think it’s really important that we get comfortable with how we look at patients and what that intention behind it is so we can better address ptosis in the patient population we are already seeing every day.”
What you need to know about the levator muscle
“Remember there are two muscles that elevate the eyelids,” said Dr. McGee. “The Mueller’s muscle and levator muscle are elevated differently.” Acquired ptosis is more often a result of stretching, dehiscence, or disinsertion of the levator muscle complex,” said Dr. McGee. “The levator muscle has that junction where it inserts into the lid and becomes the lid crease. As we get older, there is a stretching, or disinsertion, of that levator complex. And that can cause ptosis.”
Questions to ask when diagnosing ptosis
Once other causes of ptosis are ruled out, including third nerve palsy, Homer’s syndrome, myasthenia gravis, tumors, a stroke, or a neurological problem, an OD can then move on to the following questions:
1. Is this a new onset?
2. Is this a unilateral new onset?
3. Is the pupil involved?
4. How old is the patient? Ptosis often correlates with age.
5. Can you rule out trauma as the cause of ptosis?
6. Are there potentially mechanical issues such as eyelid extensions or dermatochalasis (loose eyelid skin), which could be causing the ptosis?
7. How does the patient see at night? If lids are too low and less light is coming in, a patient’s vision will suffer.
8. Do their eyelids feel heavy or bother them?
What should you look for in your assessment?
“In my initial assessment, I look for an MRD1 of between four and five, as I define anything less than four as acquired ptosis.” said Dr. McGee. “The second thing I look at is lid platform, which is the distance between where the lid fold is to the lid margin. As you can imagine, if you have ptosis, that distance is going to be longer and longer, which gives the appearance of tiredness and sadness, especially in older patients. An increased distance in lid platform can also negatively impact the visual field, so I make sure I address that.”
“Don’t make this hard,” she advises. “Low-lying lids are relatively easy to identify with one, two, three, IAP.”
1,2,3 … IAP
- Look at how much iris is obstructed
- Is there asymmetry between the lids of each eye?
- How much lid platform is there?
Dr. McGee also recommends looking at faces in general to get a better idea of how the eyelids sit and what their position is compared to the brow. That way, it’s easier to spot a patient who falls outside of the norm.
How to optimize your patient conversation about ptosis
The best conversations begin with trust. If you identify key risk factors in your diagnosis, the first thing to do is trust yourself and your professional judgment. The next natural thing might be to ask your patients, “Do your eyelids feel heavy? Do they bother you?”
Dr. McGee includes a lifestyle questionnaire as part of her practice’s pre-testing workflow.
“Do you want your eyes to be more open?” she said. “That’s my key question. That way we can have a conversation. Sometimes patients don’t know that we have non-surgical options to help them, so they are hesitant to say anything. And that’s such a shame because now we have resources like Upneeq® to help them.”
Dr. McGee offers patients a sample of Upneeq in the office, so they can assess the impact for themselves.
“If the patient is eager to try Upneeq, I ask my technician to place a drop in the patient’s right eye,” she said. “It starts to work in about 15 minutes with a peak at about two hours. By the time a patient is finished with pre-testing and I begin their exam, it’s possible to see a difference in MRD1 between the two eyes. It’s a great way to have a meaningful conversation about ptosis and let a patient know what options are available.”
How do you know which patients can benefit from Upneeq?
Dr. McGee recommends that any time you are concerned that a patient’s ptosis may be narrowing their visual field, it’s important to talk about all available options for treatment of ptosis, especially if a patient is older and at risk for falls. Because many patients are adverse to surgery—especially those who may already have undergone a blepharoplasty—it’s important that they understand there are alternatives like Upneeq.
Dr. McGee’s challenge to optometrists
Dr. McGee’s talk ended with a simple challenge.“
When you go into the clinic, assess every single patient who walks through your door with one, two, three, IAP,” she said. “You’re going to look at how much iris you see. You’re going to look for asymmetry. And you’re going to look at that lid platform and determine how shallow or long that is. Whether your patients have issues with the appearance of their eyes, or their visual field is compromised because of ptosis, it’s important to start talking about solutions that benefit our patients.”