Aponeurotic: Involutional Ptosis

Over the years, a 78-year-old man hadnoticed a progressive drooping of theright upper eyelid, which finally occludedhis right pupil and obstructedhis vision. Although the droopingworsened as the day went on, the ptosiswas evident even when the patientawoke in the morning. He denied anyophthalmic or periocular surgery ortrauma. He was otherwise healthy andhad no other neurologic complaints.

Ptosis of aging (involutional ptosis)is caused by a gradual loss of toneof both the levator aponeurosis muscleand Mueller muscle. This weaknessmay be a localized dehiscence ordisinsertion or a more generalized attenuationor stretching. The ptosis isusually bilateral but may be unilateral,as in this patient (A). A classic sign oflevator dehiscence or disinsertion isgood levator function. Test for this byhaving the patient look up; the ptoticeyelid rises accordingly (B).

Other signs, all seen in this patient,include compensatory elevationof the brow, high or absent upper lidcrease, and lateral shift of the tarsalplate (A).

Some persons with acquired ptosisalso have associated atrophy oftheir orbital fat and loss of lid supportfrom a secondary enophthalmos. Theypresent with thinning of the eyelidsabove the tarsal plates and deep,sunken sulci, as seen in a differentpatient (C).

Levator resection, in which thelevator aponeurosis is reattachedto the tarsal plate, can correct theproblem.