August 19, 2022
4 min read
As an eye care provider, I know it can be frustrating to identify an ocular abnormality without a readily available treatment.
Until recently, ptosis was one of those conditions. Patients with ptosis previously had the option of doing nothing or having surgery. A surgical procedure can benefit select patients, but for many the idea of eyelid surgery is daunting. And although adverse outcomes are rare with contemporary surgical strategies, they can occur.
We now have an effective third option — the first FDA-approved pharmaceutical treatment Upneeq (oxymetazoline HCl ophthalmic solution 0.1%, RVL Pharmaceuticals) indicated for acquired blepharoptosis in adults. When we present the options to patients, many who are good candidates opt for the drop approach.
What is blepharoptosis?
Blepharoptosis, or ptosis, refers to a low-lying or drooping upper eyelid margin when the eye is in primary gaze. We think of ptosis as being a cosmetic problem with important psychosocial ramifications, but it also can have significant effects on visual function. Marginal reflex distance 1 (MRD-1) is the distance from the central pupillary light reflex to the central margin of the upper eyelid. Visual field impairment can occur when MRD-1 is less than 4 mm, and an MRD-1 of 2 mm can impair superior visual field by 24% to 30% (Cahill, et al.).
The condition’s severity depends upon the degree of ptosis. It can be unilateral or bilateral, congenital or acquired. Congenital ptosis is typically the result of developmental myopathy of the levator muscle or innervation abnormality. The acquired form, appearing later in life due to a variety of causes, is more common. Mild to moderate ptosis affects about 12% of the population older than 50 years (Sridharan, et al.; Kim, et al.).
In our office, we have patients undergo a visual field screening as part of their pretesting, which immediately identifies any deficits in the superior visual field. We also perform confocal fundus imaging on patients presenting for their eye exam. In patients with ptosis, there will be a shadow that forms at the bottom of the fundus image. This is representative of structures that are blocking light from getting to the pupil in the superior portion of the patient’s field of view. Not only can we correlate the shadow with ptosis, but we also can clearly see if patients have more differences in ptosis between the two eyes. Their fundus images are representative of that, with shadows extending higher in the fundus image as the lid position lowers.
We also use anterior segment imaging (TelScreen) to demonstrate improvement in lid position that occurs after instilling oxymetazoline HCl 0.1%. The before image shows lid placement with respect to the pupil. After treatment, we redo the imaging and observe a rather remarkable shift, showing the patient how much difference there is in lid position.
For these ptosis patients, we offer a trial of oxymetazoline HCl 0.1% in the office. Patients can observe the cosmetic improvement in their lids. We also recapture the fundus images so they can see the portion of the image that has improved by the lack of a shadow. This demonstrates the gain in visual field for the patient as more light is allowed in the eye.
Along with the improvement in vision, patients frequently comment that their eyes feel better and “less tired.” In my experience, the patients who receive visual benefit become daily users of the drop. What has also been interesting is that they feel they get better efficacy from the drops when they use them consistently.
Ocular surface, blink improvements
One unexpected finding has been some patients reporting an improvement in their ocular surface disease symptoms. Intuitively, one might think that lifting a lid would create more exposure and therefore more discomfort. But for some patients, it is quite the opposite. Video of these patients clearly shows a more robust, faster blink 15 minutes after the drop is placed in the eyes compared with before the drop was instilled. It may be that the blink is allowing for more efficient tear film coating on the eye.
Importantly, ptosis treatment also has wide-ranging implications for patients with coexisting conditions that compromise their visual field, thereby mitigating some of the impact of the comorbidity. These include age-related macular degeneration, epiretinal membrane and vitreomacular traction, in addition to forms of optic neuropathy such as glaucoma. Any gain in visual field is critically important to these patients, adding functionality.
When it comes to patient conversations, the biggest challenge is getting patients to understand how a topical eye drop — delivered to the ocular surface — can lift their lid. I tell them that every single muscle in your body is controlled by a nerve, including your eyelid muscle. Over time in some people, that nerve’s ability to communicate with the lid muscle diminishes, which leads to eyelid drooping. The good news is we now have a drop that delivers a compound through the inside of the eyelid to the muscle, which improves its position.
With an effective pharmaceutical treatment for ptosis in our toolbox, we now can feel much more confident when identifying the condition in our patients. This attractive third option can provide obvious aesthetic benefits for our patients, but, even more powerfully, help them regain visual function by improving their visual field.
- Bacharach J, et al. Eye (Lond). 2021;doi:10.1038/s41433-021-01547-5.
- Cahill KV, et al. Ophthalmic Plast Reconstr Surg. 1987;doi:10.1097/00002341-198703030-00001.
- Cahill KV, et al. Ophthalmology. 2011;doi:10.1016/j.ophtha.2011.09.029.
- Finsterer J. Aesthetic Plast Surg. 2003;doi:10.1007/s00266-003-0127-5.
- Ho SF, et al. Eye (Lond). 2011;doi:10.1038/eye.2010.210.
- Kim MH, et al. Eye (Lond). 2017;doi:10.1038/eye.2017.43.
- Richards HS, et al. Eye (Lond). 2014;doi:10.1038/eye.2013.264.
- Slonim CB, et al. JAMA Ophthalmol. 2020;doi:10.1001/jamaophthalmol.2020.3812.
- Sridharan GV, et al. Age Ageing. 1995;doi:10.1093/ageing/24.1.21.
For more information:
Mile Brujic, OD, FAAO, is a partner with Premier Vision Group in Bowling Green, Ohio. He can be reached at email@example.com.