Abstract  The surgical treatment of blepharoptosis is in most cases dependably effective and safe; by comparison, nonsurgical treatment generally provides less satisfactory results and can be difficult for the patient to tolerate. Therefore, relatively few patients will prefer medical treatment for symptomatic, chronic ptosis, except as a temporizing measure before a definitive procedure. The possible mechanisms for lifting the eyelid nonsurgically are external mechanical devices (skin-taping, adhesives, or spectaclebased lid crutches) to retract the upper lid, topical eye drops to stimulate Müller’s muscle, and injectable botulinum toxin to weaken orbicularis tone.

Introduction

Given the availability and effectiveness of the surgical treatments for blepharoptosis discussed elsewhere in this volume, the use of medical therapies for this problem is perhaps becoming eclipsed. Nevertheless, some patients with chronic ptosis may prefer nonsurgical treatment; and even those patients choosing surgery may require interim therapy while their procedure is being planned and scheduled. Therefore, a review of available nonsurgical treatments for ptosis is presented, along with guidelines for patient selection for such therapy, keeping in

I.C.A. Matjucha (*)

Neuro-opthalmologist, Comprehensive Surgical Ophthalmologist, Private Practice, Sudbury, MA, USA e-mail: icmatjucha@verizon.net

mind that medical therapy is often not well tolerated over time.

The most common nonsurgical treatment is the mechanical lifting of the upper lid by tape, skin adhesives, and lid crutches. Pharmacological options for improving ptosis include topical ­ocular adrenergic agents and botulinum toxin. In the specific case of ptosis from myasthenia gravis, control of ptosis is best achieved by appropriate therapy for that disease (see Chapter 11: “Myasthenia Gravis”).

Patient Selection: Etiological

Disease

Successful medical treatment for ptosis starts with proper patient selection, and patients with ptosis as part of Horner syndrome may be particularly appropriate for consideration of medical therapy. As discussed in more detail below, patients with mild ptosis due to sympathetic denervation of Müller’s muscle in the upper (and lower) eyelid have at their disposal a readily available, effective topical medication, apraclonidine 0.5%, to improve their ptosis with few potential side effects; therefore, patients with symptomatic ptosis from Horner syndrome, as well as those with temporary ptosis as a side effect of botulinum toxin injections, are considered good candidates for medical treatment as an initial step.

In some patients with other disease states, ptosis of the upper eyelid may be accompanied by weakness of eyelid closure. In these cases,

surgical elevation of the ptotic eyelid may promote exposure keratoconjunctivitis, even with a frontalis sling procedure that allows patient-adjustable eyelid opening. By contrast, the temporary and easily reversible eyelid elevation provided by nonsurgical methods may be a safer alternative for these patients and should be carefully considered. Examples of disease where ptosis is combined with orbicularis weakness include myasthenia gravis (MG), myotonic dystrophy, and chronic progressive external ophthalmoplegia (CPEO). Combined cranial nerve (CN) III and VII palsies are rarely seen together due to a single lesion in nondevastated patients, given the anatomical distance between the nuclei of CN III and VII in the brainstem and throughout their courses. However, such combined palsies can be seen as part of cranial polyneuropathy presentation of infectious or noninfectious etiology [1–3].

In Bell’s palsy, the palpebral fissure will ­usually widen, as the weakened orbicularis allows the upper eyelid to rise and the lower eyelid to fall; occasionally, however, the frontalis ­weakness in Bell’s palsy produces sufficient brow ptosis to cause a secondary, mechanical blepharoptosis. Similarly, patients with Möbius syndrome (congenital­ CN VI and VII weakness) or myotonic dystrophy can present with facial weakness and ptosis [4]. Orbicularis oculi weakness can increase the risk of postoperative keratopathy, so surgical correction of ptosis in this setting must be weighed carefully, and in some patients avoided.

Just as patients with CN VII weakness are at special risk for ocular exposure problems after surgical correction of ptosis, so too are patients with coexisting ptosis and corneal hypesthesia. Combined CN III and V disease (due to compression or inflammation at the orbital apex, superior orbital fissure, or cavernous sinus) occurs with reasonable clinical frequency. Also, corneal hypesthesia can represent an independent finding (as a complication, for instance, of recurrent herpetic corneal infections or trigeminal ablative procedures for ameliorating tic douloureux) in a patient with any etiology of ptosis. Because of the higher risk of corneal complications after surgical ptosis treatment

when the cornea is hypesthetic, such patients may prefer only medical methods to reduce their blepharoptosis.

Patients whose underlying disease produces ptosis that is unpredictably variable (e.g., MG), temporary (e.g., ischemic CN III palsy), or addressable via means other than eyelid surgery (e.g., prednisone treatment for MG or Tolosa– Hunt syndrome) will also usually choose medical treatment of ptosis. And, of course, patients who have external or internal ophthalmoplegia in addition to ptosis may choose to leave the ptosis completely untreated – or treated medically from time to time – to minimize symptomatic diplopia or photophobia, respectively

Patient Selection: Other

Considerations

Patients who are considered quite fragile medically, whether from advanced age or disease, may choose to avoid the relatively low surgical risk associated with a ptosis repair procedure, and may therefore choose medical treatment alone. A few patients will not be able to tolerate the surgery without general anesthesia, which presents additional risks to some patients, especially those with advanced cardiac or pulmonary disease. Also, some patients will refuse surgical treatments for other reasons.

Some patients will be limited to medical treatment because they represent “bad surgical risks.” Besides the very ill, such patients might include those with poor nutrition, those receiving chemotherapy, and those who have received radiation therapy in the surgical field, so that the risk of slow, incomplete healing (with complicating infection) is considerable. Others may be unable to follow postoperative directions dependably and simultaneously lack the reliable social support needed to help them perform those tasks; available social and medical services, such as a temporary visiting nurse, can sometimes remove such roadblocks to surgery.

While surgical risks may be unacceptable for certain patients, it does not follow that medical