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Acquired neuromuscular ptosis — Clinical Guidelines

Overview

Acquired neuromuscular ptosis refers to the drooping of the upper eyelid due to age-related weakening of the levator muscle or aponeurosis, often requiring surgical intervention for correction. 1 9

Diagnosis

Clinical assessment focusing on eyelid position relative to the pupil margin (MRD1).

Phenylephrine test to assess levator muscle function and potential contralateral lid drop. 8

Grading systems like MRD1 (margin reflex distance) to quantify severity.

Management

Anterior approach: Commonly used for ptosis repair, involving levator resection or Fasanella-Servat procedure. 1 4 7

Posterior approach: Utilized for aponeurotic defects, though with noted complications. 9

Phenylephrine: Used preoperatively to assess levator function and occasionally as an adjunct in surgery. 5 8

Combined procedures: Blepharoplasty often performed concurrently to address dermatochalasis. 6

Special Populations

Elderly: Commonly affected by involutional changes necessitating ptosis repair; posterior approach may be considered. 1 9

Comorbidities: No specific guidelines provided in abstracts regarding management adjustments for comorbidities.

Key Recommendations

Utilize the anterior approach for routine involutional ptosis repair due to its prevalence among practitioners. (Evidence: Moderate 1)

Consider concurrent blepharoplasty during ptosis repair to optimize aesthetic outcomes in cases with dermatochalasis. (Evidence: Expert opinion 6)

Employ the phenylephrine test preoperatively to evaluate levator muscle function and predict surgical outcomes accurately. (Evidence: Moderate 8)

For aponeurotic defects, carefully weigh the risks and benefits of posterior approach repair given its variable success rate and potential complications. (Evidence: Weak 7 9)

References

1 Chawla H, Quigley C, Wong GY. A review of ptosis surgery techniques performed by British Oculoplastic Surgical Society members. Eye (London, England) 2025. link 2 Wu P, Ma J, Zhang T, Ma D. Advances in the Genetics of Congenital Ptosis. Ophthalmic research 2022. link 3 Mangan MS, Esen F. Double-Organ Bias in Controlled Trials on Eyelid Ptosis. Ophthalmic plastic and reconstructive surgery 2021. link 4 Juniat V, Golnik KC, Bernardini FP, Cetinkaya A, Fay A, Mukherjee B et al.. The Ophthalmology Surgical Competency Assessment Rubric (OSCAR) for anterior approach ptosis surgery. Orbit (Amsterdam, Netherlands) 2018. link 5 Mota PM, Norris JH. Review on surgical management of ptosis and the use of phenylephrine: A national survey of British Oculoplastic Surgery Society (BOPSS) UK Consultants. Orbit (Amsterdam, Netherlands) 2016. link 6 Gausas RE. Technique for combined blepharoplasty and ptosis correction. Facial plastic surgery : FPS 1999. link 7 Sampath R, Saunders DC, Leatherbarrow B. The Fasanella-Servat procedure: a retrospective study. Eye (London, England) 1995. link 8 Lyon DB, Gonnering RS, Dortzbach RK, Lemke BN. Unilateral ptosis and eye dominance. Ophthalmic plastic and reconstructive surgery 1993. link 9 Collin JR, Tyers AG. Senile ptosis II--posterior approach and complications. Transactions of the ophthalmological societies of the United Kingdom 1985. link 10 Fox SA. Levator tucking. Annals of ophthalmology 1979. link 11 Tenzel RR. Correction of brow ptosis. Ophthalmology 1978. link35624-4)

Acquired neuromuscular ptosis