Progressive bilateral blepharoptosis accompanied by lateral shortening of the palpebral fissure

Abstract

Introduction: The eyelids, along with their shape and position, play an important role not only in maintaining the optimal condition of the anterior ocular surface, aiding the normal function of the visual system, but also make up for our physical appearance and how we are perceived by others

Aim: The aim of this article is to present three clinical cases of bilateral phimosis of the palpebral fissure, combined with ptosis of the upper eyelids.

Materials and Methods: A retrospective analysis of the medical documentation of three women with progressive bilateral  blepharoptosis, operated on and followed up at RESBIOMED and VISION eye care clinics for the period August 2020–July 2023.

Results: The patients are women of ages 51, 61, and 78 years with complaints of bilateral ptosis of the upper eyelids, preceded by edema and shortening of the palpebral fissure. One of the patients was once operated during childhood and once again in 1997 following a relapse. The eyelids started to drop again in 2013, until in 2020, a week before being admitted for treatment, the ptosis was so severe, that the patient had to hold her eyelids open in order to see. The third patient underwent several blepharoplastic surgeries due to adhesions of the palpebral fissure. Objectively, all three patients had elongation of the lateral canthus up to 25 mm bilaterally, with referent range of 10–12 mm of length, with phimosis of the palpebral fissure up to 20 mm and MRD1 under 2 mm. All three patients underwent upper blepharoplastic surgery with shortening of the aponeurosis of the levator palpebrae superior and plastics of the lateral canthus, with subsequent full structural and functional recovery. Intraoperatively, wе discovered adhesions of the lateral canthus and infiltration of the levator palpebrae superior by an unknown substance. We obtained material for histology investigation, which did not show any deviations from the normal histological findings in patients with ptosis.

Conclusion: All available documentation from early childhood was requested from all three patients in order to exclude a hereditary or congenital disease. In both literature and practice, such cases are extremely rare, as the combination of ptosis and horizontal shortening of the palpebral fissure are usually associated with a congenital syndrome. In a differential diagnostic aspect we also considered chronic orbital inflammation, which was excluded based on the histology result. The surgical treatment led to full recovery of the normal eyelid position, elongation of the palpebral fissure with good function of the visual system and recovery of the peripheral vision, and last but not least achieving good аesthetics. The etiology of this bilateral fibrosis of the lateral canthi remains a mystery, therefore all three patients are due to be followed up.