Downgaze "hang-up" of the upper eyelid in patients with adult-onset ptosis: an important sign of possible orbital malignancy.

PURPOSE

To highlight, in patients with adult-onset ptosis, the importance of upper eyelid hang-up during downgaze as a clinical sign of serious orbital disease.

DESIGN

Retrospective, observational case series.

PATIENTS AND METHODS

Retrospective review of the presenting clinical symptoms and signs for a series of seven patients, some referred for treatment of adult-onset ptosis, with hang-up of the upper eyelid on down-gaze.

RESULTS

All patients had symptoms of upper eyelid ptosis at presentation, starting at ages ranging from 29 to 81 years (mean, 64 years; median, 70 years). All patients displayed marked hang-up of the affected upper lid on downgaze, and the levator excursion was reduced (range, 2-13 mm; mean, 9 mm) compared with the asymptomatic side. All patients with downgaze hang-up had associated orbital malignancy, but they otherwise had only minimal or no underlying orbital disease. Exophthalmometry varied between subtle (1 mm) relative enophthalmos in two cases, to mild relative proptosis (3/7 cases; range, 2-3 mm). Ipsilateral up gaze was reduced in 4 of 7 patients (57%).

CONCLUSION

In contrast to patients with adult-onset blepharoptosis (resulting from dehiscence of the levator muscle aponeurosis), adults presenting with ptosis resulting from malignant infiltration of the upper orbital tissues may display hang-up of the upper eyelid in downgaze. This important sign should alert the clinician to the possibility of serious underlying orbital disease.