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Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 114-116

Aponeurotic ptosis due to playful lid eversion: Case report and literature review

Department of Ophthalmology, King Georges' Medical University, Lucknow, Uttar Pradesh, India

Date of Submission23-Oct-2019
Date of Decision23-Dec-2019
Date of Acceptance07-Jan-2020
Date of Web Publication4-Dec-2020

Correspondence Address:
Siddharth Agrawal
Department of Ophthalmology, King Georges' Medical University, Lucknow - 226 003, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcor.jcor_85_19

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Aponeurotic ptosis is known to occur due to a wide variety of causes that lead to dehiscence of levator aponeurosis from the tarsal plate. We report here two cases with an unusual mechanism, resulting in this type of ptosis. Both the cases presented with spontaneous progressive drooping of upper lids, more on the right side, and gave a history of repeated playful eversion of upper lids. The first case underwent successful levator palpebrae superioris aponeurosis reattachment. Peroperatively, disinsertion and thinning of aponeurosis confirmed the diagnosis. Repeated habitual eversion of lids had probably caused stretching and mild chronic inflammation of the tarsus and lid retractors, leading to progressive thinning with disinsertion of the levator aponeurosis.

Keywords: Levator palpebrae superioris reattachment, levo aponeurotic ptosis, lid eversion, ptosis

How to cite this article:
Srivastava RM, Singh V, Khurana R, Agrawal S. Aponeurotic ptosis due to playful lid eversion: Case report and literature review. J Clin Ophthalmol Res 2020;8:114-6

How to cite this URL:
Srivastava RM, Singh V, Khurana R, Agrawal S. Aponeurotic ptosis due to playful lid eversion: Case report and literature review. J Clin Ophthalmol Res [serial online] 2020 [cited 2022 Jul 1];8:114-6. Available from: https://www.jcor.in/text.asp?2020/8/3/114/302203

Aponeurotic ptosis, the most common form of acquired ptosis, occurs due to dehiscence or disinsertion of the levator aponeurosis from the tarsal plate.[1] Although it mostly affects elderly patients, aponeurotic defects can occur in younger patients as a result of a variety of causes.[2],[3]

We report here a unique mechanism of thinning out of the tarsus and the eyelid skin due to playful repeated lid eversion, leading to development of this type of ptosis with dermatochalasis. To the best of our knowledge, this etiology as a causative factor for aponeurotic ptosis has not been reported so far in the literature.

  Case Reports Top

Case 1

A 24-year-old male patient presented with a 4-year history of spontaneous progressive drooping of the right upper eyelid. The patient gave a history of voluntary, habitual playful eversion of upper lids in the absence of any inciting factor [Figure 1] and [Figure 2] for 2 years before onset of drooping. Being right-handed, he everted the right upper lid (RUL) more frequently up to several times a day and for several minutes each time. All other etiological factors for ptosis, including rubbing of eyes and contact lens wear, were excluded. The findings of examination were consistent with a diagnosis of aponeurotic ptosis.
Figure 1: Case 1: Moderate simple ptosis right upper lid

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Figure 2: Case 1: Voluntary eversion of right upper lid by the patient

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Case 2

A 20-year-old female patient presented with a 5-year history of progressive drooping of both upper eyelids (R > L) associated with the loosening of the eyelid skin (dermatochalasis). The patient gave similar history of voluntary, habitual lid eversion [Figure 3] and [Figure 4]. Similarly, all other etiological factors were excluded and diagnosis of aponeurotic ptosis made.
Figure 3: Case 2: Moderate simple ptosis right upper lid with mild simple ptosis left upper lid

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Figure 4: Case 2: Voluntary eversion of both upper lids by the patient

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The first patient underwent a successful levator palpebrae superioris (LPS) reattachment by standard described technique[4] [Figure 5] and [Figure 6]. Peroperatively, disinsertion and thinning of the aponeurosis were confirmed [Figure 7]. The second patient refused surgical intervention.
Figure 5: Case 1: After levator palpebrae superioris reattachment (1st week)

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Figure 6: Case 1: After levator palpebrae superioris reattachment (3rd week)

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Figure 7: Case 1: Recessed levator palpebrae superioris noticed peroperatively

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  Discussion Top

In adults, the most common cause of acquired ptosis is an abnormality in the levator aponeurosis, that is, dehiscence, disinsertion, or stretching.[5] This type of ptosis most often affects the elderly but can occur in younger age group also.[5]

Jones et al. were the first to report that the defects in aponeurosis or disinsertion of levator aponeurosis from its anterior tarsal position were responsible for this type of ptosis.[6] This leads to spontaneous recession of the aponeurosis. Thinning and stretching, termed attenuation or rarefaction, of the aponeurosis without true dehiscence or disinsertion produces similar clinical appearance.[7]

Several kinds of physical irritations to the eyelids and their repeated manipulation (such as habitual rubbing, contact lens usage, and ocular surgery) have been reported as a cause of blepharoptosis.[8] These would also accelerate and aggravate a preexisting abnormality. These patients tend to have a bulky eyelid, a normal skin crease, and good levator function.[9] The believed pathogenic mechanisms in these, and possibly, our cases are (1) disinsertion of the aponeurosis from the tarsus, resulting in a large amount of play between the aponeurosis and the tarsus, and (2) that the aponeurosis and Mueller’s muscle get attenuated and elongated.[10]

Most patients with aponeurotic ptosis are asymptomatic with a mild degree of ptosis and do not require surgery. If the degree of ptosis is severe enough to disturb vision or causes cosmetic embarrassment, it can be corrected by repositioning the disinserted or dehisced levator aponeurosis onto the anterior surface of the tarsal plate.[9]

We assume that repeated habitual eversion of lids, as in these cases, would have caused stretching and mild chronic inflammation of the tarsus and lid retractors, leading to progressive thinning and damage of the aponeurosis, eventually causing ptosis at an early age. The frequent eversion of RUL, the asymmetry in presentation in both cases, and the successful outcome after LPS reattachment in the first case are suggestive of the etiology.

This is the first case report to suggest voluntary eversion of lids as a possible etiological factor for aponeurotic ptosis. We herein report only two cases; however, clinicians may consider this as a possibility cause of aponeurotic ptosis in younger patients with acquired ptosis and discourage children from seemingly innocuous playful eversion of lids. A larger case series may be conclusive.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Lyon DB, Khan JA. Acquired Ptosis. In: Albert and Jackobeic Principles and Practice of Ophthalmology Vol. 3. 3rd ed. Saunders Elsevier; 2010:3403.  Back to cited text no. 1
Kersten RC, de Conciliis C, Kulwin DR. Acquired ptosis in the young and middle-aged adult population. Ophthalmology 1995;102:924-8.  Back to cited text no. 2
Ahmad K, Wright M, Lueck CJ. Ptosis. Pract Neurol 2011;11:332-40.  Back to cited text no. 3
Putterman AM. Basic Oculoplastic Surgery. In: Peyman, Sanders, Goldberg Principles and Practice of Ophthalmology Vol. 3. 1st ed. New Delhi, India: Jaypee; 1987;33:2246-333.  Back to cited text no. 4
Fujiwara T, Matsuo K, Kondoh S, Yuzuriha S. Etiology and pathogenesis of aponeurotic blepharoptosis. Ann Plast Surg 2001;46:29-35.  Back to cited text no. 5
Jones LT, Quickert MH, Wobig JL. The cure of ptosis by aponeurotic repair. Arch Ophthalmol 1975;93:629-34.  Back to cited text no. 6
Anderson RL, Beard C. The levator aponeurosis. Attachments and their clinical significance. Arch Ophthalmol 1977;95:1437-41.  Back to cited text no. 7
Reddy AK, Foroozan R, Arat YO, Edmond JC, Yen MT. Ptosis in young soft contact lens wearers. Ophthalmology 2007;114:2370.  Back to cited text no. 8
Deady JP, Morrell AJ, Sutton GA. Recognising aponeurotic ptosis. J Neurol Neurosurg Psychiatry 1989;52:996-8.  Back to cited text no. 9
Sultana R, Matsuo K, Yuzuriha S, Kushima H. Disinsertion of the levator aponeurosis from the tarsus in growing children. Plast Reconstr Surg 2000;106:563-70.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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