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A community survey of ptosis of the eyelid and pupil size of elderly people.


Demographic projections point to a continuing increase in numbers of the very elderly population [1]. There is a steep rise in chronic disabling conditions with age [2], including neurological problems. Early symptoms and signs in elderly patients are often dismissed [3]. For all these reasons, there is an increasing need for epidemiological studies that will determine the present burden of neurological disabilities and assist in establishing their significance in terms of possible intervention.

Although there have been many comprehensive surveys of ophthalmic problems in elderly people [4-7], there have been no studies of the prevalence of ptosis of the eyelid in the community. There is an impression that it becomes commoner with age and it may be significant if it is the sign of some underlying disorder impinging on eyelid function or if the encroachment of the lid on the pupil is sufficient to interfere with activities such as reading. Frequently no cause is found for ptosis in older subjects and several explanations, such as backward displacement of the eye with increasing age, have been offered. The standard classification of ptosis is into four categories: neurogenic; myogenic; aponeurotic; and mechanical. Recently, age-associated changes resulting in aponeurotic disinsertion of levator palpebrae superioris (involutional ptosis) have been recognized [8]. Involutional ptosis is eminently treatable by plastic surgery [9, 10]. In 1975 Jones et al. in the USA estimated that around 20% of the entire population had aponeurotic ptosis [11], and Kaplan et al. in 1985 [12] in a prospective study of ptosis and cataract surgery in Florida, USA, found that more than half of the elderly population (55%) had pre-operative ptosis. None of the studies completed hitherto has been truly population based and used properly validated methods for diagnosing ptosis.

The primary purpose of the present study was to remedy the deficiencies in the literature by determining the prevalence of ptosis and its causes and significance in a large random sample of older people.


Subjects: The study was undertaken over a period of 12 months in Salford Health District and was based on a four-doctor general practice. Subjects were drawn from an age-sex register and 2710 over the age of 50 were identified. Of these, 851 randomly selected individuals were contacted by letter inviting them to participate in the study. All the subjects who consented in writing were examined by one of us (G.V.S.) at their homes after confirming the time of appointment by telephone.

Methods of assessment: A standardized assessment protocol was completed for each patient. This included:

1. A detailed history (listing previous eye problems, surgical procedures, visits to the optician, medication, family history);

2. Examination of the eyes as follows:

(a) assessment of near vision using the Faculty of Ophthalmologists approved test types with near correction if glasses were worn, and of external eye movements;

(b) fundoscopy with undilated pupils;

(c) assessment of levator function using the method described by Oshinskie [13];

(d) measurement of pupillary diameter under standard lighting conditions, indoors near a window, to assess for pupillary asymmetries;

(e) where consent was given, a photograph of the eyes in 'primary position' with a specially modified camera to enable consistent magnification ratios [14];

(f) examination of the neck for any pathology.

For the purpose of this study 'ptosis' was defined as either (i) drooping of the eyelid to cover at least 4 mm or more of the superior corneal limbus; or (ii) upper eyelid excursion of less than 8 mm from eyes shut to open while preventing frontalis overaction by finger pressure; or (iii) a palpebral aperture less than the normal range (men 7-10 mm; women 8-12 mm [15]). (Lid crease, superior sulcus fullness and lash rotation were not recorded, since earlier studies have clearly shown them to be inaccurate markers of levator insertion in the elderly population [12].)

Data analysis: The data were analysed by an IBM compatible computer using SPSS/PC + 4.0 statistical package and some percentages have been rounded to the nearest whole number.


Subjects entered: Invitations were sent out to 851 subjects. A total of 530 responses (62% response rate) were received. Fourteen subjects had left the district and a further 17 had died. Ninety-nine individuals refused consent. In about half of these the reason given was an inability to attend for testing owing to unusual working. hours and many emphasized that they had no problems with their eyes. The remaining 400 were examined. Their age and sex are presented in Table I. They did not differ in these respects from the 321 non-responders and the 130 responding non-participants.
Table I. Responders and non-responders

                                    Men                  Women


Number                              166                   234

Median                               65                    67.5
Min-Max                              51-92                 52-95
Quartiles                            56-70                 59-75.25


Number                               57                    73

Median                               65                    68
Min-Max                              52-94                 52-92
Quartiles                            57-75.5               59-75


Number                              145                   176

Median                               65                    66
Min-Max                              52-93                 52-98
Quartiles                            57.5-70               57-74

By Kruskal-Wallis non-parametric test there is no significant
difference between the distributions of age for men or women in all
three categories.
Table II. Prevalence with 95% confidence interval (CI) of ptosis by
sex and age group

Age                            Ptosis
(years)           Total        No.         %               CI


50-59              61           2          3        [less than]1-11
60-69              60           5          8                   3-18
70-79              38           4         11                   3-25
80+                 7           4         57                  18-90

Total             166          15          9                   5-15


50-59              62           1          2        [less than]1-9
60-69              63           6         10                   4-20
70-79              74          10         14                   7-23
80+                35          14         40                  24-58

Total             234          31         13                  10-19

Prevalence of ptosis (Table II): Forty-six (11.5%) of the 400 subjects examined had ptosis. Prevalence increased with age and there was a significant difference between the 50-79 age group compared with the over-80s (odds ratio 8.4, 95% CI 4.3-18.2). There was no significant difference between the sexes (M:F 1.5; odds ratio 1.54; CI 0.8-3.0). There was complete concordance between ptosis diagnosed according to lid excursion and according to palpebral width with the exception of two patients who had 'upside-down ptosis'. The types of ptosis are set out in Table III. In 26 (57%) of the 46 subjects with ptosis, it was bilateral and in 18 (39%) it was unilateral. The remaining two (4%) cases had upside-down ptosis caused by lid scarring.

Causes of ptosis: In the majority of cases (42, 92%), ptosis was thought to be acquired and only four cases were congenital. In 23 (50%) there appeared to be a clear aetiological factor. Eleven of these subjects had a mechanical cause: eyelid scarring secondary to trauma, chalazion excision or recurrent blepharoconjunctival infection. The remaining 12 had developed ptosis due to aponeurotic disinsertion, post-cataract extraction or post glaucoma surgery (secondary aponeurotic disinsertion). Two of these 12 also had neurovascular complications of diabetes mellitus. Of the remaining 23, 18 probably had primary aponeurotic disinsertion. The remaining patient had a family history of myasthenia gravis and had recently noticed diurnal fluctuation of bilateral ptosis and so may have had myasthenia gravis. All patients with ptosis were asked if their 'drooping eyelid' caused problems with their vision. None said it did.
Table III. Types of ptosis

                          Men              Women              Total

Unilateral                 11                17                 28
Bilateral                   5                13                 18
No ptosis                 150               204                354

Total                     166               234                400

Congenital                  1                 3                  4
Acquired                   15                27                 42
No ptosis                 150               204                354

Total                     166               234                400

None of the subjects with ptosis had other features, suggesting either a 3rd cranial nerve palsy (pupillary dilatation, gaze palsy) or Horner's syndrome (pupillary constriction, ipsilateral loss of sweating).

Pupillary diameter: The pupillary diameter ranged up to 4 mm. Forty-eight subjects (12%) had a diameter below 2 mm. The proportion of subjects with pupils of 1 mm diameter or less (Table IV) rose significantly with age (p [less than] 0.01 by trend-sensitive [[Chi].sup.2]).

Among subjects without ptosis the pupil diameter varied between 1 and 4 mm (mean 2.2 mm [+ or -] 0.6) while in subjects with ptosis it varied between 1 and 3 mm (mean 1.8 mm [+ or -] 0.45). In those with bilateral ptosis, the mean diameter was lower (1.6 mm [+ or -] 0.50). The majority of these pupils in ptotic eyes had poor reflex response to light for which clinical examination revealed no cause.

The proportion of subjects with ptosis who had pupils less than 2 mm diameter was no higher in the ptosis group than in those without ptosis; moreover the degree of pupillary asymmetry was no higher in those with and those without ptosis. In fact, none of those with ptosis had any pupillary asymmetry within the limits of the test (1 mm). This confirms that the ptosis was not due either to Horner's syndrome or to a third-nerve palsy.

Other findings: Errors of refraction were noted in 94.5% of subjects but only 75 (19%) had visited an optician within the previous 2 years. Sixteen subjects had a visual acuity worse than N 24 despite glasses designed to correct this; of these, three subjects were registered blind, being able to detect hand movements only. Age-associated macular degeneration was the commonest cause of very severe limitation in visual acuity, affecting 15 (4%) of subjects.

Two hundred and forty-four subjects (61%) were on regular medication and the most commonly prescribed medications were for the cardiovascular system (30%, n = 244) followed by the musculoskeletal system (28%, n = 244). Eleven per cent of subjects were on medication for dry eyes or glaucoma. Of the subjects with ptosis, only two were on eye drops, in both cases 0.25% timoptol. Neck examination revealed that 29 subjects (7%) had a goitre not previously known to the individual; however, all except one of these appeared euthyroid clinically. Fifty-eight subjects (14%) gave a history of major surgical procedure requiring general anaesthesia of whom nine subjects (2%, n = 400) had undergone operations on the head or neck, but there was no significant association between ptosis and such surgery.
Table IV. Both pupils of 1 mm diameter or less: prevalence by age

                                                       No. (%) with
Age group (years)                 Total                small pupils

50-59                              123                     5  (4)
60-69                              123                    16 (12)
70-79                              112                    16 (14)
80+                                 42                    11 (26)

All                                400                    48 (12)


Our survey has revealed a high prevalence of ptosis (11.5%) in the community among subjects over 50 and that this prevalence rises steeply with age. How valid are these findings? The response rate is important in the accuracy of the estimated prevalence rate in any survey. Our response rate was 62% (530 responses out of 851 approaches made) and, of these, 75% (400) agreed to participate, 47% of those initially contacted. There was no significant difference in age and six between non-responders and participants.

Those refusing to participate may do so for a number of reasons all of which may alter the prevalence figures. In our study, replies received in writing or by telephone contact revealed that some subjects believed that they had no problems with their eyes and felt that they did not need an eye examination; some had already been fully assessed by an ophthalmologist or had an appointment to see the ophthalmologist and did not want to be bothered by another examination. Some carers replied that the subject contacted was too unco-operative owing to a dementing illness. Some were afraid of allowing strangers into their homes.

All subjects were examined by the same doctor allowing the diagnostic criteria used to remain consistent throughout the study. Other studies, for example Kaplan's [12], had not been controlled in this way and not all have used a precision camera [14]; nor have they been population-based, studying unselected subjects. The results from symptomatic disease-based referrals do not reflect the true prevalence of disease in the community [16]. Population surveys provide better estimates and it is well recognized that serious under-diagnosis of treatable eye disease in elderly people still prevails and the need for preventive screening has been highlighted [17].

In view of the steep age association of ptosis in our study and the changing age-structure of the population, we may anticipate increasing numbers of individuals with ptosis in the future. Cataract and glaucoma are also age-associated and there will be an increasing demand for surgery - another reason for expecting more individuals with ptosis on the basis of secondary aponeurotic disinsertion. It is, however, difficult to determine the economic implications of this. None of our subjects complained of their ptosis, so that it is unlikely that they would request oculoplastic surgery. On the other hand, as already noted, older people have a high threshold for complaining about visual problems and may be unaware of potential benefits from surgery. Finally, it is interesting to note that none of the subjects had features suggesting their ptosis was part of either a third-nerve palsy or Horner's syndrome, although two patients had the neurovascular complications of diabetes. In only one patient was the ptosis a manifestation of serious disease: myasthenia gravis.


We are grateful to Professor Grimley Evans for his helpful comments about this paper. We acknowledge statistical support by Dr Malcolm Campbell of the University of Manchester Computing Centre. We also thank Sally Hollis, Margaret Mullen and staff of the General Office at North Manchester General Hospital for help and support. We thank Dr Peter Mooney of Bayer and Mr Syeed Mussa of Rhone-Poulenc-Rorer for financial support and are grateful to Mrs Mary Tallis for first making us aware of the problem studied.


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Authors' addresses

G. V. Sridharan Department of Adult Medicine, Royal Oldham Hospital, Rochdale Road, Oldham, Lancs OL1 2JH

R. C. Tallis University of Manchester Department of Geriatric Medicine, Hope Hospital, Salford M6 8HD

B. Leatherbarrow Department of Ophthalmology, Manchester Royal Eye Hospital

W. M. Forman Swinton, Greater Manchester
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Author:Sridharan, G.V.; Tallis, R.C.; Leatherbarrow, B.; Forman, W.M.
Publication:Age and Ageing
Date:Jan 1, 1995
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