By Derek N. Cunningham, OD
Although mild to moderate ptosis is common, affecting about 12% of the population older than 50,1,2 many eye care specialists are hesitant to engage these patients. Until now, surgery—which is not right for all patients and carries risks including infection and under- or over-correction—was the only effective treatment.3 Upneeq (oxymetazoline hydrochloride 0.1%; Osmotica) represents the only FDA-approved pharmaceutical indicated for acquired blepharoptosis.
Ptosis refers to a low-lying upper eyelid margin when the eye is in primary gaze. Untreated, it not only affects the superior visual field, but it also has important psychosocial ramifications, often causing patients to feel self-conscious about their appearance.4,5 Before my experience with oxymetazoline 0.1%, the idea of diagnosing and treating ptosis was somewhat foreign. I estimated that in our mostly referral refractive/cataract and dry eye practice, I saw one patient per month with significant drooping whom I would refer to an oculoplastic surgeon.
It wasn't until I started discussing ptosis in-depth with oculoplastic surgeons that I began to appreciate the scope of the problem and the potential unmet need. Even small amounts of ptosis can affect higher-order aberrations, for example, and often these patients would not traditionally be classified as ptotic or in need of surgical treatment.6,7
I have a special interest in performance vision and in that realm, even a relatively minor reduction in functional vision can be substantial, representing the difference between an elite athlete and someone who cannot quite get there. Similarly, I began to think about ptosis in terms of our practice's aesthetics clinic and realized that this isn't just about older patients with excessive skin folds. The lowering of the upper eyelid can affect the entire visual system and perhaps even more important to patients, how they look. I quickly realized that the vast majority of my middle-aged patients could potentially see a benefit from this drop. By one's late 30s or early 40s, eyelid skin starts to lose its elasticity as the levator muscle grows weaker and begins to stretch.
We brought oxymetazoline hydrochloride 0.1% in as a test product before it was more widely available and the response and excitement from patients and staff were beyond what I have ever seen with any drug. I have now prescribed the drop to a broad range of patients, from athletes to news anchors to celebrities. There are very few treatments that can have such a big impact on someone's appearance, instantly making them look healthier and more youthful.
A common complaint that patients have after cataract surgery or refractive lens exchange with a presbyopia-correcting IOL is that their eyes feel tired at night. Many patients say they are unable to do crafts or read at night, and they just want to go to sleep. I have tended to chalk this up to dry eye, but these patients are actually battling functional ptosis that happens throughout the day as the levator muscle tires. These patients have had a remarkable response to oxymetazoline hydrochloride 0.1%, saying they no longer felt that strain or heaviness toward the end of the day. This is probably the most appreciative group of patients I’ve seen so far.
When we first incorporated oxymetazoline hydrochloride 0.1% in practice, I thought it would decrease the number of blepharoplasty referrals to oculoplastic specialists, but in reality, the opposite has happened. We have much more awareness of ptosis now and are starting to identify patients earlier on in the development of drooping. This has resulted in an increase in oculoplastic procedures making the product synergistic with surgery. It also allows patients to trial what their results might be following a procedure. Oculoplastic surgeons are happy, optometrists are happy, and most importantly patients are happy. Patients are also coming into the clinic that have never even had an eye exam—this has never happened before.
Derek Cunnningham, OD, is director of optometry at Dell Laser Consultants in Austin, Texas. He can be reached at, [email protected]. He is a consultant for RVL Pharmaceuticals.
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2. Kim MH, Cho J, Zhao D, et al. Prevalence and associated factors of blepharoptosis in Korean adult population: The Korea National Health and Nutrition Examination Survey 2008–2011. Eye. 2017;31: 940–946. doi: 10.1038/eye.2017.43.
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5. Richards, HS, Jenkinson E, Rumsey N, et al. The psychological well-being and appearance concerns of patients presenting with ptosis. Eye. 2014;28(3):296-302. doi: 10.1038/eye.2013.264
6. Kumar DA, Agarwal A, MS, Prakash G, et al. Effect of unilateral congenital ptosis on ocular higher order aberrations in children. Med Hypothesis Discov Innov Ophthalmol. 2013;2(3): 86–91. https://pubmed.ncbi.nlm.nih.gov/24600649/.
7. Shen J, Cui H, Tang X, Zhu M, Han W. Optical quality assessment in patients with unilateral congenital ptosis: a matched case-control Study. Journal of Ophthalmology. 2020. https://doi.org/10.1155/2020/2653250.