Oxymetazoline and Blepharoptosis: A Case Series and Proposed Treatment Algorithm

Blepharoptosis, characterized by drooping upper eyelids, affects vision and daily life. Traditional management includes observation, pharmacological treatments, and surgery, though not all cases necessitate surgical intervention. Pharmacologic treatments such as apraclonidine and phenylephrine eyedrops have been used but are limited by significant adverse effects, including pupil dilation and ocular/systemic side effects. Recently, oxymetazoline ophthalmic solution, approved by the FDA in 2020, has emerged as a promising alternative, showing improvement in visual field and eyelid elevation with minimal adverse effects. This study aims to elucidate the utilization of oxymetazoline in patients with blepharoptosis by the senior author and to propose a treatment algorithm tailored for these patients. Oxymetazoline was administered to five patients with blepharoptosis in the absence of contraindications. Response to the medication was assessed clinically, and a treatment algorithm was devised. Following the oxymetazoline test, the subsequent course of action was determined as follows: a favorable response in the oxymetazoline test indicated a benefit from an internal ptosis repair with or without a blepharoplasty. A minimal or less than optimal response after the test suggested the necessity for external ptosis repair, possibly accompanied by blepharoplasty. Furthermore, in cases of asymmetric ptosis or unilateral ptosis, the test was employed on the affected or more ptotic eye initially to serve as an interdependence test. This also allowed the surgeon to determine if a unilateral or bilateral repair was necessary. Oxymetazoline offers a valuable therapeutic option for blepharoptosis, serving as both a diagnostic tool and a bridging therapy before surgery. Its extended duration of effectiveness and favorable safety profile make it an attractive choice for patients. The proposed treatment algorithm simplifies decision-making for clinicians and enhances patient satisfaction and quality of life.