Friday, August 8, 2014

A Woman with Reading Difficulty and Headache

This 58 year-old complained of persistent headache and problems with reading for the past year. She underwent bilateral cataract surgery two years ago. She had undergone a battery of tests for her headache including MRI but not organic causes could be found. She also changed her reading glasses many times but without improvement in her reading vision. When I saw her I noticed she had exceedingly high eyebrows and deep forehead furrows indicative of frontalis overaction (excessive use of the forehead muscle to lift up the eyebrows and the eyelids). Her distant vision was good at 6/6 with glasses but reading was a problem. When she read a book, her eyelids could be seen to cover most of the eyes (see pictures).

Exceedingly high eyebrows (right picture) and eyelids covering 
both eyes when she attempted to read a book. 

Her headache and problem with reading were both related to ptosis (droopy eyelids from problem of the muscle that open the eyelid). When her forehead muscles were disabled by pressing the fingers over the top of the eyebrows, the ptosis got worse.

Increased ptosis when the forehead muscle was stopped from 
acting by pressing the fingers over the areas above the eyebrows.

I performed ptosis surgery to lift both eyelids. The technique chosen is a modifie posterior approach  conjunctivomullerectomy. In this technique the scars are minimal with faster recovery. The steps of the operation are shown in the pictures (1-14) below. 

Steps 1-8 showing shortening of the conjunctivomuller complex via a posterior approach. 

Steps 9-14 showing stitching the cut end of the conjunctivomuller complex 
to the tarsal plate to open up the eyelid.

Appearance of the eyes before (right) and one week after the operation. 


  1. In the prescence of frontalis over action which is always indicative of eyelid/frontalis weakness, and the history of cataracts <60 years old, did you consider myotonic dystrophy?

  2. Myotonic dystrophy is a possibility, patient's ptosis appeared after cataract surgery so levator dehiscence is the most likely and she has no other signs to suggest myotonic dystrophy.