There are several reasons why an eyelid might droop. Sometimes, the eyelid might droop slightly, or it might not be closed all the way. Treatment usually depends on the functionality of the eyelid muscles. If the blepharoptosis (ptosis) does not affect vision and the patient does not mind the appearance, the doctor might recommend no treatment at all. If the ptosis causes a problem with vision, appearance, or both, it may need to be treated.

There is a muscle called the levator palpebrae superioris (LPS) muscle in the upper eyelid. When the strength of this muscle weakens, the eyelid droops and the gap between the eyelids becomes smaller, which can be diagnosed as ptosis.

Ptosis can be classified into congenital and acquired. In cases of congenital ptosis, the levator muscle of the upper eyelid is not properly developed, resulting in weak lifting power in most cases. When congenital blepharoptosis occurs, the child is unable to open the eyes properly. As they grow to an age where they can control their neck, they have to struggle to look directly at the objects in front of them. Consequently, they raise their head, eyebrows, forehead, and chin in an attempt to compensate. In addition, if the symptoms are severe, vision may not develop and amblyopia may occur, so special attention is required¹⁾. Acquired blepharoptosis may occur due to muscle or nerve damage from trauma, but in most cases, it appears due to the deterioration of muscle function with aging. In both acquired and congenital cases of drooping eyelids, vision obstruction, headache, and neck pain from habitually lifting the chin. And forehead muscles are often engaged to lift the eyelids, resulting in forehead wrinkles²⁾. In both cases, the patients are usually recommended to receive an eyelid surgery to resolve vision obstruction and cosmetic problems. However, in this paper, the author reports an improved case of acquired ptosis following Botulinum toxin injection, treated solely with acupuncture.

1. Patient information

A 40-year-old female patient visited the office complaining of discomfort in her right eye after receiving a botulinum toxin injection in the right eye region 2 years ago. She felt that her right eyelid was too heavy, making difficult for her to fully open it. Her eyelid swelled more after eating, and she felt a knot in her eyelid. The patient was recommended sugery to cut and lift the eyelid by her doctor. However, the patient was afraid that the surgery would leave scars on her face. So, she decided to seek acupuncture treatment and visited Healing hand acupuncture, Inc. on March 1, 2023.

2. Patient history and diagnosis

Using the House-Brackmann grading system, central and peripheral facial palsy were ruled out as the patient could evenly make all facial expressions³⁾. Despite this, the patient experienced moderate and persistent discomfort with her right eyelid, which was unable to fully open. So she needed to lift her chin to open her eyes fully and look straight ahead. Additionally, a rice-sized knot was found in the right eyelid, which was assumed to have been caused by the Botox injection and to restrict the movement of the levator palpebrae superioris muscle.

3. Assessment methods

The Marginal Reflex Distance (MRD) refers to the vertical distance between the corneal eye reflex and the eyelids. MRD-1 represents the distance to the upper eyelid, and MRD-2 represents the distance to the lower eyelids. Usually, MRD-1 is used to measure the severity of ptosis, and the normal range is 4.0-4.5 mm. And when the relative MRD-1 difference between both eyelids is more than 1mm, it is called eyelid asymmetry^4,5). The classification of ptosis with MRD-1 is as follows: mild (MRD-1 3-4 mm), moderate (MRD-1 2-3 mm), severe (MRD-1 0-2 mm)^6,7). The treatment progress was documented by video and pictures taken before and after the treatments, and it was evaluated using MRD-1.

4. Treatment methods

1) Treatment intervention

Two types of needles were used for the treatments: gamma-ray sterilized KM disposable needles (Dist. By KMS Corp., Made in Korea), 0.20×30 mm, and DBC intradermal needles (Dist. by Lhasa OMS, Made in Korea), 0.12×5 mm. The skin was prepped with alcohol pads before needling.

2) Treatment point

Focusing on the muscle and nerve outlet points listed above, the treatment points were selected based on the patient’s symptoms on the paralyzed side of the face and the needles were retained for 20 minutes (Fig. 1).

Figure 1. Acupuncture treatment points.

3) Results

The overall symptomatic changes before and after treatment sessions are shown in Fig. 2.

Figure 2. The treatment progress. (A) March 1, 2023, before treatment, (B) March 1, 2023, after treatment, (C) March 14, 2023, before treatment.

(1) March 1, 2023

Before the treatment, the left eye was within the normal MRD-1 limit (4.0 mm) (Fig. 3A). But, the right eye MRD-1 was 1.5 mm, indicating severe ptosis (Fig. 3B). Treatment was performed for 20 minutes on the acupuncture points listed on Table 1. After the session, she could open her eyes more easily and widder without lifting her chin. And one-third of the pupil appeared to be covered by the eyelid on the right eye, and the MDR-1 had recovered to 3 mm (Fig. 3C). However, the knot on the upper eyelid of rhe right eye was still palpable.

Table 1 . Acupuncture treatment points.

Treatment point	Needling target and method
BL1, BL2	Acupuncture was performed on the tender points where the superior trochlear and supraorbital nerves pass
TE23, GB1	The points were where the supraorbital nerve outlet overlaps with the temporal branch of the facial nerve. Needling was performed superficially inwards, palpating the pulse of the blood vessels to avoid them
Between EX-HN5 (Taiyang) and GB1 (locates above GB3)	Needling was performed toward the eyeball, at the point where the zygomatic branch of the facial nerve overlaps with the zygomaticofacial nerve of the maxillary nerve which originate from the trigeminal nerve
ST1	Acupuncture was performed on the tenderness point close to the infraorbital nerve
TP*s on right eyelid	Intradermal needle acupuncture was performed on the tenderness point along with a knot to reduce the scar tissue

*TP: Tenderness Point..

Figure 3. MRD-1 measurement. (A) Normal left eye, March 1, (B) ptosis right eye, March 1, before treatment, (C) ptosis right eye, March 1, after treatment, (D) treated right eye, March 14, before treatment.

(2) March 14, 2023

Before the treatment, she could lift her eyelids effortlessly, and both eyes could be opened to almost the same size when closed and opened. The MRD-1 sustained at 3 mm. The knot in the right eyelid was no longer detectable (Fig. 2C).

The levator palpebrae superioris (LPS) is a triangular-shaped muscle located in each upper eyelid (Fig. 4). The primary function is the elevation and retraction of the upper eyelid. It has an abundant blood supply, mainly provided by the ophthalmic and supraorbital arteries (from the internal carotid), anastomosing with branches of the external carotid via angular and superficial temporal arteries through the superior peripheral arcade^8,9). Lymphatic drainage travels laterally to the preauricular/parotid nodes before draining into the deep cervical lymph nodes¹⁰⁾. The muscle is innervated by the superior branch of the oculomotor nerve (cranial nerve III). Problems with the function or innervation of levator palpebrae superioris can lead to upper eyelid ptosis^5,9,11).

Figure 4. Anatomy of levator palpebrae superioris muscle (sagittal cut).

According to the reports, only 2.5% of patients who received Botulinum toxin injection show eyelid ptosis. Typically the symptom occurs 3-14 days after the injection, and it resolves within 3-4 weeks. Although Steinsapir et al. reported persistent ptosis which lasted about 6-13 weeks after cosmetic Botox injection and Crist reported botox-induced Bell’s palsy¹²⁾, the case of this paper describes a ptosis which lasted approximately 2 years following a Botox injection.

Nestor et al. explains the mechanism of Botox-induced blepharoptosis that the symptom can occur becuase the toxin affects the unintended nerve terminals of the muscles such as LPS. Botox reduces the capacity of a muscle to contract and maintain tension, and this unintended adverse effect is unpredictable¹²⁾.

Although blepharoptosis surgery is often thought of as a cosmetic purpose, in reality, it is often performed due to various health problems caused by obstruction of vision, such as poor eyesight, neck pain, and eye fatigue. However, there are reasons why patients hesitate to undergo surgery considering the potential after-effects and cosmetic scars that may occur after surgery. The patient described in this paper was also recommended by the doctor for surgical treatment to reconstruct the upper eyelid. And the patient exhibited symptoms of eye fatigue and poor neck posture. But the patient looked for alternative treatment to alleviate her symptoms.

This study was conducted based on the hypothesis that stimulation of individual muscles and nerve exit points, which was selected based on anatomical considerations, as well as intradermal acupuncture to improve blood circulation, could help the recovery of eyelid ptosis.

The effects were confirmed, and patient satisfaction was achieved through a combination of acupuncture point, needling, and adjuvant therapies. However, this study has clear limitations. Although the patient’s symptoms improved with this treatment method, it is difficult to ascertain its effects on congenital blepharoptosis. And the treatment was limited to the acquired blepharoptosis which occurs due to traumatic damage of muscles or nerves. The number of cases treated in this study was limited to only one. Nevertheless, it is considered meaningful because the patient who had ptosis after a Botulinum toxin injection, which lasted much longer than usual, but improved solely with acupuncture. And it is hoped that this case report would lead to further follow-up studies to treat patients with blepharoptosis, which will ultimately help clarify the effectiveness of acupuncture.

The authors declare no conflict of interest.