Safety of Once-Daily Oxymetazoline HCl Ophthalmic Solution, 0.1% in Patients with Acquired Blepharoptosis: Results from Four Randomized, Double-Masked Clinical Trials

The Use of Oxymetazoline 0.1% Ophthalmic Solution for Acquired Blepharoptosis: A Systematic Review

OBJECTIVE

Oxymetazoline hydrochloride has been shown to be effective in some studies for acquired blepharoptosis and for aesthetic upper eyelid elevation. This study aims to systematically review the literature on the use of topical oxymetazoline for treating acquired blepharoptosis.

DATABASES REVIEWED

PubMed (U.S. National Library of Medicine, National Institutes of Health), Scopus (Elsevier), and Cochrane.

METHODS

A systematic review of studies published between 2013 and 2024 following PRISMA guidelines was performed using the PubMed, Scopus, and Cochrane databases. Primary outcomes included pre- to posttreatment change in marginal reflex distance (MRD1) after treatment with topical oxymetazoline, and mean difference (pre-to-posttreatment) in MRD1 versus control.

RESULTS

Five articles included data from 458 patients for analysis. Meta-analysis demonstrated significant improvement in MRD1 measurements posttreatment with oxymetazoline (1.40 mm; 95% confidence interval, CI [0.41 mm, 2.40 mm]). In addition, when compared to controls, patients treated with oxymetazoline demonstrated greater increase in MRD1 values (0.83 mm; 95% CI [0.10 mm, 1.55 mmm]). Heterogeneity, measured by I2 statistic, was high in all studies (85%-95%).

CONCLUSION

The use of oxymetazoline 0.1% ophthalmic solution significantly improves MRD1 in patients with acquired blepharoptosis. Further studies comparing this treatment in other etiologies of acquired blepharoptosis should be conducted. Laryngoscope, 135:8-14, 2025.

Use of oxymetazoline hydrochloride ophthalmic solution, 0.1% for improved lid symmetry in Graves' disease

PURPOSE

The purpose of this study is to evaluate the usage of oxymetazoline hydrochloride ophthalmic solution, 0.1% in the treatment of Graves' disease to improve lid symmetry.

METHODS

Fourteen patients were identified with unilateral upper eyelid retraction, secondary to Graves' disease. A phenylephrine test was performed to evaluate whether treating the unaffected (non-retracted) side would result in improved symmetry using Hering's law. Patients were prescribed oxymetazoline hydrochloride ophthalmic solution, 0.1% to instill into the unaffected eye. Marginal reflex distance 1 (MRD1) measurements were taken pre- and post-treatment and patient satisfaction surveys were completed.

RESULTS

The average pre-treatment MRD1 difference between the right eye (OD) and the left eye (OS) was 2.46 [range 1.50-4.00]. The average post-treatment MRD1 difference between OD and OS was 0.39 [range 0.00-1.00]. One hundred percent of patients were satisfied or very satisfied with the improvement in symmetry.

CONCLUSIONS

Oxymetazoline hydrochloride ophthalmic solution, 0.1% is a potential method to improve symmetry in patients with Graves' disease and unilateral upper eyelid retraction via Hering's law, especially for non-surgical candidates or those who prefer non-surgical treatment. Our results indicate improved MRD1 differences between fellow eyes and patient satisfaction regarding the symmetry of the upper eyelids.

The Prevalence and Severity of Acquired Blepharoptosis in US Eye Care Clinic Patients and Their Receptivity to Treatment

Purpose

To assess the presence and severity of acquired blepharoptosis (ptosis) among patients visiting an eye care clinic and the receptivity of eligible patients to pharmacologic treatment with oxymetazoline 0.1% ophthalmic solution.

Patients and Methods

Patients aged 50 years or older who had a scheduled clinic appointment for any reason (eg, dry eye, cataract surgery consultation) were asked to respond to written questions about lid position and select whether their upper lid position most closely matched one of 4 images shown to them corresponding to no, mild, moderate, or severe ptosis. Patients selecting any of the mild, moderate, or severe ptosis were offered treatment with oxymetazoline 0.1% ophthalmic solution, barring any medical contraindications. The outcome measures were the proportion of patients with each self-reported lid position level (none to severe ptosis), the proportion of patients with asymmetric ptosis, and the proportion of patients willing to accept the treatment.

Results

Data for 188 eyes of 94 patients were analyzed. Overall, 73.4% of patients had ptosis in at least one eye, and 25.5% had an asymmetric upper eyelid presentation. The proportions of patients with self-reported mild, moderate, or severe ptosis in at least one eye were 41.5%, 25.5%, and 6.4%, respectively. Among those patients eligible for treatment, 19.7% were willing to accept the treatment.

Conclusion

Based on patients' self-assessment of lid position, this study suggests a higher prevalence of ptosis than reported previously. Evaluation of the eyelids should be a standard part of the comprehensive eye examination.

Topical Review: An Update of Diagnostic and Management Algorithms for Acquired Blepharoptosis

SIGNIFICANCE

Acquired ptosis is a condition of the upper eyelid that has negative cosmetic and functional effects but is likely underdiagnosed and undertreated. Given the evolving understanding of the condition and expanding therapeutic options, this review reappraised published evidence and clinical experience regarding diagnosis and treatment of acquired ptosis.The authors met over two structured virtual working sessions to review current evidence and develop timely recommendations for acquired ptosis identification, differential diagnosis, characterization, and treatment selection. Diagnostic algorithms, plus management and referral guidelines, are presented. Eyelid evaluation and, when needed, ptosis diagnostic workup are essential in the comprehensive eye examination. Acquired ptosis can be efficiently identified via patient questionnaire, history, and photograph review combined with assessment of eyelid position and symmetry using established methods. When ptosis is present, it is essential to evaluate onset, symptoms, pupil diameter, and extraocular muscle function to identify or rule out serious underlying conditions. If signs of serious underlying etiology are present, immediate referral/follow-up testing is required. After ruling out serious underlying causes, masquerade conditions, and pseudoptosis, pharmacologic or surgical treatment should be selected based on the clinical evidence. Effectively managing acquired ptosis requires practice-wide commitment to thorough eyelid evaluation, accurate diagnosis, and adoption of new treatment modalities. Aided by evolving pharmacologic therapeutic options, shifting from a "detect and refer" to a "diagnose and manage" approach can support identification and treatment of more patients with acquired ptosis, particularly mild-to-moderate cases.