title: Blepharoptosis and external ophthalmoplegia associated with long-term antiretroviral therapy.
abstract: BACKGROUND
  Long-term antiretroviral therapy (ART) is associated with lipodystrophy, peripheral neuropathy, lactic acidosis, and myopathy. Blepharoptosis, without prior ART association, is usually caused by age-associated involutional ptosis, but it is also seen in mitochondrial myopathies with external ophthalmoplegia, cardiac conduction disturbances, and neurological impairments.
  
  
  METHODS
  Patients presented over a 2-year period. Four patients underwent surgical blepharoptosis repair.
  
  
  RESULTS
  Five human immunodeficiency virus type 1-infected patients (median age, 50 years; range, 46-53 years) who were receiving ART presented with severe blepharoptosis; 2 of these 5 also presented with external ophthalmoplegia. Findings included decreased palpebral fissure height (median, 6.5 mm; normal height, 9 mm), mildly impaired levator function (median, 10 mm; normal, >13 mm), and markedly decreased marginal reflex distance (median, 0.5 mm; normal, 4 mm). A greater advancement of the levator aponeurosis was required during surgical repair, a finding consistent more with myogenic than with involutional blepharoptosis. All patients had severe lipodystrophy, which preceded blepharoptosis by a median interval of 4.7 years (range, 2.8-5.7 years). Four patients also presented with peripheral neuropathy and metabolic abnormalities before the onset of blepharoptosis, and 3 had cardiac conduction disturbances. Patients received ART for a median of 7.8 years (range, 4.9-11.2 years), thymidine analogue-containing ART for a median of 7.1 years (range, 1.2-7.9 years), and protease inhibitor-containing ART for a median of 7.1 years (range, 4.9-8.9 years).
  
  
  CONCLUSIONS
  We report the novel findings of blepharoptosis and external ophthalmoplegia in patients who are receiving ART. Ptosis was preceded by lipodystrophy with long-term use of both thymidine-analogue- and protease inhibitor-containing ART. The findings are most consistent with myogenic ptosis in a generalized mitochondrial myopathy syndrome. Clinicians should also be watchful for other potential myopathic ptosis-associated complications, including proximal weakness, dysphagia, deafness, and cardiac conduction disturbances.
authors.affiliation: Department of Internal Medicine, Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, TX 75390-9103, USA.
authors.forename: Warren L
authors.initials: WL
authors.lastname: Dinges
authors.forename: S Robert
authors.initials: SR
authors.lastname: Witherspoon
authors.forename: Kamel M
authors.initials: KM
authors.lastname: Itani
authors.forename: Abhimanyu
authors.initials: A
authors.lastname: Garg
authors.forename: Dolores M
authors.initials: DM
authors.lastname: Peterson
mesh_terms: D044966:Anti-Retroviral Agents / Q000009:adverse effects*; D001763:Blepharoptosis / Q000139:chemically induced*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy; D006801:Humans; D008134:Long-Term Care; D008297:Male; D008875:Middle Aged; D009886:Ophthalmoplegia / Q000139:chemically induced*
chemical_list: D044966:Anti-Retroviral Agents