Prostaglandin-associated periorbitopathy.

A 59-year-old gentleman with primary open-angle glaucoma was on topical bimatoprost 0.03% in the left eye since last 6 years. He presented with deepening of superior sulcus (arrow), periorbital fat atrophy, mild ptosis (a), and 2 mm of enophthalmos (b) in his left eye [Fig. 1], which are typically seen in prostaglandin-associated periorbitopathy (PAP). Comparison with old photographs taken before topical bimatoprost use showed the absence of any asymmetry between the eyes.

Figure 1

(a) Presence of left eye upper eyelid ptosis with deep superior sulcus (arrow) compared to right eye. (b) “Worm's hole view” (Nafziger method) showing left eye mild enophthalmos

PAP, first reported in 2004, is caused by prolonged use of topical prostaglandin (PG) analogs.[1] It has been reported with the use of bimatoprost, travoprost, tafluprost, and latanoprost.[234] The classical features are as seen in our patient. PAP can appear as early as a month after the use of bimatoprost and is caused by fat atrophy, inhibition of adipocyte production, and differentiation of orbital fat due to PGF receptor stimulation by PG analogs.[25] Complex effects of PG analogs on levator muscle and Muller's muscle along with orbital fat are postulated to be responsible for ptosis.[2] PAP is reversed several months to years after discontinuation of the drug.[12]

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