Biopsy-proven sarcoidosis lesion of the levator palpebrae superioris causing myogenic blepharoptosis

We describe a case of myogenic blepharoptosis due to sarcoidosis directly involving the levator palpebrae superioris, confirmed with biopsy.

A 43-year-old male with hypertension and hyperlipidemia presented with four months of progressive right blepharoptosis and two months of dry cough. Workup revealed elevated serum muramidase, hilar adenopathy, and bilateral lacrimal gland and right levator MRI enhancement. Both lacrimal gland biopsy and later levator biopsy were consistent with sarcoidosis.

Most sarcoidosis-related blepharoptosis is secondary to Horner syndrome or mass effect from lacrimal gland enlargement. On literature review, we did not identify prior biopsy-confirmed direct involvement of the levator as a cause of sarcoidosis-related blepharoptosis. No cases were identified with isolated levator enhancement without involvement of other extraocular muscles. In this case, both the lacrimal gland and levator biopsies were consistent with sarcoidosis. It is possible that prior reports of sarcoidosis-related blepharoptosis secondary to lacrimal gland enlargement with positive biopsy were in fact due to direct co-involvement of the levator. The exact mechanism of sarcoidosis-related blepharoptosis impacts the proposed surgical intervention if indicated after failed medical therapy, and direct levator involvement should be considered prior to surgical planning.