Eyelid Ptosis

ptosis, blepharoptosis, upper eyelid ptosis, droopy eyelid

When your upper eyelid droops down over your eye, this condition is known as eyelid ptosis. The drooping can range from barely noticeable to severe enough to completely cover your pupil and block your vision, affecting your ability to see clearly and perform daily activities.

Table of contents

• What is eyelid ptosis?
• Types of eyelid ptosis
• What causes eyelid ptosis?
• Signs and symptoms
• What happens if ptosis is left untreated?
• How is ptosis diagnosed?
• How is ptosis treated?

What is eyelid ptosis?

Eyelid ptosis is a condition in which your upper eyelid droops, sags, or falls over your eye^[1]. The condition gets its name from the Greek word for “falling”^[7]. It usually happens because your levator muscle — the muscle that lifts your eyelid — doesn’t work as it should^[1]. The condition can limit your vision or block it completely, depending on how much your lid droops^[1].

Ptosis of the eyelid can affect one or both upper eyelids. It can also be worse in one eye than the other^[1]. The droop may be barely noticeable, or the eyelid can sag to such an extent that it covers your pupil (the black dot at the center of your eye that lets light in)^[2].

The shape of your eyes, along with the position of your eyelids and eyebrows, determines your identity. Hence, drooping of the eyelids may produce both a functional and a cosmetic problem^[7].

Types of eyelid ptosis

Ptosis can affect both children and adults^[1]. Healthcare providers often group ptosis according to the age when it occurs and the underlying cause^[20].

Congenital ptosis means your child was born with the condition^[1]. Problems with the development of the levator muscle cause congenital ptosis^[1]. Children can be born with ptosis in one or both eyelids. It can be caused by problems with the levator muscle — the main muscle that lifts the eyelid^[2]. The most common kind of ptosis present from birth often affects only one eyelid, but both may be droopy^[1].

Acquired ptosis (also known as involutional ptosis) affects adults later in life^[1]. It occurs when your levator muscle weakens or separates away from your eyelid^[1]. Adults get ptosis when the levator muscle stretches and separates from the eyelid. This can be caused by aging, as a result of an eye injury, or sometimes as a side effect of certain eye surgery^[2].

Based on the cause, acquired adult ptosis is further classified into several types^[7]:

• Aponeurotic ptosis is the most prevalent form of adult ptosis and usually presents in the 5th or 6th decade of life. It can also occur in young individuals following trauma, recent eyelid swelling, ocular surgery, or prolonged use of contact lenses. The condition is caused by dehiscence or disinsertion of the levator aponeurosis^[7].
• Neurogenic ptosis results from any condition that disrupts the innervation of either the levator muscle or Muller’s muscle^[7].
• Myogenic ptosis is when the levator muscle, which is responsible for moving the eyelid, stops operating properly^[19].
• Mechanical ptosis occurs when the eyelid becomes too heavy to control. It can be caused by extra weight from excess skin or possibly fat^[19].
• Traumatic ptosis follows injury to the muscles or nerves^[7].

What causes eyelid ptosis?

Ptosis causes depend on the type. Some babies are born with ptosis in one or both eyelids (congenital ptosis)^[1]. Ptosis can occur later in life (acquired ptosis) if the muscles or ligaments that normally raise your eyelid are weakened by injury or disease. Sometimes, the drooping is a result of damage to the nerves that control your eyelid muscles^[1].

Your upper eyelid is connected to a muscle that helps hold it in place and move it up and down to cover or uncover your eye. A smaller, supporting muscle helps with this process. Additionally, a muscle under the skin of your eyebrow works to raise your eyelids from above. Weakness or damage in any or all three of these muscles or their tendons can cause your eyelid to droop^[18].

Diseases and conditions that may result in ptosis include^[1]:

• Stye
• Horner syndrome
• Myasthenia gravis
• Stroke
• Tumor
• External ophthalmoplegia

Most ptosis just happens with aging. As you age, the skin and muscles of your eyelids stretch and weaken^[1]. Sometimes, previous eye surgery speeds up this change because the instruments used to keep your eye open during surgery can stretch your eyelid^[1].

Occasionally other diseases can affect the eyelid muscle, causing ptosis^[2]. A large swelling or bump on the eyelid can also cause acquired ptosis^[21].

Signs and symptoms

You can typically tell if you or your child has ptosis by your eyelid’s appearance. It may cover only your upper eye, or it may cover your entire pupil^[1]. The main sign is one or both eyelids droop. It isn’t painful, but it can block your sight^[3].

Other ptosis symptoms may include^[1]:

• Excessive rubbing of your eyes
• Increased tearing
• Decreased or impaired vision
• Tiredness and achiness around your eyes
• Children may tip their heads back to see

You may have to tip your head back and lift your chin to see better. Or you might have to arch your eyebrows to lift your lids. Over time, these moves may affect your head and neck^[3]. Some patients describe fatigue and heaviness around the eye, which worsens throughout the day^[4].

Symptoms of ptosis include difficulty keeping your eyes open, eyestrain, forehead aching from the increased effort needed to raise your eyelids, and fatigue, especially when reading. In severe cases, it may be necessary to tilt your head back or lift the eyelid with a finger in order to see out from under the drooping eyelid(s)^[4].

Children may be at risk for vision problems if they have ptosis. If the child’s eyelid droops to the extent that it blocks vision, amblyopia (“lazy eye”) can develop and one eye will have better vision than the other^[2]. Some other symptoms seen in congenital ptosis can include blurry vision (from astigmatism), chin-up head position (so that vision is less blocked), and lazy eye^[1].

What happens if ptosis is left untreated?

If your child has congenital ptosis, the sooner you have it treated, the better. If left untreated, it could impact their vision development and lead to other issues^[1]. Mild acquired ptosis is less likely to cause vision problems, and you may not need to seek treatment. But severe ptosis can cause serious complications if you don’t treat it^[1].

Complications of ptosis may include^[1]:

• Astigmatism: When your eyelid puts pressure on the front of your eye, it can change the shape of your eye. This can cause distortion in your vision (your vision may be stretched or wavy)^[1].
• Amblyopia: Astigmatism and other refractive errors (issues focusing due to a need for glasses) can cause amblyopia, or lazy eye^[1].
• Chin-up position: When your child has to tilt their chin up to be able to see beyond their drooping eyelids, it can cause neck problems, tightened forehead muscles, and developmental delays^[1].

Ptosis can cause problems when you drive, read, or even walk up and down stairs^[3]. The psychological toll of droopy eyelids cannot be understated. Living with this condition can lead to social withdrawal, anxiety, and a decrease in quality of life as individuals become self-conscious about their appearance or frustrated by functional impairments^[23].

How is ptosis diagnosed?

Healthcare providers can typically detect ptosis by the appearance of a drooping eyelid. If both eyelids are affected, it may be more difficult to diagnose^[1]. Your healthcare provider will perform a physical exam. They may refer you to an eye care specialist (ophthalmologist) who will perform an eye exam and may request additional tests^[1].

A complete eye examination with special attention given to the history, to the eyelid position, vision, refraction (possible need for glasses), and the head position can help better understand ptosis^[21]. It is important to monitor children regularly for vision problems when they have ptosis^[3].

How is ptosis treated?

If the ptosis doesn’t affect your vision, your doctor may decide not to treat it^[3]. Often, doctors won’t treat children with ptosis immediately. They will check their eyes regularly and will probably treat amblyopia with drops, patches, or glasses. The doctor will also watch the eye to see if your child needs surgery as they get older^[3].

For adults, treatment usually does mean surgery^[3]. Ptosis is treated by eyelid surgery. It should be done as soon as there are signs of vision problems that cannot be improved with other treatments^[6]. If the ptosis does not cause problems with vision, surgery can wait until later in life, most commonly performed in the preschool years^[21].

Ptosis surgery usually involves tightening the levator muscle in order to elevate the eyelid to the desired position. Your surgeon will discuss with you whether the incision and stitches will be on the outside or inside of your eyelid^[4]. Your doctor may remove extra skin and tuck the muscle that lifts the lid. Or the doctor may reattach and strengthen that muscle^[3].

If the levator muscle is extremely weak, then a “sling” operation may be performed, enabling the forehead muscles to elevate the eyelid(s)^[4]. The type of eyelid surgery depends on how well the levator palpebrae muscle, the muscle that lifts the eyelid, works^[21].

The main goals of ptosis surgery are elevation of the upper eyelid to improve the field of vision, permit full visual development in children, and to establish more symmetry with the opposite upper eyelid^[4]. It is important to realize that completely normal eyelid position and function may not be possible to achieve^[4].

Ptosis surgery is an outpatient procedure. Young children are put under general anesthesia while older children and adults will often receive “twilight” anesthesia. Some surgeons will perform ptosis surgery in an office setting^[4]. This surgery is done as a day procedure so you do not have to stay in overnight^[6].

You may also be able to wear glasses with a special crutch built in. It lifts your eyelids so you can see better. That helps you avoid surgery^[3].

A new non-surgical option became available in 2020 when the FDA approved eye drops (oxymetazoline HCL 1%) that can improve appearance and functioning for patients with mild to moderate ptosis. In clinical trials, the treatment was well-tolerated and significantly improved the superior visual field^[13].