Ptosis (Blepharoptosis)

How the eyelid is lifted

Two muscles raise the upper lid:

• Levator palpebrae superioris: the main lifting muscle, supplied by the third cranial nerve. Its broad tendon (the aponeurosis) attaches to the eyelid.
• Müller's muscle: a small muscle beneath it, controlled by sympathetic nerves, which adds 1 to 2 mm of lift.

Ptosis results when either muscle, its tendon or its nerve supply fails, or when something weighs the lid down. For a symptom-focused guide to a drooping eyelid, including red flags, see drooping eyelid (ptosis).

Types of ptosis

Congenital ptosis

Present at birth in one or both eyes. The levator muscle is partly replaced by fibrous tissue, so it neither lifts nor relaxes normally. If the lid covers the pupil, or the drooping causes astigmatism, the child can develop amblyopia (lazy eye), which becomes permanent if not treated in early childhood.

Aponeurotic ptosis

The commonest acquired type. The levator muscle is healthy but its tendon has thinned or slipped. It develops gradually with age and is also linked to hard contact lens use, eye rubbing and eye surgery.

Neurogenic and myogenic ptosis

These signal an underlying disease and need investigation before eyelid surgery. Myasthenia gravis causes fatigable ptosis that varies during the day. Horner syndrome causes a mild droop with a small pupil. A third nerve palsy causes a marked droop with eye movement problems.

Symptoms

• One or both upper lids lower than normal
• Reduced upper field of vision, especially when reading or driving
• Raising the eyebrows to see, causing forehead ache and tiredness
• Head tilted back or chin lifted, especially in children
• Asymmetric appearance

Diagnosis

An eye specialist (ophthalmologist or oculoplastic surgeon) will:

1. Measure the droop: the margin reflex distance (MRD1), the distance from the center of the pupil to the lid edge. Normal is about 4 to 5 mm.
2. Measure levator function: how far the lid travels from looking down to looking up. Good function suggests aponeurotic ptosis; poor function suggests congenital or myogenic ptosis.
3. Check the lid crease, pupils, eye movements and tear film.
4. Test visual fields with the lid in its natural position and taped up. Insurers often require this to show surgery is medically necessary.
5. Look for fatigue by asking you to look up for 1 to 2 minutes, and perform an ice-pack test if myasthenia is suspected.
6. Arrange further tests for nerve or muscle causes: antibody blood tests, nerve studies, or brain and vessel imaging.

In children, vision, refraction and eye alignment are checked for amblyopia risk.

Treatment

Surgery

The main treatment. Performed under local anesthetic with sedation in adults, and general anesthetic in children. The approach depends on levator function:

• Levator advancement (external approach): the stretched tendon is reattached and tightened through a crease incision. Used for most aponeurotic ptosis.
• Müller muscle-conjunctival resection (internal approach): shortening Müller's muscle from the inside of the lid, for mild ptosis that lifts well with phenylephrine drops.
• Frontalis sling: for poor levator function (often congenital), the lid is connected to the forehead muscle with a sling of silicone or tissue, so raising the brow lifts the lid.

Surgery may be combined with removal of excess upper-lid skin (blepharoplasty).

Eye drops

Oxymetazoline 0.1% eye drops, available on prescription in the US, stimulate Müller's muscle and can lift the lid by 1 to 2 mm for several hours in adults with mild acquired ptosis. They do not treat congenital or neurogenic ptosis.

Treating the underlying condition

Myasthenia gravis is treated with medicines and sometimes thymus surgery; nerve palsies are treated according to their cause. Lid "crutches" attached to glasses can help when surgery is unsuitable.

Children

Surgery is done early if the lid blocks vision; otherwise it may be delayed until age 3 to 5 or later. Amblyopia is treated with glasses and patching.

Risks and recovery after surgery

Bruising and swelling settle over 1 to 3 weeks. Possible complications include under- or over-correction, asymmetry, dry eye from incomplete closure, infection and, rarely, bleeding. Around 1 in 10 people may need an adjustment. Results are usually long-lasting, although age-related changes continue.

Outlook

Most people with aponeurotic ptosis have a good cosmetic and functional result from surgery. Congenital ptosis repair works well, with close monitoring for amblyopia. Outcomes for neurogenic and myogenic ptosis depend on the underlying condition.

Frequently asked questions

What is the difference between ptosis and a droopy eyelid?

They mean the same thing. Ptosis (or blepharoptosis) is the medical term for an upper eyelid that sits too low. Excess eyelid skin hanging over the lid, called dermatochalasis, can look similar but is a different problem treated with blepharoplasty.

Is ptosis surgery covered by insurance?

Often it is when the drooping lid blocks the upper field of vision, documented with visual field testing and photographs. Surgery done purely for appearance is usually not covered. Check with your insurer and surgeon before the procedure.

Can ptosis be fixed without surgery?

Mild acquired ptosis can be lifted temporarily with prescription oxymetazoline eye drops. Treating causes such as myasthenia gravis or swelling can improve it. Most age-related and congenital ptosis needs surgery for a lasting correction.

Does congenital ptosis cause vision problems?

It can. If the lid covers the pupil or causes astigmatism, the brain may stop developing vision in that eye, causing amblyopia. Children with congenital ptosis need regular eye exams, and surgery is done early if vision is at risk.

How long does it take to recover from ptosis surgery?

Most bruising and swelling settle within 1 to 2 weeks, and many people return to work within a week. The final lid height and shape become clear over about 6 weeks. Avoid heavy lifting, swimming and eye makeup for the first 1 to 2 weeks.