Droopy Eyelids (Ptosis)

What is Ptosis (Droopy Eyelids, Droopy Eyes)?

Eyelid ptosis, also called blepharoptosis, is drooping of the upper eyelid. It can occur in one or both eyelids and ranges from mild to severe. 

The condition is categorized into the following:

• Mild ptosis might not be noticeable nor cause any vision problems. 
• Severe ptosis can obstruct the vision partially or entirely.
• Unilateral ptosis is when one eyelid droops.
• Bilateral ptosis is when both upper eyelids droop.

Symptoms of Ptosis

The main feature of ptosis is an upper drooping eyelid. However, ptosis can have other symptoms, such as:

• Difficulty blinking or closing the eyelids
• Limited eye movement
• Decreased vision or impaired field of vision (if the eyelid blocks the pupil)
• Having to tilt the head back to see beneath the eyelids
• Having to raise the eyebrows to lift the eyelids up
• Aching or tiredness around the eyebrows and eye area
• Difficulty looking up with the eye that has ptosis
• The eye with ptosis appears smaller
• A higher eyelid crease on the affected side
• Dry or irritated eyes related to poor eyelid function
• Noticeable eyelid changes when comparing recent and old photos 

Additionally, some people have a condition called dermatochalasis, which causes pseudoptosis. Pseudoptosis is associated with a gradual loosening and sagging of the eyelid skin and is common in older people.

Signs of pseudoptosis are often similar to ptosis, although these are separate conditions that require different treatments.

Common Causes of Ptosis

Various conditions can cause ptosis. The underlying cause usually affects the muscles that control eyelid movements.

The eyelid muscles are called the levator palpebrae and Muller’s muscle. Other causes of ptosis are related to neurological conditions.

Types of ptosis are divided into two general groups, congenital or acquired. Congenital ptosis is present at birth, while acquired ptosis develops later in life.

Listen In Q&A Format

What is Ptosis or Droopy Eyelids?

Vision Center Podcast

Causes of Congenital Ptosis

Ptosis present at birth is called congenital ptosis. Some causes of congenital ptosis include:

Myogenic Ptosis

Myogenic ptosis is related to abnormal development of the levator palpebrae eyelid muscle.

This is the most common cause of congenital ptosis.

Horner’s Syndrome

Horner’s syndrome is a neurological disorder that causes mild ptosis in one eye. The affected eye also has a smaller pupil and may have a different colored iris than the other eye.

The most frequent cause of congenital Horner’s syndrome is birth trauma.

Third Cranial Nerve Palsy

Third cranial nerve palsy is a neurological condition that causes ptosis, double vision, eye turn (down and out), and sometimes, a dilated pupil.

Congenital third nerve palsies may be related to birth trauma, infection, or developmental abnormalities.

Marcus Gunn Jaw Winking Syndrome (MGJWS)

Marcus Gunn Jaw winking syndrome (MGJWS) is the most common form of congenital ptosis with an underlying neurological cause.

The nerves controlling the eyelid muscles and the nerves controlling the jaw muscles develop an abnormal connection.

As a result, the eyelid with ptosis moves up and down anytime the mouth opens or while chewing, swallowing, or moving the jaw. 

Causes of Acquired Ptosis

Acquired ptosis is when drooping eyelids occur due to muscle damage or aging. Some causes include:

Aponeurotic Ptosis

Aponeurotic ptosis is the most common form of ptosis. It is typically associated with older age, eye surgery, or trauma.

This form of ptosis is related to the eyelid muscle’s gradual weakening and stretching.

Myasthenia Gravis

Myasthenia gravis is an autoimmune eye disease that causes muscle fatigue and weakness. It is usually worse at the end of the day.

Ninety percent of people with myasthenia gravis have eye muscle issues that cause ptosis, double vision, or eye turns (strabismus).

Horner Syndrome

Horner syndrome is rare but often presents with partial ptosis. Causes include trauma, tumors, or blood clots in your carotid artery.

Acquired Third Nerve Palsy

Acquired third nerve palsy is often related to diabetes or high blood pressure. However, a third nerve palsy involving a dilated pupil is a sign of a serious problem, such as a tumor or brain aneurysm. 

A brain aneurysm is an emergency and requires immediate medical attention.

Trauma

Trauma that damages the eyelid muscles or nerves can result in ptosis. 

Ptosis resulting from trauma may range from mild to severe, depending on the severity of the injury. 

Eyelid Tumors

Tumors, such as a neurofibroma, can cause upper eyelid drooping. They put pressure on your eyelid and affect overall eyelid function. 

Cataract Surgery

Cataract surgery has the potential to cause post-operative ptosis. While cataract surgery is generally safe, complications can still arise. 

Post-operative ptosis may occur due to surgical manipulation near the eyelids or nerve damage during the procedure.

Risks of Untreated Ptosis

Failing to seek treatment for ptosis can cause various complications. Some risks of untreated ptosis include:

Astigmatism

Astigmatism is a refractive error caused by an irregularly shaped cornea. 

Some studies show the ptosis lid can put pressure on the superior cornea, potentially leading to a corneal curvature change and astigmatism.⁶

Amblyopia (Lazy Eye)

Amblyopia (lazy eye) may also develop as a result of ptosis. The condition happens when the brain favors one eye over the other.

In ptosis, the affected eye with the drooping lid may receive less visual stimulation. This can lead to the brain “ignoring” visual input in the affected eye.  

Other Eye Conditions

Other eye-related conditions that may arise from untreated ptosis include:

• Excessive blinking
• Eye strain and fatigue
• Double vision
• Impaired vision

Treatment Options for Droopy Eyelids

Treatment might be unnecessary if the ptosis is mild and there is no underlying disease. Some people seek treatment for cosmetic reasons or if they have vision problems as a result of ptosis.

An oculoplastic specialist is an ophthalmologist who specializes in ophthalmic plastic surgery and reconstructive surgery (cosmetic surgery for the eyes). You may be referred to one if you’re seeking surgical treatment.

Treatment options include:

Ptosis Surgery (Blepharoplasty)

Blepharoplasty is the primary form of treatment. Examples of ptosis surgeries are:

• Muller resection
• Levator resection
• Fasanella-Servat
• Frontalis sling 

In milder cases, the surgery involves shortening and tightening the levator muscle or repairing the levator aponeurosis. 

Severe cases involve the surgeon attaching the forehead and eyebrow muscles to help lift the eyelid.

Is Ptosis Surgery Safe?

In general, ptosis surgery is safe. However, you should consider potential complications like:

• Undercorrection. When the ptosis is not completely repaired.
• Overcorrection. When the eyelid is lifted too high.
• Eyelid asymmetry. Can happen between the two eyes.
• Exposure keratopathy. This occurs when your eyelid doesn’t close completely.
• Other potential side effects. These include dry eyes, bleeding, or infection.

Eyelid Crutch

An eyelid crutch is a non-surgical method to lift the eyelid temporarily. These are wire loops attached to eyeglasses that act as crutches to hold the eyelid up while wearing the glasses.

Can You Prevent Ptosis?

Ptosis is not always preventable. However, a healthy lifestyle may reduce your risk of developing diseases such as high blood pressure, diabetes, and heart disease. 

These conditions can lead to complications that cause ptosis, among more serious medical problems.

These are some areas you can consider to improve your lifestyle:

• Eat a healthier diet
• Lose weight
• Exercise more often
• Quit smoking

Other things you can do to reduce your risk of ptosis:

• Avoid excessive eye rubbing or eyelid pulling
• Reduce contact lens use when possible, including hard or soft contacts
• Prevent trauma

Regular eye exams from your ophthalmologist can help detect ptosis, refractive errors, cataracts, and other eye conditions.

Watch Our Podcast on Ptosis

Summary

• Ptosis, or drooping eyelids, is characterized by a sagging upper eyelid
• The condition may be congenital (present at birth) or acquired (developed later in life)
• There are various causes of ptosis, and untreated ptosis can lead to complications
• While ptosis is not always preventable, adopting a healthy lifestyle helps reduce the risk of conditions that can lead to ptosis