Droopy Eyelids (Ptosis)

What Is Ptosis (Droopy Eyelids, Droopy Eyes)?

Eyelid ptosis, also called blepharoptosis, is a droop in the upper eyelid. The droop can occur on one or both eyelids and ranges from mild to severe. Mild ptosis may not be very noticeable nor cause any vision problems, while severe ptosis can obstruct the vision partially or entirely.

Unilateral ptosis is the term used when one eyelid droops. Bilateral ptosis refers to when both upper lids droop.

Symptoms of Ptosis

Although the main feature of ptosis is an upper drooping eyelid, other signs include:

• Difficulty blinking or closing the eyelids
• Limited eye movement
• Reduced visual field
• Tilting the head back to see beneath the eyelids
• Raising the eyebrows to lift eyelids up
• Aching or tiredness around the eyebrows and eye area
• Eye with ptosis has difficulty looking upwards
• Eye with ptosis appears smaller
• Higher eyelid crease on the affected side
• Dry or irritated eyes, related to poor eyelid function
• Decreased vision or impaired field of vision if eyelid blocks the pupil
• Eyelid appearance looks different when comparing recent photos to old photos 

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 can appear similar to ptosis, although these are two separate conditions with different treatments.

Common Causes of Ptosis

There are a variety of conditions that cause ptosis. In most cases, the underlying cause affects the muscles that control your 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 on in life.

Congenital 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 is a neurological disorder that causes mild ptosis on one eye. The affected eye also has a smaller pupil and may have a different colored iris compared to the other eye. The most frequent cause of congenital Horner’s syndrome is birth trauma.
• Third cranial nerve palsy is a neurological condition that causes ptosis, double vision, eye turn (down and out), and in some cases, a dilated pupil. Congenital third nerve palsies may be related to birth trauma, infection, or a developmental abnormality.
• Marcus Gunn jaw-winking syndrome 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 person opens their mouth, chews, swallows, or makes other jaw movements.

Acquired Ptosis

• Aponeurotic ptosis is the most common form of ptosis and is typically associated with older age, eye surgery, or trauma. This type of ptosis is related to a gradual weakening and stretching of the eyelid muscle.
• Myasthenia gravis is an autoimmune disease that causes muscle fatigue and weakness, which 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 can also be acquired. Causes include trauma, tumors, or blood clots in your carotid artery.
• 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 that damages your eyelid muscles or nerves can result in ptosis.
• Eyelid tumors, such as a neurofibroma, may cause ptosis. 
• Cataract surgery can cause post-operative ptosis.

Untreated ptosis can cause astigmatism, amblyopia (lazy eye), and other eye conditions. Surgery can help prevent the development of stimulus deprivation amblyopia.

Treatment Options & Surgery Risks

If the ptosis is mild and there is no underlying disease to address, treatment may not be necessary. Some people seek treatment for cosmetic reasons or if they have vision problems as a result of ptosis.

An oculoplastic specialist is an ophthalmologist that 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:

• 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.
• Medication may improve ptosis if there is an underlying disease to address, such as myasthenia gravis. Myasthenia gravis is often treated with oral steroids.
• Ptosis surgery (blepharoplasty) is the primary form of treatment. Muller resection, levator resection, Fasanella-Servat, and frontalis sling are examples of ptosis surgeries. For milder cases, the surgery involves shortening and tightening the levator muscle or repairing the levator aponeurosis. For cases of severe ptosis, the surgeon attaches the forehead and eyebrow muscles to help lift the eyelid.

In general, ptosis surgery is quite safe. However, there are some potential complications to consider:

• Undercorrection is when the ptosis is not completely repaired. A second surgery might be required to fix the ptosis completely.  
• Overcorrection is when the eyelid is lifted too high. If the overcorrection is mild, massaging the area may resolve the problem. Otherwise, another surgery may be needed.
• Eyelid asymmetry between the two eyes is possible, as it is often difficult to make both eyelids perfectly symmetrical.
• Exposure keratopathy occurs when your eyelid does not close completely, causing the exposed area of your eye to dry out. 
• Dry eyes, bleeding or infection are other potential side effects.

How to Prevent Ptosis

Ptosis is not always preventable. However, leading 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

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