Ptosis (Droopy Eyelid)

Ptosis is drooping of the upper eyelid below its normal position. It can affect one or both eyes and ranges from barely noticeable to severe enough to block vision. The causes vary widely, from normal aging to serious neurological conditions, making proper evaluation important.

Understanding Ptosis

The upper eyelid is lifted by the levator palpebrae superioris muscle, controlled by the third cranial nerve, with assistance from Müller's muscle (controlled by sympathetic nerves). Ptosis occurs when these muscles or their nerve supply are weakened or damaged.

Types of Ptosis

By Age of Onset

Congenital (from birth):

• Present at birth or early infancy
• Usually due to levator muscle underdevelopment
• Often stable throughout life

Acquired (develops later):

• Multiple possible causes
• May indicate underlying condition

By Cause

Aponeurotic (most common in adults)

• Age-related stretching of muscle tendon
• Contact lens wear
• Post-eye surgery

Neurogenic

• Third nerve palsy
• Horner syndrome
• Myasthenia gravis

Myogenic (muscle disease)

• CPEO
• Muscular dystrophies
• Myasthenia gravis

Mechanical

• Heavy eyelid (tumor, swelling)
• Scarring pulling lid down

Symptoms

Visual Symptoms

• Drooping eyelid blocking vision
• Need to lift chin to see under lid
• Raising eyebrows to help open eyes
• Tired appearance
• May cover pupil (severe ptosis)

Associated Symptoms (Depend on Cause)

With third nerve palsy:

• Eye turned outward and down
• Double vision
• Dilated pupil

With Horner syndrome:

• Small pupil on same side
• Reduced sweating on face

With myasthenia:

• Fatigue—ptosis worsens through the day
• Variable symptoms
• May affect both eyes differently

Red Flags

Diagnosis

Clinical Examination

• Measure lid height (margin reflex distance)
• Check levator function
• Pupil examination
• Eye movement testing
• Fatigue testing (for myasthenia)
• Check for variability

Key Distinctions

Type	Key Features
Aponeurotic	High lid crease, good levator function, elderly
Third nerve	Ptosis + eye turned out/down, ± pupil dilation
Horner	Ptosis + small pupil same side
Myasthenia	Variable, fatigable, may be bilateral
Congenital	Present since birth, poor levator function

Testing

For myasthenia:

• Acetylcholine receptor antibodies
• Single-fiber EMG
• Ice pack test

For Horner syndrome:

• Pharmacologic testing (apraclonidine, cocaine)
• Imaging neck and chest

For third nerve palsy:

• MRI/MRA brain
• CTA if aneurysm suspected

Treatment

Treat Underlying Cause First

• Myasthenia: immunotherapy
• Third nerve palsy from aneurysm: urgent neurosurgical evaluation
• Horner: find and treat cause

Surgery (for Appropriate Cases)

Levator advancement/resection

• For aponeurotic ptosis
• Tightens the lifting muscle
• Good results if levator function adequate

Frontalis sling

• For poor levator function
• Connects lid to forehead muscle
• Uses brow elevation to lift lid

Müller's muscle resection

• For mild ptosis
• Horner syndrome (if cause treated/stable)

Non-Surgical Options

• Ptosis crutches on glasses
• Eyelid tape
• Observation (if mild)

Special Considerations

Children

• Congenital ptosis may need surgery to prevent amblyopia
• Timing of surgery important
• Monitor for vision development

Variable Ptosis

If ptosis varies during the day or with activity, consider myasthenia gravis—do not proceed with surgery until this is ruled out.

Frequently Asked Questions

Is my droopy eyelid dangerous?

The ptosis itself isn't dangerous, but the underlying cause might be. That's why evaluation is important—especially if the ptosis came on suddenly, is accompanied by other symptoms, or is progressing.

Will I need surgery?

Not necessarily. If the ptosis is mild and not affecting vision, observation may be fine. If an underlying condition is causing it, treating that condition may resolve the ptosis. Surgery is an option when the lid blocks vision or for cosmetic improvement.

Why is one eyelid droopy?

Unilateral (one-sided) ptosis has many causes. The most common in adults is age-related weakening of the lid's lifting mechanism. However, it's important to rule out neurological causes like third nerve palsy or Horner syndrome.

Can ptosis come back after surgery?

Yes, ptosis can recur after surgery, especially over many years. However, modern surgical techniques generally provide good, lasting results. If ptosis recurs, revision surgery may be possible.

My ptosis is worse at night—is that significant?

Ptosis that worsens with fatigue, especially late in the day, is a hallmark of myasthenia gravis. This should be tested for before considering surgery.

References