Drooping Eyelid (Ptosis)

Ptosis (TOE-sis) is drooping of the upper eyelid. It can affect one or both eyes and may be present from birth or develop later in life. While often age-related, ptosis can sometimes indicate serious neurological conditions requiring urgent evaluation.

Types of Ptosis

By Timing

• Congenital—present from birth
• Acquired—develops later in life

By Involvement

• Unilateral—one eye
• Bilateral—both eyes

By Severity

• Mild—minimally noticeable
• Moderate—partially covers pupil
• Severe—covers pupil, blocks vision

Common Causes

Age-Related (Involutional/Aponeurotic)

The most common cause in adults:

• Stretching or thinning of eyelid muscle tendon
• Usually gradual onset
• Often both eyes (may be asymmetric)
• Higher crease in affected eyelid
• No other neurological symptoms

Neurological Causes

Third cranial nerve (oculomotor) palsy

• Ptosis often complete (lid completely down)
• Eye may be deviated outward and downward
• Double vision when lid lifted
• If pupil is dilated—possible aneurysm, emergency

Horner syndrome

• Mild ptosis (2-3mm)
• Smaller pupil on same side
• May have decreased sweating on face
• Indicates problem in sympathetic nerve pathway

Myasthenia gravis

• Ptosis that varies throughout day
• Worse with fatigue, better after rest
• May fluctuate from eye to eye
• Often associated with double vision

Muscle Disorders

Chronic progressive external ophthalmoplegia (CPEO)

• Slowly progressive bilateral ptosis
• Limited eye movements
• Mitochondrial disorder

Muscular dystrophies

• Various forms can cause ptosis
• Usually with other muscle weakness

Other Causes

• Trauma—injury to lid or muscle
• Surgery complication—after eye surgery
• Contact lens wear—long-term hard lens wear
• Mass/tumor—lid or orbital mass weighing down lid
• Inflammation—lid swelling from various causes

Warning Signs

What You'll Be Asked in Clinic

About the ptosis:

• When did you first notice it?
• Is it getting worse?
• Does it vary throughout the day?
• Worse when tired?
• One eye or both?
• Any photos showing when it started?

About associated symptoms:

• Double vision?
• Difficulty swallowing?
• Weakness anywhere?
• Headache?
• Change in pupil size?

About your health:

• Previous eye surgery?
• Contact lens history?
• Autoimmune conditions?
• Family history of similar problems?

How Ptosis Is Diagnosed

Clinical Examination

• Margin-reflex distance (MRD)—measuring lid height
• Levator function—how well the muscle works
• Pupil examination—size comparison, reactions
• Eye movement assessment—checking for nerve palsies
• Fatigue testing—looking for variability (myasthenia)
• Ice pack test—if myasthenia suspected

Additional Tests

• Acetylcholine receptor antibodies—for myasthenia
• MRI brain/orbits—if neurological cause suspected
• MRA/CTA—if aneurysm suspected (urgent)
• Chest CT—looking for thymoma in myasthenia
• Pharmacologic testing—apraclonidine for Horner syndrome

Treatment Options

Treatment depends on the cause:

Age-Related Ptosis

• Observation—if mild and not affecting vision
• Ptosis repair surgery—tightening the muscle tendon
• Usually outpatient procedure with good results

Third Nerve Palsy

• Emergency imaging if pupil involved
• Treatment of underlying cause (aneurysm, diabetes, etc.)
• May resolve if microvascular (diabetic)
• Surgery for stable persistent cases

Horner Syndrome

• Identify and treat underlying cause
• Imaging to trace the nerve pathway
• Ptosis itself rarely needs surgery (mild)

Myasthenia Gravis

• Pyridostigmine—improves muscle strength
• Immunosuppressive medications
• Thymectomy—removal of thymus
• See myasthenia gravis

CPEO

• No specific treatment for underlying cause
• Surgery may help if ptosis severe
• Manage associated conditions

Frequently Asked Questions

Is ptosis always serious?

No. The most common cause is age-related weakening of the eyelid muscle, which is benign though may need surgery if affecting vision. However, new ptosis should be evaluated to rule out more serious causes.

Why did my doctor check my pupils so carefully?

A dilated pupil with ptosis can indicate a brain aneurysm compressing the third cranial nerve—a medical emergency. Checking pupils helps distinguish this from other causes.

Can ptosis affect my vision?

Yes, if the lid droops enough to cover the pupil. Severe ptosis blocks the upper visual field. Surgery is often recommended when ptosis interferes with vision.

Will my ptosis get worse?

It depends on the cause. Age-related ptosis typically progresses slowly. Myasthenia gravis ptosis fluctuates. Ptosis from nerve palsy may improve or stabilize depending on the cause.

Is ptosis surgery effective?

Yes, ptosis surgery is generally very effective for appropriate candidates. Success rates are high, though some people need adjustment procedures. Your surgeon can discuss expected outcomes.

Can I prevent ptosis?

Age-related ptosis isn't really preventable. Avoiding hard contact lenses (or limiting wear time) may reduce risk of contact lens-related ptosis. Treating conditions like myasthenia can help control associated ptosis.

References