7 Causes of Droopy Eyelids

Ptosis is a condition that causes one or both of your upper eyelids to droop over the top part of your eye. Ptosis is usually nothing to worry about, and healthcare providers can treat most cases with a simple surgical procedure. 

Still, problems with your eyelids are nothing to ignore. Upper and lower eyelids are important for protecting your eyes from injury. They also help control how much light reaches your eyes and ensure the tear film is spread across them, preventing them from drying out.

Causes and Risk Factors

Several things can cause ptosis, including aging, muscle weakness, and congenital conditions (meaning they were present at birth). Here are some common causes and risk factors for ptosis.

Congenital Ptosis

Some babies are born with ptosis, a problem that a healthcare provider can fix. In fact, you should treat ptosis promptly.

"A child is not going to develop [normal] vision if the eyelid is in the way," Philip Rizzuto, MD, an oculofacial plastic surgeon and spokesperson for the American Academy of Ophthalmology, told Health. "When the child sees color and light, it stimulates all the nerves. The retina and brain develop pathways that will set up lifelong vision."

Surgery to bolster the eyelid muscles can prevent complications such as:

• Amblyopia (lazy eye)
• Astigmatism (blurry vision)
• Crossed eyes

Damaged Nerves

Nerve damage from an eyelid injury or conditions affecting the brain and the nervous system can cause your eyelids to droop.

Horner syndrome is one such condition. Horner syndrome is a rare syndrome that happens when there is some kind of interference with the nerves of the eyes. The cause of Horner syndrome can vary, including:

• Tumors
• Trauma to the spinal cord
• Lesions in the brain
• Growths in the lymph nodes

Sometimes, the cause of Horner syndrome may be unknown, also called idiopathic. Some evidence suggests that people can inherit the condition.

Generally, Horner syndrome also causes your pupils to get very small. The affected part of your face may be dry and won't sweat. Ptosis caused by Horner syndrome usually goes away when you treat the underlying problem.

Nerve damage from long-term uncontrolled diabetes and high blood pressure can also lead to ptosis, so it's important to identify and treat those conditions.

Muscle Problems

Primarily, three muscles control eyelid movement. The most important of those muscles is the levator muscle. Anything that affects those muscles can also affect how your eyelid works.

Oculopharyngeal muscular dystrophy (OPMD) is a rare condition affecting eye muscles. Additionally, OPMD can impair muscles used for swallowing and even some limb muscles.

Chronic progressive external ophthalmoplegia (CPEO) is another condition that involves both eyes. CPEO involves the loss of muscle functions in the eye and eyelid movement.

Aging

One of the most common causes of ptosis is aponeurotic ptosis, or involutional ptosis, which occurs mostly in older adults. Frequently rubbing your eyelids may cause aponeurotic ptosis.

"Gravity and time just move everything downward, and sometimes it gets to the point where the eyelid is drooping," said Dr. Rizzuto. "Sometimes, excess skin on the eyelid can hang over the eyelid and block vision."

In most cases, the problem is cosmetic. Elective surgery can restore at least some of your eyelids' youthful vigor if you choose. At times, the drooping lid can affect your sight. In that case, you may need surgery to maintain your vision.

Eye Surgery

Healthcare providers have become so good at performing different types of eye surgery that complications don't happen often. Still, complications may happen. If the complication is a droopy eyelid, it's called post-surgical ptosis.

"The levator muscle of the eye can separate over time after cataract surgery," Jessica Zwerling, MD, an associate professor of neurology at the Albert Einstein College of Medicine, told Health.

People have reported ptosis after cataract, corneal, refractive (like LASIK), and glaucoma surgery. Experts aren't sure exactly why ptosis occurs after surgery. However, the types of instruments and anesthesia that surgeons use may play a role.

Myasthenia Gravis

Myasthenia gravis is a rare autoimmune disease that affects how your muscles and nerves communicate, leading to muscle weakness. Drooping eyelids are often an early symptom of the condition.  

With myasthenia gravis, antibodies that normally fight invaders (like viruses) misfire. Those antibodies prevent muscle cells from receiving messages sent by nerve cells.

"The ptosis [can] fluctuate throughout the day," said Dr. Zwerling. "You may have associated double vision. It can affect the muscles, as well."

Myasthenia gravis can affect other areas of your body, too. There's no cure for the disease. But lifestyle changes and medications can keep muscle weakness under control.

Cancer

Cancers that occur inside your eye won't affect the eyelids. However, cancer around or outside the eye can affect the muscles that raise and lower your eyelids. 

That includes tumors along the nerves or arteries that supply the eye or in the muscles controlling your eye. Ptosis can also rarely be a complication of metastatic cancer, like breast or lung cancer.

Ptosis Signs and Symptoms

The most obvious sign of ptosis is drooping of the eyelid. Other symptoms may include:

• Difficulty keeping your eyes open
• Eyestrain
• Tearing
• Aching forehead from raising your eyes
• Eye fatigue
• Trouble seeing without tilting the head back and lifting the chin
• Amblyopia (sometimes called "lazy eye" because one eye seems to be looking off in another direction)
• Strabismus (eyes that aren't properly aligned)
• Astigmatism
• Double, blurred, or distorted vision
  

How Is Ptosis Diagnosed?

An ophthalmologist will ask you about your medical history, symptoms, and whether you have recently experienced other health problems or injuries.

They will perform a comprehensive eye exam to check your overall eye health. An ophthalmologist will also examine the pupils for abnormalities that can sometimes be present in people with ptosis. They can also test eye muscle function by having you look in different directions. 

An ophthalmologist can measure the degree of eyelid droop by measuring the distance between the center of the pupil and the edge of the upper lid. They will also test the strength and function of the levator muscle.

If an ophthalmologist thinks an underlying condition is causing your ptosis, they may order blood tests. They may also refer you to a neurologist to rule out other causes.

How To Treat Drooping Eyelids

If an underlying condition (like myasthenia gravis) is causing your ptosis, treating that condition will usually improve or stabilize the drooping.

Surgery

Otherwise, a healthcare provider typically surgically treats droopy eyelids. The surgeon will adjust, strengthen, or even reattach the muscle that controls the eyelid's movement. The procedure is done with local anesthesia, and you can go home the same day.

Surgery on children or babies with ptosis involves strengthening the muscle if the muscle still has some function. If it doesn't, surgeons use an insert. 

"It's basically a sling to hold the eyelid up," said Dr. Rizzuto.

Eye Drops

In 2020, the Food and Drug Administration approved Upneeq (oxymetazoline hydrochloride ophthalmic solution). Upneeq is one of the first prescription eye drops to treat some cases of ptosis by tightening the muscle. Upneeq drops are only intended for use when eyelids droop due to aging or certain cosmetic procedures.

Botox

A 2018 study published in the Journal of Clinical and Aesthetic Dermatology found that injections of Botox can potentially treat mild cases of ptosis.

Special Eyeglasses

If you do not warrant or desire surgery, there are eyeglasses with "crutches" to prop up the top eyelid. Or you may consider wearing an eyepatch.

A Quick Review

Aging or certain medical conditions may cause droopy eyelids, called ptosis. And in some cases, babies are born with droopy eyelids. Ptosis is usually not serious. However, in some cases, ptosis can interfere with your vision. 

A simple surgical procedure can treat most cases of ptosis. If droopy eyelids are associated with an underlying condition, addressing the condition may improve the ptosis.

If symptoms develop quickly over a few days or hours and are accompanied by weakness in your arms, legs, or face, a serious headache, or double vision, contact an ophthalmologist.