What Is Ptosis?

Ptosis, also known as blepharoptosis, is a medical term for a drooping upper eyelid. This condition occurs due to a weakness or disorder of the levator muscle, which controls the upper eyelid. Ptosis can vary in severity. If the drooping of your eyelid due to ptosis is more pronounced, it can limit or seriously impact your vision.

This condition is relatively rare, and it’s estimated that only 0.079% of the population is affected. Some cases, known as congenital ptosis, arise at birth and affect children, whereas others are acquired and affect adults. While all people can be affected, people assigned male at birth are more likely to experience congenital ptosis, which is the most common type.

Treatments for the condition depend on the individual case and can include specialized surgery. This article provides a quick overview of ptosis, including its symptoms and signs, how it’s diagnosed and treated, as well as what you can do to manage the condition.

Types of Ptosis  

Primarily, ptosis cases are categorized based on what’s causing the issue. Congenital ptosis, a type seen at birth, is the most common, though there are also several “acquired” types that occur due to injury or a disorder of the levator muscle. The types of ptosis include:

• Congenital: This is the most common type, representing an estimated 76% of cases in children. Congenital ptosis symptoms are typically seen at birth or develop within the first year of life.
• Neurogenic: This acquired type arises due to nerve damage in the levator muscle and can accompany other conditions, such as multiple sclerosis, Horner syndrome, and third nerve palsy, among others.
• Myogenic: With this type, there’s a disorder of the levator muscle, itself, due to myasthenia gravis, ocular myopathy, or other disorders that affect the eye muscles.
• Mechanical: Mechanical ptosis arises due to damage of the levator muscle caused by growths, tumors, or contact lens damage.
• Aponeurotic: Aponeurotic ptosis occurs when aging, trauma, or surgery damages the levator muscle.  
• Traumatic: This is when the ptosis is the result of a direct blow, cut, or other injury.

Symptoms

Ptosis varies in severity; milder cases may not affect your vision and not require treatment. However, if your case is pronounced and affects your visual field (what you see), there can be more serious symptoms. It’s estimated anywhere only 4% of people with ptosis experience it in both eyes; when only one side is affected (unilateral ptosis), the left eye is more often affected.

Ptosis can cause the following symptoms:

• Pronounced drooping of one or both eyelids
• Lack of alignment in the creases of your eyelids—about 7 to 10 millimeters (mm) above the eyelid itself
• Affected vision or even loss of vision in one or both eyes due to obstruction
• Constant backward tilting of the head to see with the drooping eyelid
• Wrinkled skin on the forehead from compensating for ptosis
• Elevated eyebrows
• Difficulty focusing the eye or eyes
• Crossed eyes or lazy eye (amblyopia)
• Double-vision (diplopia)
• A feeling of heaviness in the eye or eyes
• Slight elevation of the eyebrow when chewing

What Causes Ptosis? 

Above each eye are two muscles: the levator and Muller’s muscle, which help maintain the position and control the movement of the upper eyelid. Ptosis occurs when these muscles, especially the levator, become too weak or never fully form. As a result, the upper eyelid isn’t able to retain its position and starts to droop.  

Ptosis cans be caused by several conditions. The congenital type occurs due to a birth defect that either causes the levator muscle to be under-formed or causes issues with the nerve that supplies it. This can be a standalone issue (idiopathic congenital ptosis) or due to issues affecting the facial nerves of newborns, such as:

• Marcus Gunn jaw-winking syndrome: A nervous system condition that causes eyelids to move while chewing.
• Third cranial nerve palsy: This is when a nerve in the brain cannot move either due to excess pressure or lack of blood flow, impairing eye movements and potentially pupil responsiveness.
• Blepharophimosis syndrome: A genetic disorder that causes issues with eyelid development, which can cause them to obstruct your vision.
• Horner’s syndrome: This is caused by disruption to the nerve that connects the head and neck. The nerve is usually disrupted by a related condition (e.g. stroke, tumor, injury).

Acquired ptosis arises due to injury or other conditions that weaken or separate the levator muscle. Causes of this type include:

• Aging
• Multiple sclerosis (MS)
• Myasthenia gravis (MG)
• Growths (neoplasms or chalazions) or tumors developing in the eye
• Damage from contact lenses
• Injury or trauma to the eye
• Complications following eye surgery
• Stroke (a cause of Horner’s syndrome)
  

Diagnosis

When ptosis is suspected, healthcare providers have three jobs: to assess the scope of the issue, figure out what’s causing it, and rule out other conditions that cause similar symptoms. After taking your medical history and asking about medications you’ve been prescribed, several tests may be performed:

• Levator muscle function test: While your eyes are pointed down, the provider places their thumbs over the eyebrows, and you’re asked to look up; the ability of your eyes to move is rated, with weakness a sign of ptosis.
• Margin-reflex distance: A light is shined in the eye, and the distance between the cornea (the center of the eye) and the upper margin of the eyelid is measured; a margin-reflex distance (MRD) less than 4 to 5 mm is a sign of ptosis.
• Palpebral fissure height: The distance between the upper and lower eyelids measures the scope of the ptosis. Any differences between the two eyes indicate one-sided (unilateral) versus two-sided (bilateral) cases.
• Margin crease distance: This is the distance between the edge (margin) of the eyelid and the crease underneath the eyebrow, taken while you look downward; higher than normal measures indicate ptosis.  
• Thyroid function tests: Blood tests assessing thyroid function may be used to screen for conditions that can cause ptosis like hypothyroidism or others.
• Visual acuity: Your ability to see things close by or far away will be measured to rule out other eye disorders or diseases.
• Blood tests: Tests for acetylcholine receptor antibodies in the blood may be performed if myasthenia gravis (an autoimmune disease) is suspected.
• Imaging: If a tumor is suspected as the cause, X-ray or other types of imaging, such as computerized tomography (CT) scan or magnetic resonance imaging (MRI), may be used to assess the orbit (the area around the eye) and skull.

Grading Ptosis

When ptosis is detected, your healthcare provider will need to assess how severe the case is. This helps them determine the best treatment and plan for it. This is done by comparing margin-reflex distance (MRD) to normal ranges for bilateral ptosis, or differences between the eyes in unilateral cases. There are three “grades,” or levels of seriousness:

• Mild: Mild cases are defined as a difference in MRD of 2 mm or less.
• Moderate: In moderate ptosis, the difference in MRD is 3 mm.
• Severe: An MRD disparity of 4 mm or more indicates severe ptosis.

Treatments for Ptosis  

While more mild cases may not require treatment, it may be required for moderate and severe cases. There are several goals of therapy:

• To make the two eyes symmetric
• To fix the position of the affected eyelid or eyelids
• To correct lagophthalmos, an abnormal closure of the eye
• Reduce or remove any obstruction of the eye

Surgery is the primary treatment method, though some other therapies may be used for certain types of ptosis.

Surgeries

The primary approach to treating ptosis is surgery. Ophthalmologists (medical doctors who specialize in eye health) have several procedures to choose from, with the choice dependent on the specific case. Ptosis repair surgeries include:

• Levator resection: Several surgical procedures are used to shorten the length of the levator muscle; sometimes surrounding structures, such as the line of the eyelid, are also removed.
• Matais procedure: This involves attaching the levator to the superior rectus—an eye muscle associated with raising the lids—to reduce the ptosis.
• Hess’s procedure: The levator is connected to the frontalis muscle—another major of the eye—to position it to treat the condition.
• Frontalis brow suspension: In severe cases, this procedure involves suspending the eyelid to the frontalis muscle using a “sling” of synthetic material or tissue from the thigh or another part of the body.
• Aponeurotic strengthening: This involves using synthetic material to strengthen nerves and affected muscles to correct more severe ptosis cases.
• Blepharoplasty: This is a procedure that involves removing excess skin from the eyelid to reduce drooping. It is often indicated alongside another ptosis repair surgery

Nonsurgical Treatment

In severe cases of ptosis, you may be fitted with a special crutch that lifts the eyelid to prevent obstruction. In some cases, taping of the lid may also be indicated as a means of management.

Medication

Recently, the US Food and Drug Administration (FDA) approved a medication for adults with acquired ptosis. A prescription eyedrop called Upneeq (oxymetazoline) acts directly on the levator muscle, causing to tense up, which lifts the eyelid. While these drops can’t treat every case, they are effective for many forms of mild to moderate ptosis.

Prevention

There aren’t many strategies to prevent ptosis, especially in congenital cases. However, some exercises may help strengthen the levator muscle, which may help in management. An exercise to try involves raising your eyebrow, and holding a finger on it as you try to close your eyes for a couple of seconds at a time.

Some ophthalmologists advise applying the back of an electrical toothbrush to an affected eyelid to directly stimulate the muscles. This is done for several minutes at a time, multiple times a day. Though the evidence for efficacy of these methods is unknown, they have found a place in clinical practice.  

Related Conditions

In cases of congenital ptosis or ptosis in childhood, there’s an increased chance of developing several other health and eye conditions:

• Astigmatism: Pressure from the eyelid on the eye due to ptosis can alter its shape, which can cause distortion or stretching of what you see.
• Lazy eye (amblyopia):  Ptosis in early life can lead to amblyopia—the development of abnormally weak vision from one eye—which can sometimes cause it to wander inward or outward.
• Torticollis: To accommodate for vision disturbances due to ptosis in infants, they may develop torticollis, in which the neck muscles cause the head to be twisted or tilted.

Living With Ptosis  

Ptosis can be effectively managed if treated in a proper and prompt manner. While there is a chance of complications with surgery, including excess swelling, infection, and others, most are successful in correcting facial appearance and any associated vision problems. In fact, studies have found between 78 and 97% of patients are satisfied with their results after surgery.

Beyond the purely physical effects of ptosis, however, an additional challenge is the psychological impact. Because this condition affects appearance, it can cause anxiety, depression, or social isolation. However, managing the condition overall can help, as can additional mental health counseling.