Patient Basics: Drooping Eyelid (Ptosis)

Originally published by Harvard Health.

What Is It?

A drooping eyelid is also called ptosis or blepharoptosis. In this condition, the border of the upper eyelid falls to a lower position than normal. In severe cases, the drooping eyelid can cover all or part of the pupil and interfere with vision.

Ptosis can affect one or both eyes. It may be present at birth (congenital ptosis), or it may develop gradually over decades. Sometimes ptosis is an isolated problem that changes a person’s appearance without affecting vision or health. In other cases, however, it can be a warning sign that a more serious condition is affecting the muscles, nerves, brain or eye socket. Ptosis that develops over a period of days or hours is more likely to signify a serious medical problem.

Some of the causes of ptosis include:

• Congenital ptosis — In this condition, an infant is born with ptosis because of a developmental problem involving the muscle that raises the upper eyelid (levator muscle). In approximately 70% of cases, the condition affects only one eye. If the drooping eyelid obscures part of the baby’s visual fields, surgery must be done to correct the problem early in life to prevent permanent loss of vision.
• Aponeurotic ptosis (senile or age-related ptosis) — Aging is the most common cause of ptosis that is not present at birth. In senile ptosis, the long-term effects of gravity and aging cause stretching of a wide, tendon-like tissue that helps the levator muscle lift the eyelid. Although both eyes usually are affected, drooping may be worse in one eye.
• Myasthenia gravis — Ptosis can be one of the first symptoms of myasthenia gravis, a rare disorder that affects the ways muscles respond to nerves. Myasthenia gravis can cause progressive muscle weakness, not only in the eyelids but also in the facial muscles, arms, legs and other parts of the body.
• Muscle diseases — Ptosis can be a symptom of an inherited muscle disease called oculopharyngeal muscular dystrophy that affects eye motion and can cause difficulty swallowing. In younger adults, ptosis can be caused by a group of muscle illnesses called progressive external ophthalmoplegia, which cause ptosis in both eyes, problems with eye movement, and sometimes other muscle symptoms that involve the throat or heart muscle.
• Nerve problems — Because the eye muscles are controlled by nerves that come from the brain, conditions that injure the brain or its cranial nerves sometimes can cause ptosis. These conditions include stroke, brain tumor, a brain aneurysm (a grapelike swelling on a blood vessel inside the brain), and nerve damage related to long-term diabetes. Another cause of ptosis is Horner’s syndrome, which also can cause an abnormally small pupil and loss of the ability to sweat — on half the face. One particularly dangerous cause of Horner’s syndrome is a cancerous tumor located at the top portion of the lungs.
• Local eye problems — In some cases, an eyelid droops because of an infection or tumor of the eyelid, a tumor inside the eye socket, or a blow to the eye.

Symptoms

Doctors assess the severity of eyelid droop by taking precise measurements of the eyelid and eye opening. You can screen for the problem yourself by looking straight ahead in a mirror. As you look at your eye, a sizable part of your iris (the eye’s colored circle) should be visible above your pupil, and no part of the pupil itself should ever be covered by the eyelid.

If you have ptosis, the drooping eyelid narrows your eye’s opening, which makes your affected eye appear smaller than normal. You also may lose the crease (fold of skin) that normally lies between your upper eyelid and eyebrow. If ptosis covers your pupil and limits your vision, you may try to compensate unconsciously by raising your eyebrows. This can cause tension headaches and give your eyes an odd, surprised appearance. You also may tilt your chin up and look down your nose as a way of seeing out from under your eyelid’s lower margin.

If you have simple, uncomplicated ptosis, you won’t have any other symptoms. If your ptosis is caused by a more serious medical problem, however, you may have additional symptoms that are related to the underlying illness. For example, myasthenia gravis may also cause double vision, weakness in the arms or legs, and difficulty speaking, swallowing or breathing. Among infants with congenital ptosis, approximately 30% also have crossed eyes (strabismus) or some other disorder that affects the eye’s position or movement. In ptosis caused by Horner’s syndrome, the pupil of the affected eye is unusually small.

Diagnosis

If you notice that both of your upper eyelids have become progressively droopy with age, then you probably have simple age-related ptosis. Some old photographs usually can confirm the diagnosis because they prove that your drooping eyelids have worsened gradually over the years.

In other cases of ptosis, a doctor must diagnose the problem. The doctor will begin by reviewing all of your symptoms, not just your eyelid complaints. This review includes any symptoms of double vision, muscle fatigue or weakness, difficulty speaking or swallowing, headache, or tingling or numbness anywhere in your body. Your doctor also will review your past medical history and ask about any family history of ptosis or inherited muscle diseases.

Then, your doctor will do a physical examination, a neurological examination, and a thorough examination of your eye. If your doctor finds anything abnormal, special diagnostic tests are necessary. For example, you may need a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan if you have signs of a neurological problem or if your eye examination reveals evidence of a mass or swelling inside your eye socket.

If you have muscle weakness or other symptoms of a muscle disease, your doctor may order a blood test for myasthenia gravis. Also your doctor may do a Tensilon test. Tensilon is the brand name for a medication called edrophonium chloride, which will be injected into a vein. If you have myasthenia gravis, the drug will reverse muscle weakness for a few minutes. A muscle biopsy also may be done to diagnose less common muscle problems. In a biopsy, a very small piece of muscle is removed so it can be examined under a microscope.

Expected Duration

Ptosis is often a long-term problem. In most children with untreated congenital ptosis, the condition is fairly stable and does not get worse as the child grows. In people with age-related ptosis, however, the drooping can increase gradually over the years.

Prevention

In most cases, ptosis cannot be prevented.

Treatment

If age-related ptosis blocks your vision or seriously affects your appearance, a plastic surgeon usually can correct the problem by surgically raising your eyelid. In most adult patients, this is an outpatient procedure that is done under local anesthesia. Local anesthesia is preferred over general anesthesia because it allows the surgeon to adjust the position of your eyelids while your eyes are open.

If your baby is born with severe congenital ptosis, your doctor probably will recommend prompt corrective surgery because early treatment reduces the risk of permanent vision damage. If your child has milder ptosis without impaired vision, however, the doctor may suggest waiting until the child is 3 to 5 years old to correct the drooping eyelid. During childhood, eyelid surgery is performed under general anesthesia.

If you have ptosis that is caused by a muscle disease, neurological problem or local eye problem, your doctor will treat the illness. In some cases, this treatment either improves the drooping eyelid or keeps it from getting worse.

When To Call A Professional

Call your doctor immediately if you have a drooping eye that:

• Develops suddenly over a period of a few days or a few hours
• Is accompanied by double vision, weakness of your facial muscles, weakness in your arms or legs, difficulty speaking or swallowing, or a severe headache
• Is accompanied by symptoms of an eye infection, including pain and redness in the eye, fever, a bulging eye, or difficulty moving the eye.

Also, make an appointment to see your primary care doctor or ophthalmologist (doctor who specializes in eye problems) if your eyelids have begun to droop with age and this interferes with your vision or seriously affects your appearance.

Make an appointment with your pediatrician or ophthalmologist if your baby’s eyelids look uneven, if one eye appears to be smaller than the other, or if your child seems to hold his or her head in an abnormal posture (usually chin tilted upward) in order to see.

Prognosis

In most cases, the outlook is good. Surgery usually can correct the drooping eyelid in children with congenital ptosis and adults with age-related ptosis. In some cases, corrective surgery causes the eyes to remain open slightly during sleep, so a nighttime lubricant is applied to the eyes to prevent drying.

Additional Info

National Eye Institute
2020 Vision Place
Bethesda, MD 20892-3655
Phone: (301) 496-5248
http://www.nei.nih.gov/

National Institute of Neurological Disorders and Stroke
P.O. Box 5801
Bethesda, MD 20824
Toll-Free: (800) 352-9424
http://www.ninds.nih.gov/

American Academy of Ophthalmology
P.O. Box 7424
San Francisco, CA 94120
Phone: (415) 561-8500
Fax: (415) 561-8533
http://www.aao.org/

American Academy of Pediatrics (AAP)
141 Northwest Point Blvd.
Elk Grove Village, IL 60007-1098
Phone: (847) 434-4000
Fax: (847) 434-8000
http://www.aap.org/

Myasthenia Gravis Foundation of America
5841 Cedar Lake Road
Suite 204
Minneapolis, MN 55416
Phone: (952) 545-9438
Toll-Free: (800) 541-5454
Fax: (952) 545-6073
http://www.myasthenia.org/