Droopy eyelid, or ptosis, is a condition where the upper eyelid droops over the eye, partially or completely covering the pupil. In medical literature it is called blepharoptosis. It can affect vision and lead to a tired or asymmetrical appearance. Ptosis can be congenital (present at birth) or acquired due to aging, trauma, or neurological disorders.
The upper lid normally covers the top edge of the iris by about 1 to 2 millimetres. When the lid margin sits below that line, we speak of ptosis. At the examination I measure the distance between the lid margin and the pupil in millimetres; this single figure tells me both how severe the droop is and which surgical technique will suit the patient. A mild droop only gives a tired look, while a severe one covers the pupil and narrows the upper visual field.
The muscle that lifts the upper lid is the levator, and the thin sheet of connective tissue attaching it to the lid is the levator aponeurosis. Most cases of drooping come down to a problem with this muscle or with the point where it attaches.
Patients often ask why only one lid has dropped. Age-related aponeurotic ptosis rarely affects both sides equally: one lid falls a few millimetres earlier than the other and the asymmetry draws attention. Congenital ptosis is also frequently one-sided.
That said, newly developed one-sided drooping always deserves careful assessment. A droop that fluctuates through the day and becomes obvious towards evening suggests myasthenia gravis. If it comes with double vision, restricted eye movements or a change in pupil size, a nerve-related cause must be investigated. A small pupil with reduced sweating on the same side may point to Horner's syndrome. In these situations the cause must be established first, and surgery is postponed.
Not every patient with a heavy-looking lid has true ptosis. With age the upper lid skin loosens and hangs over the lashes together with the tissue beneath the brow. This is called dermatochalasis, or pseudoptosis. Here the lid margin is actually in its normal place; it is the skin that has come down.
I separate the two at the examination by measuring the margin-to-reflex distance and then lifting the excess skin with a finger to see where the lid margin truly sits. In true ptosis the margin does not rise; in dermatochalasis the lid looks normal once the skin is lifted. The distinction changes the treatment completely: dermatochalasis is corrected with upper eyelid blepharoplasty, while true ptosis requires surgery on the levator muscle. The two often coexist and can be addressed in the same session. A dropped brow may add to the picture, so I assess brow height separately in every patient.
In the short video below I explain the difference between true ptosis and the skin excess that blepharoplasty corrects.
Ptosis belongs to ophthalmology, and specifically to the oculoplastic subspecialty. At the examination I look at:
When I suspect a neurological cause I may request blood tests and imaging, and assess the patient together with a neurologist.
Unless the underlying cause changes, ptosis does not resolve on its own. If there is a neurological or inflammatory cause, that is treated first, and lid position is addressed surgically only once the picture has settled.
In adults I usually operate under local anaesthesia. Being able to ask the patient to open and close the eye during the procedure lets me set lid height on the table, which is a real advantage. General anaesthesia is needed in young children and in severe congenital cases. The operation generally takes about an hour and the patient rests at home the same day.
Cold compresses and keeping the head elevated reduce swelling in the first two days. Bruising and oedema begin to settle by the end of the first week, and social appearance recovers largely within the second week. Sutures usually come out on day five to seven. Because the eye may not close fully in the early weeks, dryness is common; artificial tears during the day and ointment at night protect the ocular surface.
The lid settles at its final height and small differences between the sides even out over several months, so I do not judge the result in the first weeks. Like any operation, ptosis surgery carries risks: undercorrection or overcorrection of lid height, asymmetry, an irregular lid crease, temporary dryness, and occasionally the need for a further adjustment. I discuss all of these with every patient before surgery.
In children ptosis is not only a matter of appearance. If the lid covers the pupil, visual development is blocked and amblyopia may follow, and pressure of the lid on the cornea can induce astigmatism. Children with congenital drooping should therefore be assessed early, with visual development monitored and the timing of surgery planned accordingly. See the page on eyelid drooping in children for details.
In adults, sudden drooping accompanied by double vision, headache, a change in pupil size or restricted eye movements should be assessed without delay. Slowly progressive drooping is less urgent, but if your upper visual field is closing in or you find yourself raising your brow all day, it is worth being examined.
Ptosis can coexist with other lid position problems; you can read about these on the entropion and ectropion pages.
Ayşe Dolar Bilge MD, FEBOphth.
Ophthalmologist — Oculoplastic Surgery
As an Ophthalmologist, Dr. Ayşe Dolar Bilge, I provide diagnosis and treatment services with my experienced team.
Ptosis means the upper eyelid rests lower than normal so the eye cannot open fully. Its medical name is blepharoptosis. The upper lid normally covers the top edge of the iris by 1 to 2 millimetres; when the margin falls below that line, we call it ptosis.
In adults the commonest reason is that the thin sheet attaching the levator muscle to the lid thins or slips off with age. In congenital ptosis that muscle has not developed adequately. Trauma, previous eye surgery, lid masses and neurological conditions such as myasthenia gravis can also cause drooping.
A tired look, a smaller-looking eye, asymmetry between the two sides, loss of the upper visual field and a constant need to raise the brow are typical signs. The definitive assessment is made at the examination, by measuring the margin-to-reflex distance in millimetres and testing the strength of the muscle that lifts the lid.
With age the upper lid skin loosens and hangs over the lashes. This is called dermatochalasis, or pseudoptosis. The lid margin is actually in its normal place; it is the skin that has come down. Lifting the excess skin with a finger shows the lid sitting normally. The distinction changes the treatment completely.
Age-related ptosis rarely affects both sides equally, so one lid falls before the other, and congenital ptosis is often one-sided too. However, a droop that is new, that fluctuates through the day, or that comes with double vision or a change in pupil size suggests a neurological cause and needs detailed investigation.
Ptosis belongs to ophthalmology, and specifically to the oculoplastic subspecialty. Ophthalmologists working on the eyelids, tear drainage system and periocular tissues both make the diagnosis and plan the surgery. When a neurological cause is suspected, the patient is assessed together with a neurologist.
If the lifting muscle is strong enough, the levator or its aponeurosis is shortened and reattached to the lid through an incision placed in the natural lid crease. Mild droops can be approached from behind the lid, leaving no skin scar. When muscle strength is very poor, the lid is connected to the forehead muscle with a sling. In adults the procedure is usually done under local anaesthesia and takes about an hour.
Cold compresses and keeping the head elevated reduce swelling in the first two days. Bruising and oedema begin to settle by the end of the first week, and social appearance recovers largely within the second. Sutures usually come out on day five to seven. The lid takes a few months to settle at its final height and for small asymmetries to even out.
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