Ptosis

What is ptosis?

Ptosis is when the upper eyelid droops down over the eye. If the ptosis is severe, it may block vision.

There is a main muscle that lifts the upper eyelid (levator palpebrae superioris). Another muscle helps the eye open even more (superior tarsal muscle). If there is a problem with either of these muscles or their nerves, ptosis can occur. The eyelid muscles stay relaxed and the lid hangs down over the eye.

Sometimes the condition is present from birth. This kind of ptosis is often due to a problem with the levator palpebrae superioris muscle. Other times, ptosis happens later in life because of other health conditions. Healthcare providers often group ptosis according to the age when it occurs and the underlying cause. Ptosis that is due to a problem with the levator palpebrae superioris muscle is often more severe than if it's due to a problem with the superior tarsal muscle.

Ptosis is not very common. The most common form that is present from birth is due to poor development of the levator palpebrae superioris muscle. It may affect one or both of the upper eyelids.

What causes ptosis?

Ptosis happens when the levator palpebrae superioris muscle doesn't contract correctly. It can also happen when the superior tarsal muscle doesn't contract correctly. Many kinds of conditions can cause this. For instance, ptosis may be caused by:

• Structural problems with the muscle that are present from birth

• Muscle disorders (such as mitochondrial myopathy or myotonic dystrophy)

• Rare disorders present from birth (such as congenital orbital fibrosis)

• Problems with the tendon attached to the superior tarsal muscle

• Problems with the levator aponeurosis

• Too much weight on the eyelid (such as from an eyelid tumor)

• Injury (especially during eye surgery)

• Nerve problems (such as a problem with the third cranial nerve or in Horner syndrome)

• Connection problems between the muscle and the nerve (such as in myasthenia gravis)

Some eye problems may look like ptosis even if there is no problem with the eyelid itself. For example, older adults may have extra eyelid skin and loss of fat around the eye. This can look like ptosis.

Who is at risk for ptosis?

Ptosis from certain causes may run in families. Having a health condition that can cause ptosis may raise the risk for it.

What are the symptoms of ptosis?

The main symptom is a droopy eyelid. Depending on the cause, one or both upper eyelids may droop. In some cases, the eyelid may be so low that it blocks vision. This may delay vision development in some children if not corrected.

The most common kind of ptosis present from birth often affects only one eyelid. But both may be droopy. Some other symptoms seen in this type can include:

• Blurry vision (from astigmatism)

• Chin-up head position (so that vision is less blocked)

• Lazy eye (amblyopia)

Ptosis due to other causes can have other symptoms. For example, there may be damage to the third cranial nerve. This can cause problems with eye movement and the pupil’s response to light. This can be a sign of a stroke. Medical care is needed right away.

How is ptosis diagnosed?

Your eye care provider will take a health history and do a physical exam. This will include a full eye exam. Your provider will take special note of the eyelid position. They will also look at any eye abnormalities or any problems with the nervous system or muscles.

After this, your eye care provider will likely have a good idea of what may be causing the ptosis. In some cases, they may want to do some tests for more information. For instance, the provider may want more tests if your child may have a problem with the third cranial nerve. These tests might give the provider more detailed information on the cause:

• CT scan of the brain and third cranial nerve

• MRI of the brain and third cranial nerve

• Magnetic resonance angiography (MRA) of the brain and third cranial nerve

How is ptosis treated?

If your child has ptosis at birth, the eye care provider may choose to watch your child for vision problems. In some cases, ptosis gets better over time as the facial structure develops. But some children will need surgery if this does not improve.

If your child’s ptosis is more severe, the provider may advise surgery right away. This is more likely if the eyelid is severely blocking vision.

Your child may also need treatment for the other symptoms that are often present with ptosis. For example, your child may need to wear glasses to correct astigmatism. If your child develops lazy eye (amblyopia), they might need to wear an eye patch over the eye with the normal eyelid.

Other treatments are done for some kinds of ptosis that happen later in life. For instance, your child's ptosis may be due to myasthenia gravis. Then your child may need to take a kind of medicine (acetylcholinesterase inhibitor). Many kinds of ptosis are not treatable with medicines. Your child may need to wear glasses with special wires to help keep the eyelid from closing.

People who get ptosis later in life also may need surgery. This is often the case with severely impaired vision and other failed treatments. You may also want surgery for cosmetic reasons. Talk with your eye care provider about the risks and benefits of all your treatment choices.

What are possible complications of ptosis?

If ptosis blocks vision, it may delay visual development. So eye care providers often advise surgery for severe ptosis in children. You will need careful follow-up with your child’s eye care provider. This is to make sure the ptosis is not significantly affecting your child’s vision.

The surgery to correct ptosis can sometimes cause problems. The most common of these is not being able to fully close the eye.

Key points about ptosis

• Ptosis is when the upper eyelid droops down over the eye more than it should. In some cases, it can cause major vision problems.

• It's often present from birth. This is often due to a problem with a main eyelid muscle.

• Sometimes it happens later in life. This may be due to problems with the eyelid muscles, nerves, or something weighing down the eyelid.

• Your child's eye care provider may choose to watch your child’s ptosis. If so, your child will need careful follow-up so there is no delay in visual development.

• Surgery may be needed if ptosis is severe.

Next steps

Tips to help you get the most from a visit to your eye care provider:

• Know the reason for your visit and what you want to happen.

• Before your visit, write down questions you want answered.

• Bring someone with you to help you ask questions and remember what your provider tells you.

• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.

• Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.

• Ask if your condition can be treated in other ways.

• Know why a test or procedure is recommended and what the results could mean.

• Know what to expect if you do not take the medicine or have the test or procedure.

• If you have a follow-up appointment, write down the date, time, and purpose for that visit.

• Know how you can contact your provider if you have questions.