Eyelid Ptosis: Causes, Diagnosis, and Treatment
Eyelid ptosis refers to a condition in which the upper eyelid droops. In some cases a droopy eyelid only hangs slightly while in others it can droop so far down that it covers the pupil, limiting or blocking a person’s vision.
Both adults and children can have eyelid ptosis. The good news is that this condition can be treated through eyelid surgery and other methods which will improve both function (vision) and appearance.
Types and Causes of Eyelid Ptosis
Eyelid ptosis occurs due to dysfunction of the eyelid-raising muscles or the nerves to these muscles, according to Boston plastic surgeon Samuel Lin, MD. “This dysfunction can be the result of the eyelid muscles deteriorating with age, trauma to the muscles or nerves, toxins, certain drugs, and other underlying diseases,” he says. “Underlying diseases consist of those that can cause weakness to the muscles or nerve, such as diabetes mellitus, brain tumors, or neurological conditions like myasthenia gravis.”
There are several types of eyelid ptosis. They are divided into two broad groups: congenital ptosis, or ptosis that is present at birth, and acquired eyelid ptosis, which refers to ptosis that develops after birth.
With congenital ptosis, the levator muscle fails to develop properly prior to birth. As a result the child’s levator muscle is compromised. Children born with eyelid ptosis often suffer from limited vision in the top portion of their field of vision. Consequently, they often tilt their heads back in an attempt to see.
Childhood eyelid ptosis should not go untreated, as it can lead to other vision problems like amblyopia, or “lazy eye,” which in turn leads to underdeveloped vision in the affected eye. Lazy eye occurs because when a child has ptosis the nerve pathways connecting the affected eye to the brain start to atrophy.
Given congenital ptosis can negatively affect a child’s vision, pediatricians sometimes recommend surgical intervention at a young age.
There are five principal forms of acquired ptosis that develop over time: aponeurotic ptosis, neurogenic ptosis, myogenic ptosis, traumatic ptosis and mechanical ptosis.
Aponeurotic ptosis is the most common type of acquired eyelid ptosis. With this condition the eyelid gets overstretched, typically as a result of aging. Other causes may include excessive rubbing or pulling of the eyelid and long-term use of contact lenses.
Neurogenic ptosis develops as a result of issues with the nerve pathway responsible for moving the eyelid muscles. Causes include Horner syndrome, myasthenia gravis, and third nerve palsy.
Myogenic ptosis occurs when a systemic problem causes the levator muscle to weaken. These systemic disorders include certain forms of muscular dystrophy and chronic external ophthalmoplegia.
Traumatic ptosis occurs as a result of an accident that causes injury to the eyelid and weakens the levator muscle.
Mechanical ptosis happens when excess skin or a mass weighs down the eyelid.
According to Lin, diagnosing eyelid ptosis initially involves a physical exam and a review of the patient’s medical history, including onset and duration of upper eyelid ptosis. This is done to better determine the cause, given that treatment options vary.
“For example, ptosis resulting from an underlying medical condition would require managing this condition,” he says. “Evaluation of the eye itself may follow in order to ascertain overall eye health and whether there are concurrent eyelid and eye problems. The degree of eyelid droop and the strength and function of the eyelid-raising muscles would also be determined.”
According to Flora Levin, MD, a board-certified oculofacial plastic surgeon based in Westport, Connecticut, it can be helpful to review old photographs to assess baseline appearance, “Any rapid onset ptosis, especially on one side, should be evaluated,” she says. “Although most causes of ptosis are benign, it’s very important to undergo a careful evaluation by a physician knowledgeable in the various causes and their manifestations.”
Lin says that surgical treatments for ptosis largely consist of a few eyelid surgeries called levator resection, Müller’s muscle resection, and frontalis sling operation. “Levator resection is when the levator muscle, or one of the primary muscles used for eyelid-raising, is tightened to lift the eyelids,” he explains. “Müller’s muscle resection is when the Müller’s muscle, the other muscle used for eyelid-raising, is tightened. The frontalis sling operation is when the forehead muscles are utilized to elevate the eyelids.”
As Chicago-based board-certified otolaryngologist Ben Caughlin, MD, points out, treatment depends on the cause. “It requires an upper lid incision and sometimes small incisions above the brow,” says Caughlin. “We either reattach the muscle, suspend the muscle and lid, or shorten the excess muscle.”
Levin says that the choice of procedure also depends on the amount of lift desired and individual patient characteristics. “The approach can be external (from the skin) or internal (inside the eyelid), depending on the specific procedure,” she explains. “For cosmetic reasons, blepharoplasty is often combined with ptosis repair in many patients. Other procedures involving shortening the tarsal plate (the cartilaginous portion of the eyelid) are also available.”
Prior to surgery Levin spends a considerable amount of time explaining to patients the difference between ptosis and excess eyelid skin (dermatochalasis) so they understand why both ptosis surgery and blepharoplasty may be necessary to achieve the best result. “When most people say their eyelids are droopy, they’re referring to the excess skin of the upper eyelids and unaware of the eyelid position or ptosis,” notes Levin.
With few exceptions, non-surgical treatments for eyelid surgery are generally ineffective, although they may alleviate the symptoms.
“The main non-surgical treatment is the use of ptosis crutches, or attachments to the frames of glasses, to support the eyelid and prevent drooping,” says Lin. “Other such options may be taping, adhesives, topical eye drops, or injectable botulinum toxin, depending on the cause of ptosis. These may alleviate symptoms but don’t directly address the problem, given that ptosis stems from dysfunctions of the muscles or nerves supplying the muscles. The best,most reliable treatments involve surgical intervention.”
There are, however, a couple of exceptions. Levin says that while Botox is sometimes used to treat ptosis, in some cases it can actually be the cause of the ptosis, namely if it migrates and weakens the muscle, causing the eyelid to drop. In these cases drops can be used to temporarily lift the eyelid.
Another non-surgical measure to correct ptosis in certain cases is to treat the disease that’s causing it. “In the majority of instances this is a surgical problem, ptosis can be improved once the underlying disease has been treated,” says Caughlin.
Seeking Help for Eyelid Ptosis
For this reason it’s very important that patients with eyelid drooping schedule an appointment with a qualified medical provider, as it could be a symptom of a more dangerous underlying condition. “If the eyelids block vision and impede daily functions, it’s also helpful to seek intervention,” says Lin. He points out that because the causes of ptosis range so broadly, it’s sometimes necessary to consult experts from a variety of specialties, including ophthalmology and neurology, to determine the best course of action.
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