Why is my eyelid drooping? understanding ptosis

A drooping eyelid, medically referred to as ptosis, can affect one or both eyes. While the cause is often harmless, it may sometimes indicate an underlying medical condition that needs attention.

Patients may feel a heavy eyelid, visual tiredness, difficulty seeing, especially when tired or at the end of the day, or may be unhappy with their appearance or in photos.

Many patients are reluctant to seek help because they may think nothing can be done or treatment is too complex. Often there is a surgical remedy that is commonly performed by specialist oculoplastic surgeons.

In this article, consultant ophthalmologist Mr Jimmy Uddin explains what ptosis is, its common causes, how it is diagnosed, what may look like ptosis, and the treatment options available. It also helps identify when to seek medical advice.

Bilateral ptosis, worse on the right side, and post surgical repair.

What is ptosis?

Ptosis is a condition in which the upper eyelid droops lower than normal. It can partially or completely cover the eye, sometimes affecting vision. Ptosis may develop gradually over time or appear suddenly, depending on the underlying cause. It is more common in older adults but can also affect children from birth.

What can look similar to ptosis?

Several other eyelid or eyebrow conditions can mimic the appearance of ptosis, making careful evaluation important.

Dermatochalasis

An overhanging of excess skin over the lid margin which looks like a droopy eyelid. Treatment often is excision of skin and skin reformation (type of blepharoplasty)

Brow ptosis

When there is a low eyebrow contributing to excess skin/dermatochalasis. Treatment may be a combination brow lift and blepharoplasty

Enophthalmos

When the eye is sunken back in the socket. This may be associated with trauma, congenital or other rare causes

Common causes of droopy eyelids

Acquired ptosis

As people age, the muscles that lift the eyelid, known as levator muscles, can weaken. This is the most frequent cause of ptosis in adults and usually develops gradually. Contact lens use and post-eye surgery are also risk factors.

Congenital ptosis

Some children are born with weaker eyelid muscles, resulting in congenital ptosis. Early diagnosis is essential to prevent vision problems such as amblyopia or lazy eye.

Neurological causes

Drooping eyelids can sometimes result from issues with the nerves and muscles controlling eyelid movement. Conditions such as myasthenia gravis, Horner’s syndrome, or third cranial nerve palsy can cause ptosis and require specialist assessment. Progressive muscular conditions including CPEO (chronic progressive external ophthalmoplegia) are rare and complex.

Trauma or surgery

Injury to the eyelid or previous eye surgery can lead to ptosis. The eyelid may droop immediately following trauma or develop gradually over time.

Mechanical

Lid swelling, tumours, or lumps can cause ptosis. It’s important to treat the cause timely and effectively to prevent long-term complications.

Right-sided complex ptosis with brow overaction. After right ptosis repair.

Symptoms to look out for

Aside from the visible droop, ptosis may cause:

• Difficulty keeping the eye open.
• Eye fatigue, particularly when reading or using screens.
• Increased forehead wrinkling due to compensatory lifting of the eyelids.
• Vision obstruction in severe cases.

Associated symptoms and signs that should seek prompt referral include:

• Acute or sudden onset of ptosis.
• Double vision (diplopia).
• Pain or headaches, especially if severe.
• Pupil asymmetry (a large pupil or a small pupil).
• General weakness.

Diagnosis and assessment

A healthcare professional will examine the eyelids and eyes and measure the extent of the eyelid droop. Assessment of eyelid muscle strength, tarsal plate (anatomy), and eye movement is often included. It’s important to examine the whole face, including the brow, as well as appropriate neurology.

Blood tests, imaging, or referral to a neurologist or oculoplastic surgeon may sometimes be necessary to determine the underlying cause.

Photos or videos are helpful for assessment, both pre-condition and when the problem occurs.

Treatment options

Mild ptosis may not require treatment. Very occasionally, drops may be indicated for treatment of ptosis.

Surgery is the most common approach for significant ptosis. Procedures aim to strengthen or reposition the eyelid muscles to improve function and appearance. This is also in the context of the eyelid skin crease, skin fold, and brow position. In adults, this is often a local anaesthetic and (with sedation) as a day case. The type of surgery depends on the severity and cause of the drooping eyelid.

When to see a doctor

Medical advice should be sought if an eyelid droop develops suddenly, worsens over time, or occurs alongside other symptoms such as double vision, headaches, pupil change in size or weakness. Early assessment ensures accurate diagnosis and appropriate management.

While mild cases of ptosis may not require intervention, assessment by an ophthalmologist is essential when vision is affected. Understanding the causes, symptoms, and treatment options allows patients to make informed decisions about eye health.