Ptosis

What is ptosis?

Ptosis is when the upper eyelid droops down more than it should. If the ptosis is severe, it may block vision.

The levator palpebralis muscle is the main muscle that opens the eyelid. The superior tarsal muscle is another muscle that helps the eye open even more. If there is a problem with either of these muscles or their nerves, ptosis can result. The eyelid muscles stay relaxed, and the lid hangs down over the eye.

Sometimes, ptosis is present from birth. This kind of ptosis is usually due to a problem with the levator palpebralis muscle. Other times, ptosis happens later in life because of other medical conditions. Sometimes, healthcare providers classify ptosis according to the age of onset and underlying cause. Ptosis that is due to a problem with the levator palpebralis muscle is usually more severe than ptosis 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 palpebralis muscle. It may affect the left eye slightly more often than the right.

What causes ptosis?

Ptosis happens when the levator palpebralis muscle does not contract properly. It can also happen when the superior tarsal muscle does not contract properly. Many kinds of conditions can cause this. For example, ptosis may be caused by:

• Structural problems with the muscle that are present from birth
• Muscle disorders (for example, mitochondrial myopathy or myotonic dystrophy)
• Rare disorders present from birth (for example, congenital orbital fibrosis)
• Problems with the tendon attached to the superior tarsal muscle
• Senescence, dehiscence, or disinsertion of the levator aponeurosis
• Excess weight on the lid (for example, from an eyelid tumor)
• Trauma (especially during eye surgery)
• Problems with nerves (for example, with the third cranial nerve or in Horner syndrome)
• Problems with the connection between the muscle and the nerve (for example, in myasthenia gravis)

Also, certain eye problems may look like ptosis even though there is no problem with the eyelid itself. For example, in elderly people, extra eyelid skin and loss of fat around the eye can cause the appearance of ptosis.

What are the risks for ptosis?

Ptosis from certain causes may run in families. If another family member has had ptosis, it may be more likely that you or your child will have ptosis. Having a health condition that can cause ptosis may increase the risk of ptosis.

What are the symptoms of ptosis?

The defining symptom of ptosis is a droopy eyelid. Depending on the cause, one or both eyelids may show effects. In some cases, the eyelid may be so low that it partially blocks vision. This may delay vision development in some children if not corrected.

The most common kind of ptosis present from birth usually affects only one eyelid. Some other symptoms seen in this type can include:

• Astigmatism (that makes vision blurry)
• Chin-up head position (to make vision less blocked)
• Amblyopia (lazy eye)

Ptosis resulting from other causes can have other symptoms. For example, damage to the third cranial nerve can cause problems with eye movements and the pupil’s response to light. This can be a sign of a stroke and needs immediate medical attention.

How is ptosis diagnosed?

Your eye healthcare provider will begin by performing a medical history and physical exam. This will include a complete eye exam. Your eye healthcare provider will take special note of the eyelid position. He or she will also note any eye abnormalities present, or any problems with the nervous system or muscles.

After the history and physical exam, your eye healthcare provider will probably have a good idea of what may be causing the ptosis. In a few cases, your eye healthcare provider might want a few follow-up tests to provide more information. For example, your eye healthcare provider might order additional tests if your child may have a problem with the third cranial nerve. These tests give might give your eye healthcare provider more detailed information on the cause:

• Computed tomography (CT) scan of the brain and third cranial nerve
• Magnetic resonance imaging (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, your healthcare provider may choose to watch your child for vision problems. In some cases, ptosis gets better over time as the facial structure develops. However, some children will need surgery if their ptosis does not improve.

If your child’s ptosis is more severe, your healthcare 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 might need to wear glasses to correct astigmatism. If your child develops amblyopia (lazy eye), he or she 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 example, if your ptosis is due to myasthenia gravis, you may need to take a kind of medicine called an acetylcholinesterase inhibitor. Many kinds of ptosis are not treatable with medicines. You may need to use eyeglasses with special wires to help keep your 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 to your eye healthcare provider about the risks and benefits of all your treatment choices.

What are the complications of ptosis?

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

The surgery to correct ptosis can sometimes cause complications. The most common of these is an inability to completely close the eye.

Key points about ptosis

Ptosis is a condition in which the upper eyelid droops down over the eye more than it should. In some cases, it can cause significant vision problems.

• Many times, ptosis is present from birth, usually because of a problem with the levator palpebralis muscle.
• Sometimes, ptosis happens later in life. This might be due to problems with the eyelid muscles, nerves, or something weighing down the eyelid.
• Your healthcare provider may choose to monitor your child’s ptosis. If so, your child will need careful follow-up to make sure the ptosis does not delay visual development.
• You or your child may need surgical treatment for ptosis if it is severe. Medical treatment is a choice of some people with certain kinds of ptosis.
• Depending on the cause of the ptosis, other symptoms may also be present.
• For sudden-onset ptosis, the cause of the problem needs rapid diagnosis because it might indicate a stroke or other problem with blood vessels in the brain.

Next steps

Tips to help you get the most from a visit to your healthcare 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.