Ptosis (drooping eyelid): UK causes and surgical correction

Ptosis is a drooping upper eyelid. Mild ptosis is common with age; severe ptosis can obstruct vision and force patients to lift the lid with a finger or tilt the head back to see. The important thing about ptosis is telling the harmless age-related type from the neurological causes that need urgent investigation.

Types of ptosis

**Aponeurotic (involutional) ptosis** — the commonest type. The levator muscle is intact but its tendon has stretched with age or contact-lens wear. Both lids often affected.

**Congenital ptosis** — present from birth, due to poor development of the levator muscle.

**Neurogenic ptosis** — third nerve palsy or Horner's syndrome. Usually one-sided, with other neurological signs.

**Myogenic ptosis** — myasthenia gravis, chronic progressive external ophthalmoplegia. Variable through the day.

**Mechanical ptosis** — a heavy lid due to a lid tumour, chalazion or scarring.

**Post-surgical ptosis** — after cataract or eyelid surgery.

Red-flag features — urgent review

- **Sudden onset** ptosis, especially with double vision, pain, or a large pupil (possible third nerve palsy — think aneurysm)

- **Small pupil on the same side** with a mild ptosis (Horner's syndrome — needs imaging of the neck and chest)

- **Variable ptosis** worse at end of day or after activity, with weakness of chewing, swallowing or limbs (myasthenia gravis)

- Any ptosis in a child that could cover the visual axis and cause amblyopia

Any of these needs same-day ophthalmology assessment.

Assessment

In clinic a ptosis assessment includes:

- Palpebral fissure height in primary gaze

- Marginal reflex distance

- Levator function measurement

- Assessment of eyelid crease position

- Full ocular motility, pupil, and cranial nerve examination

- Cogan's lid-twitch test where myasthenia is suspected

Surgical correction

Aponeurotic and mild congenital ptosis are corrected surgically:

**Levator advancement** (external approach) — the gold-standard for good levator function. A small incision in the skin crease is used to tighten the levator tendon. Under local anaesthetic, day-case, 45 minutes.

**Müller's muscle-conjunctival resection** (posterior approach) — for smaller degrees of ptosis where the phenylephrine test is positive. No visible skin scar.

**Frontalis sling** — for severe ptosis with poor levator function, especially congenital ptosis. A silicone or fascial sling connects the lid to the eyebrow so the patient lifts the lid with their forehead.

Recovery

- Mild bruising and swelling for 1–2 weeks

- Lubricants and antibiotic ointment for 2 weeks

- Final result at 6–8 weeks

- Small chance of over- or under-correction requiring adjustment

NHS vs private ptosis surgery

NHS surgery is offered for functional ptosis that obstructs vision, usually after formal visual field testing. Cosmetic or borderline cases are treated privately, typically £3,000–£5,000 per lid.

Book a consultant-led ptosis assessment

For a drooping lid affecting vision or appearance, book a consultation with my private practice or call **020 3137 3237**.