Ptosis explained: why the upper eyelid droops and how it is treated

Ptosis is the medical term for a drooping upper eyelid. It can affect one or both eyes, can be mild or severe, and can appear at any age. In adults it is most often a gradual, age-related change, but it can also be caused by nerve or muscle problems, previous eye surgery, contact lens wear or, rarely, more serious neurological conditions. In children, ptosis can be present from birth and needs early assessment to protect the developing vision.

Most people notice ptosis first as a tired or asymmetric appearance in photographs, followed by a gradual loss of the upper part of their visual field. Left untreated, more marked ptosis can force patients to lift their chin or raise their eyebrows to see, causing neck and forehead ache by the end of the day.

What causes ptosis?

The most common cause in adults is aponeurotic ptosis — stretching or slippage of the tendon (the levator aponeurosis) that connects the eyelid-lifting muscle to the eyelid. Long-term contact lens wear, repeated eye surgery, ageing and eyelid rubbing all contribute. Other causes include myogenic ptosis (weakness of the muscle itself, as in myasthenia gravis or muscular dystrophies), neurogenic ptosis (nerve problems such as a third cranial nerve palsy or Horner's syndrome), mechanical ptosis from an eyelid mass or scarring, and traumatic ptosis after injury.

In children, ptosis is usually congenital, from underdevelopment of the levator muscle. Congenital ptosis can be sight-threatening if it covers the pupil, because the developing brain may fail to learn to see through that eye — a condition called amblyopia.

When ptosis needs urgent assessment

A sudden onset of ptosis — over hours or days rather than months or years — always needs prompt medical assessment. Sudden ptosis with a dilated pupil, double vision or a severe headache can signal a third nerve palsy or an aneurysm and is an emergency. Ptosis with muscle weakness that varies through the day may indicate myasthenia gravis. Ptosis with a small pupil on the same side may indicate Horner's syndrome. Any child with an eyelid covering the pupil should be seen by an ophthalmologist without delay.

How ptosis is assessed

A specialist eyelid assessment measures the margin-reflex distance (from the corneal light reflex to the upper lid margin), the levator function (how far the eyelid moves from downgaze to upgaze), the position of the skin crease, and the presence of any residual muscle fatigue. A visual field test can demonstrate the functional impact of the ptosis. Additional investigations — blood tests, MRI or a neurology referral — are arranged when a systemic or neurological cause is suspected.

Treatment options

For most adults with aponeurotic ptosis, eyelid surgery is the definitive treatment. The two most common operations are an anterior levator advancement (tightening the stretched tendon through a hidden skin-crease incision) and a posterior conjunctival Müller's muscle resection (an internal, scar-free approach for milder ptosis with a good response to phenylephrine drops). Both are performed as day-case procedures under local anaesthetic and take around 45 minutes per eyelid.

For patients not fit for surgery, or in the short-term treatment of ptosis due to myasthenia or nerve palsy, specialised spectacles with a ptosis prop or medical eye drops (oxymetazoline) can lift the lid by a small amount. In selected patients, treatment of the underlying medical condition can restore normal lid position without surgery.

What to expect after surgery

Modern ptosis surgery is highly refined. Most patients go home the same day with a small amount of bruising and swelling that settles over 1–2 weeks. Fine adjustments are sometimes needed, but the majority of patients achieve a symmetric, natural eyelid position and a substantial improvement in their upper visual field. Because the incision is placed in the natural skin crease, the scar is usually invisible within a few weeks.

Related reading: explore our consultant ophthalmologist services, full service list, laser eye surgery and lens replacement surgery, or read our other condition guides: keratoconus, chalazion and xanthelasma.

If your upper eyelid feels heavy, is affecting your vision or is changing your appearance, you can book a free 15-minute call or request a full consultation for an oculoplastic assessment.