Upper Eyelid Ptosis:
A Droopy Situation

By Heidi Jarecki, MD
Ophthalmology
Chippewa Valley Eye Clinic, Eau Claire

Drooping of the upper eyelid is referred to as blepharoptosis, often shortened to ptosis (pronounced toe-sis). It is a common problem in both children and adults and can be present at birth or acquired later in life. Ptosis results from problems related to the muscle of the eyelid (the levator), the associated tendon, the nerve supply to the levator muscle, increased lid weight, or eyelid trauma.

Children born with congenital ptosis, a condition usually due to incomplete formation of the levator muscle, have fatty or fibrous tissue rather than muscle. There is not enough muscle strength to raise the lid to a normal level. (Figure 1)

Muscle related causes for ptosis are far less common in adults and include systemic diseases such as muscular dystrophy. The levator muscle tendon (the aponeurosis) assists the levator muscle in opening the upper eyelid. The majority of adults with drooping eyelids have problems with the tendon. Nerve related problems are rarely responsible for ptosis in children or adults. Often affected individuals describe double vision and demonstrate problems with eye movements when examined. Increased lid weight, called mechanical ptosis, occurs when a tumor or large lid lesion pulls down on the lid. Swelling of the eyelid can also cause mechanical ptosis. Blunt or sharp trauma to the eyelid may cause drooping by damaging the levator muscle or the levator muscle tendon. Repeated harsh eye rubbing can also cause eyelid damage. (See Figure 2)

Several conditions can imitate a drooping upper lid. An eye deviated upward, a sunken in or small eye, a deep hollowed out area above the eyelid or opposite upper eyelid can be mistaken for one sided ptosis.Excess upper eyelid skin can cause a droopy appearance when in fact the lid position is normal.

Individuals affected by upper eyelid drooping often describe a loss of side vision or a sensation of eyelid heaviness. Headaches or a general sense of facial tiredness from continuous contraction of the forehead muscle in an effort to raise the eyebrow may occur. Difficulty reading is frequently noted. Severe ptosis results in more noticeable vision loss. In order to see more clearly, people will often lift up their chin which may cause neck pain or discomfort. Children with ptosis adopt this chin up position quickly because of the vision loss, though they usually will not notice the vision change if asked about it.

Medical examination for ptosis is important for several reasons: it may be the first sign of an underlying disease, symptoms require the diagnosis be made for appropriate treatment and ptosis may cause permanent vision loss in children. If the drooping eyelid prevents a child from using both eyes together, because it blocks their vision or bends the cornea (the front clear part of the eye), the child may develop a lazy eye.

Treatment of ptosis is almost always surgical. Surgery usually involves tightening the levator muscle tendon. Local anesthesia is typically used for adults while children will require general anesthesia. Achieving equal upper eyelid position on both sides is challenging. The most common concerns after surgery relate to eyelid position. It is common for the eyelid position to change throughout the healing process. Dryness of the eyes may also be noted as more of the eye is exposed due to the lifted eyelid. Artificial tear drops may be helpful as the eye adjusts to the new lid position.

For more information, or to schedule an appointment with Dr. Heidi Jarecki » 715.834.8471, Chippewa Valley Eye Clinic