Ptosis: Drooping Eyelid

With ptosis, sometimes called blepharoptosis, the upper eyelid of one or both eyes droops somewhat. This may only sag a little and may be a cosmetic issue. Or it can obstruct the whole pupil. Ptosis can be congenital (present at birth), come about due to an injury, or commonly may be part of the aging process.

This condition comes on when there is a problem with either the levator muscle, responsible for opening the upper lid, or the superior tarsal muscle, which keeps the lids open.

This article will look at both frequent and rare symptoms of ptosis, as well as causes and treatments. It will also discuss when it's important to seek attention from an ophthalmologist (a physician specializing in eye conditions) and what it means for vision.

Symptoms of Ptosis

In cases of ptosis, it's common to notice that the skin of the upper eye sags down somewhat, sometimes affecting vision.

Other signs can include the following:

• A sense that not everything that should be in view is actually seen
• Complaints about not seeing that well, together with tipping the head up somewhat to give the eye a better view beneath the drooping lid
• Neck and shoulder issues from holding the head at an abnormal angle
• Delayed walking or even crawling in young children
• A feeling of throbbing or tiredness around the eyes
• A watery eye, even though it may feel dry
• Lazy eye, otherwise known as amblyopia, in which the nerve pathways to one eye don't develop properly. This can occur in children if the vision in one eye is blocked by the drooping lid and isn't treated.
• Blurry vision in some cases
• Trouble blinking or closing one or both eyes

Causes of Ptosis

Lids that droop from ptosis are usually related to either of the following:

• An eye muscle that's weakened and can't raise the lid enough
• Impairment of the nerves that signal the eyelid muscles

Eye muscles can be weakened by structural problems from birth or may acquire these over time. Conditions such as mitochondrial myopathy or myotonic dystrophy, which affect the muscle cells, can cause weakness. Or, sometimes, there can be a problem with the tendon attached to the muscle.

The nerves themselves can be the problem. The third cranial nerve is responsible for the movement of four eye muscles, including the position of the upper lid. If this is affected by a third nerve palsy, where the nerve doesn't operate as it should or perhaps at all, then the eyelid may droop or close completely.

How to Treat Ptosis

Cases of ptosis can be treated with either medication or surgery.

An eye drop called Upneeq (oxymetazoline hydrochloride ophthalmic solution) can be used for cases of acquired ptosis. This targets the upper eyelid muscle, making it contract and allowing the eye to open about 1 to 2 millimeters more than it could without the medication. Once prescribed, it can be taken indefinitely.

Surgery, however, is the mainstay of treatment. The most common approach is what's known as a levator advancement. With this external approach, an incision is made in the crease of the eyelid. The levator muscle is repositioned and stitched to connective tissue in the lid. This can be used in cases where the muscle itself has good function.

Or, the ophthalmic surgeon may shorten the muscle from underneath the lid. This may be either the levator muscle or what's known as Mueller's muscle, which also operates the lid. With this approach, you also need good muscle function.

If you do not have good lid muscle function, another surgical approach that can be tried is what's known as frontalis sling fixation. With this, the upper eyelid is attached to the muscle just above the brow, known as the frontalis muscle. A rod then attached to this muscle allows it to raise and lower the lid.

Complications Associated With Ptosis

Having ptosis can mean different things at different times of life. Keep in mind who it is that has the condition when evaluating what this may mean.

For an infant or child with ptosis, this may delay visual development. If just one eye is affected, then it may result in amblyopia, otherwise known as lazy eye.

In amblyopia, visual signals from the "weaker" eye start to get discounted by the brain. That's because the brain doesn't develop a strong connection with the weaker eye, which is blocked by the lid. Over time, the brain stops recognizing sight from the eye. This may result in poor vision or blindness.

Some children may develop crossed eyes in which each eye turns in a different direction. Children may also develop astigmatism, where the surface of the eye develops an unusual shape due to ptosis. This can be caused by increased pressure on the cornea (the clear covering of the eye) and can cause blurry vision.

In some ptosis cases, there can be issues with light sensitivity where bright settings can cause discomfort.

Having ptosis can mean different things at different times of life. Keep in mind who it is that has the condition when evaluating what this may mean.

Are There Tests to Diagnose the Cause of Ptosis?

To determine if you have ptosis, your ophthalmologist can check out the function of your eye muscles by having you look in different directions. The ophthalmologist can also measure the distance from the pupil center to the upper edge of the eyelid. A blood test may also be performed to see if this is related to some underlying condition.

When to See a Healthcare Provider

Most cases of ptosis are either present at birth or come on gradually sometime after. But if this develops suddenly, keep in mind that is not the norm. You should arrange to see an ophthalmologist promptly.

You should also see an ophthalmologist if the ptosis affects your own or your child's vision. Surgery can be performed to fix the muscles in one or both eyelids and preserve sight.

For some, ptosis is nothing more than a cosmetic issue in which the lid may sag a bit and only needs to be treated if you feel that this is hindering your appearance.

However, for others, particularly young children, detecting ptosis and treating this is very important to stave off conditions such as amblyopia, crossed eyes, and astigmatism. In addition, if vision is not allowed to develop properly, in some cases, this may threaten sight in the eye.

Summary

In cases of ptosis, one or both of the upper eyelids can be drooping. Other common symptoms can include tipping your head back to get a better view, neck and shoulder problems, and feeling that part of your vision is blocked.

Ptosis may be due to either weakened eye muscle or impairment of the nerves that control the eyelid muscles. It may be present at birth or acquired during life.

Once a case of ptosis is detected by an ophthalmologist, drops may be prescribed to treat it or surgery may be helpful in allowing the muscle to better operate the lid.