What is Ptosis? (Droopy Eyelid) Causes and Treatment

Ptosis is an abnormal but painless eye condition in which the upper eyelid droops, potentially obstructing your vision. It is also known as blepharoptosis. 

It’s caused when the muscles that hold the upper eyelids (levator palpebrae) cannot contract, causing droopiness.

In most cases, ptosis disorders are harmless and you will hardly notice it when affected. 

The condition can cause disruption of vision and a change in facial appearance. But it can be corrected with simple medical interventions.

Droopy eyelids affect both men and women, but it is more common among older people.

Types of Ptosis

Two main types of ptosis can affect a person: congenital and acquired. Congenital ptosis is present during birth. When the child is in the womb, the levator palpebrae muscles do not develop as they should, losing their strength to hold up the eyelids, causing droopiness.

Acquired ptosis affects someone as they grow, resulting from the gradual weakening of the muscles of the eyelids. There are five types of acquired ptosis:

Ptosis occurs about 7.9 times per 100,000 people under 19 years old.

American Academy of Ophthalmology

• Aponeurotic ptosis 
• Neurogenic ptosis
• Myogenic ptosis
• Mechanical ptosis
• Traumatic Ptosis

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Risk Factors 

There are several factors that could make you susceptible to getting ptosis, including age, presence of diabetes, neurological disorders, history of stroke and contact lenses.

Age

As you get older, your muscles become weak and lose their elastic properties. The muscles will become stretched and are unable to contract. The weak muscles can lead to droopy eyelids.

Diabetes

Researchers found a link between diabetic oculomotor nerve palsies and the ptosis. The condition will affect how the levator palpebrae functions, presenting itself as ptosis. 

Neurological Disorders

Neurological conditions that affect the third cranial nerve (oculomotor nerve), such as upper herniation and aneurysm, put you at risk of contracting ptosis.

Stroke

People who have a history of strokes are also at high risk of getting ptosis. The condition may occur on the eye lining around the brain region affected by the stroke.

Contact Lenses

Some studies show that prolonged wearing of contact lenses,  both hard and soft, puts one at a high risk of getting ptosis.

Signs and Symptoms

The obvious symptom of ptosis is sagging eyelids, but other common ones include:

• Signs of tiredness
• Difficulty in seeing because of the obstruction caused by the eyelid
• Frequent release of tears because the eye cannot close well
• Crossed eyes 
• Difficulty in closing the eyes and blinking

Diagnosis

The examining ophthalmologist decides if a patient has ptosis. The physician will first ask you about your family and drug history before performing a physical examination of your eyes.

The doctor will examine the parts of your eye, such as the pupil and the swollen eyelids. Afterward, they will review the affected eyelid for decolorization and damage or abnormal tissue changes, called lesions. 

The ophthalmologist may also employ invasive methods including: tensilon

• Imaging studies using a CT scan and MRI scan to examine the brain
• Laboratory tests if the doctor suspects underlying conditions
• An ice or tensilon test if neural diseases such as myasthenia gravis are suspected
• Procedures such as a biopsy on the muscle tissue of the eyes 

Causes of Ptosis

Ptosis may run in families, and if another family member has had ptosis, it may be more likely that you or your child will have it.

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A wide range of factors can lead to blepharoptosis. Some of them cause acquired ptosis, and others cause congenital ptosis. The leading causes include genetics, trauma, Botox injections, previous eye surgery and Horner’s syndrome.

Genetics

Genetics (family history) is the leading cause of congenital ptosis. Parents transmit the disorder to their children, which is only possible if one parent has the condition. Gene mutation can also result in ptosis.

Trauma

The eye is a delicate organ and slight injury can cause adverse effects. 

Botulinum Toxin (Botox) Injections

Botulinum is a drug used by physicians to reduce wrinkles on the face. Injected patients may experience side effects such as droopy eyelids. However, the acquired ptosis is mild and disappears in two months following treatment.

Eye Surgery

Some correctional methods, such as cataract surgery, can overstretch the eye muscles and cause blepharoptosis. Eyelid edema can also present itself as ptosis following surgery. 

Horner’s syndrome

Horner’s syndrome occurs when damage to the nerve pathway prevents neural information transmission between the brain and the eyes. It manifests itself with different symptoms such as ptosis and constriction of the pupil. 

Treatment

Treatment depends on the type of ptosis a person has and the severity. Ptosis that affects adults is different from the one that affects the children, so doctors have various forms of treatment.

Ptosis in Adults

Most adults typically contract acquired ptosis later in life from a variety of factors including:

• Using contact lenses 
• Some diseases, such as conjunctivitis 
• Trauma of the eye

Adult Treatments

Depending on the severity of the disorder, different treatment methods are usually employed including:

• Medication: The U.S. Food and Drug Administration (FDA) approved the Upneeq to treat Ptosis. It remains the only drug to receive approval. 
• Surgery: You will only receive levator aponeurosis surgery in severe cases of acquired ptosis after levator palpebrae muscles are displaced.

Ptosis in Children

Children typically have congenital Ptosis, which occurs while the baby is in the womb, and can be observed during birth. The disorder may not present itself during birth in some children, but it may appear during the first year of their life. The droopy eyelid could signify an underlying disease such as Horner’s syndrome.

Causes

The actual cause of congenital ptosis is unknown but studies strongly suggest that genetics and gene mutations are among the leading causes. Other causes of ptosis in children include:

• Growth of tumors in structures surrounding the eye
• Myasthenia gravis, a condition that causes abnormal weakness of the body’s muscles
• Birth trauma
• Mitochondrial disorders, such as ophthalmoplegia 

Treatment for Children

Like acquired ptosis, congenital ptosis is corrected either surgically or by drugs. Levator resection surgery is the operative procedure performed on children with congenital ptosis to enhance the function of the weakened muscles of the eyelids.

If there is poor eyelid function, surgeons can also perform Frontalis sling surgery. 

Drugs such as Upneeq can treat congenital ptosis, making the muscles of the eyes contract and function normally. 

Prevention 

You cannot prevent congenital Ptosis.

Most of the factors causing acquired ptosis are difficult to control. The best way to deal with it is control the symptoms. 

Regular eye exams are a great way to monitor and catch the condition early and start treatment.

References

1. Incidence and Demographics of Childhood Ptosis. (June 2011). Ophthalmology Journal.

2. Ptosis Correction. (July 2021). National Center for Biotechnology Information.

3. Ptosis in patients with hemispheric strokes. (February 2002). National Library of Medicine.

4. Hard Contact Lens Wear and the Risk of Acquired Blepharoptosis: A Case-Control Study. (June 2013). National Library of Medicine.

5. Oculomotor Nerve (Cranial Nerve III). (June 2016). ScienceDirect.

6. Ptosis as the only manifestation of diabetic superior division oculomotor nerve palsy. (November 2017). National Center for Biotechnology Information.

7. Blepharophimosis, ptosis, and epicanthus inversus syndrome. (August 2020). National Library of Medicine.

8. Clinical Heterogeneity in Familial Congenital Ptosis: Analysis of Fourteen Cases in One Family Over Five Generations. (October 2005). ScienceDirect.

9. Ptosis in childhood: A clinical sign of several disorders. (September 2018). National Center for Biotechnology Information.

10. Ptosis, Congenital. (November 2021). American Academy of Ophthalmology.

11. Diagnosis of Tensilon-Negative Ocular Myasthenia Gravis By Daily Selfie. (November 2016). National Center for Biotechnology Information.

12. Unilateral transient mydriasis and ptosis after botulinum toxin injection for a cosmetic procedure. (February 2015). National Center for Biotechnology Information.

13. Ptosis after cataract surgery. (December 2002). National Library of Medicine.