Introduction

• Ptosis is a condition characterized by the drooping of the upper eyelid, which partially obstructs the eye¹.
• It can occur in one or both eyes and has the potential to cause peripheral vision impairment, particularly affecting the upper visual field.
• In severe instances, it may be associated with life-threating causes such as pupil involving third nerve palsy and a painful Horner’s.
• Ptosis can manifest from birth (congenital) or develop later in life (acquired). In children, untreated ptosis poses risks to vision development, potentially leading to amblyopia, commonly known as “lazy eye”.

Facial photo showing a patient with involutional ptosis of the right upper eyelid.

Image from American Academy of Ophthalmology: https://www.aao.org/education/image/ptosis-5

Anatomy

Sagittal section showing the superior tarsal muscle (Müller’s muscle) and levator palpebrae superioris muscle. They both elevate the eyelid by pulling on the tarsus plate.

Image from:  Cury, M.C., Sebastiá, R. (2021). Anatomy of the Upper and Lower Lids. In: Avelar, J.M. (eds) Aesthetic Facial Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-57973-9_27

Aetiology

Ptosis may be classified based on the underlying cause – congenital, aponeurotic, neurogenic, myogenic, mechanical, and traumatic².

• Aponeurotic: This is the most common form of ptosis, as show in the facial photo above. It is  also known as senile or involution as it is occurs mainly in older adults. Over time, the fascial levator aponeurosis weakens and stretches, causing the upper eyelid to droop.
• Congenital: Some individuals are born with ptosis, which occurs due to dysgenesis of the muscles responsible for lifting the eyelid.
• Neurogenic: Conditions affecting the nerves innervating the eyelid muscles such as Horner’s syndrome or third nerve palsy.
• Myogenic: Conditions affecting the muscles controlling the eyelid such as myasthenia gravis or muscular dystrophies.
• Muscle or Nerve Damage: Ptosis may also arise from trauma, injury, or surgical complications that damage the muscles or nerves controlling eyelid movement.
• Mechanical: A large mass or excess skin on the upper eyelid (dermatochalasis) adding extra weight, resulting in drooping of the eyelid.

Signs and Symptoms

Ultimately the signs and symptoms of ptosis depend on the underlying aetiology. However, the most prominent indicator of ptosis is the drooping of the upper eyelid, which can partially or fully obscure the eye.

• Patients may present with complaints such as a sensation of heaviness in the eyes, cosmetic concerns, or perceived obstruction of peripheral vision and double vision.
• To compensate, some individuals may tilt their head back or raise their eyebrows to lift the drooping eyelid. However, relying on these compensatory actions can become strenuous over time, potentially leading to discomfort or fatigue.

Examination should include:

• Visual acuity
• Extraocular movements
• Pupillary reflex
• Inspection of ocular adnexa and the ocular surface. Particular attention should be paid to inspecting for any asymmetry of the upper eyelid crease, as this could indicate ptosis.
• The margin reflex distance 1 (MRD1) measures the distance between the corneal light reflex and the upper eyelid margin when the patient is gazing forwards. Normal MRD1 is 4-5mm; the difference in MRD1 between the two eyes can also be used to classify ptosis in cases with unilateral ptosis³.

Marginal reflex distance used to classify severity of ptosis.

image from Northamptoneye – https://www.northamptoneye.com/blepharoplasty/

Management

• Surgery: Surgical repair is the most common and most definitive treatment option, especially for cases where ptosis significantly affects vision or appearance. Depending on the levator function helps to decide the type of surgery.
  • Where there is good levator function, aponeurosis advancement is the commonest approach. This procedure involves tightening the levator muscle or resecting and repositioning parts of the eyelid to improve its elevation.
  • Where there is excess eyelid skin (dermatochalasis) or the presence of a mass, surgical excision of the affected tissue can often result in noticeable improvement in ptosis.

• Conservative: In mild cases or for temporary relief, specialised glasses (ptosis crutches) with supporting mechanisms can be worn to help lift the dropping eyelid.

• Management of Underlying Conditions: Treating underlying medical conditions contributing to ptosis, such as myasthenia gravis or space-occupying lesions causing third nerve palsy may help alleviate symptoms.

References

1. Eyewiki, Aponeurotic ptosis. https://eyewiki.aao.org/Aponeurotic_Ptosis
2. Shahzad B, Siccardi MA. Ptosis. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546705
3. Koka K, Patel BC. Ptosis Correction. [Updated 2023 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539828/

Witten by Dr Abeku Koomson (FY2) and reviewed by Dr Taiwo Makanjuola (ST5 ophthalmologist)