Eyelid ptosis – diagnosis and surgery

What is ptosis?

Normally the upper lid margin covers only a small upper part of the iris. In ptosis the lid sits lower, sometimes covering the pupil. The eye looks half-closed or sleepy, and people often raise their brows or tilt their head back to see better without noticing.

Ptosis may affect one or both eyes. It is often confused with excess eyelid skin (dermatochalasis), which is treated with upper eyelid surgery. The two often occur together.

Causes of ptosis

• acquired aponeurotic ptosis – the most common in adults; the tendon of the levator muscle stretches or detaches with age, long-term contact lens wear, frequent eye rubbing or after eye surgery,
• congenital ptosis – due to abnormal development of the levator muscle,
• myogenic and neurogenic ptosis – associated with muscle or nerve disorders such as myasthenia gravis, third nerve palsy or Horner syndrome,
• mechanical ptosis – when the lid is weighed down, e.g. by a tumour, swelling or scarring.

When to see a doctor urgently

A suddenly drooping eyelid, especially with double vision, headache, unequal pupils or weakness of other muscles, needs urgent neurological assessment, not elective surgery. Likewise, ptosis that gets worse during the day and changes from hour to hour may point to myasthenia gravis.

Diagnosis

At the consultation the doctor measures the distance between the lid margin and the centre of the pupil, levator muscle function, crease height, brow position, eyelid closure and the cornea. A phenylephrine drop test may help predict the result of some techniques, and a visual field test may be done. If a neurological cause is suspected, you will be referred for further tests.

How is ptosis corrected?

The choice of method depends mainly on levator muscle strength:

• levator advancement – through an incision in the eyelid crease; the most common method for acquired ptosis, easily combined with skin removal,
• Müller muscle–conjunctival resection – from the inside of the lid, with no skin scar; for mild ptosis with a good phenylephrine response,
• frontalis sling – for very weak levator function, so the lid is lifted by the forehead muscle.

In adults the operation is usually done under local anaesthesia. This allows the surgeon to ask you to open your eyes during surgery and adjust lid height and contour in real time.

Healing and results

Swelling and bruising usually last 1–2 weeks; stitches come out after about 7 days. In the first weeks the lid may not close completely, so keeping the eye lubricated as instructed is important. Final height and symmetry are assessed after several weeks to a few months.

Ptosis surgery demands great precision – a one-millimetre difference is visible. Despite careful planning, under-correction, over-correction or asymmetry can occur and sometimes need adjustment. We discuss this openly before surgery.

Frequently asked questions