What Is a Droopy Eyelid?

A droopy eyelid, called blepharoptosis or just ptosis in the clinic, is when the upper eyelid sits lower than it should. The lid covers more of the iris than normal because the muscle that lifts it, the levator palpebrae, has weakened, stretched, or lost its nerve signal.

This is not the same as hooded or droopy upper-lid skin. With hooded eyes, extra skin folds over a crease that sits in its normal place. With ptosis, the lid margin itself rides low. The two can happen together, but they are different problems that need different repairs.

How significantly does eyelid ptosis impact aesthetic appearance?

How much of the cornea, iris, and pupil you can see is a big part of what makes an eye look good.4 When the lid sits abnormally low it covers a large part of the cornea, and most people read that as unattractive. A 2008 study by Knoll and colleagues found that upper eyelid exposure shapes how an onlooker reads your mood and even your intellect, so people with an unusually droopy lid can be stereotyped as less intelligent.2 Vaca and colleagues, in 2019, found that an eye's attractiveness came down mainly to the amount of pretarsal show, with 2 to 4 mm seen as most attractive.3 Symmetry between the two eyes matters even more, since a mismatch in the tarsal platform show points to something like ptosis.

What causes eyelid ptosis?

Eyelid ptosis can affect one eye or both, and it traces back to a range of problems. At root it is either the eye muscles failing or damage to the nerves that supply them. It can be present at birth, but more often it is acquired and shows up later in life as the eye muscles gradually weaken with age.

Congenital ptosis

The mechanism behind congenital ptosis is not well understood, but it is thought to come from the levator muscles developing abnormally before birth.5 Under a microscope the levator is dystrophic, with muscle cells replaced by a mix of fat and fibrous tissue, and in severe cases the samples show almost no striated muscle at all. That points to abnormal muscle development at the tissue level, and because it runs in families, an inherited cause as well.

Acquired ptosis

New ptosis in older people can be neurogenic, myogenic, traumatic, or aponeurotic in origin.6 It often shows up on its own, but it can also come with an autoimmune disorder such as lupus, a malignant tumor, or an infection. When the cause is neurogenic, the ptosis can be a warning sign of something more serious underneath, like diabetes, metastatic cancer, or myasthenia gravis, an autoimmune condition that causes muscle weakness and tends to hit the eyes first. Rarely, ptosis turns up in botulism, an infection caused by eating bacterial toxin from improperly canned food.

Drugs

Opium-based drugs such as morphine, heroin, and oxycodone, along with certain anticonvulsants like pregabalin, can also bring on a mild form of eyelid ptosis.7

How can blepharoptosis be diagnosed?

A primary care physician can usually spot the condition just by looking at how close the upper eyelid margin sits to the central corneal light reflex.1 The corneal light reflex test is straightforward and can be done in an outpatient visit: the ophthalmologist shines a beam above the nose or on the forehead while the patient looks ahead, then checks where the light reflects inside the pupil. Measuring the distance between the upper eyelid margin and that point confirms whether ptosis is present. Once the diagnosis is clear, the physician gathers family and personal medical history to work out the cause and plan treatment.

Can eyelid ptosis be prevented?

There is no way to prevent congenital ptosis. The adult-onset kind can sometimes be headed off when it is driven by an underlying condition like diabetes. For someone who already has a mild form, the key is finding what is causing it, whether a drug, an autoimmune disease, or an infection, so it does not get worse.

Is it essential to treat upper eyelid ptosis?

Older patients often pass on surgery for mild ptosis, since they would rather not go under the knife for looks alone, and the risk of surgical complications can outweigh the benefit. In congenital cases, doctors watch closely for amblyopia, since missing the window for correction sharply raises the chance of permanent vision loss once it sets in.7 In adults with severe ptosis, though, treatment is essential for more than looks. The lid can cover up to a fifth of the cornea, or more in severe cases, which seriously gets in the way of reading, driving, and going up or down stairs.9

What are the treatment options for eyelid ptosis?

Treatment depends on how severe the ptosis is, what is causing it, and how much it affects vision. Surgery is used for severe cases where the patient and the surgeon agree it is necessary. Blepharoplasty, often known as Asian double eyelid surgery, is one of the most commonly performed procedures in plastic surgery; it creates a crease on the eyelid and is done mainly for aesthetic reasons. Surgeons sometimes encourage patients with slanted eyelids to get one to change their look, and in many Asian countries it is very common, with some women choosing it right after finishing high school. In the West, blepharoplasty is usually reserved for conditions like upper eyelid ptosis. Worldwide, elective blepharoplasty keeps rising as more people seek out surgeons to improve how attractive they feel.

What are the outcomes of surgical correction for eyelid ptosis?

Surgical repair of eyelid ptosis can leave patients happy with both how the eye works and how it looks. The condition can still come back over time, so some people need repeat surgeries, and there is a risk of complications. In rare cases surgery makes things look worse through granulomas, asymmetry from over- or under-correction, or infection.10