Drooping eyelids (ptosis)

Ptosis can affect one or both eyes and results from weakness affecting the muscles that raise the eyelid.

L ptosis

Left sided ptosis

Ptosis can be congenital (you are born with it), or acquired (it develops during life).

Acquired ptosis can result from a variety of problems affecting the nerves, muscles, neuromuscular junction or tendons involved in elevating the eye lids.

Neurogenic ptosis is usually unilateral, and can be caused by a lesion affecting either the oculomotor nerve or the sympathetic nerve fibers to the eye (Horner’s syndrome).

When ptosis is caused by an oculomotor nerve lesion, there is  generally also some degree of eye movement abnormality (ophthalmoparesis).  Oculomotor nerve palsy can be caused by something as simple as diabetes, but if the nerve fibers to the pupil are involved (causing a dilated pupil in addition to the ptosis and ophthalmoparesis), that is very suggestive of a compressive lesion such as an aneurysm (see below) and warrants immediate evaluation.

R ptosis, occulomotor palsy (eye is deviated down and outwards), with a dilated pupil, caused by nerve compression from aneurysm (red arrow)

R ptosis, oculomotor palsy (eye is deviated down and outwards), with a dilated unreactive pupil, caused by nerve compression from aneurysm (red arrow)

Horner’s syndrome causes mild ptosis associated with a small pupil (miosis) sometimes associated with lack of sweating (anhidrosis) on the face, and can be caused by trauma to the carotid artery, lung tumors, or strokes.

L Horner's syndrome with mild ptosis and miosis

L Horner’s syndrome with mild ptosis and miosis

Myasthenia gravis is an autoimmune disease that affects the neuromuscular junction, and frequently presents with fatiguable ptosis often associated with double vision and limb weakness.   The ptosis will usually get worse when the patients is tired at the end of the day (diurnal variation):

Fatiguable ptosis in myasthenia gravis

Fatiguable ptosis in myasthenia gravis

The ptosis of myasthenia can be temporarily improved with an acetylcholinesterase inhibitor medication, such as an injection of edrophonium (Tensilon), and this can used a diagnostic test.

Ptosis can also be seen in certain muscle diseases, including oculopharyngeal muscular dystrophy, mitochondrial myopathy and myotonic dystrophy.

Bilateral ptosis in a patient with myotonic muscular dystrophy

Bilateral ptosis in a patient with myotonic muscular dystrophy

However, acquired ptosis is most commonly caused by dehiscence or disinsertion of the levator aponeurosis, causing a disconnection between the eye lid and the elevating muscles.

This usually occurs in elderly patients, but can sometimes affect younger contact lens users.

L ptosis from levator dehiscence - Note that when the eye is closed, the lid crease is fainter and further away from the lid margin in the left eye, compared to the right eye

L ptosis from levator dehiscence – Note that when the eye is closed, the lid crease is fainter and further away from the lid margin in the left eye, compared to the right eye

Patients who notice a drooping eyelid, unequal pupils, or double vision should consult with a neurologist in order to establish the correct diagnosis.

After that, treatment might include medical therapy for an underlying disorder (such as diabetes or myasthenia), surgery or even eye lid crutches:

Myasthenic patient with isolated L ptosis, demonstrating improvement with the eye lid "crutch"

Myasthenic patient with isolated L ptosis, demonstrating improvement with the eye lid “crutch”

6 thoughts on “Drooping eyelids (ptosis)

  1. Please help me. I’ve been to a neurologist and I’ve had so much testing done to figure out what’s causing my ptosis. All my tests come back normal and healthy. However my ptosis in my left eye is mild but it seems to be getting worse. I really want it surgically fixed, but I can’t pay for it out of pocket and I don’t think they will say it’s medically necessary to fix it so. Do it’s mild. Yet , it’s literally depressingly so much to see how it had negatively affected my appearance and how people stare at me like there is something wrong withy face. I cry all the time now, because I can’t stand how ugly it makes me look and feel. This mental anguish about my ptosis is making it difficult to enjoy life and accomplish anything. I just want it to be fixed and to look normal again. What can I do ?

  2. If you have an onset of drooping in one eye (started about 2 weeks ago). The drooping progresses throughout the day to where it is almost closed by evening. Would you recommend starting with a primary care doctor or going straight to a neurologist?

  3. Hi there help me.
    I have been diagnosed with blephrospam is this along your lines? as I don’t think I have this and two others have said the same. I can’t open my eyes anymore or I find it very hard, sometimes it is ok others bad. I get a lot of shadowing or double vision and my eyes can be half mast quite a lot of the time.
    It is worse when driving and walking.
    Can you give me some answers as all they want to do is Botox which by they way doesn’t work either. Out of six lots only one has worked slightly. They have uped the dose and it has made my eyes droop even more.
    Thanks Philippa

    • Thanks for your comment Philippa. Blepharospasm can look like ptosis, because the space between the eyelids is narrowed, but is caused by an involuntary muscle spasm in the facial muscles that close the eye. The careful use of BoTox injections to partially paralyze these overactive muscles can be very helpful, but some patients do not respond well or develop resistance to this treatment. A surgical procedure known as eyelid protractor myectomy can also provide subjective benefit to patients with blepharospasm. Studies have shown that this procedure can alleviate symptoms of blepharospasm in up to 50% of affected patients. Other studies have shown that this procedure can provide increased efficacy or longer-lasting effects from BoTox injections in blepharospasm patients who had otherwise developed resistance or tolerance to this therapy .

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s