Droopy eyelid (ptosis): causes, treatment and when to see a doctor

Not every droopy lid needs treatment. The Sussex hospitals leaflet says mild drooping may only need regular check-ups and that some cases improve on their own. In adults surgery may be offered if the lid seriously affects vision. Where the cause is a condition such as myasthenia gravis, treatment is aimed at that condition: the NHS lists avoiding triggers, medicines to improve muscle weakness and, in some people, removing the thymus gland.

Surgery is performed by eye surgeons who specialise in eyelid work. Leeds says operations are mostly done under local anaesthetic, take about 45 minutes to an hour for each eye, and may be done through a cut in the upper lid crease or from inside the eyelid. Sussex describes the common operation: a small cut in the natural crease, shortening the lifting muscle and dissolvable stitches, with the scar usually hidden in the crease. If the muscle is too weak, Leeds says a sling is passed from the lid to the brow to produce a lift, and loose skin may be removed at the same time.

Moorfields explains that ptosis present from birth (congenital) is commonly due to a defect in the levator muscle that raises the eyelid, and can affect one or both lids. Sussex notes it sometimes runs in families and that baby photographs can help show when it started. A rarer form, Marcus Gunn jaw-winking ptosis, causes the lid to rise when the jaw opens because of an abnormal nerve connection and is usually noticed in small children.

In adults, Sussex says ptosis often happens because the tendon helping the eyelid muscle work becomes stretched or weak over time, more commonly with age. Leeds names this as the commonest cause, a tendon pulling away from its attachment, and says it affects contact lens wearers more. Moorfields lists long-term contact lens wear, trauma and eye surgery such as cataract operations as triggers.

Less commonly, the cause lies in nerves or muscles. Moorfields mentions rare muscle conditions such as myasthenia gravis and myotonic dystrophy, third nerve palsy, and a large cyst or swelling weighing the lid down. The NHS describes myasthenia gravis as a rare long-term autoimmune condition in which droopy eyelids and double vision are common symptoms, typically worse when tired and towards the end of the day.

Ptosis (pronounced toe-sis) is a drooping upper eyelid. Leeds Teaching Hospitals describes it as mild when the lid sits above the pupil, partial when it covers part of the pupil and blocks the upper part of the visual field, and in severe cases covering the pupil fully.

Moorfields lists the symptoms: difficulty keeping the eyelids open, eyestrain, an ache above the eyebrow from the effort of raising the lids, and tiredness, especially when reading. University Hospitals Sussex adds that people may tilt the head back or raise the eyebrows to see better and may feel self-conscious about appearance. For some people the issue is mainly cosmetic.

Most droopy lids develop slowly and are not an emergency. A lid that droops suddenly is different. Moorfields lists third nerve palsy, a nerve paralysis that can drop the lid, as a type of stroke, and the NHS says a stroke needs urgent medical help in hospital.

The NHS says to call 999 straight away if you think you are having or have had a stroke, even if the signs have stopped. Its listed signs include a drooping face, arm weakness or numbness, slurred or confused speech, sudden blurred vision or loss of sight, dizziness and a severe headache.

The NHS describes droopy eyelids and double vision as common symptoms of myasthenia gravis, which tend to be worse when tired and towards the end of the day. It advises seeing a GP for long-lasting or worrying symptoms, and says sudden severe breathing or swallowing difficulty needs urgent hospital treatment.

• Call 999 or go to A&E if a sudden droop comes with face, arm or speech problems, a severe headache or loss of vision.

• Arrange an urgent GP or optician appointment if the lid droop varies through the day, is worse when tired or comes with double vision.

• Book a routine GP or optician visit for a slowly developing droop that is bothering you or affecting your vision.

Assessment starts with when it began, whether it changes during the day, and what else is going on. Old photographs help. Examination measures how far the lid sits over the pupil and how well the lifting muscle works. If a muscle or nerve condition is suspected, the NHS says tests for myasthenia gravis can include a blood test, a test of how well the nerves work, and scans such as CT or MRI.

Moorfields observes that operating on a drooping lid can cause the unaffected lid to droop, so surgery on both sides may sometimes be needed. Leeds lists the same effect among surgical risks, due to shared nerve supply, which is why the surgeon examines both eyelids before advising.

Sussex says that in children ptosis can cause amblyopia, where vision in one eye does not develop properly, and untreated this can cause long-term vision problems. Treatment may include glasses or short periods of covering the stronger eye. Moorfields also notes congenital ptosis can be purely cosmetic but can prevent normal visual development, so surgery to correct lid position is sometimes necessary.

Sussex explains that surgery in children is only needed if the drooping affects vision development, and where it is needed it is usually delayed until about age 8, when better measurements can be taken. Children have surgery under general anaesthetic. Parents who notice a lid that covers the pupil, a chin-up head posture or one eye that seems less used should ask for an eye check.

Leeds states that swelling, bruising and blurry vision are common after ptosis repair, and that stitches are removed after 5 to 7 days unless dissolvable ones are used. Possible complications it lists include bleeding, delayed healing, scarring, infection, a lid left too low or too high, residual asymmetry, drooping of the other lid, double vision and dry eye.

It also describes a rare bleed behind the eyeball that can threaten sight. Because of this, unusual pain, a sudden worsening of vision or a tight swollen eye after surgery should be reported to the surgical team or A&E straight away, using the contact details you are given.

Leeds Teaching Hospitals adds that smokers are known to have healing problems, so you should tell your surgeon if you smoke or have smoked.

On the NHS, ptosis is usually seen in ophthalmology or oculoplastic clinics after an optician or GP referral, and surgery is generally offered when drooping affects vision or in children when development is at risk. Where the lid sags for cosmetic reasons alone, funding policy varies between areas, so ask your GP or the clinic what applies locally.

Private assessment is used for quicker appointments or when appearance is the main concern, with self-funded or insured treatment available at several eye hospitals. Whichever route you choose, ask who will perform the operation, what experience they have with ptosis repair, how asymmetry will be handled and what the aftercare arrangements are.