Ptosis (droopy eyelid): symptoms, causes and treatment

Some people have no symptoms beyond how the eyes look. Moorfields lists the others: difficulty keeping the eyelids open, eyestrain, eyebrow ache from the effort of continually raising the lids, and fatigue, especially when reading. Some people also feel self-conscious about their appearance.

A low upper lid can also interfere with vision by cutting into the top part of the visual field. University Hospitals Sussex says adults with ptosis may lose peripheral (side) vision, which can affect tasks such as driving or reading, and that people often tilt the head back or raise the eyebrows to see better.

The Dudley Group adds headaches from having to raise the eyebrows, and says the degree of droop varies from barely noticeable to enough to interfere with reading, driving or other daily activities.

• Eyebrows raised or head tilted back to see under the lid

• Tired, strained eyes, especially when reading

• An ache across the brow from continuous lifting

• Reduced upper or side field of view

• A visible difference between the two eyes

The upper eyelid is lifted by a muscle called the levator, which attaches to the lid through a tendon. When that lifting system works poorly, or when its nerve supply is disturbed, the lid edge sits lower over the eye. In a mild case the lid covers a little more of the coloured part of the eye than the other side does. In a marked case it can reach the pupil.

University Hospitals Sussex says ptosis can affect anyone, regardless of age, gender or background, and can happen from birth (congenital) or later in life (acquired). Looking at baby or family photographs helps to show when it started and whether anyone else in the family has it.

Congenital ptosis is commonly due to a defect in the levator muscle that raises the lid. Moorfields says it can affect one or both lids and, although it can be purely cosmetic, it can also prevent normal visual development. University Hospitals Sussex says it sometimes runs in families. In rare Marcus Gunn "jaw-winking" ptosis, the droopy lid rises when the jaw is opened because of an abnormal nerve connection.

Acquired ptosis appears later. Moorfields lists simple ageing or injury, long-term contact lens wear and cataract or other eye surgery. The Dudley Group adds previous stroke, corrective surgery on the other eyelid, and large lesions on the lid whose weight pulls it down.

Less often, ptosis points to a nerve or muscle disorder. Moorfields names myasthenia gravis and myotonic dystrophy as rare muscle conditions that can weaken the lid, and third nerve palsy (a type of stroke) as a nerve cause. The NHS lists droopy eyelids and double vision among the common symptoms of myasthenia gravis, and says its symptoms tend to be worse when tired and towards the end of the day.

A droop that has been there for years and has changed slowly is usually not an emergency, although it still deserves an eye check. A new droop that comes on over hours or days is different. If it comes with double vision, a severe or unusual headache, eye pain, a pupil that looks different in size, weakness elsewhere in the body, or difficulty speaking or swallowing, get medical help the same day.

The NHS says to call 999 if you think you are having a stroke, and lists face weakness (one side of the face may droop), arm weakness and speech problems as the main signs. Do not drive yourself to A&E. For a new droop without those features, contact NHS 111, an urgent GP appointment or an eye casualty service. An optometrist can also examine the eye and refer on.

The clinic visit starts with the story: when the droop began, whether it varies through the day, previous eye surgery, contact lens use, and any other symptoms. The examiner measures how high the lid sits, how well the lid lifts when you look up and down, and whether the two eyes are symmetrical. Eye movements and pupils are checked because they help separate a muscle problem from a nerve problem.

If the droop varies with time of day, or the story suggests a muscle or nerve disorder, further tests may be arranged, which can include a blood test. Photographs and visual field tests can help show how much vision is affected. In children, an orthoptist or eye specialist also checks that the eyes are developing vision evenly.

Treatment depends on the cause and on how much the lid affects vision or comfort. University Hospitals Sussex says mild ptosis may need only regular check-ups. If a condition such as myasthenia gravis is behind it, Dudley explains that it can be treated medically without lid surgery.

When the lid does affect vision, surgery is the usual route in adults. The most common operation makes a small cut in the natural crease of the upper lid and shortens the muscle that lifts it, closing the wound with dissolvable stitches, according to University Hospitals Sussex. Adults generally have local anaesthetic, while children have a general anaesthetic.

Dudley notes that some people need the lid suspended from the eyebrow, using either a tendon taken from just above the knee or a synthetic material, when the lifting muscle is too weak to shorten. For children, University Hospitals Sussex says surgery is usually delayed until about 8 years old when better measurements can be taken, unless the droop threatens vision development.

• Dudley states that the aim is a lid at a normal level, matched to the other side, with a natural curve and full, comfortable closure.

• The operation is done as a day case, and the Dudley leaflet gives a time of around 60 to 90 minutes.

• Possible risks listed by Dudley include bruising and swelling, infection, scarring, a lid set too high or too low, and incomplete closure that can leave the eye dry.

• Most people recover within about two weeks, though the lids may stay swollen for four to six weeks in some people.

None of the sources read gives a fixed duration for ptosis itself, because it depends on the cause. University Hospitals Sussex says that sometimes ptosis improves by itself and becomes less noticeable over time, and the Dudley Group says that a droop caused by myasthenia gravis can be treated medically without surgery. Congenital and age-related ptosis do not typically correct themselves without a procedure.

After lid surgery, the Dudley Group says the operation takes around 60 to 90 minutes and you only need to be in hospital for the day. The majority of patients make a full recovery within two weeks with minimal scarring, though lids may stay swollen for four to six weeks. Bruising and swelling can last up to several weeks. You are reviewed in clinic two to four weeks later, and any non-dissolvable stitches are taken out at around three weeks.

University Hospitals Sussex says ptosis can cause amblyopia ("lazy eye") in children, in which vision in one eye does not develop properly, and that if untreated this can lead to long-term vision problems. Treatment might include glasses, or covering the stronger eye (patching) for short periods.

The same leaflet says surgery is only needed if the drooping affects vision development, and when needed it is usually delayed until the child is about 8 years old, when better measurements can be taken. Children have surgery under general anaesthetic. Moorfields notes that in Marcus Gunn ptosis, operating on the affected lid could make the unaffected lid droop, so surgery on both lids may be needed.

Through the NHS, ptosis is usually referred by a GP or optometrist to an eye department. Surgery on the NHS tends to be offered where the droop affects vision, whereas operations done mainly for appearance may be handled differently from one area to another, so it is reasonable to ask how your local service decides.

If you consider seeing a private eye surgeon, ask how the cause of the droop will be confirmed before an operation, what the plan is if the lid ends up too high or too low, how asymmetry will be handled, and what the aftercare and follow-up arrangements are. Oculoplastic surgeons, who specialise in the eyelids and the tissues around the eye, usually perform this surgery.