Ptosis (Droopy Eyelid)

Ptosis (say "TOE-sis") is when the upper eyelid hangs lower than it should. It can affect one eye or both eyes. A mild droop may only change how you look. A bigger droop can cover the pupil (the black centre of the eye) and block your vision, especially your upper vision.

Your upper eyelid is lifted by a muscle called the levator. This muscle is joined to the lid by a thin sheet of tissue, and it is controlled by a nerve from the brain. Ptosis happens when there is a problem with the muscle, its attachment, or the nerve that controls it.

Most ptosis is harmless and comes on slowly. But because the eyelid is controlled by nerves from the brain, a droopy lid can sometimes be the first sign of a nerve or brain problem. This is why eye doctors treat a new or sudden droop seriously.

Image to add

Simple drawing of two faces side by side: one with normal eyelids, one with the right upper eyelid drooping over the top of the pupil. Alt text: "Drawing comparing a normal eye with an eye whose upper eyelid droops down over the top of the pupil."

What causes it?

Common causes

• Age-related (aponeurotic) ptosis: the most common type. The thin sheet that joins the lifting muscle to the lid stretches or slips over time [1].
• Contact lens wear over many years [1].
• After eye surgery or an eye injury [1].
• Congenital ptosis: a baby is born with a weak lifting muscle. It may affect one or both eyes [2].
• Swelling or a lump in the lid that weighs it down [1].

Nerve and muscle causes (less common but important)

• Third nerve palsy: the third nerve controls the eyelid, most eye movements and the size of the pupil. If it stops working, you may have a droopy lid, double vision and sometimes a large pupil. A sudden third nerve palsy with a large pupil can be caused by an aneurysm in the brain. This is an emergency [3].
• Horner syndrome: a problem with the nerves that run from the brain, down the neck and back up to the eye. It causes a mild droop and a smaller pupil on the same side. If it comes on suddenly with neck, face or head pain, especially after a neck injury, it may be caused by a tear in the neck artery (dissection), which can lead to a stroke. This needs urgent care [4].
• Myasthenia gravis: a condition where the immune system blocks the signals from nerves to muscles. The droop often changes during the day, is worse when tired and better after rest, and may come with double vision. Some people also get weakness when chewing, swallowing, talking or breathing [5].

Ptosis can happen at any age. It is more likely if you:

• are older, as the lid tissues stretch with age
• have worn hard or soft contact lenses for many years [1]
• have had eye surgery, such as cataract surgery [1]
• have had an injury to the eye or eyelid
• were born with a droopy lid (congenital ptosis)
• have certain nerve or muscle conditions, such as myasthenia gravis

You or your family may notice that one eyelid is lower than the other, or that you look tired all the time. Old photos can help show when the droop started.

Your eye doctor will:

• measure how low the lid sits and how well the lifting muscle works
• check your vision and your side (upper) vision
• look at your pupils and eye movements
• ask whether the droop changes during the day or comes with double vision

If a nerve or muscle cause is suspected, you may need blood tests, a brain or neck scan, or a check by a neurologist (nerve specialist).

What can happen?

• Blocked vision: the lid can cover part of your vision, making reading, driving and looking up harder.
• Tired eyes and forehead ache: many people lift their eyebrows all day to see, which causes eye strain and tiredness [1].
• Lazy eye in children: if a droopy lid covers a child's pupil, the eye may not learn to see properly. This is called amblyopia (lazy eye). If it is not treated early, the poor vision can be permanent [2][6].
• A hidden serious cause: rarely, ptosis is a warning sign of a problem such as a bulging blood vessel in the brain (aneurysm) or a torn artery in the neck.

See an eye doctor soon (within days) if:

• a new droop appears in an adult, even without other symptoms
• the droop comes and goes or gets worse when you are tired
• your baby or child has a droopy lid that covers part of the pupil

Treatment depends on the cause. A mild droop that does not affect vision may not need any treatment.

1. Treat the underlying cause: for example, medicines for myasthenia gravis, or urgent care for an aneurysm or artery tear. In some nerve palsies the droop gets better on its own over a few months.
2. Surgery to lift the lid: this is the main treatment for age-related, contact lens and congenital ptosis. In adults it is often done under local anaesthetic as a day case.
   • Levator advancement: the surgeon tightens or reattaches the lifting muscle to the lid.
   • Brow suspension (frontalis sling): used when the lifting muscle is very weak, often in children born with ptosis. A thin sling links the lid to the forehead muscle, so you can lift the lid by raising your eyebrows.
3. For children: the eye team will check vision regularly. Glasses or patching may be needed to treat lazy eye. Surgery is done early if the lid is blocking vision; otherwise it may be planned for when the child is older [2].

Most ptosis cannot be prevented, but you can prevent harm from it:

• Take your child for an eye check early if a droopy lid covers part of the pupil, to prevent lazy eye.
• If you wear contact lenses, follow your optometrist's advice and avoid rubbing your eyes.
• Do not ignore a sudden droop. Getting help quickly can be life-saving.

Where to get help in Brunei

You can walk in to any Community Eye Clinic at your health centre. No referral is needed. The team can check your eyelid and refer you to the eye specialists if needed.

For a sudden droop with double vision, headache, a big pupil, or breathing or swallowing problems, go to the hospital Emergency Department or call 991.