What causes a droopy eyelid?

Droopy eyelids, or ptosis (pronounced toe-sis) is a common problem as we get older. It happens when the muscles responsible for holding up the eyelid stretch and weaken, causing the upper eyelid to droop.

Occasionally, droopy eyelids can affect younger people and may be a sign of an underlying medical condition.

Let’s take a closer look at what ptosis is, what the symptoms are, and how the condition is treated.

What is ptosis?

Ptosis is the medical term for droopy upper eyelids. Ptosis has several causes and isn’t usually serious, but in severe cases the eyelid can droop over the eye, covering the pupil and making it difficult to see.

Ptosis affects men and women equally. It can affect one eye (unilateral ptosis), or both eyes (bilateral ptosis).

What are the symptoms of ptosis?

Ptosis can be mild and barely noticeable, or so severe that it prevents you from being able to see properly. Ptosis can also affect your self-esteem and many people can feel self-conscious about the way their eyelids look.

Symptoms of ptosis may include:

• A droopy eyelid on one or both eyes
• Difficulty keeping your eyelids open
• Tired facial muscles from lifting the eyelid in order to see properly
• Eye strain, especially when reading
• Head or neck problems from lifting the head or tilting the chin in order to see properly
• Impaired vision
• Astigmatism
• Headaches
• Dry eyes
• Watery eyes

What causes ptosis?

There are two types of ptosis: congenital ptosis, which people are born with, and acquired ptosis, which develops later in life.

Acquired ptosis

Acquired ptosis is when your eyelids start to droop later in life, commonly in middle to old age. It can have several causes, including:

• Aging — this is the most common cause of acquired ptosis and occurs when the muscles in the eyelid stretch as we age
• Injury to the eyelid muscles or ligaments
• Eyelid tumours or cysts
• Nerve damage
• A complication of Botox injections or eye surgery
• Medical conditions such as myasthenia gravis, myotonic dystrophy, and Horner syndrome
• Rarely, ptosis can be a sign of a serious medical condition such as a brain tumour, stroke, or certain types of cancer

Congenital ptosis

Congenital ptosis is a type of ptosis that is present at birth or develops within the first year of life. It usually happens when the levator muscle (the muscle that lifts the eyelid) doesn’t develop properly.

In a type of congenital ptosis known as Marcus Gunn (jaw-winking) ptosis the eyelid droops when the jaw is opened. Jaw-winking ptosis occurs because of an abnormal connection between the nerves in the face. The condition usually affects one eyelid and is most common in young children. In many cases, treatment isn’t necessary, and the condition often gets less noticeable as the child gets older. If jaw-winking ptosis is severe, or if it is affecting your child’s vision, it may be treated with surgery.

Other causes of congenital ptosis include:

• Trauma at birth (such as the use of forceps during delivery)
• Tumours or growths on the eyelid
• Neurological disorders
• Eye movement disorders

Children with congenital ptosis often develop amblyopia (lazy eye) if the ptosis is not corrected. They may develop the habit of tipping their head back to see better, which can cause problems with the head and neck muscles over time.

Congenital ptosis may not be noticeable at birth but usually develops within a few months.

Risk factors for ptosis

You may be more likely to develop ptosis if you:

• Are older
• Have a medical condition such as Horner syndrome, or myasthenia gravis
• Wear contact lenses regularly
• Rub your eyes a lot
• Have previously injured your eye
• Have previously had eye surgery

When should I see a doctor?

Children with congenital ptosis should see an eye doctor regularly so that the condition can be monitored, and any visual problems treated. This can prevent further eye problems from developing in the future.

For acquired ptosis, make an appointment with a consultant if:

• You have difficulty with day-to-day activities like going up and down stairs, reading, or driving
• Your eyelids start drooping suddenly
• Your ptosis is accompanied by pain
• Your droopy eyelids are affecting your self-esteem, or causing you anxiety

How is ptosis treated?

No treatment

Ptosis is often mild and doesn’t need treatment. Treatment may be recommended to fix visual problems, or you may choose to correct your droopy eyelids with surgery for cosmetic reasons.

Muscle stimulation

Ptosis caused by incorrectly administered Botox injections usually resolves by itself over time. Sometimes it is treated by stimulating the affected muscle using the back of an electric toothbrush and eye drops.

Upneeq

A new medication called oxymetazoline (Upneeq) can treat some types of acquired ptosis. It works by causing the muscle that elevates the eyelid to contract, opening the eye by a few millimetres. Upneeq is not effective in treating congenital ptosis, or ptosis caused by an eye injury or nerve problems. 

Ptosis crutch

A ptosis crutch is a non-surgical treatment where an attachment called a crutch is added to the frame of your glasses. It works by holding your eyelid in place and preventing it from drooping. There are two types of ptosis crutch, adjustable crutches are attached to one side of the frames, and reinforced crutches are attached to both sides.

Surgery

Surgery to correct ptosis involves tightening the levator muscle, the muscle that lifts your upper eyelid. The surgery is performed as a day case under local anaesthetic and normally takes between 45 and 90 minutes.

In some cases, a different type of surgery called a frontalis sling is performed to correct ptosis. During this type of surgery, a loop of material is threaded through the skin between the eyebrows and the eyelid, close to the lashes. This can be tightened, making it easier for the forehead muscles to lift the eyelid. Frontalis sling surgery is normally recommended for patients with congenital ptosis, or for acquired ptosis caused by muscle or nerve injury.

Can ptosis be prevented?

Congenital ptosis can’t be prevented and most cases of acquired ptosis are also difficult to prevent.

You may reduce your risk of developing ptosis if you:

• Limit your use of contact lenses
• Avoid rubbing your eyes
• If you have Botox injections, choose a qualified, experienced practitioner

A 2015 study in the Aesthetic Surgery Journal found no link between ptosis and lifestyle factors, such as body mass index (BMI), smoking, alcohol consumption, sun exposure, stress, or sleep.

Other causes of droopy eyelids

Droopy eyelids may sometimes be caused by other conditions that affect the eyelids, such as dermatochalasis, ectropion, or entropion.

Dermatochalasis

Dermatochalasis is a condition where there is an excess of eyelid skin and a loss of elasticity, causing ‘baggy eyes.’ It is common in elderly people but occasionally affects younger adults. Dermatochalasis can be treated with a surgical procedure called a blepharoplasty, where the excess skin, fat, and muscle is removed. A blepharoplasty is normally done for cosmetic purposes, but in cases where the excess skin is affecting your vision, it may be possible to have surgery on the NHS.

Ectropion

Ectropion is a condition where the lower eyelid droops and turns outwards. This can stop your tear ducts from working properly and lead to soreness, redness, irritation, excessive eye watering and a feeling of grit in your eye. Ectropion can also make bacterial infections like conjunctivitis (pink eye) more likely.

Ectropion is more common in older people and is due to the muscles and soft tissues of the eyelids getting weaker as you age. It can also be caused by nerve problems such as Bell’s palsy, a cyst or tumour on the eyelid, or damage to the eyelid from an injury or surgery.

Treatment for ectropion includes eye drops to lubricate your eyes and reduce irritation and, in some cases, surgery to correct the problem.

Entropion

Entropion is the opposite of ectropion and occurs when your lower eyelid turns inwards. It can cause your eyelashes and the skin of your lower eyelid to rub against the surface of your eye, causing irritation.

Symptoms of entropion are similar to those of ectropion and include redness, soreness, excessive watering, and the feeling that there is something in your eye. You may also have a mucous discharge from your eye, which may form crusts around your eye.

Left untreated, entropion can damage your cornea (the front part of your eye) which can lead to eye infections and loss of vision.

Treatment for entropion depends on the cause and how severe it is. Nonsurgical treatments include corneal bandages, Botox injections into the lower eyelid and using tape or stitches to turn the eyelid outwards. In severe cases, surgery may be needed to correct the position of your lower eyelid.

Summary

Droopy eyelids are a common problem, especially as we age, and are usually nothing to worry about. Occasionally, however, droopy eyelids can cause visual problems, or be a sign of an underlying medical condition that may need treatment.

If the appearance of your droopy eyelids is bothering you or affecting your ability to drive and carry out other day-to-day activities, make an appointment to speak to a consultant.