When evaluating patients with droopy eyelids, make sure to rule out systemic conditions.

By Julie Woodward, MD

Unlike upper lid blepharoplasty, which is often considered to be a cosmetic procedure, ptosis repair is primarily performed for functional reasons. Ptosis repair surgery can be combined with blepharoplasty to improve the eyelid appearance and restore functionality.


Blepharoptosis (ptosis) is when the upper eyelid margin rests 2mm or less from the central pupil when the eye is in primary gaze. It can be slight, or it can be severe enough to limit or even completely block normal vision. A common condition, ptosis can be categorized as congenital or acquired. Acquired ptosis is most often caused by a progressive, age-related stretching, dehiscence, degeneration, or detachment of the levator muscle complex (levator palpebrae superioris and levator aponeurosis) known as aponeurotic ptosis

Underlying etiology can also be myogenic (due to myopathy of the levator muscle), neurogenic (due to central mechanisms or dysfunction of the third cranial nerve or sympathetic nerves that innervate the eyelid muscles), mechanical (due to lesions putting excess weight on the eyelid), and traumatic (which can have myogenic, neurogenic, or mechanical features). A third nerve palsy could indicate a cerebral aneurysm, and a Horner’s syndrome indicates damage to the sympathetic fibers that could be due to a carotid artery dissection. Both conditions should be referred to the emergency department immediately.

In adults, the most common cause of acquired ptosis is a combination of the degeneration of the levator muscle with some fibrosis and fatty deposits, and there can also be dehiscence of the aponeurosis tendon from the tarsal plate; all of these are products of aging. Long-term contact lens wear and chronic inflammation can contribute to ptosis as well.

When considering a ptosis repair, you should rule out medical reasons for the condition. Causes of neurogenic ptosis, which results from defective innervation of the levator muscle of the upper eyelid, include third nerve palsy, Horner syndrome, Marcus Gunn jaw-winking syndrome, and multiple sclerosis. Myasthenia gravis is an autoimmune cause of ptosis. Chronic progressive external ophthalmoplegia and oculopharyngeal dystrophy are genetic causes of ptosis.

A significant percentage of patients I see needing a ptosis repair have floppy eyelid syndrome associated with snoring and sleep apnea. In these patients, the eyelashes tend to tilt downwards as well. These ptosis patients should be evaluated with a sleep study as untreated sleep apnea doubles the death rate when compared to age-matched controls. Remember: Patients with sleep apnea do not always look like “typical” snorers. Because other diseases, dystrophies, and even tumors can be associated with ptosis, it’s important to keep these conditions on the radar for a differential diagnosis.

Ptosis Repair

When assessing a patient for possible ptosis surgery, we first consider the levator muscle function. Normal levator function is considered 12 mm to 18 mm of excursion. In other words, when the patient’s eyes are gently closed and they look up to the ceiling, the movement of the eyelid should be at least 12 millimeters.

In that situation, a patient will do well with either a levator advancement or sometimes a Muller’s muscle-conjunctival resection (MMCR)—an internal repair—if ptosis is minimal. Note: If the levator function is only 4 mm to 12 mm, levator advancement is an option, but the lids may not elevate as much as desired. There’s a possible risk of over-lifting the lid with surgery and leaving the patient unable to completely close their eye. 

For an MMCR, the surgeon cuts out a small piece of conjunctiva and Mueller’s muscle on the underside of the lid. A single stitch will lift the eyelid, usually 1 to 2 mm. But remember: The tissue includes glands, and this procedure is not reversible. If the eyelid is stitched too close to the eyeball, it can become tethered with a resultant symblepharon. Another option, ptosis surgery is an external repair in which the incision is the same as for a blepharoplasty, although not quite as big—perhaps less than an inch in the lid crease. The difficulty is in creating symmetry and avoiding peaking; however, this approach is adjustable and reversible.

In congenital ptosis, where the eyelid doesn’t have much excursion (0 mm to 4 mm) a levator advancement surgery or MMCR is not indicated. Instead, the patient will require a frontalis sling to be placed in the eyelid and then will learn to raise the eyebrow. Ptosis surgery is commonly covered by insurance because there is typically some degree of visual obstruction, although patients do not always realize it.

Ptosis surgery is often an office-based procedure and is generally well tolerated. I always tell patients that the greatest risk of surgery is asymmetry because it’s very difficult to get the two eyes perfectly even. Even half a millimeter may be cosmetically displeasing to patients. I inform them that there is a 20% chance of needing an adjustment; personally, I like to under promise and overdeliver in this situation.

Nonsurgical Option

Upneeq, preservative-free oxymetazoline HCl ophthalmic solution 0.1% (RVL Pharmaceuticals), is a recently approved pharmacologic option for the treatment of acquired blepharoptosis. This ophthalmic alpha-adrenergic agonist can be instilled once daily to raise the upper eyelid and improve superior visual field by activating the superior tarsal muscle. The drop is a nice alternative to surgery or for someone who wants to see what they would look like with a wider eye. The good thing? It’s temporary. For example, if a patient has dry eye disease and is concerned about how their eyes may feel after surgery, they may be able to use Upneeq intermittently.

Another advantage of Upneeq is that it provides a nice, uniform lift of the eyelid. Interestingly, it not only works on the Mueller’s muscle to lift the eyelid, but it also works somewhat on the inferior tarsal muscle to pull down the lower lid. It blanches the vessels in the eye, making the eye(s) appear whiter. The result is that the eyes look both brighter and wider open.


Blepharoplasty is indicated when there are no problems with the levator muscle or tendon, but there is extra skin, fat, and muscle hooding either close to or over the eyelashes. A ptosis patient can have almost no extra skin, yet the lid margin can hang close to or over the pupil. In a blepharoplasty candidate, there is redundant tissue; but underneath the heaviness of the extra skin and fat, the muscle is in good shape. A blepharoplasty can sometimes be a functional operation covered by insurance if the patient’s view is obstructed; more often, it’s a cosmetic procedure to provide a more youthful appearance.

In my practice, I use a CO2 laser to re-sculpt the extra skin and fat. Sometimes, I take a small amount of nasal fat and move it into the hollow A-frame area centrally—a move that improves upper sulcus volume with a more youthful contour. For the best result, the lid crease must be set at the right place and the incision must curve properly. I explain to patients that there will be some bumpiness along the incision after the stitches are removed that may last a few months. Eventually, the scars will fade into little white lines that are hidden in the lid crease.

Sometimes blepharoplasty is performed at the same time as a concurrent ptosis repair.

Final Thoughts on Ptosis

When encountering a ptosis patient, it’s crucial to rule out any medical/congenital causes. Physicians should be asking questions regarding systemic, as well as visual, symptoms.

Julie Ann Woodward, MD, is professor of ophthalmology; chief, oculoplastics ophthalmology; and professor in dermatology at Duke University School of Medicine in Durham, N.C. She may be reached at [email protected].


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