Everything You Need To Know About Eyelid Ptosis

Pardon the pun, but, right now, the eyes have it. Months (and months) of COVID-19-related masking has left many of us hyper focused on our eye area: Should we tint our lashes at home? What about trying our hand at falsies? Brave Botox® during the pandemic?

With more emphasis than ever on the expressiveness of our upper face — chiefly, the eyes — we figured it was time to examine a relatively common complaint that is not often discussed: eyelid ptosis (a.k.a. droopy eyelids). Here’s what you need to know about the condition and treatment options.

What Is Eyelid Ptosis?

Eyelid ptosis (the ‘p’ is silent, friends), also known as blepharoptosis, is the medical term for a drooping eyelid. The condition can be caused by trauma, age, genetics, or various medical conditions, and there are two general classifications for ptosis:

1. Congenital ptosis (present at birth)
2. Acquired ptosis (developed later in life)

Ptosis affects both men and women, and it may be present in one eyelid (unilateral) or both eyelids (bilateral). It’s estimated that somewhere between 10 and 20 percent of adults have some level of eyelid ptosis. While mild degrees of blepharoptosis may only have a cosmetic impact, more severe cases can be medically significant.

What Causes Eyelid Ptosis?

We tend to take blinking for granted, but it’s actually a pretty complex marvel of physiology. Just so we’re seeing eye to eye (right?), let’s breeze through some orbital anatomy. The eyelids are composed of several muscles that are responsible for opening and closing the eye. The orbicularis oculi is the muscle that encircles the eye socket and controls the closing of the eyelids.

There are also two main muscles involved in raising and maintaining the position of the eyelids. The levator palpebrae superioris does the heavy lifting and the superior tarsal muscle provides an extra boost. Damage to either of these two muscles (or to the nerves that signal them) can lead to eyelid sagging.

With that said, there are a host of factors that may contribute to blepharoptosis. In some cases, eyelid droop is simply the result of heavy, excess skin in the area (not impaired muscle function). Other times, it’s caused by conditions that can damage the delicate eyelid muscles:

• Genetics (researchers have found at least one gene so far)
• Age (muscles wear out as we get older)
• Eyelid tumors or cysts
• Eye injury
• Muscle disorders
• Nerve issues (including stroke and Horner’s syndrome)
• Cataract surgery (an estimated 4 to 12 percent of patients experience post-op ptosis)

And then there are the risk factors that are more lifestyle dependent. Turns out, your mother was onto something when she told you to stop flipping up your eyelids (gross) because ‘someday they’ll stay like that.’ Eyelid ptosis is sometimes the result of:

• Contact lens use (primarily hard contacts)
• Eye rubbing
• Elective eye surgery (including LASIK)
• Neurotoxin injections (Botox®, Dysport®, Jeuveau®, Xeomin®)

If that last one got your attention, we’re here to explain…

Can Botox Cause Ptosis?

While the so-called ‘Botox Brow Lift’ has been making headlines recently, one of the most common side effects of neuromodulators is brow and eyelid ptosis. Visiting a highly experienced injector decreases your chances of this complication, but it's always a possibility. “Neuromodulators may cause temporary ptosis if they come in contact with the levator superioris palpebrae muscle,” says Kian Karimi, MD, a double board certified facial plastic and reconstructive surgeon in Los Angeles. “Some patients also complain of brow ptosis when the frontalis muscle (forehead) is treated with these injections.”

The good news? Neuromodulator-related ptosis generally wears off faster than the rest of your treatment. It usually resolves in three to four weeks.

How to Treat Eyelid Ptosis

Sometimes ptosis is a symptom of something innocuous, like aging (sigh). But because blepharoptosis can be indicative of a serious condition like a stroke or a tumor, it’s smart to see your board certified ophthalmologist or plastic surgeon when you notice sagging. If left untreated, ptosis can cause:

• Vision disruption
• Amblyopia (a.k.a. lazy eye)
• Astigmatism
• Neck problems (tilting the head to see causes tension)

Fortunately, eyelid ptosis is treatable, and your course of treatment will depend on the cause of your condition. In some cases, treating an underlying medical condition will resolve the ptosis. Otherwise, the most common eyelid ptosis treatments include:

• Eyelid Exercises: Dr. Karimi says that while special exercises may work in certain cases, results may not last.
• Eye Crutch: Also called a ‘ptosis crutch,’ this device is useful for treating temporary ptosis or for patients who aren’t candidates for surgery.
• Surgery: The most permanent solution, though it may not be appropriate in every case.

It should be noted that serious cases of blepharoptosis may qualify for insurance coverage. “There are measurements that are taken to assess the degree of eyelid ptosis and tests to show if there is impairment of vision from eyelid ptosis and/or from redundant skin that can diminish peripheral vision,” Dr. Karimi explains. Once you’ve been diagnosed with eyelid ptosis, your provider will evaluate whether or not your case qualifies.

Eyelid Ptosis Surgery

Patients who have acquired ptosis unrelated to an underlying (and treatable) medical condition or those born with a droopy eyelid may be good candidates for surgical blepharoptosis repair. Eyelid ptosis surgery is typically performed as an outpatient procedure under local anesthesia.

Depending on the severity of sagging and the provider’s preference, incisions may be made on the surface or the underside of the upper eyelid. “In general, milder cases can be treated with an internal approach, whereas more significant or complex cases may require an external approach with an outer incision,” Dr. Karimi says. The surgeon shortens (or reattaches, if necessary) the levator palpebrae superioris or the superior tarsal muscle based on the anatomy and needs of the patient.

It’s common to incorporate eyelid ptosis repair into a larger set of facial rejuvenation procedures, particularly in older patients who’ve developed the condition with age. Brow lift and upper eye lift (read: blepharoplasty) surgeries can often make the eyelids appear more elevated, but the simultaneous repair of true ptosis will yield the best aesthetic results.

Although every case is unique, Dr. Karimi says ptosis surgery typically has a one- to two-week recovery period, which is usually tolerated quite well. Eye drops and wound care are part of the recovery process, and strenuous activity is usually limited for two to three weeks. Risks include poor scarring, asymmetry of the lids after correction, infection, and need for additional procedures.

A Prescription Ptosis Solution

For patients seeking a non-invasive alternative, the United States Food and Drug Administration (FDA) approved Upneeq® — a once daily eye drop — for the treatment of acquired eyelid ptosis in July 2020. The solution, which includes oxymetazoline hydrochloride (the active ingredient in nasal decongestant spray), causes contraction of the levator muscle, raising the eyelid by about one to two millimeters. While he has yet to prescribe it, Dr. Karimi sees Upneeq® as a non-surgical treatment option, particularly for patients experiencing temporary ptosis from neuromodulators.

The Takeaway

Eyelid ptosis is not always just an aesthetic concern, so it’s important to see your doctor if you notice eyelid drooping to rule out underlying medical conditions. Depending on the cause(s) and type of ptosis, your provider will advise on what treatment option(s) that are best for you.