Upper Eyelid Ptosis (Droopy Upper Eyelid)

Upper eyelid ptosis, or droopy upper eyelid, is defined as the sagging of the upper eyelid that reduces the opening between the two eyelids in a normal gaze. The upper eyelid typically covers 0.5 to 2 mm of the colored part of the eye (iris). When it covers more than 2 mm, it is considered ptosis. Ptosis can be present at birth (congenital) or develop later in life. In some cases, it may affect only one eye, while in others, both eyelids can be involved.

The most common cause of ptosis that develops later in life is the mechanical weight of the upper eyelid skin, which creates sagging. Congenital ptosis, on the other hand, is often caused by dysfunction in the muscles responsible for lifting the eyelid or the nerves that control these muscles. In most cases, ptosis is isolated and does not accompany other health problems. However, if ptosis develops suddenly and progresses within hours or days, it could be associated with a serious health condition.

Ptosis can be classified based on whether it is congenital or acquired, as well as by the severity of the deformity. Mild ptosis involves a droop of 1–2 mm, moderate ptosis is 3–4 mm, and severe ptosis is greater than 4 mm. In congenital ptosis cases, the upper eyelid crease is often absent, and there is usually dysfunction of the eyelid muscles. Children with congenital ptosis often tilt their heads upward to see better or excessively use their forehead muscles to lift the eyelid.

In cases of myogenic ptosis (muscle-related), the muscle responsible for lifting the eyelid is weak. In neurogenic ptosis (nerve-related), underlying conditions such as aneurysms, tumors, or diabetes should be investigated. In older individuals, ptosis may occur due to the detachment of the muscle that moves the eyelid from the eyelid itself. Ptosis can also develop in individuals who wear contact lenses, have had severe eye infections, or have undergone cataract surgery.

If not treated in children, ptosis can lead to amblyopia, also known as lazy eye. Mild congenital ptosis in children may improve over time. However, moderate and severe ptosis cases require surgical intervention, which should be performed by Plastic Surgeons.

In older individuals, the treatment for ptosis is also surgical and is similar to upper eyelid blepharoplasty. During surgery, an incision is made in the upper eyelid crease to access the levator muscle (the muscle that lifts the eyelid). The length of the muscle is adjusted, and the ptosis surgery is completed. These procedures can typically be performed under local anesthesia.

In severe congenital ptosis cases, the muscle may have little to no function. In such cases, the eyelid is suspended from the forehead muscle (frontalis muscle) to help lift the eyelid. For this suspension procedure, a tendon graft is typically harvested from the leg.