Ptosis is the excessive drooping of one or both upper eyelids, which can be constant, progressive, or intermittent, and unilateral or bilateral. Severity ranges from mild (covering part of the iris) to complete eyelid closure. Severe cases may impair vision and affect head posture (forehead furrowing or head tilting).

Classification

• Congenital: Levator muscle underdevelopment or third cranial (oculomotor) nerve disorders

• Acquired: Trauma, inflammation, systemic disease, drugs, intracranial lesions, aneurysms, or senile changes

• Senile Ptosis: Most common cause in older adults due to decreased muscle elasticity

Pathophysiology

• Neuromuscular: Weakness or dysfunction of the levator palpebrae superioris or superior tarsal (Müller’s) muscle reduces eyelid elevation.

• Neurologic: Oculomotor (cranial nerve III) compression or injury impairs innervation to levator muscles.

• Neuromuscular Junction Disorders: Myasthenia gravis impairs acetylcholine-mediated signaling at the neuromuscular junction, causing fatigable ptosis.

• Structural: Trauma, tumors, or congenital muscle dysplasia can mechanically or anatomically restrict eyelid movement.

• Toxic/Metabolic: Drugs (vinca alkaloids) or lead poisoning interfere with neuromuscular function.

History and Physical Examination

History

• Onset and progression (sudden or gradual)

• Trauma history

• Vision changes (diplopia, blurred vision)

• Headaches or eye pain

• Drug exposure, especially chemotherapy or neurotoxins

Examination

• Degree of ptosis (mild, moderate, severe)

• Eyelid edema, exophthalmos, deviation, conjunctival injection

• Extraocular muscle function (six cardinal fields of gaze)

• Pupillary size, shape, reactivity

• Visual acuity assessment

• Signs of systemic disease or neurologic deficit

Medical causes

Other Causes

• Drugs: Vinca alkaloids

• Lead poisoning: Gradual ptosis over months with systemic signs (GI upset, neurological deficits)

Special Considerations

• Ensure patient orientation and safety if visual acuity is reduced

• Provide special spectacle frames with eyelid traction for temporary support

• Prepare for diagnostic tests: Tensilon test, slit-lamp examination

• Surgery for levator dysfunction may be indicated; explain procedure and risks

Patient Counseling

• Explain underlying cause, diagnostic tests, and treatment options

• Discuss self-esteem and functional impact

• Provide guidance on visual adaptation and safety

Pediatric Pointers

• Congenital ptosis often unilateral and detected in infancy

• Associated with astigmatism or myopia

• Teach proper eye care to prevent exposure keratopathy in infants with lagophthalmos

References

1. Biswas J, Krishnakumar S, Ahuja S. Manual of ocular pathology. New Delhi, India: Jaypee—Highlights Medical Publishers; 2010.

2. Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.

3. Levin LA, Albert DM. Ocular disease: Mechanisms and management. London, UK: Saunders, Elsevier; 2010.

4. Roy FH. Ocular differential diagnosis. Clayton, Panama: Jaypee—Highlights Medical Publishers, Inc.; 2012.