Ptosis (Blepharoptosis)

Ptosis, also called blepharoptosis, is a condition in which the upper eyelid droops lower than its normal position, partially covering the eye. The word comes from the Greek words for eyelid (blepharon) and falling (ptosis). It can affect one eye or both, and its severity ranges from a barely noticeable droop to a lid that completely blocks the pupil. In most cases, ptosis is an isolated eyelid problem, but it can also be an early or prominent sign of an underlying neurological or muscular condition—which is why a new or sudden droop of the upper eyelid should always be evaluated by a doctor.

Ptosis is among the most commonly seen eyelid disorders in both eye care and general medical practice. Studies suggest it affects between 4.7 and 13.5% of adults, depending on the population studied and the age range included. In children, simple congenital ptosis—the most common form present at birth—occurs in approximately 1 in 842 live births. Ptosis is broadly divided into two categories by when it develops: congenital ptosis, which is present at or shortly after birth, and acquired ptosis, which develops later in life. Acquired ptosis is the more common of the two forms in adults.

Ptosis is classified first by when it develops—congenital (from birth) or acquired (developing later in life), and then by what caused it within each category. Identifying the type guides both the urgency of evaluation and the choice of treatment.

• Simple congenital ptosis: the most common form of ptosis in children, accounting for roughly three-quarters of all childhood cases. It is caused by a developmental problem in the levator palpebrae superioris muscle—the main muscle that lifts the upper eyelid. In affected children, part of this muscle is replaced by fibrous or fatty tissue that does not contract properly. It typically affects one eye, with the left eye more often involved than the right. Because the levator muscle is also responsible for keeping the lid open during downward gaze, children with congenital ptosis often have a lid that paradoxically rises when looking down—a characteristic not seen in acquired ptosis.
• Blepharophimosis-ptosis-epicanthus inversus syndrome (BPES): an inherited syndrome caused by a mutation in the FOXL2 gene, passed down in an autosomal dominant pattern (one copy of the abnormal gene is enough to cause the condition). In addition to drooping upper lids, affected individuals have narrowed eyelid openings, folds of skin running from the lower lid toward the inner corner of each eye (epicanthus inversus), and widely spaced inner eyelid corners (telecanthus). In some families, the syndrome is also associated with premature ovarian failure in women.
• Marcus Gunn jaw-winking syndrome: a form of congenital ptosis in which the drooping eyelid rises involuntarily when the jaw moves—such as during chewing, sucking, or opening the mouth wide. This unusual connection occurs because of an abnormal nerve pathway that links the muscle controlling the eyelid to a branch of the nerve that controls jaw movement. The winking motion can be startling and socially noticeable, particularly in infants during feeding.
• Congenital Horner’s syndrome: caused by disruption of the sympathetic nerve pathway that supplies the eyelid. The classic triad of signs includes a drooping upper lid, a smaller-than-normal pupil on the same side, and reduced sweating on that side of the face. In children with congenital Horner’s syndrome, the iris of the affected eye may be a different color than the other eye—a finding called iris heterochromia.
• Aponeurotic ptosis (involutional ptosis): the most common type of acquired ptosis. The levator aponeurosis—a thin, tendon-like sheet of tissue that connects the levator muscle to the eyelid—stretches, thins, or detaches from the eyelid with aging. This is the form of ptosis that develops gradually over years in older adults. It can also be caused or worsened by long-term contact lens wear, eyelid rubbing, and prior eye surgery.
• Neurogenic ptosis: caused by damage to or disease of the nerves that control eyelid lifting. The two most important causes are third cranial nerve (oculomotor nerve) palsy and Horner’s syndrome. Third nerve palsy causes ptosis alongside other signs, including a large or poorly reactive pupil and difficulty moving the eye—this combination can indicate a life-threatening aneurysm and requires urgent evaluation. Horner’s syndrome causes a milder ptosis alongside a small pupil on the same side and can result from a tumor, stroke, or other lesion along the sympathetic nerve pathway.
• Myogenic ptosis: caused by disease or weakness of the muscles themselves. Myasthenia gravis is the most important cause—an autoimmune disease in which the immune system attacks the connections between nerves and muscles, causing variable, often fatigue-related weakness. Ptosis in myasthenia gravis typically fluctuates, is often worse at the end of the day, and may shift from eye to eye. Other myogenic causes include muscular dystrophies and mitochondrial disorders affecting the eye muscles (chronic progressive external ophthalmoplegia—CPEO).
• Mechanical ptosis: The eyelid is weighed down or physically limited by a growth, swelling, or scarring. Causes include eyelid tumors, large chalazia (blocked meibomian gland cysts), severe eyelid swelling, or scarring from prior inflammation or injury.
• Traumatic ptosis: Develops after injury to the eyelid, including cuts, blunt trauma, or damage during eyelid or orbital surgery.

Ptosis develops when the normal mechanisms that hold the upper eyelid in its raised position are disrupted. The upper eyelid is primarily lifted by the levator palpebrae superioris muscle, controlled by the oculomotor nerve (cranial nerve III). A smaller muscle called Muller’s muscle provides an additional small lift and is controlled by the sympathetic nervous system. When either of these muscles, their tendons, or the nerves supplying them are weakened or damaged, the eyelid droops. The underlying cause determines both the appropriate workup and the best treatment.

The most common cause in adults is aponeurotic—the tendon-like tissue connecting the levator muscle to the lid stretches and thins with aging, gradually reducing the muscle’s ability to lift the lid effectively. In children, the most common cause is a failure of the levator muscle to develop properly before birth. Other important causes include:

• Aging and levator aponeurosis stretching: The connective tissue of the eyelid weakens progressively over decades, leading to the gradual droop most common in adults over 50.
• Contact lens wear: Long-term hard or rigid contact lens use, and the repeated insertion and removal of any contact lens, can stretch and thin the levator aponeurosis over years, causing or worsening ptosis.
• Neurological conditions: These could be damage to the oculomotor nerve (cranial nerve III) from an aneurysm, tumor, or ischemia (loss of blood supply); disruption of the sympathetic nerve pathway from Horner’s syndrome, or neuromuscular junction failure from myasthenia gravis can all cause ptosis.
• Autoimmune disease: Myasthenia gravis, in which the immune system blocks the receptors at the nerve-muscle junction, causes fluctuating, often asymmetric ptosis that worsens with fatigue.
• Inherited and developmental muscle disorders: Muscular dystrophies, mitochondrial myopathies (such as chronic progressive external ophthalmoplegia), and congenital fibrosis of the extraocular muscles all impair levator muscle function from birth or early childhood.
• Eyelid trauma and scarring: Injury to the eyelid, prior surgery, or scarring from infection or inflammation can physically disrupt the levator muscle or its connections.
• Mechanical causes: Eyelid tumors, cysts, or severe swelling can physically weigh the lid down beyond the muscle’s ability to lift it.
• Medication side effects: Certain medicines, including some used to treat psychiatric conditions and some topical eye drops, have been associated with eyelid changes, including ptosis.

Ptosis can develop in people of any age, sex, or background. However, certain factors are associated with a higher likelihood of developing the condition.

• Older age: Aponeurotic ptosis is strongly age-related. Gradual weakening of the levator tendon is one of the most common age-related eyelid changes. Prevalence increases significantly after age 50.
• Long-term contact lens wear: particularly with rigid or hard lenses. The mechanical stress of daily insertion and removal over many years is a recognized risk factor for aponeurotic ptosis in otherwise healthy adults.
• Prior eyelid or eye surgery: Operations on the eyelid, eye socket, or anterior segment of the eye (such as cataract surgery) can stretch, thin, or directly damage the levator aponeurosis.
• Family history of ptosis: Congenital ptosis can run in families, as can BPES and other hereditary muscular and neurological conditions associated with eyelid drooping.
• Autoimmune disease: Having myasthenia gravis or a systemic autoimmune condition raises the risk of neurogenic or myogenic ptosis.
• Neurological conditions: A history of aneurysm, stroke, brain tumor, diabetes (which can cause nerve damage), or Horner’s syndrome increases the risk of neurogenic ptosis.
• Muscular disorders: Hereditary conditions such as muscular dystrophy and mitochondrial myopathy affect the levator muscle and are associated with ptosis, often alongside weakness of other eye movements.
• Chronic eyelid rubbing: Habitual rubbing of the eyelids can stretch and weaken the levator aponeurosis over time.

There is no formal population-wide screening program for ptosis. In infants and young children, congenital ptosis is typically identified by the pediatrician during newborn or well-child exams, or by parents who notice the drooping eyelid at home. Because congenital ptosis can interfere with normal visual development, it is important for parents to report any suspected eyelid droop to a pediatrician or pediatric ophthalmologist promptly—early evaluation is critical to prevent amblyopia (lazy eye) from developing in the affected eye. In older children and adults, ptosis is most often identified during a routine eye examination or when a person seeks care for the drooping itself.

A new or sudden droop of the upper eyelid in an adult—particularly when accompanied by double vision, a large or abnormally small pupil, facial drooping, difficulty swallowing, or other neurological symptoms—should be evaluated as an emergency, as it may signal a brain aneurysm, stroke, or other serious condition. Do not wait for a scheduled appointment if a drooping eyelid appears suddenly alongside any of these symptoms.

Most forms of ptosis cannot be fully prevented because the most common causes—aging and genetic factors—are not modifiable. However, some practical steps may reduce the rate at which aponeurotic ptosis develops in adults:

• Avoid prolonged or excessive eye rubbing: Habitual rubbing stretches and weakens the levator aponeurosis. Treating the underlying cause of the urge to rub (such as allergies or dry eye) reduces this risk.
• Discuss contact lens options with your eye doctor: If you are a long-term contact lens wearer and develop early ptosis, your doctor can advise whether switching lens type or modifying your wear schedule may help slow progression.
• Protect the eyelids from trauma: Wearing appropriate eye protection during sports, construction, and other high-risk activities prevents traumatic ptosis from injury.
• Seek genetic counseling for inherited syndromes: Families with a history of BPES or other hereditary forms of ptosis can benefit from genetic counseling to understand inheritance patterns and the implications for other family members.

The hallmark sign of ptosis is a drooping of the upper eyelid that partially covers the eye. In mild cases, the droop may be subtle—a few millimeters—and noticed only in photographs or by others. In more severe cases, the lid may cover the pupil entirely, blocking the line of sight. The degree of drooping, which eye is affected, whether the condition fluctuates, and what other signs are present are all clues that help doctors identify the underlying cause.

Signs and symptoms of ptosis include:

• A drooping upper eyelid: The lid appears lower than normal on one or both sides. The droop may be constant or may vary with fatigue, time of day, or specific activities.
• Reduced or blocked vision: When the drooping lid covers the pupil, it directly limits the field of sight. In children, even partial obstruction can interfere with visual development.
• Chin elevation and backward head tilt: To see under the drooping lid, many people unconsciously tilt their head back or lift their chin upward. This compensatory posture can cause neck pain and headaches over time.
• Eyebrow raising: The forehead muscles are recruited to help lift the drooping lid, causing the eyebrows to rise higher than normal on the affected side. Over time, this constant effort causes forehead fatigue and can create asymmetric brow lines.
• Eye fatigue and heaviness: The effort of holding a drooping lid up through compensatory muscle use causes tiredness and heaviness around the eyes.
• Dry eye or irritation: When the lid does not close fully due to ptosis, the corneal surface is exposed, leading to dryness, tearing, and irritation.
• Amblyopia (lazy eye) in children: In children with congenital ptosis, a lid that covers the pupil during the critical years of visual development prevents normal stimulation of the retina and visual pathway. The brain progressively stops using the affected eye, causing permanent reduction in vision that cannot be fully corrected with glasses alone if treatment is delayed.
• Fluctuating droop: Ptosis that is worse at the end of the day, after sustained reading or screen use, or that varies from day to day, suggests myasthenia gravis. This fluctuation is a very important distinguishing feature.
• Associated eye movement problems or a large pupil: Ptosis alongside an inability to move the eye normally, or alongside an enlarged, poorly reactive pupil on the same side, is a potential emergency. This combination suggests third cranial nerve palsy, which may be caused by a brain aneurysm and requires immediate evaluation.
• A small pupil on the same side as the droop: Ptosis combined with a smaller-than-normal pupil on the same side (without a large pupil or eye movement abnormality) is characteristic of Horner’s syndrome and warrants investigation for causes along the sympathetic nerve pathway.

An ophthalmologist or oculoplastic surgeon (an ophthalmologist who specializes in the tissues around the eye) evaluates and diagnoses ptosis. Because ptosis can be a sign of serious neurological disease, the diagnostic process goes beyond simply measuring the lid droop—it involves identifying the underlying cause. In children, evaluation by a pediatric ophthalmologist is important to assess the risk to visual development. The following assessments and tests are used:

• Clinical history: The doctor asks when the droop started, whether it came on suddenly or gradually, whether it fluctuates or is constant, whether there are any associated symptoms (double vision, pupil changes, swallowing difficulty, generalized muscle weakness), and whether there is a family history of ptosis or related conditions. This history often points directly to the likely cause.
• External photograph review: Photographs of the patient’s eyes from earlier in life—even an old driver’s license or passport photo—can show when the droop began and how much it has progressed, which helps determine the type.
• Margin-reflex distance 1 (MRD1) measurement: The doctor shines a penlight at the eye and measures the distance from the center of the pupil’s light reflex to the upper eyelid margin. A normal measurement is approximately 4 to 5 millimeters. This is the primary objective measure of the degree of ptosis.
• Levator function testing: The doctor holds the brow to prevent forehead muscle compensation, then measures how far the upper eyelid travels from full downward gaze to full upward gaze. This movement reflects the strength and excursion of the levator muscle and is critical for choosing the right surgical approach.
• Pupil examination: Both pupils are examined carefully for any size difference (anisocoria) and for their reaction to light and near focus. A large, poorly reactive pupil on the ptotic side raises concern for third nerve palsy. A small pupil on the ptotic side suggests Horner’s syndrome.
• Ocular motility testing: The doctor assesses movement of the eye in all directions to detect limited or abnormal eye movement that may indicate neurological or muscular disease.
• Ice test: A bag of ice is placed over the closed eyelid for two minutes. In myasthenia gravis, cooling temporarily improves neuromuscular transmission, and the lid will noticeably rise after the test. A significant improvement strongly suggests myasthenia gravis.
• Blood tests: If myasthenia gravis is suspected, blood tests for acetylcholine receptor antibodies and anti-MuSK antibodies are ordered. Thyroid function tests may also be relevant in some cases.
• Neuroimaging: When neurogenic ptosis is suspected—particularly when the presentation could represent an aneurysm, tumor, or stroke—urgent computed tomography (CT) scans or magnetic resonance imaging (MRI) of the brain and blood vessels is performed. CT angiography (CTA) or MR angiography (MRA) is used to examine the blood vessels supplying the brain when an aneurysm is a concern.
• Pharmacological testing for Horner’s syndrome: Eye drops (apraclonidine or cocaine) are used to confirm Horner’s syndrome and help identify where along the sympathetic nerve pathway the disruption has occurred.

Treatment for ptosis depends on the type, the underlying cause, and how severely the drooping is affecting vision, comfort, and daily function. Not every case of ptosis requires immediate treatment—mild ptosis in an adult that is not affecting vision or quality of life may be safely observed. However, ptosis that causes vision blockage, amblyopia risk in a child, significant compensatory head posture, or is caused by an underlying serious condition requires timely intervention. Your doctor will recommend a treatment approach based on all of these factors.

When ptosis is caused by a treatable underlying condition, addressing that condition is the first priority. Myasthenia gravis is managed with medicines that improve neuromuscular transmission—pyridostigmine (Mestinon®) is the most commonly used symptomatic treatment, and immunosuppressive medicines (including steroids and steroid-sparing agents) or intravenous immunoglobulin are used for more severe disease. Thyroid eye disease, when it contributes to mechanical ptosis from swelling, is managed in coordination with an endocrinologist. Ptosis caused by a brain aneurysm or tumor requires urgent neurological and neurosurgical management.

For most patients, the definitive treatment for ptosis is surgery. The specific surgical procedure depends on the degree of ptosis and, most importantly, the strength of the levator muscle as measured during the preoperative examination. When levator function is good to excellent, the surgeon tightens or advances the levator aponeurosis—the tendon-like structure connecting the levator muscle to the eyelid—through an incision in the eyelid crease. This is called levator advancement or levator repair and is the most commonly performed operation for aponeurotic ptosis in adults. When levator function is very poor—as in severe congenital ptosis where the levator muscle did not develop properly—the eyelid is suspended from the brow using a sling made from the patient’s own fascia (a tough connective tissue taken from the thigh, called frontalis suspension with autogenous fascia lata) or a synthetic material. This allows the forehead muscles to take over the lifting function. In children, the timing of ptosis surgery is dictated by visual development risk—if the drooping lid is blocking the pupil or causing significant astigmatism, surgery should not be delayed to avoid amblyopia. After surgery, vision therapy (patching of the better eye) may be needed to stimulate the amblyopic eye. A nonsurgical option is available for mild acquired ptosis: oxymetazoline hydrochloride 0.1% ophthalmic solution (Upneeq®) was U.S. Food and Drug Administration (FDA)-approved in 2020 as the first prescription eye drop for acquired ptosis in adults. Applied once daily, it stimulates Müller’s muscle—the smaller sympathetically controlled eyelid muscle—to partially lift the lid. It provides a modest improvement in lid position and is useful for patients with mild ptosis who prefer to avoid or delay surgery, or for whom surgery carries higher risk. It does not treat the underlying cause and its effect lasts only while the drop is active.

For most adults with aponeurotic ptosis, surgical repair is straightforward and highly effective, with most patients achieving a symmetric, natural-looking lid position and relief of any visual obstruction. Recovery from eyelid surgery typically takes one to two weeks for the initial swelling and bruising to subside, with the final position assessed at six to eight weeks postoperatively. For children with congenital ptosis, successful surgery and any needed vision therapy during the early years of life can allow completely normal visual development and long-term visual function. Living with ptosis while awaiting treatment—or in mild cases that are being observed—involves practical adaptations such as positioning screens and reading material lower to reduce the need to tilt the head, and using artificial tears if dry eye from incomplete lid closure is a problem. If you have ptosis caused by a systemic condition such as myasthenia gravis, working closely with your neurologist and ophthalmologist together gives you the best chance of managing both the underlying disease and its effects on your eyes. Do not hesitate to tell your care team if your droop worsens suddenly, if new eye movement problems or pupil changes develop, or if vision becomes blocked—these changes warrant prompt reassessment.

To further your understanding of your diagnosis and to contribute to cutting-edge research, consider participating in a clinical trial so clinicians and scientists can learn more about causes, symptoms, treatment, and prevention of ptosis and related disorders. Clinical research uses human volunteers to help researchers learn more about a disorder and perhaps find better ways to safely detect, treat, or prevent disease.

All types of volunteers are needed—those who are healthy or may have an illness or disease—of all different ages, sexes, races, and ethnicities to ensure that study results apply to as many people as possible, and that treatments will be safe and effective for everyone who will use them.

To learn more about clinical trials and find studies that may be right for you, visit National Institutes of Health (NIH) Clinical Research Trials and You and ClinicalTrials.gov to search active studies by condition, location, and age group.