Leah Mangham
Introduction
Ptosis is a common eyelid complaint, encountered across a range of specialties, including general practice, emergency medicine and neurology, and whilst often benign, ptosis may be the presenting feature of underlying neurological disease. This article provides a comprehensive overview of ptosis, including anatomy, assessment, key differentials, red flags and management principles.
Anatomy of the eyelid
The upper eyelid is anatomically divided into anterior and posterior lamellae, which provide structural support, facilitate eyelid movement, and protect the ocular surface. Table 1 summarises the key anatomical structures involved in upper eyelid elevation and closure.
| Structure | Function | Innervation |
| Levator palpebrae superioris (LPS) | Primary elevator of the upper eyelid (voluntary) | Superior division of the Oculomotor nerve (CN III) |
| Levator aponeurosis | Transmits force from LPS to tarsal plate | Not directly innervated |
| Superior tarsal muscle (Müller’s muscle) | Provides approximately 2mm of additional elevation | Sympathetic fibres from superior cervical ganglion |
| Tarsal plate | Structural support maintaining eyelid shape and rigidity | Not directly innervated |
| Orbicularis oculi | Closure of eyelid | Facial nerve (CN VII) |
| Skin and subcutaneous tissue | Allows eyelid mobility and protects underlying structures. | Sensory innervation via Ophthalmic division of Trigeminal nerve (CN V1) |
Clinical presentation
Ptosis presents as unilateral or bilateral drooping of the upper eyelid and can have an acute or gradual onset. In addition to eyelid drooping, patients may report a fatigued appearance, blurred vision and epiphora (1). Compensatory features such as brow elevation and forehead creases may also be seen due to frontalis muscle overactivity.
The impact of ptosis extends beyond its physical appearance and can significantly affect quality of life, particularly when the visual axis is obstructed. Patients have reported difficulty in activities such as driving and reading, and may also experience brow strain and tension headaches (1) secondary to compensatory frontalis contraction.
Furthermore, ptosis has been associated with increased psychosocial burden, including reduced self-confidence, concerns regarding self-image and perceived external judgement (2,3), and higher rates of mental health disorders (4). In milder cases, ptosis can be subtle and asymptomatic, with eyelid asymmetry often first noticed by others or identified incidentally in photographs.
Red flags
Ptosis associated with diplopia, ophthalmoplegia or pupillary involvement should raise concern for third nerve palsy. A painful ptosis, particularly with a dilated pupil, is concerning for a compressive lesion. Fluctuating or fatigable ptosis, especially with bulbar symptoms or diurnal variation, is suggestive of myasthenia gravis. Horner’s syndrome should be considered if ptosis is accompanied by anisocoria. These features should be investigated urgently (5).
Causes
True ptosis results from impaired function of the eyelid elevating mechanism and can be broadly classified as congenital or acquired (5). Table 2 summarises the important aetiologies that should be considered.
| Category | Subtype | Examples |
| Congenital | – | Levator palpebrae superioris dysgenesis |
| Acquired | Involutional | Levator aponeurosis dehiscence (age – related; most common) |
| Neurogenic | Third nerve palsy, Horner syndrome | |
| Myogenic | Myasthenia gravis, myopathies | |
| Mechanical | Eyelid tumours, chalazia, scarring | |
| Traumatic | Levator muscle or aponeurotic injury |
Clinical assessment and investigation
Assessment should include measurement of eyelid position using the palpebral fissure height and marginal reflex distance 1 (MRD1), alongside a full ocular examination to assess visual acuity, pupillary responses and extraocular motility (6).
Pseudoptosis should be excluded, as the eyelid can appear drooped despite normal function of the eyelid elevating muscles. Examination of eyelid and periocular structures can identify causes such as dermatochalasis, brow ptosis, enophthalmos, or contralateral lid retraction. Further investigations, including neurovascular imaging or serological testing, should be guided by clinical findings (5).
Management
Management of ptosis is guided by the underlying cause, severity, degree of functional impairment, and residual levator function (1). Patients with mild, stable ptosis that does not impair vision can be managed conservatively with observation (5). Secondary causes should be treated appropriately, including medical therapy for myasthenia gravis and urgent management of neurogenic pathology.
Surgical correction remains the mainstay of treatment for symptomatic ptosis and is guided by the degree of ptosis and residual levator function (1). Surgical options include levator advancement and frontalis sling procedures. Patients report significant improvements in visual function, quality of life, and overall wellbeing following ptosis surgery (7).
References
1. Finsterer, J. Ptosis: Causes, presentation, and management. Aesthetic Plast Surg.
2003;27(3):193-204.
2. Richards HS, Jenkinson E, Rumsey N, White P, Garrott H, Herbert H, Kalapesi F, Harrad RA. The psychological well-being and appearance concerns of patients presenting with ptosis. Eye (Lond). 2014 Mar;28(3):296-302.
3. Warwar RE, Bullock JD, Markert RJ, Marciniszyn SL, Bienenfeld DG. Social implications of blepharoptosis and dermatochalasis. Ophthalmic Plast Reconstr Surg. 2001 Jul;17(4):234-40.
4. Shah J, Lin M, Schmuter G, Kovacs KD, Godfrey KJ. Association of Ptosis with Mental Health Conditions in Adults from a Large United States Research Database. Complex Psychiatry. 2025 Jun 10;11(1):94-98.
5. Koka K, Zeppieri M, Vadeo A, et al. Blepharoptosis (Ptosis): Classification, Evaluation, and Surgical Management. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539828/
6. Morris CL, Chesnutt DA. Acquired ptosis: evaluation and management. EyeNet Magazine. 2020;24(6):18-20. Available from: https://www.aao.org/eyenet/article/acquired-ptosis-evaluation- management
7. Richards HS, Jenkinson E, White P, Harrad RA. Patient reported psychosocial functioning following successful ptosis surgery. Eye (Lond). 2022 Aug;36(8):1651-1655.