Upper Eyelid Ptosis (Blepharoptosis)

Upper Eyelid Ptosis (Blepharoptosis)

The ultimate guide to causes, anatomy, examination and treatment of upper eyelid ptosis with labelled drawings and tables.

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5 Key Points – Upper Eyelid Ptosis

1. What is Ptosis? Upper Eyelid Ptosis (Blepharoptosis) is defined as a drop in the eyelid 1-2mm below the upper corneal limbus when examined in primary gaze.

2. What is the cause of Ptosis? The commonest cause of ptosis is senile/involutional ptosis due to laxity in the Levator aponeurosis. Other causes can be myogenic, neurological, mechanical.

3. How to examine for Ptosis? The Upper Eyelid Ptosis assessment involves a detailed history, examination and specialist tests. The aim to to determine aetiology, degree of ptosis and Levator function. These factors influence surgical management.

4. What is pseudootosis? Pseudoptosis is an apparent ptosis not caused by an issue related to eyelid elevation. Common causes include brow ptosis and Dermatochalasia.

5. What is the treatment for ptosis? Surgical management is dependent on surgeon’s preference, degree of ptosis and levator function. Options include skin resection, muscle shortening, fat resection, aponeurosis repair.

Definition of Eyelid Ptosis

Ptosis is defined as drooping of the upper eyelid in primary gaze 1-2mm below the upper corneal limbus. It can be congenital or acquired.

The upper eyelid normally rests as 1-2mm below the corneal limbus and is highest just nasal to the pupil​1​. This limbus is the border between the cornea and the sclera, as shown in this labelled diagram. More detail on upper eyelid anatomy available here.

Ptosis is the drooping of the upper eyelid below its normal level of 1-2mm below the upper corneal limbus. This is a labelled drawing.
Anatomy of Ptosis

Other conditions that are similar to Ptosis and should be differentiated include:

  • Apparent ptosis unrelated to deficiency of eyelid elevation but instead a separate orbital issue such as :
  • Brow Ptosis
  • Enophthalmos
  • Orbital Tumours
  • Dermatochalasia (excess eyelid skin)
  • Autosomal dominant condition
  • Congenital small palpebral fissures due to Ptosis, Epicanthal folds, and Telecanthus
  • Excess eyelid skin and laxity of supporting structures
  • Seen in young adults
  • A complication of recurrent and episodic eyelid oedema, usually painless, which is refractory to anti-histamines and steroids.
Less Common:
  • Steatoblepharon: excess or protruding fat through a lax septum
  • Ptosis Adiposa: extreme attenuation of the canthus and septum
  • Pseudoblepharoptosis: eyelid in normal position but appearance of ptosis as a result of a ptotic brow and brow skin.

Causes of Upper Eyelid Ptosis

Ptosis has congenital or acquired causes. Common acquired causes can be classified as myogenic, neurogenic, aponeurotic, mechanical, or traumatic conditions.

Senile/Involutional Ptosis is the most common cause of upper eyelid ptosis. It is caused by the stretching of the Levator aponeurosis and muscle with age. Other common causes of ptosis can be classified as myogenic, neurogenic, and mechanical causes of ptosis. This was first classified by Freuh in 1980​2​ , as illustrated in the table below. It us best understood with a good understanding of upperand lower eyelid anatomy.

Senile/Involution 3rd Nerve Palsy (paralysis Levator muscle)Dermatochalasis
Myaesthenia GravisHorner’s Syndrome (paralyses Müller’s muscle)Upper Lid Tumour
Congenital Levator DystrophyDemyelination (eg MS)Scar
Blepharophimosis SyndromeAnophthalmos
Progressive External Opthalmoplegia

To help determine the exact aetiology of the upper eyelid ptosis, here are some clues which may help in the diagnosis.

Senile/InvolutionalLevator function is usually good 
Myasthenia Gravis Worse in the day
Tensilon test is diagnostic 
Horner’s SyndromeEffects reduced with 10% phenylephrine hydrochloride

Assessment of Upper Eyelid Ptosis

The cause, degree of ptosis and levator function should be established through history, examination, and specific ptosis tests. These 3 factors will guide treatment options for upper eyelid ptosis.

Ptosis History

  • Time: Congenital, Acquired, and Precipitating and Exacerbating events
  • Symptoms: Functional, Aesthetic or both
  • Medical History: Diabetes, Myasthenia Gravis, Grave’s Disease, Coagulopathies, Renal or Cardiac issues that may predispose to edema.
  • Specific Ocular History: Visual Impairment or Correction, glaucoma, excess tearing, dry eyes, Laser Surgery, Contacts
  • Family History
  • Social History: Smoking, Occupation, Home Support

Forehead Examination

Exam LocationNotes
LookFrontalis CreaseSign of effort to keep brows raised
Glabellar CreaseIndicates corrugator hyperactivity
Brow PositionIf ptotic, can cause pseudootosis of the eyelid. 
Feel/MoveCompensated Brow Ptosis Increased Brow ptosis when hyperactive frontalis is immobilised. If present, keep brow in correct position for remainder of examination 

Upper Eyelid Examination

Exam LocationNotes
LookLid position1-2mm below superior limbus 
Globe PositionProptosis, enopthalmos causes pseudoptosis.
Globe Vector​3​Negative vector (anterior cornea is anterior to the orbital rim) is linked to post-op lid malposition. A canthopexy is an option.
Intercanthal Tilt​4​Lateral 2mm superior to medial. Negative tilt linked to lateral canthus pathology. 
Skin Quantity Dermatochalasis causes pseudoptosis & lateral hooding
Fat Quantity Herniation (pseudohernia) or excess pre-septal fat.
Levator dehiscence Higher skin crease with a deeper upper lid sulcus.
Feel/MoveLevator function/excursionThe upper eyelid movement when brow is immobilised (10-15mm).
Bell’s PhenomenonUpward rolling of eye on resisted eyelid closure, suggests the cornea can be protected in the event of lagophthalmos.

Lower Lid Examination

Exam LocationNotes
LookLid position1-2mm below inferior limbus. Scleral show linked to proptosis & poor support. 
SkinRhytids: Redundant Skin 
Pigment: Blepharomelasma
Fat Herniation3 compartments
Festoons Eye closure improvess festoon if caused by ptotic orbicularis. 
Malar Bag Shelving of orbicularis over orbital retaining ligament with excess intra-orbital fat. Correction involves improving lid-cheek junction (Loeb procedure, septal reset, midface lift)
Trough DeformityMedial Concavity at the border of eyelid and cheek due to fat herniation and tight attachment of the orbital septum.
Feel/MovePinch Test/Snap Back If slow to conform to eye it is indicated of tarsal laxity

Additional Tests

Exam HowWhy
Vision Snellen Chart, Fundoscopy, Ocular Movements Baseline assessment 
Tears Production Schirmer Test Filter paper in the inferior fornix should collect >5mm in 5 minutes. Consider if dry-eye symptoms
Müller Muscle Phenylephrine TestIf stimulation of Muller’s muscle restores normal lid position, this suggests suitability for Muller’s muscle shortening.
FatigueLook up for 30 seconds Drop in upper eyelids from fatigue is linked to myasethenia gravis.
Marginal-reflex distance Look at light source 50cm away and measure distance from corneal light reflex to lid<2.5mm is clinically significant ptosis. 

Normal Eyelid Measurements

Normal Eyelid Measurements / Treatment of Upper Eyelid Ptosis with Blepharoplasty.

Normal eyelid measurements have been extensively published. More information on upper eyelid anatomy is available here. The following table provides approximations of upper eyelid measurements​5,6​

Vertical Palpebral Fissure12-14mm
Horizontal Palpebral Fissure28-30mm
Visible Pre-Tarsal Skin3-6mm
Lash line to supra tarsal crease8-10mm
Lateral Canthus1-2mm above medial cants 
Anterior hardline to brow5-6cm
Brow to orbital rim1cm (less in males) 
Brow to midpupil 2.5cm

Treatment of Upper Eyelid Ptosis

Treatment of upper eyelid ptosis is influenced by patient factors, surgical preference, aetiology and examination findings. In particular, the degree of ptosis and Levator function.

The surgical treatment options for upper eyelid ptosis is dependent on both patient and surgeon factors. The goal of a blepharoplasty The following table provides a rough guide to management, which is influence by degree of ptosis and Levator function.

Mild (1-2mm)Good (>10mm)Müller Shortening Fasanella-Servat
Moderate (3-4mm)Good (>10mm)Aponeurosis RepairAnterior or Posterior
Moderate (3-4mm)Fair (5-10mm)Levator resection or advancement Anterior or Posterior
Severe (>4mm)Poor (<5mm)Frontalis Suspension Crawford or Fox


Upper Eyelid Ptosis Bibliography

  1. Finsterer J. Ptosis: causes, presentation, and management. Aesthetic Plast Surg. 2003;27(3):193-204. doi:10.1007/s00266-003-0127-5
  2. Frueh B. The mechanistic classification of ptosis. Ophthalmology. 1980;87(10):1019-1021. doi:10.1016/s0161-6420(80)35135-x
  3. Jelks G, Jelks E. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg. 1991;18(1):183-195. https://www.ncbi.nlm.nih.gov/pubmed/2015744
  4. Jelks G, Jelks E. Preoperative evaluation of the blepharoplasty patient. Bypassing the pitfalls. Clin Plast Surg. 1993;20(2):213-223; discussion 224. https://www.ncbi.nlm.nih.gov/pubmed/8485931
  5. Bartlett S, Wornom I, Whitaker L. Evaluation of facial skeletal aesthetics and surgical planning. Clin Plast Surg. 1991;18(1):1-9. https://www.ncbi.nlm.nih.gov/pubmed/2015737
  6. Farkas L, Kolar J. Anthropometrics and art in the aesthetics of women’s faces. Clin Plast Surg. 1987;14(4):599-616. https://www.ncbi.nlm.nih.gov/pubmed/3652607

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