What Is Blepharoptosis?

What Is Blepharoptosis?

December 12, 2022

Blepharoptosis involves abnormal lowering or drooping of the upper lid due to structural abnormalities (muscular or aponeurotic) or neurogenic problems.

Causes of Blepharoptosis

a graphic giving details about blepharoptosis

There are several categories of ptosis depending on the following:

Age of Onset

Blepharoptosis is most commonly differentiated based on the age of onset (congenital or acquired) and etiologies (myogenic, neurogenic, aponeurotic, or mechanical). In children, isolated congenital ptosis is the most frequent subtype, but aponeurotic involutional ptosis is the most prevalent variety in adults. Congenital ptosis has a myogenic origin and is caused by dysgenesis in the levator palpebrae muscle.


1. Myogenic: A levator muscle dysfunction causes myogenic ptosis or disruption of impulse transmission at the neuromuscular junction (neuromyopathic). Myasthenia gravis, myotonic dystrophy, and progressive external ophthalmoplegia make up acquired myogenic ptosis.

2. Neurogenic

3rd CN palsy contains a classical triad of ptosis, exotropia, and mydriasis. It can manifest in children through viral infections and in adults through ischemic mononeuropathy associated with diabetes mellitus and hypertension.

Horner’s Syndrome is an oculosympathetic palsy characterized by an association of ptosis, anhidrosis, and miosis. It can manifest in both congenital and acquired forms. Acquired forms are preganglionic lesions at the first-order cervical neurons (occlusion of the vertebral artery), second-order thoracic neuron lesions (Pancoast tumor or aortic aneurysm) and third-order neuron lesions in the head and neck region.

Progressive external ophthalmoplegia is characterized by bilateral ptosis and progressive ophthalmoplegia affecting extrinsic muscles of the eye. The underlying mechanism involves progressive mitochondrial myopathy.

Blepharophimosis Syndrome: It has an autosomal dominant inheritance pattern and is characterized by ptosis, epicanthus invertus, and telecanthus.

Marcus Gun Jaw Winking: It is caused by an aberrant connection between the fifth and superior branches of the third cranial nerve fibers, which innervates the levator muscle. It manifests as ptosis that disappears with the movement of the jaw.

Myasthenia Gravis: Myasthenia Gravis presents as variable asymmetrical ptosis with associated diplopia and oculomotor paresis. The symptoms tend to increase at the end of the day and resolve with rest. Ophthalmologists can confirm the diagnosis with the cold test by applying an ice pack to the eyelids for 5 minutes, settling the drooping.

3 Aponeurotic ptosis is the most common acquired ptosis, typically developing after age 60. Detachment, dehiscence, or thinning of the levator aponeurosis causes this condition. A prominent eyelid crease and effective levator muscle activity distinguish aponeurotic ptosis.

4. Mechanical ptosis contains several underlying etiologies, including inflammation, infection, scarring, or tumor. It can also be accompanied by aponeurotic type as the early mechanical ptosis causes aponeurotic detachment causing the development of that type.

Signs and Symptoms of Blepharoptosis

Misaligned eye

Diplopia or double vision

Head Tilting to correct diplopia

Eye Fatigue

Problems in closing the eyes completely

Irritation and dry eyes

How is Blepharoptosis Diagnosed?

Clinical History:


Mode of onset (Sudden or Progressive)

Progression and Variation

Personal, Family, and Ocular history

Old photographs to determine type and progression

Examination Points

1. Gross Vision and retinoscopy

2. Give distant targets to fixate

3. Inspection with torch

Compensatory Head posture

Symmetry of face

Position of globe


Pupils- to check RAPD

4. Measurement with torch and scale

Palpebral Fissure Height

Marginal Reflex Distance

Upper Lid Crease

Levator Muscle Function

Extraocular movements

Check for Lid Lag

Check for Marcus Gunn's jaw wink

Check Bells phenomenon

 Management of Blepharoptosis

Indications:  Indications for ptosis treatment are both functional and esthetic. There is no definite optimal age for surgical intervention. In the absence of amblyopia, surgery can wait until 4-5 years of age (preschool). In neurogenic or traumatic ptosis, a wait of at least 6 to 9 months is advised before surgery.

Cause of ptosis

Severity of ptosis by MRD

Levator function

1. Type of surgery: Depends upon Levator Function and Severity of Ptosis (MRD)

Levator function good (> 10 mm) — Fasanella-Servat procedure/Muller Resection

Levator function moderate (4 to 10 mm) —  Levator resection/Advancement

Levator function poor (< 4 mm) — Brow suspension

Ptosis severe (> 2 mm) — aponeurotic repair  

Ptosis mild (< 2 mm) — Fasanella-Servat (tarsomullerectomy)

2. Follow-up:

1st Post-Op day: Look for hematoma. If there is a risk of exposure, treat it with lubricants.

One week: Remove Sutures

Three weeks: Look for over and under correction

Author: Dr. Muhammad Saad, Resident Ophthalmologist at Al-Shifa Trust Eye Hospital in Rawalpindi, Pakistan