Aponeurotic Ptosis (Adult onset acquired Ptosis)

General Overview :

Ptosis means falling or drooping of upper or lower eyelid. The drooping can be as a result of being awake for a long time, sometimes also known as “lazy eye” wherein the individual’s ocular muscles are tired. If this drooping is not treated or becomes severe it may lead to conditions such as “amblyopia” (lazy eye) or “astigmatism” (blurring of vision due to inability of the optics of eye to focus). Hence, this problem should be treated in a young age itself, so that it doesn’t worsen in the adulthood in future.

Causes & Risk factors:

Ptosis occurs when the muscles which are responsible for elevating the eyelid (levator & superior tarsal muscle) fail to do so. This is more likely to happen in the elderly people, as with age the muscles of the eyelid tend to lose their strength as a result of which there is deterioration in the movements of eyelids.

Types of Ptosis :

  • Congenital Ptosis – since birth
  • Acquired – age-related

Other causes include :

–      Trauma/damage to the muscle raising eyelid

–      Damage to the Superior cervical sympathetic ganglion

–      Damage to 3rd Cranial Nerve (Oculomotor Nerve)

–      This damage may be due to underlying conditions such as diabetes mellitus, brain tumor, pancoast tumor (tumor in the apex of lung) and diseases resulting in causing weakness of muscles or nerve damage like myasthenia grevis.

–      Exposure to toxins such as Snake venoms especially Black mamba.

Ptosis may be –

  • Myogenic – myasthenia grevis, ocular myopathy, blepharophimosis syndrome etc.
  • Neurogenic – 3rd Nerve palsy
  • Aponeurotic – age-related
  • Mechanical/traumatic

Acquired ptosis is most likely caused due to aponeurotic ptosis. This may happen as a result of dehiscence, senescence, or disinsertion of the levator aponeurosis. Most of the times, post-operative causes are considered to be one of the major causes. Intraocular surgery or chronic inflammation may produce  the same effect. Wearing contact lenses for a long amount of time is said to also cause or aggravate this eye condition.

Also, drugs like opioid derivatives such as oxycodone, hydrocodone, morphine may lead to Ptosis. Abuse of drugs like diacetylmorphine (Heroin) may give rise to droopy eyelids. Pregabalin (Lyrica) is also been found to cause mild drooping of eyelids.

Aponeurotic Ptosis is not an eyelid disease as such. It is characterized by drooping of eyelids associated with aging.

Usually the involvement is bilateral (both the eyes are affected) but one eye may be more droopy than the other. The major cause being gravity & stretching of eyelid tissue that prevents the muscle which lifts the eyelid from functioning normally.

Main Characteristic features of Aponeurotic disinsertion are:

Ptosis with a good levator excursion, absent/raised upper lid skin crease and thinning of upper lid.

Aponeurotic ptosis may also occur as a result of trauma, eyelid edema & ocular surgery. In this case, external eye movements are unaffected, unlike in myogenic ptosis.

The pupillary reactions are normal.

Clinical Management:

-Patient History:

  • Is one or are both the eyes affected?
  • Are there associated symptoms, such as pain, malaise, visual disturbance, diplopia (double vision), dysphagia (difficulty in swallowing) or muscle weakness elsewhere?
  • When did it start? Since how long does it exist? What has been the progression of Ptosis? Are there any evident aggravating and ameliorating factors?
  • Does the patient have any underlying conditions? Especially, are there vascular risk factors, a history of trauma to the neck, head or chest, a history of HIV or other immunosuppressive diseases, features of metabolic syndrome, cancer or ocular disease? Are there any systemic features of giant cell arteritis?
  • Is there a history of trauma, ophthalmic surgery or rubbing of the eyelid? Does the patient wear contact lenses?
  • Has the patient had a blepharoplasty (eye lift surgery) in the past?
  • Is the patient taking any medications, regular or new?
  • Is there a family history of ptosis or of other muscle weakness?


Patients with blepharoptosis should undergo a general systemic and neurological examination. Of particular importance are the pupils, visual acuity and fields, funduscopy, extraocular and facial movements and other cranial nerve function. It is advisable to the patients to have their eyes examined specifically to note inflammatory changes in the anterior chamber.

The eyelids should be examined for symmetry, visible lesions, thickening, any kind of discolouration and involuntary movement. The skin crease position must be taken into consideration. The upper marginal reflex distance, palpebral fissure and eyelid excursion should be measured. The behaviour of the eyelid during eye movements should then be noted as well.

Laboratory investigations:

CT scan or MRI scan of brain to rule out other causes of drooping eyelid such as brain tumors etc.



Aponeurotic blepharoptosis may need surgical correction, if severe enough to produce disturbed vision or if turns to be a cosmetic embarrassment. Treatment depends on the type of ptosis and is generally performed by an ophthalmic plastic and reconstructive surgeon specializing in diseases and problems of the eyelid & structures related to the eye.

Surgical procedures include:

  • Levator resection
  •        Muller Muscleresection
  • Frontalis sling operation

Non-surgical treatment – usage of “crutch” glasses or special type of Scleral contact lenses which provide mechanical support to the eyelid, thus preventing it from drooping.