If your eyelids droop, chances are you simply chalk it up to aging. But that could be a mistake.

What most people don’t realize: Even though drooping upper eyelids are most often caused by excess skin and fat that accumulate and sag with age, an underlying medical condition—sometimes serious—can be to blame.

Finding the real cause

An open upper eyelid edge normally sits 4 mm to 5 mm above the center of the pupil. When the eyelid sags below that level, it is known as ptosis (pronounced “toe-sis” and derived from the Greek word for “falling”).

Besides drooping, ptosis can blur or impair sight by physically obscuring your field of vision. Men and women of all races and ethnicities are affected equally. Among the most common causes of eyelid ptosis…

Muscle slippage. The levator, a muscle in the upper eyelid that helps hold the lid open, often begins to slip from its original connection in one’s 50s or 60s, resulting in a droopy appearance to one or both eyelids. But age alone isn’t the only factor.

The contact lens link: Muscle slippage of the eyelid is up to 20 times more common in contact lens wearers…of any age. Inserting and removing contacts requires chronic eyelid manipulation that can cause levator detachment.

What helps contact wearers: Use of a DMV suction-cup device to reduce levator manipulation. This device gently adheres to the contact lens and can facilitate insertion and removal of the lens, reducing the amount of wear and tear on the eyelid. Wearing clean lenses with a thin, smooth edge may help, too.

Excessive eye rubbing also may contribute to this form of ptosis.

What to do: Visit an oculoplastic surgeon, an ophthalmologist specializing in eyelid repair. This physician will do a visual field test, in which you look through a special machine with one eye patched and the other eyelid carefully taped up so vision is ­unobscured.

If taping significantly improves vision, insurance often pays for corrective surgery. If the drooping doesn’t disrupt your vision, expect to pay from $1,000 to $5,000 out of pocket (per eye) to correct it. Note: The same test is used to determine whether vision is obscured by excess eyelid skin (mentioned earlier). If this condition obscures vision and vision improves with removal, insurance typically covers surgery for this, too.

Corrective surgery is performed under conscious sedation by an oculoplastic surgeon or sometimes a facial plastic surgeon. You can expect some bruising and swelling for up to two weeks. As with all surgery, there are risks. It is possible that the eyelids do not end up in the desired location—they can be higher (or lower) than you wanted. Other risks include infection, scarring or, in rare cases, vision loss.

Botox. Drooping eyelids can be caused by Botulinum toxin type A (often sold under the brand name ­Botox), which is widely used to paralyze facial muscles to reduce and improve wrinkling and to treat migraine.

In 4% to 10% of patients who receive Botox for wrinkles, when the injection is given into the forehead, around the eyes or in the “frown lines” between the eyes, it migrates to the surrounding areas, including the upper eyelids. The drooping usually starts about three to seven days after the injection, occurring in one or both eyelids. This is also a risk when Botox is given for migraine.

Warning: Botox-induced drooping eyelid tends to occur when a less experienced practitioner is administering the injection. With an experienced practitioner, expect it to occur less than 1% of the time.

What to do: If you develop eyelid drooping in the week following facial Botox, tell your doctor. He/she may prescribe thrice-daily eyedrops containing 0.5% apraclonidine (Iopidine) until the drooping subsides. This medication, which is commonly used to treat glaucoma, stimulates the eyelid muscle to open. Even without treatment, most of these cases resolve within three to four weeks.

Horner syndrome. With sudden drooping of just one eyelid, a neurologic condition called Horner syndrome (HS) may be suspected. It has three main symptoms—drooping of an upper eyelid…a small pupil only in the affected eye…and lack of sweating on the affected side of the face.

Other symptoms may include eye or neck pain…and “upside-down” ptosis in the affected eye, meaning that the lower lid rises up slightly.

Any sort of interruption in the nerve fibers that travel from the brain to the face and eyes can lead to HS—such as a tumor (in the brain or lung, for example)…or a spontaneous or ­trauma-induced tear of the carotid artery, one of the main arteries to the brain.

What to do: If you suddenly experience one-sided eyelid drooping and a small pupil in that eye, go to the emergency room…or to your ophthalmologist if you can be seen immediately. Your doctor will use apraclonidine eyedrops to test your pupils for reactivity—in healthy eyes, the pupil will not dilate when exposed to apraclonidine, but in HS, the affected pupil will ­dilate. The majority of HS patients with eyelid drooping will not improve on their own—surgery is needed to raise the eyelid.

A head-and-neck MRI also may be ordered to look for blood vessel tears. If a tear is identified, treatment may range from aspirin (to prevent blood clots) to surgery to fix the tear, depending on its severity. If no obvious cause is found but eyedrops confirm HS, it is considered idiopathic (no known cause).

Important: If you’re experiencing sharp, one-sided head, face or neck pain in addition to eyelid drooping, call 911—that suggests a carotid artery tear, which can lead to a stroke if not treated immediately. Carotid tears, called carotid artery dissections, are rare. They can happen at any age but tend to occur in those under age 50.

Myasthenia Gravis (MG). This rare autoimmune disorder disrupts communication between nerves and muscles, resulting in muscle weakness that often affects chewing, swallowing and walking. Most people with MG also experience eyelid ptosis and double vision. In fact, more than half of all MG cases involve only ocular features.

Ptosis from MG tends to affect both eyes…can change moment to moment…and worsens as the day progresses. Men who are in their 60s and older are at highest risk…for women, MG usually occurs under age 40.

What to do: See your primary care physician for a physical and neurological examination to check for issues with eye movements, overall muscle strength, coordination and more. You may be referred to a neurologist who can order several tests, including a blood test used to help confirm MG.

The drug pyridostigmine (Mestinon) can improve MG symptoms by increasing communication between nerves and muscles. Oral prednisone may help by suppressing the immune response.


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