[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Ophthalmology](https://durgical.com/en/ophthalmology/) › [Approach by symptom](https://durgical.com/en/ophthalmology/areas/approach/) › Drooping eyelid (ptosis)

# Drooping eyelid (ptosis)

- Clinical approach

Most drooping lids in older adults are a stretched tendon. A new droop with a big pupil, diplopia or pain, or a baby's lid covering the pupil, is urgent.

Updated Nov 5, 2026

**See it in 3D:** [Eyelids](https://durgical.com/en/anatomy/superior-tarsus/) · [Levator palpebrae](https://durgical.com/en/anatomy/levator-palpebrae-superioris/) · [Oculomotor nerve (III)](https://durgical.com/en/anatomy/oculomotor-nerve/)

## Key points

- Commonest adult ptosis: aponeurotic, with good levator function.
- Ptosis + dilated pupil = third nerve palsy; ptosis + small pupil = Horner.
- Fatigable ptosis improved by ice = myasthenia.
- Child's lid covering the pupil = amblyopia risk.

## What it is

Ptosis is a low upper eyelid. In adults the commonest cause is aponeurotic ptosis, a stretching or detachment of the levator tendon with age, contact lens wear or eye surgery. Other causes are neurological (third nerve palsy, Horner syndrome), neuromuscular (myasthenia gravis, chronic progressive external ophthalmoplegia, myotonic dystrophy), mechanical (a lid mass) and congenital. Pseudoptosis is excess lid skin or retraction of the other lid.

## Red flags

- Ptosis with a dilated pupil or eye-movement palsy: third nerve palsy.
- Mild ptosis with a small pupil and neck pain: Horner syndrome from carotid dissection.
- Fatigable ptosis with diplopia or trouble swallowing or breathing: myasthenia gravis.
- A child whose lid covers the pupil: risk of amblyopia.
- A lid mass or thickening: tumour.

## Step-by-step approach

- Look at both lids: true ptosis, extra skin (dermatochalasis), or retraction of the other lid.
- Measure the distance from the light reflex on the cornea to the upper lid margin.
- Measure levator function: lid excursion from down to up gaze with the brow held still.
- Check the pupils and eye movements.
- Test fatigue: sustained upgaze for a minute, or an ice pack on the lid for two minutes.

## Causes of ptosis

| Cause | Levator function | Clue |
| --- | --- | --- |
| Aponeurotic (age, contact lenses, surgery) | Good | High or absent lid crease, older adult |
| Congenital | Poor | Present from birth, lid lags on looking down |
| [Third nerve palsy](https://durgical.com/en/conditions/oculomotor-nerve-palsy/) | Poor | Eye down and out, often dilated pupil |
| [Horner syndrome](https://durgical.com/en/conditions/horner-syndrome/) | Good | Mild ptosis, small pupil |
| [Myasthenia gravis](https://durgical.com/en/conditions/myasthenia-gravis/) | Variable | Worse late in the day, improves with ice |
| [Mechanical (chalazion, tumour)](https://durgical.com/en/conditions/chalazion-and-hordeolum/) | Normal | Visible or palpable lid mass |

## Keys to the differential

- The ice pack test improves myasthenic ptosis because cold slows the breakdown of acetylcholine.
- Slowly progressive bilateral ptosis with limited eye movements but no diplopia suggests chronic progressive external ophthalmoplegia, a mitochondrial disorder.
- Lifting a ptotic lid can unmask retraction of the other lid (Hering law), changing the surgical plan.

## Next step / Initial management

- Ptosis with pupil involvement or eye-movement palsy: emergency CT or MR angiography.
- Painful ptosis with a small pupil: same-day imaging for carotid dissection.
- Suspected myasthenia: acetylcholine receptor antibodies, chest CT, neurology; emergency if swallowing or breathing are affected.
- Congenital ptosis covering the pupil: urgent paediatric ophthalmology for amblyopia prevention.
- Aponeurotic ptosis that blocks vision: routine oculoplastic referral.

## Test yourself

Think of the answer, then tap the question to see it.

## What is the commonest cause of ptosis in older adults?

Aponeurotic ptosis: stretching or detachment of the levator tendon, with good levator function.

## How does an ice pack help in the diagnosis of ptosis?

Cooling the lid improves ptosis due to myasthenia gravis, because it slows the breakdown of acetylcholine at the junction.

## Why is congenital ptosis covering the pupil urgent?

Because blocking the visual axis during the critical period causes amblyopia.

[Add to my cards (3)](https://durgical.app/estudiar/?add=/en/ophthalmology/drooping-eyelid/)

## Connections

## See it in 3D 3

The structures of Durgical's 3D anatomy where it is found.

- [Eyelids](https://durgical.com/en/anatomy/superior-tarsus/)
- [Levator palpebrae](https://durgical.com/en/anatomy/levator-palpebrae-superioris/)
- [Oculomotor nerve (III)](https://durgical.com/en/anatomy/oculomotor-nerve/)

## Related 4

- [Anisocoria: which pupil is abnormal](https://durgical.com/en/ophthalmology/anisocoria-which-pupil-is-abnormal/)
- [Double vision: monocular or binocular](https://durgical.com/en/ophthalmology/double-vision-monocular-or-binocular/)
- [The orbit, orbital septum and eyelids](https://durgical.com/en/ophthalmology/the-orbit-orbital-septum-and-eyelids/)
- [Amblyopia: the critical period, patching and atropine](https://durgical.com/en/ophthalmology/amblyopia-the-critical-period-patching-and-atropine/)

## Related conditions 4

- [Horner syndrome](https://durgical.com/en/conditions/horner-syndrome/)
- [Myasthenia gravis](https://durgical.com/en/conditions/myasthenia-gravis/)
- [Oculomotor (third) nerve palsy](https://durgical.com/en/conditions/oculomotor-nerve-palsy/)
- [Chalazion and hordeolum (stye)](https://durgical.com/en/conditions/chalazion-and-hordeolum/)

## In Pharmacology 1

- [Pyridostigmine](https://durgical.com/en/pharmacology/pyridostigmine/)

[← All of ophthalmology](https://durgical.com/en/ophthalmology/)

Educational content; not a clinical guideline and no substitute for assessment by a health professional. For sudden visual loss, severe eye pain, a chemical burn or an eye injury, go to an emergency department at once.

Sources: [Blepharoptosis (Ptosis): Classification, Evaluation, and Surgical Management](https://www.ncbi.nlm.nih.gov/books/NBK539828/) (StatPearls Publishing (NCBI Bookshelf), 2026); [Congenital Ptosis](https://www.ncbi.nlm.nih.gov/books/NBK568688/) (StatPearls Publishing (NCBI Bookshelf), 2023); [Myasthenia Gravis](https://www.ncbi.nlm.nih.gov/books/NBK559331/) (StatPearls Publishing (NCBI Bookshelf), 2023).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/ophthalmology/drooping-eyelid/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/ophthalmology/drooping-eyelid/