Acquired Ptosis

Part of our complete guide to Ptosis (Droopy Eyelid) — this page covers acquired (age-related) ptosis in depth.

Acquired Ptosis

Most adult ptosis is aponeurotic — the levator muscle is intact and still strong, but the fibrous aponeurosis (tendon) that transmits the muscle’s pull to the tarsus has stretched, thinned, or detached. The lid sits low not because of muscle weakness but because the mechanical connection is lost.

Common Causes

• Aging: the most common cause by far — the aponeurosis disinserts from the tarsus gradually over decades. Levator function typically remains excellent (≥ 10 mm)
• Long-term contact lens wear: repeated mechanical trauma from lens insertion and removal stretches the aponeurosis; a common cause in younger adults
• Prior intraocular surgery: lid speculum use during cataract surgery is a well-recognized precipitant
• Chronic eye rubbing or inflammation: repeated lid traction weakens the aponeurosis over time
• Myasthenia gravis: a neuromuscular disorder producing variable, fatigable ptosis that characteristically worsens as the day progresses — must be excluded before planning surgery
• Third nerve (CN III) palsy: can cause ptosis (often marked) and impaired eye movements; when the pupil is dilated and poorly reactive (pupil-involving form), it is a neurological emergency requiring urgent imaging, though pupil-sparing forms also occur

Clinical Examples

Examples of acquired ptosis — note the low upper-eyelid margin and the raised (high) eyelid crease.

Treatment of Acquired Ptosis

Because the levator muscle itself is usually strong in aponeurotic ptosis, repair simply re-attaches or tightens its stretched tendon. The approach is guided by the phenylephrine response:

• External — levator advancement: through a hidden upper-lid-crease incision, the levator aponeurosis is re-secured to the tarsus. The most common and versatile repair, and the one that allows excess skin to be removed at the same time.
• Internal — Müller’s muscle–conjunctival resection (MMCR): done from the back of the lid with no skin incision; ideal for mild ptosis with a positive phenylephrine test.
• Upneeq® drops: a once-daily, non-surgical, temporary lift (typically about 1 mm, up to ~2 mm) for mild cases or patients avoiding surgery.