What Causes Ptosis?

Patient Presentation
An 8-year-old female came to clinic with a 3 day history of painful left eyelid swelling with redness, swelling and one area that was somewhat painful. She denied problems seeing, walking or other activities. She had no eye problems previously. She had noted some crusting on the eyelids after awakening. The review of systems was negative.

The pertinent physical exam showed a well-appearing female with normal vital signs and growth parameters that were 10-25%. Visual acuity was 20:20 by Snellen chart. Extra ocular movements were intact. The left eyelid margin showed one 4-5 mm swelling in the center of the eyelid with an area that pointed outward that was slightly yellowish. There was mild erythema of the swelling and surrounding tissue. She had a notable localized ptosis, that came to the top of the pupil. There were no other lesions noted with eversion of the eyelid. Neurological examination was intact and she had normal head position. The rest of the examination was normal. The diagnosis of a simple external hordeolum was made. The family was instructed to do warm compresses for 15 minutes four times/day. They were to call if the swelling or pain increased, or if changes in vision or generalized symptoms such as fever developed. They were also to call if any neurological symptoms appeared or the hordeolum was not improving in about 3 days.

Ptosis or blepharoptosis is the downward displacement of the upper eyelid. The eyelid aponeurosis, levator muscle and Muller muscle retain the proper position of the upper eyelid. Ptosis can be congenital or acquired. Some causes require immediate attention by an ophthalmologist for proper treatment to preserve eyesight including trauma, uveitis, orbital cellulitis, etc.. Other causes require additional subspecialty assistance such as a cerebrovascular accident, thyroid disease, myasthenia gravis, etc.

Mild ptosis can be a cosmetic problem, but proper function and position of the eyelid is essential to preserve eyesight. Ptosis may decrease the amount of light entering the eye and therefore decrease acuity. Abnormal structural relationships of the globe and eyelid may cause secondary eyelid and other visual problems.

For more information about styes, chalazions and hordeolums, click here.

Learning Point
The differential diagnosis for ptosis includes:

  • Infection
    • Blepharochalsis
    • Conjunctival scarring including trachoma
    • Chalazion
    • Hordeolum
    • Preseptal cellulitis
    • Orbital cellulitis
    • Uveitis
  • Neuromuscular
    • Benign essential blepharospasm
    • Botulism
    • Congenital ptosis
    • Congenital fibrosis syndrome
    • Cerebrovascular accident
    • Horner’s syndrome
    • Oculomotor (Third nerve) palsy
    • Ophthalmoplegic migraine
    • Myotonic dystrophy
    • Myasthenia gravis
    • Multiple sclerosis
  • Pseudooptosis
    • Blepharospasm
    • Contralateral proptosis
    • Lid apraxia
    • Enophthalmosis
    • Hypotropia
    • Microophalmosis
    • Misalignment
  • Trauma
    • Contact lens trauma
    • Eyelid foreign body
    • Eyelid laceration
    • Globe malposition
    • Orbital fracture
    • Previous eye surgery
    • Transection of the levator muscle or aponeurosis
  • Tumor
    • Capillary hemangioma
    • Primary or secondary malignancy
  • Other
    • Blephalophimosis syndrome
    • Drugs – vincristine
    • Genetic syndromes – Noonon, Leigh
    • Fabry disease
    • Marcus Gunn jaw-winking phenomenon
    • Porphyria
    • Thyroid disease

Questions for Further Discussion
1. How would you evaluate a child with ptosis?
2. When can a child’s visual acuity be evaluated in a health supervision visit?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Eyelid Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:197.

Mulvihill A, O’Keefe M. Classification, assessment, and management of childhood ptosis. Ophthalmol Clin North Am. 2001 Sep;14(3):447-55.

Ahmadi AJ, Sires BS. Ptosis in infants and children. Int Ophthalmol Clin. 2002 Spring;42(2):15-29.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:2167,2363.

Sajja K, Putterman AM.Evaluation of Ptosis. ePocrates. Available from the Internet at https://online.epocrates.com/u/29111168/Evaluation+of+ptosis/Differential/Overview (rev. 11/08/2010, cited 5/16/2011).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.


    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital