What Is Ptosis and Why Does It Happen?
Ptosis is when your upper eyelid droops low enough to cover part of your eye. It can happen in one or both eyes, and it’s not just a cosmetic issue. If your eyelid is blocking your vision, you might find yourself constantly raising your eyebrows or tilting your head back just to see clearly. That’s eye strain right there-and it’s not normal.
The most common cause? Aging. As you get older, the muscle that lifts your eyelid (the levator) stretches and weakens. This is called involutional ptosis, and it’s why about 5% of adults over 70 deal with it. But it’s not only older people. Some are born with it-congenital ptosis-because the muscle didn’t develop properly. Others develop it after trauma, nerve damage, or even long-term contact lens use, which can irritate the eyelid over time.
Doctors measure ptosis using something called the margin reflex distance, or MRD. A normal MRD is 4 to 5 millimeters. If it drops below 2mm, that’s moderate ptosis. Below 3mm? That’s severe. You don’t need fancy tools to notice it: if your eyelid is covering even a little of your pupil, it’s time to get it checked.
Entropion: When Your Eyelid Turns Inward
Entropion is the opposite problem. Instead of drooping down, your eyelid rolls inward. This is most common in the lower lid, and it’s painful. Your eyelashes start rubbing against your eyeball like sandpaper. That leads to redness, tearing, mucus buildup, and a constant feeling that something’s stuck in your eye.
The biggest culprit? Age. Around 80% of entropion cases in Western countries are involutional-meaning they happen because the eyelid’s supporting structures loosen and weaken over time. But scarring from past infections, burns, or surgeries can also cause it. In places with poor sanitation, trachoma (a bacterial infection from Chlamydia trachomatis) is a leading cause. Left untreated, entropion can scratch your cornea, leading to ulcers and even permanent vision loss.
There are four types: involutional (most common), cicatricial (from scarring), spastic (temporary, caused by inflammation), and congenital (rare). If you’re over 60 and your lower lid keeps turning in, this is likely what’s going on. And yes, it gets worse with time.
How Are These Conditions Diagnosed?
It starts with a simple exam. Your eye doctor will look at how your eyelids move, check your vision, and test your cornea for scratches. They might use a phenylephrine drop to see if your eyelid lifts better after stimulation-that helps decide if you’re a candidate for a specific surgery.
For entropion, they’ll check how tightly your eyelid holds against your eye. If it’s loose, that’s a sign of muscle weakness. For ptosis, they’ll measure the eyelid’s position relative to your pupil and test how well the levator muscle works. If you have blepharitis (crusty, inflamed eyelids), they’ll look for that too-it often shows up alongside both conditions.
High-resolution imaging is now used in many clinics to map out the exact structure of your eyelid before surgery. This helps surgeons plan precisely, especially if you’ve had previous eyelid surgery or scarring.
Surgical Repair for Ptosis: What’s Involved
If your ptosis is affecting your vision or quality of life, surgery is usually the fix. The goal? Tighten the muscle that lifts your eyelid. But the method depends on how strong that muscle still is.
For moderate to severe ptosis with decent muscle function (more than 4mm of movement), a levator resection is common. The surgeon shortens the muscle to give it more pull. Success rates? Around 90%.
If your levator muscle is very weak-common in congenital cases-you’ll need a frontalis sling. This connects your eyelid to your forehead muscle so you can lift your eyelid by raising your eyebrows. It’s not perfect-you might not blink fully afterward-but it restores vision.
For mild ptosis, especially if your eyelid lifts well after phenylephrine, a Müller’s muscle-conjunctival resection might be done. It’s less invasive, done from inside the eyelid, and recovery is faster.
Newer techniques like adjustable sutures (introduced in 2018) let surgeons fine-tune the eyelid height the day after surgery. That cuts down on revision surgeries by about 25%.
Fixing Entropion: Surgical Options
Entropion rarely gets better on its own. Eye drops and taping can help temporarily, but surgery is almost always needed.
For involutional entropion (the most common type), the tarsal fracture procedure is the gold standard. The surgeon makes a small cut, rotates the eyelid back into place, and tightens the tendons. Success rates? 90-95%.
If scarring is the cause-say, from an old burn or trachoma-you’ll need a tarsal wedge resection. That means removing a small piece of scarred tissue and stitching the lid back together.
For a quick fix, the Quickert suture technique uses stitches to pull the lid outward. It’s temporary-only about 60-70% effective long-term-but useful for people who aren’t good surgical candidates yet.
Minimally invasive methods using absorbable sutures are now common. Recovery used to take 4-6 weeks. Now, most people are back to normal in 1-2 weeks.
What About Blepharitis and Other Related Problems?
You can’t talk about eyelid disorders without mentioning blepharitis. It’s not a malposition like ptosis or entropion, but it’s often the root cause. Blepharitis means your eyelid margins are inflamed-crusty, red, itchy. It’s caused by clogged oil glands (posterior blepharitis) or bacteria.
Chronic blepharitis can lead to trichiasis, where eyelashes grow inward and scratch your eye. That’s a big reason why entropion gets worse over time. Treatment? Daily warm compresses, lid scrubs, and sometimes antibiotics. It’s not a one-time fix-you need to keep doing it for life.
Also watch for ocular rosacea. It’s often missed, but it causes burning, blurred vision, and swollen lids. It’s linked to both blepharitis and eyelid malpositions. If you’ve had rosacea on your face, your eyes might be affected too.
When Should You See a Doctor?
Don’t wait. If your eyelid suddenly droops or turns inward, get checked immediately. Rapid changes can signal nerve problems or even tumors.
Also seek help if you have:
- Constant eye pain or redness
- Blurred vision that doesn’t improve with blinking
- Corneal abrasions (feeling like sand in your eye)
- Signs of infection: pus, swelling, fever
Even if it’s slow, don’t ignore it. The longer entropion goes untreated, the more damage it does to your cornea. And ptosis can make you fatigued from straining to see.
What to Expect After Surgery
Recovery is usually quick. You’ll have swelling and bruising for a week or two. Cold compresses help. You’ll need to avoid heavy lifting, bending, or rubbing your eyes for at least a week.
Most people go back to normal activities in 7-10 days. But full healing takes 6-8 weeks. You might notice slight asymmetry at first-that’s normal. Surgeons aim for balance, but perfect symmetry isn’t always possible.
Complications? Yes, but rare. Overcorrection (eyelid too high) happens in 5-10% of ptosis cases. Undercorrection (still droopy) in 3-8%. Dry eye is common after surgery-about 1 in 5 people need artificial tears for a while. For entropion, recurrence is 5-15%, especially if the cause is scarring.
Who’s at Risk?
Age is the biggest factor. But other things raise your risk:
- Wearing contact lenses for more than 10 years (30% higher risk for ptosis)
- Previous eyelid surgery (40-60% higher risk for entropion)
- Chronic eye inflammation or dry eye
- Family history of eyelid disorders
- Living in areas with poor sanitation (higher trachoma risk)
If you’re over 60 and have any of these, get your eyelids checked every year. Prevention is easier than repair.
The Bigger Picture: Why This Matters Now
The global market for eyelid surgery is growing fast-projected to hit $2.7 billion by 2028. Why? Because people are living longer. More older adults mean more cases of ptosis and entropion.
And it’s not just about vision. It’s about safety. Drooping lids make it harder to see steps, curbs, or oncoming cars. Inward-turning lashes cause constant discomfort, making people avoid reading, driving, or even socializing.
These aren’t minor issues. They’re quality-of-life problems that modern medicine can fix-safely, effectively, and often with a single outpatient procedure.
What You Can Do Today
Start with simple care:
- Use warm compresses daily if your lids feel crusty
- Wash your eyelids with baby shampoo and water every night
- Use preservative-free artificial tears if your eyes feel dry
- Stop rubbing your eyes-even if they itch
- See an eye doctor if you notice changes in your eyelid position
Don’t assume it’s just aging. If your eyelids are changing, they’re sending you a signal. Listen to them.
