Droopy eyes refers to drooping of an upper eyelid of one or both eyes. The droop may be barely noticeable, or the lid can descend over the entire pupil. Droopy eyelids can affect both children and adults. In children, it usually occurs before birth, but in adults, the condition usually occurs because of aging. If excess skin of the upper eyelids hangs down to cause visual problems, the condition is called dermatochalasis. If the eyelid itself falls, the condition is called ptosis.
Ptosis is an abnormally low position (drooping) of the upper eyelid and occurs when the muscles that raise the eyelid (levator and Muller’s muscles) are not strong enough to do so properly. It can affect one eye or both eyes and is more common in the elderly, as muscles in the eyelids may begin to deteriorate. The drooping may also be worse after being awake longer, when the eyelid muscles are tired. If severe enough and left untreated, the drooping eyelid can cause other conditions, such as amblyopia or astigmatism. Ptosis can also be congenital, and results from an abnormal formation of the muscle. This leaves the eyelid without normal lifting power.
The workup for ptosis involves taking eyelid photographs, obtaining measurements of the eyelid position, and a visual field test to determine how much peripheral vision is affected by ptosis. Most insurance companies require this information to qualify the condition for payment. Occasionally, other testing may be required if other medical conditions are being considered as a cause for ptosis.
If an underlying medical condition causing ptosis is found, the treatment will be specific to that disease. Most cases of ptosis are associated with aging and there is no disease involved. Surgery can be done to improve the appearance of the eyelids in milder cases if the patient wants it. In more severe cases, surgery may be necessary to correct interference with vision. In children with ptosis, surgery may be necessary to prevent amblyopia (lazy eye). Surgical treatment for children may involve surgery directly on the muscle, or by attaching the eyelid to the eyebrow (frontalis suspension).
Redundant and lax eyelid skin and muscle are known as dermatochalasis. Dermatochalasis is a common finding seen in elderly persons and occasionally in young adults. Gravity, loss of elastic tissue in the skin, and weakening of the connective tissues of the eyelid frequently contribute to this lax and redundant eyelid tissue. These findings are more common in the upper eyelids but can be seen in the lower eyelids as well. Genetic factors and family traits may play a role in some patients.
Dermatochalasis can be a functional or cosmetic problem for the patients. When functional, dermatochalasis frequently obstructs the superior visual field. In addition, patients may note ocular irritation, entropion (turned in position) of the upper eyelid, ectropion (turned out position) of the lower eyelid, eyelash infection, and dermatitis. When cosmetic, patients note a fullness or heaviness of the upper eyelids, “bags” in the lower eyelids, and wrinkles in the lower eyelids and the lateral canthus, both of which contribute to an aged appearance.
The most common visual difficulties encountered include loss of the superior visual field, difficulty in reading, and loss of peripheral vision when driving. In addition, patients with moderate-to-severe dermatochalasis chronically elevate their brows to improve their visual field. This frequently is associated with frontal headaches. Ocular irritation, dry eyes, and dermatitis also may be the presenting signs of dermatochalasis.
The treatment of dermatochalasis usually involves surgery, either cosmetic or functional (medically necessary). If the droopy eyelids block more than 20 – 25 % of the peripheral vision, insurance may pay for the surgery. Medical therapy may be helpful, and involves eye drops or eye ointment to reduce infection, skin irritation, and dry eye problems that may occurs with droopy eyelids. Surgical care involves an office procedure or outpatient surgery. The excess skin is measured and removed, with care taken to avoid removing too much skin. Occasionally, removal of excess fatty tissue may be involved, and this helps improve the contour and appearance of the eyelids.