Topical Review: An Update of Diagnostic and Management Algorithms for Acquired Blepharoptosis : Optometry and Vision Science

Secondary Logo

Journal Logo


Topical Review: An Update of Diagnostic and Management Algorithms for Acquired Blepharoptosis

Nichols, Kelly K. OD, MPH, PhD, FAAO1∗; Malloy, Kelly A. OD, FAAO2; Karpecki, Paul M. OD, FAAO3; Bacharach, Jason MD4; Douglas, Raymond S. MD, PhD5,6; Foster, Shane OD7; Gromacki, Susan J. OD, MS, FAAO8; Whitley, Walter O. OD, MBA, FAAO9

Author Information
Optometry and Vision Science 99(3):p 230-240, March 2022. | DOI: 10.1097/OPX.0000000000001868
  • Open



Blepharoptosis (ptosis), defined as a drooping of the upper eyelid observed with the eye in primary gaze,1,2 is a common condition that can be congenital or acquired and varies in its timing of onset, duration, severity, laterality, and underlying etiology.1,3–5 Acquired ptosis is most often caused by a progressive, age-related stretching, dehiscence, or detachment of the levator muscle complex (levator palpebrae superioris and levator aponeurosis) known as aponeurotic ptosis.6 Underlying etiology can also be myogenic (due to myopathy of the levator muscle), neurogenic (due to central mechanisms or dysfunction of the third cranial nerve or sympathetic nerves that innervate the eyelid muscles), mechanical (due to, for example, lesions putting excess weight on the eyelid), and traumatic (which can have myogenic, neurogenic, or mechanical features).1,3,5

Accurate and timely diagnosis of ptosis and its underlying etiology is essential to making informed management and treatment decisions. Therapeutic options have traditionally been limited to surgery,1,4 and modern diagnostic and management algorithms have not been available to aid in early diagnosis. Recent changes in the availability of therapeutic options for earlier-stage acquired ptosis in adults7 warrant an evaluation of current approaches to identifying, diagnosing, and treating this condition and, further, an examination of the role of eye care practitioners in ptosis management. The objective of this review is to examine current knowledge and clinical experiences and propose practical recommendations regarding the diagnosis and treatment of acquired ptosis, with a view toward the evolving understanding of the condition and emerging therapeutic opportunities.


A broad literature search was carried out in the PubMed database to identify relevant English-language, peer-reviewed primary research and review publications reporting on the prevalence, etiology, diagnosis, and treatment of acquired ptosis. Search terms used included “ptosis,” “eyelid,” “etiology,” “prevalence,” “differential diagnosis,” “surgery,” “pharmacologic,” and “treatment.” Articles were included for group review and discussion if they were judged to provide a current view of fundamental concepts or unique primary data relevant to the development of clinical recommendations. Articles not identified via PubMed search but cited in reviewed publications or identified as relevant before or during working sessions were also included for review.

Two virtual working groups were convened using a specialized online collaboration tool (Within3, Lakewood, OH). During the first moderated online session (June 8 to 21, 2020), all authors responded to and debated 23 questions in four broad categories developed in advance by KK Nichols and PM Karpecki. At the close of the first online session, responses were compiled, and major themes, points of consensus, and points requiring further research and discussion were identified. Summaries of these themes and subcategories, including new references, were subsequently presented during the second moderated online session (August 19 to September 8, 2020), during which all authors reviewed preliminary findings and conclusions, confirmed and expanded upon these, and discussed proposed clinical recommendations. This article summarizes the results of this process.


Current State of Ptosis Diagnosis and Treatment

Ptosis is a common condition of the upper eyelid that both optometrists and ophthalmologists see in clinical practice, although the frequency with which it is seen will tend to vary by specialty and patient population. Optometrists, for example, may see ptosis more frequently if they primarily serve middle-aged or elderly patients. Similarly, oculoplastic or ophthalmic surgeons who receive ptosis referrals will likely see the condition more frequently than individuals in more generalized ophthalmology or optometry practices.

Although relatively common in adult populations,8–10 clinical experience suggests that ptosis is likely underdiagnosed and underreported, for a variety of reasons. First, many cases of ptosis are mild or moderate in severity and may not be raised as a concern by patients. Second, measures of upper eyelid position, such as the marginal reflex distance 1 (MRD-1) or palpebral aperture,11 may not be routinely collected as part of the comprehensive eye examination, particularly in patients with milder forms of the condition. Finally, effective treatment options have been limited to surgical intervention. Although surgery can deliver favorable cosmetic, functional, and quality-of-life (QoL) outcomes,12–14 it may not be the appropriate (or preferred) intervention for all patients, particularly those with mild or moderate drooping of the eyelid or who may be wary of potential complications inherent to surgical procedures.

Evaluation of the eyelids should be a core aspect of the comprehensive eye examination for all eye care providers, as should the ptosis diagnostic workup and subsequent management when appropriate. Acquired ptosis can develop at any age and for a variety of reasons, and although overall prevalence will vary, eye care providers will encounter cases regardless of practice location or mode of practice. One reason for this is the ubiquity of known risk factors in the general population. The U.S. population is aging,15 and studies have revealed a clear association between increasing age and ptosis incidence.8–10 Contact lens wear, whether rigid or soft lenses, is another common factor that can lead to development of bilateral or unilateral acquired ptosis,16–20 and patients are now wearing contact lenses for a greater part of their life span because of, for example, availability of multifocal contact lenses for presbyopia. Unilateral or asymmetric acquired ptosis may arise in patients wearing the same or different lenses bilaterally or in patients wearing lenses monocularly. In addition, ocular surgery, including common procedures for cataracts and glaucoma, can likewise lead to transient or persistent forms of acquired ptosis.21,22

Together, clinical experience and the published literature demonstrate that ptosis can negatively affect patient QoL. The characteristic “sleepy” or asymmetric appearance caused by drooping of the eyelids can lead to increased levels of appearance-related anxiety and depression, comparable with levels observed in individuals with other ophthalmic conditions that can alter appearance, such as strabismus.23 Furthermore, even in mild cases of ptosis, there can be measurable functional impairment of the superior visual field, which can in turn negatively affect QoL by reducing independence or the ability to perform daily activities.23–27

The Importance of an Active Diagnostic Approach

Historically, the relatively narrow range of treatment options for acquired ptosis has limited practitioners' ability to meaningfully address the condition with patients, particularly in mild or moderate cases. Evolving treatment options, however, such as the availability of a recently approved once-daily oxymetazoline 0.1% eye drop (discussed in Step 3: Characterize and Treat Acquired Ptosis with a Patient-focused Approach), offers the potential to treat a wider range of patients. With a condition such as ptosis that has generally been undertreated and for which patient awareness is typically low, therapeutic decision making and the use of novel options depend on timely and accurate diagnosis. Although acquired ptosis is most often of the aponeurotic form,1,6 drooping of the upper eyelid can also be a result of a serious underlying neurologic or muscular condition requiring immediate intervention.1,3 Furthermore, there are several “masquerade” conditions that can appear to be ptosis but involve no pathology of the upper eyelid retractor muscles or aponeurosis (they are “pseudoptosis” conditions) and require accurate identification and condition-specific therapeutic approaches.1,3

Identification and Characterization of Acquired Ptosis: Clinical Recommendations

Practitioners currently have the tools to identify acquired ptosis in an efficient and accurate manner. The key is to incorporate eyelid evaluation into the comprehensive eye examination and take the appropriate diagnostic steps based on clinical observation. Given the prevalence of ptosis, its range of underlying causes, and the fact that eyelid examination can be performed in a streamlined way, all patients should be evaluated for the presence of ptosis or other eyelid abnormalities. Steps 1 to 3 present a stepwise approach to identifying, characterizing, and treating acquired ptosis.

Step 1: Screen for and Identify Ptosis

The following assessments and tests are important in screening for ptosis.

Patient Questionnaire

The first step to identifying ptosis is patient self-assessment (Fig. 1). Brief questions about eyelid appearance can be added to intake questionnaires or posed by technical staff during the patient's workup. Questions to help identify potential cases of ptosis can be simple, with an emphasis on anything that the patient (or patient's family or friends) may have noted about their eyelid appearance. Examples of useful starter questions include the following: “Do you ever feel that one or both of your eyelids is droopy, heavy, or has a ‘sleepy’ look? If yes, is this new?” “Has anyone mentioned that one or both of your eyelids may be drooping?” and “Are you ever bothered by the appearance of your eyes or eyelids?” It can also be helpful to include visual examples of ptosis, ranging from mild to severe, on the questionnaire (examples in Fig. 2) and allow patients to indicate which example(s) they believe their eye appearance most resembles.

Clinical recommendations, Step 1: screening and identification. Ptosis can be efficiently identified using a combination of simple intake questions, photograph review, and patient history, followed by eyelid examination. An initial assessment of timing of onset, symptoms, pupil diameter, extraocular muscle function, and facial symmetry/asymmetry can identify potential serious underlying causes requiring immediate testing or referral. ED = emergency department; EOM = extraocular muscle; MRD-1 = marginal reflex distance 1.
Examples of varied degrees of right-sided ptosis, from no ptosis (top) to complete ptosis (bottom). Example images, as in panel A, can be used in intake questionnaires to aid self-reporting of ptosis by patients. When assessing eyelid position, it is important to document measurements (MRD-1 and/or palpebral aperture), rather than simply classifying by severity (B). Degree of ptosis alone does not indicate etiology, and a serious underlying neurologic cause may be present even if ptosis is mild. Although not shown in these images, it is essential to immobilize the frontalis muscle with the palm of the hand when taking MRD-1 and palpebral aperture measurements (see Step 1: Screen for and identify ptosis and Fig. 3). In panel B, the red line corresponds to upper eyelid margin (used to measure palpebral aperture and MRD-1), the orange line corresponds to location of corneal light reflex (used to measure MRD-1), and the gold line corresponds to lower eyelid margin (used to measure palpebral aperture). MRD-1: distance from the orange line to the red line. Palpebral aperture: distance from the red line to the gold line. MRD-1 = marginal reflex distance 1.

In addition to starting the process of identifying potential ptosis cases, these types of questions also help raise patients' awareness about ptosis, even if they are not presently affected. Age-related ptosis can progress slowly and might not necessarily be noticed by patients. Similarly, many patients, particularly if their ptosis is relatively mild, may simply accept it as another age-related condition with limited or no treatment options. In any case, when discussing ptosis with patients, it is important that they understand that it is most often related to aging, but that other more concerning causes must also be identified or excluded. Like with other ocular conditions, such as cataract and presbyopia, starting the conversation early helps raise patient awareness, making them more likely to notice ptosis but also feel reassured that treatment is available, when needed.

Photograph Review

Assessing for interval change in upper eyelid position can help identify ptosis and track its progression. This can be done by comparing in-office observations or digital images collected during the clinical workup to images from previous visits or to driver's license or smartphone photographs.

In-office Patient History

A review of patient history, to understand timing of ptosis onset, is essential. This can be done by asking the patient about when they started to notice drooping of their eyelid(s) and by reviewing previously collected digital images. It is also important to ask about past eye trauma or eyelid surgery, as well as symptoms of pain, diplopia, reduced visual function, weakness, or any other neurologic symptoms. These questions provide essential information about potential serious underlying causes requiring immediate testing or referral.

Eyelid Measurements

Eyelid evaluation should be performed on all patients and is summarized in Fig. 3. From a practical perspective, measurements of pupil size and eyelid position can be efficiently collected in immediate sequence using the same equipment. Upper eyelid position can reliably be measured using MRD-1, the distance from the central pupillary light reflex to the central margin of the upper eyelid (Table 1).28 Alternatively, palpebral aperture, the distance between the upper and lower eyelid margins, can be used to assess the relative position of the eyelids. Because patients with ptosis often adopt compensatory behaviors, such as raising their brow and tilting their head back, to help overcome their ptosis, it is important to hold and inactivate the frontalis muscle and ensure that the head is held straight when taking eyelid measurements.

Upper eyelid measurements to identify ptosis and assess upper eyelid function. (A) Marginal reflex distance 1 (distance from the center of the corneal light reflex [orange line] to the central margin of the upper eyelid [red line]; 7 mm in example). (B) Palpebral aperture (distance between the central margin of the upper [red line] and lower [gold line] eyelids; 14 mm in example). (C) Levator function (amount of upper eyelid excursion when the patient shifts from downward gaze [dotted red line] to upward gaze [solid red line]; 16 mm in example). (D) Eyelid crease height (distance from the central margin of the upper eyelid [red line] to the upper eyelid crease [blue line]). When collecting objective measurements of the eyelid, it is essential to consider natural anatomical variation based on sex, ethnicity, or other factors. *Measured after immobilizing the frontalis muscle with the palm of the hand. †Measured with the patient's head and the ruler held still during gaze shift. MRD-1 = marginal reflex distance 1.
TABLE 1 - Upper eyelid measurements to identify and characterize acquired ptosis
Measurement Technique and ranges Application
MRD-1: distance from the center of the pupillary light reflex to the central margin of the upper eyelid11,28 • Performed with head held straight (i.e., not tilted) and frontalis muscle inactivated (by holding the brow with the thumb or palm of hand)
• Can be assessed immediately before or after pupil size, using the same equipment (mm ruler, transilluminator, pupillograph, penlight)
• Typical range: 4–5 mm with the eye in primary gaze
• Identification of upper eyelid ptosis, symmetry/asymmetry, and characterization of acquired ptosis etiology
• Decrease (even if relatively small) can indicate ptosis due to pathology of the upper eyelid retractor muscles and/or aponeurosis, or potentially due to a serious underlying cause
Palpebral aperture: distance between the upper and lower eyelid margins3,11 • Performed with head held straight (i.e., not tilted) and frontalis muscle inactivated (by holding the brow with the thumb or palm of hand)
• Corresponds to combined MRD-1 and MRD-2 (distance from center of the pupillary light reflex to the central margin of the lower eyelid) values
• Can be assessed immediately before or after pupil size, using the same measuring device (mm ruler/pupillograph)
• Typical range: 10–12 mm
• Identification of upper eyelid ptosis, symmetry/asymmetry, and characterization of acquired ptosis etiology
• Decrease (even if relatively small) can indicate ptosis due to pathology of the upper eyelid retractor muscles and/or aponeurosis, or potentially due to a serious underlying cause
Levator function: amount of upper eyelid excursion that occurs as the patients shifts from downward to upward gaze11 • Performed with the frontalis muscle inactivated (by holding the brow with the thumb)
• Typical range: >15 mm, normal function; 12–14 mm, good function; 5–11 mm, fair function; 0–4 mm, poor function
• Characterization of acquired ptosis etiology
• Decrease indicates reduced levator function and can inform therapeutic approach3
Eyelid crease height: distance from the upper eyelid crease to the upper eyelid margin3 • Assessed with the eye in down gaze
• Typical range: 7–8 mm in males, 9–10 mm in females
• Characterization of acquired ptosis etiology
• Increase can indicate disinsertion of the levator aponeurosis (aponeurotic ptosis) and inform therapeutic approach
MRD = marginal reflex distance.

Marginal reflex distance 1 and palpebral apertures can be evaluated using a variety of instruments (transilluminator, penlight, pupillograph, millimeter ruler), and if technical staff already perform pupil diameter measurements, the addition of MRD-1 or palpebral aperture to their workflow can be relatively seamless. Typical MRD-1 is 4 to 5 mm,11 and typical palpebral aperture is 10 to 12 mm.3 It is important to identify even relatively mild drooping of the eyelid, as it can, in some cases, reflect the presence of a serious underlying cause. The ptosis observed in Horner syndrome, for example, is typically mild and unilateral but can be secondary to trauma, tumor, or carotid dissection.1 Furthermore, mild forms of acquired ptosis caused by pathology of the upper eyelid retractor muscles (levator, Müller muscle) or aponeurosis are treatable and therefore warrant full evaluation. When evaluating the eyelids, it is important to capture digital images to track position over time and assess for interval change, whether taking a conservative or more active approach to treatment.

Levator muscle function should be assessed using Berke method, which measures the amount of upper eyelid excursion that occurs as the patient shifts from downward to upward gaze. As with MRD-1 or palpebral aperture measurements, this test is performed while applying downward pressure on the forehead with the palm of one hand to negate frontalis muscle function. As a general rule, a lid elevation of 0 to 4 mm is classified as poor function, 5 to 11 mm as fair, 12 to 14 mm as good, and >15 mm as normal.11 Eyelid crease height, the distance from the upper eyelid crease to the eyelid margin while in downgaze, typically ranges from 7 to 8 mm in males and 9 to 10 mm in females, and an increase in this measurement can be indicative of disinsertion of the levator aponeurosis from the tarsal plate (i.e., aponeurotic ptosis).11 Clinically, eyelid crease height measurements can be particularly helpful in determining whether eyelid asymmetry may be aponeurotic in nature.11 When assessing an individual for the presence of ptosis, it is essential to consider the natural anatomical variation in the eyelids in the population based on, for example, sex or ethnicity and, when feasible, collect multiple objective measures. Combining these objective findings with patient history and intake questionnaire responses provides important information that can help guide diagnosis and treatment decision making.

If drooping of the eyelid is evident from MRD-1 or palpebral aperture assessment, all potential etiologies must be considered and assessed. It is essential to establish that ptosis is not the result of a more serious underlying neurologic or muscular condition requiring immediate intervention, such as Horner syndrome, third cranial nerve palsy, myasthenia gravis, or chronic progressive external ophthalmoplegia.1,3,11

Step 2: Rule Out or Identify Neurologic Etiology

It is imperative to perform a comprehensive evaluation on all patients with observable ptosis. To rule out a neurogenic etiology, the following tests are critical: pupil sizes in both bright and dim illumination, ductions and versions, cover testing measurements in multiple positions of gaze using horizontal and vertical prism bars, and exophthalmometry (Fig. 4).29–33 The results of these tests, in combination with patient symptoms and information about onset, will discern whether there is a serious underlying pathology requiring immediate action. Prompt referral to a hospital emergency department is required for patients presenting with suspected third cranial nerve palsy secondary to aneurysm or suspected Horner syndrome secondary to carotid dissection.29,30,32,33 If dysfunction of Müller muscle is suspected in nonemergent cases, diagnostic pharmacologic testing with topical apraclonidine3,11,29,32,34–36 can be performed to either confirm or rule out Horner syndrome, with a reversal of anisocoria confirmatory of this condition. Other presentations, for example, those suggesting myasthenia gravis, require further evaluation and specialized workup to confirm diagnosis, as well as referral to neuro-ophthalmology or neurology for treatment considerations.31

Clinical recommendations, Step 2: differential diagnosis. A timely detailed workup should be performed (either by the primary eye care practitioner or by the specialist) for any patient with a suspected serious underlying cause, to rule out or identify the specific pathology.29–33 AChR = acetylcholinesterase receptor; CN = cranial nerve; CT = computed tomography; CTA = computed tomographic angiography; ED = emergency department; EMG = electromyography; MRA = magnetic resonance angiography; PCOM = posterior communicating artery.

It is also important to identify any pseudoptosis conditions, for example, mechanical or anatomical causes, or contralateral eyelid retraction indicative of thyroid eye disease, which can either masquerade as or accompany ptosis.1,3,11 A relatively common pseudoptosis condition, dermatochalasis, caused by the presence of excess upper eyelid skin, can be identified by lifting the excess eyelid skin before examining upper eyelid retractor muscle function, and examination of the globe can help identify globe dystopias.3 The periocular tissues should likewise be examined and palpated for the presence of any mass or lesion (such as a tumor) that may cause ptosis, with referral to appropriate specialists, as warranted.1,3,37

Step 3: Characterize and Treat Acquired Ptosis with a Patient-focused Approach

Following steps 1 and 2, patient-focused characterization of acquired ptosis aids in its management. Once ptosis is confirmed via MRD-1 or palpebral aperture measurements and serious underlying neurologic or myogenic causes are ruled out, closer examination of the ptotic eyelid(s), including comparison with previous observations and photographs, should allow for differentiation of acquired ptosis from congenital forms. If acquired, the ptosis can be further defined as aponeurotic, mechanical, or traumatic, and consideration can then be given to treatment options.

Treatment decision making is multifactorial (Fig. 5). If clinical examination rules out a serious underlying condition and ptosis is determined to be a result of pathology of the upper eyelid retractors and/or aponeurosis, then all treatment options, ranging from conservative (observation and tracking) to proactive (pharmacologic, surgical), should be considered.

Clinical recommendations, Step 3: characterization of acquired ptosis and treatment. Upon ruling out serious underlying causes, acquired ptosis etiology can be discerned based on the clinical examination (upper eyelid observation, retractor muscle function, patient history) and treatment subsequently selected, with surgical referral as appropriate. Pharmacologic treatment with oxymetazoline 0.1% is advisable as a first treatment option for most cases of acquired ptosis.

Demonstration of a meaningful visual field deficit is required to justify medical necessity and obtain reimbursement of surgical ptosis repair and should be carried out when the patient has been identified as a candidate for surgery. A range of visual field tests, including manual kinetic perimetry (Goldmann Visual Field Test [VFT]) and automated static perimetry (standard Humphrey VFT, modified Humphrey VFT [Leicester Peripheral Field Test], Octopus VFT) methods, can be used to identify visual field deficits. Although visual field testing can be useful in tracking functional impairment due to ptosis and subsequent improvement with treatment, it is not a requirement for initiation of pharmacologic treatment. Visual field testing is therefore not essential for ptosis treatment purposes until a surgical referral is made, to evaluate for functional indication.

The recent Food and Drug Administration approval of a preservative-free oxymetazoline 0.1% eye drop (Upneeq; RVL Pharmaceuticals, Inc., Bridgewater, NJ) for the treatment of acquired ptosis in adults presents a novel ptosis management option. Oxymetazoline is an α-adrenergic agonist that acts by stimulating receptors expressed on Müller muscle, causing contraction and raising the upper eyelid. Clinical data indicate that oxymetazoline 0.1%, when used once daily, effectively elevates the upper eyelid and improves superior visual field deficits after administration in patients with acquired ptosis. It also has a favorable safety and tolerability profile.7,38,39

Reports have also described the off-label use of topical α-adrenergic agents developed for other ophthalmic applications, such as apraclonidine, phenylephrine, brimonidine, and naphazoline, to raise the upper eyelid. These reports, however, are generally limited in scope, and these therapies have not undergone rigorous clinical trials to evaluate their utility for the treatment of ptosis. Based on clinical experience, as well as the available evidence, off-label management of acquired ptosis with these agents is less suitable, especially long-term, particularly in light of their known adverse effect profiles. Topical ophthalmic phenylephrine use, for example, is associated with significant pupil dilation,34 whereas prolonged daily ophthalmic use of apraclonidine is associated with both ocular and systemic adverse effects.40–42

As a nonsurgical therapeutic, oxymetazoline 0.1% should be considered once diagnosis of ptosis with no serious underlying neurologic or muscular condition is confirmed (steps 1 and 2), regardless of severity. Given the topical administration route and pharmacokinetics of oxymetazoline 0.1%, its observable effects are reversible with time, and daily dosing is therefore needed. In addition to the efficacy and safety profile of oxymetazoline 0.1%, its formulation as an eye drop is likely to be appealing to patients, either as an alternative to surgery for individuals who may not be clear surgical candidates or who are wary of surgery, or as a “bridge” to surgery for those eventually desiring permanent surgical correction. Furthermore, the applications of oxymetazoline 0.1% are relatively broad, including not only persistent forms of acquired ptosis but also acquired forms that are more transient, such as ptosis caused by periocular neurotoxin injection or after other ocular surgery,21,22,43,44 given that there are currently no other effective ways to treat transient forms of the condition. Mechanical alternatives such as eye crutches or adhesives are not recommended, as their inconvenience outweighs any potential benefit. Scleral contact lenses, which similarly provide mechanical support to the upper eyelid during wear, can be a more useful treatment adjunct in some cases. Published case reports from patients with complex ptosis indicate measurable upper eyelid elevation with scleral lenses, along with acceptable on-eye comfort.45,46

A surgical approach to ptosis correction should be considered when the ptosis is particularly severe or accompanied by other conditions also correctable surgically, such as dermatochalasis, if the underlying cause is mechanical (and thus, pharmacologic intervention is unlikely to have meaningful effect), or if the patient prefers a more permanent solution. After assessing candidacy (absence of risk factors or contraindications) and expected benefit, as well as relevant clinical (short- and long-term adverse effects, recovery time) and logistical (timing, reimbursement) considerations, patients can be referred for surgical consultation, with external photograph acquisition and visual field testing to establish medical necessity performed by either the referring optometrist or the surgeon post-referral. For surgical candidates, the procedure (or combination of procedures) selected by the surgeon is based on underlying etiology and severity. Common targets are the levator, Müller muscle, and levator aponeurosis, with the goal of achieving the desired cosmetic outcomes and, in the case of ptosis causing functional impairment, improving the superior visual field.1,11,13 When referring a patient for surgical consultation, it may also be beneficial to prescribe oxymetazoline 0.1% as a bridge treatment, and this should be discussed between the referring doctor, patient, and surgeon. If effective in the interim, pharmacologic treatment can be continued and surgical options revisited for the future in consultation with the patient and clinician. When the patient opts for surgical correction, clinical experience suggests that oxymetazoline 0.1% should be discontinued (i.e., washed out) for a period of 1 to 2 weeks before preoperative assessment. Although the long-term duration upper eyelid elevation after a single dose of oxymetazoline 0.1% has not yet been evaluated, its mean systemic terminal half-life of approximately 8 hours47 suggests that adequate clearance would be expected after a 1- to 2-week washout period.

For any patient treated with oxymetazoline 0.1%, follow-up is essential to assessing results and revisiting treatment, as needed. Simple questions such as “Are you happy with your results? How do your eyelids look/feel? Have you noticed any improvement in your eyelids?” can provide patient-based quality assessments of the patient's QoL experiences and perception of treatment, and should be documented. Upon subsequent visits, eyelid height measurements and new digital photographs should also be collected to aid in future management decisions (step 1).


Eye care, particularly as it relates to age-related conditions such as cataract, ocular surface disease, and presbyopia, continues to emphasize more proactive approaches to diagnosis and treatment. Furthermore, clinical advances increasingly involve a move toward less invasive treatments, and these advances provide an important opportunity to revisit practice patterns. In the case of ptosis diagnosis and management, there is an opportunity to deliver more comprehensive care and for primary eye care practitioners to have a more prominent role in this care.

Diagnosis and management of acquired ptosis require a stepwise approach, beginning with active screening and identification (step 1), ruling out or identifying neurologic etiology (step 2), and using a patient-focused characterization and treatment algorithm (step 3). It is important to remember that, although effective13 and an excellent option for many patients with ptosis, surgery will not be appealing or convenient for all patients, given cost and logistical considerations, as well as its inherently invasive nature,1 which is one possible reason why ptosis may in some cases be overlooked until it becomes severe. For eye care practitioners accustomed to identifying and tracking ptosis, and then referring for surgical consultation when the ptosis is severe enough to qualify for payer reimbursement or when the patient chooses to pay out of pocket, the availability of a pharmacologic treatment option (oxymetazoline 0.1%) can help shift from a “detect and refer” to a “diagnose and manage” approach (Fig. 5).

For practitioners, added focus on ptosis is expected to enable identification of more cases and subsequent treatment for patients who previously may have had limited therapeutic options. In all likelihood, a broader commitment to diagnosing ptosis will identify not only candidates for pharmacologic treatment but also more surgical candidates. In addition, an emphasis on diagnosing acquired ptosis will allow for earlier detection of cases of neurogenic and myogenic ptosis, which can be warning signs of serious underlying conditions. This earlier identification and subsequent treatment of these potentially life-threatening conditions would be expected to translate into better patient prognosis.

A more active and patient-centered approach to treating acquired ptosis begins with early efforts to raise awareness for the practitioner and patient alike. This requires ptosis education and a practice-wide commitment, including all doctors and staff, to engage with patients and start the discussion. To effectively identify candidates for pharmacologic or surgical treatment, evaluation of the eyelids should be a standard part of the comprehensive eye examination, followed by accurate differential diagnosis to exclude serious underlying conditions (and referral/appropriate workup as necessary) and to define ptosis etiology. Patients with acquired ptosis should be presented with the range of appropriate treatment options. Given its minimally invasive nature and clinical evidence of its efficacy and safety,7,38,39 eye care practitioners should consider pharmacologic treatment with oxymetazoline 0.1% as the first treatment option for all appropriate patients with acquired ptosis. Although the clinical trial data regarding oxymetazoline 0.1% use seem to be promising, it is also important that practitioners continue to evaluate this novel treatment option based on their clinical experience and emerging data, including long-term efficacy outcomes. Similarly, although current diagnostic approaches can support accurate and timely diagnosis of ptosis, practitioners should consider incorporating any future advances in diagnostics or tracking that may help to further improve efficiency or help broaden diagnostic capabilities.

In a broader context, it is important to emphasize a commitment to education regarding acquired ptosis diagnosis and treatment among all eye care professionals (doctors, students, residents, and technical staff). This will help ensure that not only the current generation but also the next one is well equipped to effectively manage this common condition.


1. Finsterer J. Ptosis: Causes, Presentation, and Management. Aesthetic Plast Surg 2003;27:193–204.
2. Tan MC, Young S, Amrith S, et al. Epidemiology of Oculoplastic Conditions: The Singapore Experience. Orbit 2012;31:107–13.
3. Latting MW, Huggins AB, Marx DP, et al. Clinical Evaluation of Blepharoptosis: Distinguishing Age-related Ptosis from Masquerade Conditions. Semin Plast Surg 2017;31:5–16.
4. Zoumalan CI, Lisman RD. Evaluation and Management of Unilateral Ptosis and Avoiding Contralateral Ptosis. Aesthet Surg J 2010;30:320–8.
5. Bacharach J, Lee WW, Harrison AR, et al. A Review of Acquired Blepharoptosis: Prevalence, Diagnosis, and Current Treatment Options. Eye (Lond) 2021;35:2468–81.
6. Lim JM, Hou JH, Singa RM, et al. Relative Incidence of Blepharoptosis Subtypes in an Oculoplastics Practice at a Tertiary Care Center. Orbit 2013;32:231–4.
7. Slonim CB, Foster S, Jaros M, et al. Association of Oxymetazoline Hydrochloride, 0.1%, Solution Administration with Visual Field in Acquired Ptosis: A Pooled Analysis of 2 Randomized Clinical Trials. JAMA Ophthalmol 2020;138:1168–75.
8. Sridharan GV, Tallis RC, Leatherbarrow B, et al. A Community Survey of Ptosis of the Eyelid and Pupil Size of Elderly People. Age Ageing 1995;24:21–4.
9. Hashemi H, Khabazkhoob M, Emamian MH, et al. The Prevalence of Ptosis in an Iranian Adult Population. J Curr Ophthalmol 2016;28:142–5.
10. Kim MH, Cho J, Zhao D, et al. Prevalence and Associated Factors of Blepharoptosis in Korean Adult Population: The Korea National Health and Nutrition Examination Survey 2008–2011. Eye (Lond) 2017;31:940–6.
11. Pauly M, Sruthi R. Ptosis: Evaluation and Management. Kerala J Ophthalmol 2019;31:11–6.
12. Battu VK, Meyer DR, Wobig JL. Improvement in Subjective Visual Function and Quality of Life Outcome Measures After Blepharoptosis Surgery. Am J Ophthalmol 1996;121:677–86.
13. Cahill KV, Bradley EA, Meyer DR, et al. Functional Indications for Upper Eyelid Ptosis and Blepharoplasty Surgery: A Report by the American Academy of Ophthalmology. Ophthalmology 2011;118:2510–7.
14. Federici TJ, Meyer DR, Lininger LL. Correlation of the Vision-related Functional Impairment Associated with Blepharoptosis and the Impact of Blepharoptosis Surgery. Ophthalmology 1999;106:1705–12.
15. US Census Bureau Population Division. National Population Projections Tables: Detailed Age and Sex Composition of the Population, 2017–2060. Available at: Accessed September 1, 2021.
16. Bleyen I, Hiemstra CA, Devogelaere T, et al. Not Only Hard Contact Lens Wear But Also Soft Contact Lens Wear May Be Associated with Blepharoptosis. Can J Ophthalmol 2011;46:333–6.
17. Hwang K, Kim JH. The Risk of Blepharoptosis in Contact Lens Wearers. J Craniofac Surg 2015;26:e373–4.
18. Kitazawa T. Hard Contact Lens Wear and the Risk of Acquired Blepharoptosis: A Case-control Study. Eplasty 2013;13:e30.
19. Satariano N, Brown MS, Zwiebel S, et al. Environmental Factors That Contribute to Upper Eyelid Ptosis: A Study of Identical Twins. Aesthet Surg J 2015;35:235–41.
20. Thean JH, McNab AA. Blepharoptosis in RGP and PMMA Hard Contact Lens Wearers. Clin Exp Optom 2004;87:11–4.
21. Godfrey KJ, Korn BS, Kikkawa DO. Blepharoptosis Following Ocular Surgery: Identifying Risk Factors. Curr Opin Ophthalmol 2016;27:31–7.
22. Wang Y, Lou L, Liu Z, et al. Incidence and Risk of Ptosis Following Ocular Surgery: A Systematic Review and Meta-analysis. Graefes Arch Clin Exp Ophthalmol 2019;257:397–404.
23. Richards HS, Jenkinson E, Rumsey N, et al. The Psychological Well-being and Appearance Concerns of Patients Presenting with Ptosis. Eye (Lond) 2014;28:296–302.
24. Alniemi ST, Pang NK, Woog JJ, et al. Comparison of Automated and Manual Perimetry in Patients with Blepharoptosis. Ophthal Plast Reconstr Surg 2013;29:361–3.
25. Ho SF, Morawski A, Sampath R, et al. Modified Visual Field Test for Ptosis Surgery (Leicester Peripheral Field Test). Eye (Lond) 2011;25:365–9.
26. McKean-Cowdin R, Varma R, Wu J, et al. Severity of Visual Field Loss and Health-related Quality of Life. Am J Ophthalmol 2007;143:1013–23.
27. Meyer DR, Stern JH, Jarvis JM, et al. Evaluating the Visual Field Effects of Blepharoptosis Using Automated Static Perimetry. Ophthalmology 1993;100:651–8.
28. Putterman AM. Margin Reflex Distance (MRD) 1, 2, and 3. Ophthalmic Plast Reconstr Surg 2012;28:308–11.
29. Davagnanam I, Fraser CL, Miszkiel K, et al. Adult Horner's Syndrome: A Combined Clinical, Pharmacological, and Imaging Algorithm. Eye (Lond) 2013;27:291–8.
30. Fang C, Leavitt JA, Hodge DO, et al. Incidence and Etiologies of Acquired Third Nerve Palsy Using a Population-based Method. JAMA Ophthalmol 2017;135:23–8.
31. Jayam Trouth A, Dabi A, Solieman N, et al. Myasthenia Gravis: A Review. Autoimmune Dis 2012;2012:874680.
32. Kanagalingam S, Miller NR. Horner Syndrome: Clinical Perspectives. Eye Brain 2015;7:35–46.
33. Tamhankar MA, Biousse V, Ying GS, et al. Isolated Third, Fourth, and Sixth Cranial Nerve Palsies from Presumed Microvascular versus Other Causes: A Prospective Study. Ophthalmology 2013;120:2264–9.
34. Barsegian A, Botwinick A, Reddy HS. The Phenylephrine Test Revisited. Ophthalmic Plast Reconstr Surg 2018;34:151–4.
35. Ben Simon GJ, Lee S, Schwarcz RM, et al. Muller's Muscle-conjunctival Resection for Correction of Upper Eyelid Ptosis: Relationship between Phenylephrine Testing and the Amount of Tissue Resected with Final Eyelid Position. Arch Facial Plast Surg 2007;9:413–7.
36. Maheshwari R, Maheshwari S. Muller's Muscle Resection for Ptosis and Relationship with Levator and Muller's Muscle Function. Orbit 2011;30:150–3.
37. Sudhakar P, Vu Q, Kosoko-Lasaki O, et al. Upper Eyelid Ptosis Revisited. Am J Clin Med 2009;6:5–14.
38. Bacharach J, Wirta DL, Smyth-Medina R, et al. Rapid and Sustained Eyelid Elevation in Acquired Blepharoptosis with Oxymetazoline 0.1%: Randomized Phase 3 Trial Results. Clin Ophthalmol 2021;15:2743–51.
39. Wirta DL, Korenfeld MS, Foster S, et al. Safety of Once-daily Oxymetazoline HCl Ophthalmic Solution, 0.1% in Patients with Acquired Blepharoptosis: Results from Four Randomized, Double-masked Clinical Trials. Clin Ophthalmol 2021;15:4035–48.
40. Araujo SV, Bond JB, Wilson RP, et al. Long Term Effect of Apraclonidine. Br J Ophthalmol 1995;79:1098–101.
41. Robin AL, Ritch R, Shin D, et al. Topical Apraclonidine Hydrochloride in Eyes with Poorly Controlled Glaucoma. The Apraclonidine Maximum Tolerated Medical Therapy Study Group. Trans Am Ophthalmol Soc 1995;93:421–38.
42. Stewart WC, Ritch R, Shin DH, et al. The Efficacy of Apraclonidine as an Adjunct to Timolol Therapy. Apraclonidine Adjunctive Therapy Study Group. Arch Ophthalmol 1995;113:287–92.
43. Cavallini M, Cirillo P, Fundaro SP, et al. Safety of Botulinum Toxin a in Aesthetic Treatments: A Systematic Review of Clinical Studies. Dermatol Surg 2014;40:525–36.
44. Steinsapir KD, Groth MJ, Boxrud CA. Persistence of Upper Blepharoptosis After Cosmetic Botulinum Toxin Type A. Dermatol Surg 2015;41:833–40.
45. Katsoulos K, Rallatos GL, Mavrikakis I. Scleral Contact Lenses for the Management of Complicated Ptosis. Orbit 2018;37:201–7.
46. Shah-Desai SD, Aslam SA, Pullum K, et al. Scleral Contact Lens Usage in Patients with Complex Blepharoptosis. Ophthalmic Plast Reconstr Surg 2011;27:95–8.
47. Upneeqtm (Oxymetazoline Hydrochloride Ophthalmic Solution), 0.1% [Package Insert]. Bridgewater, NJ: RVL Pharmaceuticals, Inc.; 2020.
Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Optometry.