Ptosis (blepharoptosis) is a condition in which, due to dysfunction of the levator palpebrae superioris or its innervating nerve, the eyelid margin sits lower than normal when the eyes are open. It is defined as MRD-1 (margin reflex distance-1: the distance from the central corneal light reflex to the upper eyelid margin) of 3.5 mm or less. Normal values are 3.5–5.5 mm.
Severity is classified by the MRD-1 value as follows.
| Severity | MRD-1 |
|---|---|
| Mild | 3.5–2 mm |
| moderate | 2–0 mm |
| severe | less than 0 mm |
Surgical treatment for ptosis is broadly divided into two types. When levator function is good (10 mm or more), levator advancement (aponeurosis advancement) is chosen; when levator function is poor (less than 4 mm), frontalis sling surgery is chosen. The purpose of choosing the procedure is to improve visual field impairment and relieve frontalis muscle compensation (chin-up posture, headache, shoulder stiffness).
There are two main types. If levator function is normal at 10 mm or more, levator advancement (aponeurosis advancement) is chosen. If levator function is poor at less than 4 mm, frontalis sling surgery is chosen. Levator advancement is usually done through a transcutaneous approach, and it has the advantage that excess skin can be removed and double-eyelid formation can be done at the same time.
Ptosis is classified by cause as follows.
| Classification | Main cause | Features |
|---|---|---|
| Aponeurotic (most common) | Aging, contact lens use, use of an eyelid speculum | Aponeurosis thinning; levator function normal |
| Neurogenic | Oculomotor nerve palsy; Horner syndrome | Treat the underlying disease first |
| Myogenic | Myasthenia gravis; extraocular myopathy | Fluctuates during the day; worsens with fatigue |
| Congenital | Congenital degeneration of the upper eyelid levator muscle | Poor levator function; frontalis sling is indicated |
| Other | Trauma and pseudoptosis (dermatochalasis) | Treat according to cause |
Aponeurotic ptosis is the most common acquired ptosis, and it is mainly due to thinning and stretching of the levator aponeurosis (aponeurosis). In addition to age-related degenerative changes, it often develops after long-term contact lens wear or after intraocular surgery using an eyelid speculum.
In acquired ptosis, aponeurotic ptosis accounts for most cases. The main risk factors are aging and long-term contact lens wear. Aponeurotic ptosis can also occur after intraocular surgery (especially surgery that uses a lid speculum)4).
About 90% of congenital ptosis is due to congenital dysgenesis (simple type) of the levator palpebrae superioris. The remaining 10% includes complex forms such as blepharophimosis syndrome and Marcus Gunn phenomenon. In congenital cases, levator function is often poor, making frontalis sling surgery the main indication5).
Among neurogenic causes, ptosis due to myasthenia gravis (MG) is seen as the first symptom of MG in about 70% of cases, and diurnal fluctuation (worsening in the evening) is characteristic.
Preoperative evaluation determines the surgical method and the extent of surgery (one side or both sides).
| Evaluation item | Method | Normal values / criteria |
|---|---|---|
| MRD-1 | Distance from the corneal light reflex to the upper eyelid margin | Normal 3.5–5.5 mm |
| Levator function | Distance the eyelid margin moves from downgaze to upgaze | Normal ≥10 mm |
| Hering’s law | Ptosis on the opposite side when the affected side is manually lifted | If positive → consider bilateral simultaneous surgery |
| Dry eye assessment | Schirmer test and BUT | Assessment of risk of worsening after surgery |
MRD-1 measurement: Measure the distance from the center of the cornea (light reflex point) to the upper eyelid margin. To rule out frontalis compensation, it is important to gently press on the forehead with your fingers during the measurement.
Levator function test (levator function test): With the patient looking down, set the upper eyelid margin position as 0 mm, and measure the distance to its position in upgaze. Hold the brow from above to rule out frontalis compensation. Normal is 10 mm or more, and less than 4 mm means severe levator dysfunction.
Check for Hering’s law: See whether the opposite eyelid drops when the affected upper eyelid is manually lifted. If positive, contralateral ptosis may become apparent after one-sided surgery, so simultaneous bilateral surgery is indicated. This is an important point in the pre-op explanation.
Dry eye assessment: After ptosis surgery, widening of the palpebral fissure increases tear evaporation, so dry eye is more likely. Check for dry eye before surgery and prepare for pre-op intervention and postoperative management in high-risk patients.
Measure MRD-1 (distance from the center of the pupil to the upper eyelid margin), levator function (range of eyelid movement in the up-and-down direction), check Hering’s law (whether the opposite side moves down when one side is lifted), and whether dry eye is present. Based on these results, decide the surgical method and extent of surgery (one side or both sides).
Indications for surgery in congenital ptosis:
Indications for surgery in acquired ptosis:
When the objective findings (decreased MRD-1, abnormal eyelid crease, brow elevation, and forehead wrinkles) match the subjective symptoms (heaviness of the eyelids, narrowing of the upper visual field, eye pain, and shoulder stiffness), and ptosis surgery is thought to improve both.
The surgical procedure is determined by levator function.
Levator advancement
Indications: Mainly for aponeurotic ptosis with levator function of 10 mm or more.
Approach: There are two methods: transcutaneous (skin-side) or transconjunctival (conjunctiva-side).
Advantages: Intraoperative adjustment, excision of excess skin, and creation of a new eyelid crease can all be done at the same time.
Frontalis sling
Indications: Severe cases with levator function less than 4 mm. The main surgery for congenital ptosis.
Materials: Gore-Tex® sheet (commonly used in adults), nylon suture (first surgery in children), autologous fascia, etc.
Features: Because the eyelid is lifted by contraction of the frontalis muscle, eyelid opening remains even when looking downward.
Used for aponeurotic ptosis with normal levator function of 10 mm or more. The transcutaneous method is mainly selected because it allows intraoperative adjustment, removal of excess skin, and creation of a new eyelid crease.
From the viewpoint of the approach and the target, there are the following three patterns.
Procedure overview (transcutaneous method): skin incision → dissection beneath the orbicularis oculi muscle → identification of the levator aponeurosis → advancement and fixation of the aponeurosis to the tarsal plate → creation of the double eyelid, in that order. During surgery, the patient is asked to open the eyes so the effect can be checked while the amount is adjusted.
Choose this when levator function is poor, less than 4 mm. Because the eyelid is raised using the contractile force of the frontalis muscle, the patient will need to use the frontalis muscle to open the eye. Explain beforehand that the palpebral fissure may remain widened on downward gaze after surgery.
The choice of material is determined by considering the patient’s age, general condition, and the possibility of reoperation.
| Material | Advantages | Disadvantages | Indications |
|---|---|---|---|
| Fascia lata / temporalis fascia | Long-term stability with autologous tissue | Risk of donor-site scarring and postoperative contracture | Adults |
| Gore-Tex® sheet | Minimal scarring, maintained traction | Synthetic material, infection risk | Frequently used in adults |
| Nylon suture | Few complications; returns to the preoperative state after suture removal | Traction weakens over the long term | First choice in children |
| Silicone rod | — | No domestically approved products | Essentially not used |
In children, reoperation is often needed as they grow, so nylon sutures, which have few complications and can return the eye to its preoperative state by removing the stitches, are suitable for the initial surgery. For adults whose skeletal and muscle conditions are stable, a Gore-Tex® sheet is often used.
Oxymetazoline 0.1% eye drops are a nonsurgical treatment that acts as a partial agonist of sympathetic α1-adrenergic receptors, contracts the Müller muscle of the upper eyelid, and corrects acquired ptosis1). In Japan, treatment guidelines were established in 2025.
Indications: Acquired ptosis (mild to severe). If the cause is a neurological disease, tumor, or trauma, priority should be given to evaluating and treating the underlying disease.
Physician criteria1): ① a specialist certified by the Japan Ophthalmological Society or a board-certified ophthalmologist by the Japan Medical Specialty Board, ② must fully understand the safety and efficacy of this drug and be able to manage adverse effects.
How to use: Instill one drop in the affected eye once daily. The effect lasts about 8 hours after instillation. It provides temporary improvement and is not a curative treatment2). If no effect is seen, do not continue indefinitely; consider other treatments, including surgery.
Contraindications and precautions1): Caution is needed in patients with cardiovascular disease (effects on blood pressure and heart rate), patients with angle-closure glaucoma (risk of acute attack), and pregnant or breastfeeding women (safety not established).
Main side effects: punctate keratitis, conjunctival hyperemia, dry eye, blurred vision, eye pain, headache.
In two phase III RCTs (total 304 patients), oxymetazoline efficacy was evaluated, and the treatment group showed significant differences in MRD-1 and upper visual field improvement compared with the placebo group 3).
Oxymetazoline (0.1%) eye drops were approved in Japan in 2025. It is a non-surgical option that helps open the eyelid by contracting the Müller muscle. It is used for acquired ptosis under the supervision of an ophthalmologist. Caution is needed in patients with cardiovascular disease or angle-closure glaucoma. If the effect is insufficient, surgery should be considered.
In the early postoperative period, the wound is cooled, and antibiotic eye drops and steroid eye drops are used. Swelling peaks over the first few days after surgery and improves over 1 to 2 weeks. Follow-up should be done regularly to detect complications early.
Hematoma: One of the complications that requires the most caution after surgery. If a large hematoma is found, the wound must be opened, the hematoma removed, and hemostasis confirmed. Leaving a hematoma untreated can cause infection and fibrosis.
Overcorrection (overcorrection): If incomplete eyelid closure occurs, there is a risk of corneal dryness and exposure keratopathy. Ending surgery with incomplete eyelid closure of 2 mm or less is an important indicator for preventing postoperative overcorrection. During follow-up, artificial tears and eye ointment are used to protect the cornea.
Undercorrection (insufficient correction): If the effect is insufficient, refixation is performed. The limit for refixation is about up to 2 weeks after surgery. After 2 weeks, fibrosis progresses and refixation becomes difficult.
Worsening dry eye: Dry eye is likely to occur after surgery because widening of the palpebral fissure increases tear evaporation. Patients with preexisting dry eye require particular caution, and artificial tears should be used proactively.
Contralateral ptosis due to Hering’s law: After unilateral surgery, ptosis on the opposite side may become apparent. Adequate explanation before surgery is necessary, and this can be avoided by choosing simultaneous bilateral surgery in advance.
Revision surgery for congenital ptosis: After frontalis sling surgery, revision surgery may be needed as the child grows. In cases using nylon sutures, long-term weakening of the lifting force can occur, so continue regular follow-up.
Watch for postoperative hematoma (if it is large, open the wound and remove it), poor eyelid closure due to overcorrection (risk of corneal dryness), and undercorrection (refixation is possible until 2 weeks after surgery). After unilateral surgery, the opposite side may become ptotic according to Hering’s law. In congenital cases, revision surgery may also be needed as the child grows.
The levator palpebrae superioris originates near the apex of the orbit and runs forward, becoming the levator aponeurosis just distal to Whitnall’s ligament. The aponeurosis has a two-layer structure: an anterior layer (thick, penetrates the skin to form the eyelid crease) and a posterior layer (inserts into the upper one-third of the tarsal plate). The Muller muscle is a sympathetically innervated smooth muscle that attaches from the posterior surface of the aponeurosis to the superior border of the tarsal plate and provides about 2 mm of lifting force.
Age-related degenerative changes and mechanical irritation from long-term contact lens wear cause stretching and thinning (fibrosis) of the aponeurosis. This reduces the levator’s ability to raise the tarsal plate. When the skin-penetrating branches are no longer drawn in, the eyelid crease disappears or becomes higher and irregular. Persistent compensatory contraction of the frontalis muscle can cause tension-type headache and neck and shoulder pain.
Elevating force is reduced by congenital degeneration of the levator palpebrae superioris (fibrosis and hypoplasia). Because fibrosis of the muscle is the main issue, it does not fully relax even on downgaze, and widening of the palpebral fissure on downgaze (lid lag) is characteristic. Some cases also have delayed movement of the superior rectus. The eye often opens well on downgaze, and amblyopia due to visual-axis obstruction is limited to severe cases.
The oculomotor nerve innervates the levator palpebrae superioris (striated muscle), and oculomotor nerve palsy causes complete ptosis. The sympathetic nervous system innervates the Müller muscle (smooth muscle), and Horner syndrome causes mild ptosis of about 2 mm. Contraction of the Müller muscle can also be promoted by alpha1 receptor stimulation with oxymetazoline, but no benefit is expected in cases of oculomotor nerve palsy.
As an alpha1-adrenergic receptor agonist, it binds to alpha receptors in the Müller muscle of the upper eyelid, promotes muscle contraction, and lifts the eyelid. In aponeurotic ptosis, the aponeurosis is the main structure affected, but Müller muscle function is often preserved, producing a compensatory lifting effect. This mechanism is the same principle behind why Müller muscle resection is effective for ptosis associated with Horner syndrome.
Japanese approval and treatment guidelines for oxymetazoline 0.1% eye drops: In 2025, treatment guidelines were established for oxymetazoline (0.1%) eye drop therapy for acquired ptosis1). Criteria for the treating physician, indications, contraindications, and adverse event management are clearly specified, and a system for appropriate use in Japan is being developed.
Expanded indications for the Fasanella-Servat procedure (Müller muscle resection): Transconjunctival Müller muscle resection is highly effective in phenylephrine test-positive cases (cases in which Müller muscle contractility is confirmed)7). Expansion of its indications to mild to moderate aponeurotic ptosis with good levator function is being considered.
Phenylephrine test: Before surgery, 2.5% or 10% phenylephrine eye drops are used to confirm remaining Müller muscle function and are used to help choose candidates for Müller muscle resection and oxymetazoline treatment.
Medical treatment for ptosis associated with myasthenia gravis: Cholinesterase inhibitors (pyridostigmine), steroids, and immunosuppressants are the main treatments. Surgery for ptosis should be considered carefully only after the underlying disease has stabilized.
Standardization of outcome assessment: Standardization of surgical outcome assessment using the amount of numerical improvement in MRD-1 and patient-reported outcomes (PRO) is progressing, and comparative studies between procedures are accumulating6).
