Causes of Ptosis in Adults and Children
Neurogenic Causes
Third nerve palsy is a critical neurogenic cause requiring urgent evaluation based on pupillary involvement. 1
Pupil-Sparing Third Nerve Palsy
- Microvascular disease (diabetes, hypertension, hyperlipidemia) is almost always the etiology when there is complete ptosis, complete motility dysfunction, and normal pupillary function. 1
- However, partial extraocular muscle involvement or incomplete ptosis cannot reliably exclude compressive lesions, even with pupil-sparing presentation. 1
Pupil-Involving Third Nerve Palsy (Urgent)
- Posterior communicating artery aneurysm is the most urgent consideration and must be ruled out emergently. 1, 2, 3
- Compressive tumors including meningioma, schwannoma, and metastatic lesions. 1
- Trauma and subarachnoid hemorrhage. 1
- Viral illnesses including COVID-19, Epstein-Barr virus. 1, 2
- Demyelinating disease (multiple sclerosis). 1, 2
- Leptomeningeal disorders and infectious meningitis. 1, 2
- Infectious diseases including syphilis and Lyme disease. 1, 2
Horner Syndrome
- Disruption of the oculosympathetic pathway causes mild ptosis with miosis and anhidrosis. 3
- In children, carotid dissection must be ruled out until proven otherwise. 4
Cavernous Sinus and Orbital Apex Pathology
- Lesions at these locations may cause ptosis accompanied by 6th and 4th nerve paralysis. 1, 2
- Associated optic neuropathy and proptosis suggest orbital apex or orbital involvement. 1
Myogenic Causes
Myasthenia Gravis
Variable, fatigable ptosis that worsens with prolonged upgaze and improves with rest is pathognomonic for myasthenia gravis. 1, 2, 5, 3
- Ocular myasthenia affects only the levator, orbicularis oculi, and extraocular muscles, known as "the great masquerader." 1
- Cogan lid-twitch sign and slow saccades are characteristic findings. 1, 2
- Ice pack test (applying ice over closed eyes for 2-5 minutes) showing reduction of ptosis by approximately 2 mm is highly specific. 1, 2, 5, 3
- Acetylcholine receptor antibodies are present in 40-77% of ocular myasthenia cases. 1
- Thymoma is present in 10-15% of myasthenia patients and requires chest CT screening. 2
- Increased risk with autoimmune thyroid disease. 1, 2
- Myasthenic crisis with respiratory failure is life-threatening and requires immediate assessment. 2
Congenital Myogenic Ptosis
- Dysgenesis of the levator palpebrae superioris muscle is the most common cause of pediatric ptosis. 6
- May be associated with syndromes or hereditary disorders. 7, 6
Aponeurotic Causes
Aponeurotic ptosis is the most common acquired form in adults, resulting from dehiscence or disinsertion of the levator aponeurosis. 7, 8, 4
- Typically occurs with aging or following trauma. 7, 8
- Characterized by good levator function despite significant ptosis. 8, 4
Mechanical Causes
Mechanical ptosis results from physical weight or mass effect on the eyelid. 7, 8
Congenital Causes (Pediatric-Specific)
Simple Congenital Ptosis
- Unilateral congenital ptosis with levator dysgenesis is the most common pediatric form. 6
- May be associated with strabismus or anisometropia with corneal astigmatism. 6
- Amblyopia risk is critical if ptosis covers the pupil and must be recognized and treated early. 5, 7, 6
Syndromic Associations
- Marcus Gunn jaw-winking syndrome. 6
- Blepharophimosis syndrome. 6
- Other hereditary or degenerative disorders. 7
Critical Diagnostic Pitfalls
Do not assume pupil-sparing indicates benign microvascular disease when ptosis is incomplete or ophthalmoplegia is partial—compressive lesions can present this way and require urgent neuroimaging. 1, 2
- Missing pupil-involving third nerve palsy as a neurosurgical emergency (aneurysm) can be fatal. 5, 3
- Overlooking myasthenia gravis due to variable presentation; consider ice test even in pediatric patients. 2, 5
- Failing to diagnose and treat amblyopia early in children leads to permanently poor vision. 5, 7, 6
- In children with Horner syndrome, carotid dissection must be excluded. 4