Ptosis (droopy upper eyelid)

Disclaimer

These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Acute ptosis should be referred immediately to the PCH Ophthalmology department. Call PCH switch and ask to speak to the ophthalmology registrar on call.

Introduction

Ptosis in children is usually the result of an underdeveloped / weak levator palpebrae superioris eyelid muscle. It can be unilateral or bilateral, an isolated feature or a component of systemic syndrome or disease process.

If the ptosis is significant the child may compensate by adopting a chin up head posture in order to see. In other cases, an elevated brow position may be a compensatory sign.

The normal position of the upper eyelid is 1-2mm below the upper corneal limbus. Mild ptosis that does not cover part of the pupil generally does not require treatment.

Moderate or severe ptosis that obscures part of or the entire pupil can impact normal visual development and needs to be diagnosed and treated in a timely manner to prevent permanent vision loss.

When to refer

Ptosis obscuring or partially obscuring the pupil.
Ptosis associated with chin up head posture.
Sudden onset ptosis.
Ptosis associated with any pupillary asymmetry or abnormal eye movements.
Ptosis associated with any suspected mass lesion on the eyelid or orbit.

How to refer

Routine non-urgent referrals from a GP or a Consultant are made via the Central Referral Service
Routine non-urgent referrals from optometrists or doctors in private settings are made via the PCH Referral Office.
Urgent referrals (less than seven days) are made via the PCH Referral Office. Please call Perth Children’s Hospital Switch on 6456 2222 to discuss referral with the opthalmology registrar.

Essential information to include in your referral

History of onset of ptosis i.e., congenital (present since birth) or acquired
Any abnormal head position
Pupil examination findings – reaction to light and symmetry
Any eye movement abnormality noticed
Any family history.

Useful resources

Ptosis - Royal Children's Hospital, Melbourne

References

Marenco M, Macchi I, Galassi E, Massaro-Giordano M, Lambiase A. Clinical presentation and management of congenital ptosis. Clinical ophthalmology (Auckland, NZ). 2017;11:453-63.
Pavone P, Cho SY, Praticò AD, Falsaperla R, Ruggieri M, Jin D-K. Ptosis in childhood: A clinical sign of several disorders. Medicine. 2018;97(36):e12124.

Reviewer/Team:	Ophthalmology Department, PCH	Last reviewed:	March 2024
		Next review date:	March 2027
Endorsed by:	CPAC	Date:	March 2024

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