1. If you're told "your eyes have gotten smaller lately?" or "you always look sleepy"... that may be "ptosis"!?
"Even though I sleep well, people around me tell me I 'look sleepy'" "My eyes have gotten smaller than before, and my eye makeup won't come together"... Do you have such worries? Perhaps the cause is not mere sleep deprivation or aging, but a state called "ptosis."
Ptosis refers to a state in which the upper eyelid droops abnormally lower than its normal position (Bacharach et al. 2021). When in this state, the eyelid covers part of the pupil (the iris), and the width between the upper and lower eyelids (the palpebral fissure width) narrows. As a result, not only do the eyes look small and give a sleepy impression, but the field of vision is blocked, causing various hindrances to daily life.
The mechanism of lifting the eyelid: the levator and Müller's muscle
Our eyelids open and close by the action of very intricate muscles and tissues. The main muscles for raising (opening) the upper eyelid are two: the "levator palpebrae superioris" and "Müller's muscle (the superior tarsal muscle)."
- Levator palpebrae superioris: A muscle that moves on the command of the brain's oculomotor nerve (the 3rd cranial nerve). The tip of this muscle transitions into a thin, hard tissue called the "levator aponeurosis" and attaches to a cartilage-like plate at the edge of the eyelid called the "tarsal plate." When this muscle contracts, the tarsal plate is pulled up through the aponeurosis and the eyelid opens.
- Müller's muscle: A smooth muscle located behind the levator palpebrae superioris, controlled by the action of the sympathetic nerve. Through the action of the autonomic nerve, it plays the role of unconsciously fine-tuning the degree of eyelid opening.
When some abnormality arises in these muscles, nerves, or the aponeurosis, the eyelid can no longer be lifted sufficiently, and ptosis is caused.
What is "MRD1," the criterion for ptosis?
In ophthalmology and plastic surgery, the most important indicator for objectively diagnosing whether it is ptosis is"MRD1 (Margin Reflex Distance 1)."This is a measurement, in millimeters, of the distance from the point of light reflected at the center of the iris (the corneal reflection) to the edge of the upper eyelid, with the patient looking straight ahead and light shone into the eye.
In a healthy state, MRD1 is usually "4–5 mm" (Clauser et al. 2006). However, when the upper eyelid droops and this distance shortens, generally whenMRD1 is "2.0 mm or less (or less than 2.5 mm),"it is diagnosed as ptosis. Furthermore, the severity of the ptosis is classified by this MRD1 value as follows.
2. Don't miss it! The SOS signs your eyelids send and their psychological impact
Ptosis does not stop at the physical change of "the eyelid drooping"; it also has a great impact on appearance, function, and even the psychological aspect. Do you recognize any of the following symptoms or signs?
Signs that appear in appearance and field of vision (a symptom list)
- The field of vision narrows (loss of the upper field of vision): Because the eyelid covers the pupil, the upper field of vision in particular is blocked. As it progresses, reading and performing tasks that require looking down for long periods become difficult.
- Forehead wrinkles increase (overuse of the frontalis muscle): To unconsciously compensate for the field of vision narrowing due to the drooped eyelid, one tries to forcibly lift the eyebrows using the forehead muscle (the frontalis). Therefore, deep wrinkles tend to form on the forehead despite being young.
- One adopts a chin-up posture: Because one tries to look at things through the gap below the eyelid, one unconsciously adopts a posture of thrusting the chin up or tilting the head back (chin-up posture).
- Change in the double-eyelid line: Due to sagging of the eyelid skin and muscle, the double-eyelid width can become abnormally wide, become a triple eyelid, or conversely the double-eyelid line can disappear.
- Facial asymmetry (left-right difference): When only one eye is ptotic, the size of the left and right eyes clearly differs, and the facial balance looks broken.
The serious "psychological impact" brought by the change in appearance
For women in their 20s to 40s, changes in the eye area are a great mental stress. There are research results that patients with eye diseases affecting appearance, ptosis foremost, are more prone to clinical depression and anxiety compared with healthy people of the same generation (Richards et al. 2021), and report strong distress about appearance and "avoidance of social behavior (such as avoiding meeting people)." In addition, there is also data that, because of having ptosis symptoms, one tends to be given negative impressions by those around them, such as "low attractiveness" or "unlikable."
However, it has been proven in postoperative interviews and surveys of many patients that, by receiving appropriate treatment (surgery, etc.), not only does the field of vision improve, but such psychosocial function and sense of well-being also improve dramatically (Richards et al. 2021), and anxiety and depression are reduced. Before worrying that "it's my fault," it is important to realize that it is a sign that can be solved by the power of medicine.
3. Why does the eyelid droop? The "three causes" women in their 20s to 40s should especially be careful of
Ptosis has two major categories: "congenital" from birth and "acquired" that develops after growth. Let us compare the characteristics of each and the causes common in modern women.
(1) Congenital ptosis (a cause from birth)
Congenital ptosis is a state often noticed at birth or within the first year of life. The majority of it is due to developmental failure (hypoplasia) of the "levator palpebrae superioris" that lifts the eyelid, or myopathy (an abnormality of the muscle). Because the normal muscle fibers are replaced by fibrous tissue, the muscle cannot contract and relax well. In the case of the congenital type, it rarely heals naturally even with growth, and it is characterized by an indistinct double-eyelid line (the upper eyelid crease). In addition, because there is a risk of hindering the development of vision and causing "amblyopia," early treatment may be necessary.
(2) Involutional/aponeurotic ptosis (change due to age)
The overwhelmingly most common among acquired ptosis is "aponeurotic ptosis." This occurs when, due to a natural process such as aging, the "levator aponeurosis" that transmits the force of the levator palpebrae superioris to the tarsal plate stretches, becomes thin, or peels off (dehisces) from the tarsal plate.
It is characterized by the fact that, despite the function of the levator muscle itself being normal (moving 10 mm or more, etc.), its force is not transmitted well to the edge of the eyelid, and the eyelid does not fully lift. It comes to be seen often in the senior population from the 40s onward, but recently cases of it developing even in the young generation are increasing.
(3) Contact-lens-induced ptosis (surging in the 20s to 40s!)
Those who "have used contact lenses for years" should beware. In recent years, many studies have revealed that not only hard contact lenses but also the long-term wear of soft contact lenses (Bacharach et al. 2021) carries a high risk of causing acquired aponeurotic ptosis.
[Why do contacts make the eyelid droop?]
The following two are considered the main causes.
- Physical friction and traction: The excessive operation (physical stimulation) of strongly pulling the eyelid sideways or rubbing it every day when removing contact lenses damages the thin levator aponeurosis and loosens the connection.
- Chronic inflammation (fibrosis of Müller's muscle): Dirt adhering to the edge or surface of the lens causes chronic stimulation or an allergic reaction on the back of the eyelid. In studies that examined under a microscope the eyelid tissue of patients who have used contacts for a long time, it was confirmed that marked "fibrosis (Watanabe et al. 2006) (collagen fibers proliferating and hardening)" and fatty degeneration occur in "Müller's muscle" on the back of the eyelid. When Müller's muscle hardens, the fine-adjustment function of the eyelid is lost, and the droop progresses.
In one survey, many of the young to middle-aged patients who underwent surgery for aponeurotic ptosis of unknown cause had a long-term history of contact lens use. With the spread of cosmetic color contact lenses as well, it can be called the most familiar and dangerous cause for young women.
4. Chronic headaches or stiff shoulders... in fact, "eyelid sagging" may be the cause
"My headaches have been severe lately" "The sense of fatigue in my shoulders and neck won't go away"... that symptom may have "ptosis," which is not cured by massage or painkillers, as its trigger.
As mentioned above, when ptosis occurs, the field of vision (especially the upper field of vision) is blocked by the drooped eyelid. To compensate for this, the human body unconsciously strongly contracts the forehead muscle, the "frontalis," and tries to lift the eyelid up along with the eyebrows. In addition, one comes to adopt an unnatural posture of lightly raising the chin and looking at things with a downward gaze.
Thus, byconstantly overusing (keeping in a state of tension) the facial and head muscles that are originally unnecessary in order to open the eyes,the muscles around the forehead fatigue, and "prefrontal headache," "brow ache," and a whole-body chronic sense of fatigue are caused. Eye strain from poor vision also adds fuel to this.
In fact, there are many patients who report that, after undergoing ptosis surgery and the eyelids coming to open easily, the overuse of the frontalis muscle decreased, the brow pain, headache, and sense of fatigue that had tormented them for years improved dramatically, and they came to be able to read and work comfortably. Without making light of it as "just an eyelid," let us suspect whether an eyelid SOS is hidden behind chronic fatigue or pain.
5. Just 10 seconds in front of the mirror! The ptosis self-check method you can do starting today
Whether it is ptosis can be checked to some extent in front of a mirror at home, even without special instruments. By the following steps, let us confirm the state of your own eyelid (MRD1 and compensatory actions).
[Step 1] Confirming MRD1 (the distance from the center of the iris)
- In a bright room, hold a hand mirror directly in front of your face. Relax and gaze straight at your own eyes in the mirror.
- Confirm that the room's lighting and the like is reflected as a glinting point of light (the corneal reflection) at the center of your iris (pupil).
- Estimate by eye how many millimeters the distance is from that point of light to the edge of the upper eyelid, holding a ruler or the like against the side of your face.
<Judgment>
▶ There is 4–5 mm: Normal. The eyelid is firmly lifted.
▶ It is 2 mm or less (the upper half or more of the iris is hidden): The possibility of ptosis is high (MRD1 ≤ 2.0 mm).
▶ The eyelid covers below the point of light (0 mm or less): Severe ptosis.
[Step 2] Confirming the compensatory action (use of the forehead muscle)
- With the eyes closed, lightly press the forehead (around above the eyebrows) with the fingers of both hands.
- While keeping the forehead muscle fixed with the fingers so it does not move, try to open your eyes suddenly.
<Judgment>
If, when you fix the forehead, the eyes are very hard to open, or the eyelids feel heavier than usual, it is proof that you normally "forcibly open the eyelids using the forehead muscle (the frontalis)." This too is a powerful sign of ptosis.
6. "When should I fix it?" The best timing of treatment and the surgical methods you're curious about
Because ptosis almost never heals naturally, fundamentally solving it requires treatment at a medical institution (mainly surgery). So, at what timing should one decide on treatment?
The timing at which treatment should be considered
Based on the views of the American Academy of Ophthalmology and the like, when functional impairments like the following appear, it becomes a clear indication (timing) for surgery.
In addition, not only the functional aspect, but cosmetic and psychological reasons such as "I want to improve my sleepy appearance" or "I want to return to the bright eyes I used to have" are also important factors in deciding on treatment.
Representative surgical methods (options)
Surgery is chosen depending on the cause of the droop and "how much the levator palpebrae superioris is functioning."
- Levator Advancement / levator resection:
The most commonly performed surgery for "aponeurotic ptosis" caused by aging or contact lenses. The loosened or detached levator aponeurosis is re-sutured to its original position (the tarsal plate), or pulled forward and fixed. It is very effective when the function of the muscle itself is good (moving 8 mm or more, etc.) and can reconstruct a natural eyelid curve. - Müller's muscle-conjunctival resection:
A method of approaching from the back of the eyelid (the conjunctival side) and cutting and suturing part of Müller's muscle and the conjunctiva short. It is indicated for mild to moderate droop with good levator function. The merit is that no scar remains on the surface of the skin. - Frontalis Suspension:
Performed when the function of the levator palpebrae superioris is "poor" due to congenital and other causes. Using one's own fascia (fascia lata, etc.) or an artificial material such as a medical silicone tube or mesh (a sling), the tarsal plate of the eyelid and the forehead muscle (the frontalis) are directly connected. By this, one comes to be able to open the eyelid using the forehead force that raises the eyebrows.
* In addition, when operating on only one eye, caution is needed regarding the neural masking phenomenon called "Hering's law." When one eyelid is lifted by surgery, the brain's command to "open the eyes" weakens, and the other, non-operated eye can droop (the contralateral droop becomes apparent). Therefore, before surgery, meticulous simulation and evaluation of both eyes by a physician are indispensable.
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7. Summary: let us regain bright, wide-open eyes and comfortable days
Ptosis does not stop at mere "looking old" or "a cosmetic worry"; it is a medical disease that narrows the field of vision, causes chronic headaches and a sense of fatigue, and greatly lowers our quality of life (QoL).
Especially in the case of women in their 20s to 40s, cases of developing aponeurotic ptosis at a young age due to years of contact lens use or excessive friction of the eye area (makeup removal, etc.) are not few. Those who feel "my eyelids are heavy lately," "I feel my forehead is straining," or "my MRD1 self-check was 2 mm or less," please do not worry alone; first try visiting an ophthalmology, plastic surgery, or specialized clinic.
It has been proven in many studies that, by receiving appropriate diagnosis and treatment (surgery, etc.), not only does the field of vision open up brightly, but one is freed from headaches and fatigue around the shoulders, and psychological anxiety and complexes also improve dramatically. Let us take the first step toward regaining "the bright, wide-open eyes of the past" and "comfortable days in both mind and body."
If you have any concerns, please feel free to consult us first.
References
- Bacharach et al. 2021. A review of acquired blepharoptosis: prevalence, diagnosis, and current treatment options. Eye. 2021 DOI
- Clauser et al. 2006. Palpebral Ptosis: Clinical Classification, Differential Diagnosis, and Surgical Guidelines. J Craniofac Surg. 2006 DOI
- Unknown et al. 2018. Approach to a patient with blepharoptosis. Medicine. 2018 DOI
- Lee et al. 2019. The Epidemiology and Clinical Features of Blepharoptosis in Taiwanese Population. Aesth Plast Surg. 2019 DOI
The author of this article
Hiromitsu Nakamura Physician
Zetith Beauty Clinic Ginza / Osaka / Fukuoka
He has a track record of research presentations at domestic and international conferences in Japan and is also involved in technical guidance and education across the entire Zetith Beauty Clinic. Specializing in precise cosmetic medicine based on anatomical grounds, he pursues natural results tailored to each individual's bone structure and tissue.