Eyelid Disorders: Understanding Ptosis, Entropion, and When Surgery Is Needed

Imagine waking up one morning and noticing your eyelid feels heavier than usual. You lift your brow just to see clearly. Or maybe your eye stings constantly, like there’s sand in it-even though you haven’t been near a beach. These aren’t just minor annoyances. They could be signs of ptosis or entropion, two common but serious eyelid disorders that affect vision, comfort, and even eye health long-term.

What Is Ptosis, and Why Does It Happen?

Ptosis is when the upper eyelid droops low enough to cover part of the pupil. It can happen in one eye or both. In mild cases, you might just feel like you’re always tired. In severe cases, it blocks your vision entirely, forcing you to tilt your head back or raise your eyebrows just to see.

The main cause? Aging. As we get older, the levator muscle-that’s the one responsible for lifting the eyelid-stretches and weakens. About 80% of ptosis cases in adults over 60 are due to this natural wear and tear. But it’s not just age. Some people are born with it (congenital ptosis), others develop it after eye surgery, trauma, or nerve damage from conditions like diabetes or myasthenia gravis. Even frequent contact lens use or rubbing your eyes can contribute over time.

Doctors measure ptosis using something called the margin reflex distance (MRD). A normal MRD is 4 to 5 millimeters. If it drops below 3 mm, that’s considered severe. Anything between 1 and 2 mm is mild. This isn’t just a number-it tells the surgeon exactly how much muscle needs to be tightened.

Entropion: When Your Eyelid Turns Inward

Entropion is the opposite problem: the eyelid, usually the lower one, rolls inward. This causes your eyelashes to rub against the cornea-the clear front surface of your eye. Think of it like sandpaper slowly scraping your eyeball every time you blink.

The result? Constant irritation, redness, tearing, mucus buildup, and a gritty feeling that won’t go away. Left untreated, this can lead to corneal ulcers, scarring, and even permanent vision loss. That’s not theoretical-it happens in real patients, often too late because people think it’s just dry eyes or allergies.

Most entropion cases (about 80%) are involutional, meaning they’re caused by aging. The eyelid tissues loosen, the tendons stretch, and the lid loses its shape. About 15% are cicatricial-caused by scarring from burns, trachoma (a bacterial infection common in areas with poor sanitation), or previous surgeries. There’s also a rare congenital form, seen in about 1 in 10,000 newborns.

And here’s something many don’t realize: entropion and blepharitis often go hand in hand. Blepharitis is chronic inflammation of the eyelid margins, where oil glands get clogged. It causes crusty eyelashes, swelling, and itching. Over time, the inflammation can distort the eyelid’s structure, making entropion worse.

Surgical Repair: What Works and What Doesn’t

Eye drops and ointments can help with symptoms, but they won’t fix the problem. Surgery is the only reliable cure for both ptosis and entropion.

For ptosis, the approach depends on how strong the levator muscle still is. If it’s working okay (function >4mm), surgeons do a levator resection-they shorten the muscle to lift the lid. If the muscle is very weak, they use a frontalis sling, which connects the eyelid to the forehead muscle so you lift your eyelid by raising your brow. For mild cases, a Müller’s muscle-conjunctival resection is often enough. It’s less invasive and works well if the eyelid responds to a phenylephrine eye drop test.

Success rates? Around 85-95% for first-time surgeries. But complications happen. About 5-10% of patients end up with an overcorrected lid that won’t close fully. Another 5-15% get asymmetry-one lid higher than the other. Dry eyes are also common after surgery, affecting up to 20% of patients.

For entropion, the go-to fix for age-related cases is the tarsal fracture procedure. It tightens the eyelid by repositioning the tendon and removing a small piece of tissue. Success rate? 90-95%. For scarring-related entropion, a tarsal wedge resection removes the damaged section and stitches the healthy parts back together. There’s also the Quickert suture-a temporary fix with only 60-70% success, used mostly for patients who aren’t good surgical candidates.

Recent advances? Adjustable sutures. Introduced in 2018, these let the surgeon fine-tune the eyelid position the day after surgery. That’s huge-it cuts revision surgery needs by about 25%. New minimally invasive techniques using absorbable sutures mean recovery time has dropped from 4-6 weeks to just 1-2 weeks.

What Happens If You Don’t Treat It?

Ignoring ptosis might seem harmless at first. You just live with the fatigue, the brow ache, the need to constantly lift your eyelids. But over time, your brain adapts to the blocked vision. Your peripheral sight shrinks. Children with untreated congenital ptosis can develop amblyopia-lazy eye-because their brain stops processing input from the covered eye.

Entropion is even more urgent. That constant friction from eyelashes? It doesn’t just hurt. It scratches the cornea. One small ulcer can turn into an infection. In severe cases, the cornea can perforate. That’s not just vision loss-it’s the risk of losing the eye entirely.

And don’t underestimate blepharitis. It’s not just “dirty eyelids.” Chronic inflammation changes the eyelid’s anatomy. It thickens tissue, distorts glands, and makes both ptosis and entropion more likely. People with ocular rosacea-a hidden inflammatory condition-often have worse outcomes because the inflammation runs deep under the skin.

Who’s at Risk? And What Can You Do Now?

You’re at higher risk if you’re over 60. The incidence of eyelid malpositions jumps from 0.5% in people aged 50-60 to over 2.5% in those over 80. If you’ve had eyelid surgery before, your risk goes up 40-60%. People with chronic dry eye, autoimmune diseases, or a history of eye infections are also more vulnerable.

And yes-family history matters. If your parent had ptosis, you’re more likely to develop it too.

Before surgery, conservative steps help manage symptoms:

• Use lubricating eye drops to reduce friction and dryness
• Apply warm compresses daily if you have blepharitis
• Tape your eyelid gently at night if it won’t close fully
• Avoid rubbing your eyes-this worsens tissue damage
• See an ophthalmologist if you notice sudden drooping, pain, or blurred vision

Don’t wait for it to get worse. Rapid drooping of the eyelid is a red flag. It could signal a neurological issue, like a stroke or nerve tumor. Same with sudden entropion-especially if it’s only on one side. That needs urgent evaluation.

The Bigger Picture: Why This Matters Now

The global market for oculoplastic surgery-procedures like these-is growing fast. It hit $1.8 billion in 2022 and is expected to reach $2.7 billion by 2028. Why? Because people are living longer. And as life expectancy rises, so does the number of older adults dealing with age-related eyelid problems.

Studies show about 5% of adults over 70 have some kind of eyelid malposition. That’s 1 in 20 people. Yet most don’t seek help until it’s advanced. They think it’s just aging. It’s not. It’s a medical condition that can be fixed.

Specialists like those in the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) report that eyelid malposition repairs make up 15-20% of all oculoplastic surgeries in the U.S. That’s a lot of people-many of them seniors-who just needed the right information to act.

High-resolution imaging now helps surgeons plan better. They can see exactly how much tissue has stretched, where the scar tissue is, and how the muscle is functioning-all before the knife even touches the skin. That means fewer surprises, better outcomes.

And research is moving forward. Scientists are looking for genetic markers that predict who’s likely to develop age-related eyelid changes. The goal? Early detection. Maybe one day, we’ll catch ptosis or entropion before it starts-through a simple blood test or scan-instead of waiting for the eyelid to fall.

When to See a Doctor

You don’t need to wait for disaster to strike. If you notice any of these, make an appointment with an ophthalmologist or oculoplastic specialist:

• Your eyelid droops enough to cover your pupil
• You feel like you’re always squinting or lifting your brow to see
• Your eye stings, tears up, or feels like there’s something in it
• Your eyelashes are rubbing your eyeball
• You have crusting, redness, or swelling along your eyelid margins
• You’ve had sudden changes in your eyelid position

It’s not vanity. It’s vision. And it’s fixable.