Ptosis is a drooping of the upper lid. Causes include myasthenia gravis, damage to the oculomotor nerve, and damage to the sympathetic nerve supply (Horner'ssyndrome). A weakened muscle, relaxed tissues, and the weight of herniated fat may cause senile ptosis. Ptosis may also be congenital.

Retracted Lid

A wide-eyed stare suggests retracted eyelids—in this case, the upper lid. Note the rim of sclera between the upper lid and the iris. Retracted lids and a lid lag (p. 150) are often due to hyperthyroidism but may be seen in normal people. The eye does not protrude forward unless exophthalmos coexists.


In ectropion the margin of the lower lid is turned outward, exposing the palpebral conjunctiva. When the punctum of the lower lid turns outward, the eye no longer drains satisfactorily and tearing occurs. Ectropion is more common in the elderly.


In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves' disease, a form of hyperthyroidism. Edema of the eyelids and conjunctival injection may be associated. Unilateral exophthalmos may be due to Graves' disease or to a tumor or inflammation in the orbit.


Entropion, more common in the elderly, is an inward turning of the lid margin. The lower lashes, which are often invisible when turned inward, irritate the conjunctiva and lower cornea. Asking the patient to squeeze the lids together and then open them may reveal an entropion that is not obvious.

Periorbital Edema

Because the skin of the eyelids is loosely attached to underlying tissues, edema tends to accumulate there easily. Causes include allergies, local inflammation, cellulitis, myxedema, and fluid-retaining states such as the nephrotic syndrome.


An epicanthus (epicanthal fold) is a vertical fold of skin that lies over the medial canthus. It is normal among many Asian peoples. These folds are also seen in Down's syndrome and in a few other congenital conditions. They may falsely suggest a convergent strabismus (see p. 182).

Herniated Fat

Puffy eyelids may be caused by fat. It pushes weakened fascia in the eyelids forward, producing bulges that involve the lower lids, the inner third of the upper ones, or both. These bulges appear more often in elderly people but may affect younger ones.

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