Acquired blepharoptosis is no mystery to optometrists, but the experiences of high-performance athletes and military personnel can put a new spin on our understanding of this condition characterized by droopy upper eyelids that restrict a patient’s field of vision.
Understanding functional ptosis
While acquired ptosis is most often attributed to age-related lid changes,1 it can also occur in younger people, especially those involved with athletics. When the lids become temporarily lethargic due to demanding physical activity, the condition may be more accurately described as functional ptosis, as it affects a patient’s production or function.
Consider a competitive motorcycle driver hanging off the edge of a bike moving 200 miles per hour, a volleyball player, or National Football League (NFL) lineman tracking a quickly moving ball and the locations of other players, or a military tactical shooter lying prone while looking upward through a scope.
Each must hold an unnatural stance and gaze for extended periods of time, which can put extreme strain on the levator muscle in the upper lids and the frontalis muscle of the forehead, causing progressive drooping over minutes and hours.
Potential sequelae of functional ptosis
In addition to sparking neck and brow pain and headache,2,3,4 functional ptosis affects higher-order aberrations and diffraction, decreasing an athlete’s visual acuity and contrast sensitivity—even if the lid never encroaches on the pupil margin.5
This means that the condition can slow an elite performer’s reaction time, compromising not only skills, but safety as well.
Fortunately, our field has excellent strategies for treating functional ptosis, from surgery to eye drops that temporarily lift the upper lid, and that makes it crucial for optometrists and ophthalmologists to recognize the condition so they can take measures to resolve it.
Contributing factors to functional ptosis
As a sports-vision expert, I’ve had the opportunity to work with physical performers of all levels and ages. In addition to serving as a team doctor for the Longhorns baseball players at the University of Texas, I regularly work with motorcycle and racecar drivers who compete at Circuit of the Americas, Austin’s Formula One (F1) and MotoGP track.
Further, I conduct field training for military special forces members, including US snipers and Israeli fighter pilots. I’ve observed plenty of athletes in action and have seen just how much functional ptosis can slow them down.
Along with the diminished visual field it causes, the stress that leads to functional ptosis also frequently sparks extreme dry eye, which can significantly decrease an athlete’s contrast sensitivity.6
In addition, some elite physical performers face a greater risk of vision restriction because they present with baseline ptosis, either due to naturally hooded upper lids or because they have undergone refractive surgery to replace their eyes’ own lenses with presbyopia-correcting intraocular lenses (IOLs).
While ptosis is a rare side effect of refractive lens exchange that is often preventable through careful patient selection, it’s one that should be considered in any sports vision evaluation.
The challenge of diagnosing performance-related ptosis
But what else should such an evaluation include?
First, athletes should be checked for functional ptosis even if they don’t complain of symptoms because many do not recognize that their lids begin to droop during competition.
Doctors should also be aware that standard tests may fail to detect functional ptosis because they assess the eyes in primary gaze. Therefore, optometrists should ask these patients to sit, stand, or lie in their primary performance positions before testing their eyes for sports-related ptosis.
Unfortunately, few eyecare professionals understand the need for this exercise, and many don’t have appropriate office space for it. Therefore, it can be beneficial for doctors to refer athletes to sports vision specialists, who can evaluate them in the facilities where they regularly train.
Treatments for functional ptosis
Once functional ptosis has been diagnosed, patients and their doctors can consider a number of treatments, which range from invasive to nonsurgical.
These include:
Blepharoplasty
Blepharoplasty can repair droopy upper lids by removing muscle, skin, and fat. However, this procedure carries the risks that come with any invasive surgery, including the risk of inducing exposure-related dry eye if the ptosis is overcorrected and the need for some downtime for recovery.
In addition, blepharoplasty can change the way a patient looks, and that may not seem desirable or necessary to athletes whose eyes meet normal standards in primary gaze.
Botox injections
For those seeking to avoid surgery, there is evidence that injecting botulinum neurotoxin A into the orbicularis oculi muscle can help manage ptosis. In eight subjects, a small 2022 study found that Botox noticeably lifted ptotic eyelids by week 2, but that its effects diminished after 24 weeks.7
However, this is a little-used strategy that will need more study before we incorporate it into standard care.
Oxymetazoline eye drops
A more widely used temporary fix for functional ptosis is Upneeq (oxymetazoline hydrochloride 0.1%, RVL Pharmaceuticals), a once-daily eye drop whose popularity is spreading quickly in athletic circles.
While Upneeq has frequently been used as a cosmetic treatment for acquired ptosis since its Food and Drug Administration (FDA) approval in 2020,8 it also provides a unique solution for patients with functional ptosis. Upneeq works by stimulating alpha-adrenergic receptors in Müller’s muscle, resulting in contraction and elevation of the upper eyelid for a temporary improvement in ptosis.
The drop works best in patients without excess skin along the tarsal plate. In other words, someone who can apply eyeshadow and easily see it in primary gaze is a good candidate for Upneeq.
To check the efficacy of the drug, practitioners should administer it monocularly, wait half an hour, and then alternately cover the eyes of patients as they mimic their typical athletic stances and gazes. Most will perceive a clear difference in their visual field, indicating that the medicine is beneficial.
Although Upneeq is not covered by health insurance, those who save their doses strictly for their athletic pursuits can help control their costs.
Sports vision training
Vision training techniques designed to boost performance and alleviate eyestrain include digital devices worn by athletes during practice, such as stroboscopic eyewear or mobile tablets that create virtual or augmented reality simulations.9 Other field exercises involve periodic relaxation techniques aimed at preventing dry eye.
These techniques are advantageous because they’re noninvasive and can be used either alone or as a complement to other treatments.
Evidence supporting the success of this approach is accumulating,9 with a recent small study I conducted demonstrating that members of the Texas Rangers baseball team who underwent sports vision training using game-like tasks on a mobile device achieved improvement in sports-related visual skills, including visual processing speed and visual acuity.10
Closing thoughts on functional ptosis best practices
With all this in mind, optometrists and ophthalmologists treating athletes and military personnel should remember a couple of best practices.
First, those who conduct sports vision evaluations must consider the way their patients typically stand and hold their heads when they engage in competitive physical activities.
Then, if functional ptosis seems probable, doctors should review all the treatments that can ease or prevent the condition, engaging in discussions with their patients about which to choose.
Since the beginning of human history, it’s likely that countless elite physical performers have struggled with functional ptosis. It’s exciting that we can finally provide them with a host of options for alleviating this frustrating and potentially dangerous condition.
