Eyelid ptosis (also called blepharoptosis) is when the upper lid droops, sags, or falls and may reduce or block vision depending on severity. It can be congenital (present at birth) or acquired later, and may relate to problems with the muscles/ligaments that raise the eyelid or with the nerves controlling them. Ptosis (blepharoptosis) refers to a drooping of the upper eyelid margin. It is clinically distinct from “dermatochalasis” (excess skin). Ptosis is caused by weakness or separation of the levator muscle or a nerve abnormality, whereas dermatochalasis is a skin-only issue.
ICD-10-CM Code(s):
H02.40- - Unspecified ptosis of eyelid
Explanation: This is the most common code for acquired ptosis. It requires a 6th digit for laterality: H02.401 (Right), H02.402 (Left), H02.403 (Bilateral).
Use Case: Standard age-related (involutional) drooping of the eyelid muscle.
Q10.0 - Congenital ptosis
Explanation: Used when the ptosis is present from birth due to improper development of the levator muscle.
>- Use Case: Pediatric patients or adults with a documented lifelong history of the condition.
H02.41- - Mechanical ptosis
Explanation: Used when the eyelid is drooping because of a physical weight, such as a large cyst or tumor, pushing the lid down. Requires a 6th digit for laterality: H02.411 (Right), H02.412 (Left), H02.413 (Bilateral).
greekPtosis comes from Greek ptōsis, literally “a falling/a fall,” from a verb meaning “to fall.”
In medical word-building lists, -ptosis is explicitly glossed as “falling, drooping, downward placement, prolapse,” reflecting that original sense.