Ptosis is a drooping of the upper eyelid. A droopy eyelid can cause blurring of vision or watering of the eye due the weight of the eyelid pressing on the front of the eye.
If left untreated, a ptosis in a child can cause affect visual development with consequential amblyopia (lazy eye). It can also affect the superior field of vision causing patients to raise their eyebrows constantly (leading to headaches) or tipping their head back in an attempt to gain clear vision. It can become a cosmetic issue, affecting a persons self esteem and often patients prefer not to get photographed (as the ptosis often looks more pronounced in photos).
The commonest cause of ptosis is as a result of ageing which stretches the tendon & muscle of the eyelid. In addition, ptosis can occur after contact lens wear, following an injury or previous surgery to the eye (e.g. cataract) or as a manifestation of another disease involving the eyelid muscle or its nerve supply, e.g. myasthenia gravis or third nerve palsy in diabetes.
Ptosis can also be present at birth (congenital ptosis) due to abnormal development of the muscle that lifts the eyelid, which can be hereditary.
How can ptosis or drooping of upper eyelid be treated?
Ptosis is most commonly treated by surgical correction.The aim of surgical correction is to restore the anatomy, by addressing the various causative factors. Most ptosis surgery in adults is performed under local anaesthesia with or without sedation. All ptosis surgery in children is performed under general anaesthesia.
Non Surgical Treatments : Occasionally patients with eyelid trauma or a myopathic cause of ptosis (with restricted eye movement as seen in chronic progressive external ophthalmoplegia, etc) may benefit from ptosis props/ crutch spectacles or a scleral contact lens.
Although the outcome may not as good an aesthetic result, they are an option to consider in certain cases, and these options will be discussed by your surgeon.
Surgical correction for droopy upper eyelid
The commonest operation for age related ptosis is a tightening of the tendon / muscle that lifts the eyelid. Less commonly a strip of tissue from the thigh (called fascia lata) or a silicone band is used to lift the eyelid. The cut can be hidden within the inside of the eyelids resulting in scarless minimally invasive operation or it is hidden within the skin fold (thus hiding the scar). Depending upon the cause of ptosis, surgery can range from a simple 30 minute procedure to a more complicated 90 minute procedure. Recovery times are generally quick, most patients achieving complete recovery within 14 days.
What are the potential risks & complication of Ptosis surgical correction?
The risks of ptosis surgery include:
- Infection : this is very rare, occasionally the stitches may have an infective or inflammatory response, which settles with oral and topical antibiotics.
- Scarring (generally hidden in the skin fold). Normally stitches are visible for the first week, then when they are removed, a faint scar is visible. The scar may seem a bit thickened & red for 6 to 12 weeks, becoming almost invisible after that period. Not every scar heals equally well. A thickened or reddened scar can be improved with silicone scar remodelling gel, but the treatment needs to be continues for months to have a good result.
- Large bruise or haematoma. This is minimised by avoiding heavy exercise for 2 weeks after surgery, stopping aspirin and other anticoagulants (if safe so to do) 2 weeks pre operatively, and regular use of ice packs. A haematoma may mean you have to go back into theatre to have the blood clot evacuated and then be re-stitched with the risk of a worse scar.
- Theoretical risk to vision. Any eyelid surgery carries the risk that an undiagnosed infection or bleed could damage the optic nerve. This is so rare that in comparison a normal car journey is a much greater risk to your vision.
- Asymmetry of eyelid shape, height or upper lid fold : this is rare, but can occur. Often asymmetry may be due to lid bruising and settles spontaneously as swelling resolves. Rarely, this may require revision surgery. Occasionally pre existing asymmetry of the face, eyebrow or eyeball position, may be responsible, however this will be discussed with you prior to the operation by your surgeon.
- Temporary poor blink, as the muscle that shuts the eyelid has been cut to access the muscle that lifts the eyelid. Generally blink returns to normal within 12 weeks.
- Incomplete eyelid closure / nocturnal lagophthalmos (eyelids staying a bit open when asleep) or lid lag (upper eyelid hangs up in downgaze). This is seen in congenital ptosis patients who undergo surgical correction. This is because the muscle that lifts the eyelid has not developed properly & so does not tighten (to lift the eyelid) and does not relax (to allow the eyelid to close). This side effect may warrant permanent use of lubricant drops and ointment, to keep the eye comfortable.
1. Child with congenital left upper lid ptosis, with 6mm levator function. The droopy eyelid is occluding visual axis and needs to be corrected to prevent development of ambylopia (lazy eye).
2. 1 week post surgical repair of left upper lid congenital ptosis with levator resection
3. 2 years post surgical repair of left congenital ptosis
1. Correction of congenital ptosis with resultant “Lagophthalmos” (incomplete eyelid closure) which is secondary to a dystrophic levator muscle that does not relax to allow eyelid closure.
2. Correction of congenital ptosis with resultant “Lid lag ” ( hang up of eyelid on down gaze) which is secondary to a dystrophic levator muscle that does not relax to allow eyelid movement.
3. Two years post surgical repair of left congenital ptosis
- Recurrence of ptosis: This can occur early post surgery (3 months) or late (after a few years), due to early suture dissolution or a weakening/stretching of the scar. This will need to be corrected by re-operation.
- Contralateral ptosis: The eyelids are a pair, and often when one eyelid is droopy, the contralateral eyelid can appear to be in a “normal” position. However, immediately after surgery, the “normal” eyelid can droop. This can correct itself within a few weeks or require a ptosis correction.