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Eyelid ptosis

What is eyelid ptosis?

It is a droopy upper eyelid.  If the lid edge displaces downwards it can cover part of the pupil and block the upper part of the vision, or cause fatigue.  In severe ptosis patients have to tilt their head back, or lift the eyelid with a finger, in order to see out well. These are functional problems.  Mild ptosis can be a cosmetic problem.

What is the cause of ptosis?

Congenital (present since birth) due to a poorly developed muscle.  It is more common in older adults where the muscle that lifts the eyelid thins and the eyelid drops.  It occurs with age, contact lens wear, trauma and, rarely, tumour or from a neurological problem, such as a nerve palsy or muscle weakness (myopathy).

Are you a candidate for ptosis surgery?

The oculoplastic surgeon will examine the whole of the upper and middle part of the face to detect asymmetry.  Eyelid measurements are made and photographs taken of the eyelid position and area around the eyes.  The under surface of the lids and the front surface of the eye are carefully examined with a special microscope and visual fields may be mapped.  Depending on the findings, you will be advised of the best treatment.

What happens at eyelid ptosis surgery?

Eyelid ptosis surgery is usually done under local anaesthesia as a day case.  Local anaesthetic drops are placed on the eye and a small bleb of local anaesthetic is given into the upper eyelid to numb the area.  A short incision is made in the natural skin crease and the eyelid raising muscle (the levator palpebrae superioris) is identified and shortened to lift the eyelid.  Dissolving sutures are used inside the lid and on the skin.

What happens  after surgery?

An eye pad may be applied for 24 to 48 hours.  The upper eyelid will usually appear swollen for the first 7 to 10 days.  The wound should be kept clean and dry and there should be no discharge from the wound.  Instructions will be given on how to clean the wound daily and lubricating and antibiotic drops, or ointment, prescribed for 1 to 3 weeks. 

What are the risks of ptosis surgery?

  • Local bruising and swelling of the eyelids.
  • A small risk of wound infection to the eyelid.
  • Risk of over-correction (eyelid too high), or under-correction (eyelid still too low) which may require a second operation.
  • Inability to close the eyelids completely, which may be temporary or permanent.  This requires lubricant drops and ointment.  If it is permanent and threatens the vision, then the eyelid will have to be subsequently lowered again to protect the eye.
  • Sometimes if the other eye has a tendency to drop, this may become more noticeable after ptosis surgery on one side.  Your oculoplastic specialist will warn you of this possibility. 

What are the benefits of ptosis surgery?

  • Improved upper part of your visual field and quality of vision, where part of the eye was previously covered by the upper eyelid drooping and interfering with visual function.  
  • Restoring the normal anatomical appearance of the eyelid.
  • Improved cosmesis and symmetry.

What is congenital ptosis?

This is drooping of the eyelid, affecting one or both eyes, present since birth.

What causes congenital ptosis?

Most causes of congenital ptosis are unclear, but it is usually due to an incomplete development of the muscle which raises the eyelid, the levator palpebrae superioris muscle.

Can this condition be associated with other eye problems?

Children with congenital ptosis may also have an amblyopic or lazy eye, strabismus or squint (eyes that are not properly aligned or straight), or refractive error (need for glasses).  Therefore all children with ptosis should have a thorough examination by an orthoptist for visual development, with a refraction by the oculoplastic surgeon and eye and eyelid measurements.

What is the treatment for congenital ptosis?

Congenital ptosis is treated surgically and the operation is based on the individual child's severity of ptosis and the strength of the levator palpebrae superioris muscle.  If the ptosis is not severe, surgery can be deferred until the child is aged 3 or 5 years i.e. the pre-school years.  However, if the ptosis is interfering with the child's vision, surgery may be performed at a much earlier age, even as young as 3 weeks, to allow proper visual development. 

How is the operation done?

Ptosis surgery on a child is done under general anaesthetic, usually as a day case.  An eye patch is rarely put on and the stitches, or sutures, on the skin are dissolvable. 

Types of surgery:

Surgery can be done as in an adult, involving a small skin incision into the skin crease of the upper eyelid or, if the levator palpebrae superioris is extremely weak, it may be necessary to do a sling operation

What is a sling operation?

A frontalis sling, or brow suspension, is where the muscle of the forehead (frontalis muscle) is used to help lift the eyelid by placing a sling of material, either taken from the child or synthetic, between the forehead and the eyelid.  Tissue taken from the child is called autogenous fascia lata and is a small strip of tendon taken from the leg through a 1 cm incision just above the knee, on the side of the leg.  If the child is too young to have this done, and a sling or brow suspension is required before the age of 4 years, synethetic material, such as silicone, or prolene, or gortex, may be used instead.

What will happen after the operation?

The wound should be kept clean and dry and there should not be any discharge.  There will be a bit of swelling and redness of the eyelid for the first 1 to 3 weeks.  The child will be prescribed lubricating antibiotic eye drops and cream, to be used as directed. 

What are the risks of congenital ptosis surgery?

  • Bruising of the eyelids and around the eye.
  • A small risk of infection of the eyelid or the eye.
  • Possibility of under-correction or over-correction of the eyelid height, requiring a second operation.
  • Unable to close the eyelid completely, with the eye slightly open at night.  This is usually not a problem and the parents should be warned of this.  There is a strong protective reflex, called Bell's phenomena, which protects the surface of the eye on blinking and eyelid closure, so that as long as the muscle that closes the eyelid is strong, there is no risk to vision. 

What are the benefits of congenital ptosis surgery?

  • Prevention of lazy eye or amblyopia and strabismus or squint.
  • Improved appearance will improve the child's self-confidence, especially if being teased at school
  • Restoration of a normal anatomical position of the eyelid.
  • Restoration of the normal cosmetic appearance of the eyelid.