Ptosis of the Eyelids
What is Ptosis?
Ptosis is drooping of the upper eyelid margin (where the eyelashes are) to an abnormally low position. Normally, when your eyes are looking straight ahead, the upper eyelid margin should sit just at the top of the iris (the coloured part of your eye). In ptosis, the upper eyelid margin sits much lower, and may cover all or part of the pupil of the eye.
Ptosis can affect one or both upper eyelids.
What causes it?
In adults, ptosis can be due to many causes, and it is crucial that the correct cause is identified in order for the correct treatment to be applied.
In most cases, ptosis is due to aging of the muscle that lifts the upper eyelid (the LEVATOR muscle). We all develop varying degrees of ptosis as we get older, leading to the “sleepy-eyed” look. This is due to aging, stretching and detachment of the tendon of the levator muscle from its normal attachments into the firm plate of the eyelid (the tarsal plate) and into the skin. This form of aging ptosis is called INVOLUTIONAL ptosis. It usually affects both upper eyelids, but one side may appear lower than the other. Involutional ptosis is often accompanied by other aging changes in the eyelid, including excess eyelid skin and droopy eyebrows.
Involutional ptosis may also be worsened or brought on by long-term contact lens wear, or after any eye surgery (especially cataract surgery), due to further traumatic stretching of the levator muscle by eyelid manipulation.
Other causes of ptosis include:
MYOGENIC ptosis –due to weakness of the levator muscle (eg myaesthenia gravis, myotonic dystrophy)
NEUROGENIC ptosis –due to abnormalities in the nerves that supply the levator muscle (eg nerve palsies)
MECHANICAL ptosis –due to tumours, trauma and infection of the eyelid, which result in the eyelid being pushed or pulled down.
Some forms of ptosis are best treated with surgery, whilst other forms are best treated medically. Your ophthalmologist has the expertise to determine the correct cause and treatment for your ptosis.
How do I know I have a ptosis?
Patients with the common form of aging (involutional) ptosis will experience one or more of the following symptoms:
- Looking tired or “sleepy-eyed”
- “Heavy” discomfort in the eyelids, especially at the end of the day
- “Tired” eyes when reading, watching TV, computer work
- Blockage of the superior or central vision from the droopy eyelids
- Frontal headaches, from having to lift the eyebrows to help lift the droopy eyelids
Some patients may have to lift their chin or use a finger to manually lift their eyelids, in order to see, in severe cases of ptosis.
Symptoms which may indicate a more unusual form of ptosis include:
- Ptosis which is significantly worse at the end of the day or when tired
- Double vision
- Weakness in the arms or legs, or difficulty swallowing, or changes in the voice
Your ophthalmologist will comprehensively examine your eyelids and eyes to determine the severity and type of ptosis that you have. Sometimes, special tests and investigations will need to be performed to find the cause, and a neurologist may also need to be involved if there is a neurogenic or myogenic ptosis.
What can be done to repair Ptosis?
Surgery is the best method to fix the common form of aging (involutional) ptosis.
Surgery aims to identify, tighten and reattach the levator muscle to improve the height of the upper eyelid.
There are 2 main ways in which ptosis surgery is performed:
1.Through the skin of the upper eyelid
This is the most common technique. A fine cut is made in the natural crease of your upper eyelid, and the levator muscle is identified and tightened with internal sutures. The skin incision is closed with fine self-dissolving sutures.
If you also have excess skin or fat (puffiness) in the upper eyelid, or droopy eyebrows, these can also be dealt with at the same time, if appropriate.
2.Through the under-surface of the upper eyelid
This is suitable for certain patients. Here, the levator muscle is also identified and tightened with internal sutures, but from the under-surface of the eyelid. Therefore, there is no visible cut made to the skin. Your oculoplastic surgeon will advise you if this approach is suitable for your ptosis.
Ptosis surgery is best performed under local anaesthetic, and as a day case procedure.
In most cases, it will be covered by your health insurance.
What are the benefits of Ptosis surgery?
Some benefits of ptosis surgery:
- More “awake” and refreshed appearance
- Improved field of vision
- Reduced “heavy” or tired feeling to the eyelids
The aims and goals of surgery will be individualised to each patient, and be comprehensively discussed before surgery to ensure an optimal outcome.
What are the risks of Ptosis surgery?
The risks of any anaesthesia or sedation used during surgery will be discussed with you by your anaesthetist.
It is important to remember that ptosis surgery is not an exact science. Whilst every effort is made to achieve the desired height, contour/shape and symmetry between the eyelids, the final result may occasionally be unsatisfactory. Approximately 1 in 8 patients will require “touch-up” surgery to address any sub-optimal results.
The risks of ptosis surgery include (but are not limited to) the following:
- Asymmetry between the eyelid heights or contours (shapes)
- Scarring of the eyelid
- Cysts or whiteheads along the skin suture line
- Temporary numbness of the eyelid skin
- Dry eyes
Very rarely, vision loss can occur if there is bleeding into the orbit around the eye. This is more likely to occur in ptosis procedures that excise excess fat in the eyelids, or in patients who are on anti-coagulant medication (eg warfarin, clopidrogel).
Are there any alternatives to surgery?
Ptosis due to aging is unlikely to spontaneously improve.
There are no medications or eye drops that will definitively treat involutional ptosis.
Eye “exercises” also have not been shown to be of any benefit in improving ptosis.
What to expect after ptosis surgery?
Click here for information on Eyelid Surgery.
There will be bruising and swelling of the eyelids after surgery, which is often worse the day after surgery, and can take 1-2 weeks to subside. Sometimes the bruising and swelling extends into the lower eyelids and cheeks.
The eyelids may initially appear over-corrected (“over-done”) or the eyes may not fully close, in the first few weeks. This is normal, and usually settles as the swelling subsides within the first few weeks. If the eyes are uncomfortable or dry due to this overcorrection or incomplete closure, additional artificial tears are used to treat this until it improves.
Final eyelid height and contour and symmetry should not be judged until 4-6 weeks after surgery, when optimal outcome is usually reached.
You will be reviewed 1 week and 3 months after surgery to assess your results.