Droopy eye lids (ptosis)
What is ptosis?
Ptosis is the medical name for drooping of the upper lid, which can be present in one or both eyes. A droopy upper eye lid can interfere with vision by affecting the top part of the visual field and may also be a cosmetic problem. Some people are aware of looking through of “fringe” of eye lashes which interferes with their vision.
Patients might have difficulty keeping their eyelids open particularly towards the end of the day, and may experience eyestrain or eyebrow ache from increased effort needed to raise the eyelids, and fatigue, especially when reading.
Ptosis most commonly occurs with aging, but can also be present from birth (congenital). It can also be caused by long-term contact lens wear (particularly rigid gas permeable lenses), trauma, eye surgery (including cataract surgery) and occasionally neurological or muscle disease.
What will happen at my clinic appointment?
In clinic I will assess your vision, examine your eyes, eye movements and eyelids and measure the degree of ptosis, ie the degree of eye lid droop. It is important to assess whether you have pre-existing dry eyes as symptoms of dryness can be temporarily worsened following the surgery. It can be helpful to see old photographs if you have any available to show me. Occasionally further tests and assessments may be required to assess the less common types of ptosis including: blood tests, orthoptic (formal measurements of eye movements) assessment and neurological assessment. If I think surgery can help we will discuss the risks and benefits of surgery. You may need a pre-assessment appointment depending on the type of anaesthetic that will be used (see below) and any other medical conditions that you may have.
How is ptosis treated?
The most common ptosis operation involves re-attaching or shortening of the muscle that lifts the upper eye lid (the levator palpebrae superioris muscle or levator for short). An incision is made in the skin in the existing eyelid crease (skin fold) and the muscle is found. It is reattached to the rigid tissue in the eyelid that gives the eye lid structure – the tarsal plate. This is done with sutures that either dissolve or remain under the skin surface. Ptosis surgery is often combined with removing excess skin in the upper eyelid (blepharoplasty). The skin incision is closed with further suturesthat are removed 1-2 weeks after the surgery. I perform multiple different types of ptosis surgery depending on the degree and cause of the drooping and I will tailor the surgery to your specific eyelid.
I will arrange for studio photos to be taken by a photographer prior to the operation so that I can plan the surgery and compare the position of the eye lids after surgery. The operation takes about 30-45 minutes per eye and is almost always a day case procedure, with no need for an overnight stay in hospital. It is usually done with local anaesthetic (injections to numb the eyelid skin) as this enables me to assess the eyelid position during the operation (by asking you to open and close your eyelids) so I can make adjustments as required. However, in some operations, for example for patients with severe tremor or anxiety, we can offer sedation, which makes you feel relaxed and a little sleepy during the operation. Very occasionally in adults and always in children we do ptosis surgery under general anaesthetic (asleep). If both eyes have ptosis it is may be best to operate on both sides at the same time to give the best chance of a symmetrical result. However, if there is a chance of excess bruising which can make the outcome less predictable or if there is a lot of bruising during the procedure it may be advisable to operate on one eye at a time.
There are other ptosis operations that are used in specific situations that are not discussed in this information sheet.
What are the aims of surgery?
The surgery aims to lift the eyelid(s) to achieve the following:
Improve the upper field of vision
Achieve a symmetrical height between the right and left sides
Achieve a natural and symmetrical curve or contour of the upper lid .
Retain the ability to fully close the eye.
Improve the appearance of the eyelids.
What should I do in preparation for surgery?
Blood thinning medications such as aspirin, clopidrogel (Plavix, Iscover) and warfarin can make bleeding more likely during and after surgery. If you are taking these drugs please tell me and we can discuss if and when to stop these medications prior to surgery. You might also consider stopping drugs like ibuprofen (Nurofen), fish oil, ginger, ginseng, St Johns wort, Arnica and garlic containing supplements 2 weeks before surgery.
If you smoke I would recommend that you stop smoking for at least 3 days prior and 1 week after surgery. This is important as smoking impairs wound healing and increases the risk of infection.
It may be sensible to avoid alcohol for a day before and a day after surgery. If you are having sedation or general anaesthetic, you are required to have nothing to eat or drink for at least six hours before surgery.
On the day of surgery please dress casually and wear a top which buttons at the front. Please wash your face on the morning of surgery and ideally men should shave. Do not wear any makeup, jewellery or contact lenses.
What happens after my operation?
An eye patch is sometimes placed over the eye after surgery. You can remove it the next morning unless the nurse or I give you different instructions. If surgery has been done on both eyelids and we need to patch both sides, one or both of these will be removed before you go home. You will be given drops and ointment to use and a clinic appointment will be made for a check-up about a week later.
You will usually need about one week off work. Try to avoid driving for a few days after the operation.
What are the possible complications or risks of surgery?
The local anaesthetic will wear off in the first few hours after surgery. At this time, the eyelid can become quite painful. You can take simple painkillers such as paracetamol if you have no allergies or contraindications to these. If you are in pain immediately after the operation, please let me know and we can give you painkillers. If you experience scratching, pain and a feeling as though your eye might be opening under the eye dressing its best for the dressing to be removed to avoid a pad abrasion.
Bruising of the eyelid or the whole area around the eye is common after eyelid surgery. You may have a ‘black eye’, which can take a week or so to settle. There also may be a scab along the suture line or some numbness of the upper eyelid.
You may have a little bit of bleeding or oozing of blood stained fluid in the hours or even first few days after surgery. You can gently dab this with a clean tissue. Occasionally there is more bleeding at about five days after surgery, particularly in people who take blood thinners such as aspirin. If there is a lot of bleeding at any time please put some firm pressure on the bleeding area with a pad of tissues and if it does not stop contact me immediately.
Infection is uncommon after eyelid surgery, although any wound can become infected. Infection will cause the eyelid to become increasingly red, swollen and tender a few days after surgery and there may be some discharge. If this occurs you should contact me or the clinic or your GP as you may need antibiotics.
Unsatisfactory eyelid position
About 90-95% of patients are corrected satisfactorily after the ptosis operation. Approximately 5-10% may require further surgery to adjust one or both eyelids because the eyelid remains too low or is too high, or the right and left sides are not symmetrical . A second procedure is most commonly delayed until after surgery when the tissues have healed. The eye lid position may continue to improve with time and if a reoperation is performed early whilst the fibroblasts (wound healing cells) are very active there is an increased risk of scar tissue formation. The longer the time interval between the first operation and the re-operation the more stable and predictable the result and therefore the better the outcome.
The droopy eyelid can reoccur, although usually many years after the initial operation. This may require a repeat procedure to correct it again. Repeat surgery such as this can be more complicated and lengthy to undertake due to scar tissue from the previous operation. More local anaesthetic may be required than for the first procedure.
Poor eyelid closure
The eyelids may feel ‘tight’ after surgery. Inability to close the eyelids after surgery (lagophthalmos) occasionally happens, although it is not uncommon to have a small gap between the eyelids when sleeping. Eye lubricating cream can be used to keep the surface moist and comfortable and this usually settles with time. However if the eyelid is overcorrected (too high), massaging the lid and pulling it down in a special, controlled manner can be performed to lower the lid, or revision surgery may be required, both of which I will discuss with you at the follow up appointment.
Dryness and grittiness of the eyes
The combination of eyelid surgery and the wider opening can cause the eyes to feel dry and gritty after ptosis surgery. This can usually be managed with artificial tear/lubricant drops, gels or creams and almost always settles in time. If the eyes are already slightly dry before surgery, they might be worse after the operation and I will discuss this carefully with you before the surgery.
There is a tiny (less than 1 in 10,000) risk of visual loss with any eyelid procedure.
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