Conditions: Ptosis

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What is ptosis?

Ptosis means downward displacement. Ptosis in ophthalmology usually refers to a drooping upper eyelid but it can also refer to a drooping of the eyebrow (brow ptosis).

Congenital Ptosis

What causes congenital ptosis?

Ptosis which is present at birth is often caused by poor development of the eyelid-lifting muscle, called the levator muscle.

What problems can occur as a result of childhood ptosis?

The most serious problem is amblyopia. This is poor vision in an eye that failed to develop normal sight in the early years of life. The ptosis can also result in an abnormal head posture with the head tilted backwards. This can cause neck problems.

How is congenital ptosis treated?

The treatment is usually surgery. Mild or moderate ptosis in children usually does not require surgery early in life, but severe ptosis does require early surgery in order to prevent amblyopia. During surgery the levator muscle is tightened. In severe ptosis when the levator muscle is very weak, the eyelid may be suspended from the brow so that the forehead muscles do the lifting (a frontalis suspension procedure). This is done using either a nylon (polypropylene) stitch or fascia lata, a wide tendon sheet in the outer aspect of the thigh, accessed via a small incision just above the knee.

	Before bilateral congenital ptosis with poor levator function (movement up and down of the eyelids)		After bilateral frontalis suspension surgery

What causes adult ptosis?

The most common type of adult ptosis is caused by a separation of the levator muscle tendon (the levator aponeurosis) from the lower aspect of the eyelid (the tarsus) or from a stretching of the tendon. This can occur as a result of ageing, after eye surgery e.g. glaucoma surgery, contact lens wear, or following an injury.

What are the signs and symptoms of adult ptosis?

A drooping eyelid is the primary sign of ptosis. There may be some vision loss in the upper field of vision. There may be fatigue from attempting to elevate the lid or there may be a marked compensatory elevation of the eyebrows which act as a secondary elevator of the eyelids. Droopy eyelids can have a profound effect on a person’s cosmetic appearance and self-esteem.

How is adult ptosis treated?

The treatment is usually surgery although there are a few very rare disorders that may be treated medically (e.g. myasthenia). During surgery the levator tendon is tightened, usually under local anaesthesia with intravenous sedation provided by an anaesthetist (“twilight anaesthesia”). Very rarely the lids may be attached to the brow so that the forehead muscles do the lifting. The eyelids may be suspended using synthetic material e.g. a nylon suture (polypropylene), or tissue taken from the outer aspect of the thigh (fascia lata) through a small incision just above the knee.

	Patient with contact lens-induced ptosis		The same patient 6 weeks following a left levator aponeurosis advancement

An ophthalmic consultation can provide a comprehensive assessment of your ptosis, and a discussion of the available treatment options. Ptosis surgery can be combined with an upper lid blepharoplasty (eyelid lift, eye lift, or cosmetic eyelid operation).

What are the risks of ptosis surgery?

The risks of ptosis surgery include infection, bleeding and reduced vision, but these complications occur very infrequently. A temporary inability to fully close the eye after ptosis surgery is not uncommon. Lubricant drops and ointments are frequently useful in this situation. It is also important to know that although improvement of the lid height is usually achieved, perfect symmetry in the height and contour of the two eyelids and full eyelid movement is sometimes not achieved. More than one operation is occasionally required.

What happens at surgery?

Ptosis surgery can be performed under local anaesthesia, local anaesthesia with sedation by an anaesthetist (“twilight anaesthesia”), or under general anaesthesia. In adults it is usually preferable to perform the surgery under local anaesthesia with some mild sedation. A small incision is made in the upper eyelid skin crease to camouflage the scar. The surgery is performed using a "Colorado needle" which greatly reduces bleeding and is safer than a laser. Tiny dissolvable sutures are inserted to close the wound.

The procedure may be carried out as a day case or with an overnight stay in hospital depending on the patient's individual requirements. After surgery, the eyes are initially covered with pressure dressings to reduce postoperative swelling and treated with antibiotic ointment. A lower eyelid stitch is normally placed (a "Frost" suture) and taped to the forehead so that the lower eyelid is pulled over the cornea for eye protection from the dressings. The dressings are normally left in place overnight and removed the following day in clinic along with the suture.

What happens before ptosis surgery?

You will visit the hospital a few weeks before the date of your surgery, to have a preoperative consultation with your surgeon. He will ask you questions about your current and past health, and will need to know about any allergies you may have, medications you are taking (including over the counter products e.g. aspirin, indomethacin or vitamin supplements), previous surgery, and whether you smoke. You may also be required to have a physical examination of your heart and lungs by your GP to make sure it is safe for you to have an anaesthetic. You may need to have some routine laboratory tests, such as urinalysis (tests of your urine), chest x- rays, or complete blood cell counts. These should reveal potential problems that might complicate the surgery if not detected and treated early. No testing may be necessary if you are in good health and younger than age 65.

Please answer all questions completely and honestly as they are asked only for your own well being, so that your surgery can be planned as carefully as possible. If you are unsure of the names of any medications, bring them with you. You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure. If you can, try to stop smoking at least six to eight weeks prior to surgery.

Your eyes are examined carefully; your vision in each eye is measured, the pressure within each eye is measured, and the back of the eye (called the retina) is examined as well as the eyelid itself. The positioning of the eyelashes is noted. The surgeon takes a photograph of your face before surgery so that the results of surgery can be compared with the original appearance.

What should I expect at the hospital?

The procedure will be explained to you and you will then be asked to sign a consent form saying that you understand the procedure and that you have been told about any possible complications. Very rare complications will be described, as well as any more common ones, so try to keep things in perspective. If you have any questions or worries, make sure they are answered, before you sign the consent form. You are quite free to go away and consider the options before committing yourself to any surgery. You can then write to us requesting further information if required.

How long will I stay in hospital?

Most eye surgery procedures are performed as day cases where you arrive at the hospital in the morning and leave an hour after the operation. Someone must be available to take you home and stay with you for up to 24 hours after the operation. Alternatively an overnight stay may be required if you live some distance from the hospital.

What happens after a ptosis surgery?

You will be asked to clean the eyelids and repeat the application of antibiotic ointment to the eyelid wound 3 times a day for 2 weeks. The stitches used are usually dissolvable but can be removed after 2 weeks if necessary. The skin around the eyes should be protected from direct sunlight, by avoidance if possible or by using sunglasses. Wearing make-up should be avoided for at least 2 weeks. Postoperative bruising and swelling usually takes 2-3 weeks to subside. The upper eyelid scar following a levator advancement is hidden within the upper eyelid skin crease. The tiny scars in the forehead following a frontalis suspension procedure gradually fade to fine marks within a few weeks to months.

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