Conditions: Ptosis

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What is ptosis?

Ptosis means downward displacement of an organ or tissue. Ptosis in ophthalmology usually refers to a drooping upper eyelid (blepharoptosis) but it can also refer to a drooping of the eyebrow (brow ptosis) or the midface (midface 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 due to occlusion of the eye by the ptosis. Amblyopia is poor vision in an otherwise healthy eye that has 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 or can interfere with normal motor development. Patients should be examined to ensure that amblyopia is not also due to any other eye problems e.g. a squint, or a untreated optical error that might require glasses.

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 or brow 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, long term 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 (the levator aponeurosis) is tightened, usually under local anaesthesia with intravenous sedation provided by an anaesthetist (“twilight anaesthesia”). This is referred to as a “levator aponeurosis advancement”. For minor degree of ptosis, an alternative operation can sometimes be performed via an incision on the inside of the eyelid. This is referred to as a “Müller’s muscle resection”. Not all patients are suitable for this, however e.g. contact lens wearers. Very rarely the lids may be attached to the brow so that the forehead muscles do the lifting. This is referred to as a “brow or frontalis suspension procedure”. 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.

	A patient with a bilateral contact lens induced ptosis.		The same patient 6 weeks following a bilateral levator aponeurosis advancement procedure.

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 “twilight anaesthesia”. For a levator aponeurosis advancement, 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. A Müller’s muscle resection procedure is performed via an incision on the inside of the eyelid with the use of the same tiny dissolvable sutures. This leaves no visible scar.

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 sometimes 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 may be left in place overnight and removed the following day in clinic along with the suture. For some patients, no dressing is required and only cool packs are used for 24-48 hours intermittently.

You will need to use artificial tear drops very frequently for the first few days. These will be prescribed for you e.g. Hyabak drops, Systane eyedrops preservative free, or Viscotears preservative free, or Liquifilm tears preservative free, or Cellusvisc drops and Lacrilube ointment at bedtime. It is often recommended that you use Lacrilube ointment to the eyes 2 hourly for the first 48 hours after surgery but note that this will cause blurring of vision. (You should not drive for the first few days after surgery). These medications can be purchased from my clinic Face & Eye or online from the clinic’s online shop (www.faceandeyeshop.co.uk).

What happens before ptosis surgery?

You will visit the clinic to have a preoperative consultation with me. This usually lasts approximately 30 minutes. You will be asked to complete a healthcare questionnaire before seeing me, providing information about your current and past health, about any previous eye, eyelid or facial surgery or treatments including refractive surgery or laser eye surgery, and any previous non-surgical aesthetic treatments e.g. Botox injections, as these can cause a ptosis.  I need to know if you have a past history of any eye problems e.g. dry eyes, or if you use contact lenses. I need to know about any allergies you may have, medications you are taking (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements), previous major surgery or illnesses, any past dermatology history and whether or not you smoke.

You will have your blood pressure checked by the nurses. The nurses are also happy to answer any further questions and to show you the facilities at Face & Eye, including the operating theatre if it is not in use.

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 as long as these are not medically essential. You might need to check this with your GP. Any anti-inflammatory medicines e.g. Ibuprofen, Nurofen must be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. Your blood pressure should also be under good control if you take medications for hypertension. This is very important.

If you can, try to stop smoking at least six to eight weeks prior to surgery.

Your vision in each eye is measured. Your eyes are examined carefully using a slit lamp (a special ophthalmic microscope). Your tear film status is determined and the back of the eyes (called the retina) is examined as well as the eyelids themselves. Photographs of your face and eyelids are taken before surgery so that the results of surgery can be compared with the original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.

What should I expect at the clinic/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 me requesting further information if required.

How long will I stay in hospital?

Most eyelid surgery procedures are performed as day cases where you arrive at the clinic or 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 in a local hotel or in hospital 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, or you may need antibiotic drops to the eye if you have undergone a Müller’s muscle resection procedure. 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. It is then preferable to use mineral make-up. The nurses at Face & Eye can advise you about this. Postoperative bruising usually takes 2-3 weeks to subside. Swelling takes longer. You will not see a final result from the surgery for about 3 months, although the appearance of the eyelid is usually acceptable after 3-4 weeks. The upper eyelid scar following a levator advancement is usually 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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