Eyelid ptosis is a drooping of the upper eyelid. It is usually caused by detachment of the muscle, which raises the eyelid.
This may be due to aging, trauma, contact lens wear or eye surgery. It may also be congenital (present at birth). This may affect your vision and you may notice that you are raising your eyebrows to lift the eyelids. This may in turn cause tiredness of the forehead muscles and extra forehead wrinkles.
What are the benefits of surgery?
The operation should lift the eyelid so that it is easier to see from that eye. This may improve not only your field of vision but also near and distance vision. There will also be a cosmetic improvement by making the eyelids more symmetrical.
Top - bilateral upper eyelid ptosis, worse on the right than the left; Bottom - after bilateral upper eyelid ptosis surgery
What is Ptosis Surgery?
Ptosis surgery is an operation to raise the upper eyelid. There are several different procedures, which are outlined below. Mr McCormick will discuss with you which one is most suited to you. The choice of operation depends mainly on whether you were born with the problem or if it developed later in life and how much the eyelid has drooped. Many operations are carried out under local anaesthetic without sedation. After anaesthetic drops have been put in both eyes, an injection of local anaesthetic is given just beneath the skin of the upper eyelid. This is similar to dental anaesthesia and usually takes less than 30 seconds to give. Local anaesthetic with sedation involves an anaesthetist administering intravenous sedation via a drip so that you are very relaxed and may not remember having the operation. General anaesthetic means that you are completely asleep.
Levator aponeurosis advancement
An incision is made in the natural skin crease of the upper eyelid. The muscle that lifts the eyelid is reattached or advanced and secured with sutures. The skin incision is closed with sutures, which are removed at 1 week. In some cases of congenital ptosis a levator resection is carried out. This is very similar to a levator aponeurosis advancement except that a segment of the muscle is removed and the muscle advanced in effect strengthening or tightening it. Both of these procedures are usually carried out under local anaesthetic, with or without sedation.
Mullers muscle resection and advancement
No skin incision is made. Instead an incision is made on the inside of the eyelid (posterior approach). A muscle called Muller’s muscle is partially removed and the cut end of it advanced and sutured. This is carried out under local anaesthetic, with or without sedation. This procedure is useful for small amounts of ptosis (e.g. 1-2mm)
People who are born with ptosis (congenital) and ptosis associated with muscular dystrophies often require this procedure. In congenital ptosis the eyelid muscle is usually abnormal so strengthening it with sutures does not work. A brow suspension procedure uses the forehead muscle to lift the eyelid. This muscle is called frontalis: it is what causes us to have forehead lines and it enables us to lift the eyebrow. Using either a non absorbable suture or tissue harvested from the thigh, the eyelid is connected to the forehead. The suture/tissue is tunnelled under the skin and eyebrow using 5 small incisions, each less than ½ centimetre long. Two of these are in the eyelid and 3 at the upper border of the eyebrow.
Are there alternatives to surgery?
A ptosis prop is a simple thin plastic arm that attaches to a pair of glasses. When the glasses are put on it gently pushes the eyelid upwards. It can be quite effective but is usually reserved for people who can’t have or don’t want surgery.
What will happen if I decide not to have surgery?
The ptosis may stay the same or gradually get worse. The ptosis does not damage the eyelid. In other words, leaving it un-operated does not make surgery in the future more difficult.
What will happen before surgery?
Before the operation you will be seen in the clinic by Mr. McCormick. He will ask you about the eyelid problem. He will also ask about other medical problems you have, medications you take and any allergies (bring a list or the tablets themselves with you). He will examine your eyes and take some measurements of your eyelid position. If you are to proceed with surgery the operation will be discussed in detail. This will include any risks or possible complications of the operation and the method of anaesthesia. You will be asked to read and sign a consent form after having the opportunity to ask any questions. If you are to have a general anaesthetic or local anaesthetic with sedation you will also see a preoperative assessment nurse. She/He will carry out blood tests and an ECG (heart tracing) if required. She/He will also advise you if you need to starve before the operation. If simple local anaesthesia is used you will not need any of these investigations and you will not need to starve prior to surgery.
What should I do about my medication?
Mr. McCormick will want to know all the medication that you take and about any allergies you have. In some cases you may be asked to stop or reduce the dose of blood thinning tablets like: warfarin, apixaban, dabigatran, aspirin, clopidogrel (plavix), dipyridamole (persantin). This decision is made on an individual basis and you should only do so if it is safe and you have been instructed by your GP, surgeon or anaesthetist. This will be discussed with you before surgery. You should avoid non steroidal anti inflammatory medications for 2 weeks prior to surgery. Other medication should be taken as usual. You should avoid herbal remedies for 2 weeks prior to surgery as some of these may cause increased bleeding at the time of surgery.
What are the risks and possible complications of surgery?
All surgery caries a risk of bleeding and infection, both are fortunately uncommon in these operations. Infection might present as increased swelling and redness of the skin. There might also be yellow discharge from the wound. It is treated with antibiotics. Bleeding may present as fresh blood oozing from the site of surgery or a lump appearing near the wound after the operation. Simple pressure on the area is usually enough to control minor bleeding. A collection of blood (haematoma) may be massaged and will usually settle without further surgery. A haematoma collecting in the orbit, behind the eye, may compress the nerve of vision and threaten eyesight. It is extremely rare for this to occur after eyelid surgery. It presents as pain, loss of vision and a bulging forwards of the eyeball. It is an emergency and as such is initially treated in an accident and emergency department. Whenever the skin is incised a scar may form. Every attempt is made by the surgeon to minimise and hide scars but sometimes they can be visible. It is difficult to achieve exactly the same height for each eyelid following surgery and some degree of asymmetry is unavoidable. Occasionally further surgery may need to be carried out to lift an eyelid further or to lower a lid that is too high. The contour or curve of the eyelid may initially look abnormal. This is often due to swelling and will usually settle within 3 months. If the lid is lifted too high, it may be difficult to close the eyelids completely. In some cases this over-correction is intentional and is managed by regular eye ointment until the eyelid drops naturally. In other cases further surgery may be needed to lower the eyelid. The cornea is at risk of ulceration, thinning and infection if the eyelids are not able to close completely after surgery. The eyelid is in close proximity to the eyeball. Although extremely unlikely, whenever surgery is carried out close to the eye there is a potential risk of damage to the eye and therefore to eyesight. You will have the opportunity to discuss the risks and benefits of surgery and anaesthesia with Mr McCormick and the anaesthetist prior to surgery.
What should I expect after surgery?
Usually a pad will be placed on the eye, which will remain until the following day when you can remove it. For 10 days the wound should be cleaned using boiled water that has cooled down and sterile cotton wool balls. After the pad is removed, antibiotic ointment should be applied to the skin wound three times a day for 2 weeks. If you have had Muller’s muscle ptosis surgery where the incision is on the inside of the eyelid, apply the antibiotic to the eye itself not the eyelid. Because ptosis surgery may temporarily impair your ability to close your eyelids you need to apply chloramphenicol ointment into the eye itself to protect the surface of the eyeball for the first 2 days. It is normal for there to be swelling of the eyelids following surgery. This gets worse over the first 48 hours then starts to improve. It may take up to 6 weeks to resolve. During the first 48 hours after the pad has been removed cold compresses may be applied, 5 minutes at a time as often as is comfortable. It is important to keep the wound clean in this period. You will usually be seen 1 week after surgery when any non-absorbable sutures will be removed. Some skin sutures are dissolvable and will be left to fall out by themselves. Often people notice that the non operated eye has dropped a little following surgery. This is not a complication of surgery but the brain adjusting for the new position of the operated eye. For this reason, although you may initially appear to have ptosis on one side only, it is often bilateral and you may wish to proceed with surgery to the other side at a later date. The time when you can return to normal activities varies from person to person. Many are happy to do so after 2 – 3 days and the vast majority after a week.
If an eye pad is placed it should remain until the next morning when you may remove it. For the first 10 days clean the wound using either sterile water sachets or boiled water that has cooled down and sterile cotton wool balls. Cool compresses should commence as soon as the pad is removed or immediately if there is no pad. 10 minutes, six times a day for the first 2 days. Chloramphenicol ointment to wound, four times a day for 2 weeks and to the eye for 2 days. No hot drinks or straining for 48 hours. Sleep at 45 degrees for 48 hours. Follow up appointment 1 week later for suture removal (if required).