Ptosis: Drooping Eyelids
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Age related ptosis of both upper eyelids: Before surgery
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Age related ptosis of both upper eyelids: After surgery
What is Ptosis?
Ptosis (pronounced TOE-SISS) commonly refers to a drooping upper eyelid. This droop may be only slight or it may be enough to cover part or all the eye. It can affect one or both upper eyelids.
What Causes Ptosis?
- default_titleThe commonest cause is as a result of ageing. The main tendon within the eyelid (levator aponeurosis), which helps lift up the eyelid when looking up, may become stretched resulting in an eyelid tendon which essentially is too long - leading to a drooping eyelid
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Less common causes include:
- default_titleFollowing an injury or surgery to the eye e.g. glaucoma surgery
- default_titleFrom long term contact lens wear.
- default_titleAs a complication of another disease involving the eyelid muscle or its nerve supply, e.g. stroke, myasthenia gravis or diabetes.
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Contact lens related ptosis
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Immediately following surgery
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After surgery. The swelling has disappeared
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The surgical wound disappears in time
2. In children
Ptosis can be present at birth (congenital ptosis) as a result of abnormal foetal development of the muscle involved in lifting the eyelid. Ptosis in children may also be caused by eye movement abnormalities or diseases affecting the muscle or nerve of the eyelid. Uncommonly, the ptosis may also be associated with abnormal movements of the eyelid itself such as winking whilst chewing, known as “Jaw Winking”.
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Left upper eyelid ptosis due to contact lens wear.
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2 weeks following surgery
Symptoms and Signs of Ptosis
Severe eyelid ptosis of both upper eyelids: this lady's eyelids are so droopy that they interfere with her vision even when looking ahead.
- default_titlePatients may complain about the cosmetic appearance of a drooping eyelid
- default_titleThe droopy eyelid may obstruct the upper field of vision
- default_titlePatients may tip their head back or raise their eyebrows in an effort to raise their eyelids, occasionally leading to headache or neck strain
- default_titleA severe or moderate congenital ptosis, especially if it blocks the line of sight, may hinder normal childhood development of vision, causing a lazy eye (also called amblyopia), which if left untreated, may lead to permanently poorer vision in the affected eye
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How is Ptosis treated?
Treatment may include the following:
Investigations e.g. blood tests. To determine a possible cause of the ptosis.
Non surgical methods for patients who don't want surgery or who aren't suitable for surgery e.g. using ptosis props or Lundi loops. These are typically fitted by specialist opticians.
Surgery to lift the position of the eyelid.
- default_titleThe operation is usually done as a day case procedure under local anaesthetic for adults. Surgery performed in young children is usually done under general anaesthesia.
- default_titleThe type of surgery performed is dependent on the individual characteristics of the patient’s ptosis, however the vast majority of patients do very well with minimally invasive surgery with no visible scarring. This entails making a small incision within the skin crease of the eyelid, finding the main tendon within the eyelid (levator aponeurosis), strengthening the levator aponeurosis tendon using sutures and then finally suturing the skin back together (Levator aponeurosis advancement). Some surgeons prefer to offer this operation via a posterior approach, by making an incision in the back of the eyelid.
- default_titleMost ptosis correction operations are performed under local anaesthetic as an outpatient procedure and take 20-30 minutes.
- default_titleMany patients undergoing surgery for age related ptosis also request simultaneous blepharoplasty (removal of hooded excess skin of the upper eyelids) so that a better cosmetic result can be achieved. Here the excess tissues of the eyelid are removed at the same time as the ptosis operation and on average extends the operation by 30 minutes. There are no additional scars or incisions since both operations are performed via the same incision, using the same anaesthetic.
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Congenital ptosis: this young lady was born with a drooping right upper eyelid.
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1 week following surgery
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4 weeks following surgery. (Mascara: patient's own)
Before and after pictures of Ptosis Surgery
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Before Upper and Lower Blepharoplasty Surgery with Ptosis Correction for cosmetic improvement
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2 weeks following surgery
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The patient remarked how her friends were amazed with the subtle natural looking improvement
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Ptosis due to previous trauma
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4 weeks following surgery.
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Contact lens related ptosis
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2 weeks following surgery
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Note the tiny wound which often disappears
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Age related ptosis of both upper eyelids
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2 weeks following surgery
It is often advisable to have someone accompany you on the day of surgery, particularly if the surgery is performed as a day case procedure. Rarely, the eyes may be covered with pressure dressings for an hour, to help reduce the build up of any postoperative swelling. As the anaesthetic wears off, your eyelids may feel tight and sore, but this wears off quickly and is usually easily treated with simple painkillers. If the postoperative pain is severe, this may indicate a serious problem and patients should get in touch with their surgeon immediately.
You will be advised to sleep upright and apply regular cold compresses to the eyelids to reduce the postoperative swelling. It is especially important to keep your wounds clean and dry. Eye drops are commonly provided to help soothe the eyes which can feel slightly dry due to temporary impairment of the normal blink reflex following surgery.
- Swelling and minor bruising is normal and peaks about 24-48 hours after the procedure.
- However 90% of the swelling usually disappears by 10 days but minor swelling may still persist for 10-12 weeks depending on the complexity of the procedure. For example, most of Mr Cheung's patients who return to work after 10-14 days.
- The first clinic visit following surgery is usually scheduled for 1 - 2 weeks following surgery.
- Make up can be safely used usually from the 10th postoperative day.
- Most patients are usually discharged at 3-6 months following surgery.
During consultation, Mr Cheung will assess:
• Eyelid height and symmetry
• Muscle function
• Tear film and eye surface health
You will have the opportunity to discuss expected outcomes, limitations of surgery, and any concerns you may have before deciding whether to proceed.
All surgical procedures carry risks. Most side effects are temporary and include bruising, swelling, mild discomfort, dryness, and blurred vision from ointment use.
Possible complications include:
• Under-correction or over-correction of eyelid height
• Asymmetry between the eyelids
• Difficulty fully closing the eye during early healing
• Dry eye symptoms
• Infection or delayed wound healing
• Visible scarring (usually well hidden in the crease)
Rare but serious complications include bleeding behind the eye which can threaten vision, although this is extremely uncommon in eyelid surgery.
Further surgery may occasionally be required and is usually deferred until healing is complete.
The success of most ptosis correction operations is very dependent on the health of the internal structures e.g. the levator aponeurosis. Unfortunately, these structures are discovered to be weak or damaged during the surgery and therefore the risk of complications such as recurrence, asymmetry and under correction may be higher in these patients.
