What is ptosis?
Ptosis is pronounced “toe-sis”.
The upper eyelid normally covers only a small amount of the coloured part of the eye (the iris). If the eyelid sits lower than this, it is called ptosis (or sometimes blepharoptosis). It may affect one (as in the patient photo below) or both upper eyelids and one may be more affected than the other.
What causes ptosis?
There are many causes of ptosis. The following is a list of some of the more common causes:
- being born with a droopy lid or lids (congenital ptosis)
- advancing age (involutional or age-related ptosis)
- injury (traumatic ptosis)
- muscle disease (myopathic ptosis)
- damage to the nerve to the muscle that lifts the eyelid (neurogenic ptosis).
How is ptosis diagnosed?
Usually the cause of ptosis can be diagnosed by your specialist without the need for special tests. In some circumstances, special tests may need to be ordered or another specialist may be asked to see you to help establish a cause for the ptosis. It is important to know why the ptosis has occurred as the cause can influence the treatment.
How is ptosis treated?
Most types of ptosis are treated by surgery. Some rare forms are treated with medication. Occasionally an operation is not advisable.
Ptosis surgery
In most cases, the aim of a ptosis operation is to return the eyelid to a normal position, where it covers only a small part of the coloured part of the eye (the iris). Sometimes it will not be possible to return the eyelid to this position but some improvement should still be expected. The surgery aims to even the left and right eyelids with each other, but in some less common circumstances, this may not be possible or advisable.
An incision is made in the fold or crease of the eyelid so that the scar is largely hidden and not visible when the eye is open. If the eye is closed, a thin fine scar may be visible in the early months after surgery but should fade after that.
Ptosis occurring in older people
In some ptosis operations, and especially those performed for age-related ptosis, there is usually some excess skin in the upper eyelid that would hang over the eyelashes if it was not reduced. In these cases, some of the excess skin may also be removed at the time of surgery.
What sort of anaesthetic will be used?
Surgery for ptosis is usually performed under a local anaesthetic because this allows the surgeon to more accurately adjust the level of the eyelid during the operation. Before any local anaesthetic is injected into the skin of the upper eyelid, your anaesthetist will give you some medicine in the form of a sedative and pain killer so that the eyelid injection will not be painful. Often it is not even noticed or remembered. During the operation, you will be aware that the eyelid is being operated on but it will not be painful. It is important for you to say if there is any pain during the operation.
For children with congenital ptosis or in a few adults, a full general anaesthetic will be required.
How long will I stay in hospital?
Most patients having ptosis surgery can go home on the day of surgery, but a few are kept in overnight after the operation. You will be told at the time the surgery is booked how long you will stay in hospital.
What problems can occur with ptosis surgery?
A large majority (about 80-90 per cent) of ptosis operations are successful in returning the upper eyelid to a more normal position. In a small proportion of cases however, the eyelid may be too high or too low, or not matched with the other side. Sometimes the shape of the upper eyelid may not be right. If any of these things occur and are noticeable enough to be a concern, it is nearly always possible to correct this with a second operation to adjust the eyelid.
It is very rare that more than two operations are required. In most patients however, only one operation is required to achieve a satisfactory result.
Other problems with ptosis surgery are uncommon, but may include:
- A dry eye after the surgery: this is often temporary and will settle after some weeks but if it does not, then lubricating drops and ointments may be required.
- Difficulty closing the eye: this can occur especially in the first few weeks after the surgery and can lead to dryness of the eye. In most cases, the eyelid closure will return to normal.
- Infection in the eyelid: while this is very rare after ptosis surgery, it can be treated with antibiotics.
- Change in vision: sometimes the eye can be a little different in its focus after ptosis surgery. This usually settles after several weeks but occasionally your glasses may need to be slightly adjusted.
- Scarring: there is always a thin scar hidden in the fold of the eyelid and this is not visible when the eye is open. In the first weeks after surgery, the scar may feel tight and can be a little ‘lumpy’. Over several months, this feeling of tightness and hardness of the scar passes so that the scar is barely visible with the eye closed.
- Numbness: the upper lashes and skin above the lashes may be numb for some weeks after the surgery. This is normal and recovers in about 6–8 weeks.
- Opposite eyelid: if ptosis surgery is performed on one side only, sometimes the other eyelid may droop a little as the two sides work together.
Follow up care
After you are discharged from hospital, you will usually be seen again in the clinic after about a week for a final check-up, and then again about 2–3 months after the surgery.
During the first week or two, you will be asked to apply ointment to the eyelid wound, and sometimes also lubricating drops, gels or ointments for the eye. Pain is usually mild after ptosis surgery and strong pain killers are very rarely needed. The eyelid(s) are usually bruised and swollen for 1–2 weeks only.
