What is eyelid ptosis?

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). You may be aware of the droopy eyelid appearance. 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 with a more natural open appearance. 


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 you are most suited for. 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 with 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, whilst an anaesthetist administers intravenous sedation via a drip so that you are very relaxed and may not remember having the operation. General anaesthetic is rarely used and means that you are completely asleep for the surgery. Better results are obtained with you awake so that the height and contour of the eyelid may be assessed during surgery. 


Levator aponeurosis advancement


An incision is made in the natural skin crease of the eyelid. The muscle, which lifts the eyelid, is reattached or advanced and secured with sutures. The skin incision is closed with sutures, which are removed at 1 week (non absorbable) or left to dissolve over 2-3 weeks (absorbable). 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 is advanced, in effect strengthening or tightening it. Both of these procedures are usually carried out under local anaesthetic, with sedation. 


Mullers muscle resection and advancement


No skin incision is made. Instead an incision is made on the inside of the eyelid. 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, usually with sedation. This procedure is useful for small amounts of ptosis (e.g. 1-2mm)


Brow Suspension


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 tunneled under the skin and eyebrow using 5 small incisions, each less than ½ centimetre long. Two of these are in the eyelid, 2 at the upper border of the eyebrow and 1 in the forehead.

Are there alternatives to surgery?

A ptosis prop is a simple thin plastic arm, which 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 are the risks and possible complications of surgery?
Infection might present as increased swelling and redness of the skin. There might also be yellow discharge from a wound. Infection 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 a skin wound is usually enough to control minor bleeding. In rare cases, a deeper haematoma may require a return to theatre to prevent loss of vision.
Loss of vision: Total loss of vision in an eye due to this surgery is extremely rare ( less than 0.1% or 1 in 1000 operations ). A blood 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. It presents as pain, loss of vision and a bulging forwards of the eyeball and is an emergency. If not treated quickly it can lead to permanent loss of vision.
Scar: 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.
Further surgery: Your surgeon will take great care to raise your eyelid to the correct height. It is possible for the eyelid to be too high or too low. If this is the case he will discuss with you whether it is best to wait or return to theatre to correct it. Emergency return to theatre due to bleeding is extremely rare.

Dry eye: If you have a pre-existing dry eye problem or weakness of the eyelids, these symptoms may be made worse by ptosis surgery. Your surgeon should investigate this prior to surgery and advise you accordingly.

Skin puckering: If deep sutures are placed, there is a risk of puckering of the skin above them or discomfort. This is usually temporary but may necessitate further surgery to remove the suture if persistent.

Loss of sensation: After surgery there may be numbness of some of the skin around the incision. This is usually temporary returning gradually over months. Rarely it is permanent and may involve larger areas like the forehead.

Inflammation: Swelling and bruising of the skin after surgery always occurs but in varying degrees. A big improvement will be noticed after 2 weeks, with most resolved 3 months later. Rarely inflammation may cause small lumps to form called granulomas. Most resolve spontaneously but some require further surgery.

Altered appearance: One of the goals of surgery may be to positively improve appearance. Some people may be unhappy with the appearance after surgery due to: asymmetry of facial features; eyelid contour or eyelid position changes.

What will happen before surgery?

Before the operation you will attend a consultation with Mr. McCormick. He will listen to your problems, examine your eyes and face and explain treatment options including risks and benefits.

Mr. McCormick will ask you about your problem. He will also ask about other medical problems you have, medications you take (bring a list or the tablets themselves with you) and any allergies . 

He will examine your eyes and will determine if you are suitable for surgery. He will explain exactly what type of surgery he could carry out. 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. You may also see a preoperative assessment nurse. He/She will carry out blood tests and an ECG (heart tracing) if required. They will also advise you if you need to starve before the operation.

What should I do about my medication?

In some cases you may be asked to stop or reduce the dose of blood thinning tablets like: warfarin, 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.
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. You should avoid non steroidal anti inflammatory medications for 2 weeks prior to surgery. Other medication should be taken as usual. 


What type of anaesthesia will I have?

Three types of anaesthesia are used for these procedures: local anaesthetic alone; local anaesthetic with intravenous sedation; general anaesthesia.
You will choose one of them based on the advice of your surgeon.
Local anaesthetic involves an injection just under the skin with a tiny needle. It is similar to dental anaesthesia. Initially the injection is painful but after 10 – 15 seconds the area becomes numb.
Local anaesthesia with Intravenous Sedation means that you are breathing for yourself and don’t have a breathing tube inserted but you are very relaxed and sleepy and often don’t remember the operation or the local anaesthetic injection.
General anaesthetic means you are completely asleep with a breathing tube inserted.

What are the risks of anaesthesia?

You will have the opportunity to discuss the risks of anaesthesia with your surgeon and anaesthetist prior to surgery. It is worth noting that modern anaesthesia in all its forms is extremely safe.
Local anaesthetic may cause bruising, bleeding and swelling. There is a theoretical risk of the needle penetrating the eye and causing loss of vision.
Intravenous sedation should be carried out by an anaesthetist in a controlled environment. In this way it is very safe. There is a risk of loss of airway, which theoretically could lead to brain injury or death.
General anaesthetic has an extremely low risk of heart attack, stroke and death. The risk very much depends upon your general health and will be assessed prior to surgery.
Anaesthetic risks can usually be greatly reduced by thorough pre operative assessment, which you will receive.

What should I expect after surgery?

After surgery you may experience some pain. Simple paracetamol is usually enough to control this. The eyelids will be a bruised and swollen. Bruising will take up to 2 weeks to settle. Swelling is greatly reduced after 2 weeks but may not completely resolve for 3 months.
Some people report not feeling ‘back to normal’ for up to 6 months after surgery. Initially it may feel difficult for you to close your eyelids and this will be managed with eye ointments.
It is important not to have surgery too close to important events, in case you have not fully recovered in time.
Each individual responds differently to surgery and of course the more extensive the surgery the greater the downtime. For some people the down time after upper and lower eyelid surgery is significant