Drooping upper eyelids — ptosis
Video of surgery performed by Raman Malhotra
Below is a link to video of ptosis surgery performed by Raman Malhotra at the Fusion 2012 International Conference. LV Prasad Eye Institute, Hyderabad, India. WARNING: The following video contains footage of a graphic nature and may not be suitable for all audiences. If you are squeamish then scroll down and read the patient's blog entry of their experience undergoing ptosis surgery.
SEE BELOW FOR A PATIENT'S BLOG OF THEIR EXPERIENCE UNDERGOING PTOSIS SURGERY
When the edge of the eyelid falls and covers part of the pupil, it blocks the upper part of your vision. In severe cases, you may have to tilt your head back or lift the eyelid with a finger in order to see out from under the drooping lid.
This droopy eyelid, or ptosis, is generally age-related and occurs when the tendon that attaches the lifting muscle to the eyelid stretches, so the eyelid falls too low. Sometimes, there is a separation between the tendon and the muscle that lifts the eyelid.
It is not uncommon to develop a drooping eyelid after cataract surgery or long-standing contact lens use. A similar drooping may also affect the eyebrow and is known as brow ptosis — the word simply means downward displacement.
Ptosis can also be present at birth, or congenital. This form of the condition is often caused by poor development of the muscle that lifts the eyelid. If uncorrected, normal vision may fail to develop and the child may adopt an abnormal posture, with his or her head tilted backwards.
Ptosis surgery may be performed in combination with other procedures such as blepharoplasty or brow lift. Mr Malhotra will discuss all the possibilities with you in detail, so you are able to make an informed decision.
In most cases, ptosis surgery is covered by health insurance.
Ptosis surgery shortens the stretched tendon or re-attaches it back to the eyelid — there is usually no need to make alterations to the muscle that lifts the eyelid, as this tends to remain strong.
It is usually performed under local anaesthesia, often with intravenous sedation, as a day case procedure, with no need for an overnight stay in hospital. It lasts approximately an hour and aims to restore the symmetrical height and contours of the upper eyelids.
In most cases, Mr Malhotra carries out ptosis surgery through an incision under the eyelid (a posterior approach), which avoids the need to cut through the skin and leave any external scars. Occasionally, the procedure is similar to an upper eyelid lift, with a fine incision made in the existing eyelid crease to camouflage any scarring. Excess skin and muscle and, very rarely, fat can be removed and the tendon is re-attached or shortened. The incision is then closed with fine stitches, which are generally removed within one week, or dissolve.
Very rarely, the lids may be attached to the brow, using silicone or nylon thread or tissue from the upper thigh (fascia lata), allowing the forehead muscles to lift the eyelid. This is known as a brow-suspension ptosis procedure. It is not the same as a brow lift.
What to expect
- After surgery, you will experience some degree of swelling and bruising — cold compresses and elevation of the head will help to relieve any discomfort.
- Your eyes may feel dry because they are more open than before, especially if very droopy eyelids have been corrected — the remedy is to use artificial tear solution, which Mr Malhotra will prescribe.
- It is important to avoid strenuous activity for the first week after surgery but you can return to work if you want.
- You may take walks during the first week and fly within two days but should avoid heavy lifting, strenuous gym work-outs or running for four weeks because of the risk of increased bruising and swelling.
- Antibiotic eye ointments are prescribed for several days after surgery.
- You cannot wear contact lenses for a minimum of two weeks after surgery, because the eyelids may be stiff and the eyes dry.
- Some people experience blurred vision or sensitivity to light for a few days, mainly caused by dry eye.
- In rare circumstances, tiny whiteheads may appear along the line where the stitches were — these can easily be removed in the clinic, using a needle.
- In rare cases, there may be some imbalance between the eyes after healing is complete — this can easily be rectified in a subsequent minor operation.
All procedures begin with a consultation. For full information about what to do before and after surgery, see Patient information .
Surgical blog of a patient's experience of ptosis surgery
A bit of background, for the benefit of the reader – I am an ophthalmic surgeon with special expertise in the front of the eye and have performed corneal transplants as well as refractive (including laser eye surgery) for over 2 decades. Over the years the issue of quality of vision has become increasingly important and a number of measures including contrast sensitivity testing as well as wavefront evaluations are being used to understand what patients see.
So for me to gradually over the last few months to start noticing starbursts was a moment of understanding in terms of visual disturbance. Initially I thought this might be related to my slightly abnormal corneal shape and got a bit concerned that this might be getting worse (shouldn’t as corneas do become more rigid with age and less likely to change). I made a mental note to get my corneas checked out with topography to see if things had changed.
One day after a long day operating, while driving I blinked hard and noticed the starburst problem worsened prompting me to lift my lid with my finger and suddenly all the starbursts radiating downwards to the road just disappeared! Tried this with the other eye and sure enough the same thing. Huh – it must be my droopy eyelids causing the problem. Got home and took a look in the mirror and realised that my eyelids were worse than usual and I was also frowning excessively, my compensatory mechanism to lift my lids.
I have had Ptosis (droopy eyelids) for a long time as a result probably of excessive contact lens wear combined with a history of severe hay fever in my teens and twenties. The type of droopy eyelid was one where the muscle that lifts the lid had become disinserted from the main cartilage of the eyelid, the tarsal plate. This was easily recognizable from the appearance of my eyelid crease which was set further back than usual. My own view was – well if it does not bother me functionally I shall live with it – this however changed and not being able to drive without holding up my lid by my eyelashes was definitely compromising and probably dangerous. Had a discussion with my wife (also an eye surgeon) who basically agreed and felt that having this repaired was long overdue.
The next issue was to whom should I go to for care? I had a chat with my friend and colleague Raman Malhotra who basically convinced me that a posterior approach (under the lid) and restoring the anatomical defect i.e. reattaching the muscle to the tarsal plate, was the way to go and that he should do it! As a friend I was a bit apprehensive having him do the surgery. I decided to have a formal consultation with Raman, and he took all sorts of images and the one that really bothered me was the “visible iris sign” (see image) especially on the right. This is where my iris was visible through my eyelid! That is definitely not normal. I was particularly impressed that Raman went through all the motions that he would with any other patient including a Schirmer’s test to evaluate my ability to produce tears – dry eye following lid surgery is not uncommon and best to get a baseline prior to performing surgery.
So the conclusion was I needed my Levator muscle reattached on both sides and this would not interfere with my ability to wear contact lenses – important considering my profession as well as my slight corneal steepening. Having Raman do this would be convenient and we discussed possible dates and came up with one that was mutually acceptable: Tuesday October 19 th at 6pm.
On a plane returning from the American Academy of Ophthalmology meeting in Chicago. Not a bad meeting and Chicago – great place for food especially steaks. Now getting a bit apprehensive about surgery tomorrow and also feel like I am getting a cold. Oh well – I can recover from both surgery and the cold at the same time!
10am – arrived from Chicago and have a couple of hours sleep. Yes, definitely have a cold. Need to get some rest as not only am I going to have surgery, I added in a couple of Lasik procedures to do myself beforehand !
4.00pm – arrived at the surgical centre and evaluated the results of my patient (an old family friend now living in Singapore). Yes, all data fine for surgery, signed off the forms and checklists to proceed and nurses go ahead and prepare him for surgery. Laser surgery completes checked the patient afterwards and at 6.00pm ready to undergo surgery myself !
I remained in surgical scrubs – very comfortable and remember an icepack on my eyes and being wheeled into the operating theatre. After that all I recall was drifting in and out in terms of awareness. The sedation provided by Glenn Wearne the anaesthetist was great and have to admit to not recollecting much. I do remember asking if local anaesthetic was going to be administered (the bit I was not looking forward to), only to be told that had already been accomplished and that surgery was underway! Well, that was easy. I am told the process took just over an hour. The left side required a slight readjustment, Raman doing the eyelid art thing, ensuring perfection!
The next thing I remembered was being wheeled out and sitting upright having a glass of water! I wanted to get up out of the surgical table/chair and it was politely suggested I wait. My vision was incredibly blurry from the ointment and I had a very odd sensation around my eyes and my cold seemed a lot worse. Within 30 mins I was ready to go home and my wife drove me back with me reclined in the front passenger seat.
When I got home, was not sure what I looked at and my wife was not enthusiastic about the kids seeing me. They were awake and my daughter took a look and said “OMG – what did they do to you?” My wife reassured her telling her not to worry and that the appearance was normal at this stage and I would be be better in a few days. I took a look in the mirror and realised what she meant. With a very blurry view I could see my eyelids appeared a bit peaked and my eyes looked ultra-wide open! I thought – goodness – hope this does not last long – glad I have 2 weeks off! Later my daughter asked my wife if Raman had put new lashes in my eyelids. My usually long eyelashes which I used to think were normally positioned were now very visible pointing straight upwards!
My wonderful wife did what lovely wives do – and made sure I was comfortable – I had to sleep on a couple of pillows (difficult) and use a cool eye compress which strapped around my head. This eye compress provided by Raman had been in the freezer and on my eyelids felt quite good. Several Paracetamols and some eye ointment and I went to sleep. I woke up in the middle of the night with a bit of an ache and took several more Paracetamols.
Wednesday, October 20
Woke up and aware of this heavy feeling on my eyelids. Tried to take a look around and realised I just could not see because I could not get my eyelids open. They were very swollen – and yes hurt when I tried to open the lids. I sat upright in bed with another cold compress and had breakfast in bed – (taken great care of by the other half). About an hour later, my lids managed to open and I could see a bit – very blurry – not worth getting out of bed and I also felt a bit miserable with the cold/flu. Thought best to just stay in bed.
Woke up later at about 2pm and had another dose of medication and cool compress. Could not stay in bed and ventured downstairs. Sat and listened to the TV with my eyes closed. Not much discomfort at this stage. Kids arrived home and daughter remarks that the lids are still swollen – “Are your eyes going to stay that way?”. Had dinner and early bed – unable to do much – not even watch TV as my vision was really blurred.
Thursday, October 21: second postoperative day
Woke up – no pain but difficult time opening my lids again. Sat upright in bed with a cold compress. Swelling improved and eyes opened after an hour. Decided to get out of bed and had a shower – very blurry one at that. Felt remarkably better and took a look in the mirror – yes a lot of upper lid swelling – Hmmm. lids did not look too symmetric either – right one peaked and higher than the left. Well it is early days – but thought I’d better let Raman know.
Spent the day watching a bit of TV and attempting to answer e-mails – had to give that up as I just could not read. Glasses were not the right strength – ointment in my eyes, everything conspiring to prevent me from doing anything constructive. By the end of the day, upper lid swelling had reduced considerably and looked more normal – encouraging. Cold almost gone.
Another early night.
Friday, October 22: third day postop
OK – today – enough of lazing around and prior meeting arranged at 2 – so need to be up and standing to promote a reduction in swelling. Avoided midday ointment because of blurry vision – naughty but being practical. Went to the meeting with a little upper lid swelling – everyone too polite to comment !
Well on way to recovery and vision a lot better today. Lids still asymmetric with less peaking.
Monday, November 1: sixth day postop
Mild lid swelling – tried contact lenses on – right one moved a lot but kept them in for 3 hours. Vision much better with lenses in.
Friday October 29: 10 days postop
Swelling only minimally present in the mornings and gone in an hour. Lids look normal except so used to frowning, I keep doing this which has the effect of pulling my eyelids up further – look like I am a bit hyperthyroid – need to actively think about not frowning – besides no need to anymore.
Wednesday November 3: 15 days postop
More or less normal now with a little asymmetry – right lid higher than the left. 2pm saw Raman in follow up. He seemed pretty pleased and reckoned lids would become more symmetric – still only a short while postop – although a doctor and an eye surgeon – easy to forget being objective when it comes to yourself. Another important lesson from being on the receiving end. What the doctor tells you keeps you going and provides the reassurance and confidence required. Those concluding remarks at the end of a consultation are super-important – substantiates the practice of doing the same with my own patients.
Saturday November 28
Good party last night – a bit of a headache – other reasons…
Now almost 6 weeks following surgery – everything more or less normal. Lid creases are now symmetrical and the points where the stitches were placed on the eyelid cartilage have almost disappeared. Asymmetry – barely there. Fantastic. My corneas have also become more normal in shape and as a result I can see extremely well again. Also not frowning any more and more relaxed at the end of the day. It is amazing what impact droopy eyelids have, tiredness, abnormal corneal shape, poor vision let alone the poor cosmetic appearance. Thanks Raman for correction and rejuvenation.
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