Ptosis (drooping upper eyelid)

What is Ptosis?

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 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 commoner causes:

  • Congenital ptosis (being born with a droopy lid or lids)
  • Involutional or age-related ptosis (comes on with advancing age)
  • Traumatic ptosis (due to an injury)
  • Myopathic ptosis (due to a muscle disease)
  • Neurogenic ptosis (due to damage to the nerve to the muscle that lifts the eyelid)

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 and occasionally an operation is not advisable.

What sort of anaesthetic will be used?

Surgery for ptosis is most commonly 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 and is often not even noticed or remembered. During the operation, you will however 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.

What is the aim of the 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. Another aim is to have the two eyelids even with each other, but again, in some less common circumstances, this may not be possible or advisable.

In some ptosis operations, and especially those performed for age-related ptosis (ptosis occurring in older people), there is also some excess skin in the upper eyelid that would hang more 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.

Where is the incision made?

The incision is made in the fold or crease of the eyelid so that the scar is largely hidden here 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 is very difficult to see after that.

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 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 finish up in a position that is not expected or desirable.  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, and very rarely, more than two operations may be 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. This is very rare after ptosis surgery and can be treated with antibiotics.
  • Change in the vision. Sometimes the eye can be a little different in its focus after ptosis surgery. This usually settles after several weeks but occasionally, 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” but over several months, this feeling of tightness and hardness of the scar passes so that the scar can no longer be felt and the scar is barely visible with the eye closed.
  • If ptosis surgery is performed on one side only, sometimes the other opposite eyelid may droop a little as the two sides work together and after the more droopy lid is lifted, both relax a little so that the unoperated eyelid may drop a little.
  • The upper lashes and skin above the lashes may be numb for some weeks after the surgery. This is normal and recovers over about 6 to 8 weeks.