Ptosis Surgery Before and After
Overview
What is ptosis (droopy eyelid)?
Ptosis is the term used for the abnormal dropping of the upper or lower eyelid from its normal position. It is caused due to weakness or damage to the muscle involved in maintaining the normal aperture and blink of the eye. Ptosis can be classified as congenial, acquired, or traumatic. It can affect one or both of the eyes.
Ptosis is also associated with various types of syndromes and complications depending upon the cause. The statement to make on ptosis surgery before and after depends upon the severity and the cause of the ptosis. In our articles the causes, symptoms, signs, evaluation, and treatment options including ptosis surgery before and after will be discussed in detail.
SYMPTOMS AND CAUSES OF PTOSIS
Why do people get ptosis (droopy eyelid)?
The normal lift of the eyelid is maintained with the help of the eyelid muscles known as levator aponeurosis and muller muscle. Any damage to the muscle directly or indirectly or poor development of the same muscle will lead to the problem of maintaining the normal eyelid level. The causes of ptosis can be broadly categorized as congenital ptosis and acquired ptosis. Acquired ptosis encompasses various neurological, traumatic, and senile causes. The classification of ptosis is summarized as followed
CLASSIFICATION OF PTOSIS
- Congenital ptosis: It is caused congenitally due to the failure of neuronal migration or the development of muscle sequelae. Congenital ptosis can be associated with a positive family history. The associated conditions with congenital ptosis include weakness of the superior rectus muscle, compensatory chin elevation in severe bilateral ptosis, and associated refractive errors.
- Acquired ptosis: The ptosis occurring later in life due to any cause is labeled as acquired ptosis.
- Neurogenic ptosis: It is caused due to a defect in the neurological supply of the eyelid muscles. Examples include third nerve palsy and Horner’s syndrome.
- Myogenic ptosis: It is caused by the myopathy of the levator muscle itself or due to impairment of impulse transmission through the neuromuscular junction. Examples include myasthenia gravis, myotonic dystrophy, progressive external ophthalmoplegia, etc.
- Aponeurotic ptosis or involutional ptosis: It is a senile ptosis caused due to a defect in the levator aponeurosis.
- Mechanical ptosis: It is caused due to the gravitational pull on the mass over the eyelid or due to the presence of any scar on the eyelid area.
- Traumatic ptosis: Trauma to the eyelid or eyelid muscle at any stage of life can lead to ptosis.
SYMPTOMS
The major presentation of ptosis is the drooping appearance of the eyelid. The family and friends may notice that the particular person is having sleepy eyes. The drooping itself may be associated with a change in refractive error of the eye due to the covering of the pupil with the eyelid margin. There will be a change in head posture to a chin-up position for getting a better view.
The patient may try to lift their eyebrows to get a better view and develops a headache. In conditions of any syndrome, ptosis may be associated with fatigue at the end of the day. Some conditions may also give an appearance of ptosis, that is actually not ptosis. These include
CAUSES OF PSEUDOPTOSIS
- Lack of support: by the globe may be due to conditions such as microphthalmia, phthisical eye, or enophthalmos.
- Contralateral lid retraction: may give an appearance of the drooping of the other eye. normally the eyelid margins cover a 2mm area of the pupil superiorly.
- Ipsilateral hypotropia: It occurs because the eyelid of the hypo-trophic eye follows the globe downward.
- Brow ptosis: The condition is related to extra skin on the brow area or associated seventh nerve palsy.
- Dermatochalasis: In dermatochalasis, there is overhanging of extra skin on the upper eyelid.
COMPLICATIONS OF PTOSIS
The most drastic complication of untreated ptosis in pediatric age is amblyopia due to blockage of the visual axis by the ptotic eyelid. It is important to relieve ptosis before the age of 8-9 years so that specific amblyopic therapy can be instituted.
EVALUATION OF PTOSIS
History taking:
The evaluation of ptosis begins with detailed history taking. The patient is inquired about the onset of the ptosis and the associated history of trauma. If the date of ptosis can’t be dated, then questions should be asked about old photographs. Associated systemic history should also be taken about diplopia, fatigue, and any syndromes from childhood. Past history of surgical procedures is also important.
Measurements:
The ophthalmologist will perform the following tests and measurements before reaching a diagnosis and making a plan for further management of ptosis.
MRD: is the distance between the pupil reflex and the margin of the eyelid.
PFH: is the distance between upper and lower eyelids.
Lid crease distance: is measured between the eyelid margin and the lid crease.
Levator function:
it is measured by putting a finger on the frontalis muscles so that its function is negated. The patient is asked to look all the way down, the lower value is measured first and the patient is then asked to look high up. The measurement is made again. It is the best predictor for performing the selected surgical procedure.
Pupils: involvement of the pupil is crucial in excluding diagnoses such as 3rd nerve palsy.
Ocular motility: is important for documentation of associated muscle involvement such as superior rectus muscle and hypo and hypertropia.
Bells phenomenon: both the eyelids are open forcefully and the patient is asked to close the eye. it is important for the pre-surgical evaluation of exposure keratopathy.
Fatiguability test: it is performed by asking the patient to look upward for several minutes and the time of fatiguability is noted. It is used for the exclusion of myasthenia gravis.
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Management and Treatment
Ptosis Treatment without Surgery
The treatment of ptosis mainly depends upon the cause of the ptosis. In some cases, no treatment will be beneficial while in other cases the associated condition should be treated. In many situations, no treatment of ptosis should be the first priority. However, any associated problem should be treated first for example if a mass on the eyelid is causing the ptosis, then the mass should be promptly treated.
Any other cause of pseudoptosis such as hypotropia and lid retraction should be addressed first. Any overhanging skin should be removed or treated accordingly. In some cases, eyelid crutches can be used for temporary relief and treatment of ptosis.
How is ptosis (drooping eyelid) treated?
The specific treatment of ptosis is mainly surgical. However, depending upon the severity and the function of the levator muscle, the desired type of surgery can be selected.
Types of eyelid surgeries for ptosis
- Muller resection: Muller muscle is a small eyelid muscle playing its role in the elevation of the eyelid up to 2mm height. If the levator function is good and the ptosis level is minimal, muller resection surgery should be performed. It includes a conjunctival approach and cutting of the muller muscle up to the desired level.
- Levator resection: The rest of the elevation of the eyelid is performed by the levator muscle. If the patient has a levator function of more than 4mm then levator resection can be performed. It includes making a surgical incision on the skin of the eyelid, exposing the levator muscle, and cutting it to the desired level to strengthen its action.
- Brow suspension: This procedure is performed in persons with very poor levator function and preferably in whom both eyes are involved. The procedure involves using a silicone or prolene wire to be inserted subcutaneously. The procedure aims at using the frontalis muscle for the purpose of blinking instead of the levator muscle.
What happens during surgery for ptosis?
The ptosis surgery is performed under local anesthesia in adults and under general anesthesia in children. The site of incisions on the skin or conjunctiva is injected with local anesthetic and adrenalin for control of bleeding. The incision is made on the lid crease; the tissue is removed until the levator muscle is exposed. The desired strength of levator muscle is cut and reattachment is done.
The incision is closed accordingly. There are some complications experienced after surgery. These includes bruising, swelling. The management lies in taking pain medication and applying cold compresses. The health professional will guide you about how to protect the eye after surgery, use of medication regularly and to avoid strenuous exercises for a period of time.
Ptosis Surgery Recovery Time
Without any complications, you will hardly need a day or two to spend in the hospital. After that, the health professional will discharge you to the home with special instructions about taking care of the wound and use of medication. The skin wound will take 1 to 2 weeks to heal. However strenuous exercise should be avoided until complete healing.
What to expect after ptosis surgery/ ptosis surgery before and after
Unsuccessful ptosis surgery/ Ptosis surgery risks/ Uneven eyes after ptosis surgery
There are some complications associated with ptosis surgery. These includes.
Eyelid complications
- Loss of lid crease
- Asymmetrical lid level
- Loss of eyelashes
- Entropion
- Ectropion
Eye complications
- Globe perforation
- Corneal abrasion
Other complications
- Hemorrhage
- Infection
- Scarring
- Wound dehiscence
Unsuccessful Ptosis Surgery
There are chances in some cases that the ptosis surgery will go wrong and the desired outcome may not be obtained. In such a case re-surgery is performed for the desired outcome.
What is the success rate of ptosis surgery?
Ptosis surgery success rate
the success rate of ptosis surgery is usually 95% however, there are many factors associated with outcome of the surgery such as surgeon factor, any complication such as scarring or wound dehiscence, strength of levator muscle, etc.
Ptosis Surgery Cost
How Much Does Eyelid Surgery Cost
the cost of eyelid surgery varies according to the geographical location and the type of health care center you have opted for your surgery, as well as the surgeon experience should also be kept in front line. In some countries, there are insurance policies and the treatment can be provided free of cost.
Conclusion
Ptosis is an eye condition with a drastic cosmetic and psychosocial influence on one’s life. Beside avoiding amblyopia and other complications of ptosis, it is crucial to treat it for cosmetic purpose. There are certain non-surgical steps and surgical procedures depending upon the cause of ptosis. The surgical procedure will depend upon the function of levator muscle. Anyone experiencing the symptoms of ptosis should get a medical appointment as soon as possible.
Can I walk after ptosis surgery?
Yes, you can walk after ptosis surgery. Ptosis surgery focuses primarily on the upper eyelid and usually does not affect your ability to walk or engage in regular physical activities.
Is ptosis surgery high risk?
Ptosis surgery is generally considered to be a safe procedure with a low risk of complications. Risks may include infection, adverse reactions to anesthesia, scarring, asymmetry, temporary or permanent changes in eyelid position, and double vision.
Is ptosis surgery painful?
Ptosis surgery is usually painless due to the use of local anesthesia. There may be some mild discomfort or pain after surgery, but this can be managed with pain medication and cold compresses.
Does ptosis surgery leave scar?
Ptosis surgery may leave a scar, but its appearance may vary. Incisions are usually made in the natural crease of the eyelid to reduce the scar, and the scar will fade over time.
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References
- American Society of Ophthalmic Plastic and Reconstructive Surgery. (n.d.). Ptosis. Retrieved from ][]
- Cleveland Clinic. (2021, January 26). Ptosis Surgery. Retrieved from https://my.clevelandclinic.org/health/treatments/17568-ptosis-surgery
- Mayo Clinic. (2021, March 17). Ptosis (Drooping Eyelid). Retrieved from https://www.mayoclinic.org/diseases-conditions/ptosis/symptoms-causes/syc-20375899
- MedlinePlus. (2021, January 19). Ptosis. Retrieved from https://medlineplus.gov/ency/article/001018.htm
- National Eye Institute. (n.d.). Ptosis. Retrieved from https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/ptosis
- RealSelf. (n.d.). Ptosis Surgery Cost. Retrieved from https://www.realself.com/ptosis-surgery/cost
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