Droopy Eyelid / Ptosis

PTOSIS/DROOPY EYELID

What is Ptosis ?

Ptosis or droopy eyelid occurs due to dysfunction of muscle which lift the eyelid (levator).

What are the Symptoms and Causes ?

When one gets older, s/he may have noticed the eyelid has dropped.  Sometimes, it associated with excess skin on upper eyelid (dermatochalasis) and droopy brow.  S/he will notice that reading/ watching TV/ driving is getting difficult towards the end of the day.  Some will observe upper corner of the visual field no longer visible.  This may become even more obvious after eye surgeries eg. cataract surgery.  In addition to the inability to see, people who has ptosis often get comments such as  'you look tired’, ‘ you look sleepy’ from others. 

In addition to aging changes of elevator muscle which either weaken or detached from its usual attachment, other cause of ptosis include contact lens wear, trauma, mechanical (lump in upper eyelid causing eyelid to drop), neurological such as third nerve palsy, Horner Syndrome and Myasthenia Gravis.

Important cause of ptosis
While most ptosis are benign, its development may associated with some serious medical conditions that require urgent medical attention

  • Develop suddenly over a short period of time
  • Droopy eyelid together with double vision
  • Associated with pain, redness, bulging eyes or eye movements difficulty

Congenital Ptosis | Ptosis in a Child

Ptosis may happen to a child since birth (congenital ptosis or pediatric ptosis).  Child ptosis poses a more dangerous condition as it may disturb the child’s visual development and the child is at risk of developing subsequent lazy eye or ambylopia.  Amblyopia means normal looking eye but not able to see well. In addition, if the ptosis is only one side (unilateral ptosis), the child will look asymmetry and hence may be teased by others at school. It will adversely affect the child self esteem and self confidence. 

A very under diagnosed condition which Dr. Ho Shu Fen notice among oriental children is lash ptosis.   Whilst the opening of eyelid may be adequate, the direction of lashes facing downwards lead one not able to see well. Usually this group of children have single eyelid.  Changing the direction of lashes by pressing on the eyelid will allow the child to see better,  Usually the child will not complain as they do not know they are not able to see in the first place.

Bilateral droopy eyelid in a child may lead the child to develop a chin up position as s/he not able to see the top.  It may strain their neck and potential musculoskeletal tissue which they grow older.

TREATMENT

As long as it is ruled out to be neurological (myasthenia of other progressive neurological disease), the intervention is invariably surgical. The ptosis surgery which lift the eyelid  usually in the form of reattach or shortening the muscle  (levator advancement or levator resection).  However, for those with very weak levator muscle, eyelid can be lifted by using synthetic material (such as silicon rod) or fascia lata, a tough tissue from the side of the thigh.


In adult, it is usually performed under local anesthesia and the patient can go home the same day. Swelling is expected, and patient is also expected to perform ice pack and put in cream. Patient is advised to be reviewed by oculoplasitc surgeon after one week and have sutures removed.   In general, the down time is about 1- 2 weeks, but it may last longer depending on individuals.


For children and those adult which require tissue (fascia lata) harvested from the thigh, the ptosis surgery is performed under general anesthesia.   The person may find their thigh a bit sore and slightly painful to walk for two to three weeks but usually can resume normal walking after one month.

It is important for such a delicate and complicated job to be performed by qualified trained oculoplastic surgeon to minimize complication and for the patients to look aesthetically pleasing.

Pre op:  Severe ptosis (Droopy eyelid), right more than left.

Pre op:  Severe ptosis (Droopy eyelid), right more than left.

Post op: He looked more refreshed, energised and can see much better.

Post op: He looked more refreshed, energised and can see much better.

Pre op: Severe pre op ptosis with frontalis overaction.

Pre op: Severe pre op ptosis with frontalis overaction.

Post op: She is able to see clearly now and both eyes look symmetrical

Post op: She is able to see clearly now and both eyes look symmetrical

Pre op: Droopy eyelid, left > Right leading to sad look

Pre op: Droopy eyelid, left > Right leading to sad look

Post op: Both eyelid looks symmetrical and better

Post op: Both eyelid looks symmetrical and better

Pre op: Left ptosis in a young lady who wear contact lenses

Pre op: Left ptosis in a young lady who wear contact lenses

Post op: Symmetrical and natural appearance

Post op: Symmetrical and natural appearance

Pre op: A child with a congenital left upper eyelid ptosis. This can affect the normal development of vision

Pre op: A child with a congenital left upper eyelid ptosis. This can affect the normal development of vision

Post op: symmetrical looking eyes. It is very difficult to take photos of a child

Post op: symmetrical looking eyes. It is very difficult to take photos of a child

Pre op: Age is never a hindrance. This 85 years old lady present with droopy eyelid especially in the evening stopping her from reading.

Pre op: Age is never a hindrance. This 85 years old lady present with droopy eyelid especially in the evening stopping her from reading.

Post op: This 85 years old lady recovered well after surgery. Looking more alert and can enjoy reading now.

Post op: This 85 years old lady recovered well after surgery. Looking more alert and can enjoy reading now.

Pre op: Sometimes, ptosis can develop after cataract surgery as speculum can easily damage the levator muscle

Pre op: Sometimes, ptosis can develop after cataract surgery as speculum can easily damage the levator muscle

Post op: A symmetrical and natural look.

Post op: A symmetrical and natural look.

Pre op: Is eyelid surgery only for woman? No, this man feels that the droopy eyelid has hampered his vision and make people false perceive him as uninterested and tired.

Pre op: Is eyelid surgery only for woman? No, this man feels that the droopy eyelid has hampered his vision and make people false perceive him as uninterested and tired.

Post op: A pair of natural well elevated eyelid gives patient a sophisticated and interested look.

Post op: A pair of natural well elevated eyelid gives patient a sophisticated and interested look.

Pre op: droopy bilateral upper eyelid gives a sleepy appearance

Pre op: droopy bilateral upper eyelid gives a sleepy appearance

Post op:  Both eyes wide open.

Post op:  Both eyes wide open.

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