Milind Naik

Introduction

Droopy eyelid (ptosis) can occur as a result of birth defect, injury, muscle disorder, nerve disorder, or simply due to aging. It gives a sleepy appearance, and can even obstruct vision if severe. Ptosis may also cause excessive forehead wrinkling, abnormal head posture such as chin elevation, and eye fatigue. In children below 8 years of age, severe droop might obstruct development of vision leading to a lazy (amblyopic) eye thus reducing vision. In adults, droopy eyelid is mainly a cosmetic concern. Surgery can correct this problem by repairing the muscle that lifts the eyelid.

Surgical Technique

Several surgical options are available, and the type of surgery used depends upon the severity of the droop. When the eyelid droop is mild, a simple lift of the tissues is performed from the back of the eyelid (Mullerectomy). There is no skin scar in this surgery. Moderate droop requires tightening of the muscle that lifts the eyelid (levator), and is preferably done from the skin side, though the scar remains hidden in the upper eyelid skin fold. In severe droop, tightening the eyelid muscle may not be effective, and hence the eyelid has to be connected to the eyebrow muscle (frontalis) to effect eyelid lift. This surgery (called tarso-frontal sling surgery) can be preformed using a fine string that holds the eyelid up. This is very much similar to a curtain string, which holds the curtain up! This surgery involves small (2-3mm) scars over the eyelid and just above the brow. Sling surgeries are not permanent, and the eyelid often droops in a few years due to blinking and gravity. A patient who needs a sling surgery may therefore need multiple revisions of the surgery over his/her lifetime. The good news however, is that the same scars can be used for multiple revisions.

Surgical time and Recovery

Surgery for mild to moderate droop can be performed as a day-care procedure under local anesthesia and takes about 30 to 45 minutes. Discomfort is minimal, and stitches are removed in 5-7 days. Most patients are back to light work within a week. Minimal bruising may persist for 1-2 weeks. For severe ptosis (sling surgery) and for children, general anaesthesia is preferred and hence, one day admission is needed.

Note

Often times, ptosis surgery needs one or two sessions of suture adjustment (1-6 weeks after surgery) to match it to the other eye. In case of severe ptosis, correction is optimal only in straight gaze. The eye appears slightly droopy in upgaze, and slightly wider in downgaze. Closure may also be incomplete, especially during sleep. Ptosis surgery may also be combined with upper eyelid blepharoplasty or lower eyelid blepharoplasty.

Insurance

Health insurance will cover the costs of ptosis surgery, if the cause is acquired. Any congenital deformity (present since birth) is not covered by insurance.

Other Procedures

Other commonly performed reconstructive procedures include correction of

Before-After photos
 

 

 

 

 

 

 

 

 

 

Right eye mild ptosis treated by a scarless technique (Mullerectomy)

Left eye levator muscle slippage (dis-insertion). Simple reattachment surgery corrects the ptosis, and scar is hidden in the eyelid fold.

Both eyes asymmetric ptosis treated by a levator resection surgery (right followed by left).

Left eye moderate ptosis treated by a levator resection surgery.

Left eye moderate ptosis treated by a levator resection surgery.

Left eye mild ptosis treated by a scarless technique (Mullerectomy)

Right eye severe ptosis : Notice the good correction in straight gaze, but  downgaze lag. Scar gets hiddend in the eyelid fold

Right eye revision surgery: When muscle action is poor, a downgaze lag and incomplete closure while sleeping is inevitable. it is well-tolerated by an otherwise normal eye.