Ptosis - Tetbury Hospital Trust

Ptosis can either be present at birth (congenital) or appears later in life (acquired).

Congenital ptosis is usually due to a defect in the levator muscle which raises the eyelid and can affect one or both sides.

Acquired ptosis affects patients later in life and can be due to a defect in the muscles or nerves of the eyelid as a result of ageing, injury or illness:

A weakness in the eyelid muscles is sometimes associated with rare conditions such as myasthenia gravis or myotonic dystrophy.
Paralysis of the nerves supplying the eyelid can also cause it to droop and is known as a third nerve palsy (a type of mini stroke).
The eyelid may be weighed down by a large cyst or swelling.
It can occur following long-term contact lens wear, trauma or in rare cases, after cataract surgery or other eye operation.
A rare cause is Marcus Gunn ‘jaw-winking’ ptosis. An abnormal connection of the nerves causes the jaw to open when the droopy eyelid rises. This condition is usually only found in small children and affects one eyelid.

Surgery may be necessary for ptosis, however operating on the affected eyelid can encourage the other eyelid to droop as well so you may eventually need surgery on both sides.

About 80-85% of patients are corrected satisfactorily after the first operation, with asymmetry of 1mm or less.
Approximately 15-20% of patients may require a further operation.

Your doctor will explain the statistical risks fully at your appointment.

Risks

There is no absolute guarantee of success with any operation and ptosis surgery is no different.

Under or over correction. Any under correction can be addressed after a period of settling down. If your eyelid seems overcorrected (too high) after surgery, massaging the lid and pulling it down using a proper technique (you will be shown how) and controlled manner can help lower it. This should only be done if your doctor thinks it may help. Very rarely, further surgery may be necessary to lower the eyelid. Repeat surgery such as this can be more complicated to carry out. Ointment is often required at night if your eyes are not closing completely while sleeping in the early stages.

Lid lag. Lid lag is when the upper lid is higher than normal while you are looking down. In congenital ptosis, lid lag can be a problem even before surgery, and it might be worse following the operation.

Dry eyes. Since full closure of the eyes is necessary to keep the surface (cornea) moist, poor eyelid closure will inevitably lead to dry eyes. The eyes may look red and can feel gritty, sore and prone to infection. Simple lubrication with artificial tears and ointment can help, but if your eyes were already slightly dry before surgery, they might be worse after.

Cosmetic change. Any change to the height of your eyelid will slightly alter your appearance, and most patients are delighted by this. Sometimes the contour of the eyelid may be affected, although we will always try to avoid this.

Temporary bruising. Bruising of the eyelids and the surrounding area is common after ptosis surgery, but it fades quickly.

Bleeding and infection. Although potential risks, they are not common.

Lagophthalmos. This is the inability to close the eye after surgery and may particularly occur after large ptosis corrections. It usually corrects itself with time as the muscles relax.

Ptosis of the other eye. Correcting the droopy eyelid on one side can reveal a previously unnoticed droopy eyelid on the other. This is because successful ptosis surgery should stop you over-using the brow muscles.

Initial consultation

When you are first referred to Tetbury Hospital, an eye doctor will see you in an outpatient clinic. You will have a full eye examination to check your vision and measure the extent of the droop. Once a decision to operate is made by you and your doctor, you will be listed for surgery and receive an appointment through the post. You will also need a pre-operative assessment review to check your general health and ensure it is safe for you to proceed with surgery.

Aspirin and anti-coagulants. If you take aspirin or drugs such as warfarin to thin your blood, you will be asked to seek advice from your GP about whether you could reduce or stop these medications prior to your surgery. This is because blood thinning medications can make bleeding more likely during and after surgery. Please do not stop your anticoagulant medication without consulting a doctor. The consultant will inform you when to restart your medication before you leave the Day Surgery Unit.

Ptosis surgery

In adults, surgery is usually performed using a local anaesthetic (you will be awake but not feel anything) as this allows for good lid positioning during surgery. You may be offered a mild anxiolytic such as diazepam to keep you calm. Skin stitches may be visible on your eyelids, but these will be removed around one to two weeks after surgery. The nurse will explain the detail to you.

Recovery

After surgery your eye may be padded shut for 24 hours to reduce any swelling. You can remove this eye pad at home the following day. Some surgeons prefer to leave the eye without a dressing, so that any change in the vision caused by internal bleeding inside the eye socket can be picked up quickly, but this is extremely rare. Usually, ointment will be prescribed/provided for use at home; the nursing staff will show you how and when to use it.

Bleeding. If you start to bleed, wash your hands and apply gentle pressure with a swab/make-up pad over the wound for 10 minutes.

An appointment is usually made for one week after surgery. Your stitches will be removed or be left to dissolve if they are absorbable. A second appointment will be arranged for four to six weeks after that. By then, the swelling in your lid will have gone down and a more accurate assessment of the surgery results can be made.

Please follow this post-operative advice:

Please carry on using any other eye drops you were prescribed before your surgery unless the doctor treating you has advised you to stop.
You can use a cold compress on the area for 10 mins every hour if needed; this will help reduce any swelling and bruising. A pair of non-rubber surgical gloves filled with cold water is an easy method or just a packet of frozen peas covered in something clean to avoid direct skin contact (to avoid frostbite).
We recommend you sleep with your head raised on a couple of pillows for two nights.
It is often advisable to keep the operated area relatively dry for between two and ten days. You can shower as normal, but make sure you dry your eyelid with a clean cotton pad after.
If your eye remains red, we advise you avoid swimming, contact lens wear and eye make-up for two weeks or longer.