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Upper Eyelid Drooping (Ptosis)

What is ptosis?
Ptosis is a condition of the upper eyelid that causes it to droop (Figure 4). The eyelid margin (the area of the eyelid where the eyelashes come out of) hangs down in front of the pupil (black opening) of the eye. The pupil is the window into the eye—like a window in your house. The pupil allows the images from the outside world to enter your eye. If the upper eyelid margin is lower than it should be and blocks the pupil, ptosis results. As a result, ptosis can interfere with your vision.

What are the symptoms of ptosis?
As can be inferred from above, visual complaints are the most common symptoms of ptosis. These can range from loss of peripheral vision to difficulty reading. Many patients with ptosis complain of “tired eyes”. Patients will often complain that they have to “hold their eyelids up in order to see”. Sustained reading also becomes very difficult with ptosis of the upper eyelid.

Is ptosis different from baggy eyelids (dermatochalasis)?
Baggy upper eyelids (dermatochalasis) are different from ptosis. With baggy upper eyelids the lid margin is in a normal position-unlike ptosis. Baggy eyelids describe a condition of the upper lids caused by excess skin that hangs over the lid. The symptoms of baggy eyelids and ptosis, however, can be very similar. Both interfere with vision as described above. Treatment involves a different type of operation. An oculoplastic surgeon can easily make this distinction.

What are the causes of ptosis?
Ptosis is broken down into a congenital form (present from birth) and an acquired form. The acquired form can occur at any age, but typically occurs after the age of 60. Most cases of ptosis are caused by a defect in the muscle that raises and lowers the upper eyelid called the levator muscle. Let’s talk briefly about the muscles involved with opening and closing the eyes.
As mentioned above, the muscle in the upper eyelid that raises the lid is called the levator muscle. There is a separate muscle that surrounds the eye in both the upper and lower eyelid called the orbicularis muscle that closes the eye. Thus the levator muscle allows the eye to open and the orbicularis muscle causes the eye to close. There is fat between the orbicularis muscle and the levator muscle that acts as a shock absorber and allows for smooth movement of the eyelid. So if you really think about it, the blink reflex is a very complicated interplay between these two muscles.
In congenital cases, the levator muscle does not form properly. In the acquired cases, the muscle functioned normally prior to the onset of the ptosis. For some unknown reason, the levator muscle stretches and weakens over time causing the eyelid to drop. Possible causes of

levator weakening includes (1) previous surgery, (2) eyelid swelling secondary to infection or allergies, and (3) manipulation and stretching of the eyelid from contact lens use.
There are some neurological conditions that can cause ptosis, such as myasthenia gravis. Your history and physical exam can provide clues. A neurology consultation may be necessary.

What are the treatments for ptosis of the upper eyelid?
If the ptosis is caused by certain neurological conditions, medicine may elevate the eyelid. If the ptosis is mild enough and there are no real symptoms, the condition can be followed conservatively with no treatment. If symptomatic with visual difficulties, ptosis is corrected by surgery.

What type of surgery is done for ptosis?
Congenital Ptosis: Surgery is usually postponed until age 3-4 unless the ptosis is severe enough to be causing a lazy eye and permanent visual loss. Surgery is aimed at strengthening the weak and malformed levator muscle. Sometimes the levator is so weak that the brow muscles must be used in the surgical correction.
Acquired ptosis: Surgery to strengthen the levator muscle is my preferred choice to correct ptosis. Some surgeons will elevate the eyelid by tightening the posterior (back) tissues of the eyelid. This technique is equally as effective.

What can I expect after the surgery?
Usually the eyelid will remain swollen for one to two weeks. In addition, varying amounts of “black and blue” will be present. Pain is minimal for the first 24 hours. I have my patient return to their full activity level as soon as they feel up to it. This is usually after 48 hours. The incision sites are treated with ointments. The stitches come out in one week. Most people complain that the eyelids feel a little tight and numb for a few days. These feelings almost always disappear.

What are the complications of ptosis surgery?
As with other eyelid surgery, bleeding and infection are risks. In addition, ptosis surgery can result in an under correction about 5-10% of the time. This means that the procedure may need to be repeated either with the same or a different technique. Over corrections can occur as well. Fortunately over corrections are much less common. They are also more difficult to fix.

Does my insurance cover ptosis surgery?
Most insurance companies have criterion that determines whether ptosis surgery will be covered. Usually your insurance company will require precertification. My staff will take care of this. Medicare is the exception. They do not do precertifications.

If dermatochalasis is also present, can it be corrected at the same time as a ptosis repair?
Dermatochalasis (baggy eyelids) can be corrected at the same time as a ptosis repair. Your insurance company may consider it to be cosmetic, however, and not covered for payment. Dermatochalasis surgery would then be treated as a cosmetic procedure.

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