What is ptosis?
Ptosis is the medical term for drooping of the upper eyelid, which can affect one or both eyes.
The most common reason for this is stretching of the eyelid opening tendon over time, due to factors such as ageing and contact lens wear. This can give a tired appearance, and in more severe cases can interfere with vision.
The eyelid can droop due to other reasons, such as problems with the nerve supply to the eyelid opening muscles, or problems with the muscles themselves, and it is important to have your eyelids assessed by a specialist. Ptosis can also be congenital (from childhood) due to misdevelopment of the eyelid opening muscle.
What does ptosis surgery involve?
In most cases, ptosis correction surgery involves tightening the eyelid opening tendon and muscle to raise the eyelid. It is usually carried out under local anaesthetic, with sedation if desired. This allows the measuring of the eyelid height during the procedure for optimal results.
Ptosis correction surgery can be carried out on one side or both sides, and can be combined with other procedures, for example upper lid blepharoplasty to remove excess skin.
Surgery can be carried out through an incision hidden in the upper eyelid crease (anterior approach) or through the inside of the eyelid (posterior approach). A full assessment in clinic will guide which approach is best in your case.
Anterior approach ptosis correction
An incision is made in the natural skin crease of the upper lid, and the eyelid opening tendon is tightened to provide more lift for the eyelid. The eyelid height is checked during the operation and adjusted as necessary. Once a good eyelid height has been achieved the skin is closed, typically with a combination of dissolving stitches and skin glue.
Posterior approach ptosis correction
In posterior approach (transconjunctival) ptosis correction surgery, an incision is made on the inside of the upper eyelid, and the tendon is tightened internally. This avoids an incision on the skin, although the eye can feel gritty initially due to the incision on the inside of the eyelid.
On the day of surgery
When you arrive at the hospital our nursing staff will make sure you are comfortable and take you to our ward area.
On the ward, you will see Mr Peden prior to your surgery, and have the opportunity to ask any further questions you may have.
The surgery is carried out in our operating theatre, after which you will be taken back to the ward to relax and recover before going home later the same day.
After surgery
After ptosis correction surgery you will have some bruising and swelling of the eyelids, which typically largely settles after 10-14 days. In a small number of patients the swelling may persist longer than this. A good pair of sunglasses can be helpful to hide the swelling initially.
It is advisable to take measures to reduce the swelling, and in particular cool compresses such as ice packs should be applied for up to a week after surgery, at least 3-4 times a day for several minutes at a time. Keeping your head elevated with extra pillows in bed when you sleep will also encourage the swelling to settle more quickly. You should avoid strenuous activity for at least a week after the surgery, and ideally until the swelling subsides (gentle walking is fine).
You will be given some antibacterial ointment to apply to the incisions for 10 days to help them heal and to reduce the risk of infection. This ointment can also be applied to the eyes themselves, particularly at night, to help with any dryness you may be experiencing. It is also possible to use artificial tear drops if the eyes are feeling particularly dry (it is common to experience some dryness of the eyes initially following surgery).
It is usually possible to close the incision with a combination of dissolving sutures and glue, meaning in most cases no suture removal is necessary. Make-up should be avoided for the first two weeks after surgery.
When washing, you should try to keep the eyelids dry for 48 hours after surgery. You can shower, avoiding the eyelids, or have a bath with your head out of the water. You can wash your hair if desired, trying to minimise getting water on the eyelids (small splashes are very unlikely to cause any problem). After 48 hours, you can wash the eyes gently if desired, but avoid any rubbing. After 10 days you can return to your usual washing routine.
It is possible to work from home with a computer as soon as you feel ready, typically after a few days. For most other work it is advisable to take 1-2 weeks off due to the swelling.
The eyelid height may fluctuate over the first few weeks after surgery, due to factors such as swelling and disruption of the eyelid closing muscle. The blink/closure of the eye may also be incomplete initially, but this usually settles well.
Risks and complications
Every operation has risks and potential complications. In the case of ptosis correction surgery, there will always be some bruising and swelling, and in some cases the swelling can be persistent. Infection is very rare, but is possible. There can be some bleeding from the incision after surgery, particularly when the adrenaline in the local anaesthetic wears off, but usually firm pressure with a clean tissue is enough to make this subside.
There will be a scar where the incision has been made in the upper lid crease in the case of anterior approach ptosis surgery, and this tends to fade well with time. A small number of patients will have a reaction to dissolving sutures, which can cause swelling and inflamed lumps (granulomas) where the stitches are. If this occurs, these can be treated with steroid ointment or injections, along with removing the dissolving sutures if necessary.
There is often a degree of incomplete blink or eye closure immediately after the surgery due to disruption of the eyelid closing muscle and the eye being more open, but in most cases this will resolve within 2-3 weeks. A small number of patients may experience a persistent problem with eye closure (particularly in cases where there is reduced function of the eyelid opening muscle, such as in congenital ptosis), which can lead to dryness and exposure of the eye, and may occasionally require further procedures to address.
Many factors can affect the final height of the eyelids, and sometimes the eyelids may sit higher or lower than desired. There may be asymmetry of the height or contour of the lids, although every effort is made to minimise this. When only one lid is lifted, the other lid can sometimes droop, as the brain lifts the eyelids as a pair, and can 'relax' when the worse lid is lifted.
There can be some numbness of the skin of the eyelids after surgery, which is sometimes noticed when applying make-up. This usually settles well, but can take several months to do so.
There is a very rare risk of damage to or loss of vision, for example from a bleed into the eye socket. The risk of this is likely to be similar to that of blepharoplasty surgery (0.0033% of patients having blepharoplasty suffered permanent visual loss in a large study, i.e. three in 100,000 patients).