“Understanding the underlying cause of ptosis is paramount, whether it is acquired, congenital or associated previous surgery. It’s important to rule out the rare causes of acquired ptosis such as acute Horner’s syndrome, third nerve palsy and enophthalmos. Symptoms to be cautious of include double vision, headaches and neck pain”
Mr Uddin has been treating patients with ptosis for over 25 years. From his extensive experience of treating patients with ptosis, Mr Uddin understands the impact that a change in a person’s appearance can have on their self-confidence, as well as their, such as affecting the ability to work and carry out day to day tasks.
For patients with ptosis, Mr Uddin undertakes a comprehensive assessment in conjunction with necessary investigations to find the underlying cause. He will then deliver a treatment plan specific to the individual.
“Ptosis surgery is usually successful and symmetry is often achieved. It is best performed by an oculoplastic surgeon who understands the importance of the function of the eye first, and has the skills and training to be able to handle the delicate, specific eyelid anatomy whilst respecting the cosmetic outcome”
What is ptosis?
Ptosis, also known as blepharoptosis, refers to the drooping of the upper eyelids. Often, it is first noticed by other people or in photographs.
There may also be drooping of the brow known as brow ptosis.
What are the symptoms of ptosis?
As well as the appearance, additional symptoms include difficulty in keeping eyes open, eye strain, eyebrow ache and fatigue whilst reading. These symptoms usually appear gradually in chronic cases (eg age or contact lens ptosis).
Some people with more severe or sudden ptosis may also experience double vision (diplopia), headaches and neck pain. These can be signs of a serious underlying condition and may require urgent care.
What causes ptosis?
Ptosis can be congenital (present at birth) or acquired (developed later on).
Congenital ptosis is usually due to an abnormality in the muscle which raises the eyelid (the levator muscle); it may affect one or both eyelids. In some rare cases it can be caused by trauma during birth or by disorders called Marcus Gunn jaw winking syndrome or blepharophimosis syndrome.
Acquired ptosis is usually due to a stretching of the levator muscle (which lifts the eyelid) or its attachment (called the levator aponeurosis). This is commonly due to ageing, previous eye surgery, eyelid swelling, a previous cyst or after long-term contact lens wear.
Ptosis may also be a result of neuromuscular conditions such as myasthenia gravis or myotonic dystrophy. With myasthenia gravis a person may experience variable changes in their vision or double vision and with myotonic dystrophy they may experience ptosis in both eyes with a reduction in the ability to show facial expressions.
In rare cases ptosis may be a sign of:
- An intracranial aneurysm (dilated blood vessel in the brain)
- Third cranial nerve palsy
- Horner’s syndrome
- Mechanical ptosis (when a mass pushes the eyelid down)
- Enophthalmos (sunken looking eye)
- An eyelid or orbital (eye socket) tumour
- Chronic progressive external ophthalmoplegia (paralysis/weakness of eye muscles)
Blood tests or additional scans may be needed to investigate these.
An old photograph is often helpful to see if the droopy eyelid has been there for a long time. Usually the cause of ptosis can be established by conducting a clinical examination and taking the patient’s medical history.
Occasionally an orthoptic assessment may be needed, as well as a special test for the pupils. Very rarely other investigations such as a blood test, computerised tomography (CT) scan or magnetic resonance imaging (MRI) scan may be needed.
How is ptosis treated?
The treatment depends on the type of ptosis, severity and the strength & function of the eyelid muscles. The underlying cause of the ptosis needs to be considered first. For many patients the ptosis can to be treated with surgery, although in rare cases this may not be an option and the eyelid can be taped or an eyelid prop can be used to open the eyelid.
Often the type of surgery needed depends on the function of the levator muscle or how well the eyelids move. As well as other issues such as dry eyes and contact lens wear.
If the ptosis is due to a stretching of the levator muscle or to the attaching tissue (levator aponeurosis) the surgery is relatively straightforward. The aim of the procedure is to reattach and strengthen the muscle or attachment. If the levator function is reduced, surgery involves shortening the levator muscle. This procedure is called a levator resection. In some cases, stitches are used, which are removed about a week after surgery.
Those with very poor muscle function may benefit from brow suspension surgery. This involves suspending the eyelid from the brow in order to raise it. Usually, a synthetic suture or silicone material is used, but tissue from another part of the body can also be utilised, including fascia lata from the leg or temple area.
For adults having levator surgery, this can be done under local anaesthetic and takes about 45 minutes. It involves a local anaesthetic injection into the eyelid which numbs the area. Surgery is then comfortable. surgery is performed to restructure and reposition the muscle, adjacent tissue and skin. In some cases a person may choose to be sedated during the procedure, particularly if they are nervous.
Ptosis surgery can be done through an anterior or posterior approach.
Anterior approach ptosis surgery: an incision is made in the skin which allows the skin crease to be adjusted and excess skin to be removed if necessary (blepharoplasty).
Posterior approach ptosis surgery: no incision is made into the skin. It is performed under from the undersurface of the eyelid.
Following surgery, a pad is placed over the eye; these are usually removed after 4 to 12 hours. Most people are sent home straight after surgery. However, if both eyes undergo surgery, patients will remain in the hospital for a few hours so that Mr Uddin can review the patient after the eye pads are removed prior to discharge.
After surgery, it takes one to two weeks for the initial swelling to settle down. During this period, driving, cycling, swimming and operating heavy machinery is prohibited. The healing of any incision may take up to six weeks and is usually not visible
With an anterior approach ptosis surgery, an incision is made into the skin along a natural crease line. This usually heals well, looks natural and is hidden. For some skin types, including those with rosacea or very fair skin, the scar may be slightly visible following the surgery.
Success rates of ptosis surgery are very high with most patients successfully gaining eyelid symmetry and function. With more complex cases of ptosis surgery, there could still be a noticeable difference between the eyelids or the lid may have reduced movement. This is often called lid lag or downgaze ‘hang -up’.
Due to changes in eyelid closure, some people may also experience dry eyes. This can be treated with eye drops. There is also a small risk of bleeding around the upper eyelid and infection.
After surgery, ptosis is unlikely to reoccur. However, there are a small number of cases where the ptosis returns.
Children as young as six months can have a levator resection or brow suspension surgery. Additional information can be found in the Children section.
The 3 small marks on the brow fade and become almost invisible with time.
“Ptosis surgery is usually successful and symmetry is usually achieved. It is best performed by an oculoplastic surgeon who understands the importance of the function of the eye first, and has the skills and training to be able to handle the delicate eyelid anatomy whilst respecting the cosmetic outcome”
This is the most common form of ptosis, occurring with older age, where the tissue connecting to the levator muscle (aponeurosis) is stretched. This can also be caused by eyelid swelling, frequent eye rubbing, previous surgery or long-term contact lens wear.
This is where a swelling or a mass, such as a chalazion or occasionally a tumour, causes the eyelid to droop. It is important to exclude this and look on the underside of the lid.
This is associated with injury to the eyelids from a trauma or swelling. This may weaken or damage the levator muscles. On rare occasions there may be neurological damage.
In Marcus Gunn 'jaw-winking' ptosis, a rare disorder, the drooping eyelid rises when the jaw is opened. This condition is apparent from birth and usually affects one eye. The exact cause of this disorder is not known and can be helped with surgery.
Myasthenia gravis is a rare autoimmune condition that causes muscle weakness. It particularly affects the muscles that control eye movements,eyelids, facial expressions and sometimes chewing, swallowing and speaking. The condition can affect people of any age, but signs usually start in women under 40 and men over 60.
Horner’s syndrome is a rare condition which is caused by damage to particular nerve fibres to the face, eyelids and pupils. This damage may be caused by a tumour, stroke, injury or underlying disease. In addition to ptosis, a person with Horner’s syndrome may also experience a decrease in the size of their pupils (miosis) and a lack of sweating on one side of the face. Occasionally, the lower eye lid may also rise (inverse ptosis) giving the appearance the eyeball is receding into the socket. Both types of ptosis can be improved with surgery.
Chronic progressive external ophthalmoplegia (CPEO) is a genetic condition where the muscles of the eyes and eyelids slowly deteriorate, loos function and become weaker. Signs and symptoms of CPEO tend to appear in early adulthood. Sometimes those with the condition have additional eye movement problems and poor eyelid closure, which can be improved with very careful management and surgery.
Myotonic dystrophy is a genetic disease that affects the function of muscles around the body. It is a type of CPEO and is characterised by muscle loss and weakness. In some cases a person may not be able to relax certain muscles. Symptoms tend to become apparent in early adulthood.
This is when the third cranial nerve is damaged; it is the nerve that enables most movements of the eye and pupil. This may be acquired due to a medical problem such as diabetes or is present from birth (congenital). It could be an indicator of a brain aneurysm when associated with a sudden, severe headache and ptosis and squint. This will need to be seen urgently in an emergency department.
This is when the eye is sunk into the socket, resulting in a droopy upper eyelid. This can be caused by previous injury or inflammation. A tumour can also cause the tissue behind the eye to shrink and scar, similar to breast cancer.
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