Ptosis or droopy eyelid is a condition where there is a problem with the muscle, nerve or connective tissue responsible for raising the eyelid resulting in a ‘droopy’ or ‘sleepy’ appearance. If severe, it can obstruct a person’s field of vision.
When this happens, the patient may try to constantly raise their eyebrows to compensate leading to headaches. It can affect one or both eyes and is commoner in older age. It is also more frequent in contact lens users and very rarely may also be present at birth.
In young children, uncorrected ptosis, if severe, can result in the development of a ‘lazy eye’. A ‘lazy eye’ is one where full, normal vision is not attained in adulthood. Ptosis is corrected with surgery directed at the underlying cause. Usually surgery in adults is performed under local anaesthetia with sedation but surgery in children is performed under general anaesthesia.
The commonest method is to tighten the muscle that lifts the eyelid directly but less frequently, a silicone band or fascia lata (strip of tissue) is taken from the thigh to lift the eyelid. The incision is usually hidden in the lid skin fold (if present) which minimizes the appearance of a scar. Recovery usually takes 2-4 weeks.
Eyebags refer to the bulges that develop under the eyes resulting in a tired appearance. As people age, the tissues supporting the eye thin and allow fat to push forwards. For moderate to severe eyebags, lower lid blepharoplasty surgery may be needed to restore a more natural appearance.
Eye creams and lotions do not work as surgery is needed to remove the fat that causes the eyebag. Depending on the condition of the lower eyelid skin, surgery may also be needed to remove excess lower lid skin.
The skin incision is hidden in a skin crease that lies just beneath the eye lashes or alternatively, it may be made inside the eyelid in younger patients who do not need any skin to be removed.
The second approach where the incision is inside the eyelid is also called ‘scarless’ or ‘transconjunctival’ blepharoplasty. Surgery is usually performed under local anaesthesia with sedation or general anaesthesia.
Recovery depends on the technique performed and can take 3 months for post-surgery swelling to subside. The risks of surgery include scarring, infection, bruising, asymmetry and a theoretical risk to vision from deep bleeding or infection.
Upper eyelid entropion
Lower lid entropion
Left droopy eyelid or ptosis
Lower lid eyebags
Upper lid hooding or dermatochalasis
In general, the lower eyelid may be involved in disorders where it either turns inwards (entropion) or outwards (ectropion). In the case of entropion, the in-turned eyelid causes the lashes to rub against the cornea and conjunctiva resulting in irritation and discomfort of the eye.
With ectropion, there is irritation and watering due to exposure of the eye. Usually, age related changes are the cause of eyelid malpositions but sometimes they can be due to scarring from either trauma or infection.
In some cases, the eyelid is turned inwards in childhood as a result of an excess fold of skin and muscle – this is called epiblepharon. Irregardless of cause, the short term management is to administer topical lubricants, antibiotics and temporary skin taping.
Surgery is usually required to correct eyelid malpositions permanently. Eyelid malposition surgery usually is performed under local anaesthetic with sedation meaning that half a day is spent in hospital.
There will be redness and swelling after surgery which gradually subsides over the next 4 to 6 weeks although sometimes residual swelling can take even longer to resolve.
Sometimes, the upper eyelids may look ‘puffy’ and this condition is called dermatochalasis. This is due to loosening of the skin resulting in a tired appearance.
If the excess upper eyelid affects the upper field of vision, then surgery would be medically indicated. The treatment for this is to remove the excess skin, fat and muscle with a blepharoplasty surgical procedure.
This is done under local anaesthesia with sedation with the incision hidden in the skin crease line (if present). A ‘Double Eyelid’ appearance can be created in patients who do not already have one. Typically swelling and tenderness will persist after the operation for 2 to 3 months but in some cases take even longer.
Complications from blepharoplasty procedures include scarring, bruising, asymmetry and a theoretical risk of visual loss (bleed or infection affecting the optic nerve). Sometimes, a droopy brow is also present which may mean that a brow lifting operation is also necessary.