- Ptosis (blepharoptosis) is the abnormally low (droopy) position of the upper eyelid margin due to a weakness in the lifting mechanism. This mechanism consists of muscle (levator palpebral superioris) and its soft tissue extension (levator aponeurosis)
- It must be differentiated from dermatochalasis. In this condition excessively lax upper eyelid skin causes droopy appearance rather than true weakness of the lifting mechanism of the eye.
- Blepharoptosis can also co-exist with dermatochalasis.
- Patients with blepharoptosis or dermatochalasis has tired looking eyes even though they have adequate rest. They usually use their forehead muscles to assist in lifting up the upper eyelids resulting in persistent frownlines.
|Mechanism||Droopy lid due to weakness in the lifting mechanism of eyelid.||Droopy lid due to excessive eyelid skin.|
|What covers the limbus?||Ciliary margin (eyelash margin)||Skin edge of redundant upper eyelid skin|
|Age group||All age||Older age|
|Associated disorder||Both conditions can co-exist|
|Medical claims||Considered medical condition||Considered cosmetic condition|
*Limbus – Junction between the cornea and the sclera (the black and the white of the eye)
ASSESSMENT OF BLEPHAROPTOSIS
- Blepharoptosis is assessed based on two parameters :
- Degree of blepharoptosis – severity of blepharoptosis
- Levator function – the residual lifting ability of the upper eyelid opening mechanism
DEGREE OF BLEPHAROPTOSIS
There are two methods to measure the severity of blepharoptosis
- Amount of upper lid droop or descent (over the limbus)
- Marginal Reflex Distance
- Most accurate method to measure degree of blepharoptosis
- It is a vertical distance between the pupillary light reflex and the eyelid margin.
- Types of MRD :
- Distance from the pupil center to the upper eyelid
- Blepharoptosis present if MRD1 < 4 mm
- Distance from the pupil center to the lower eyelid
- Lower lid retraction if MRD2 > 6 mm
|Lid Descent over Upper Limbus||MRD1|
|Degree of Blepharoptosis|
|Mild||1-2 mm||3-4 mm|
|Moderate||3 mm||2 mm|
|Severe||> 4 mm||1 mm|
- The levator palpebral superioris is the main muscle responsible for eye opening.
- To measure the residual lifting ability of the upper eyelid opening mechanism, the patient is asked to look downwards and then upwards while immobilizing the brow. The amount of eyelid movement is called levator excursion and this reflects levator function.
- The levator function and degree of blepharoptosis determines the type of corrective surgery to be done.
Table of Levator Function Assessment
|Levator Excursion||Levator Function|
|Good : >10 mm|
|Fair : 5-10 mm|
|Poor : 0-5 mm|
- Patient with established blepharoptosis.
- Patient with blepharoptosis concomitant dermatochalasis.
DESCRIPTION OF PROCEDURE
Table of Status of Levator Function and Corresponding Ptosis Correction Procedures
|Excellent (> 10 mm)||Moderate (5-10 mm)||Poor (0-5 mm)|
|Type of Procedure|
- Many surgical procedures have been described for the correction of blepharoptosis tailored according to levator function.
- The most common procedures done by our plastic surgeon are levator plication and levator advancement.
- The levator aponeurosis is shortened by pleating and suturing in levator plication procedure. A portion of the excess aponeurosis is removed and the free edges are overlapped and sutured together in the levator advancement procedure.
- The incisions and scar for blepharoptosis correction is similar to conventional blepharoplasty. The scar is hidden in the eyelid crease.
- However, the scope of surgery is vastly different. It is a very delicate surgery that require meticulous dissection of the opening mechanism of the eye and it takes longer duration than conventional blepharoplasty.
- During the operation patient may be required to sit-up and check for symmetry of eye opening several times after correction.
- Ptosis correction ( droopy eyelid surgery ) can be combined with conventional upper blepharoplasty procedure for :
- Surgical duration: 2-4 hours
- Day Surgery (home on the same day)
- Combination of local anaesthesia with light intravenous sedation administration :
- Maximal patient comfort
- Patient able to participate in checking symmetry of eye-opening during the surgery.
- General anaesthesia :
- At special request of the patient.
- Result might be affected because of inability to check for symmetrical eye-opening.
POST OPERATIVE CARE
- Mild discomfort to be expected includes:
- Swelling usually resolves by 1 week.
- In rare instances swelling may take several weeks to resolve.
- Avoid exertion and rest 30 degree head up to hasten resolution of swelling.
- Bruising usually resolves by 2 weeks.
- Incomplete eyelid closure – usually transient
- May need lubricant eye drop or eye gel to prevent corneal desiccation (drying).
- Eye pad may be required during sleep.
- Post-operative medication:
- Antibiotic ointment to be applied regularly 3-5 times a day
- Antibiotic eye drop 3 times day
- Oral antibiotics
- Analgesics (pain relief) and anti-swelling medications
- Removal of suture at 1 week.
- Resumption of light exercise for 3-4 weeks.
- Refrain from wearing contact lens up to 4 weeks post-surgery.
- Swelling usually resolves by 1 week.
RISK AND COMPLICATION
- Bleeding/ Haematoma (blood clot accumulation)
- Avoid exertion post-operative.
- Very rare
- Avoided by clean (sterile) technique during the surgery.
- Asymmetrical eye-opening is fairly common in the early post-operative period
FREQUENTLY ASKED QUESTION
Is asymmetrical eye opening common after blepharoptosis correction?
- This is a common occurrence and it is usually transient. The eye will take a short while to adjust to its new eyelid opening position.
- Many patients have pre-existing asymmetrical height of the globe of eye, size of eye-opening, the amount of extra skin and fat in the eyelids, and the distance between the brow and upper lid.
- Due to all these factors, asymmetry can still result despite best efforts during surgery.
Is it common to perform ptosis surgery in only one eye?
- Although blepharoptosis may be unilateral (exist in one eye) it is common to suggest correction in both eyes because ptosis correction in one eye can affect the eye opening of the opposite un-operated eye. During consultation, Dr Ng would explain why this is affected by the complex nature of equal innervation of both eyes (Hering’s law).
- Blepharoptosis correction is considered medical and financial assistance by medical insurance is possible provided a set of strict criteria are met. These criteria include special test e.g. visual field testing by eye specialist.
- The amount of reimbursement by the insurance company is determined on a case-by-case basis by their assessment team.
After a consultation our plastic surgeon would explain the most common causes of ptosis, sagging or droopy lid and recommend the best droopy eyelid correction surgery method that is used by top plastic surgeon in Singapore.