Ptosis – Drooping eyelid – Disease and surgery
Ptosis refers to a drooping upper eyelid. It can droop to the point of covering the pupil, thus narrowing the field of vision. Ptosis can affect both children and adults. It is generally caused by muscle weakness or excess skin on the eyelid. Treatment is surgical: the levator muscle is strengthened, restoring a satisfactory eyelid opening.
Adult ptosis
Adult ptosis is caused by a weakening of the levator palpebrae superioris muscle. This is a degeneration of this muscle, hence it is referred to as acquired or involutive ptosis.
Levator ani muscle weakness is usually caused by aging. Less frequently, ptosis is linked to external factors such as trauma, surgery, a muscular disease (myasthenia gravis), or the presence of a lesion weighing down the eyelid.
The treatment for ptosis is exclusively surgical. It is generally performed by an ophthalmologist specializing in eyelids, in order to take a comprehensive functional and aesthetic approach to your eye.
The procedure can be performed for cosmetic purposes (no visual impact) or for functional reasons, if there is a visual impact. The extent of visual field impairment will determine whether or not it is covered by social security.
Symptoms
Ptosis causes a sensation of drooping eyelids. When they droop excessively, a feeling of loss of field of vision may develop.
To compensate for ptosis, some patients adopt a posture with their head tilted back and eyes looking down. This uncomfortable position can cause torticollis.
Causes
Ptosis is most often of degenerative origin, that is to say, related to age. This is referred to as aponeurotic ptosis.
Other causes of ptosis include:
Myogenic – A muscular weakness such as myasthenia gravis.
Neurogenic – Nerve paralysis results in an absence of stimulation of the levator palpebrae superioris in cases of facial paralysis or Claude Bernard Horner syndrome (miosis, ptosis, enophthalmos).
Mechanics – A tumor of the upper eyelid causes ptosis of the eyelid due to the effect of weight.
Diagnosis
The diagnosis of ptosis is clinical. The ophthalmologist confirms the presence of ptosis of the eyelids.
To assess its impact, it measures the coverage of the pupil by the upper eyelid. The width of the eye opening (palpebral slit) and the amplitude of eyelid blinking (function of the levator muscle) are also measured.
During the preoperative assessment, the eyelid surgeon may instill a drop of Neosynephrine® to evaluate the function of the Müller muscle. If this function is sufficient, the surgeon may be able to perform surgery internally, leaving no visible scar.
He will also look for a possible triggering factor. If there is doubt about a neurogenic origin, brain imaging and blood tests to look for nerve compression or myasthenia gravis may be ordered.
Treatment and surgery for ptosis
The treatment for ptosis is exclusively surgical. The operation is usually performed on an outpatient basis, meaning you can go home the same day as the surgery.
Local anesthesia will be used to numb your eyelid.
Both eyelids can be operated on the same day or separately, depending on the surgeon's habits.
Before the operation
Before starting the operation, your surgeon will first:
To create the pre-operative drawings that will be used to make the incisions and possibly remove excess skin.
He then infiltrates the eyelid with Xylocaine, a local anesthetic, in order to relieve any pain.
The operation – Surgical technique
Depending on the degree of muscle damage, three surgical techniques can be used:
Conjunctival-Müllerian resection – This is the least invasive technique. Only the accessory levator palpebrae muscle of the eyelid, known as the Müllerian muscle, is reinforced. This technique has the advantage of not leaving a scar on the skin. However, its effectiveness is limited. The technique should be reserved for small cases of ptosis.
Levator ani suspension – This is the most commonly used surgical technique. The main levator muscle of the eyelid is strengthened and tightened to the stabilizing structures of the eyelid. The scar is hidden in the eyelid crease. This procedure can be combined with the removal of excess skin (dermatochalasis).
Frontal suspension – This is the most radical surgical technique. The eyelid is held up by strips attached to the forehead muscles. The patient then opens their eyes by lifting their frontalis muscles. This surgical technique is reserved for the most severe cases, particularly patients who have lost all movement of the levator palpebrae superioris muscle. This technique is generally performed on children.
After the operation
Once the operation is complete, your surgeon will apply a compression bandage to put pressure on your eyelid and limit the formation of swelling or hematoma.
You will spend a few minutes under observation in the recovery room, before returning to your room and preparing to go home.
Post-operative care and convalescence
Post-operative recovery is usually straightforward. It is advisable after the operation to:
Apply a cold mask 2 to 3 times a day to limit swelling.
Apply the ointment and eye drops rigorously for 10 to 15 days.
The stitches will be removed between the 7th and 10th day following the operation.
The swelling and bruising will disappear within 15 days.
The work stoppage will be 7 to 10 days.
Complications
Childhood ptosis
Ptosis present at birth is called congenital ptosis. It is usually caused by paralysis of the levator palpebrae superioris muscle or a lack of nerve development. Diagnosis at birth is easy: the eyelid droops. The crease of the upper eyelid may also be flattened.
To compensate for the drooping eyelid, the child maintains a head tilted back, chin raised, and eyebrows furrowed in an attempt to open their eyes. These movements can lead to torticollis and an abnormal head posture.
The inability of the eyes to open at birth can also cause vision problems. If the eyes are blocked, the child develops amblyopia (lazy eye). In the case of a weak eye, not only does visual development not occur correctly, but the alignment of the eyes can also be affected: the child develops strabismus (crossed eyes).
Treatment of ptosis in children
The decision to perform ptosis surgery is based on a benefit-risk assessment. The factors considered in the surgical decision are:
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The child's age.
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Unilateral or bilateral involvement.
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Eyelid height – Is the visual axis clear?
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The strength of the levator palpebrae superioris muscle.
When the visual axis is obstructed, surgery is usually performed quickly to prevent the development of amblyopia. The procedure involves either strengthening the levator muscle by shortening it, or attaching the levator muscle to the forehead muscles to help the eyelids open.
In cases of associated amblyopia, it must be treated by wearing an eye patch and/or corrective glasses to strengthen the weaker eye.
All children with ptosis, whether they have had surgery or not, should see their ophthalmologist regularly.