When should you consider treatment of ptosis?
If you want to have your ptosis treated, you need to consider surgery by an oculoplastic surgeon. We recommend surgery when there is a significant cosmetic or a functional effect from the ptosis. A cosmetic effect can occur if there is an asymmetry between the two eyelids, or if the skin crease has gone unusually high making the eyelids look very sleepy and tired. If the eyelids are falling towards – or over – the visual axis, this can affect your visual field, particularly the upper visual field. This situation can have a functional effect on your vision. We can measure this functional effect on your vision at Clinica London by doing visual field tests. Once we have established that you have ptosis and that there is no serious cause, we have to consider what is the best treatment will be. However, before we do that, we have also to check the health of the front of the eye and make sure that you have enough tears and that no associated dry eye syndrome could be exacerbated by surgery.
I have already said the most common cause of ptosis is involutional or age-related. For this type of ptosis, you can have an anterior approach ptosis repair, which is a levator muscle tuck or advance, or you can do the same thing using what is called a posterior approach and going through the conjunctiva underneath the lid. Whichever approach of ptosis surgery your oculoplastic surgeon recommends this is usually done as a day case or as an outpatient treatment if it is unilateral under local anaesthetic. You will not typically require sedation.
Your ptosis surgery takes anything up to an hour or slightly longer if it is bilateral. After we have cleaned the skin and marked the eyelids in the sitting up position, we make a fine incision into the skin crease and then we identify, release and advance the aponeurosis or fine tendon of the levator muscle within the eyelid. At the end of the procedure, we close the skin with some stitches. My patients at Clinica London get some TISSEEL fibrin adhesive and then usually I do not put on dressing, but I often give transparent Cartella shields to protect the eyes at night and dark glasses during the day. I particularly emphasise the use of antibiotics and lubricant drops to reduce the risk of infection and dry eye after the surgery and some ointment at night. I then see you again back at Clinica London about a week after the surgery.
What can you expect after my treatment of ptosis?
Well, you can expect to have a slightly puffy swollen lid with a bruise. This swelling usually settles within five to 10 days. As a rule of thumb, younger patients tend to bruise less; older patients tend to bruise more. You can reduce the bruising by using a cold eye mask and by mobilising and walking around from 48 hours after your surgery. You can also avoid taking any drugs or food or vitamin supplements before your operation that may thin the blood and increase your risk or bruising. You can expect the upper eyelid to feel a little numb for a few weeks, with feeling returning over weeks or months. It always returns.
The most significant worry for the surgeon of ptosis surgery is that despite you being awake for the operation, we have had to give local anaesthetic and that slightly impairs the function of the lid during the surgery. So, we are making assumptions and adjustments to try and make sure that two upper eyelids are equal and there is an excellent height after surgery, but sometimes when the local anaesthetic wears off, there can be an eyelid, which appears to be too high or too low. I use a high degree of artistic assessment and judgement throughout your eyelid surgery. If an asymmetry persists weeks after surgery, it may indicate further refinement surgery. We usually do not do this until the eyelids have completely healed and all the bruising and swelling completely disappears. I certainly would not consider altering the height of an eyelid within three months of doing the original surgery.
Are there any serious risks of having treatment of ptosis?
Yes, of course, there are. All operations carry risks. We have already mentioned bruising, swelling, redness and then overcorrection and under correction. Studies show that about 20% of patients may not have a completely perfect result following ptosis surgery despite it going well during surgery. However, only about 10% or 11% of patients require any refinement surgery, and that could be something as small as removing a little bit of thickened skin or putting in an extra stitch to improve the curve. This follow-up procedure does not usually represent a full redo of the ptosis.
If your ptosis has been a more complex one such as a congenital one or one with a nerve or muscle problem, then it may be that we have to leave the eyelid a little lower than you would like because I want to make sure that you can completely close the eye whilst you are asleep and protect the eye. Furthermore, I want to make sure you do not get any corneal abrasion, corneal exposure, dryness and discomfort after the surgery. If there is slight dryness that does not respond to eye drops though, I can put in a punctual plug which will help you maintain the tears that you produce and maintain them on the eye surface. I may also recommend additional lubricant drops.
One thing I will have checked before your surgery is whether the eye can roll up underneath the closed eyelid naturally, which is called the Bell’s phenomena, or whether that is defective. If that Bell’s is flawed and if the eyelid closure is also weak, then I have to be extremely careful in how I position the eyelid for you to maintain a healthy cornea afterwards. I have to both undercorrect and carefully place the skin crease to give an allusion of symmetry.
There is a tiny risk of damage to your eye and your eyesight with all eyelid surgery even in the hands of highly specialised well-trained oculoplastic surgeons. Although this risk is tiny, I must always mention it to patients. To date, I have never seen these risks materialise with ptosis surgery, but damage to the eye or eyesight is possible with any operation close to or around the eye.
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