Ptosis Correction

Overview 

The term "ptosis" is derived from the Greek word "falling" and refers to a body component drooping. Blepharoptosis is the drooping of the upper eyelids with the eyes in the predominant position of gazing. The form of one's eyes, as well as the location of the eyelids, as well as the shape and position of the brow, establish one's identity. As a result, drooping eyelids may result in a functional or aesthetic deficiency.

Ptosis may occur at any age and is caused by a variety of reasons. It is important to note that when a patient complains of drooping, it is only a symptom and not the diagnosis. To discover the reason, a comprehensive assessment is essential.

Ptosis definition 

Ptosis refers to the sagging or drooping of a certain part of the body, especially the eyelid. Eyelid ptosis can occur and affect one or both eyelids. It involves drooping of the upper eyelid such that it partially covers the pupil. This results in a sleepy, tired appearance and reduced vision. In most cases, a corrective procedure is necessary to correct the issue and enhance vision. 

For this case, a ptosis correction is mostly recommended. It aims at correcting the saggy eyelid(s) to give you a vibrant and more youthful appearance. Professional ophthalmologists who specialize in surgery of the eyelids usually perform the correction procedure. Apart from extensive experience, this type of surgery requires proper care when planning and executing the operation. 

Anatomy and Physiology

The palpebral fissure is an oval aperture between the upper and lower eyelids. The upper eyelid curvature is greatest just nasal to the mid pupillary point, which is a critical location to mark before surgery in order to get the best aesthetic effects. The top lid covers 1 to 2mm of the superior limbus, whereas the lower lid is located at the lower limbus.

Structures forming the eyelid

1. Skin and subcutaneous tissue
2. Orbicularis oculi
3. Orbital septum
4. Preaponeurotic fat pad
5. Tarsal plate
6. Levator aponeurosis and Muller’s muscle
7. Conjunctiva

Skin

The skin on the eyelids is the thinnest layer of skin on the body. The levator aponeurosis attaches to the skin and produces the eyelid crease.

Orbicularis oculi

It is a circular muscle with three sections: preseptal, pretarsal, and orbital orbicularis. Contraction is responsible for both gradual and forcible eyelid closure. 

Orbital septum

It is made up of several layers of thin fibrous connective tissue. The septum connects to the periosteum superiorly above the superior orbital margin. It connects with the levator aponeurosis fibers below the superior tarsal border. The septum is opened during ptosis surgery to provide access to the levator muscle. To minimize post-operative lid retraction, the septal attachments to the levator muscle should be separated carefully.

Preaponeurotic fat pad

The fat pad is located behind the septum and in front of the levator. Intraoperatively, this fat pad can be recognized by putting pressure on the globe, causing it to prolapse forward. It aids in the identification of the levator muscle, which is located directly posterior to it.

Tarsal plate

Tarsal plate is a strong connective tissue structure that comprises the structural skeleton of the eyelid. The upper eyelid has a vertical height of 10 to 12 mm while the lower lid has a vertical height of 4 to 5 mm. The Meibomian glands are located in the tarsal plates, and their orifices open posterior to the grey line.

Levator Palpebrae superioris muscle (LPS)

The major elevator of the eyelid is LPS. It emerges from the periosteum above the lesser wing of the sphenoid near the orbital apex. It moves ahead beneath the orbit's ceiling. It switches direction from horizontal to vertical near the superior orbital rim and produces the tendinous sheath known as the levator aponeurosis. The Whitnall's ligament, which is visible as a thick white band of connective tissue and works as a pulley, is located at this transition. It is positioned 10 to 12 mm above the tarsal plate.

There are various insertions of the levator aponeurosis. It enters into the upper lid skin anteriorly, generating the lid crease. It enters inferiorly on the anterior surface of the upper one-third of the tarsus. It is attached to the superior conjunctival fornix posteriorly. It generates the medial and lateral horns, which subsequently enter into the posterior lacrimal crest and Whitnall's tubercle, as well as the canthal tendons.

Muller’s muscle

It is a smooth muscle that is sympathetically innervated. It arises from the undersurface of the levator aponeurosis at the level of the Whitnall ligament and inserts into the tarsal superior border. It adds to a 2 mm elevation of the eyelids.

Conjunctiva

It is the deepest layer of the eyelid that is made up of non-keratinizing squamous epithelium. It extends throughout the globe's anterior surface. It includes goblet cells, the secretions of which are crucial in keeping the eyes moist. 

Understanding the Common Types of Ptosis 

 Eyelid ptosis is usually divided into two main categories, including; 

• Congenital ptosis 

Congenital ptosis condition is present during birth and can go undiagnosed till childhood. At this stage, it tends to get more visible. It happens when the levator muscle that facilitates the raising of the eyelid does not mature well in the uterus. Congenital eyelid ptosis impairs the upper area of the field of vision. As a result, children with the disorder often turn their heads backward in order to see properly.

If congenital ptosis is left untreated, it could result in other vision problems such as amblyopia or lazy eye. 

• Acquired ptosis 

While some people may be born with ptosis, others acquire the condition later in life. It can occur when the ligaments or the muscles that naturally lift the eyelid become weakened following a disease or injury. At times, drooping can happen due to damage of the nerves controlling the lid muscles. 

In general, acquired eyelid ptosis exists in various forms such as; 

• Mechanical ptosis: 

This develops when the eyelid is subjected downwards due to excess tissue mass or skin. 

• Aponeurotic ptosis: 

Aponeurotic ptosis is the most common kind of adult ptosis and generally appears in the fifth or sixth decade of life. It is sometimes referred to as involutional ptosis. However, it can develop in young people as a result of trauma, recent eyelid swelling, ocular surgery, or long-term usage of contact lenses. The most common cause of aponeurotic ptosis is levator aponeurosis dehiscence or disinsertion. True dehiscence is occasionally lacking in involutional instances, and ptosis arises as a result of aponeurosis stretching or thinning. Fatty infiltration of the levator muscle is uncommon.

Patients with this kind of ptosis have an excellent levator function with a high lid crease, the afflicted eyelid looks lower on down gaze, and a thin upper eyelid with excess skin.

• Neurogenic ptosis: 

This type of condition is caused by a problem associated with the nerve paths that regulate the movement of the eyelid muscles. Third nerve palsy, Horner syndrome, and myasthenia gravis are examples of these disorders. 

Ptosis and limitation of adduction, elevation, and depression movements of the eyeball are symptoms of oculomotor nerve lesions. Pupillary participation might be present or absent. Bell's phenomena is frequently ineffective. Pupil-involving third nerve palsy is a neurological condition caused by a posterior connecting artery aneurysm squeezing the nerve.

Pupil-sparing third nerve palsy is most commonly caused by an ischemic vascular source and normally cures on its own within 3 months. Other reasons include inflammation, damage, or tumors along the nerve's path. Superior orbital fissure, orbital apex, or cavernous sinus lesions occur in conjunction with other cranial nerve palsies.

• Traumatic ptosis:

 This occurs following a trauma or injury of the eyelid that alters the levator muscle.

• Myasthenia gravis

Myasthenia gravis is an autoimmune illness characterized by antibodies to acetylcholine receptors found in the neuromuscular endplates of voluntary muscles. This causes cholinergic activity to be reduced, resulting in muscular weakness and tiredness. Myasthenia can be universal or specific to the eye (ocular myasthenia).

Variable ptosis with diplopia is the most typical presenting characteristic. Unilateral or bilateral symptoms are possible. Myasthenia patients initially have normal levator function. Prolonged upgaze causes ptosis worsening in these patients owing to muscular exhaustion.

The ice test, serum acetylcholine receptor antibody assay, single fiber electromyography, and repeated nerve stimulation test are further procedures that might assist confirm the diagnosis.

Assessment of patients with Ptosis

A detailed history and clinical examination aid in determining the cause of ptosis and planning suitable therapy.

History

The age of commencement of ptosis, progression, duration, and any aggravating or alleviating variables should all be included in the history. Any accompanying symptoms, such as diplopia, diurnal fluctuation, discomfort, lid swelling, dysphagia, or muscular weakness, aid in the preliminary diagnosis.

Trauma, ocular or eyelid surgery, contact lens usage, and botulinum toxin injection should all be thoroughly checked out as risk factors. To rule out genetic illnesses, a family history of ptosis should be sought. When a patient's history is ambiguous, an examination of historical pictures might help determine the period of onset.

Documentation is required for any systemic ailment, mental health difficulties, or medication history. Patients using blood thinners, such as aspirin, should be instructed to discontinue their drugs one week before surgery.

Clinical examination

Clinical examination begins the minute the patient enters the doctor's office. Look for any facial asymmetry, frontalis overactivity, chin up, or head tilt posture.

Ocular examination

1. Refraction and visual acuity
2. Cover exam to search for hypotropia and exclude out any pseudoptosis components.
3. Extraocular motility disturbance, as well as any abnormal eyelid motions
4. Pupillary examination for Horner syndrome or third cranial nerve palsy
5. Examine the eyes for large papillary conjunctivitis or symblepharon.
6. Corneal feeling and dry eye should be evaluated since they can lead to post-operative keratopathy.
7. Examine the fundus for signs of retinal pigmentary degeneration.

Indications of ptosis correction 

The majority of patients who seek ptosis treatment do so owing to visual obscuration and loss of peripheral range of vision caused by the drooping eyelid. Another typical complaint is heavy eyelids. A considerable proportion wants surgery for aesthetic reasons, since sagging eyelids give the appearance of tiredness.

Contraindications

1. Severe dry eye
2. Patients with myogenic ptosis, such as persistent progressive external ophthalmoplegia - if ptosis correction is planned in these patients, conservative surgery to clear the visual axis should be considered.
3. Poor Bell’s phenomenon
4. Ptosis associated with oculomotor nerve palsy
5. Myasthenia gravis: These patients should be treated medically first with anticholinesterase agents

What Does Ptosis Correction Involve?

Eyelid ptosis correction aims at raising the upper eyelid that is causing unclear vision and asymmetrical appearance. This generally helps enhance the visual field as well as the cosmetic features. There are several distinct surgical methods that the physicians use to lift the eyelid. The specific type of technique to apply depends on the underlying cause of ptosis. 

Maximum calmness and cooperation are necessary to determine the height of the upper eyelid correctly. As such, the procedure is normally performed under local anesthetics, which are administered through the eye. After administering the anesthetic eye drops, local anesthesia is directly injected into the eyelid. This helps numb the part where the procedure is to be performed. 

When it comes to performing the procedure, the physician can opt for either levator muscle advancement or brow suspension surgical approaches. 

• Levator muscle advancement 

This is the most widely performed type of ptosis surgery. It involves the creation of an incision in the natural upper eyelid skin crease. Through the incision, the doctor will identify the levator muscle raising the eyelid. It's then reconnected or pushed forward to reinforce it, and dissolving stitches are used to protect it. The eyelid crease skin incision is sutured using dissolving stitches, which normally fall out on their own within a few weeks. At times, you may have to go back to the hospital to have them taken out. 

• Brow suspension surgery 

This technique is used whenever the patient has a levator muscle that is abnormally thin or weak. While some children are born with the disorder, others can acquire it as they grow. A plastic material, like a non-dissolving suture, is used to attach the upper eyelid to the forehead. Alternatively, the doctor can extract tissue from the upper thigh to use it as a sling. The eyelid will then be lifted using the muscles in the forehead. The procedure requires two incisions on the upper lid, two incisions just above the brow, and one small cut on the forehead.

Preparing for Ptosis Correction 

Before the correction surgery, you and the physician will meet to discuss the procedure further. Typically, ptosis correction surgery is a decision made on a personal basis. Hence it’s only practical to do so if it’s safe and after consulting the doctor. 

You will be instructed to stop taking blood thinners such as aspirin prior to the procedure. Also, ensure that you inform the doctor if you are using any herbal medicine. In most cases, they can ask you to stop taking them for at least 14 days before the operation. 

Smoking interferes with the recovery process. Therefore, you should try to quit at least six to eight weeks before operation if at all necessary. If you have high blood pressure, make sure it's under control because it will increase severe bleeding and bruising risks.

Be sure to carry a list of all the current drugs as well as details of any allergies you have. There is no doubt that you will be able to drive yourself back home after the treatment. Therefore, make arrangements to have someone to give you company after being discharged. 

Pos 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.
• Tearing
• Lagophthalmos

• 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
• Suture removal after one week.
• Light activity can be resumed after 3-4 weeks.
• Wear contact lenses for at least 4 weeks after surgery.

What to Expect After Ptosis Correction?

After ptosis surgery, it’s normal to experience pain and discomfort. Mostly, the doctor will prescribe some pain relievers such as ibuprofen. Bleeding can also occur in the surgical area. Thus, you should apply pressure using a clean pad for at least 10 to 15 minutes to ease the bleeding. 

Always ensure that the incision is clean. You can use warm boiled water or sterile saline content and clean cotton wool to clean the area. It also essential that you put ointment or eye drops at least four to six times a day for one or two weeks. This ensures that the eyes remain lubricated at all times. 

Swelling and bruising are common after the procedure. You can use an ice pack or apply cool compresses to ease the condition. How fast the swelling and bruising condition heals varies from one patient to another. However, it’s likely to subside after two to three weeks. Sometimes, it can extend into the upper cheeks leading to swelling of the lower eyelid bags. Nonetheless, this will disappear with time. 

Most people usually resume their normal day-to-day activities after two to three days of the procedure. However, you should refrain from demanding activities for at least two weeks following surgery. This enhances the healing process and enables the wounds to heal well. Also, avoid direct sunlight as this can interfere with the healing process of the scar. You can consider putting on the sunglasses during sunny days as you recover. 

The eyelid scar and the white line will gradually disappear with time. Luckily, most lid scars are concealed by natural eyelid creases. 

Before and After ptosis correction

Risks and Complications of Ptosis Correction 

All types of surgical procedures carry varying risks of complications. Ptosis correction, on the other hand, is also associated with a number of risks that can occur during or after the operation. They include; 

• Swelling and bruising around the surgical area
• Blurry vision often a result of the eye drops and ointment used. 
• Watering of the eyes due to irritation and pain 
• Chemosis (swelling of the conjunctiva, the clear covering of the eye)
• Eye dryness. After surgery, you can experience reduced blinking and limited eye closure for several days or weeks. Doctors recommend using artificial tears to ease the condition. 
• Eyelid asymmetry. At times, it becomes difficult to attain the same height for every eyelid after surgery. Hence, a small difference may be noticed. 
• Inability to properly close the lids for a few days following surgery. It may be difficult to completely close the eyes if the lids are raised too high. 
• Lids contour defects where the curve of the lid appears abnormal due to swelling. Occasionally, another surgery might be required. 
• Scarring. Although incision wounds often heal well, abnormal scars can occur in the lid and deeper tissues. 
• Sensation loss, especially when the nerves are damaged or cut. This can cause numbness in the incision area. 
• Asymmetry whereby the eyelid area and the face are uneven. 
• Hematoma (bleeding around the eyeball)
• Infection  
• Additional surgery 

Conclusion 

Eyelid ptosis is a medical condition that can affect both children and adults. It’s characterized by sagging or drooping of the upper eyelids, hence partially covering the visual field. Physicians often recommend ptosis correction to address such disorders. Apart from improving the general vision, the procedure also enhances the cosmetic appearance. 

Ptosis correction helps restore the field of vision and also improves the aesthetic appearance; it reverses the feeling of heaviness in the eye. Most patients feel and look younger thus improving their quality of life.