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Ptosis is a condition that occurs when one or both upper eyelids droop and the edge of the upper eyelid falls towards or over the pupil. Ptosis is usually caused by stretching or thinning of the tendon between the muscle that raises the eyelid, and the eyelid itself. The muscle that normally raises the eyelid has to work harder to lift it. This leads to symptoms of eyelid and forehead muscle fatigue, and eyelid heaviness. Other less common causes of ptosis are nerve or muscle damage from any cause, various types of eyelid surgery, infection, muscle weakness, and systemic diseases such as stroke and tumours behind the eye, myasthenia, hypertension, thyroid disorders and diabetes. Children can be born with congenital ptosis; the muscle is abnormally stiff and does not function well. This condition usually lasts until it is surgically corrected. Ptosis surgery is not the procedure of choice for removing excess fat and skin in the upper eyelid. Under certain circumstances it can be combined with the operation known as blepharoplasty when fat and skin removal is an added goal of surgery.
Treatment
To correct ptosis, an incision is made in the skin of the upper eyelid to reach the muscles and tendons. The surgeon chooses where to make the incision based upon what treatment the eyelid needs. With the front or anterior approach, the surgeon makes an incision in the skin in the upper eyelid crease or fold in order to reach the muscle and tendon; if there is no eyelid fold, one can be created when the incision is made. The anterior approach allows the surgeon to trim excess skin and fatty tissue from the upper eyelid if needed during the surgery. If the muscle is not strong enough to lift the eyelid, the surgeon must create a “sling” by connecting the moving eyelid to the frontalis muscle in the forehead.
It must be noted that ptosis surgery only corrects vision loss caused by droopy eyelids, it will not improve blurred vision caused by problems inside the eye, or by visual loss caused by neurological disease behind the eye. To prevent amblyopia or poor visual development in children born with congenital ptosis, the surgery needs to be done early in life.
When the eyelid is raised in ptosis surgery, patients usually prefer the new eyelid position, and feel it improves their appearance as well as their peripheral vision. When only one eyelid is raised, it may affect how the eyelid on the other side looks. If this happens, ptosis surgery on the other side may be needed. If the position and shape of the eyelids do not match, additional surgery may be needed. The result of ptosis surgery cannot be guaranteed. Ptosis correction involves surgery on the tendon and /or muscle inside the eyelid, which can make the results unpredictable. At times the surgeon may need to adjust the position and shape of the eyelid after ptosis surgery. The adjustments can be done early (within the first 10 days) after surgery, or later on if asymmetry of the eyelid position or shape occur. The final result depends on your anatomy, your body’s wound healing response, and the underlying cause of the ptosis. Some patients have difficulty adjusting to changes to their appearance. Some patients have unrealistic expectations about how changes in their appearance will impact their lives. Carefully evaluate your goals, expectations and your ability to deal with changes to your appearance and the possible need for repeat surgery before agreeing to this surgery. The re-operation rate is approximately one in every nine patients.
Post-Operatively
Post-operatively it is recommended that you do not do anything too vigorous for at least 2 weeks, you should avoid heavy lifting, avoid bending your head down low, and avoid rubbing your eyes. Do not swim in a swimming pool for several weeks. If you work you should have at least one week off work, and more if you have a physically demanding job. Most patients will feel some mild discomfort after their operation. This should be controlled by regular Paracetamol. Patients may feel mild grittiness in their eye for several weeks following their operation. Anything more than mild discomfort should be reported immediately. To reduce swelling and bruising, we advise that you put ice (or frozen peas) in a tea towel over the operation site for about 10 minutes every hour (while you are awake) for the first two days after the operation. However if there is associated pain, redness, or decreased vision or any concern at all, you must call the surgery.
A blepharoplasty is the removal or repositioning of skin, muscle and fat of the upper and/or lower lids. In the upper lid, the incision is made and hidden in the natural lid crease. With age, the skin and muscles of the eyelid can sag and droop. In addition, the fat that surrounds and cushions the eyeball can bulge forward through the skin of the upper and lower lids. Excess skin, muscle and fat also create what many feel is an unattractive, aged appearance, especially in the lower lids (“bags under the eyes”). In this Practice, we only do blepharoplasty surgery for visual reasons. However because excess skin, muscle and fat are consequences of aging, most patients feel that blepharoplasty improves their appearance and makes them feel more youthful. Some patients have difficulty adjusting to changes to their appearance. Some patients have unrealistic expectations about how changes in their appearance will impact their lives. Carefully evaluate your goals and your ability to deal with changes to your appearance before agreeing to this surgery.
The results of blepharoplasty depend upon each patient’s symptoms, unique anatomy, appearance goals, and ability to adapt to changes. Blepharoplasty only corrects vision loss due to excess skin, muscle or fat that blocks the eye. By removing this excess skin blepharoplasty of the upper lids may allow more light in and improve your peripheral vision. Blepharoplasty does not improve blurred vision caused by problems inside the eye, or by visual loss caused by neurological disease behind the eye.
Post-operatively it is recommended that you do not do anything too vigorous for at least 2 weeks, you should avoid heavy lifting, avoid bending your head down low, and avoid rubbing your eyes. Do not swim in a swimming pool for several weeks. If you work you should have at least one week off work, and more if you have a physically demanding job. Most patients will feel some mild discomfort after their operation. This should be controlled by regular Paracetamol. Patients may feel mild grittiness in their eye for several weeks following their operation. Anything more than mild discomfort should be reported immediately. To reduce swelling and bruising, we advise that you put ice (or frozen peas) in a tea towel over the operation site for about 10 minutes every hour (while you are awake) for the first two days after the operation. However if there is associated pain, redness, or decreased vision or any concern at all, you must call the surgery.
Ectropion is a condition where the lower eyelid turns away from the eyeball. As the condition becomes more severe, the lining of the eyelid (the conjunctiva) is exposed to the air and can become red and swollen and sometimes crusty.
Risk factors
The commonest reasons for an ectropion developing are:
Increasing age. The eyelid loses its elasticity and tone with age and tends to fall away from the eye.
Sun exposure. In some people the skin under the eyelid and on the cheek become tight due to a lifetime of sun exposure, and this can pull the eyelid downwards.
Facial muscle weakness. If the muscles of the face, and particularly the muscles that close the eye are weak, the eyelid can develop an ectropion (eg. Bell’s Palsy)
Scars of the lower eyelid or upper cheek (eg from previous surgery to remove skin cancers.)
Symptoms
Ectropion tends to result in an exposed red inferior eyelid lining (conjunctiva), and can also cause:
Watering eyes. The opening of the lower tear duct sits away from the eye with ectropion, so the tears can no longer drain normally and build up in the eye before running onto the cheek.
Soreness of the eyelid and eye. As the conjunctiva is exposed to the air, it can become swollen, red, inflamed, and sometimes crusty. The lower eyelid is no longer helping to perform its function of helping to spread tears over the front surface of the eye and dry eye can result.
Redness and crusting of the eyelid edge and lining
Discharge from the eye. Due to dryness and irritation, mucous will be produced can dry and form a crust on the eyelid or at the inner corner of the eye.
Corneal ulcer. Rarely as the ocular surface and tear film are compromised, a corneal ulcer can develop and this can be serious for the eye and vision.
Treatment
If the ectropion is mild and not causing much in the way of symptoms, then no treatment at all may be required. Sometimes the redness, inflammation and crusting of the lower eyelid can be treated with topical ointments to partially relieve these symptoms, but this sort of treatment will very rarely correct the ectropion completely. Ectropion is usually treated by surgery. It is not major surgery.
Ectropion surgery can be performed with a local anaesthetic, and if in a theatre setting you will also have sedation. During the operation, you will however be aware that the eyelid is being operated on but it will not be painful. It is important for you to say if there is any pain during the operation.
The type of surgery will depend on the causes of the ectropion. In most cases the eyelid will be “tightened”, usually by making a very small incision at the outer corner of the eye and pulling the eyelid across to reattach it just inside the rim of the bony eye socket at the outer corner (this is sometimes called a “tarsal strip” operation). In combination with this, there may be other procedures performed. These can include some stitching on the onside of the lower eyelid, re-opening of the lower teat duct if it is narrowed or closed, and a skin graft to the lower eyelid. The skin graft is used when there has been significant sun damage to the skin or there is scarring of the lower eyelid.
While most ectropion operations are successful, it is important to be aware that occasionally problems may occur, and further surgery may be required. The surgery may not fully correct the ectropion, however the lid will be in a better position than before the surgery, and so there may still be some watering. Ectropion can recur sometime years later, as the tissues continue to lose their elasticity with time. If a skin graft is required, the graft may be a slightly different colour and texture to the surrounding tissue, but will generally get less noticeable over several months.
Post-operatively it is recommended that you do not do anything too vigorous for at least 2 weeks, you should avoid heavy lifting, avoid bending your head down low, and avoid rubbing your eyes. Do not swim in a swimming pool for several weeks. If you work you should have at least one week off work, and more if you have a physically demanding job. Most patients will feel some mild discomfort after their operation. This should be controlled by regular Paracetamol. Patients may feel mild grittiness in their eye for several weeks following their operation. Anything more than mild discomfort should be reported immediately. To reduce swelling and bruising, we advise that you put ice (or frozen peas) in a tea towel over the operation site for about 10 minutes every hour (while you are awake) for the first two days after the operation. However if there is associated pain, redness, or decreased vision or any concern at all, you must call the surgery.
Dacryocystorhinostomy or tear duct bypass surgery may be required when due to age, injury or chronic sinus disease, the bony tunnel that drains tears away from the eye into the nose has become blocked. When this occurs, tears can back up and run down the cheeks and, in some cases, an infection can develop underneath the skin between the eye and the nose (dacryocystitis). Many patients also complain of a gooey discharge and eye irritation.
Treatment
DCR surgery involves an incision being made near the inside corner of the eye or within the nose and a new opening is made to allow tears to drain from the eye into the nose. A small piece of nasal bone is removed but this does not change the external shape or structure of the nose. A very small stent may be left in place for a few weeks (sometimes longer) to keep the new drain open. This tube can be removed in the office at a post-operative review. If the tubing becomes loose in the corner of the eye, simply tape it to the side of the nose and contact us. The surgery is usually done under general anaesthesia with an overnight admission. There is often a small amount of nose bleeding in the first 24 hours after the procedure. This generally settles quickly. The nose may have gauze packing placed for a short period of observation. Infection following surgery is uncommon. Long term pain or discomfort is rare.
You should plan to be fairly inactive for the next 10 days (no exercise, heavy lifting or swimming), and try to sleep on several pillows for the first three nights in order to keep your head elevated. This will help decrease the post-operative swelling. There is minimal pain and discomfort following the surgery, which usually responds well to simple oral analgaesia such as Paracetamol. It is important NOT to blow your nose for about 7 days following the surgery as this can cause a nosebleed. If you have ceased blood thinning medication you can restart this in three days after the surgery unless otherwise specified. The eye-watering symptoms may persist immediately post-operatively but should resolve as the operation heals in the first few weeks. Following DCR surgery, a small number of patients will notice “air” blowing on the eye when blowing the nose. This air reflex can be a good sign of successful surgery and is rarely a significant issue.
The goal of surgery is to eliminate tearing, discharge and irritation, and to reduce the risk of infection. The surgery is generally successful but there is a small chance that the new drainage channel may not stay open. Approximately 5-10% patients may require additional surgery. The decision to proceed with surgery depends on an individual’s assessment and likelihood of a successful result. This is best balanced against the risks associated with surgery and the inconvenience of the eye watering symptoms. You may elect to avoid surgery and live with the tearing, discharge and irritation that a blocked tear duct can cause, however if you have had an infection, your surgeon will likely advise surgery to prevent future infections.
A chalazion is a localised inflammatory response involving sebaceous glands of the eyelid that occurs when the gland duct is obstructed. A chalazion may resolve spontaneously or with warm compresses, lid scrubs and lid massage. When there is no improvement, the chalazion may be incised and drained. After local anaesthesia, a chalazion instrument is put in place and an incision is made in the inner aspect of the eyelid. The contents of the chalazion are then carefully drained with a curette followed by gentle pressure or heat to control any bleeding.
Alternatives to surgery include:
When we deal with your eye problems, you can expect to be treated with the same degree of care and commitment as if you were a member of our family.