Droopy eyelid is a very common medical condition in which the margin of one or both upper eyelids falls to a lower position than normal. The medical term used to describe a droopy eyelid is ptosis. Eyelid ptosis tends to get worse during the day, especially if the person feels tired or has worked long hours in front of a computer. If only one eyelid is droopy, the person will be said to have a “lazy eye”, but this term is incorrect and should not be used to describe eyelid ptosis. On the other hand, when both eyes are droopy the person takes on a tired or sleepy appearance.
Eyelid ptosis must be differentiated from excess skin on the eyelids, a condition known as dermatochalasis. Dermatochalasis can certainly make the eyes look droopy, but the muscle responsible for eyelid opening is working adequately and true ptosis is not present.
What causes eyelid ptosis?
Ptosis is a result of a malfunction of the muscle responsible for elevating the eyelid – called the levator muscle – or the tendon attached to it. In the former, the muscle is too weak to raise the eyelid to its normal position. In the latter, the levator muscle tendon (aponeurosis) has become detached from its connection to the eyelid plate.
Once the correct diagnosis of eyelid ptosis is made, the best treatment option can be selected. To determine the right surgical approach for the patient, it is important to distinguish between congenital ptosis, that is, ptosis present since birth, and acquired ptosis.
Treatment of congenital ptosis
Congenital ptosis is by definition a condition that affects babies and small children. The droopy eyelid(s) is noticed since birth or during the first months of life. The baby may adopt a chin-up position to avoid interference of the eyelid with his or her vision. It is crucial to make the diagnosis early, as an untreated ptosis may affect the child’s vision permanently.
In congenital ptosis there is poor function of the levator muscle. Therefore, the conventional surgical techniques used in adults with ptosis do not work. Instead, it has to be treated with a surgical technique called frontalis fixation. This operation consists of fixating the levator muscle to the forehead muscle above the brow. The child will use the action of the forehead muscle to pull the droopy eyelid upward, above the visual axis. The surgery is done as an outpatient procedure with general anesthesia.
Treatment of acquired ptosis
When a droopy eyelid presents later in life, it is normally due to trauma to the levator muscle or a weakening of its tendon, also known as the aponeurosis. The latter is by far the most common cause of acquired ptosis, so we will be focusing on its treatment. To fix the ptosis, the surgeon has two options. He can reattach the aponeurosis through an incision in the eyelid skin (transcutaneous approach), or he may decide to remove part of the muscle and conjunctiva on the inside part of the eyelid (conjunctivomüllerectomy).
The skin approach: levator aponeurosis repair
The transcutaneous approach is very popular among eyelid surgeons, but it has several limitations that patients should be aware of. First, the skin incision may leave a visible scar in the eyelid. Second, this surgery is less accurate because it requires patient cooperation during the procedure. Finally, the skin approach may cause asymmetry in the shape or contour of the eyelid margin, making it less aesthetic in some cases.
The posterior approach: müllerectomy
Another way to raise a droopy eyelid is with a procedure called müllerectomy or conjunctivomüllerectomy. Instead of tightening the muscle through the skin, the operation is done from the inside part of the eyelid by removing part of the muscle and conjunctiva. Thus, an incision is avoided which eliminates the risk of a scar. Furthermore, this procedure does not require patient cooperation during the operation, making it a more precise technique. Lastly, the eyelid contour tends to look more natural after a müllerectomy.
Müllerectomy is predictable, safe, and effective, but not all patients are good candidates for the operation. It should be reserved for individuals with mild to moderate ptosis who respond to the phenylephrine test. This test is done in the surgeon’s office and consists of instilling a drop of 5% phenylephrine in the affected eye(s). Five minutes later, the eyelid is inspected to see if its margin was elevated. If that is the case, the patient is good candidate for the operation (see image).
Before deciding which surgical approach is better for a patient with ptosis, a consultation with the surgeon is necessary. During this consultation, the physician will explore eyelid function and the severity of the ptosis. He will also perform the phenylephrine test in mild and moderate cases. After the going over the pros and cons of the operation you and your surgeon will the decide what is the best option.
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