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Acquired Ptosis (Drooping Eyelids)

Definition

The word “ptosis” is the medical term for a drooping upper eyelid. Normally, the upper lid is opened by what’s called the levator muscle. The muscle runs from the upper edge of the eye socket into the upper eyelid. It fans out and enters the connective tissue, which gives the upper lid its strength.

The acquired ptosis usually occurs on both sides in adults and may have various causes. The point of attachment of the levator muscle on the upper eyelid slips upwards over time: the muscle works well, but it can no longer lift the upper eyelid to the correct height. In severe cases, the upper lid may partially or completely cover the pupil.

Ptosis can narrow the field of vision and also damage the even damage the region of the spine spine between the shoulders and the base of the skull, as patients try to balance the limited field of vision by constantly raising their chin.
The success of the operation also depends on how good the remaining power of the eyelid muscle is. Different approaches can be used, from Fasanella-Servat surgery (see below) to levator muscle resections and reinsertions

Causes

  • An age-related relaxation of the connective tissue
  • Wearing hard contact lenses. These stretch the levator muscle. Approximately 10% of all wearers of hard contact lenses experience slowly progressive ptosis after approximately 10 years
  • Previous eye surgeries in which a lid speculum was used
  • Previous severe inflammation or accidents that resulted in massive swelling of the upper lid
  • In very rare cases, ptosis is triggered by an as yet undetected muscle disease or neurological condition (myotonic dystrophy, myasthenia gravis)

The operation

In principle, there are two different surgical techniques that can be used to treat ptosis. Which one is chosen depends on the condition of the levator muscle and the extent of ptosis. After the examination, we will discuss the findings together with you and plan the further course of action with you.

Levator reinsertion

Here, the levator muscle is attached to its original attachment in the upper lid. This operation is performed under local anaesthesia because it is important that we can check the height of the upper lid several times during the operation.
Following a skin and muscle incision, the levator muscle is exposed and re-attached to the connective tissue plate of the upper lid (tarsus). Then we check the level of the upper lid and adjust the height until a satisfactory result is achieved. If there is excess skin on the upper lid, it may also be removed during surgery. If this does not happen and the upper lid is (correctly) higher after surgery, skin excess will be even worse.

Fasanella-Servat

Here, the connective tissue plate of the upper lid is shortened from the inside. This operation lasts about 30 minutes and is performed under general anaesthesia. We perform a Fasanella Servat operation when there is a low amount of ptosis.

The “perfect” symmetry

In about 15% of cases, you’ll see a good result for each eye after surgery, but there is a certain asymmetry between the eyelid opening of both eyes. It is not always possible to avoid this because wound healing can also change lid height.

 

But a perfect symmetry of both upper eyelids is rare – even in healthy eyes. A certain, small difference in the sides after the operation should be tolerated.

With this surgery, it’s all about patience, patience and patience: the final lid height stabilizes only about 6 months after surgery. Until then, there may be under- or overcorrection. Therefore, it is particularly important in this operation to be patient: If after 6 months, a significant difference (> 2mm) before, then we will possibly suggest a re-operation.

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