Acquired Ptosis

Ptosis is the drooping of one or both upper eyelids. It is acquired when it occurs after birth.

WHAT ARE THE CAUSES OF ACQUIRED PTOSIS?

The most common cause of acquired ptosis is stretching of the tendon of the lifting muscle. Since the muscle typically retains its original strength, surgical correction of a previously normal eyelid is based on repairing the stretched tendon.

A frequent cause of acquired ptosis is the prolonged use of contact lenses. The procedure to insert and remove the lenses can stretch the eyelid and promote tendon disinsertion. It is not uncommon for a person to develop this problem after cataract or other eye surgery. This operation is usually the “last straw” that causes a weak tendon to finally stretch. There are patients who develop this problem because of muscular or neurological diseases. This is highly infrequent and can be identified during consultation and examination in the office. Ptosis secondary to trauma can also be corrected.

HOW IS ACQUIRED PTOSIS TREATED?

The type of surgery used to treat acquired ptosis depends mainly on the degree of movement of the levator muscle of the upper eyelid. Surgery to correct ptosis acquired by tendon stretching is performed under local anesthesia on an outpatient basis.

There are three ways to repair acquired ptosis: Anterior surgery, posterior surgery, and frontalis suspension surgery.

ANTERIOR APPROACH SURGERY

The tendon of the muscle that lifts the eyelid is accessed through a small incision in the skin, and adjusted gradually. Due to the use of local anesthesia, the patient is usually asked to open and close their eyes during surgery to adjust the height and shape symmetrically. This technique achieves a 90 % success rate. In 1 out of 10 cases, a subsequent adjustment is necessary to achieve the best possible result. Sometimes, a blepharoplasty or cosmetic surgery of the eyelids can be performed in the same surgical procedure to remove excess skin.

POSTERIOR APPROACH OR CONJUNCTIVAL SURGERY (CONJUNCTIVAL MULLERECTOMY)

During the in-office diagnosis, a test is performed by placing a drop of phenylephrine. This drop stimulates Muller’s muscle (involuntary). If an adequate height is obtained after applying this drop, this technique can be used. The advantages are that no skin incisions are made, it has the highest success rate (95 %) and it does not require intraoperative adjustments, so it is very useful in patients who cannot or do not wish to be alert during surgery.

FRONTALIS SUSPENSION SURGERY

When ptosis presents with poor function of the upper lid levator, the best alternative to be able to open and close the eye is through frontalis suspension surgery. This procedure replaces the function of the eyelid levator muscle with the lifting action produced by the eyebrow. It is very common for people who do not lift their eyelids properly to compensate by raising their eyebrows. In frontalis suspension surgery, the eyebrow on the affected side is attached to the eyelid. In this way, the eyelids are lifted by raising the eyebrows, allowing the eyelids to close properly.

After ptosis surgery, can the eyes remain open?

Ptosis with good levator function, which accounts for the majority of adult cases, can be repaired with minimal risk of lack of closure. Exceptionally, there may be minimal opening during the night. This is usually not a problem, as the eyes have a reflex, called Bell’s reflex, which causes the eyes to rotate upward when closed. This means that even though there may be a small opening, the corneas are protected by this mechanism. Should there be any symptoms, they can be treated by using a drop of gel before going to sleep.