In the third of a series of interviews about eye conditions and treatments, Dr Audrey Looi discusses ptosis surgery.

What is Ptosis?

Ptosis is a medical term that refers simply to a droop. For example, if the eyebrow is droopy, the condition is referred to as brow ptosis. With regards to a droopy upper eyelid, the proper medical term is blepharoptosis.

But, as droopy upper eyelids are much more common than droopy brows, when eye doctors use the term ptosis, they are generally referring to a droopy upper eyelid.

In the specific definition of ptosis, the distance between the light reflex in the centre of the eye (the reflection in the centre of the pupil when light is shone at the eye) and the upper eyelid margin must be ≤ 2mm.

What causes Ptosis?

Ptosis can be caused by degenerative changes that occur in the upper eyelid as one ages. This is the most common cause of ptosis.

The structural changes in the eyelid that are seen in older adults can also be brought on earlier in life by certain risk factors such as contact lens wear, previous eye surgery eg LASIK or cataract surgery, or excessive eye rubbing.

As a whole, this group is known to have aponeurotic ptosis. Fortunately, aponeurotic ptosis is an oculoplastic condition that can be corrected with ptosis repair surgery with good, long-lasting results.

However, before one can be diagnosed with aponeurotic ptosis, one must be examined to rule out other more serious causes of ptosis.

Of greatest concern is whether a patient has neurological causes such as Horner’s syndrome and oculomotor nerve palsy, neuromuscular causes such as myasthenia gravis or myopathic causes where the problem lies within the eyelid lifting muscle itself.

The treatment for this more complex group depends on the exact diagnosis after a detailed examination by the eye doctor. Surgery may or may not be the solution.

Ptosis can also be present from birth. This is known as congenital ptosis. It can be mild and not affect vision. These patients tend to present to the doctor later in life when they wish to have a cosmetic improvement.

In severe cases, the droopy upper eyelid can cause visual obstruction and lead to a lazy eye. These patients present earlier to the doctor and surgery may be required at an early age to avoid the complication of lazy eye.

Is Ptosis considered a medical condition?

Yes, but only if the degree of droop falls within criteria set by Ministry of Health (MOH).

Several measurements and tests, including special visual field tests and photography to document the extent of the droop, are necessary to provide evidence that the ptosis is severe enough to be considered a medical case.

It is worthwhile to see an oculoplastic doctor for an assessment to see if one is considered a medical case as surgery for medical conditions is covered by insurance. Medisave claims can also reduce cost significantly for those without insurance coverage.

However, if one’s aponeurotic ptosis is not advanced enough to satisfy MOH criteria and one still wishes to proceed with surgery, cosmetic charges will apply.

Who is suitable for Ptosis Surgery?

After eye examination to rule out more serious conditions, all patients diagnosed with aponeurotic or congenital ptosis are good candidates for ptosis surgery. Generally speaking, when the ptosis is mild, the main benefit is to improve cosmetic appearance.

For more severe or medical cases, the main benefits are improved ability to keep the eyes open with lesser fatigue on the forehead muscles and less strain on the neck (due to long-term lifting of the chin that occurs in an attempt to see with droopy eyelids). The cosmetic improvement is a good side benefit that patients will appreciate and enjoy.

Patients with neurological, neuromuscular or myopathic causes of ptosis may undergo ptosis surgery in a limited manner but only after consultation with an oculoplastic doctor who is trained to assess safety in going ahead with surgery.

What treatments exist for Ptosis?

For aponeurotic and congenital ptosis, surgery is the only form of treatment. There is no medicine, oral or cream form, that can allow the upper eyelid to lift spontaneously.

For certain neurological and myopathic conditions, limited surgery may be possible. In the case of myasthenia gravis, oral medications may help to improve signal transmission at the nerve-muscle junction.

In these cases, if incomplete recovery is seen, a limited ptosis repair may be possible. Consultation with an experienced oculoplastic doctor is essential in deciding whether it is safe to proceed with surgery.

Who can perform Ptosis Surgery?

In Singapore, ptosis surgery is performed by oculoplastic surgeons and plastic surgeons only. Oculoplastic surgeons tend to have performed the most cases as they deal with both medical and cosmetic patients. You may visit eye specialist to find out more.

What should you expect during Ptosis Surgery?

It is good to be aware that ptosis surgery is performed with the patient awake. Local anaesthetic is injected into the eyelids when the patient is under sedation at the start of the operation. An anaesthetist is present when sedation is given.

The surgery can be performed without sedation if the patient is calm and not prone to anxiety. Generally speaking, sedation gives the patient a more relaxed experience.

The surgery involves the isolation of the muscle that elevates the upper eyelid and the strengthening of the muscle by re-attaching it to a structure within the eyelid known as the tarsal plate.

A slight shortening of the muscle may also be required in cases where the muscle has undergone significant stretching. In most cases, the surgeon also takes the opportunity to remove any excess skin on the upper lids so that the patient has both a functional and a good cosmetic result.

During the surgery, your surgeon will ask you to open your eyes and look straight ahead to see if the eyelid height and contour are pleasing. Adjustments may be made till your surgeon is satisfied with the new look. When closing the wound, most surgeons will take care to create the double eyelid cease for the patient.

Once the surgery is over, one can expect to rest for a short while for the sedation to wear off completely before heading home. One should always arrange for family or friend to accompany one home.

Read more: What To Expect During Ptosis Surgery?


Is Ptosis Surgery painful?

With the right sedation and adequate local anaesthesia, the vast majority of patients will not feel much discomfort.

However, it must be noted that some patients are unable to receive higher amounts of sedation for safety reasons. Or their pain threshold may be low due to background anxiety issues. In these cases, a small amount of discomfort may be perceived.

What is the recovery period for Ptosis Surgery? What should you expect?

Most of the post-operative eyelid swelling and mild bruising will usually resolve by one to two weeks. Patients have stitches removed between 10 – 14 days depending on the healing rate.

Removal of stitches earlier is possible but may run the risk of the wound re-opening with an accidental hard rub of the eye.

Read more: What To Expect After Ptosis Surgery?


At what age does Ptosis start to develop?

Most cases of acquired adult aponeurotic ptosis occur in the fifties and above. However, as discussed above, aponeurotic ptosis can develop earlier in the twenties to forties due to risk factors such as contact lens wear, LASIK or other eye surgery, or excessive eye rubbing.

Congenital ptosis is seen from birth.

What about children who are born with Ptosis?

Congenital ptosis is a more challenging condition to treat as the eyelid lifting muscle is not well developed and does not contract or relax in a normal way.

Consultation with an oculoplastic doctor is key to find out when the surgery should be performed, what technique best suits the child and what limitations the parents must be aware of.