• Ptosis Repair

  • What is Ptosis?
    Ptosis (pronounced “toe-sis”) refers to a drooping of the upper eyelid. The eyelid may droop only slightly or it may droop enough to partially or completely cover the pupil, restricting or obscuring the field of vision. Ptosis may be inherited, can affect one or both eyelids and may be present at birth or occur later in life. Ptosis present at birth is called Congenital Ptosis. If the ptosis develops with age it is referred to as Acquired Ptosis.

    Acquired Ptosis
    The most common type of adult onset ptosis is due to a weakening of the attachment between the levator muscle (the muscle that raises the upper lid) and the eyelid. This may occur as a result of the aging process, after cataract surgery or contact lens wear, or from an injury. Adult ptosis is less frequently due to other causes such as diabetes, myasthenia gravis, or eyelid tumors.

    What are the signs and symptoms of Adult Ptosis?
    The most obvious sign is a droopy upper eyelid. The patient may complain of peripheral visual loss or fatigue from attempting to elevate the droopy eyelid. Reading may be difficult, as the droopy eyelid tends to block the visual axis when the eye is looking down. Adults with ptosis will often tip their heads back to see past their eyelids or raise their eyebrows in an effort to raise their eyelids. Prominent forehead wrinkles (or furrows) may be present from chronic elevation of the eyebrows by muscles in the forehead. If the ptosis is severe, individuals may bump into things (such as cupboard doors) at forehead level.

    How is Adult Ptosis Treated?
    Treatment, when necessary, is usually surgical and is done as an outpatient under local anesthesia. The patient or physician often elects to have an anesthesiologist present to administer intravenous sedation and provide monitored care. It is important to do the surgery under local anesthesia with minimal sedation because this allows the surgeon to better gauge how much to raise the eyelids. The patient is typically sat upright during the surgery to assess for eyelid symmetry and adequate correction of the droopy eyelid(s). Eyelid ptosis surgery is a more technically challenging operation than blepharoplasty surgery (removal of extra eyelid tissue) and should only be performed by surgeons specializing in eyelid surgery with considerable experience in the nuances of ptosis repair.

    In cases where the eyebrows area also droopy (brow ptosis), a procedure to elevate the eyebrow may be appropriate. This procedure known as a “brow lift”, may be done directly above the eyebrow, within the forehead creases, or endoscopically behind the hair line. It is important to recognize that a droopy eyebrow may be contributing to the excess skin and fullness seen in the upper eyelids. Blepharoplasty and/or ptosis surgery will not correct redundant tissue resulting from brow ptosis.

    Will the Extra Skin Above or Below my Eyes be Treated at the Same Time as my Ptosis Repair?
    Patients with upper eyelid ptosis often have redundant (extra) upper eyelid skin referred to as dermatochalasis. This can be corrected by performing an upper eyelid blepharoplasty at the time of the ptosis repair. If the dermatochalasis is severe and the extra skin is pushing down on the eyelashes and significantly interfering with vision, then the blepharoplasty procedure may be covered by insurance or Medicare. If significant visual field loss can not be documented and the photographs do not show eyelid skin hanging over the eyelashes, then the blepharoplasty procedure will be considered cosmetic and the patient will be required to make separate payment arrangements. Lower eyelid blepharoplasty surgery is rarely covered by insurance or Medicare and is considered cosmetic in almost all cases. There are certain advantages to having cosmetic blepharoplasty procedures at the time of your ptosis repair and Dr. Klapper can discuss this with you if you are interested.

    Does Insurance Cover Eyelid Surgery?
    There are certain criteria that must be satisfied for most insurance carriers (including Medicare) to pay for part or all of your eyelid surgery. For any health care plan to cover surgery, a patient’s eyelids must restrict the superior field of vision resulting in some limitation of daily activities such as reading, writing, driving, sewing, etc. Photographs must be submitted and demonstrate significant narrowing of eye opening with a diminished distance from the upper eyelid to the light reflex (near the center of the pupil). Visual fields may also be required to further document constriction of the superior field. Visual fields are performed with the eyelids at rest and with the eyelids elevated to demonstrate the improvement expected with surgery. The predetermination process for commercial insurance may take a few weeks to a few months to complete.

    What Is Different about Medicare Coverage?
    With Medicare, the decision to cover surgery is not made until after surgery when the claim (with the photograph and/or visual field) is submitted from the surgeon’s office. Medicare does not have a pre-approval process. Dr. Klapper will discuss with you whether your photographs and/or visual fields meet the criteria outlined by the local carrier for Medicare. Dr. Klapper can not, however, guarantee whether your surgery will be a covered service. A referral from your primary care physician or eye doctor does not insure that Medicare will cover your eyelid surgery. All Medicare patients considering functional blepharoplasty and/or ptosis surgery will be asked to sign Medicare’s Advance Beneficiary Notice (ABN) indicating that you understand your financial responsibility if Medicare does not cover your surgery.

    The Surgery
    If eyebrow elevation is to be performed, this is carried out prior to eyelid ptosis repair. Following the administration of a local anesthetic, an incision is made in the upper eyelid crease (if present) and the levator muscle is identified, tightened, and reattached to the tarsal plate (the firm supporting structure of the upper lid). Temporary sutures are initially placed. The patient will then be asked to sit up during the surgery to insure that the eyelids are as symmetric a possible and that adequate eyelid elevation has been achieved. Absorbable buried and skin sutures are routinely used so that no suture removal is typically required postoperatively.

    After Surgery
    Following surgery, cold compresses (ice packs) and a topical antibiotic ointment are applied for 3 to 4 days followed by warm compresses. Eye patches are not required. Discomfort is usually minimal and is typically handled by acetaminophen (Tylenol®). Aspirin containing compounds and non-steroidal anti-inflammatory products (Advil, Ibuprofen, Motrin, etc.) including many arthritis medications should be avoided 2 weeks prior to surgery and 1 week following surgery.

    After surgery, the patient should expect to temporarily experience minor discomfort, tightening or numbness of the eyelids, swelling, redness, itching, bruising, and dryness of the eyelids. Most of these symptoms will settle over the first 1 to 3 weeks. Patient healing, however, is variable with some patients healing slower than others. Near complete tissue healing usually occurs by 2 to 3 months. The eyelid blink rate also temporarily slows down following surgery leaving the eyes with a gritty or sandy feeling. The eyelids may not completely close during the first 1 to 3 months after ptosis surgery. Artificial tears during the day and a lubricating eye ointment at night (both available over-the-counter) are commonly recommended to keep the eyes moist during the healing process. The eyelids will frequently have diminished sensation (feel numb) for several weeks after surgery. As the incisions heal and the eyelid mobility returns to normal, these symptoms will usually resolve.

    One week off of work is average but may be longer if your occupation involves significant physical exertion. Individuals may only require 3 or 4 days off of work if their job involves little or no physical activity. Makeup can be applied to help hide residual bruising and redness after two weeks. Contact lens wear is typically avoided during the first 3 weeks after surgery or until adequate blinking and eyelid closure returns.

    Complications
    Excessive pain, bleeding, and infection are very uncommon. Blurry vision may occur during the healing period as a result of the decrease in eyelid blink rate or ointment getting into the eye but should return to normal in 1 to 3 weeks. Loss of vision following surgery has been reported but fortunately is extremely rare (approximately 1 in 2,000 cases). It may occur if deep orbital hemorrhage (bleeding) occurs postoperatively following fat removal. This typically would occur within the first 24 hours following surgery, so it important for patients to have a responsible adult with them the afternoon and night following surgery.

    Up to 3 % of patients may require an office touchup procedure to adjust eyelid height at around one week after surgery. This involves opening the incision and removing and/or adding sutures to reposition the eyelid height. Rarely, once the healing process has settled (at around 3 months), eyelid asymmetry requiring a touchup procedure may be considered.

    Summary
    Adult ptosis (droopy eyelids) is a common condition. Surgical correction of droopy eyelids is highly successful and typically results in improved eyelid comfort and appearance as well as an expanded visual field.

    Stephen R. Klapper, M.D., F.A.C.S. is a board certified Ophthalmologist and has completed extensive fellowship training in Ophthalmic Plastic and Reconstructive Surgery. In addition to his clinical practice Dr. Klapper has published numerous scientific articles in peer reviewed journals and presented several papers at regional, national, and international meetings on topics related to the field of eyelid and facial plastic surgery. Dr. Klapper’s practice is limited to adult and pediatric cosmetic and reconstructive eyelid and facial surgery, tear duct surgery, orbital disease, thyroid eye disease and the anophthalmic patient. Dr. Klapper also has extensive experience performing facial Botox® injections and Restylane® lip and facial fold injections.

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