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What causes droopy eyelids?

Drooping of the upper lid occurs due to an increased weight on the eyelid from:

  •  excess upper lid skin (dermatochalasis)
  •  relaxation/weakness of the muscle in the upper eyelid that usually opens the eye (ptosis)
  •  drooping of the eyebrow downwards (brow ptosis).

It is commonly an age-related change.

Dermatochalasis

Dermatochalasis means excess upper eyelid skin that usually develops as an age related change, loss of skin tone and changes to the fat pads of the eyelids and orbit. Occasionally, skin inflammations e.g. dermatitis and rosacea, orbital inflammatory conditions and other systemic diseases of the body can cause fullness of the eyelid skin. When the upper eyelid skin folds on top of the eyelashes, the eyelashes sit rotated downwards instead of upwards, the upper field of vision can be reduced, and the upper eyelid margin is often rotated inwards causing irritation of the eye surface.

How is dermatochalasis treated?

Surgery (blepharoplasty) removes the excess skin and the wound is hidden within the natural upper eyelid crease. This procedure can be performed under local anaesthetic, but to reduce the risk of bruising post procedure, the eye will need to be padded for a short period of time. Therefore, if both eyes are treated on the same day, it is recommended that you have someone to assist you homewards. Your Specialist will discuss with you requirements with regards to any changes to your usual medication, including blood thinning agents, or fish oil or garlic supplements pre surgery.

Ptosis

Ptosis refers to drooping of the upper lid downwards where it often obscures the pupil and upper field of vision. It may be present from birth or develop later in life, usually due to an age-related weakness or disinsertion of the levator muscle (muscle that pulls the upper eyelid open). Occasionally it can occur in association with a nerve weakness or stroke or as part of a generalized muscle weakness. Often the ptosis appears as one-sided, but commonly a weakness of the other upper eyelid is un-masked upon examination.

How is ptosis treated?

Treatment is mostly surgical, with a direct tightening or tuck of the levator muscle being performed, either from the front skin or under the eyelid approach. In congenital or muscle weakness cases, tightening the upper eyelid levator muscle is often not sufficient to lift the lid and allow reasonable closure function. In this circumstance, a sling technique lifting the eyelids using the strength from the eyebrows ability to elevate is most appropriate, and may require both eyelids to be done, even if only one appears droopy. Sling techniques include silicone tubing, synthetic slings or using part of the patient’s own fascia lata tendon from the outer aspect of the thigh or the ‘spare’ Palmaris longus tendon of the wrist to act as sling material. Non-surgical options include ptosis prop attachments secured to the glasses to allow the eyelid to be lifted up for periods of time. Ptosis in children requires consideration of vision development and may necessitate patching therapy or more than one surgical procedure to get the best outcome.

Brow Ptosis

Drooping of the brow occurs mostly as an age change, but also after facial palsies and trauma. The increased weight of the eyebrow tissue on the upper eyelid causes the upper eyelid to droop and interrupt the upper field of vision. As a result, the brow and forehead muscles try to compensate by overworking to try to elevate the brow. This leads to brow ache and headache.

How is brow ptosis treated?

Correction of this problem includes muscle relaxant injections or surgical options. Surgery may include an upper eyelid blepharoplasty or a direct lift of the brow itself. Your Specialist will discuss the most suitable option for you.

What are the risks of upper eyelid and brow surgery?

Risks of any eyelid surgery include bruising, scar formation, infection, asymmetry of appearance, need for further surgery, visual blurring or extremely rarely visual loss. However, surgery to the upper eyelid may also cause some difficulty in closing the eyelid, usually temporarily, and you will be prescribed lubricants to protect the eyes in the recovery period.The risks of brow surgery include scar, bruising, and recurrence of the droopiness, numbness to the forehead and extremely rarely vision loss from a deep bruise tracking behind the eye.

What can I expect during and after surgery?

Eyelid surgery is usually performed under local anaesthetic (numb area but awake) as a day case procedure. Sedation can be given to make you drowsy, not remember much of the procedure and reduce anxiety. Alternatively, a general anaesthetic (fully asleep) may be offered. Usually the eyelids can remain closed during the procedure, but occasionally you will be asked to open the eyelids if your surgeon wishes to assess the upper eyelid height, contour and appearance, to give you the best post surgical outcomes.

After surgery, expect to appear bruised over the upper eyelid and lower eyelid (even if you have only had upper eyelid surgery) and occasionally the cheek. Usually this only lasts 10 days to 2 weeks and a pair of sunglasses will hide the appearance. The end result of the eyelid opening will not be fully apparent until approximately 6 weeks as there can be subtle eyelid swelling up to this time. Occasionally this lasts longer. Usually at one week, your Specialist will ask to see you in clinic to remove any skin stitches and ensure that you close your eyelids well. You may be given eye lubricants in the immediate post-operative period to help protect your eye surface whilst your eyes are swollen. The majority of people heal quickly and smoothly but you will be given advice on what to do if you feel your eyelids are not healing as expected and what to look out for.