Ptosis (Adult)

What is Upper Eyelid 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 or other eye surgery, contact lens wear, or from an injury. Adult ptosis is less frequently due to other causes such as diabetes, myasthenia gravis, or eyelid or orbital 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 field loss or forehead fatigue from attempting to elevate the droopy eyelid(s). Reading may be difficult, as the droopy eyelid tends to block the visual axis when looking down. Adults with ptosis will often tip their heads back (chin up positioning) to see past their eyelids/eyelashes 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 household objects (such as cupboard doors) at forehead level.

How is Adult Ptosis Treated?

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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 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 eyebrow area is also droopy (brow ptosis), a procedure to elevate the eyebrow may be appropriate. A procedure known as a “brow lift”, may be done directly above the eyebrow, within the forehead creases, or at the hairline. An endoscopic “forehead lift” is a state-of-the-art cosmetic procedure performed through small, well-hidden incisions just behind the hairline. 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 for any anticipated non-covered services. Lower eyelid blepharoplasty surgery is rarely covered by insurance or Medicare and is considered cosmetic in almost all cases. There may be 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.

What to Expect from an Eyelid Consultation

A preoperative comprehensive eye examination is essential to document a patient’s visual acuity, tear film stability, strength of eyelid closure, symmetry of palpebral fissures (eyelid height), previous eyelid surgery, etc. For those considering surgery for functional reasons, a visual field test (with the eyelids relaxed and elevated) is required. Preoperative photos are routinely performed prior to both functional and cosmetic blepharoplasty.

Does Insurance Cover Eyelid and Ptosis Surgery?

There are certain criteria that must be satisfied for most insurance carriers and Medicare (see below) 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 margin to the corneal 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 potential improvement expected with surgery. The amount of restriction present and improvement seen with eyelid taping or elevation that insurance companies require to provide coverage varies between carriers. The predetermination process for commercial insurance may take a few weeks to a few months to complete. Lower eyelid blepharoplasty surgery is rarely covered by insurance or Medicare and is considered a cosmetic, non-covered service in almost all cases.

What Is Different about Medicare Coverage?

Medicare does not pay for everything. With Medicare, the decision to cover surgery is not made until after surgery when the claim is submitted from the doctor’s office. Traditional Medicare does not have a pre-approval (predetermination) process. Dr. Klapper will discuss with you whether your photographs and/or visual fields may, in his opinion, meet the specific criteria outlined by the local carrier for Medicare. Dr. Klapper can not, however, guarantee whether your surgery will be a covered service. Lower eyelid blepharoplasty surgery is rarely covered by Medicare and is considered cosmetic in almost all cases. Patients with Medicare Advantage or a Medicare Replacement plan may be able to do a surgical predetermination similar to the process for commercial insurance. 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 of Noncoverage (ABN) indicating that you understand your financial responsibility if Medicare does not cover your surgery. Similarly, Medicare patients electing to proceed with blepharoplasty, ptosis, or brow/forehead lifting procedures that do not appear to meet Medicare’s criteria for medical necessity will also be asked to sign Medicare’s Advance Beneficiary Notice of Noncoverage (ABN) indicating that the procedure(s) is(are) considered cosmetic, non-covered service(s) and will not be filed with Medicare. Secondary insurance carriers generally follow Medicare guidance.

Ptosis Surgery

If eyebrow elevation is to be performed, this is typically carried out prior to eyelid ptosis repair and/or blepharoplasty surgery. 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 upright during the surgery to insure that the eyelids are as symmetric as possible and that adequate eyelid elevation has been achieved. Absorbable (buried and skin) sutures are routinely used so that suture removal is typically not required postoperatively.

What to Expect After Surgery

Following surgery, cold compresses (ice packs) and a topical antibiotic ointment are applied for 3 to 4 days followed by warm compresses beginning around day 5. Eye patches are not required and are discouraged so that patients can monitor their progress (bleeding, vision, wound integrity). Discomfort is usually minimal and is typically handled byacetaminophen (Tylenol®). Non-preserved artificial tears (ex/ Bion Tears, Refresh Plus, Celluvisc) should be instilled frequently (often hourly) to maintain eye lubrication. Lubricating eye ointment (ex/ Refresh PM, Lacrilube) should be instilled nightly if incomplete eyelid closure is present. Lubricating eye ointment may need to be used during waking hours as well if artificial tears do not provide adequate ocular comfort. More frequent ocular lubrication is generally required for ptosis patients than patients only undergoing blepharoplasty surgery. Patients unable to instill lubricating eye drops or ointment should not undergo ptosis surgery

Patients generally experience blurred vision at distance for around 10-14 days following ptosis repair. Blurred vision at near may take 3-4 weeks or more to resolve. Visual changes may be the result of reduced blinking, poor eyelid closure, and the use of eye drops and ointments. Some patients (<5%) may have a change in their refractive error and require an update in their spectacle correction. It is generally recommended that patients defer changes in their eye glass prescription for 3-4 months following ptosis surgery. Each patient heals differently and the time it takes for patients vision to return to baseline varies considerably from patient to patient.

Most individuals will have swelling and some degree of bruising that will gradually improve over the first 1 to 3 weeks. Patient healing, however, is variable with some individuals healing much quicker than others. Near complete tissue healing usually occurs by 4 months. For upper eyelid blepharoplasty and ptosis surgery, 3 to 5 days off work is average while up to 10-12 days may be best for those patients having both upper and lower eyelid blepharoplasty surgery. Patients with occupations requiring minimal physical activity may return to work sooner than those that operate a motorized vehicle or perform heavy lifting or climbing. Makeup can be applied to help hide residual bruising after two weeks. Contact lens wear is typically avoided during the first 2-3 weeks after surgery or until adequate blinking and eyelid closure returns.

Up to 2-3% of ptosis patients may require an office touch-up procedure to adjust eyelid height at around one to two weeks after surgery. This involves opening the incision and removing and/or adding sutures to reposition the eyelid height. Once the healing process has settled (at around 3-4 months), eyelid asymmetry requiring a touch-up procedure may be considered in up to 3-5% of ptosis patients. Patients with substantial overcorrection of their ptosis repair may require earlier surgical intervention to improve eyelid position and closure.

Complications of Eyelid Surgery

Excessive pain, bleeding, and infection are very uncommon. Severe 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. 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, evening, and day following eyelid surgery. Inadequate lubrication of the eyes following surgery may also result in corneal scarring or infection causing vision loss.

Summary

Adult ptosis (droopy eyelids) is a common condition. While ptosis surgery is a frequently performed operation, it is still considered one of the more challenging eyelid procedures performed in an oculoplastic surgeon's practice. The variability of eyelid position inherent in adjusting a muscle in a thin, dynamic structure (The Eyelid) can not be over emphasized. In experienced hands, surgical correction of droopy eyelids is highly successful and typically results in improved eyelid comfort and appearance as well as an expanded field of vision. An acceptable result requires substantial patient compliance and close follow-up.

Female, 50 years old

Left Eyelid Ptosis Repair

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Dr. Klapper treats disorders, injuries, and other abnormalities of the eyelids, eyebrow, tear duct system, eye socket, and adjacent areas of the mid and upper face.

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