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Ptosis of the Upper Eyelid
A droopy upper eyelid is called "ptosis." It may affect one eye or both
eyes. Ptosis may be congenital (present at or shortly after birth) or it
may develop later in life. When mild, ptosis may only be a cosmetic
concern. When more severe, however, it may cover the pupil and result in
significant interference with vision.
Congenital ptosis results from an improper development of the levator
muscle responsible for raising the eyelid. These children may also show
some degree of strabismus (where the eyes are not properly aligned),
amblyopia ("lazy eye," where vision is reduced in the eye with ptosis),
and a cosmetically undesirable appearance.
The treatment of congenital ptosis depends upon the degree of ptosis and
on the associated findings. If mild and only of cosmetic concern,
surgical correction should be performed between 3 and 5 years of age,
before the child begins school. When more severe and interfering with
vision, the repair must be performed at an earlier age to allow normal
development of vision. Surgery usually involves tightening of the
levator muscle to elevate the eyelid. In severe cases where the muscle
is very weak, a "sling" procedure may be needed to allow the forehead
muscles to help lift the eyelid.
In acquired ptosis, the levator muscle is usually normal, but most often
the tendon between the muscle and the eyelid is stretched. This may
happen following eye surgery, such as for a cataract, or as a result of
normal aging. It may also be seen following trauma with injury to the
levator muscle, its tendon, or its nerve. Acquired ptosis may be of
cosmetic concern only, or it may result in loss of the upper visual
field.
Acquired ptosis is treated surgically, with the specific operation based
on the severity of the ptosis and the remaining strength of the levator
muscle. In general, tightening of the levator tendon is sufficient for
repair. Surgery is typically performed under local anesthesia to numb
the upper eyelid, with the patient lightly sedated.
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Entropion and Ectropion of the Lower Eyelid
With malpositions of the lower eyelid, the lid margin may be turned
inward toward the eye, or outward away from the eye. In both cases,
there may be significant symptoms involving vision, appearance, or
comfort. Symptoms typically include ocular discomfort, tearing, mucous
discharge, and reduced vision. In some cases, corneal infection and
scarring may be seen.
Entropion refers to a condition where the eyelid and eyelashes are
turned inwards. As a result, the eyelid skin and lashes rub against the
cornea of the eye causing irritation and pain. It is most often seen in
older patients as a result of relaxation of the eyelid tissues. It may
sometimes be seen as a congenital condition in young children.
The treatment of entropion involves tightening of the eyelid tissues to
restore its elasticity and position. The exact surgical procedure
depends upon the cause, and the surgeon’s preferences. In more elderly
patients who may not be able to undergo surgery, other procedures may be
used, such as sutures or injected medications, although they tend not to
be permanent.
Ectropion is the term used to describe an abnormal out-turning of the
lower eyelid away from the eye. As a result, the eye surface may become
exposed and dried out. This condition is caused by a relaxation of the
eyelid tissues, commonly related to aging. Scarring of eyelid skin, from
cancers, scars, or skin diseases, can also cause a shortening of lower
eyelid skin and ectropion.
When the eyelid is turned away from the eye, symptoms include drying of
the cornea, chronic irritation, and the feeling of grit in the eye.
Excessive tearing and reduced vision are also common complaints. In rare
cases, severe eye damage can result.
The treatment of ectropion may be medical with the use of topical
lubricating drops and ointments to keep the eye surface moist. A
protective shield may be worn over the eye at night, or the lids may be
taped closed. When laxity of eyelid tissue is responsible, it is best
treated surgically. Tightening of these tissues will usually restore
normal elasticity and allow the eyelid to be repositioned. Surgery is
performed under local anesthesia with the patient under light sedation.
When scarring is the cause of the ectropion, excision of the scar or
even a skin graft may be needed.
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For the eye to stay healthy, it must remain moist. The lacrimal gland
located under the outer portion of the upper eyelid, helps to secrete
tears. During blinking, these tears wash across the eye and drain into
small ducts on the nose side of the upper and lower eyelids. From here,
the tears pass down the nasolacrimal duct into the nose.
Blockage of the tear drainage system may be seen anywhere from the
eyelid ducts to the nose. This can be congenital, seen in young infants,
or acquired in later adult life. Symptoms include watering of the eye,
accumulation of mucous, and, occasionally, infections in the lacrimal
sac, seen as a red painful mass at the corner of the lids and nose.
Congenital nasolacrimal duct obstructions are seen in about 7% of
newborns. In most cases, it is due to a membrane over the lower end of
the tear drainage system. In most cases, this resolves over several
months without specific treatment other than massage and topical
antibiotics. If the condition is not corrected within 6 months, the
membrane may be perforated by a probing procedure which will cure the
tearing in most cases. A second probing with placement of tiny silicone
tubes is rarely needed. The tubes are removed after six months.
In acquired nasolacrimal duct obstruction the duct slowly becomes
narrowed from chronic inflammation from sinus disease or following
trauma or nasal surgery. If tearing is the only symptom, no specific
treatment is needed unless there is infection of the drainage system.
When symptoms are bothersome, surgery is required to create a bypass
channel from the nasolacrimal system into the nose. This is performed
under local or general anesthesia, and the success rate is about 90% to
95%.
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The eyes are usually the first thing people notice about your face. Over
time, the upper or lower eyelids may become “baggy” because eyelid skin
stretches, muscles weaken, and fat pockets bulge forward from behind the
eyes. The eyebrows may also droop as part of the same aging process.
These may result in a tired or older appearance. When severe, these
processes may also obstruct the upper visual field and may interfere
with wearing of glasses.
Surgery to improve the appearance of the eyelid is termed
"blepharoplasty." This is usually an outpatient procedure performed
under local anesthesia. The goal of this surgery is to remove excess
eyelid skin and bulging fat pockets and to tighten underlying muscles.
In the lower eyelid, sometimes only the bulging fat may need to be
removed. When skin is removed, incisions are placed within natural folds
so that they are virtually unnoticeable after healing. When only fat is
excised, the incision can be placed behind the eyelid as a
"transconjunctival blepharoplasty" with no skin incisions at all.
When the eyebrows are droopy, it is usually best to repair these in
conjunction with a standard blepharoplasty. This can be achieved through
incisions along the eyebrow hairs, or when the forehead also needs to be
elevated, through various other forehead or scalp incisions.
Blepharoplasty surgery provides both cosmetic and functional improvement
with minimal risk of serious problems. Most patients can expect to look
younger and often have an improved visual field.
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Skin cancers often involve the eyelids or adjacent face. Usually they
appear as painless elevations or nodules, most commonly on the lower
eyelids or at the corner of the lids near the nose. The lesions may be
irritated, ulcerated, or crusted, but often they cause no specific
symptoms.
The single most important cause of skin cancers on the face is excessive
exposure to sunlight. People with fair skin and those who spend much
time outdoors are most susceptible.
The most common type of skin cancer around the eye is basal cell
carcinoma. These grow slowly over several years and can be locally
destructive. However, they do not spread to other parts of the body. The
basal cell carcinoma ususally appears as a well-defined nodule with a
depressed center. The squamous cell carcinoma is less common and may
appear as a somewhat more indistinct nodule. Although this type may
spread to other parts of the body, this is very rare.
The two most-serious types of skin cancers of the eyelids are the
sebaceous cell carcinoma and the malignant melanoma. Both represent only
a very small percentage of all cancers of the lids, but both spread
rapidly.
In all cases of eyelid cancers, it is important that diagnosis and
treatment happen as soon as possible. This prevents spread and allows
removal and reconstruction of the eyelid with minimal functional
cosmetic deformity. Complete excision is essential to prevent
recurrence, which may be even more difficult to treat.
The most appropriate method of tumor removal from the eyelids is
surgery. A pathologist will then examine the specimen to ensure that the
entire tumor was eliminated (Mohs Technique). Once the cancer is
removed, the eyelid is reconstructed using a variety of different
techniques which depend on the size and the location of the defect.
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Skin ages. As you get older, your skin shows the results of sun damage,
a loss of elasticity, surface blemishes, and reduction of collagen that
causes surface wrinkles. While nothing can reverse this process,
chemical peels and face-lift surgery have been used to turn the clock
back, resetting the skin to an earlier appearance.
The CO2 UltraPulse laser can be used to reduce facial wrinkles, acne
scars, and sun-damage blemishes efficiently. It is comparable to
superficial chemical peels in its effect, but cannot remove very deep
wrinkles. While the laser cannot correct areas of significant sagging
such as neck skin and jowls, it will moderately tighten the skin, smooth
the surface, and provide a more youthful appearance.
It is believed that the laser allows the body to generate new collagen
that reverses the skin’s aging process. In two passes, a specific
therapeutic wavelength of laser-guided energy is applied to the skin
using a computer-generated pattern of spots. The first pass removes the
outermost-damaged skin layer, or epidermis. The second pass tightens and
shrinks the deeper collagen-containing dermis, which is responsible for
wrinkles. More passes may be required if the skin is severely damaged.
The treated areas become resurfaced with new undamaged epithelial cells,
and new collagen is laid down in the dermis.
Treatment usually takes 20 to 60 minutes, depending on what areas of the
face are resurfaced. After treatment, dressings are applied for 2 to 10
days to encourage rapid healing. Although complete healing may require
several months, the patient can usually return to work in 10 to 14 days.
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