Importance of Diagnosing Drooping Eyelid Cause before Undergoing Ptosis Repair Surgery

Is it normal for a 25 year old to have one droopy eyelid? My right eyelid is droopy and has been getting progressively worse. I'd say I noticed this 3 years ago and this is what my eyes look like today. (Friends and family say they don't notice it until I point it out, but it's glaringly obvious to me.) Is surgery a viable option for me? When I'm tired, my eyes feel "off" or "uneven" and it makes me want to just close the droopy one. Would surgery be able to fix that "uneven" feeling and is it worth the risk? Thank you for your question! You’re 25 years old and you noticed your eyelid drooping which you’ve shown with the photos you submitted for the past 3 years and you’re asking if it’s normal and the feelings that you have like when you get tired and of course whether or not surgery is an option. So, this type of a question is not an unusual question. To begin with, to give you a little bit about my background, I’m a cosmetic oculofacial plastic surgeon practicing for 20 years which means I have a background in eye surgery and plastic surgery of the eyes and face so ptosis is something we deal a lot with in our practice. So to begin with, to understand the drooping of the right upper eyelid with the photos you submitted, I would ask you to look at previous photos. There’s a condition called congenital ptosis which is where one or both eyes are drooping because of the way the muscle that lifts the eyelid called the levator muscle just like word elevator develops during gestation.

So, what we want to know is and in a lot of situations is someone may have symptoms of drooping eyelid causes the eyelid progress a little bit lower but they have some degree of drooping eyelid throughout their lives. So that is one thing that we want to ask. Now, if that’s not the case, then we want to also rule out any unusual neurologic issues. So an examination with an ophthalmologist, neuro-ophthalmologist, neurologist is indicated to at least make sure that the eyelid drooping is not a sign or symptom of something else that may need intervention other than surgery. Traditionally or routinely, people have drooping eyelids as they get older and when I say older, over 50 or 60 years older.

And why is that? The muscle called the levator muscle has a tendon called the aponeurosis and this tendon tends to get thinner and detaches and we refer to that as involutional ptosis, a very common problem as we get older. Now that’s different, that’s an acquired ptosis, probably the most common type of ptosis there is. So being very young, you’re very young for that type of situation. So again, it is very important to establish whether or not this is congenital ptosis, whether or not there is any other neurologic reason for the ptosis and then once those things are ruled out, especially the systemic issues, then you can entertain the surgical options. Typically, we perform this surgery under local anesthesia with LITE™ sedation. And ptosis surgery is deceptively complex. It is a very small space in the eyelid area where there’s a very sensitive muscle has to be manipulated so that the eyelid height, shape, contour is symmetric with the other eye. There are situations where if someone presents with one drooping eyelid, when we physically lift that eyelid during an examination, the other eyelid droops and that is one of the manifestations of something called Hering’s law.

And that has to do with the way the brain feeds a certain amount, we call juice to the eyelids, so that when you correct one, the other one will droop. We check that and we decide whether or not it’s significant enough to do both eyes. Other things that we do when we do an evaluation is to do the proper evaluation of eye function in terms when you blink and how high your eye rolls to protect the eye when you are blinking. These are part of a standard opthamological examination.

During surgery, we actually often sit the patient up several times to evaluate what the eyelid level is relative to the effects of gravity. So we actually have you open and close your eyes during surgery. You never feel any pain, you’re not uncomfortable but it helps us a lot predict the appearance of the eyes after the surgery is completed. Once the surgery is completed, we basically do the same thing we do with other cosmetic eyelid procedures. We put cold compresses in the eyes and we watch you and a week later, we take stitches out. So to answer the question about the surgical option, the answer is probably as long as we’ve eliminated the neurological cause.

Whether it’s congenital ptosis, whether it’s an acquired ptosis and we should also mention that sometimes trauma or history of trauma whether it’s a vehicle accident or an accident during childhood or baseball, all kinds of things that can cause an eye to swell, the eyelid can droop because the eyelid can stretch. So having an evaluation first by an ophthalmologist, possibly a neurologist would first get you on the way of eliminating the other systemic causes of ptosis. Once that’s eliminated, then it’s time to then identify a doctor you feel comfortable with most likely an oculofacial or oculoplastic surgeon who almost by definition who does a lot of ptosis surgery. Hopefully, has a cosmetic sense that resonates with you and once you identify the right doctor then ptosis surgery can really be very fulfilling and can restore the patient’s confidence and not feel so self-conscious about the asymmetry of their eyes. Within the normal population, a lot of people have a difference between the two eyes. Between 1-2 millimeters and that’s acceptable. That’s part of the reason why your family is not acknowledging an obvious difference that they can tell.

But at the same time, when you take photos, a lot of those differences are obvious. When you get tired, those differences get obvious. So once again, begin the journey with first medical evaluation and hopefully, you’ll find an oculoplastic surgeon that you like then move forward with your surgery. So I hope that was helpful, I wish you the best of luck and thank you for your question!.