Eyelids can look closed or droopy from either dermatochalasis or true droopiness of the eyelid, called ptosis. Ptosis is a downward deviation of any part of the body, but in this case the upper eyelids. These are the the eyes that appear to be half closed and the person has to really struggle to lift them up.
How the Upper Eyelid Works
The upper eyelid is made of a combination of skin on the front side, 3 muscles, fat and a supporting structure called the tarsal plate in the middle, and the smooth wet layer on the back side called the conjunctiva. The front and back layers protect the eyelid structures and the eyeball behind it. There has to be enough extra of both for the eye to open and close for blinking to keep the eye healthy and protected. The orbicularis muscle is just under the skin and helps close the eye. Behind it is some fat and then the levator muscle. This is the main muscle responsible for lifting the eyelid. It attaches to the tarsal plate and when it contract it lifts the eyelid. Behind the levator and in front of the conjunctiva is Mueller’s muscle. This is a small muscle that give a small amount of lift to the eyelid.
Causes of Droopy Lids
There are multiple causes of the lids drooping. One of the main causes is aging. Often the levator muscle can slip off the tarsal plate so it can not grasp the lid as well and lift it. This can occur from natural aging and stretching of tissue. This can also be seen in patients with long term contact lens use or recent eye surgery since both of these can stretch the muscle and pull it off the tarsal plate. There are neurologic causes of droopy lids such as myasthenia gravis, brain strokes, cranial nerve 3 damage, other neuromuscular disorders.It is important to see your eye doctor for evaluation of droopy eyes to rule out some of these causes.
When to treat Droopy Lids
I see patients all the time with droopy eyelids, and they usually ask when is it time to have the lids raised. Well this is a questions the patient must actually answer. I tell the patient that when they are watching to lift their lids with a finger and see if this makes a difference. Often the patient is amazed at how much this improves the light coming in and opens up their visual field area. If there is no improvement then raising the lids is more of a cosmetic procedure (not covered by insurance) not a functional procedure (covered by insurance). That is why we often ask if the lids are noticeable in the patients vision and test this with visual fields. Once it is determined to do lid surgery the two most common procedures are a blephroplasty or a levator advancement.
Droopy Eyelid Surgery
In a levator advancment the eyelid itself is actually raised by moving the muscle forward and giving it a stronger pull on the tarsal plate. The surgery is done with the patient awake but the eyelid is numbed up with a local injection. The patient is then covered to keep the area clean, and an incision is made through the skin. Both the tarsal plate and levator muscle are exposed. A suture is then passed through both to pull the muscle onto the plate. After this is done on both sides the patient is then sat up and asked to open the eyes. This allows adjustments to be made for both lid height and contour for adequate elevation and symmetry. Once this is accomplished the sutures are tied in place and the skin is then closed. The patient is then sent home to use ointment and ice. There is often bruising for about 1-2 weeks and some swelling that can last up to 1-2 months. The sutures are often removed in 2 weeks in the clinic.
Droopy eyelids can be a cause of significant loss of a patients visual field. It is important to have a trained eye care specialist evaluate them and recommend the proper fix. This is often done with surgery but even then there are multiple ways to fix it and each fix needs to be right for that patient.
Jody Abrams, MD, FACS
Sarasota Retina Institute
Sarasota, Florida 34239