Common Eyelid problems

Ageing causes a form of ptosis called “senile ptosis”, which is a type of aponeurotic ptosis. This means the tendon that attaches the levator muscle (the main muscle that lifts the eyelid) to the tarsus (main structural support of the eyelid) becomes stretched and weaker with time, causing the eyelid to fall.

Other causes of aponeurotic ptosis include intraocular procedures such as cataract surgery, or even long-term contact lens wear or chronic rubbing of the eyes. These all result in stretching and weakening of the levator muscle tendon and its attachment to the eyelid.

Apart from aponeurotic ptosis, other causes include congenital weakness, trauma, or neurologic disease (cranial nerve palsy, myasthenia gravis, etc)

Senile ptosis usually does not improve with time. If left untreated, senile ptosis may progress and obscure part of the visual field of the person. It may interfere with his/her daily activities. Some patients may also be unhappy with the way ptosis changes his/her appearance, especially if there is asymmetry with the other side, or if both eyelids are droopy and gives him/her a sleepy or haughty look.

Any patient who is bothered by his or her droopy lids should not hesitate to seek help as ptosis can be easily treated.

Once the cause of the ptosis is determined, treatment is aimed at the individual patient. Senile ptosis can be corrected surgically and usually involves tightening the levator muscle to elevate the eyelid. Other forms include a brow suspension (frontalis sling) or surgery on the muscle on the inside of the lid (conjunctivomullerectomy), but the various methods will be depend on the type and severity of your ptosis.

The surgeon will perform testing to determine the best form of correction for the individual patient. The goal is to elevate the eyelid to permit a full field of vision and to achieve good height, contour and symmetry with the opposite upper eyelid.

Baggy eyes/dermatochalasis is commonly seen in older adults as ageing changes both the upper and lower eyelids. The most common cause for the condition is the progressive stretching of tissues and loss of elasticity.

Blepharoplasty is a day surgery procedure that improves the appearance and function of the eyelids. An eyelid crease (double eyelid) may be created at the same time. A detailed evaluation by your eye plastic surgeon will determine if it is a medically indicated or aesthetically desired procedure. It is often combined with ptosis surgery in the same sitting the patient has co-existing droopy eyelids.

Upper Blepharoplasty
Upper blepharoplasty is eyelid surgery of the upper lid. As we age there is excess skin and fat that may hang over the eyes, causing them to have a tired appearance, or even affecting our vision. Upper blepharoplasty removes this excess skin and fat, to give the eyes a more open, lifted and youthful appearance. In younger patients who seek to enhance their eyes by creating “double eyelids”, upper blepharoplasty can be used to make the eyes larger, and create a more distinct crease that enhances the beautiful Asian eye.

Lower Blepharoplasty
Lower blepharoplasty is eyelid surgery of the lower lid. As we age, the eyelid skin stretches, the fat bulges, and the muscles weaken. All these may give rise to prolapse of fat in the lower lids, causing a puffy appearance. In some people, the fat does not bulge, but shrinks, giving the eye a prematurely aged appearance by increasing the hollows below the eye, giving the appearance of dark circles. Lower blepharoplasty addresses these fat bags and hollows by removing excess fat and redistributing them to fill the hollows where necessary.

Both upper and lower blepharoplasty can be done alone or in combination. They are usually performed under local anaesthesia. The incision cuts are hidden in the natural lines of the eyes to minimise visible scarring. Excess fat and skin are removed to give the eyes a rejuvenated appearance.

Both upper and lower blepharoplasty are day-surgery procedures. They usually take one to two hours, depending on the extent of the surgery. Patients can go home on the day of the surgery.

Inturning- or outward-turning of the eyelid. Also called Entropion and Ectropion respectively, this is most often seen as an aging change which can result in irritation, tearing and rarely blindness from corneal damage. Common causes are stretching and weakening of the eyelid structures. Correction usually involves tightening of the eyelids to enhance the form and function.

With age, the skin, muscles and tendons of the lower eyelid can sag and droop. In addition, the fat that surrounds and cushions the eyeball can bulge forward through the skin of the lower lids. As the tendons of the lower lid sag, the lower lid can invert and turn inward with the lashes rubbing the eyeball. This can lead to tearing, eye redness, mucous discharge (mattering), crusting of the eyelashes and scratching of the cornea.

What is the treatment option for Entropion?

Repair of a lower lid entropion is typically done as an outpatient procedure. The patient usually gets a “local” injection of anaesthesia, and sedation although deeper anaesthesia can be given if needed. The inferior retractors of the lower lid are tightened to their correct position so the eyelid margin is no longer turned in. The tendons of the eyelid in the corners of the eye are usually tightened with sutures through small incisions. The specifics are tailored to each patient’s needs.

The results of entropion repair depend upon each patient’s symptoms, unique anatomy, appearance goals, and ability to adapt to changes. Entropion repair only corrects the droopiness and sagginess but is not considered a cosmetic procedure. By correcting this droopiness of the lower lid, the surgery typically improves tearing and mucous discharge as well as the foreign body sensation that is caused by lashes rubbing the eye. Because saggy in-turned eyelids are typically consequences of aging, most patients feel that entropion repair improves their appearance and makes them look better with eyes that are not red all the time.

With age, the skin, muscles and tendons of the lower eyelid can sag and droop. In addition, the fat that surrounds and cushions the eyeball can bulge forward through the skin of the lower lids. As the tendons of the lower lid sag, the lower lid can evert and turn inside out. It may also occur in patients with facial palsy, which results in a paralytic form of ectropion. This can lead to tearing, eye redness, mucous discharge, crusting of the eyelashes and skin irritation. Excess skin and fat also create what many feel is an unattractive, aged appearance in the lower lids (“bags under the eyes”).

What is the treatment option for Ectropion?

Repair of a lower lid ectropion is typically done as an outpatient procedure. The patient usually gets a “local” injection of anaesthesia, and sedation although deeper anaesthesia can be given if needed. The tendons of the eyelid in the corners of the eye are usually tightened with sutures through small incisions. The specifics are tailored to each patient’s needs. Also, some patients may choose to have cosmetic “add-on” procedures performed at the same time as functional (insurance) surgery. For example, they may choose to have their lower lid fat bags removed knowing that this is NOT covered by insurance.

The results of ectropion repair depend upon each patient’s symptoms, unique anatomy, appearance goals, and ability to adapt to changes. Ectropion repair only corrects the droopiness and sagginess but is not considered a cosmetic procedure. By correcting this droopiness and outward turning of the lower lid, the surgery typically improves tearing and mucous discharge.

Often seen in children and young adults of East Asian origin (Chinese, Japanese and Koreans), the lower and sometimes upper eyelashes are turned inwards causing corneal irritation, redness, watering and irritation. While in most patients the condition is mild and improves over time with lubrication, surgical correction may be required to alleviate the symptoms providing permanent relief.

Epiblepharon can be characterised by the following -

• Extra horizontal fold of skin that stretches across the border of the eyelid
• Anterior part of eyelid overrides posterior part
• Abundant orbicularis muscle
• Lashes brushing against eye
• May result in scratches on the cornea
• Some have reported association with astigmatism

• Rubbing eyes
• Irritation
• Itchiness
• Discomfort
• Tearing

• Observation
  • Some improve spontaneously with age
• Lubricant eyedrops
• Non-incisional method
  • Suture correction (may have higher recurrence rate)
• Incisional
  • Modified Hotz procedure (lower lid)
  • Cilia rotational suture (lower lid)
  • Asian blepharoplasty (upper lid)