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Droopy Eyelids:
Problems and Treatments
Craig Lewis, MD
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Disclosure Statement
• Speaker, Craig Lewis, M.D. has a financial
interest/agreement or affiliation with Lansing
Ophthalmology where he is a shareholder and
employed as an oculoplastic specialist.
• I have no financial interest in any of the products
discussed.
• Off-label use: I will discuss off-label use of
botulinum toxin products.
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Oculoplastic Specialist
• What is oculoplastics?
– Specialized field of
ophthalmology: ASOPRS
• Eyelids
• Tear drain
• Orbit
–Medical problems
–Cosmetic concerns
ASOPRS
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Droopy Eyelids
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Droopy Eyelids
• Droopy upper eyelids • Extra eyelid skin
• Ptotic upper eyelid
• Droopy eyebrow
• Droopy (loose) lower eyelids • Outward turning (ectropion)
• Inward turning (entropion)
• Floppy eyelid syndrome
• Eyelid surgery basics
• Q & A
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Upper Eyelid Changes
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• Extra upper eyelid skin
– Blocks vision
– Heavy, tired sensation
Extra
skin
Eyelid
height
normal
Eyelid Problems
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Eyelid Problems
• Extra upper eyelid skin: Dermatochalasis
– Problem: Extra skin hangs over eyelid
– Cause: Time + gravity + movement of eyelids
– Treatment: Blepharoplasty surgery
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Eyelid Problems
• Blepharoplasty surgery
– Treats extra skin
hanging over eyelid
– Removes redundant
skin and extra fatty
tissues
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• Steps:
– Mark skin
– Remove flap of skin and orbicularis muscle
– Open orbital septum to remove fat
– Close skin
Blepharoplasty
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Blepharoplasty
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Blepharoplasty
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Potential Benefits of Surgery
• Side vision improved
• Reading vision better (more light)
• Less strain by not lifting brow
• Rested appearance
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• Hemorrhage
• Lagophthalmos
• Retraction
• Under-correction
• Over-correction
• Ptosis
• Web
• Crease
Possible Complications
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Before After
Blepharoplasty
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After
Before
Blepharoplasty
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Ptosis
Drooping of eyelid due to weakness of the lifting muscle.
Excess skin Weak lifting muscle
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Eyelid Problems
• Ptotic upper eyelids
– Blocks vision
– Tired sensation, often worse in evening
– Brow aches
Eyelid not
open
enough
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Eyelid Ptosis
• Droopy upper eyelids
– Problem: Eyelid does not open far enough to see well
– Cause:
• Most common: gradual stretch or dehiscence of levator palpebrae superioris or Muller’s muscle
• Other causes, some serious
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Levator
palpebrae
superioris
Muller’s
muscle
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Eyelid Ptosis
• Potential serious causes:
– Muscle disorders
• Myasthenia Gravis, Lambert-Eaton Syndrome
– Nerve disorders
• Multiple sclerosis, compression from mass (lung cancer)
– Blood vessels problems
• Aneurysm, Diabetes
– Orbital disease
• Orbital mass, Graves Eye Disease
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• Potential serious causes:
– Warning signs:
• Droopy lid + double vision
• Droopy lid + pain/headache
• Suddenly droopy lid
Eyelid Ptosis
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Eyelid Problems
• Ptotic upper eyelids
– Most common cause:
stretching levator muscle
– Treatment: Eyelid ptosis
repair surgery
• Eyelid ptosis repair
surgery
– May be done from under
the eyelid or through the
skin
BEFORE
AFTER
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Blepharoptosis surgery
• Internal approach: CML
– Conjunctivo-mullerectomy-levator resection
– All from inside, no skin incision
– Advantages: natural contour, no skin scar, more
predictable
• External approach: ELR
– External levator resection
– From outside through bleph-type incision
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Blepharoptosis surgery: CML
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Blepharoptosis surgery: CML
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Blepharoptosis surgery: CML
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Blepharoptosis surgery: CML
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Blepharoptosis surgery: CML
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Blepharoptosis surgery: CML
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Blepharoptosis surgery: CML
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Blepharoptosis surgery: CML
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Blepharoptosis surgery: CML
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Blepharoptosis surgery: CML
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After Before
Ptosis
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After Before
Ptosis
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Ptosis
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After Before
Ptosis
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Ptosis surgery: Complications
• Bleeding
• Retrobulbar hemorrhage: rare after CML
– Orbital septum not violated
• Lagophthalmos
• Retraction
• Under-correction: most common complication
• Over-correction: rare
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Congenital Ptosis
• Causes:
– Poor development of
levator muscle
– Horner’s syndrome
– Many others
• Problems:
– Amblyopia
– Abnormal head
position
Photo from: http://www.aapos.org/terms/conditions/90
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Congenital Ptosis
• Challenges:
– Poor levator muscle
function cannot be
directly improved
– Lagophthalmos may
worsen after ptosis repair
– Cosmetic concerns
Photo from: http://www.aapos.org/terms/conditions/90
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Eyebrow Position
• Determine normal for each individual
• Maintain facial expression
• Proportional to face
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Eyelid Problems
• Droopy eyebrow skin
– Blocks vision, especially to the side
– Heavy sensation
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Eyebrow ptosis
• Droopy eyebrow skin
– Problem: Extra tissue
from eyebrow hangs over
eyelid
– Cause: Time + gravity
– Treatment:
• Eyebrow ptosis repair
surgery
• BOTOX® brow lift
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BOTOX® • BOTOX®
– Purified BOtulinum TOXin
– Temporarily weakens muscles
• 3 month effect per treatment
– Indicated for wrinkles between
brows (glabellar area)
– Black-box warning 2009
– Other similar drugs:
• Dysport®, Myobloc®, Xeomin®
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Eyebrow Surgery
• Above eyebrow
• Above hairline
• Hairline
• Forehead Crease
• Internal (through eyelid
surgery opening)
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Before
After
Eyebrow Surgery
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Before After
Eyebrow and Upper Lid Surgery
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Before
After
Brow Surgery
After
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Part I: Droopy Eyelids
• Droopy upper eyelids • Extra eyelid skin
• Ptotic upper eyelid
• Droopy eyebrow
• Droopy (loose) lower eyelids
• Outward turning (ectropion)
• Inward turning (entropion)
• Floppy eyelid syndrome
• Eyelid surgery basics
• Q & A
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Droopy Lower Eyelids
• Eyelid entropion
– Lower eyelid that rolls in
– Problem: Irritation as
lashes rub against eye
– Cause: Loose eyelid with
spasm of orbicularis oculi
muscle
– Treatment:
• Usually surgery
• BOTOX®
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Eyelid Problems
• Eyelid ectropion
– Lower eyelid that turns out
– Problem: Irritation or tearing
as eyelid doesn’t protect eye
– Causes:
• Usually loose eyelid (time and
gravity)
• Mechanical (ex: tumor)
• Cicatricial (ex: dermatitis, post-
surgical)
– Treatment: Drops or ointment,
often surgery
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Cicatricial Ectropion
Lower eyelid blepharoplasty complication
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Cheeklift
Loose
lower
eyelids
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Cheeklift and
Upper Eyelid Blepharoplasty
1 month after Before
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1 year after Before
Cheeklift and
Upper Eyelid Blepharoplasty
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Eyelid Problems
• Floppy eyelid syndrome
– Chronic eye irritation due to extremely loose eyelids
– Often worse on ‘downhill’ side
• Eyelid turns over while sleeping
– Strong association with obstructive sleep apnea
– Treatment: Shield eyes at night, surgical eyelid tightening, identify and treat OSA
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FAQs and Eyelid
Surgery Basics
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FAQs
•Will insurance cover surgery costs?
•Where is surgery performed?
•What type of sedation is used?
•How long does surgery take?
•How long is recovery?
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FAQs
• Does insurance cover eyelid surgery?
–Lower eyelid malpositions: Yes
–Upper eyelid/eyebrow surgery: Maybe...
• Must meet criteria
• Varies by insurance carrier
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FAQs
• Medically necessary upper eyelid surgery criteria:
1. Causes problem with comfort or vision
• Blocks vision, heavy, tired feeling
• No good: Hard to put on make-up, looks bad in mirror
2. Blocks vision by visual field test
3. Photos: Eyelid skin drapes over eyelashes OR eyelid crosses near pupil
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Eyelid Surgery Basics
• Out-patient surgery
at surgical center or
hospital
• Monitored anesthesia
care most common
• ~1/2 hour per eyelid
surgical time
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Eyelid Surgery Basics
• Comfort/recovery
– Most patients have some discomfort/pain for a few days after surgery
– Usually patients feel fine within 2-4 days after surgery
– Bruising/swelling universal
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• Scars
– Any skin incision will leave a scar
– Eyelid skin is thin & scars are usually minimal
• Follow-up
– 1 week post-op
• Remove any stitches
– 6-8 weeks follow-up visit
Eyelid Surgery Basics
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Eyelid Surgery Basics
• Down time
– Plan for two week recovery
– Vision may be blurry for
several days
– Swelling/bruising for 1-3
weeks
– During recovery: read, watch
TV, listen to music, chat on
phone all OK
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• Inactivity for 2 to 3 days
• Ice packs for 2 days
• Ointment to suture line
• Can usually drive in 2-3 days
• Avoid strenuous activity for 2 weeks
Eyelid & Eyebrow Surgery
Early Recovery
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• “Tight” sensation in eyelid area
• Incision line blends after 3-5 months
• Some swelling in upper & lower lid area
Eyelid & Eyebrow Surgery
Late Recovery
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Questions and Answers
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Thank you!