What is upper eyelid repair?

It is an operation used to treat a droopy upper eyelid (ptosis).

Why do I need this surgery?

You have a common condition called ptosis where your upper eyelid droops down. If the droopy eyelid is not treated it can affect your sight and make everyday tasks trickier.

If you also have excess skin on your eyelid, you may also have this removed during surgery (blepharoplasty). For more information, please read our ‘Upper eyelid blepharoplasty repair for dermatochalasis’ leaflet.

What causes ptosis?

  • The commonest cause is age. As you get older, the muscle connection in your upper eyelid gradually gets stretched and so you cannot keep your eyelid fully open.
  • You may have been born with a droopy eyelid because the muscle that lifts it has not developed properly and is weaker than normal (congenital ptosis).
  • A lump or excess skin may make your eyelid heavier, weigh it down and make it droop.
  • A neurological (neuromuscular) cause is where the nerve supplying your eyelid-lifting muscle may be damaged or the muscle itself may be damaged.
  • You may have had surgery such as cataract surgery which involves stretching your eyelids using a speculum.

What are the risks of surgery?

We will try to make the operation as safe as possible. Some of the risks are serious and can cause loss of sight. Your doctor may be able to tell you if your risk of a certain complication is higher or lower.

Risks of upper eyelid repair surgery

  • Under-correction: if we do not lift your eyelid enough, it will still be droopy. This is fairly common at around 9% of patients, however, not all go on to have further surgery as the symptoms of visual impairment are much improved.
  • Over-correction: if we lift your eyelid too much, it will sit too high.
  • Asymmetry: the height and shape of the edge of your eyelid or the skin fold may look uneven when compared with your other eyelid. In 5% of unilateral repair, the other normal eyelid drops following the surgery requiring an operation to correct it. This is because the eyelids are co-innervated or ‘talk’ to each other.
  • Hang-up on downgaze: this is where the white part of your eyeball can be seen by others when you look down.
  • Dry eye: you may need to use artificial tears (eye drops) temporarily after surgery. Rarely, you can have a permanently dry eye. This means you would have to use artificial tears for life.
  • Corneal abrasion: the surface of your cornea may be slightly damaged during surgery. This will cause discomfort for a short while, but the damage is not permanent. It can also cause blurred vision, which again is only temporary.
  • Weak/limited eyelid closure: your eyelid may be weaker or will not close as well as before, especially at night.
  • Unsuccessful surgery/ptosis recurrence: the surgery may not work or the ptosis may recur and you would need to have repair surgery again. Congenital ptosis has a higher risk of recurrence because the muscle is weak from birth and the repair has to last longer. It will need to be repaired about three times over a lifetime.
  • Cysts/whiteheads: you may develop cysts or whiteheads along the area where you had the stitches. In most cases these settle down, however, they can be removed surgically if they are unsightly.
  • Numbness: you may have temporary patches of numbness over your eyelids.
  • Wound dehiscence: the stitches come apart and need to be redone.
  • Bleeding in your eye socket (orbital haemorrhage): This is extremely rare, but is a risk of any procedure around the eyes. If you get increasing pain and decreasing vision, these are the symptoms that warrant an immediate return to A+E whereby the bleeding can be dealt with. Nevertheless, it could cause permanent loss of sight.

 

General risks of an operation on your face

  • Bruising: it is normal to have some bruising. Most people look like they have significant bruising, but this will ease over the 10 – 14 days after your surgery but may be visible for up to one month. This will be worse if you are taking a blood thinner.
  • Pain: your eye area is naturally sensitive, so it is common to have discomfort after an eye operation. We will make sure you are comfortable before you go home. You can also take over-the-counter painkillers such as paracetamol regularly.
  • Swelling: some swelling is normal due to local anaesthetic liquid being placed under the skin and by having an operation. Most people look swollen and this should gradually ease over 2 to 4 weeks.
  • Infection: there will be a little redness around the wound as it heals, along with some tenderness. There is a small risk of the wound becoming infected. Infection symptoms include increasing pain under your wound and the surrounding area; increasing redness around your wound; a foul-smelling discharge from your wound; a temperature of 38°C (100.4°F) or more. If you experience these symptoms please get in contact with us and do not wait for your post-operative appointment. Please contact use using the details on page 6 under Who can I contact with queries or concerns?
  • Blood clot: you may develop a blood clot in your leg (deep vein thrombosis) or in your lung (pulmonary embolus). This is more likely after a long operation, particularly if you have a general anaesthetic.

Risks of general anaesthetic (GA)

Children usually have this surgery under a general anaesthetic but not adults. Please ask your anaesthetist for information about the risks.

Risks of local anaesthetic (LA) with conscious sedation

Adults usually have this surgery under local anaesthetic with conscious sedation.

  • Swelling and bruising: it is common to have swelling and bruising around the area where the local anaesthetic is injected. We give you plenty of local anaesthetic to ensure you have no pain and this is what causes most of the swelling. The swelling will ease as the anaesthesia is absorbed.
  • Stinging: the local anaesthetic will sting as it is put in but the area will quickly become numb.
  • Cardiovascular or central nervous system problems: these do not usually happen with a local anaesthetic and are very rare.
  • Allergic reaction/anaphylaxis: this is rare but if it happens you will be given treatment to reverse it straight away.

What are the benefits of surgery?

  • Most people who have this surgery make a full recovery. Their quality of life is improved and they can go back to normal activities.
  • Your upper eyelid will no longer droop down.
  • It will make your eyelid height and shape more even (symmetrical).
  • It will improve your field of vision and make it easier to see around you.
  • It prevents permanent loss of sight in children whose eyelid covers the pupil as their sight develops.

Are there any alternatives?

You can use ptosis props. These are devices that you fix to your glasses to hold your eyelids up.

But many people find them uncomfortable or that they do not work very well. Surgery is the best way to cure ptosis.

What will happen if I decide not to have the operation?

Consent

We must by law obtain your written consent to any operation and some other procedures beforehand. Staff will explain the risks, benefits and alternatives before they ask you to sign a consent form. If you are unsure about any aspect of the treatment proposed, please do not hesitate to ask to speak with a senior member of staff again.

You do not need surgery for mild ptosis that does not affect your sight. If you have significant ptosis, it can get worse over time, your eyelid can get even droopier and it can affect your sight. It can cause loss of sight if your eyelid completely covers the pupil.

What happens before the operation?

Medication

Let us know any medication you take. This includes blood thinners as well herbal and complementary remedies, dietary supplements and over-the-counter medication. We will tell you if you need to stop taking any of them.

You can usually keep taking blood thinners as long as your warfarin INR is in range and ideally less than 3. This does not affect the success of the surgery, but you may have more bruising.

Making your surgery successful

  • If you smoke, stopping smoking several weeks before your operation may reduce your risk of complications and will improve you general wellbeing.
  • Try to maintain a healthy weight as your risk of complications is greater if you are overweight, especially if you have a general anaesthetic.
  • Exercise regularly to help you to get ready for the operation. See your GP (home doctor) for advice before starting to exercise.

The day before your surgery

Try to shower or bathe the day before or on the day of your surgery. Keep warm around the time of your operation.

Who will do my surgery?

You will be cared for by a team of doctors and nurses which includes a surgeon with specialist ophthalmic and oculoplastic training.

What anaesthesia will I have?

  • General anaesthetic: children usually have a general anaesthetic so they will be asleep during the surgery.
  • Local anaesthetic: adults usually have this surgery under local anaesthetic so you will be awake but will not feel any pain. You often have conscious sedation as well, which will make you drowsy and less aware of what is going on around you.

What happens during surgery?

Before your surgery, we will do a number of checks to make sure you are having the right operation on the correct side. It is normal for us to keep checking this – and your name – to reduce the risk of error.

There are several different ways of treating ptosis and which one the surgeon uses depends on things including:

  • the strength of the muscle that lifts your eyelid
  • the type of ptosis you have
  • whether you wear contact lenses
  • your personal choice.

Posterior approach: this involves going from the inside of your eyelid and making a cut in the skin around your eyeball but not going into your eyeball. The surgeon will shorten the muscles or tendons that raise your eyelid, then reattach the muscle or tendon to your eyelid using hidden stitches. This provides a good lift, a good eyelid shape and you will not have a scar on the outside of your eyelid.

Anterior approach: this involves cutting into the natural skin crease of your upper eyelid, so hiding the scar. The surgeon will shorten the muscles or tendons that raise your eyelid, then reattach the muscle or tendon to your eyelid using stitches. This provides a good repair without the risk of damaging the skin around you eyeball, which can be important if you wear contact lens or have an inflammatory eyeball disease.

Frontalis suspension: this involves using the muscle in your forehead to lift your eyelid. You usually have this surgery if you have a poor eyelid-lifting muscle. Stab incisions are made above the eyebrow on the forehead and on the eyelid itself. The surgeon will use special synthetic materials such as Supramid or silicone, or your own leg tendon tissue (taken from a small cut just above your knee), to connect your eyelid to your forehead muscle.

You may have an antibiotic cream put in your eye at the end of the procedure which can blur your vision for a short while if you had posterior approach surgery or frontalis suspension.

How long does it take?

It usually takes about 45 minutes for one eyelid and 75 minutes for two eyelids.

What happens after surgery?

You usually stay in hospital for a few hours so we can check your recovery. You will be discharged on the same day. If you have had conscious sedation or a GA, a chaperone will be needed to take you home and look after you that night. You must not drive and we do not advise using public transport.

Will I need a follow-up appointment and who will take out my stitches?

With posterior approach surgery, the stitches dissolvable and so are left in. For frontalis suspension the stitches that close the stab incisions are also dissolvable and left alone. In anterior approach ptosis, the stitches that are used are normally non-absorbable blue prolene stitch. These are covered by steri-strips (small plasters) that can be taken off on day 5. You will be asked to remove the stitch yourself on day 6 after the operation. You can use clean fingers or a pair of tweezers. Once you have grasped the blue suture, you will need to pull slowly and consistently to gather momentum: importantly do not stop once it gets moving as the hardest part is the initial movement. In some cases, we will ask you to come back to remove the sutures.

We will make an appointment for you to have your stitches removed if you are unable to do it yourself or for a check-up in the eye outpatient clinic at the PRUH between 2-4 weeks after your surgery. In many cases we will make a virtual appointment (telephonic or video – see page 7).

How long will I take to recover?

  • You will have a lot of swelling and bruising for the first week but this should ease and disappear within about one month.
  • You are likely to have blood in your tears for the first few days and sometimes longer if you take blood thinning drugs such as aspirin, warfarin or clopidogrel.
  • Do not do any heavy lifting for two weeks or bend down. This can increase pressure in your wound could make it bleed.
  • The position of your eyelid is usually stable about three months after the procedure.

Getting back to your normal activities

  • Just do some walking for the first 48 – 72 hours after your surgery. Get up and walk around your house every two hours to help maintain your normal blood circulation. After two days, you can start going for regular walks outside your home as well.
  • Do not do any heavy lifting or excessive straining in the first two weeks
  • You can start doing gentle exercise such as swimming and jogging two weeks after surgery
  • You can start doing more vigorous exercise such as the gym, squash and football four weeks after surgery.
  • Do not force yourself to exercise if you still feel regular pain.

Who can I contact with queries or concerns?

If you have any queries or concerns, please contact West Kent Eye Clinic, PRUH.

Tel: 01689 865779 or 8657789am-5pm, Monday to Friday (not bank holidays)

You can also attend the Rapid Assessment Unit (RAU) at QMH or Kings Rapid Eye Services (KRESS) during the weekend or if they are nearer to where you live during the weekday

Out of hours you can attend accident and emergency department at the PRUH or DH

More information

Surgery: British Oculoplastic Surgery Society

www.bopss.org

Anaesthesia: Royal College of Anaesthetists – download their booklet, ‘You and your anaesthetic’

www.rcoa.ac.uk

Virtual Video consultation

Link for consultation

https://www.kch.nhs.uk/patientsvisitors/patients/outpatients/video-consultations

Click on the ophthalmology link and you will be directed to the video consultation platform. Please note this does not require any software to be downloaded onto your device.

Then, click on the hospital site that you are having you care (DH/PRUH/QMH)

Care provided by students

We provide clinical training where our students get practical experience by treating patients. Please tell your doctor or nurse if you do not want students to be involved in your care. Your treatment will not be affected by your decision.

PALS

The Patient Advice and Liaison Service (PALS) offers support, information and assistance to patients, relatives and visitors. They can also provide help and advice if you have a concern or complaint that staff have not been able to resolve for you. The PALS office is in the main hospital foyer at PRUH – staff will be happy to direct you.

PALS at Princess Royal University Hospital, Farnborough Common, Orpington, Kent BR6 8ND

Tel: 01689 863252 Email: kch-tr.palskent@nhs.net

You can also contact us by using our online form at www.kch.nhs.uk/contact/pals

If you would like the information in this leaflet in a different language or format, please contact PALS on 020 3299 1844.