Patients with droopy or tired upper eyelids commonly seek consultation by an oculoplastic surgeon. The eyelid has a complex anatomy and a “droopy” eyelid can actually be due to several different problems with several different treatments. The two most common causes of a droopy lid are excess skin/ tissue (dermatochalasis) and a low lid margin (ptosis). Ptosis and dermatochalasis may occur alone or together and one or both may need to be corrected for optimal surgical results.
Dermatochalasis, or excess eyelid skin and tissue, is an extremely common problem. The clinical appearance can range from a mild lowering of the eyelid crease to an extra fold of skin that hangs over the eyelashes. Excess fat can also cause a bulge to appear in the upper lids, particularly in the corner of the eyelid near the nose. Dermatochalasis is usually an age related process, but can occasionally be caused by other more serious conditions like thyroid eye disease. If severe, dermatochalasis may block the upper and outer field of vision and interfere with activities such as reading or driving. Dermatochalasis can be treated surgically by a blepharoplasty (removal of excess eyelid skin and tissue).
Ptosis (also called blepharoptosis) is present when the margin of the eyelid is low. This distinct from dermatochalasis which excess eyelid skin and tissue is present. There are many causes of ptosis, but by far the most common is stretching or slippage of the tendon of the muscle that raises the upper lid (the levator aponeurosis). This is also usually due to age, can also be due to contact lens wear and trauma among other causes. Occasionally muscular disorders (myogenic ptosis), developmental issues (congenital ptosis), and neurologic disorders (neurogenic ptosis) can cause ptosis. Some people have naturally ptotic lids and it is normal for their genetics and anatomy. Ptosis can be treated surgically by a procedure called ptosis repair. There are several ways to repair ptosis. A careful oculoplastic examination can determine the appropriate surgical technique to use.
Ptosis can be differentiated from dermatochalasis by shining a light into the eyes while holding any excess skin off the lashes and measuring the distance between the light reflection and margin of the eyelid. This distance is called the “margin to reflex distance” or MRD1. Any eyelid with a MRD1 measurement less than 2mm can be considered to have ptosis. While a significant amount of excess skin and tissue may actually push the eyelid margin down, when this tissue is gently elevated off the lashes, an eyelid with ptosis will remain low. Another important ptosis measurement is the amount of “levator function” or LF. Levator function determines the amount of muscle function helps determine what type of ptosis repair surgery would have the best outcome.
Dermatochalasis is commonly see in conjunction with ptosis. It is important to assess for both to determine a proper diagnosis and course of treatment. Ptosis is commonly masked by dermatochalasis, and dermatochalasis can go undetected when significant ptosis is present. Evaluation for both is important to make sure that the appropriate surgical correction is performed.
Consultation with an oculoplastic surgeon can determine if droopy upper eyelids are due to dermatochalasis, ptosis, or both. An oculoplastic surgeon can also determine the most appropriate surgical technique to use for blepharoplasty, ptosis repair or a combination procedure.