CNA938 Rewind - The Wellness Hour: Understanding Ptosis and When to Seek Help

Cheryl Goh

Now, The Wellness Hour with Cheryl Goh.

Yes, hello. Welcome to The Wellness Hour with me, Cheryl Goh. Drooping eyelids are often dismissed as a natural part of ageing, but for some people, they can be much more than a cosmetic concern. Known as ptosis, the condition can affect vision, cause eye strain and even lead people to unconsciously raise their eyebrows or tilt their heads to compensate.

So, how can you tell if a drooping eyelid is simply age-related or something that perhaps may require some medical attention? That’s what we’re going to find out today from our guest, Dr Samuel Ho, who is Consultant Plastic Surgeon and Medical Director of Allure Plastic Surgery, a member of Beyond Medical Group.

Dr Ho, nice to have you with us. Welcome to The Wellness Hour.

Dr Samuel Ho

Thank you, Cheryl. Thanks for having me.

Cheryl Goh

When people hear the term “ptosis”, the word itself is quite interesting. What exactly does that mean? How can someone tell the difference between an actual medical condition and perhaps just normal age-related changes around the eyes?

Dr Samuel Ho

“Ptosis”—actually, we’ve shortened the word. It’s really “blepharoptosis”, which means eyelid droop. “Ptosis” by itself just means something drooping. It can be mammary ptosis, which is breast drooping. In this case it’s blepharoptosis, so it’s eyelid drooping. But we make it easier and shorten the word to “ptosis”.

I think the easiest way people can tell whether their eyelids are drooping, or drooping significantly, is to look at past photos of themselves. A lot of my patients come in because they look at photos of themselves, then go back and look at photos of themselves years ago. They notice it’s a very gradual thing for most patients.

Videos also seem to show it because they capture any asymmetry, any significant droop or covering of the iris. That’s the easiest way.

Sometimes they come in with symptoms. The most common symptoms would be things like heaviness of the forehead and headaches. Sometimes it’s asymmetry of the brows. Funnily enough, for a lot of the ladies, it would be because their brow embroidery lady tells them, “Hey, your brows aren’t right. There’s something wrong.” They’ve seen so many that they kind of know.

Cheryl Goh

I see. Then they direct their customers to maybe get it checked out. That’s very interesting. So your brow lady can do more than just give you nice brows; they can also help you watch out for ptosis.

What are the most common causes of ptosis, Dr Ho? Is it always something to do with age?

Dr Samuel Ho

Ageing is one of the major causes. We call it “involutional”, which is a fancy word for saying ageing. But a lot of the time, we don’t really know, so we call it “idiopathic”—we can’t find the exact cause.

Ageing is one. In a lot of my patients now, because they are getting younger, I do think prolonged screen use—phone use and so on—plays a part because of eye strain. When you strain your eyes, you tend to rub a lot because they are dry. You blink less when you work on a laptop for prolonged hours. I think persistent eye rubbing causes microtrauma through the years; all this builds up.

Sometimes it’s trauma. Sometimes it’s infections—repeated eye infections, styes and so on—but they don’t form a big group. In a lot of cases, we can’t isolate a particular cause. But yes, you’re right: ageing, or involutional ptosis, forms a big group.

Cheryl Goh

I’m just curious, Dr Ho. Nowadays eyelash extensions are very popular, right? We have a lot of weight on our eyelashes, which again are linked to our eyelids. Would that cause ptosis also, because there’s a constant weight on the lids?

Dr Samuel Ho

It’s not really the weight. I feel it’s actually the adhesive they use for the eyelash extension—the glue. In a lot of patients, it causes a little irritation, or almost an eczema-like reaction. That in itself can cause some changes in the eyelid skin, so it becomes a little thicker.

If you look at patients who have applied double-eyelid tape or glue for many years, there are changes that occur in their skin that kind of mimic long-term eczema. I think that plays a role.

For a lot of patients, eyelash extensions or fake eyelashes act almost like a camouflage agent for the underlying ptosis. It makes them look better; it makes the ptosis look a little less severe. The same goes for contact lenses, especially coloured contact lenses. They work in the short term to make it look a little better, but in the long run they do not stop the progression of the condition.

Cheryl Goh

These are cosmetic quick fixes, but they wouldn’t solve the larger underlying problem.

Dr Samuel Ho

Yes, they don’t.

Cheryl Goh

Many people with droopy eyelids may unconsciously raise their eyebrows to see better, or they might even tilt their head over time. How can this affect the face and contribute to things like deeper forehead lines or even a constantly tired appearance?

Dr Samuel Ho

You’re right. The number-one thing people do when they have ptosis, or droopy eyelids that impact their visual field, is raise their brows. It’s an involuntary compensatory reaction.

The forehead muscle—the frontalis muscle—raises the brows, and it naturally opens your eyelids a little better. To some extent, double-eyelid tape does the same thing in the short term. It assists the eyelid-opening muscle to open a little more, so you have a brighter, bigger visual field.

But in the long term, yes, you get forehead lines. Sometimes they get headaches, and in some cases they get one-sided headaches because one side is compensating a lot more than the other. Ptosis is not always a symmetrical condition; it may be worse in one eye than the other. I would say about 30 to 40 per cent of my patients have asymmetrical severity of ptosis.

Especially in the younger group, one side may be worse than the other. One side of the brow may compensate much more than the other side, so they get headaches particularly on one side of the head from the constant lifting of the brow.

Besides the cosmetically unpleasant deeper forehead lines, they get headaches, heaviness and strain. Some patients tilt their head slightly because, when you tilt your head back, it allows your lids to open a little more easily. It’s a mechanical thing. The constant tilting of the head can cause a little neck strain because you’re not looking at the laptop with the correct posture. Over time, it does build up.

Cheryl Goh

So these do impact our daily life in a way?

Dr Samuel Ho

Yes. It does impact your function and cause symptoms in your daily life.

Cheryl Goh

Beyond appearance, tell us more about how ptosis can affect our actual vision and concentration. Like you said, it could lead to symptoms such as eye strain and headaches.

Dr Samuel Ho

The main thing is that it causes visual-field deficits, which means part of your normal visual field is blocked. We can test for this. We send patients for a visual-field analysis, which is basically almost like playing a video game where you’re trying to see light spots appear on the screen.

You would see that, in a relaxed state where they’re not compensating hard with their forehead, they won’t be able to pick up certain light spots in the upper and outer parts of the visual field. Basically, the window they can see out of is a lot smaller now.

Cheryl Goh

It’s almost like you have blinkers on, in a way.

Dr Samuel Ho

Yes, correct. The severe cases will tell me that, when they’re driving, they actually have to turn their head to see on the lateral, left and right sides, rather than being able to see out of their normal visual field because it is blocked.

Similarly, they lift their forehead or brows because their upper, or superior, visual field is blocked off. It’s like somebody has partially closed the curtains on what you can see out of. I think that is one of the major symptoms.

In the more severe cases, sometimes it can cause lash inversion. This is typically in patients who have both ptosis and what we call dermatochalasis long-term, which basically means a lot of excess skin and orbital fat. When the eyelids are droopy and you have all this excess skin compressing down on the eyelashes, sometimes the eyelashes get pushed in. They get lash irritation; the eyes are very itchy. Over time, the lashes can cause scratches on the eyeball, so they get pain in addition to the itch. These are some of the functional outcomes of ptosis.

Cheryl Goh

Wow. Can we ask about the treatment options then, Dr Ho? How do you assess the severity?

Dr Samuel Ho

We look at the severity before suggesting treatment options, as well as the cause. You have to look at the cause and severity.

Severity is based on what we call the MRD measurement—MRD1. That’s getting a bit technical, but it basically measures how much of your iris is covered by your upper lid.

Cheryl Goh

I see. Obviously, in the more severe cases, more of it is covered, in terms of millimetres.

Dr Samuel Ho

That’s how we gauge the severity, in addition to the symptoms. This is an objective measure.

The second thing we look at is the cause, because the cause of ptosis is not always mechanical. It’s not always due to ageing, where the tendon of the muscle is loose or detached. It may be due to other things. It may be a nerve issue or a muscle-belly strength issue, which is a separate group.

The type of treatment is based on the severity as well as the cause of the ptosis. Generally, ptosis correction really is surgical because, in a lot of cases, the problem is structural or mechanical. For milder cases, sometimes they try eye drops for a period, but it doesn’t really work in the long run.

Cheryl Goh

So surgery is the main treatment?

Dr Samuel Ho

Yes, unfortunately.

Cheryl Goh

We just had a listener text in. He or she is asking: Does the surgery for droopy eyelids take a long time?

Dr Samuel Ho

It depends on what needs to be done—and “long” is subjective. In the vast majority of cases, the surgery is a day-surgery procedure, and it usually shouldn’t take longer than an hour or two in a simple case.

Obviously, if it’s a more complex case or the type of surgery needed is more complex, it’s going to take longer. But it’s not a five- or six-hour kind of surgery, simply because the eyelid is part of the body that tends to swell easily. If you take very long, the swelling sets in and you can’t assess accurately. It’s not a surgery that’s supposed to take many hours.

Cheryl Goh

Thanks for answering our listener’s question as well. For those who are considering surgery for ptosis, what can they expect from the recovery process? Will that take a long time too?

Dr Samuel Ho

The length of recovery depends on two big factors. One would be the age of the patient. Number two would be the extent of surgery required. Generally, older patients take longer. When the extent is smaller—sometimes we can do the surgery through smaller incisions and less needs to be done—the recovery is shorter.

What they can expect is definitely some bruising and swelling. The eyelid crease won’t look so natural and nice in the early period. Expect about one or two weeks of bruising in most cases, and about two to four weeks of swelling.

If you want to look exactly normal and look like you’ve not had any surgery done, don’t expect it to take less than four weeks in most cases. Sometimes you’re a bit luckier and it’s shorter, but generally these are my younger male patients who recover faster. I think it’s something to do with hormones.

Cheryl Goh

Before we let you go, Dr Ho, what is one piece of advice you would like to give our listeners who may be noticing changes in their eyelids but are still unsure whether treatment is necessary?

Dr Samuel Ho

The number-one thing is that, if you can correct some habits early, I think it spares you a lot of longer-term problems. Eye rubbing is the number-one thing. If you love to rub your eyes, please do something different. Get artificial tears—natural eye drops—and just use the drops. You’re rubbing your eyes simply because they’re dry or a little irritated, so eye drops play a big role.

If you need to be on the laptop for long periods of time, just take a minute or two: look away, look up, look at something green far away. All these are simple things you can do to help yourself.

If you feel that something’s really not right, just get an early assessment. You don’t have to opt for surgery, but at least you know what’s going on, because occasionally there can be certain medical conditions that are a little more acute and are contributing. You want to catch that early.

Cheryl Goh

All right, so correct some habits: don’t rub your eyes, use eye drops, take screen breaks and, of course, try to get an early assessment so you can better understand your condition.

Dr Ho, this has been very insightful and very helpful. Thank you so much for sharing with us and our listeners.

Dr Samuel Ho

Thank you very much for having me.

Cheryl Goh

We’ve been speaking today on The Wellness Hour to Dr Samuel Ho, Consultant Plastic Surgeon and Medical Director of Allure Plastic Surgery, a member of Beyond Medical Group, telling us about ptosis.

This is The Wellness Hour on CNA938. I’m Cheryl Goh.