Monday, February 1, 2016

Doc, Could You Balance My Eyes for the Festive Season? - Part 1

With the Chinese New Year round the corner, most patients want to defer surgery until the festive season is over. This patient is distressed by her droopy eyelid after undergoing a left cataract surgery one month ago in another clinic. Examination shows she has a left significant droopy eyelid (ptosis) and extracapsular cataract extraction and implant (ECCE +IOL). 

Left significant ptosis.

Left eyelid lower when the patient looks down. 

Left eyelid has reduced excursion on upgaze.

Left ECCE + IOL which is likely to contribute to the droopy eyelid.

Nowadays, most cataracts are removed with phacoemulsification (clicked here for video of the technique) under topical anaesthesia, this techniques has the advantages of faster recovery due to smaller wounds and less post-opertive inflmmation compared with ECCE+IOL. Unfortunately, the surgeon this patient went to was not trained in phacoemulsification and still offers the older technique of ECCE +IOL. The droopy eyelid is likely to be the consequence of a longer post-operative inflammation causing dehiscence of the muscle (levator) that opens the eyelid.

Diagrams showing normal levator attachment and following it 

The forehead muscle helps with eye opening. When it is stopped from doing 
so by placing the finger firmly above the eyebrow, the droopy eyelid is worsened.

The eyelid excursion on upgaze is also limited when the forehead muscle 
is not used.

Although droopy eyelid caused by post-operative inflammation may improve when the inflammation settles,  in eyes that develops levator dehiscence the droopy eyelid is unlikely to fully recover. The only permanent treatment is surgical correction to reattach the levator. Posterior approach conjunctivomullerectomy is suggested but the patient is not keen for surgery for fear of post-operative swelling which may not recover in time for the Chinese New Year. However, she is desperate to look her best for the festive season. 

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