Specialities

Ptosis

Ptosis is when the upper eyelid droops over the eye. The eyelid may droop just a little, or so much that it covers the pupil (the black dot at the center of your eye that lets light in). Ptosis can limit or even completely block normal vision.Children and adults can have ptosis. Fortunately, this condition can be treated to improve vision as well as appearance.

Ptosis in children

Children born with ptosis have what is called congenital ptosis. This can be caused by problems with the muscle that lifts the eyelid (called the levator muscle).
The most obvious sign of ptosis is a drooping eyelid. Another sign is when the upper eyelid creases do not line up evenly with each other. A child with ptosis may tip their head back, lift up their chin, or raise their eyebrows to try to see better. Over time, these movements can cause head and neck problems.
Sometimes, a child born with ptosis can also have other eye-related problems. They can include eye movement issues, eye muscle disease, tumors (on the eyelid or elsewhere) and other problems.
Having ptosis puts a child at risk for vision problems. If the child’s eyelid droops so much that it blocks vision, amblyopia (also called “lazy eye”) can develop. One eye will have better vision than the other. A child with ptosis can also have astigmatism, where they see blurry images. The child may also develop misaligned (crossed) eyes.

Ptosis in adults

Adults get ptosis (called involutional ptosis) when the levator muscle stretches or separates away from their eyelid. This can be caused by aging or an eye injury. Sometimes ptosis happens as a side effect after certain eye surgery. Rarely, diseases or tumors can affect the eyelid muscle, causing ptosis.
Your ophthalmologist will find the cause of your ptosis in order to recommend treatment. They will do a complete eye exam, and may also want you to have blood tests, X-rays, or other tests. The ophthalmologist will likely recommend surgery to help the eyelid muscle work better.

Ptosis treatment for children

Ophthalmologists consider the following factors when deciding the best way to treat ptosis in children:

• The child’s age
• Whether one or both eyelids are involved
• The eyelid height
• The strength of the eyelid’s muscle
• The eye’s movements
• In most cases, ophthalmologists recommend surgery to treat ptosis in children. This is to either tighten the levator muscle or attach the eyelid to other muscles that can help lift the eyelid. The goal is to improve vision.
• If the child also has amblyopia, that condition must be treated as well. Amblyopia may be treated by wearing an eye patch or special eyeglasses, or using certain eye drops, to strengthen the weaker eye.
• All children with ptosis—whether or not they have surgery—should see their ophthalmologist regularly for eye exams. Ask your child’s ophthalmologist how often exams are needed. Because kids’ eyes grow and change shape, they need to be checked for amblyopia, refractive disorders, and other eye problems.

Adult ptosis surgery

• Ptosis surgery is done as an outpatient procedure in your ophthalmologist’s office. A local anesthesia will be used to numb your eye and the area around it.
• Sometimes, the surgeon may only need to make a small adjustment to the lid’s lifting muscle. Extra skin from the eyelid also may be removed to help the eyelid lift properly. For more severe ptosis, the levator muscle may need to be strengthened and reattached to the eyelid.
• As with any type of surgery, there are possible risks and complications with ptosis repair. Your ophthalmologist will discuss these with you.
• Before eyelid surgery, be sure to tell your ophthalmologist about all the medicines you take. Include all prescription and over-the-counter medications, vitamins, and supplements. It is important for your eye surgeon to know if you take aspirin (or aspirin-containing drugs) or blood thinners, or if you have a bleeding problem

Nasolacrimal duct obstruction

What is a tear duct obstruction?

• Tears normally drain through small openings in the corners of the upper and lower eyelids called puncta and enter the nose through the nasolacrimal duct. Tear duct obstruction prevents tears from draining through this system normally [See figure 1]. If the tear duct is blocked, there will be backflow of tears and discharge from the eye.

What causes nasolacrimal duct obstruction in children?

• The most common cause is the failure of a membrane at the end of the tear duct (valve of Hasner) to open normally at or near the time of birth. Other causes of blocked tear ducts in children include:
• Absent puncta (upper and/or lower eyelids)
• Narrow tear duct system
• Infection
• Nasal bone that blocks the tear duct entering the nose.

How common is nasolacrimal duct obstruction?

• Over 5% of infants have symptoms of nasolacrimal duct obstruction affecting one or both eyes. Most (approximately 90%) clear spontaneously during the first year of life.

What are the signs/symptoms of tear duct obstruction?

• Blockage of the drainage system causes tears to well up on the surface of the eye and overflow onto the eyelashes, eyelids, and down the cheek. This usually occurs within the first days or weeks of life.
• The eyelids can become red and swollen (sometimes stuck together) with yellowish-green discharge when normal eyelid bacteria are not properly “flushed” down the obstructed system. Severe cases result in a serious infection of the tear duct system (dacryocystitis).

Can a tear duct obstruct intermittently?

• The severity of the signs can vary under different conditions such as upper respiratory illnesses (“colds” or nasal congestion) or outdoor exposure such as wind or cold. If a child has cold, he or she may have increased tearing or discharge.

How is tear duct obstruction diagnosed?

• A history of tearing and discharge at a very early age is strongly suggestive of a blocked tear duct. An ophthalmologist is able to perform certain tests in the office to confirm the diagnosis. It is important that the eyes be examined for uncommon but important other causes of tearing in infants including childhood glaucoma.

What is the treatment of a blocked tear duct?

• Fortunately, tear duct obstruction resolves spontaneously in a high percentage of cases. When obstruction is persistent, one or more of the following treatments may be recommended: tear duct massage, topical antibiotic eye drops, tear duct probing, balloon tear duct dilation, and/or tear duct intubation.

How does tear duct massage work?

• Tear duct massage can be performed at home to help the tear duct open. A pediatric ophthalmologist or primary care physician can demonstrate the most effective massage technique.

When should topical antibiotics be used?

• Antibiotic eye drops or ointment may be used to treat discharge or mattering around the eye. The medication does not open the blocked tear duct and symptoms often recur when the eye drops are discontinued.

When should tear duct probing be performed?

• If the tear duct remains blocked after one year of age, a nasolacrimal duct probing may be performed.

How does tear duct probing work?

• A smooth probe (resembling a thin straight wire) is gently passed through the tear duct and into the nose. Using probes of progressively larger diameters can widen a tear duct system.

What type of anaesthesia is used for tear duct probing?

• Some younger children have a tear duct probing done in the office using topical anaesthetic drops. Older children usually have a brief general anaesthetic in an outpatient surgery setting. Sometimes a tube (stent) is placed in the nasolacrimal system while a child is asleep to prevent recurrence of tearing.

How successful is tear duct probing?

• Tear duct probing is generally very successful. Additional procedures with enhancements are sometimes necessary. In some cases, a more involved operation may be needed to open the tear duct system (dacryocystorhinostomy, DCR).

Entropion & Ectropion

Entropion

Entropion (inversion of an eyelid) is caused by age-related tissue relaxation, postinfectious changes (particularlytrachoma), posttraumatic changes, or blepharospasm. Eyelashes rub against the eyeball and may lead to corneal ulceration and scarring. Symptoms can include foreign body sensation, tearing, and red eye. Diagnosis is clinical. Definitive treatment is surgery.

Ectropion

Ectropion (eversion of the lower eyelid) is caused by age-related tissue relaxation, cranial nerve VII palsy, and posttraumatic or postsurgical changes. Symptoms are tearing (due to poor drainage of tears through the nasolacrimal system, which may no longer contact the eyeball) and symptoms of dry eyes. Diagnosis is clinical. Symptomatic treatment can include tear supplements and, at night, ocular lubricants; definitive treatment is surgery.