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The most common type of adult onset ptosis is due to a weakening of the attachment between the levator muscle (the muscle that raises the upper lid) and the eyelid. This may occur as a result of the aging process, after cataract surgery or contact lens wear, or from an injury. Adult ptosis is less frequently due to other causes such as diabetes, myasthenia gravis, or eyelid tumors.
The most obvious sign is a droopy upper eyelid. The patient may complain of peripheral visual loss or fatigue from attempting to elevate the droopy eyelid. Reading may be difficult, as the droopy eyelid tends to block the visual axis when the eye is looking down. Adults with ptosis will often tip their heads back to see past their eyelids or raise their eyebrows in an effort to raise their eyelids. Prominent forehead wrinkles (or furrows) may be present from chronic elevation of the eyebrows by muscles in the forehead. If the ptosis is severe, individuals may bump into things (such as cupboard doors) at forehead level.
Treatment, when necessary, is usually surgical and is done as an outpatient under local anesthesia. The patient or physician often elects to have an anesthesiologist present to administer intravenous sedation and provide monitored care. It is important to do the surgery under local anesthesia with minimal sedation because this allows the surgeon to better gauge how much to raise the eyelids. The patient is typically sat upright during the surgery to assess for eyelid symmetry and adequate correction of the droopy eyelid(s). Eyelid ptosis surgery is a more technically challenging operation than blepharoplasty surgery (removal of extra eyelid tissue) and should only be performed by surgeons specializing in eyelid surgery with considerable experience in the nuances of ptosis repair.
In cases where the eyebrows area also droopy (brow ptosis), a procedure to elevate the eyebrow may be appropriate. This procedure known as a "brow lift", may be done directly above the eyebrow, within the forehead creases, or endoscopically behind the hair line (see Brow Lift). It is important to recognize that a droopy eyebrow may be contributing to the excess skin and fullness seen in the upper eyelids. Blepharoplasty and/or ptosis surgery will not correct redundant tissue resulting from brow ptosis. See Preoperative and Postoperative Patient Photographs of Dr. Klapper's patients.
Patients with upper eyelid ptosis often have redundant (extra) upper eyelid skin referred to as dermatochalasis. This can be corrected by performing an upper eyelid blepharoplasty at the time of the ptosis repair (ask Dr. Klapper for additional information on blepharoplasty surgery). If the dermatochalasis is severe and the extra skin is pushing down on the eyelashes and significantly interfering with vision, then the blepharoplasty procedure may be covered by insurance or Medicare.
If significant visual field loss can not be documented and the photographs do not show eyelid skin hanging over the eyelashes, then the blepharoplasty procedure will be considered cosmetic and the patient will be required to make separate payment arrangements. Lower eyelid blepharoplasty surgery is rarely covered by insurance or Medicare and is considered cosmetic in almost all cases. There are certain advantages to having cosmetic blepharoplasty procedures at the time of your ptosis repair and Dr. Klapper can discuss this with you if you are interested.
There are certain criteria that must be satisfied for most insurance carriers (including Medicare) to pay for part or all of your eyelid surgery. For any health care plan to cover surgery, a patient's eyelids must restrict the superior field of vision resulting in some limitation of daily activities such as reading, writing, driving, sewing, etc. Photographs must be submitted and demonstrate significant narrowing of eye opening with a diminished distance from the upper eyelid to the light reflex (near the center of the pupil). Visual fields may also be required to further document constriction of the superior field. Visual fields are performed with the eyelids at rest and with the eyelids elevated to demonstrate the improvement expected with surgery. The predetermination process for commercial insurance may take a few weeks to a few months to complete.
With Medicare, the decision to cover surgery is not made until after surgery when the claim (with the photograph and/or visual field) is submitted from the surgeon's office. Medicare does not have a pre-approval process. Dr. Klapper will discuss with you whether your photographs and/or visual fields meet the criteria outlined by the local carrier for Medicare. Dr. Klapper can not, however, guarantee whether your surgery will be a covered service. A referral from your primary care physician or eye doctor does not insure that Medicare will cover your eyelid surgery. All Medicare patients considering functional blepharoplasty and/or ptosis surgery will be asked to sign Medicare's Advance Beneficiary Notice (ABN) indicating that you understand your financial responsibility if Medicare does not cover your surgery.
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Contact our office to discuss your eyelid problem with Dr. Klapper or a member of his staff. (317) 818-1000
