Ptosis Surgery
(correcting droopy upper eyelids)

Mr Das-Bhaumik will see you on Cumberlege Wing of Moorfields Eye Hospital. You will be asked to sign a consent form. Again, any questions you have will be answered prior to surgery.

The following is advised:

• Bring in all your current medication and take them as usual unless otherwise advised.
• Wash the face to remove makeup to reduce your chance of an infection.
• Dress in comfortable clothes.
• Remove your contact lenses.
• Remove all metallic items including piercings and hair metallic hair extension clips if possible.

The procedure itself is very comfortable and patients are usually woken before the end of the procedure. Patients usually report the procedure to be relaxing and restful in a calm environment. Patients are also encouraged to choose the music played in the theatre.

After meeting Mr Das-Bhaumik on the ward, a nurse will escort you to the theatre anaesthetic room. Mr Das-Bhaumik will put very specific marks on the eyelid skin to guide the surgery and instil soothing eyedrops to numb the eyes. The anaesthetist will then put a small cannula into your hand to give you sedation. Once sedated, Mr Das-Bhaumik will place a little gentle local anaesthetic, tailored to your specific medical needs, into the lids. You will not feel any of this.

You will then be taken to the operating theatre. Mr Das-Bhaumik will clean and drape your head and put in protective opaque contact lenses. A fine radiofrequency needle (not a scalpel) is used to make the precise incision into your upper eyelid crease. The fine instrument cauterises any blood vessels in the skin resulting in an almost bloodless procedure and reduced bruising. It also allows very precise identification of the various structures within the eyelid. The levator muscle is carefully identified and separated from the overlying and underlying muscles, which serve different purposes in the eyelid (closing and assisting in opening). The muscle is often so thin that it is transparent. Next the tough plate which gives the eyelid margin its shape and strength is identified. Up to three fine adjustable stitches are placed between the levator muscle and the eyelid plate. You will then be gently woken up so that Mr Das-Bhaumik can accurately adjust the stitches to assess for height, contour and symmetry of the lids. He will ask you to open and close your eyes to ensure the position of the eyelids is optimal in all positions at the completion of surgery.

Fine skin stitches (the width of human hair) are placed. The protective contact lenses are removed, then, antibiotic ointment, a soothing jelly gauze and soft eye pad are placed at the end of the procedure.

• A firm eye pad is put on after the procedure. This should stay on until you are instructed to remove the pad and will depend on the type and extent of surgery.
  Vision is initially blurred as ointment is put in the eye with a protective contact lens.
• You will be given eye drops and eye ointment for the wound before you are discharged.
• You will also be given saline and sterile gauze to help clean the lids once the pad is removed.
• A follow up appointment will be made for you.
• If stitches need to be removed, they are done at a follow up appointment, usually 10 – 14 days post surgery.
• Do not pick any crusts on the wound as this is healing. Just keep the wound moist with the antibiotic ointment.
• The stitches are designed to self unravel and some will fall out by themselves.
  Cool compresses to the eyelids reduce any swelling after the dressing has been removed.
• Eye makeup can be worn a couple of days after the removal of stitches.

Some swelling, bruising and a little blood in the wound are common. Blood in the wound can occur for a couple of days, bruising and swelling is usually improved in a week and markedly improved at 2 weeks post-surgery.

Mr Das-Bhaumik performs revision ptosis (further surgery) for surgery originally performed elsewhere that has not gone completely to plan and patients seek his expertise to correct the eyelids.

Lid too high or too low
This is rare but can occur post-surgery. The lid can drop again and the stitches can work their way through the lid as the muscle is so thin. This may require further correction but has the advantage the second time around that there is some scar tissue in the muscle from the original procedure that allows the stitch to attach more securely. A lid that is too high can usually be stretched with exercises post-surgery.

Bruising and Bleeding (Haemorrhage)
Bruising to some extent is fairly common and fades as any bruise does.
There can be a little blood at the wound as healing takes place but this settles over a day or two post-surgery.

Infection
Due to the excellent blood supply to the lids, infections are very unusual and you will be given antibiotic ointment to use 2 times a day after surgery. A course of tablet antibiotics may be required in rare cases.

• Several steps are taken to ensure surgery is as safe as possible.
• You will not be listed for surgery if surgery is not deemed to be safe. It may need to be postponed if there are modifiable factors.
• Ensuring you are in good health, with no current infection, refraining from NSAID medication for a week and refraining from alcohol 2 days either side of surgery will reduce the chances of infection, bleeding and bruising.
• The choice of local anaesthetic use reduces the chances of bleeding and bruising by titrating the amount of adrenaline used in the mixture to suit each patients’ individual need.
• Mr Das-Bhaumik is also highly trained as a micro-surgeon and surgical trainer, and performs all surgery under high magnification to enhance the accuracy of the surgery and to stem and signs of bleeding before a bleed occurs.
• A very fine radiofrequency needle is used to perform the surgery. This allows for very accurate incisions and gives Mr Das-Bhaumik a bloodless surgical field. It means surgery is also quicker, reducing the time and amount of anaesthetic used.
• The stitches are placed and tied in such a way that they self unravel in case of any bleed behind the eye, making the surgery as safe as possible regarding sight. The material of the stitches also helps them unravel if necessary.
• Mr Das-Bhaumik uses a protective contact lenses to both protect the eyes and to make the experience far more comfortable as the patient wakes toward the end of the surgery. It also allows him to check the eyelids are in a good position when open or closed. The contact lenses are removed before the end of the procedure. It means the patient is not dazzled by bright lights during the procedure as the sedation is reduced.
• Antibiotic ointment and soothing jelly gauze are placed on the eye at the end of the procedure reducing the chance of scratches to the surface of the eye from the eyepad.
• A soft eyepad placed is firmly at the end of the procedure reduces postoperative swelling and bruising.

Patients are asked to refrain from taking any non-steroidal anti-inflammatory (NSAID) medication, such as ibuprofen and aspirin, for a week prior to surgery.

Please inform Mr Das-Bhaumik if you are on medication that thins the blood, e.g. aspirin, apixaban, clopidogrel, aspirin and warfarin as he will have to change the composition of local anaesthetic to compensate for these or reduce the medication if your GP deems it safe to do so. Please also refrain from alcohol consumption 2 days either side of surgery.