Eyelid Malposition

Content Reviewed by AEDIT Medical Advisory Board

What is Eyelid Malposition?

Eyes are one of our most important physical features, which is why they’ve become such a focus in the ongoing advancement of cosmetic plastic surgery techniques. Not only do our eyes allow us to see the world, but they also reveal how engaged a person is in a conversation, are a measure of attractiveness, friendliness, and intelligence. They can also be an indicator of a person’s age, which can negatively affect people with advanced signs of aging.

Throughout the article, we will explore in-depth the different forms of ptosis along with its symptoms. We will cover the different causes for ptosis as well as various treatment options for those interested in correcting eyelid malposition with a cosmetic procedure.

What are the Specifics of Eyelid Malposition​?

The normal eyelid crease is six to seven millimeters away from the eyelid margin in grown adults, although this may differ in people of certain ethnic backgrounds, including Asian eyelids, where the crease is often not as appreciable. The upper eyelid normally covers the top one millimeter of the cornea, and the lower eyelid typically lies at the junction of the cornea and sclera.

When ptosis of the eyelid occurs, however, the eyelid droops and presents a visually unappealing appearance. In addition to a poor appearance, a severe enough case of ptosis can also obstruct a person’s vision and create other physical problems. Ptosis can also be a secondary effect from a greater medical condition. In general, the condition comes in many forms that affect a person’s appearance in a variety of different ways.

What Terminology is used with Eyelid Malposition?

Eyelid Malposition(Ptosis): Marked by the drooping of the upper eyelid. This condition can be congenital (at birth) or acquired later in life. In addition to drooping, patients most often complain about a tired appearance, blurred vision, and increased tears. Entropion: This condition is an inversion or inward turning of the eyelid. When this occurs, trichiasis can occur. This is when the eyelashes become directed toward the eyeball. If left unchecked, corneal and conjunctiva damage can occur leading to corneal abrasions, scarring, and thinning of the cornea. The condition can happen in either one or both eyes. Ectropion: This form of malposition is the most frequent form. Highlighted by the visible process of turning inside out, the cornea and conjunctiva are exposed to this condition. Ectropion can occur at birth or later in life.

Signs and Symptoms of Eyelid Malposition

Regardless of the type of eyelid malposition, improper positioning of the eyelids surrounding the eyes marks all of them. However, there are some specific symptoms to watch out for to help determine the difference between the various causes and to determine the best course of treatment.

With ptosis, a reduction in the patient’s visual field is the main symptom, caused by a lowered or drooping eyelid, along with the actual appearance of the malposition of the eyelid itself.

When symptoms of eyelid ptosis are caused by ectropion, it can cause a wide range of secondary symptoms in addition to the ptosis, which includes:

• Poor tear distribution
• Possible irritation
• Burning sensation
• Feeling of grit in the eye
• Reddening of the eyelid and conjunctiva
• Tearing of the eyelid and conjunctiva

Entropion, on the other hand, makes a person feel like there is a foreign body in the eye. This is similar to feeling an eyelash or speck of dirt causing pain or discomfort in the area. Tearing, irritation of the cornea, and crusting of the eyelid plus mucous secretion are other signs of entropion.

What are the Causes and Reasons of Eyelid Malposition?

Eyelid malposition can develop at birth, can be acquired later on in life, or as the result of a trauma or injury. The different sources have different reasons and causes as a result. Most eyelid malposition cases are caused by involutional entropion of the lower eyelid, or ectropion of the upper eyelid—both secondary symptoms where the eyelid is turned out and away from the eyeball (the ocular surface), causing eye conditions such as eye dryness, chronic conjunctivitis, upper and lower eyelid retraction, and an unpleasing physical appearance. In these cases, patients will require some form of ectropion repair for health care treatment and to restore a normal upper and lower eyelid margin and orbital rim.

Five types of ectropion malposition exist, including involutional, cicatricial, paralytic (the result of paralysis), mechanical, and congenital, caused by a wide number of medical conditions including those listed below.

Congenital Ptosis: This is a rare condition marked by the lowered position of the upper eyelid at birth. This condition is persistent if not treated. The condition is benign and may affect one or both eyes, the upper eyelid, and the lower lid. However, while the condition itself is benign, its effects are not. Most people suffer from functional, cosmetic, or psychological issues (low self-esteem) if left untreated. Aponeurotic: This form of ptosis is an acquired form. This form is marked by a disinsertion of the levator aponeurosis. Most patients with this have ongoing growing ptosis that exacerbates the levator aponeurosis. Physical trauma can cause this condition to occur. Neurologic: (Third nerve palsy, Bell’s Palsy, Homer syndrome, Botulism, Pseudoptosis) Generally a secondary concern in light of the main diagnosis. Some patients with neurological disorders like Homer syndrome or Botulism can acquire ptosis (eyelid malposition) from facial paralysis as a symptom. Where possible, treating the main condition can help correct the ptosis, but it will depend on what condition the patient has developed. Hyperthyroidism and Graves’ Disease: Hyperthyroidism is the overproduction of the thyroid. Grave’s disease is the most common form of hyperthyroidism and thyroid eye diseases. Either condition is associated with neuromuscular issues, which can lead to acquired ptosis in one or both eyes and mild to severe eyelid retraction symptoms. Just like with neurologic disorders, treating the main illness takes priority over ptosis. Overcorrection From Previous Surgery: Sometimes a previous surgery can lead to acquired ptosis for a patient. This occurs when the eyelid is stretched past its limits affecting the facial nerves and muscles. This creates a drooping effect and changes the eyelid position which will need to be corrected to restore a normal appearance.

Surgical Procedures & Treatments to Fix Eyelid Malposition

Treatment options for eyelid ptosis repair range from invasive to minimal, and can mean the difference between long-lasting adverse symptoms and achieving a more normal position of the eyes. Surgical procedures for ptosis can enhance a person’s appearance making them look younger and refreshed. These treatments can also greatly enhance the function of the eyelids and eyelid closure resulting in increased confidence.

To determine which surgical techniques are best for your eyelid tightening procedure, an oculoplastic surgeon will evaluate your eyelid ptosis symptoms, your medical history, and perform a variety of tests to measure the orbicularis muscle, orbicularis tone, the palpebral fissure, the canthal tendon, and other factors. You’ll also likely receive an eyelid distraction test to evaluate the horizontal laxity of the eyelid skin, which is located below the lateral canthus area beneath the eye. While the appropriate course of action will depend on your medical history and the cause of your ptosis, these are some of the most common eyelid surgery options used for correcting eyelid malposition.

Massage and Steroid Injection: This treatment is designed to correct complications that occur due to overcorrection of the skin during a blepharoplasty. The massage and steroid injection helps to correct ectropion and eyelid ptosis. The success of this treatment is dependent on the early identification of abnormal healing and scar tissue. Scar Excision and Spacer: This treatment is used when excessive scarring has occurred. The spacer provides vertical height and stiffness to help support either the upper or lower eyelid. Before the spacer is put in, the original scarring has to be excised or cut away. This is a recommended treatment for those who had a blepharoplasty that failed to heal correctly or that had complications due to poor surgical techniques. Lateral Canthal Suspension Canthopexy: Another treatment to fix complications from a blepharoplasty. This treatment would be the next step if massage and steroid injections failed to fix the eyelid laxity. The main goal is to correct ectropion while promoting better vision and cosmetic appearance. Lateral Tarsal Strip Canthoplasty: This is used to treat many lid malpositions. The treatment corrects retraction and ectropion of the eyelid. It’s a great procedure to elevate and tighten the eyelid as needed. Sometimes the procedure is combined with a midface lift. Proper function with improved aesthetics is the goal of this procedure. Transconjunctival Blepharoplasty: This type of procedure can be used for surgical correction of upper and lower eyelid malposition due to aging, including upper sclera show and lid malposition.