Lid droop after cataract surgery can be due to many reasons: DERMATOCHALASIS & BLEPHAROCHALASIS VS BLEPHAROPTOSIS (Same as PTOSIS)


REMEMBERING the difference between DERMATOCHALASIS & BLEPHAROCHALASIS can be confusing.
Here is how I remember them:

1. DERMATOCHALASIS: think: death of lid: lid dropping

2. BLEPHAROCHALASIS: think: Beauty, young person usually; female often; recurrent swelling of upper part of upper lid

3. BLEPHAROPTOSIS is the same thing really as PTOSIS is drooping of upper eyelid and is due to 
1. Involutional: old age mostly; aponeurotic. Due to aging and disinsertion of levator aponeurosis. This is the most common reason for ptosis or lid droop. This is the MOST COMMON cause of eyelid droop after Cataract Surgery: the elastic fibers of our eyelid as we get older are not as elastic. When a lid speculum is placed to open the eye even for a few minutes, it can stretch fibers enough that they do not bounce back, thus giving a permanent lid droop in some cases (risk is 7.3% of ptosis after surgery at 6months: see only paper I could find on this below). 
2. Mechanical: Levator function is good. Usuallly due to tumors or something pushing down on eyelid, such as below. 
a. Blepharochalasis (fluid pushes down)
b. Dermatochalasis (skin pushes lid down) 
c. cicatricial ptosis (scar pushes lid down). 
3. Myogenic: Poor Levator Function noted; This is due to a muscular disorder such as 
a. CPEO: Chronic Progressive External Ophthalmoplegia
b. Myasthenia Gravis: difficulty swallowing often or shaking hands
4. Neurogenic: Levator Function is variable depending on underlying defect; usually due to:
a.Cranial Nerve 3 Palsy (bad nerve connection to the Levator muscle)
b. Horner’s syndrome (bad nerve connection to Muller’s muscle)
c. Multiple Sclerosis
5. Congential: Leavor function is poor from birth. Usually myogenic and unilateral (on 1 side) from fibrosis and fat infiltration of Levator muscle. 
Eur J Ophthalmol. 1998 Jan-Mar;8(1):12-5.

Eyelid malpositions after cataract surgery.



To estimate the incidence and the factors that may play a role in the etiology of eyelid malpositions aftercataract extraction.


We followed up 124 patients for six months after cataract extraction. Palpebral aperture, levator function, height of the upper lid crease, lower eyelid laxity and position of the punctums were recorded preoperatively and postoperatively. Post-cataract ptosis was defined as a 2 mm or greater drop in the lid margin after correcting for any change in the fellow eye.


None of the patients developed ectropion or entropion, but five (4%) developed punctal ectropion aftersurgery. The incidence of post-cataract ptosis was 7.3% at six months. Age, sex, preoperative measurements of levator function, lid crease and dermatochalasis were not predictive for the development of ptosis at six months. However, there was a significant difference in the preoperative palpebral fissure width between the patients with ptosis and those without (p<0.05). There was a positive correlation between the mean volume of local anesthetic and the degree of ptosis on the first postoperative day (p<0.05, r: 0.1873). The presence and amount of ptosis on the first postoperative day was the best predictor of post-cataract ptosis at six months (p<0.001).


Several factors are involved in the development of post-cataract ptosis. Temporary ptosis may be related to the myotoxicity of the local anesthetic. The presence of ptosis on the first postoperative day is the best predictor for the development of ptosis at six months.
Signs and Symptoms 
Upper eyelid swelling in blepharochalasis.
Dermatochalasis describes a common, physiologic condition seen clinically as sagging of the upper eyelids, and to some degree, the lower lids. It is typically bilateral and most often seen in patients over 50 years of age, but may infrequently occur in some younger adults. Inspection of these patients’ lids reveals redundant, lax skin with poor adhesion to the underlying muscle and connective tissue. An excess flap or fold of skin in the upper lid is characteristic, and the normal upper lid crease may be lost. Dermatochalasis typically results in a ptosis, though occasionally patients will utilize the frontalis muscle to pull the lids open; this eliminates the ptosis but results in a wrinkling or furrowing of the forehead. Additional findings may include upper eyelid entropion, lower eyelid ectropion, blepharitis, or dermatitis.
Most commonly, dermatochalasis presents a cosmetic concern only, with patients complaining of “droopy eyelids” and “bags under the eyes,” which may cause them to appear “older than they truly are.” Some patients report true functional difficulties however, the most common being obstruction of the superior visual field.1 Less commonly, patients may complain of ocular irritation secondary to misdirected lashes or chronic blepharitis.
Dermatochalasis is sometimes confused with blepharochalasis. Though similar in nomenclature, these two disorders are quite different in presentation and etiology. Blepharochalasis is a rare condition that appears to be inflammatory in nature. It typically affects only the upper eyelids, and may be unilateral as well as bilateral.It is encountered more commonly in younger rather than older individuals.3 The condition is characterized by exacerbations and remissions of eyelid edema, which results in a “stretching” and subsequent atrophy of the eyelid tissue. Complications of blepharochalasis may include conjunctival hyperemia and chemosis, entropion, ectropion, and ptosis.
The tissue alterations encountered in dermatochalasis are not unlike the normal aging changes of the skin seen elsewhere in the body. There is thinning of the epidermal tissue with a loss of elastin, resulting in laxity, redundancy, and hypertrophy of the skin. The etiology of dermatochalasis appears to be nothing more than repeated facial expression–smiling, laughing, squinting, crying, etc.–combined with the action of gravity over many years. Less commonly, systemic disorders such as Ehlers-Danlos syndrome, cutis laxa, thyroid eye disease, renal failure, and amyloidosis may hasten the development of dermatochalasis.4 Some patients may additionally have a genetic predisposition toward developing dermatochalasis at a younger age.
Blepharochalasis stems from recurrent bouts of painless eyelid swelling, each instance of which may persist for several days. The swelling most likely represents a form of localized angioedema, although this remains speculative. Ultimately, after numerous episodes, the skin of the lids becomes thin and atrophic, and damage to the levator aponeurosis ensues. Ptosis then becomes manifest. Blepharochalasis is idiopathic in most cases, though it has been linked to kidney agenesis, vertebral abnormalities, and congenital heart defects in rare instances.5
Patients with asymptomatic dermatochalasis require little trea tment, although automated perimetry may be beneficial to document any significant compromise to the visual field and is often necessary prior to surgical correction. Patients should also be evaluated for blepharitis, trichiasis, or dry eye and treated accordingly with palliative and/or therapeutic agents. If examination reveals any other indications of underlying systemic disorders (e.g. thyroid or renal disease), then appropriate laboratory testing should be performed. Those individuals with symptomatic dermatochalasis should be referred for oculoplastic consultation with regard to blepharoplasty, which is the procedure of choice for this condition. Patients with significant ptosis due to levator dehiscence may require a combined procedure.
Likewise, blepharoplasty with or without ptosis repair is the preferred management option for patients with symptomatic bleph-arochalasis.6 Acute instances of lid swelling may be addressed with cold compresses and oral anti-inflammatory agents in hopes of averting the ultimate outcome.
Clinical Pearls
  • Realize that dermatochalasis is a normal, physiologic condition that affects virtually all patients over the age of 50, to varying degrees. It is commonly asymptomatic and requires little intervention. In contradistinction, blepharochalasis is an atypical, pathologic syndrome that can result in significant visual impairment of young, active adults.
  • A common feature to both dermatochalasis and blepharochalasis is the herniation of orbital fat through the septum orbitale in the upper or lower eyelids. This phenomenon is referred to as steatoblepharon. Like dermatochalasis, steatoblepharon is common with age, and may be quite pronounced in some individuals. It is most often noted in the medial upper eyelid. Treatment of this condition involves transconjunctival blepharoplasty with resection of the excess fatty tissue.
  • Dermatochalasis should not be confused with floppy eyelid syndrome, a condition in which the lids become flaccid due to a loss of tarsal elastin.
  1. Fay A, Lee LC, Pasquale LR. Dermatochalasis causing apparent bitemporal hemianopsia. Ophthal Plast Reconstr Surg 2003;19(2):151-3.
  2. Collin JR. Blepharochalasis. A review of 30 cases. Ophthal Plast Reconstr Surg 1991; 7(3):153-7.
  3. Huemer GM, Schoeller T, Wechselberger G, et al. Unilateral blepharochalasis. Br J Plast Surg 2003; 56(3):293-5.
  4. DeAngelis DD, Carter SR, Seiff SR. Dermato-chalasis. Int Ophthalmol Clin 2002; 42(2):89-101.
  5. Ghose S, Kalra BR, Dayal Y. Blepharochalasis with multiple system involvement. Br J Ophthalmol 1984; 68(8):529-32.
  6. Custer PL, Tenzel RR, Kowalczyk AP. Blepharochalasis syndrome. Am J Ophthalmol 1985; 99(4):424-8.
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