Can ptosis indirectly cause glare?

[Robo_I]

Hi,

Back in August I posted a question centered on glare issues and the response was to get a full corneal topography to check for irregular astigmatism.

To sum up I'm getting glare from anything that puts out light e.g. light through a window, light from a candle, light from a monitor etc... in both eyes.

There was a bit of a wait for that (2 months~) but finally got it done with some extra tests as well.

The ophthalmologist states that both eyes are healthy with no irregularities or anomalies showing up on the scan or other tests.

I then mentioned that my optician noted that my eyelashes are somewhat long and slanted down (I get the odd tingle / itch from a lower eyelash when I blink and an upper eyelash contacts a lower eyelash) which had me thinking that I had a degree of ptosis in both eyes after examining myself in the mirror.

The ophthalmologist did a bit of checking and yes I have mild / moderate ptosis in both eyes but this was in the "normal variance".

Now the way to fix the glare I get is either to use my fingers to gentle push up my eyelids or to consciously open my eyes wide.

Here's a practical example:
-Sit in a dark room directly facing a candle.
-I get streaks of light from the tip of the candle coming in at my eyes.
-Using my fingers I push up my eyelids slightly and I don't get these streaks of light coming at my eyes anymore.
-If I tilt my head forward while still focusing on the candle then the streaks of light become worse.
-If I tilt my head back while still focusing on the candle then the streaks of light vanish.  

Now this may sound crazy but can my eyelids be causing this problem? Maybe its the eyelashes or something else that changes in relation to the eyelid position?

[decafcjm]

I went to the eye doc today who took a photo and showed me that when dilated my puils are big and my upper lid is halfway coving the pupil, thus causing the streaks: I also have no streaks if I hold my eyes open. But she said if I had surgery to tighten my lids there is danger that my eyes will not close completely. I did not understand this comment „ This can be a real problem and is reason that a laser hole in the iris (iridotomy) has been moved to the 3 or 9 oclock position on the iris instead of 12 o'clock where it was found to cause ghosting, arcs of light and unwanted light reflexes (dysphotopsia)“ Can someone explain?

[John C Hagan III, MD, FACS, FAAO]

To answer your question I would to know your age and wether a biological male or female. When surgery is done it basically takes a tuck out of the upper lid. Like any surgery there is the possibility of under or over correction.  In some people after eyelid surgery the eye does not completely close during sleep. If it is only a tiny non-closure and the eye is not a 'dry eye' (usually a post menopausal female) or the person sleeps with a fan in the bedroom, the lower cornea (6 o'clock) can dry out, come painful and every scar or form an ulcer.  NOTE; The position of the eyelid APTER DILATING DROPS INSTILLED ARE OFTEN NOT ACCURATE.  Photos should be taken before any drops and with the muscles of the forehead relaxed. Dilation drops can stimulate the lid making it look higher than normal, or the dilated pupil can cause squinting due to light sensitivity making it look lower than normal.  If you are really concerned see a Eye MD ophthalmologist that specializes in oculoplasti surgery and take in some good facial photos taken 10-15 years ago so the surgeon can evaluate the changes.

[decafcjm]

I have exactly the same problem and have been to 3 ophthalmologists but no one seems to take me seriously. All else is fine with my eyes. It only happens at night or when looking at white text on a black background on the TV – so maybe my pupils enlarge making the droopy eyelids cover vision more?

[LightStreaks]

I'm suffering from the same thing too , any update on yours ?

[John C Hagan III, MD, FACS, FAAO]

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[Bat2626]

Excatly same problem and observations what you have. I am looking solution for this problem,  but cant find it.

[JohnHaganMD]

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[JohnHaganMD]

The upper tear meniscus acts as a base up prim and the lower lid meniscus acts as a base up prism.  So your observations are plausible. This can be a real problem and is reason that a laser hole in the iris (iridotomy) has been moved to the 3 or 9 oclock position on the iris instead of 12 o'clock where it was found to cause ghosting, arcs of light and unwanted light reflexes (dysphotopsia)

Good luck with the consult and treatment if indicated

JCH MD

[weirdconditions]

"The upper tear meniscus acts as a base up prim and the lower lid meniscus acts as a base up prism." Both of them are base up prism?

[JohnHaganMD]

Lower lid is base down.

[PaulF123]

Hi
I know this has been a while since the original question but would appreciate any response.

I have the exact same issues that started a number  of months after lasik. All the scans come back normal and have never been able to find out the cause which has persisted for a number  of years.
I do feel like my eyelids feel heavy and sit slightly lower especially when concentrating and this causes all the glare and light streaking both day and night. I suffer dry eyes which i think adds to this.
Firstly how can this be diagnosed if it is the tear prism causing it? Would  surgery likely change the tear prism enough to not notice these issues?
Thanks

[John C Hagan III, MD, FACS, FAAO]

PaulF123: Your problem is not a all like the original poster. It is not at all likely that your problem would be helped by eyelid surgery and since you have dry eyes it could make it a great deal worse. I suggest you start a new discussion thread by reposting. Glare and ghosting after LASIK is not at all uncommon, droopy eye is rarely a cause.  Since you have dry eyes I would suggest you use preservative free artificial tears 6 times/day and see if that helps. I would suggest you see a different cornea/Refractive surgeon than the one that did your surgery for a second opinion.   These are some things that might help:
1. If you have residual refractive error then glasses might help a great deal. I know you had LASIK so you would not have to wear glasses but it does't always work out that way.
2. If your symptoms are worse at night or in the dark you woud ask about a trial of Alphagan-P at night to keep your pupil from dilating so large in the  dark.  There is also a new medicine just out Pilocarpine 1.25% the some cornea surgeons speculate may help.
3. You need a repeat corneal topography, you may have irregular astigmatism. In that case glasses may be less helpful and you might be tried fitting with gas permeable contact lens.
4. It would be important to be sure you are not developing an early cataract which can cause those problems.

Bottom line is you need to get second opinions. Take your old records and topographies to get the maximum benefit.

Good luck DO SOMETHING

[Robo_I]

Hi Dr. Hagen,
Thanks for your help. I'm due a meeting with the oculoplastic surgeon of my hospital in a couple of weeks.

I think you actually hit the issue dead on with your tear meniscus suggestion.

Let me elaborate in an example. In the middle of the night I look at a street light. I get glare coming down from the light at me (top of pupil meets the upper tear meniscus due to eyelid position resulting from ptosis).

Now if I tilt my head back far enough (quite a tilt) while staying focused on the light I now get glare coming up instead of down at me from the light. That's where the bottom of my pupil is making contact with the lower tear meniscus isn't it? If I pull my lower eyelids down and thus move the lower tear meniscus away from the bottom of my pupil then the glare is gone!

[JohnHaganMD]

I suppose it might be possible but not common. Not likely that the eyelids are so tight they are causing an induced astigmatism. Perhaps lowering the tear meniscus into the pupil might do this. Again not anything someone in my practice has noticed.

I suspect you will either need to put up with it or discuss with an oculoplastic surgeon about whether to correct the minor ptosis.

JCH MD