What do about a droopy upper eyelid due to long-term eye troubles.

[Benjamin0417]

I have been seeing by an ophthalmologist for nearly 8 years now. I have iritis (my doctor also refers to it as "uveitis), and I have continually been taking multiple types of eye drops every single day since it started. The main one is Pred Forte. Because of being on so many kinds of eyedrops and having an eye surgery a few years back, my left upper eyelid is very swollen. I can no longer take a decent picture. People have told me I look like I have a lazy eye, or they ask "what's wrong with your eye?" and I look like I have had a stroke in pictures because one eye is clearly smaller looking than the other. I hate it and I want it fixed. My doctor doesn't think it's a priority as there are other issues to deal with (which is understandable).

Does anyone know of any remedies that will work for reducing swelling in an upper eyelid? I tried pressing a cold compress on and it didn't work. I am so tired of my eye continually looking terrible and the flare-ups continue to happen about twice a year. Right now I cannot see anything out of my left eye. If anyone has had a similar experience, please feel free to give me some advice.

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

First of all if you have uveitis (iritis is one form, others are irido-cyclitis and choroiditis) for 8 years you need to be under the care of an ophthalmologist that specializes in uveitis AND a rheumatologist. You should have had a complete medical work-up to determine what is the cause of your uveitis (likely you have some underlying systemic disease) and you should probably be on oral medication for uveitis monitored by the rheumatologist.  Have you had that done? Where do you live?   Chronic use of pred forte besides causing cataracts and often glaucoma can make the eyelid droop (called ptosis). Given how serious this problem is and what a threat it is to your sight in that eye doing surgery to elevate the eyelid (ptosis surgery) is not a high priority.   Have you had a uveitis work up? Is your ophthalmologist a uvieitis specialist? Have you seen or are you seeing a rheumatologist?  Where do you live that may determine what resources are available.

[Benjamin0417]

Hi, thanks for answering.

Yes I see an ophthalmologist regularly and a rheumatologist once a year.  The rheumatologist has me on Humira injection once every two weeks. I have been told that I tested positive for the HLA-B27 marker in my blood, which is why I am prone to immune problems (that's how my doctor put it). I have had psoriasis in the past, and I my rheumatologist diagnosed me with ankylosing spondylitis, however since then she has told me I no longer have it, but to stay on the Humira because it helps with my eye problems. The only oral medication I am right now is Diamox to help bring down the pressure in my eye. From taking pred forte for so long, yes I did develop a cataract and had surgery for it 3 years ago, as well I have glaucoma, and have a surgery scheduled in August for a left trabeculectomy, which is supposed to help with the pressure as well.

Often times I don't completely understand what is going on with my eye. Every appointment I have it seems to be something slightly different than the last. My ophthalmologist has literally had me on dozens and dozens of different types of eyedrops in attempt to control my eye from flaring up and the pressure from spiking. The most recent flare-up happened on June 10th, and I still have extremely poor vision in my left eye. He has me on 4 kinds of eyedrops, 1 pill, and an ointment at night. The eyedrops all need to be taken 3 times a day (I try my best but it is very difficult to remember which ones I need to take and how many times I have taken them already).

I live in Brandon, MB, Canada

I just keep hoping that someday this will all pass, my eye with go back to being normal and not being so puffy/swollen. But here's to hoping.  

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

Well hopefully the other eye is okay and doesn't have uveitis/cataract/glaucoma? Is that correct. If so that's much to be thankful for as I have patients that have these in both eyes.  Diamox is a miserable medicine when taken orally and rarely used in the States.  It is available in drop form that doesn't have all the problems with: weight loss, bad taste to food and carbonated beverages, cold feet,  tingling in the toes and fingers.  The drops are Azopt (brand name) and Trusopt have you been on those?  Also if you are going to have a trabeculectomy that makes a passage for fluid to leave the eye and drain outside the eye under a "filtering bleb". This is protected by the upper lid.  Glaucoma surgeons almost NEVER want the eyelid lifted before or after a trabeculectomy as it can expose the bleb and cause it to fail or get infected.

[Benjamin0417]

Yes, my other eye has been fine. There has only been one time where it flared up with the iritis. I am taking Diamox in pill form, and I have only experienced tingling in my hands as a side effect. I have lost some weight recently but I am more active and eating healthier, so I am not sure if that is from the Diamox or not. I have never been on Azopt or Trusopt.

Sounds like I won't ever be able to get my eyelid lifted then. Seriously sucks, I understand that it isn't a priority, but I am pretty self-conscious about it. Question though, what if my eyelid wasn't drooping whatsoever, and it was up where it was supposed to be, would the glaucoma surgeon put the bleb up underneath the lid? (where the lid was sitting naturally), so then why couldn't he just put the bleb up as high as it would need to be, to allow for me to still someday have an eyelid lift.  Basically just allow for me to still someday have an eyelid lift without the risk of the bleb failing or getting infected.

I understand that I am the patient who knows basically nothing, so asking these questions might seem dumb, but to me, they are still valid.

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

The bleb is at the limbus. That is where the cornea joins the white sclera.  It is there regardless of whether the lid is higher, lower or normal position. Normal and low position don't present a problem but if the lid is higher than normal it 'exposes" the bleb which often cause the bleb to 'fail" and the IOP goes up or a serious infection sets in.  The problem with eyelid surgery is you can never predict the final position of the lid and if its higher than it should be the bleb is exposed. So most glaucoma eye MDs do not want their patients to have lid surgery.   HLA-B27 uveitis can be really bad, and the orthopedic problems like the ankylosing spondelitis of the spine can be severe.

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

Look up "trabeculectomy" on google images so you have an idea about how this surgery is done.  There is a new type of glaucoma surgery that is quickly  replacing the trabeculectomy its called by the acronym  MIGS (minimally invasive glaucoma surgery)  as your glaucoma surgeon if you would be a candidate for that or better yet if he/she knows how to do MIGS surgery. Most do not create blebs and at some point down the line you might be a candidate for eyelid surgery.

[Benjamin0417]

Update. My trabeculectomy is now changed to an Ahmed Valve surgery. My doctor decided to change the type of surgery a few weeks ago, which sounds perfectly fine to me. What should I expect from having this type of surgery versus the trabeculectomy? Will I be able to someday have the eyelid correction surgery?

I look forward to your feedback.

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

The Ahmed Valve is a more predictable, more modern type of surgery and does NOT create a thin walled bleb. The fluid is shunted to a reservoir that is suture to the eye.  You would be more likely to get an okay from your glaucoma surgery to consider eyelid surgery after AV surgery than trabeculectomy.    AV is not considered MIGS surgery but is better than Trab.

[Benjamin0417]

The surgery went well. Painless and quick. It looks terrible right now though, one half of my eye is completely red and it looks like there is some sort of "pocket" on the surface of my eye next to my iris, it feels wet and is slightly going outside onto my lower eyelid. I got back to work in a week, any tips on recovery after this kind of surgery?

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

No. That should come from your surgeon.