Information on Oculoplastic Surgery
Most of us care how we look and how we feel. We use proper nutrition and exercise to enhance our health, appearance and well being. Some of us may have abnormal appearance of the eyelids and the surrounding structures. These abnormalities, like drooping eyelids, bulging eyes, watery eyes and many more may be present since birth or early childhood. Some of these may be acquired during various stages of life or as a result of any accidental trauma.
Over time, the upper and/or lower eyelids and/or eyebrows may become droopy, hooded, puffy or baggy, giving a tired appearance which distracts from the overall attractiveness of the face. The eyelid tissues stretch, the muscles thin and fat pockets bulge, becoming more noticeable. The cheek tissue descends a little and the chin line becomes "jowly". Eyebrows become drooping, the forehead furrows and deep tear troughs appear below our eyes.
These changes may be cosmetically unattractive and when severe, may also affect eye function. This includes discomfort from the weight of excess eyelid skin on the lashes, impaired visual field from overhang of upper eyelid skin, (or) difficulty wearing glasses because of lower eyelid bulges and tearing problems.
Both men and women are increasingly requesting plastic / cosmetic (aesthetic) surgery on the eyelids or face. They need to be fully informed about the surgical options for their eyelids and surrounding areas.
Oculoplastic Surgeon
What is an Oculoplastic Surgeon?
Oculoplastic surgeons are ophthalmologists (eye doctors) who have specialised in eyelid and facial plastic surgery. Oculoplastic surgeons are trained to do many different types of eyelid and facial surgery, ranging from simple eyelid malpositions to more complex reconstruction involving the eyelids and surrounding forehead, temporal and cheek areas. They understand the delicate anatomy and function of the eyelids and their surrounding structures. They also specialise in the lacrimal (tear) system, the orbit (bone cavity around the eye), adjacent periocular (around the eyes) and facial structures and the forehead and cheeks.
Oculoplastic surgeons are also known as ophthalmic plastic and reconstructive surgeons and oculo-facial surgeons.
- As dedicated eyelid plastic surgeons, an oculoplastic surgeon routinely does surgeries in these areas, and recognises potential problems
- Oculoplastic surgeons are trained to manage the complications or eyelid and facial plastic surgery which can involve the eye itself
- Oculoplastic surgeons have a professional society which helps them maintain a high standard of care, called the Oculoplastic Association of India (OPAI).
Why are Oculoplastic Surgeons important around the eyes?
Oculoplastic surgeons are trained ophthalmologists (eye doctors) who understand the proper anatomy of tissues around eyes, how eyelid surgery can affect the comfort of the eye and the clarity of vision. They are accustomed to working around the eye and face.
How do I find an Oculoplastic Surgeon?
You should look for a Consultant Oculoplastic Surgeon who is members of any Oculoplastic Surgery Society like Oculoplastic Association of India (OPAI).
Plastic/Cosmetic Surgery of Eyelid and Face
What is Plastic/Cosmetic Surgery of Eyelid and Face?
It is another term for plastic / cosmetic periocular (around the eyes) surgery. It embraces a number of procedures to correct abnormal, hooded or baggy eyelids and improve the aesthetic appearance of the eyelids and surrounding area of the face, including the eyebrows, forehead and midface. There are also related aesthetic treatments.
What does Oculoplastic Surgery include?
- Ptosis Correction
- Upper / lower eyelid blepharoplasty
- Browplasty
- BOTOX (botulinum toxin) for Blepharospasms and Hemifacial spasms
- BOTOX (botulinum toxin) for lines and brow ptosis
- Fillers and other injections around the eyes and face
- Dacryocystorhinostomy (DCR)
- Entropion Correction
- Ectropion Correction
- Socket Reconstruction
- Cosmetic Rehabilitation of Blind eyes (including Prosthesis)
- Ocular and Orbital Cancers
Who should perform cosmetic eyelid and facial plastic surgery and aesthetic treatments?
A number of different surgeons can perform cosmetic eyelid and facial plastic surgery and aesthetic treatments
- Ophthalmologists trained as oculoplastic surgeons
- Plastic surgeons
- Ear Nose and Throat (ENT) surgeons
- Maxillofacial surgeons
Eyelid Ptosis
What is eyelid ptosis?
It is a droopy upper eyelid. If mild, the asymmetrical lid height is cosmetically unacceptable. In severe ptosis patients have to tilt their head back, or lift the eyelid with a finger, in order to see out well. If the lid edge displaces downwards it can cover part of the pupil and block the upper part of the vision, or cause fatigue. These are functional problems.
What is the cause of ptosis?
Congenital (present since birth) due to a poorly developed Levator (LPS) muscle. It is also common in older adults where the muscle that lifts the eyelid thins and the eyelid drops. It may occurs with age, contact lens wear, trauma and, rarely, tumour or from a neurological problem, such as a nerve palsy or muscle weakness (myopathy).
How can ptosis be corrected?
The oculoplastic surgeon will examine the whole of the upper and middle part of the face to detect asymmetry. Eyelid measurements are made and photographs taken of the eyelid position and area around the eyes. The under surface of the lids and the front surface of the eye are carefully examined with a special microscope and visual fields may be mapped. Depending on the findings, you will be advised of the best treatment. Generally you may require ptosis surgery; but in some cases (Nerve palsies or Ocular Myaesthenia) conservative management may help.
What happens at eyelid ptosis surgery?
Eyelid ptosis surgery is usually done under local anaesthesia as a day care. Local anaesthetic drops are placed on the eye and a small bleb of local anaesthetic is given into the upper eyelid to numb the area. A short incision is made in the natural skin crease and the eyelid raising muscle (the levator palpebrae superioris - LPS) is identified and strengthened to lift the eyelid. Dissolving sutures are used inside the lid and on the skin. For children similar procedure is done under general anaesthesia.
What happens after surgery - the recovery period?
An eye pad may be applied for 24 to 48 hours. The upper eyelid will usually appear swollen for the first 7 to 10 days. The wound should be kept clean and dry and there should be no discharge from the wound. Instructions will be given on how to clean the wound daily and lubricating and antibiotic drops, or ointment, prescribed for 1 to 3 weeks.
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What are the risks of ptosis surgery?
- Local bruising and swelling of the eyelids.
- A small risk of wound infection to the eyelid.
- Risk of over-correction (eyelid too high), or under-correction (eyelid still too low) which may require a second operation.
- Inability to close the eyelids completely, which may be temporary or permanent. This requires lubricant drops and ointment. If it is permanent and threatens the vision, then the eyelid will have to be subsequently lowered again to protect the eye.
- Sometimes if the other eye has a tendency to drop, this may become more noticeable after ptosis surgery on one side. Your oculoplastic specialist will warn you of this possibility.
What are the benefits of ptosis surgery?
- Improved upper part of your visual field and quality of vision, where part of the eye was previously covered by the upper eyelid drooping and interfering with visual function.
- Restoring the normal anatomical appearance of the eyelid.
- Improved cosmesis, symmetry and self-confidence.
What is congenital ptosis?
This is drooping of the eyelid, affecting one or both eyes, present since birth.
What causes congenital ptosis?
Most causes of congenital ptosis are unclear, but it is usually due to an incomplete development of the muscle (levator palpebrae superioris - LPS) which raises the eyelid.
Can this condition be associated with other eye problems?
Children with congenital ptosis may also have an amblyopic or lazy eye, strabismus or squint (eyes that are not properly aligned or straight), or refractive error (need for glasses). Therefore all children with ptosis should have a thorough examination by an ophthalmologist.
What is the treatment for congenital ptosis?
Congenital ptosis is treated surgically and the operation is based on the individual child's severity of ptosis and the strength of the levator palpebrae superioris muscle.
When should the surgery for congenital ptosis be done?
If the ptosis is not severe, surgery can be deferred until the child is aged 3 or 5 years i.e. the pre-school years. At this age the child is able to understand his problem and may develop inferiority complex if left untreated. However, if the ptosis is interfering with the child's vision, surgery may be performed at a much earlier age, even as young as 3 weeks, to allow proper visual development.
How is the operation done?
Ptosis surgery on a child is done under general anaesthetic, usually as a day care. An eye patch is usually put on and the stitches, or sutures, on the skin are generally dissolvable.
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Types of surgery:
Surgery can be done as in an adult, involving a small skin incision into the skin crease of the upper eyelid or, if the levator palpebrae superioris is extremely weak, it may be necessary to do a sling operation
What is a sling operation?
A frontalis sling, or brow suspension, is where the muscle of the forehead (frontalis muscle) is used to help lift the eyelid by placing a sling of material, either taken from the child or synthetic, between the forehead and the eyelid. Tissue taken from the child is called autogenous fascia lata. Synethetic material, such as silicone, or prolene, or gortex, may be used instead. Silicon Rod is the most preferred.
What will happen after the operation?
The wound should be kept clean and dry and there should not be any discharge. There will be a bit of swelling and redness of the eyelid for the first 1 to 3 weeks. The child will be prescribed lubricating antibiotic eye drops and cream, to be used as directed.
What are the risks of congenital ptosis surgery?
- Bruising of the eyelids and around the eye.
- A small risk of infection of the eyelid or the eye.
- Possibility of under-correction or over-correction of the eyelid height, requiring a second operation.
- Unable to close the eyelid completely, with the eye slightly open at night. This is usually not a problem and the parents should be warned of this. There is a strong protective reflex, called Bell's phenomena, which protects the surface of the eye on blinking and eyelid closure, so that as long as the muscle that closes the eyelid is strong, there is no risk to vision.
What are the benefits of congenital ptosis surgery?
- Prevention of lazy eye or amblyopia and strabismus or squint.
- Improved appearance will improve the child's self-confidence, especially if being teased at school.
- Restoration of a normal anatomical position of the eyelid.
- Restoration of the normal cosmetic appearance of the eyelid.
The two most common cosmetic surgery operations carried out by Oculoplastic Surgeons are:
The most common aesthetic treatment carried out by Oculoplastic surgeons are:
- Botulinum toxin A (also known as BOTOX® see Allergan and Dysport)
- Restylane® injections
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Blepharoplasty
What is blepharoplasty?
Blepharoplasty is an operation to remove excess tissue from hooded upper and puffy lower eyelids. Surgery is done for functional reasons to improve vision if there is marked hooding, with extra skin folds overhanging and impairing the vision or causing fatigue. Surgery is cosmetic if the excess tissue removed is to restore a more youthful appearance.
In some patients with hooded upper eyelids and overhanging skin, that causes an eyebrow droop, blepharoplasty may not be the first line of treatment and could worsen the appearance of the eyebrow droop. A brow lift operation to raise the eyebrows may be more appropriate. This will be discussed with the patient after the face and eyelids have been examined.
Are you a candidate for blepharoplasty surgery?
The oculoplastic surgeon will examine the whole of the face, forehead, eyebrows and eyelids, to determine the appropriate surgery. They look especially at the relationship between the eyelids and the brows and the surface of the eyes to exclude dry eye. The vision is measured, eyelid and brow measurements made, and photographic documentation taken.
What happens at blepharoplasty surgery?
Upper eyelids : Upper eyelid blepharoplasty is usually done under local anaesthesia, as a day care. Local anaesthetic drops are placed on the eye and a small bleb of local anaesthetic is given into the upper eyelid to numb the area. The amount of excess tissue to be removed is carefully outlined, a short skin incision is made in the natural skin crease and around the area of tissue to be excised, delicate layers of muscle and fat are shaped out. The aim is to remove the excess tissue without damaging eyelid function and eye comfort.
Lower eyelids : Lower eyelid blepharoplasty may be done under local anaesthesia. Only very small amounts of skin muscle and/or fat are removed from the lower eyelids.
Protruding fat and excess skin are removed usually through a small incision made just below the lower eyelashes (subciliary incision). It is also common for the surgeon to remove fat bulges from inside the eyelid (transconjunctival) without taking any skin. The scars that result from these incisions are usually inconspicuous once healed.
Many patients do not need any fat at all removed during surgery or they will get a sunken looking eye.
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What happens after my blepharoplasty surgery?
The eyes may be padded for the first 1 to 2 hours to reduce bruising and swelling. The eyelids will usually appear swollen for a few days after surgery. Ice packs are recommended, and sitting upright and sleeping with four pillows will help reduce excess swelling around the eyelids. Your surgeon will give you lubricant drops and ointment to reduce the sensation of grittiness and dryness.
Blepharoplasty is not a very painful operation, but you may take Paracetamol, if need, but should avoid Aspirin based components which can cause increased bruising. Most forms of light exercise and a normal work pattern may be resumed within a few days of surgery and eyelid make-up worn from about two weeks after surgery.
What are the risks and side effects of blepharoplasty surgery?
Serious complications are rare but may occur even in the hands of trained and experienced surgeons. You need to help by stopping aspirin, clopidrogel and non-steroidal anti-imflammatory tablets two weeks beforehand if you physician will allow it, in order to reduce the risks from bleeding.
- Sunken appearance - a sunken-looking "cadaveric" eye appearance can occur if too much fatty tissue is removed
- Asymmetry - a minimally uneven skin crease or lid height may be noticeable if there is asymmetrical swelling, more marked on one side than the other. If asymmetry is present after two weeks, it may persist and require later secondary surgery
- Scar - rare as the incisions are hidden in the natural skin folds
- Need for repeat surgery - Though rare, patients should be warned of the need for further surgery if an optimum result is not achieved.
- Eyelid and cheek swelling and bruising - May be noticeable for up to 6 weeks)
- Blurred vision - For a few hours or overnight, due to surface ocular drying during the procedure, from effect of the local anaesthesia and ointment instilled. If this persists more than 24 hours, inform your oculoplastic surgeon
- Watery eyes - Reflex tearing may occur for 24 - 48 hours due to mild ocular discomfort and surface dryness
- Dry gritty eyes - This may occur for the initial two to three weeks after surgery due to reduced blinking. You will be prescribed artificial tears (lubricants) to prevent this. Topical antibiotics are used for few weeks if surgery has been done from inside the eyelid.
- Scratched surface of the eye - Minor injury to the eye surface can result in pain for 24 hours. If it persists or is severe, your oculoplastic surgeon must be informed.
- Bleeding behind the eye - Bleeding behind the eye is rare but can cause the eye to go blind. This is an Ophthalmic Emergency which Oculoplastic Surgeons are trained to prevent and manage. Oculoplastic surgeons are trained to prevent and manage this (repetition).
- Wound infection - This is rare, but can result in delayed healing and sometimes unsatisfactory result.
- Incomplete eyelid closure - For a day or two after surgery the eyelids will feel stiff and not entirely cover the surface of the eye when closed. It usually settles in days - associated discomfort is eased by lubricant drops and ointment. Poor blinking, inability to close the eyes completely and eye surface problems due to excessive skin and muscle removal can aggravate a pre-existing dry eye problem.
- Lower eyelid malposition - or eyelid sag (ectropion) with an inability to completely close the eye, causing soreness, dryness and an unsightly appearance, due to excessive skin removal from the lower eyelids.
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Brow lift
What is eyebrow ptosis?
This is eyebrow droop. This can cause significant overhang of upper eyelid skin over the lashes and interfere with the visual function or appear unsightly. It is usually bilateral but can be asymmetrical, appearing on one side.
Gender differences:
The male brow is naturally lower and less arched than that of the female. The female brow is finer, more curved and is situated above the bony rim.
What is the cause of eyebrow ptosis?
Eyebrow ptosis occurs simply with ageing, due to thinning and descent of the tissue of the forehead. It can co-exist with true upper eyelid ptosis and true excess skin on the upper eyelids (dermatochalasis). Occasionally, eyebrow ptosis is caused by a paralysis of the facial nerve (facial palsy), or weight of a tumour, or trauma on one side.
Are you a candidate for eyebrow ptosis surgery?
First the oculoplastic surgeon assesses the appearance of the forehead, eyebrows, upper eyelids and peri-ocular region. They will be looking specifically at the lines of the forehead, how active the eyebrows are, whether the eyebrows are used a lot to keep the eyelids open, or whether they are immobile, suggesting a nerve palsy. Measurements will be made and photographs taken. The amount of associated upper eyelid ptosis and excess skin on the eyelids is determined. According to the findings, the surgeon may recommend brow ptosis surgery.
Indications for eyebrow lift:
- Drooping eyebrows causing a visual field problem.
- Fatigue and headaches at the end of the day because of over-action of the forehead muscles which raise the eyebrows.
- Aesthetic/cosmetic reasons.
What happens at brow lift surgery?
There are various approaches used to raise the eyebrows, ranging from a direct incision just above the eyebrow, to incisions up in the scalp above the hairline. Your oculoplastic surgeon will assess you and advice on the surgical procedure most suited for your individual condition.
1. Direct operations on the brow:
This is removal of a segment of scalp tissue from above the eyebrow. It does not correct the forehead position, or get rid of forehead wrinkles and lines; it only corrects the eyebrow position. This type of operation is mostly recommended for the older patient, or patient with facial palsy, and can be done under local anaesthesia. It leaves a small scar which is hidden by natural forehead lines.
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2. Trans-eyelid brow lift:
If the patient also needs upper eyelid blepharoplasty, the brow lift can be done via the same eyelid skin incision. Either sutures are placed beneath the brow attached to deeper fibrous tissue, or an absorbable fixation plate placed to keep the eyebrow up.
3. Endoscopic forehead and brow lift:
This lifts both the eyebrows and the forehead and gets rid of the horizontal lines. Surgery is done through incisions in the scalp above the hairline. It gives a good brow and forehead lift, but is a longer operation than the direct or trans-eyelid incision approach.
What happens after brow ptosis surgery?
You will have forehead and eyebrow dressings, usually with a bandage around the head to reduce bruising and instructions to instil lubricant and antibiotic eye drops and ointment for 1 to 3 weeks.
What are the risks of brow ptosis surgery?
The possible complications include:
- Local bruising and swelling.
- Blurred vision from dry eyes or ointment.
- Asymmetry of brow height.
- Gradual reversal of effect, requiring further surgery.
- Loss of sensation on the forehead, temporary or permanent.
- Facial nerve paralysis causing facial nerve weakness.
- Loss of hair at the incision sites.
It is important for the patient to be well informed about the different operations available and the risks of surgery.
What is BOTOX® treatment?
This is injection of botulinum toxin A (BOTOX is the name of one brand of botulinum toxin) into overacting muscles which cause deep activity lines on the face, especially the forehead and around the eyes, such as the vertical frown lones (Glabellar lines) and the smile lines around eyes (crow’ feet). BOTOX causes reversible inactivation (chemodenervation) of the facial muscle causing these lines. Mulitiple small injections are made which have a peak effect one week after the injection then gradually wear off over three to four months approximately.
What is filler?
Filler is an inert synthetic substance such as Restylane ® which is injected into the depressions or tear troughs below the eyes and the lines between the nose and the mouth (nasolabial folds). Fillers can be temporary, semi-permanent or permanent, depending on what material is injected. Restylane is temporary. The patients' own fat (autologous Coleman fat) can also be used to fill out depressed areas around the eyelids.
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Facial Palsy
What is facial palsy?
This is paralysis of part of the face caused by non-functioning of the nerve that controls the muscles of the face, especially the muscles around the eye and to the mouth. This nerve is called the facial nerve.
What is the facial nerve?
The nerve affected in facial palsy, the facial nerve, is one of the cranial nerves. It is also called the seventh cranial nerve. It has a complex course from the brain stem to reach the muscles of facial expression. It supplies and controls the muscles that lift the eyebrows high, the muscles that close the eyelids, the muscles of the cheek and around the mouth.
What are the causes of facial palsy?
Facial palsy can be congenital i.e. present at birth or shortly after, or can be acquired. Acquired causes of facial palsy include most commonly Bell's palsy. This can have no cause or be secondary to infection, or can be because of lack of the blood supply to the nerve. Sometimes a tumour, such as an acoustic neuroma, or parotid gland, or temporal bone tumour can compress the nerve and damage it. Birth trauma or skull fracture can also cause a facial palsy.
What are the symptoms of facial palsy?
Facial paralysis usually affects one half of the face. There is a flattening of the affected half of the face, with loss of the forehead wrinkles and horizontal lines, a droopy eyebrow, difficulty closing the eye, an inability to whistle and the corner of the mouth pulled down.
Why are the eye changes so important?
The eye findings are particularly important, as the upper eyelid can be a little bit too high and the lower eyelid can sag and have an ectropion (outward turning of the lid margin) resulting in a watering eye, inability to close the eye and exposure or drying of the cornea. The eye can become red, the vision blurred and occasionally the vision can be severely affected by an exposure keratopathy, with an ulcer then scarring of the cornea and loss of useful vision.
How is facial palsy managed?
Most patients can be managed medically, with local eye drops and ointment to lubricate and wet the eye. Simple horizontal taping of the eyelids at bedtime is very beneficial. Some patients require upper eyelid lowering with Botox (Botulinum Toxin A), which specifically paralyses the eyelid muscle which opens the eye, and allow the eyelid to drop over the surface of the eye and protect it if there is a severe keratopathy present.
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When is a surgery required?
Surgery may be advised for facial nerve palsy if there is difficulty in protecting the eye from incomplete closure of the eye causing drying and there is a lot of discomfort and/or effect to the eyesight. Surgery is also done to improve symmetry and regain the normal anatomy, in order to improve not only cosmesis, but help improve the function of the eyelids and reduce watering.
Common surgical procedures for facial palsy
Lateral tarsorrhaphy : This is the surgical closure of the outer portion of the eyelids to reduce the length of the eyelids that is open and decrease the evaporation and improve the coverage of the eye by the eyelids. This is usually done in an emergency. It is not the best rehabilitative procedure and it has a poor cosmetic result, can cause a blinkering effect to the vision towards the side of the surgery, and is therefore reserved for special cases only. The lateral tarsal strip is preferred.
Lateral tarsal strip : This is a tightening of the lower eyelid when there is lower eyelid laxity, sagging and ectropion. The lower eyelid is shortened and re-attached a little higher to improve eyelid closure and comfort. An augmented strip - tarsorrhaphy is often needed for facial palsy to help close the eyelid fully on blinking.
Lateral tarsal strip tarsorrhaphy : a combined procedure called an augmented lateral tarsal strip tarsorrhaphy can be done when there is a lot of lower eyelid laxity, sagging and ectropion, and in this surgery there is a long lateral tarsal strip performed with a very small lateral tarsorrhaphy combined, which does not shorten the lower eyelid opening so much as to affect vision or appearance, but does help protect the eye well.
Medial canthoplasty : This surgery is done at the medial corner of the eyelids (in a corner) and consists of some specially positioned stitches to pull up the sagging lower eyelid towards the inner corner. It is usually done in conjunction with a lateral tarsal strip, or augmented lateral tarsal strip tarsorrhaphy.
Gold weight upper eyelid : More animated and better closure of the upper eyelid can be obtained by placement of a gold weight in the upper eyelid. This helps to give a better cosmesis along with near physiological eyelid closure.
Drooping eyebrow surgery : This is called brow ptosis correction and there are several different procedures to improve the position of the drooping eyebrow. Some of these procedures are done over the eyebrow, whilst others are carried out via the forehead or small scalp incisions. Brow ptosis can be necessary as part of the rehabilitation in a patient with longstanding facial palsy.
Face surgery : The midface or cheek can be lifted to help improve the lower lid position and more extensive facelift type surgery done to improve the symmetry between the two sides of the face and help restore the normal anatomy.
Non-surgical procedures
Botulinum Toxin A chemodenervation upper eyelid lowering: in certain urgent situations the front of the eye, or cornea, becomes ulcerated and very painful, or the eye red. This is called exposure keratopathy with severe keratitis. Lubricants and other eye drops may not be adequate to improve this and it is necessary to lower the upper eyelid temporarily.
This is done by a small injection underneath the upper eyelid of Botox, or Botulinum Toxin A, to temporarily paralyse the muscle that lifts the eyelid open and allow the eyelid to drop over the eye (protective ptosis) so that the keratitis or ulcer can heal. These injections can last up to three months and be repeated or definitive surgery done.
Specific eye problems with facial palsy
Blepharospasm / Hemi Facial Spasms or aberrant regenerataion of the facial nerve to the eyelid closing muscle : Patients with facial nerve palsy may have some regeneration of the nerve and, if this goes along the wrong pathways, can cause the eyelids to close up slightly and to have spasm, as well as the muscles of the side of the face (cheek) and to the mouth. This causes involuntary flickering or twitching or spasmodic contractions. These patients may require Botox, or Botulinum Toxin A, treatment to the muscles which are in spasm.
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Watering eyes
Why do eyes water?
In order for the eyes to be healthy they need to be kept moist with tears. However, too many tears, or failure of drainage of the tears, will result in a watering eye.
Where do tears come from and how do they drain?
Tears are produced in the lacrimal gland, which is a special gland located under the outer one third of the upper eyelid. Each time you blink the eyelid spreads the thin layer of tears over the surface of the eye, and then there are some muscles in the corner of the eye which help drain, or pump, the excess tears down into the lacrimal sac and duct towards the back of your nose.
What is the cause of a watering eye?
Watering eye can occur when there is excess tear production or due to obstruction in the drainage channels. Excess tear production can be caused by simple common conditions, such as inflammation of the eyelid margins (blepharitis) or, paradoxically, having a dry eye so that there is excessive or hypersecretion of tears. An obstruction of the drainage channels is a common cause of watering eyes. It may occur at various levels e.g. At Punctum (Punctal Stenosis/ atresia), at canaliculus (Canalicular block) or at naso-lacrimal duct (chronic dacryocystitis). Rarely, the blinking, or pumping action of the eyelids, may fail and cause a watering eye.
What are the symptoms of a watering eye?
Typically the symptoms of a watering eye, due to an obstruction of the drainage channel, is watering worse outdoors, aggravated by cold and windy weather.
What can happen with an obstructed drainage channel?
If the drainage channel, or tear duct, or nasolacrimal duct as it is called medically, gets blocked there can be a swelling of the tear sac above it, at the corner of the eye on the side of the nose. This can cause, in addition to the watering, a small swelling at the corner of the eye, regurgitation of mucous to the eye if the swelling is pressed, or even a painful abscess condition called dacryocystitis. Sometimes the blockage of the drainage channels affects the very fine ducts close to the eyelids called the canaliculae.
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What is the treatment of a watering eye?
If the watering eye is caused by an obstruction of the drainage channels, then surgery can be done to overcome the obstruction. Surgery is performed to create a new tear duct by an operation called dacryocystorhinostomy, or DCR. This operation is most commonly done under local anaesthesia, but can be done under general anaesthesia if the patient is a child or apprehensive for pain.
If the punctum (initial opening to the drainage channel) is stenosed then widening the punctum surgically (punctoplasty) is done with great success.
Tell me more about a DCR operation
A DCR operation can be done via a small skin incision on the side of the nose, which is called external approach dacryocystorhinostomy. Alternatively, it can be done via the nose using a special endoscope, light source and fine instruments. This is called endoscopic endonasal dacryocystorhinostomy. Another approach is using a fibreoptic through canalicus and then Diode laser is used to make opening through sac wall, nasal bone and mucosa. This is called Trans - Canalicular lase DCR. Sometimes, at DCR surgery small silicone tubes are placed temporarily along the duct while healing occurs. These tubes are removed a few weeks later, after which the watering and/or stickiness should be eliminated.
Can watering eyes affect children?
Children are frequently born with an obstruction within the tear duct called congenital nasolacrimal duct obstruction, resulting in tearing. Fortunately, the tear duct usually opens spontaneously as the child's face develops and over 80% of children born with this obstruction will have opened their duct completely and resolved the problem of watering by the age of one year. Occasionally the stagnant tears in the tear sac become infected, causing a small lump to appear at the inner corner of the eye and some pus or heavy matter to collect between the eyelids, which might require earlier surgical intervention. If a child still has a watering eye after the age of one, the ophthalmologist can carry out a simple surgical manoeuvre under a short general anaesthetic to probe and open the obstructed tear duct, possibly pass tubes or, if there is a significant block found, do a DCR, as in adults.
Are there any specific situations I need to be aware of?
Occasionally the tear duct obstruction will be beyond repair, such as following severe trauma, or if the fine canaliculae (the little drainage tubes in the eyelids) are severely obstructed in the midway. When this happens, it is necessary to surgically implant an artificial tear duct behind the inner corner of the eyelid to drain the tears into the nose. The artificial tear duct is made of pyrex glass and is called a Jones' tube.
Alternatively, Botulinum Toxin A (Botox) can be inected in the lacrimal gland to decrease the production of tears and hence decrease watering.
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Ectropian
What is an ectropion?
Ectropion of the lower eyelid is sagging and outward turning of the eyelid margin and eyelashes away from the eye. This can lead to excess tearing, crusting of the eyelid, mucous discharge, irritation of the eye and redness of the eyelid.
What are the causes of ectropion?
Most cases of ectropion are due to simple laxity of the eyelid as a result of ageing. In some cases scarring of the eyelid skin, caused by chemical or thermal burns, trauma, or mechanical effect from skin cancers, or previous eyelid surgery, can result in the eyelid turning outwards, away from the eye.
How is this condition managed?
Ectropion symptoms can occasionally be relieved temporarily with ointment, but should be repaired surgically. The aim of surgery is to reduce the symptoms of tearing, crusting, discharge, irritation and redness of the eyelid, +/- the eye's surface.
What types of surgery are there for ectropion?
Ectropion surgery is done by an oculoplastic surgeon, under local anaesthesia, as an out-patient. In most cases the oculoplastic surgeon will tighten the eyelid and its attachments to put the eyelid back in the normal anatomical position. This may require an overnight eye pad, followed by installation of antibiotic drops, or ointment, into the eye for one to three weeks. This is not a painful operation and you can return to work, or normal activities, within few days. Whilst the eyelid is healing, the eye may feel a little gritty and ache at the corner, but after it has healed the eye will feel comfortable and there will no longer be symptoms of tearing, crusting, mucous discharge, irritation or redness.
What are the risks of side effects of ectropion surgery?
- Bruising of eyelid.
- Bruising of eye.
- Infection of the eyelid or eye.
- Recurrence or over-correction of the eyelid position, requiring further operation.
- Allergic reaction to the local anaesthetic or antibiotics drop or ointment.
What are the benefits of eyelid surgery?
- Relief of symptoms, particularly watering and irritation.
- Correction of anatomical position of eyelid, with restoration of normal appearance of eyelid.
- Reduction of risk of eye infection and exposure.
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Entropian
What is an entropion of the eyelid?
Entropion is inward turning of the lower eyelid, resulting in the eyelashes directing towards the surface of the eye, causing discomfort. The skin of the eyelid and the eyelashes may rub against the cornea (front part of the eye) and the conjunctiva (the white mucous membrane that protects the surface of the eye). Rubbing of the eyelid skin and lashes against the eye can result in excess tearing, crusting of the eyelid, mucous discharge, foreign body sensation, irritation of the cornea and impaired vision from keratitis.
What are the causes of eyelid entropion?
Most commonly entropion is due to relaxation of the tissue in the eyelid as a result of ageing. It can be caused occasionally by scarring of the inner surface of the eyelid from chemical or thermal burns of inflammatory diseases, such as ocular pemphigoid or allergic reactions.
How is entropion managed?
Temporary relief of entropion can be by taping of the eyelid outwards, putting in comforting lubricant drops, or temporarily paralysing the muscle that turns the eyelid in (orbicularis muscle) with a tiny injection of Botox, or Botulinum Toxin A, to the muscle of the lower lid. In the long term, surgery is recommended to prevent rubbing damage of the eyelid skin and lashes on the front of the eye, by reducing infection and risk of scarring.
What type of surgery is done for entropion of the lower eyelid?
Surgery for entropion is usually done under local anaesthesia, as an out-patient. The oculoplastic surgeon will tighten the eyelid and its attachments, which can be done by either some simple sutures, or stitches, placed through the lower eyelid, or sutures plus eyelid tightening and stabilisation with a lateral tarsal strip. You may have an eyepad overnight and then will put in antibiotic drops or ointment for one to three weeks. After the eyelid has healed, the eye should feel comfortable, the eyelid is in a normal position and there will no longer be any risk of corneal scarring, infection or loss of vision.
What are the risks of entropion surgery?
- Bruising around the eyelids and on the eye.
- Infection of the eyelid or eye.
- Recurrence or over-correction of the eyelid, resulting in it turning outwards, requiring further operation.
- Allergic reaction to the local anaesthetic injection, or the antibiotic ointment or drops.
What are the benefits of entropion surgery?
- Complete relief of symptoms of tearing, crusting, mucous discharge, foreign body sensation, irritation and blurred, impaired vision.
- Reduction of the risk of eye infection and restoration of the normal position and appearance of the eyelid.
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Eyelid and peri-ocular skin cancer
What is eyelid and peri-ocular skin cancer?
Skin cancers can affect the eyelids or adjacent face (peri-ocular region). Eyelid skin cancers are most often on the lower eyelid, but may be found anywhere on the eyelid margins, corner of eye, eyebrow skin or adjacent areas of the face. Usually they appear as painless elevations or nodules, often with a pearly appearance, with either loss or distortion of the eyelashes, or fine hairs of the skin. There may be ulceration of the involved area, with bleeding, crusting, redness and/or distortion of the normal skin appearance. These findings need to be evaluated and will require a biopsy to confirm the diagnosis as skin cancer.
What are the common eyelid and peri-ocular skin cancers?
The most common type of skin cancer is the Sebaceous Gland Carcinma, or SGC, second is basal cell carcinoma or rodent ulcer, followed less commonly by squamous cell carcinoma. There are other rarer cancers which may also occur, affecting different parts of the skin micro-structure. Basal carcinoma, or BCC, and squamous cell carcinoma or SCC, both enlarge locally and usually do not spread or metastasise to distant parts of the body. However, with time, if these tumours are not completely removed, either type will invade adjacent structures and a squamous cell carcinoma may spread to lymph nodes in the head and neck.
It is important to know that BCC and SCC are relatively slow growing, but do require treatment to eradicate them. Therefore early detection and treatment in an appropriate manner, in an oculoplastic clinic, is required. The tumour must be removed completely and at the same time minimise the amount of normal tissue around the tumour being removed, in order to do the best surgical reconstruction of the area using oculoplastic techniques.
What are the early warning signs?
If you develop a skin lesion, or soreness, that fails to heal within 4 to 6 weeks and has two or more of the following features, you should seek medical advice :
- Painless lump in skin which can appear smooth or have an open sore or ulcer on it, bleed or crust, and does not heal.
- Red patch on the skin which is itchy, painful or crusty, or may have no symptoms, but the lesion fails to heal or fade.
- Smooth raised growth with an ulcer in the centre, which can be flesh coloured, pink, shiny, red or pigmented like a mole.
- Firm nodule on the skin which can be flesh coloured, pink, shiny, red or pigmented like a mole.
- Small elevation that looks like a flat scarred area on the skin, which is pale, or white, compared to the surrounding skin, and may have an ulcer or an indentation in the centre. This form of BCC can grow more quickly, making the affected skin look taught and shiny.
Remember that basal cell carcinomas are curable and recognise the early warning signs.
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How BCC’s are treated?
There are two very important principles in the management of eyelid and peri-ocular skin cancers: (1) complete removal and (2) delicate peri-ocular and eyelid reconstruction. Complete removal of the tumour is critical to minimise the possibility of recurrence. The tumour should be removed with as little normal tissue surround as possible, but enough to ensure safe and complete removal of the tumour, to minimise the possibility of recurrence. Recurrences can be very difficult to manage.
The surgeon removes the tumour and asks a pathologist to check the tissue microscopically to ensure that the margins have been completely removed. This can either be done immediately as a frozen section, or take 2 or 3 days if the tissue is first fixed. The gold standard is to ask a dermatological surgeon, specialising in Mohs' micrographic surgery, to excise the tumour in a special way to ensure its total removal, after which the oculoplastic surgeon will do the reconstruction on the same day, or within 48 hours.
Once the tumour has been completely removed and there is microscopic confirmation that no tumour cells remain, reconstructive surgery is usually necessary. Occasionally the wound can be left to heal on its own by a process called granulation, or laissez-faire. Most commonly, reconstructive surgery is performed to make a new eyelid or repair the defect.
What types of reconstructive surgery are there?
There are many excellent oculoplastic techniques available to reconstruct almost any surgical defect around the eyelids and peri-ocular region. Each operation will be specifically tailored to the defect that is present, following removal of the tumour. The goals remain the same, which is to reconstruct the eyelid so that it functions properly and protects the eye, preserves the vision and has a satisfactory aesthetic or cosmetic appearance, matching the rest of the face as well as possible. Any surgical treatment for eyelid and peri-ocular skin cancer will leave a fine scar, but every effort is made to minimise visible scarring and to obtain an optimum cosmetic result. If surgery involves flaps, it may require a two stage procedure. After surgery the healing process can take up to 6 months or a year to complete.
What precautions do we need to protect ourselves in the future from eyelid and peri-ocular skin cancers?
If you have had one BCC, it is likely that you will develop others over the ensuing years, on parts of your face, neck, shoulders and hands which are sun exposed.
- Examine your skin every 6 to 12 months for early warning signs and look and feel for any changes in your skin.
- Ask your partner to examine your back, neck, ears and scalp. Alternatively, use a mirror to examine these areas.
- If you are concerned about a lump, seek advice from your GP.
- Wear protective clothing and wide-brimmed hats when outdoors, which will protect the skin most at risk.
- Wear 100% UV protective sunglasses, as the
skin surrounding the eyes is vulnerable.
- Avoid sunshine during midday hours if possible.
- Use high factor sunscreen (SPF 15 or 30), this is vital. Apply sunscreen before going out in the sun and re-apply every 2 to 3 hours, or more frequently if perspiring or swimming.
Advise others, especially family and friends, to protect themselves from the sun.
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Thyroid Eye Disease
What is thyroid eye disease?
Other names of thyroid eye disease (TED) are Graves' ophthalmopathy (GO), Graves' orbitopathy (GO), thyroid associated orbitopathy (TAO). Thyroid eye disease is an orbital disease and is most commonly associated with a disorder of the thyroid gland, hyperthyroidism. It is an auto-immune eye condition. It can sometimes occur in patients who have no thyroid dysfunction, or patients who have thyroid hypo-function. Most patients with thyroid diseases do not develop thyroid eye disease or, if they do, it is only mild. A small proportion develops thyroid eye disease, which may go on to require treatment either with eye drops or surgery.
Risk factors for thyroid eye disease include smoking, which results in a more severe form of the disease.
What are the signs and symptoms of thyroid eye disease?
- Staring appearance with upper and lower eyelid retraction, resulting in more white of the eye being apparent.
- Bulging or proptotic eyes, where the eyes protrude forwards and look very big.
- Peri-ocular swelling, with puffiness of the eyelids, sub-brow area and peri-ocular region.
- Orbital ache, particularly on eye movements.
- Double vision (diplopia), either looking straight ahead, or on extremes of gaze.
- Bloodshot appearance to the eyes associated with one or more of the above.
- Reduced vision, particularly for colour vision, if the optic nerve is compressed.
Etiology:
Thyroid eye disease is an auto-immune disorder, in which there is a reaction within the orbit which results in local inflammation, swelling and fibrosis of structures in the orbit, including the fat around the eye ball and the muscles that move the eyes.
What is active thyroid eye disease?
Thyroid eye disease has well recognised stages. There is an early active phase, in which there is inflammation, and usually this can last between 3 and 12 months before beginning to stabilise and become inactive. During the active phase maximal symptoms will develop, with eyelid retraction, eye protrusion, possible double vision and redness. If the active thyroid eye disease is treated early enough, it may be possible to reduce the severity of the disease and need for surgery. It is important to stop smoking and to have good control of the thyroid hormones, so that they are in the normal range and there is no over-action, or under-action, of the thyroid gland.
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How is thyroid eye disease managed?
Treatment is aimed at improving the symptoms of the orbital involvement.
Mild thyroid eye disease
Patients with mild involvement, such as irritation, foreign body sensation and only a very small amount of protrusion of the eyes (proptosis) and no double vision, may just require reassurance, artificial tears during the day and lubricant ointment at night. If the eyelids do not close fully at night, the eyelids can be taped, to protect the surface of the eye.
Moderate thyroid eye disease
If there is more marked eyelid malposition, with retraction and proptosis, difficulty closing the eyes and corneal problems, surgery may be required.
How is the condition managed?
The oculoplastic surgeon will monitor the colour vision, eyelid measurements, degree of proptosis, examine the surface of the eye and behind the eye, look at the optic nerve and do special radiological investigations, as required.
Severe thyroid eye disease:
Lid and orbital surgery may be required.
The principle of management is:
- Medical control of thyroid gland and thyroid hormone, so that the patient is not hyper or hypothyroid.
- Treatment of active thyroid eye disease if moderately severe or severe, with tablets, such as steroids and other immuno-suppression drugs, +/- low dose orbital radiotherapy.
- Surgical rehabilitation in the acute phase, or stable phase.
What type of surgery is available for thyroid eye disease?
In the acute phase, if there is optic nerve compression with the vision being affected, or there is severe exposure of the front of the eye because of such severe eyelid retraction and eye protrusion (proptosis), urgent surgery may be required to decompress the orbit and retain vision. Some younger patients who have healthy, tight tissue may have reduction of vision from optic nerve compression, but not have particularly protruding eyes, and this group must be recognised and urgent medical treatment, and/or decompression, carried out to preserve the nerve function.
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Stable thyroid eye disease - rehabilitation of thyroid eye disease:
Once the patient has overcome the acute phase, the oculoplastic surgeon will do rehabilitative surgery. The goal of rehabilitative surgery is to:
- Restore normal function to the orbit and eyelids.
- Restore normal comfort.
- Restore normal cosmesis and symmetry.
There are several operations available for rehabilitation of thyroid eye disease.
1. Orbital Decompression
Orbital decompression is surgery to reduce the protrusion, or proptosis, of the eyes by making the orbits larger internally by creating openings into the adjacent air cells (air sinuses). This is done by an oculoplastic orbital surgeon through a small eyelid incision at the outer corner of the eye, with most of the incision hidden on the inside of the lower eyelid. Sometimes an additional approach is done through the inside of the nose, in order to open up into the medial, or ethmoid, sinus, in preference to opening that sinus via the eyelid. A balanced decompression is aimed for, in which the orbit is widened horizontally, thus reducing the risk of causing double vision. This is the same operation that is done in the acute phase if there is an optic nerve compression, in which the pressure, or tension, on the optic nerve is reduced by increasing the internal size of the orbit by operating surgically on the bony walls of the orbit.
2. Eye Muscle Surgery
If there is a squint (strabismus) with double vision and the eyes cannot be easily corrected with small prisms, eye muscle surgery, or strabismus surgery is necessary. The oculoplastic surgeon waits until the double vision, or eye motility, is completely stable before carrying out eye muscle surgery. The aim of this surgery is to restore a good field of binocular i.e. two eyes seeing together of single vision, when both eyes look straight ahead and in the reading position. Squint surgery may not completely remove all double vision and the patient may still notice some double vision in extremes of gaze. Squint surgery is usually done under general anaesthetic and may involve an adjustable stitch on the eye muscle, which is then locally adjusted with the patient awake a few hours after surgery to give the best possible single vision.
3. Eyelid Retraction.
If the upper eyelids are too high, or the lower eyelids too low, resulting in white of the eye appearing either above or below the coloured iris and difficulty in closing the eyes, eyelid surgery can be done to correct the eyelid position. The upper eyelid is lowered, or the lower eyelid raised, the latter sometimes requiring a small spacer using placement of tissue from the patient's roof of mouth, for instance, to help restore the normal position of the eyelids and eyelid closure.
4. Further Eyelid Surgery - Blepharoplasty & Peri-Ocular Surgery
Debulking of peri-ocular puffiness may be required by upper eyelid and sub-brow removal of fatty tissue and lower eyelid removal of fatty tissue. Further treatment can also be done to the lower eyelid skin, to tighten it where it has been swollen by the thyroid eye disease. This is known as blepharoplasty, and is done as part of rehabilitative surgery for patients with thyroid eye disease. Lid and orbital surgery may be required.
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