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MultiPurpose                                         Dr. Saurin Gandhi

Eyelid


Eyelid ptosis

  • What is eyelid ptosis?

    It is a droopy upper eyelid. If the lid edge displaces downwards it can cover part of the pupil and block the upper part of the vision, or cause fatigue. In severe ptosis patients have to tilt their head back, or lift the eyelid with a finger, in order to see out well. These are functional problems. Mild ptosis can be a cosmetic problem.

  • What is the cause of ptosis?

    Congenital (present since birth) due to a poorly developed muscle. It is more common in older adults where the muscle that lifts the eyelid thins and the eyelid drops. It occurs with age, contact lens wear, trauma and, rarely, tumour or from a neurological problem, such as a nerve palsy or muscle weakness (myopathy).

  • Are you a candidate for ptosis surgery?

    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.

  • What happens at eyelid ptosis surgery?

    Eyelid ptosis surgery is usually done under local anaesthesia as a day case. 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) is identified and shortened to lift the eyelid. Dissolving sutures are used inside the lid and on the skin.

  • What happens after surgery?

    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.

  • What are the risks of ptosis surgery?

    1. Local bruising and swelling of the eyelids.
    2. A small risk of wound infection to the eyelid.
    3. Risk of over-correction (eyelid too high), or under-correction (eyelid still too low) which may require a second operation.
    4. 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.
    5. 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?

    1. 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.
    2. Restoring the normal anatomical appearance of the eyelid.
    3. Improved cosmesis and symmetry.

  • 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 which raises the eyelid, the levator palpebrae superioris muscle.

  • 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 orthoptist for visual development, with a refraction by the oculoplastic surgeon and eye and eyelid measurements.

  • 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. 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. 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 case. An eye patch is rarely put on and the stitches, or sutures, on the skin are dissolvable.

  • 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 and is a small strip of tendon taken from the leg through a 1 cm incision just above the knee, on the side of the leg. If the child is too young to have this done, and a sling or brow suspension is required before the age of 4 years, synethetic material, such as silicone, or prolene, or gortex, may be used instead.

  • 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?

    1. Bruising of the eyelids and around the eye.
    2. A small risk of infection of the eyelid or the eye.
    3. Possibility of under-correction or over-correction of the eyelid height, requiring a second operation.
    4. 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?

    1. Prevention of lazy eye or amblyopia and strabismus or squint.
    2. Improved appearance will improve the child's self-confidence, especially if being teased at school
    3. Restoration of a normal anatomical position of the eyelid.
    4. Restoration of the normal cosmetic appearance of the eyelid.

Entropion

  • 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 be 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?

    1. Bruising around the eyelids and on the eye.
    2. Infection of the eyelid or eye.
    3. Recurrence or over-correction of the eyelid, resulting in it turning outwards, requiring further operation.
    4. Allergic reaction to the local anaesthetic injection, or the antibiotic ointment or drops.

  • What are the benefits of entropion surgery?

    1. Complete relief of symptoms of tearing, crusting, mucous discharge, foreign body sensation, irritation and blurred, impaired vision.
    2. Reduction of the risk of eye infection and restoration of the normal position and appearance of the eyelid.

Ectropion

  • 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 about four 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?

    1. Bruising of eyelid.
    2. Bruising of eye.
    3. Infection of the eyelid or eye.
    4. Recurrence or over-correction of the eyelid position, requiring further operation.
    5. Allergic reaction to the local anaesthetic or antibiotics drop or ointment.

  • What are the benefits of eyelid surgery?

    1. Relief of symptoms, particularly watering and irritation.
    2. Correction of anatomical position of eyelid, with restoration of normal appearance of eyelid.
    3. Reduction of risk of eye infection and exposure.

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. There are many artificial tear preparations available. 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.

  • 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. Surgery is also done on the forehead, brow, midface and lower face and corner of the mouth to improve symmetry.

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

    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.

  • 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.

  • 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. Incisions in front of the ear and into the hairline are used. A sling of the patients own leg fascia (fascia lata) or an inert strip of material can be used to help resuspend the mouth.

  • 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

  • Neurotrophic keratitis

    patients with facial palsy due to the facial nerve, or seventh cranial nerve, loss of function may also have loss of the nerve which controls the sensation of the eye, called the trigeminal or fifth cranial nerve. These patients are usually those who have had surgery for a large acoustic neuroma tumour, where there has been involvement of both the facial nerve to the muscles and the sensory nerve to the front of the eye.
    This results in diminished or no sensation on the front surface of the eye, so that the patient cannot feel dryness, or foreign bodies, or trauma to the surface to the eye, and as a result have a much higher risk of corneal ulceration. The options are:
    1. Emergency eyelid closure with tarsorrhaphy to allow for the ulcer on the front of the eye to heal.
    2. Urgent upper eyelid lowering with Botox (Botulinum Toxin A) protective ptosis.
    3. Increased lubrication, punctual plugs to stop the tears draining away and eye padding with taping at night.
    4. Definitive surgery to narrow the eyelid opening so that there is excellent eyelid coverage by the eyelids and protection of the cornea.
    NB: It is important to warn patients with a neurotrophic keratitis that they are at risk of severe loss of vision, unless great care is taken, and one or more of the above steps may be required if they develop a corneal ulcer.

  • Crocodile Tears

    This is a rare sequelae facial nerve paralysis, when the facial nerve tries to grow back along its old pathway but misdirects and goes instead to the lacrimal gland and to the muscles of the jaw, so that when the patients chews there is embarrassing tearing. The treatment is Botulinum Toxin mini injections to the lacrimal gland.

  • Blepharospasm 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. These patients may require Botox, or Botulinum Toxin A, treatment to the muscles which are in spasm.