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MultiPurpose                                         Dr. Saurin Gandhi

Orbit/ Reconstructive Procedures


  • Reconstruction of the eyelids and tear drainage system
  • Treatment of trauma and tumors affecting the upper face and eye sockets (orbit)
  • Treatment of thyroid eye disease (Graves')
  • Facial palsy Surgery
  • contacted socket surgey and rehabilitation.

Loss of an eye (Enucleation/ Evisceration)

Following enucleation or evisceration of an eye, for tumour, after severe trauma or painful blind eye, a primary orbital implant is usually inserted to replace the volume of the lost eye. An eye prothesis (artifical eye) fits neatly in front of the embedded orbital implant and behind the eyelids, looking like a normal eye.

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 develop 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.

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.

  • 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:
    1. Medical control of thyroid gland and thyroid hormone, so that the patient is not hyper or hypothyroid.
    2. 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.
    3. 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.

    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:

    1. Restore normal function to the orbit and eyelids.
    2. Restore normal comfort.
    3. 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.

Eye Socket Reconstruction

Eye socket reconstruction is a surgical procedure that restores function and provides rehabilitation to the soft tissues and bone around the eye including the eyelids, socket, and conjunctival fornices. This type of orbital surgery is usually needed after any type of trauma, defects, or scarring in the general eye area from disease or accident.

By using various techniques, our surgeons at the Orbital Surgery Center of Excellence restore proper function to the remaining structure of the eye to provide the best possible opportunity before a prosthetic (fake eye) can be made by an ocularist. These types of techniques include implants or fat grafts, eyelid tightening, and upper eyelid ptosis surgery.

The overall goal of any type of reconstructive eye surgery at the Orbital Surgery Center of Excellence, especially socket reconstruction, is to preserve vision, restore normal eye function, and repair any abnormalities of the eyelids. Preparing the eye socket for an artificial eye that fits naturally helps to allow our patients to over come their loss.

Prosthetic Eyes

Losing an eye can cause insecurities around the patient’s appearance. Dr. Saurin can restore proper function to the remaining and surrounding structures (eye socket, eyelids) to provide the best possible opportunity before a prosthetic or fake eye can be made by an ocularist.

Causes of Eye Socket Reconstruction

The need for eye socket reconstruction surgery is primarily due to any type of abnormalities affecting the orbit, eyelids, or the midface caused by traumatic injury, various diseases, and defects.

The most common conditions that require reconstructive eye surgery include:
  • Congenital eyelid abnormalities – displacement and malposition of eyelids in children
  • Ectropion – lower eyelid is turned out away from the eye
  • Entropion – the eyelids and lashes are turned toward the inside of the eye
  • Lacrimal abnormalities – blockage of the tear ducts and improper drainage
  • Orbital fractures – broken or fractured bones surrounding the eye
  • Orbital tumors – benign or malignant tumors around or on the inside of the eye

What To Expect From Eye Socket Reconstruction

Before Your Eye Surgery

One of our oculoplastic surgeons will walk you through in detail the available options and their benefits after he fully examines you. Since every situation is different, every surgery is individualized towards exactly what you need. Arrange for a ride and have someone reliable, perhaps a family member or close friend bring you to from our surgical center. This person should also be available to offer care giving services to you for the next night as well. If you don’t have such a person, please let us know in advance so that we can recommend available after-care facilities to you. You will be given light anesthesia and your surgery should take about a couple hours.

After Your Surgery

After your surgery, don’t be alarmed if you wake up and your eyes are covered. Recovery from eye socket reconstructive surgery is normally a pretty speedy recovery, lasting only a couple weeks. Most patients can go home that same day as long as they have someone to care for them. To reduce swelling, use ice compresses. And if you are given eye drops, be sure to administer them gently. In some cases, your doctor may give you a pressure patch to wear for about a week to control the swelling. This is usually removed at your postoperative appointment.


EYELID RECONSTRUCTION

Eyelid reconstruction may be undertaken in a variety of situations. Defects in the eyelid may arise form a variety of situations, but most commonly after trauma or tumor excision. These topics are covered in greater detail in other sections, but a brief overview is warranted here.

Simple superficial defects in the eyelid may occur after minor trauma or removal of small growths. Many of these require nothing more than local wound care and will heal on their own in a week to 10 days. Some simple superficial defects may require a few sutures with the same local wound care.

In some instances, such as after traumatic injuries or removal of larger growths or skin cancers, larger defects may extend through the entire lid. Many of these can be sutured together directly, but many others may require more complex reconstructions. In many of these more complex cases, the surgeon will need to use transfer of adjacent tissues (what we call ”flaps”), or transfer of skin from other parts of the eyelid face or body (what we call “skin grafts”) to complete the reconstruction. Some of these more complex reconstructions may require more than one operation to complete (what we call “staged reconstruction”).

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.