Oculofacial Plastic Surgery

Anophthalmos is the absence of an eyeball within the eye socket. Anopthalmos usually occurs after surgical eyeball removal for cancer of the eye or for an eye that is blind and painful. Very rarely, babies are born without an eye.

Eye sockets without an eye are treated with implants or tissue grafts to fill the space. When the socket is healed, a prosthetic eye can be worn. The eye prosthesis is usually custom-made by an ocularist. It is usually clam-shaped and rests under the eyelids and looks like a real eye. If the muscles in the eye socket are not damaged, the prosthetic eye can move in concert with the other eye.

In children, anophthalmia may lead to serious problems due to not only the absence of a seeing eye, but also the secondary disfigurement of the orbit, the lids, and the eye socket. Proper growth of the orbital region is dependent on the presence of an eye, which stimulates growth of the orbit and proper formation of the eyelids. Early treatment with various expanders or surgery, when necessary, will help decrease the orbital asymmetry and cosmetic deformities in these children.

Treatment:

An oculoplastic surgeon can evaluate and determine the best treatment option, which may include surgery or placing a conformer to stimulate tissue growth. Eyelid or orbit implant surgeries are sometimes necessary.

Aging may cause “bags,” dark circles, or excess skin. Time and heredity can lead to the appearance of hooded upper eyelids, dark circles, wrinkles or under-eye bags. It happens when skin around the eye loosens and combines with protruding fat and sagging ligaments.

Signs and Symptoms:

These are sometimes medically significant when affecting the upper eyelids (dermatochalasis and blepharoptosis) and are often bothersome cosmetically. These features may cause a sad or tired appearance.

Treatment:

Depends on the exact findings, but may include eyelid lifting, cheek lifting, laser resurfacing, or fat contouring.

Blepharospasm is an episodic, involuntary spasm or contraction of the orbicularis oculi muscle (the circular muscle around the eye), resulting in uncontrolled blinking and squeezing of the eyelids. It occurs in both eyes and is sometimes accompanied with head and neck movements. Blepharospasm usually begins gradually and as the condition progresses the spasms may intensify and occur more frequently. In many cases, it can cause visual problems due to the closure of the eyelids.

Signs and Symptoms:

• Uncontrolled blinking
• Twitching or closure of eyelids
• Decreased vision in severe cases

Treatment:

• Botulinum Toxin (Botox) injection by an oculoplastic surgeon
• Lifting the eyelids or surgical excision of the orbicularis muscle is sometimes necessary in severe cases

Blepharoptosis (ptosis for short) is the medical term for drooping of an upper eyelid, a condition that may affect one or both upper eyelids. When the level of the upper lid falls, it can interfere with the upper field of vision. Symptoms include a decreased ability to keep the eyes open, eyestrain, and eyebrow fatigue from the increased effort needed to raise the eyelids.

Signs and Symptoms:

• Drooping eyelid
• Loss of upper peripheral vision

Treatment: 

Outpatient procedure to strengthen the muscles around the eye. In some cases, it may be necessary to remove excess skin from the upper eyelid. 

Tears keep the exposed surface of the eye moist. Excessive tearing (epiphora) is common when a person is upset or the eye is irritated, including from dryness. It can also result from disorders to the external surface of the eye, blockage of the tear drainage system, or flaccid lower eyelids. When the lacrimal system works well, the eyelids distribute tears over the surface of the eye each time a person blinks and pump the excess into a duct that drains into the nose. If a tear duct is blocked, then tears back up and the excess spills over the eyelid and runs down the face.

Signs and Symptoms:

• Blurred vision
• Tears running down the side of the face
• Possible infection from stagnant tears

Treatment: 

Surgery to eliminate the obstruction of the tear duct or to create a new tear duct.

Canaliculitis is an inflammation of the tear drainage passageways within the eyelids. It may cause tearing, discharge, red eye, and mild tenderness. Redness and tenderness are most prominent at the side of the eye near the nose.

Signs and Symptoms:

• Tearing
• Discharge
• Red eye
• Tenderness

Treatment:

• Irrigation of the infected duct or surgical removal of the infected material
• Warm compresses and/or antibiotic eye drops

A chalazion is an inflammatory nodule on the eyelid and is akin to facial acne.

Signs and Symptoms:

• Tenderness
• Redness
• Unsightly eyelid nodule

Treatment:

• Warm compresses and eyelid hygiene at first
• Some require further management with antibiotics, steroids, or surgical drainage

Dacryocystitis is an infection of the lacrimal sac, a small chamber into which tears drain located along the nose. The usual cause of dacryocystitis is a blockage of the nasolacrimal duct, which leads from the lacrimal sac into the nose. Dacryocystitis may occur suddenly (acute) or be long-standing (chronic). In acute infection, the area around the lacrimal sac is painful, red, and swollen. The eye may become red and watery and may ooze pus. Slight pressure applied to the lacrimal sac may push pus through the lacrimal punctum, the opening at the inner corner of the eye, near the nose.

Often the infection is mild. Sometimes, the infection is severe and can cause fever or an abscess may form, which can rupture through the skin in an effort to create a passage for drainage.

Signs and Symptoms:

• Red-eye
• Watery eye
• Occasional pus, indicating infection
• Fever

Treatment:

• Antibiotics
• Warm compresses
• Surgery (dacryocystorhinostomy or DCR) to bypass the blocked nasolacrimal duct

Dermatochalasis is an excess of skin in the upper or lower eyelid. The weakening of the connective tissues of the eyelid frequently contributes to this lax and redundant eyelid tissue. It is most commonly seen in the upper eyelids; however, it can occur in lower eyelids. If dermatochalasis is more than minimal, then it may block superior peripheral vision. Sometimes the problem is due to or worsened by droopy eyebrows.

Signs and Symptoms:

• Excess of skin
• Reduced peripheral vision

Treatment:

Blepharoplasty (eyelid lift) and/or sometimes brow lift

Ectropion is when the eyelids droop outward, away from the eye. It is most common in the lower eyelids. Drooping is commonly a result of reduced muscle tone in the muscles that control the eyelids. Sometimes it is due to scar tissue from previous surgery, sun damage, or trauma. When ectropion occurs, the eyelids can no longer protect the eyes and the surface of the eye may become dry and irritated. In addition, drooping eyelids can prevent tears from draining normally, so tears may run down your cheeks.

Signs and Symptoms:

• Drooping eyelids
• Excessive tearing
• Infection
• Foreign body sensation
• Irritated or red eye

Treatment: 

Ectropion repair

Entropion is when the eyelid turns inward forcing the lashes onto the eye, causing irritation and possible damage. It is most common in lower eyelids. The eyelid turning may be due to reduced muscle tone in the eyelids or scar tissue.

Signs and Symptoms:

• Excessive tearing
• Infection
• Foreign body sensation
• Irritated eye or red eye

Treatment:

Entropion repair

Aging may cause “bags,” dark circles, or excess skin.  Time and heredity can lead to the appearance of hooded upper eyelids, dark circles, wrinkles, or under-eye bags. It happens when skin around the eye loosens and combines with protruding fat and sagging ligaments.    

Signs and Symptoms: 

These are sometimes medically significant when affecting the upper eyelids (dermatochalasis and blepharoptosis) and are often bothersome cosmetically. These features may cause a sad or tired appearance.

Treatment: 

Depends on the exact findings, but may include eyelid lifting, cheek lifting, laser resurfacing, or fat contouring.

Enophthalmos is the recession of the eyeball within the orbit. It is caused by degeneration and shrinking of the orbital fat, injury or sometimes cancer.

Signs and Symptoms:

• Sunken eye
• Droopy upper eyelid
• Aymmetric facial appearance

Treatment:

Depends on the underlying problem, but sometimes orbital volume augmentation and/or sometimes eyelid surgery.

Exophthalmos is a protruding eyeball anteriorly out of the orbit (eye socket). Exophthalmos can be either bilateral (both eyes bulge out) or unilateral (just one eye bulges out). Doctors use an exophthalmometer to measure the degree of exophthalmos.

Signs and Symptoms:

• Bulging or protruding eyeballs
• Eye redness
• Eye irritation
• Sometimes intermittent tearing

Treatment:

Exophthalmos is not a condition, but rather a sign of a condition, usually related to thyroid disease, but sometimes due to tumors in the eye socket or inflammation. Depending on the cause, an oculoplastic surgeon can offer various treatments.

Eyelid retraction is when the upper eyelid is too high or the lower eyelid is too low. It can cause the eye to be irritated, red or dry. It can be caused by scarring from previous surgery, thyroid eye disease or aging.

Signs and Symptoms:

• Irritated eye
• Red or dry eye
• Sometimes tearing

Treatment:

Eyelid retraction repair

Facial Nerve Palsy is a nervous system disorder in which a damaged nerve in the skull affects the movement of the muscles of the face. It can affect vision and closing one eye and can change the appearance of the face.

Signs and Symptoms:

• The eye won’t close and then becomes irritated, dry, or red
• Sometimes tearing is a symptom
• Other features include a change in the appearance of the face, difficulty making expressions or fine movement, drooping, paralysis, difficulty eating (items fall out of the weak corner of the mouth), face feels pulled to one side or stiff, headaches, impairment of taste, sensitivity to sound

Treatment:

Oculoplastic surgery including temporary or permanent fastening of the corner of the eye, sometimes implants to the eyelid to improve eyelid closure, and sometimes procedures to lift the facial droop. Eye drops, eye ointments, or an eye patch are usually necessary to protect the surface of the eye.

Hemifacial spasm results in involuntary contraction of the facial muscles limited to one side of the face. The eyelids are involved, and upturning of the corner of the mouth is observed.

Signs and Symptoms:

• Facial twitching
• Involuntary closure of the eyelids

Treatment:

• Imaging of the head and brainstem are sometimes necessary to rule out a vascular abnormality
• Botulinum toxin (Botox) or oculoplastic surgery are also sometimes effective

Lagophthalmos is when the eyelid will not completely close. When the eye does not close completely or blink, the thin layer of tear fluid is not refreshed along the surface of the eye. This fluid helps promote a moist area for the eye. In addition, tears flush out the eyes. Some have nocturnal lagophthalmos meaning they sleep with their eyes slightly open. Having lagophthalmos of any kind can lead to abrasions, infections, corneal drying and ulceration.

Signs and Symptoms:

Inability to completely close eyelids

Treatment:

• Tear drops
• Eyelid repair

An orbital fracture is a break in one of the bones that make up the orbit. It can be a serious fracture and can threaten sight. The orbit is made up of parts of six bones: the frontal, ethmoidal, lacrimal, sphenoid, maxilla, and zygomatic bones.

Signs and Symptoms:

• Pain
• Sometimes double vision or a sunken eyeball

Treatment: 

Orbital repair

Orbital trauma encompasses injuries to the eye including the soft tissues, lacrimal system, and the bony orbit. The injury to the eye may not be obvious and may appear minor. Even minor injuries can lead to more complicated problems if not addressed early. If a patient feels that there has been trauma to their eyes, they should consult a physician immediately.

Signs and Symptoms:

Discomfort or trauma to the eye

Treatment:

Physician will determine treatment based on diagnosis.

An orbital tumor occurs within the orbit of the eye. The orbit is a complex structure that houses the globe, extraocular muscles, and fat, as well as vascular, nerve, glandular, and connective tissues. It is a relatively small area and therefore even a small tumor can occupy much needed space.

Signs and Symptoms:

Diagnosed during eye exam, in some cases the eye will bulge.

Treatment:

• Sometimes tumor excision
• Some types of tumors may need radiation or chemotherapy
• Other tumors can just be monitored

Basal cell carcinoma

Basal cell carcinoma is the most common form of skin cancer. Basal cell carcinoma (BCC) is rarely life-threatening but can be disfiguring and cause damage to adjacent structures – including the eyeball. It occurs mainly on the face and neck. 

Signs and Symptoms:

• Pimples that don’t heal
• Pink or red bumps, or red, scaly areas
• Eyelash loss
• Notching of the eyelid or spontaneous bleeding

Treatment:

Complete surgical removal and oculoplastic reconstruction of the area.

Squamous cell carcinoma

Squamous cell carcinoma is the second most common form of skin cancer. Squamous cell cancer may appear as a firm red bump, an abnormal patch of skin, or a sore that bleeds and does not heal. On the eyelids, eyelash loss or eyelid notching may be evident. It is highly treatable but it can metastasize. The most common places affected are sun-exposed areas such as the back of the hand, scalp, lip, and upper portion of the ear.

Signs and Symptoms:

• Firm red bump or unusual patch of skin
• Sore that bleeds and doesn’t heal

Treatment:

Complete surgical removal and oculoplastic reconstruction of the area.

Thyroid eye disease (TED) is a disorder that causes inflammation of the eye muscles or fat that may enlarge within the eye socket. As a result, the eyes bulge, the eyelids retract and often cannot close, and the eye's surface dries and becomes uncomfortable. The swollen muscles can exert pressure on the optic nerve and threaten vision loss, the most serious consequence of TED. An oculofacial plastic surgery specialist offers many rehabilitative surgeries for TED. Sometimes doctors specializing in strabismus surgery, radiation, and endocrinology are also necessary.

Signs and Symptoms:

• Enlargement of the eyelid openings or “buggy” eyes
• Facial asymmetry
• Dry scratchy eyes
• Poor or double vision

Treatment:

• Mild cases: artificial tears and lubricating ophthalmic ointment to relieve dry eyes
• Severe cases: administration of corticosteroid medications, external beam radiation, or a combination of these to reduce pressure on the optic nerve
• Depends on the severity, but may include steroids, orbital decompression surgery, eyelid surgery, and strabismus surgery.

Trichiasis is a medical term for misdirected eyelashes that grow toward the eye, sometimes touching the cornea or conjunctiva. Severe cases may cause scarring of the cornea and lead to vision loss if untreated. Mild cases may not require treatment. This can also be a result of entropion.

Signs and Symptoms:

Abnormally directed eyelashes

Treatment: 

Removal or destruction of the affected eyelashes. Removal with forceps, however with this method, the lashes grow back.