Oculoplastic and Aesthetic Conditions

WHAT IS PTOSIS?

Ptosis is a condition that occurs when one or both upper eyelids droop and the edge of the upper eyelid falls towards or over the pupil. Ptosis is usually caused by stretching or thinning of the tendon between the muscle that raises the eyelid and the eyelid itself. With stretching or thinning, the muscle that normally raises the eyelid has to work harder to lift it. This leads to symptoms of eyelid and forehead muscle fatigue, and eyelid heaviness. Children can also be born with congenital ptosis where the muscle is abnormally stiff and does not function well. This condition usually lasts until it is surgically corrected.

HOW IS PTOSIS CORRECTED?

To correct ptosis, the surgeon needs to make an incision or cut the skin of the upper eyelid in order to reach the muscles and tendons.

WHEN MAY EYELID SURGERY BE NEEDED?

With age, the skin and muscles of the eyelid can sag and droop. In addition, the fat that surrounds and cushions the eyeball can bulge forward through the skin of the upper and lower lids. Excess skin, muscle, and fat can weigh down the upper lid and, in some cases, block your vision. This can lead to fatigue, eyestrain, skin irritation, and loss of peripheral vision. Excess skin, muscle, and fat also create what many feel is an unattractive, aged appearance, especially in the lower lids (“bags under the eyes”).

WHAT IS BLEPHAROPLASTY?

Blepharoplasty is the removal or repositioning of skin, muscle, and fat of the upper and/or lower lids. In the upper lid, the incision is made and hidden in the natural lid crease. For the lower lid, an incision can be made through the skin just beneath the lashes, or through the moist inside surface if the lid called the conjunctiva.

WHAT CAN CAUSE ENTROPION?

With age, the skin and muscles of the eyelid can become lax. This can result in inward rolling of the eyelid margin, usually the lower lid, towards to the eye. This can result in the lashes constantly rubbing the cornea or the conjunctiva. Occasionally, the condition is caused by scarring of the inner surface of the eyelid, caused by inflammation, chronic infections or trauma.

WHAT IS THE TREATMENT FOR ENTROPION?

Long-standing, uncorrected entropion can lead to gradual scarring of the cornea, as well as increase the risk of infection of the cornea. It is therefore important to try to correct this condition before the complications of scarring permanently impair vision.

Epiblepharon refers to an in-turning of the eyelashes caused by an abnormal congenital horizontal fold of skin near the upper or lower eyelid. This condition is typically seen in children and young adults of Asian descent.

Symptoms:

The most common symptoms that these patients have are itch and redness of the eye, tearing, and children especially are noted to have frequent rubbing or blinking of the eyes. These symptoms arise due to the constant friction from the lashes which touch the clear surface of the eyes (cornea). If chronic, it can even lead to permanent scarring of the cornea.

What kinds of treatment are available for Epiblepharon?

Treatment depends on the severity of the condition and whether there is evidence of permanent damage to the cornea surface. Some children with mild epiblepharon get better on their own as they get older. This occurs with growth and elongation of the facial structures. Mild cases can therefore be treated with lubricating eye drops or ointment. In severe cases, surgery may be required. Surgery involves stitches to turn the lashes out accompanied by the removal of a small amount of skin and muscle, through a small cut just beneath the lashes in the lower lid and through the double fold in the upper lid.

WHY DO BLOCKED TEAR DUCTS REQUIRE SURGERY (DCR = DACRYOCYSTORHINOSTOMY):

The cure for a blocked tear drainage system is DCR. Because of age, injury, or chronic sinus disease, the bony tunnel that drains tears from the eye into the nose can become blocked. Tears may then back up and run down the cheeks and, in some cases, an infection can develop underneath the skin between the eye and the nose (“dacryocystitis”). Many patients complain also of a sticky discharge and eye irritation.

HOW IS DCR SURGERY PERFORMED?

This surgery can be performed with the use of a scope through the nose, which avoids a scar on the skin, or it can be performed externally through a cut on the skin near the inner corner of the eye.

A flexible stent tube may be left in place for a few weeks to months (sometimes longer) to keep the new drain open. This tube can be removed in the clinic. The goal of surgery is to eliminate tearing, discharge, and irritation, and reduce the risk of infection. Surgery can be performed under local or general anesthesia and usually takes about an hour to an hour and a half.

What is Thyroid Eye Disease?

Thyroid eye disease (TED) is an eye condition related to thyroid disease. Patients with excessive thyroid hormone in the circulation (hyperthyroidism) can develop eye diseases. Hence patients with Thyroid hormone problems should get an assessment by an eye doctor who manages Thyroid eye disease patients. Such patients may require more intensive follow-up if their symptoms are severe. Early monitoring and treatment of the Thyroid Eye disease is beneficial to prevent long term complications.

The Eye symptoms include the following:

• Bulging or prominent eyes
• Eyelid retraction (“staring appearance”)
• Swelling of the eyelids
• Frequent redness and tearing of the eyes
• Dry eyes
• Double vision due to swelling and stiffness of the eye muscles
• Loss of vision from the compression of the optic nerve (rare but serious complication)

What causes Thyroid Eye Disease?

Thyroid eye disease is part of an autoimmune disease that affects the tissues surrounding the eye. The body produces antibodies that attack its own tissues, specifically the fat around the eyes and the eye muscles. It can precede, coincide or follow the diagnosis of thyroid dysfunction of the rest of the body. It is known to be about 2.5-6x more common in women, however it is usually more severe when it occurs in a male.

Treatment of Thyroid Eye Disease

The treatment depends on the severity and activity of the condition. The condition typically goes through a cycle of active phase followed by a quiescent phase which can span over 18 to 24 months from the time of the diagnosis.

If the condition is mild and the main symptoms are dry eyes, then copious and frequent lubricants will be prescribed. Should the condition be active and severe, the patient may require suppression of the immune system either with oral or intravenous steroids or other forms of immune suppression. Usually surgery is reserved for the more serious conditions, where there could be compression of the optic nerve and compromise of the vision, or severe exposure of the eyes from extreme protrusion of the eyes. Other forms of surgery may be needed if the double vision from tight muscles is persistent, or if eyelid surgery is required to lower the eyelid and reduce exposure of the eyes.

Patients who have lost the eye due to trauma or diseases such as tumors, may require socket reconstruction in order to restore some normality in the appearance of their eyes. This may involve replacement of the volume of the eyeball with a special ball implant, reconstruction of the surrounding supporting tissues of the eye with grafts and customized fitting of the prosthetic eye (false eye).

Some long-term problems that may arise in such patients include:

• Discharge or discomfort from the wearing of the prosthesis (false eye)
• Difficulty with retaining the prosthesis in the eye,
• Progressive contracture of the supporting tissues surrounding the eye leading to a sunken deformity especially in the upper lid
• In-turning of eyelashes from laxity and lack of support the lid structures

The management of these conditions depend on the nature and severity of the condition. A mild allergy or irritation from constant friction to the prosthesis can be treated with eyedrops while progressive shortening of the grooves between the eyelid and eyeball or ball implant or contracture of the surrounding tissues may require more extensive surgery to reconstruct the whole socket area.

Wrinkles at the corner of the eye contraction of (Crow's Feet)

It has been used safely to treat unwanted wrinkles and frowns of the face. Wrinkles occur when we make repeated facial expressions from the contraction of our facial muscles. Botox can be used to target specific muscles to relax these muscles and hence eliminate the dynamic wrinkles. This results in a less wrinkled, more relaxed and more youthful appearance.

The injections are done with a very fine needle by our trained specialist and treatment takes about 10-15minutes. The discomfort and sides effects are minimal and the effect of the botox can be appreciated after 3-7 days. The effects of Botox can last from 4-6 months depending on each individual.

As our skin ages, it loses it natural ability to retain moisture. This is made worse by chronic sun exposure and smoking. The face also loses volume and fat resulting in a more sunken appearance. Fillers containing hyaluronic acid (natural sugars normally present in the skin) can be used to fill up static wrinkles and scars in order to smoothen the skin surface. Fillers can also be used to replace the volume loss, resulting in a more youthful and rejuvenated appearance. Commonly treated areas include the laugh lines (lines along the side of the nose), the tear trough (sunken area beneath the eyebag region), marionette lines (lines from the corner of the mouth), jaw line and cheek areas.

The injections can be done on the same day of consultation and takes about 20-30minutes. The results can be seen almost immediately and the effects can last from 9-18 months depending on the type of filler used.

About 50% of Asians are born without a double fold in the upper lid. This can result in down-turned lashes which may occasionally touch and rub the clear part of the eye (cornea). A lack of a double fold may result in apparently smaller looking eyes. There are various methods which can be performed to create the double fold and improve the appearance of the eyes. Very often these procedures result in a brighter, refreshed look with bigger looking eyes. These procedures can be performed in our specialized procedure room within our clinic. Depending on the type of eyelid shape, skin thickness and presence of excess upper lid skin, our specialists will recommend the most appropriate surgery for you. This ranges from the non-incision method (stitches alone), to the small incision method to the full incision method. The non-incision and small incision method have a shorter downtime and can be performed within 30-45 minutes under local anaesthesia.

As the skin and supporting structures around the eyes sag, the fat that cushions the eyeball can also bulge forwards underneath the skin of the upper and lower lids. This often results in the unsightly bulge beneath the eye, which we term as “eyebags” This often makes a person look older and more tired as it is often accompanied by dark eye circles as well. Surgery can be performed to remove the fat or reposition the fat to reduce the bulge beneath the eyes and smoothen and rejuvenate the area beneath the eyes. This can be done either through a scar-less procedure from a hidden cut or through the skin just beneath the eyelashes should excess skin need to be removed.