Oculoplasty

Oculoplasty or Oculoplastic surgery is the cosmetic, corrective, and reconstructive surgery of the eye.
Oculoplasty deals with various disorders of orbit, eyelids and Lacrimal system.
Oculoplasty involves the socket in which the eye is placed and also the related structures around the eyes, like eyelid, eyelashes, lacrimal apparatus etc.

Cosmetic Procedures

Eyelid

One of the first areas of the body to exhibit signs of aging is the area around the eyes. Under eye bags and sagging upper eyelids that come with age can be corrected through cosmetic eyelid surgery. This relatively minor cosmetic correction can refresh the appearance of the face and leave it looking years younger. Cosmetic eyelid surgery dramatically improves the appearance of tired, droopy eyes. This is accomplished by removing excess skin and pockets of fat from the upper and lower eyelids. Many patients combine eyelid surgery with other treatments, such as brow lifting to eliminate drooping eyebrows and various cosmetic dermal fillers or other agents to reduce facial wrinkling.

Who is a candidate for Eyelid Surgery?

Cosmetic eyelid surgery is best suited to patients in good physical health who have realistic expectations about the outcome. While most are more than 35 years old, some younger patients who have inherited droopy eyelids elect to undergo eyelid surgery at an earlier age. You may be a good candidate for eyelid surgery if you have any of the following conditions:

Upper Eyelids
  • excess skin that hides the natural fold of the upper eyelids
  • loose skin that hangs down from the upper eyelids
  • puffiness in the upper eyelids that creates a tired look
Lower Eyelids
  • excess skin and fine wrinkles of the lower eyelids
  • puffy “bags” and, in some cases, dark circles

Those who may not be well suited for eyelid surgery include patients who suffer from insufficient tear production or patients with severe dry eye syndrome.

The Eyelid Surgery Procedure

Cosmetic eyelid surgery can be performed on either the upper, lower or both lids. The goal for the upper lids is usually to lift it by removing excess skin. For the lower lids, a combination of excess skin and fatty deposits are removed to eliminate the bag under the eyes. The result of either or both is a smoother, more youthful and well-rested appearance. Patients can expect the results to last for many years. Over time a small amount of excess skin or fat may be noticed. If this does occur, the skin or fat can easily and safely be removed.

Brow Lift / Forehead Lift

The brow lift is a rejuvenating surgical procedure aimed at restoring a more youthful appearance to the brow, forehead and indirectly, the upper eyelids. Patients seeking brow lifts usually have sagging brows and forehead skin. Typically this causes the patient’s eyes to look tired and upper lids to look heavy. They also notice deeper horizontal wrinkles in the forehead.

The brow lift is primarily designed to restore a more youthful position of the brow giving it a beautiful arched look. The operation involves the tightening or lifting of the select facial muscles responsible for the drop in brow position. At the same time, it smoothes the forehead, reduces wrinkles between the eyes and can, to a lesser degree, reduce the appearance of skin excess in the upper lids.

Who is a candidate for Brow Lift Surgery?

A brow lift is most commonly performed in the 40 – 60 age range to minimize the visible effects of aging. However, it can also help people of any age who have developed furrows or frown lines due to stress or muscle activity. Individuals with inherited conditions, such as a low, heavy brow or furrowed lines above the nose can achieve a more alert and refreshed look with this procedure.

The Brow Lift Surgery Procedure

When performing a brow lift procedure, muscles and tissue areas that droop or cause creases are lifted or corrected to smooth the skin on the forehead to reduce frown lines and raise the eyebrows. There are several surgical brow lifting procedures, and during your initial consultation, the procedure that works best for you will be recommended.

Brow lift surgery results in a more rested and revitalized appearance of the upper portion of the face. This surgery reduces the angry, unhappy, sad, or tired appearance. The improvement often lasts many years.


Functional Procedures

Eyelid ptosis


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.

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. The 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 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 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.

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

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.

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.

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 congenital ptosis?

This is drooping of the eyelid, affecting one or both eyes, present since birth.

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 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 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 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 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).

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.


Entropion


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.

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 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.

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 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.

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.


Ectropion


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.

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 types of surgery are there for ectropion?

Ectropion surgery is done by an oculoplastic surgeon, under local anesthesia, 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.

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 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.

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.



Instructions after Surgery

Reducing swelling and bruising

These instructions are for adult patients to help reduce eyelid swelling:

1. Eyepad

You may leave the operating theatre with an eye pad on. Please do not remove the eye pad before the time instructed to by the surgeon.

2. Reduce eyelid swelling by sitting up

Sit up as much as possible during the day and sleep with your head propped up on 2 to 3 pillows at night the first few days after your surgery.

3. Cool eye masks / ice packs

Once you have removed the eyepad, or if you do not have one, you should begin cool eye mask or ice pack treatment as soon as possible.

Ice Pack Treatment

1. Specially designed masks are available from chemists – you would need to purchase several so that there is always one cooled.

2. Alternatively, a small bag of frozen peas or similar wrapped in a clean cotton cloth will make a good ice pack. If ice cubes are used they need to be in a non-leaking clean clear plastic bag.

3. Sitting upright, put some clean gauze over the eyelids then apply the icepack. This can be cold and you need to hold a cloth in your hand or wrapped around your head in order to secure the icepack.

4. Try icepack application for 45 minutes every hour during waking hours if possible, but if you cannot manage this, anything longer than 15 minutes every hour is satisfactory.

5. Continue icepack applications for 3 days after surgery.

Procedure:

1. After cleaning the eyelids, place clean gauze gently over them, then apply the ice pack for a minimum of 15 minutes every hour for 48 hours. Then reduce for the next two days to 15 minutes every 3 hours.

2. 4 days after surgery switch to warm flannel applications for 15 minutes every 3 hours for 3 days.
For further instructions re eyelid cleaning, sutures (stitches) and how to put in eyedrops, please enquire at the Clinic.