Ophthalmic Plastic & reconstructive Surgery

Ptosis is the medical term for drooping of the upper eyelid, a condition that may affect one or both eyes.

Droopy eyelid (ptosis) can occur in children from birth (congenital). It can also result from injury, muscle disorder, nerve disorder, or due to aging process.

In children severe drooping of upper lid can obstruct vision development leading to a lazy eye (amblyopia) It gives a sleepy appearance, and abnormal head posture such as chin elevation.

In adults, droopy eyelid is mainly a cosmetic concern, however if severe enough it can obstruct vision. Continuous effort to keep eyelids ehevated leads to forehead wrincles & fatigue.

Except some rare muscle disorder (Myasthenia), management of droopy eyelid is surgery which can correct this problem by repairing the muscle that lifts the eyelid. Several surgical options are available, and the type of surgery used depends upon the severity of the droop. After evaluation, your specialist will decide which surgery best suits your need.

(Ectropion, Entropion, Lid retraction)

Normally the eyelid remaims in contact with eyeball and the lashes are directed outwards. During straight gaze (looking forward), upper lid covers a small part of central black portion (cornea) of eyeball, whereas lowerlid remains just at the lower border of the same (cornea).

Eyelid malposition means abnormal position of the eyelid.

It can be inward turning (Entropion) or out turning (Ectropion) of the eyelid margin; or the whole eyelid can be retracted from eyeball (lid retraction).

This can occur as a birth defectin a child (uncommon), or secondary to injury or aging (common).

Eyelid malpositions lead to eye irritation, watering, foreign body sensation, dryness and even a cosmetic blemish. These can be corrected by various eyelid plastic surgery.

The lacrimal (tear) glands produce tear constantly to keep the eye lubricated. The tears drain away from the eye through the lacrimal drainage system.

Dacryology deals exclusively with watering of the eyes and disorders of the tear drainage. Any disorders affecting this system can lead to impaired tear flow with resultant watering,

Infection of the large drainage pathway (lacrimal sac) leads to dacryocystitis (NASOOR), which may progress to orbital (back part of eye) infections.

Blockage of the tear drainage pathway can occur as birth defect (CNLDO). Simple lacrimal sac compression can relief the condition. If not resolved by 1 year of age, here at CLGEI, babies can be examined under anaesthesia with endoscopic (DOORBIN) guidance through nose by highly specialized and skilled doctors and the condition can be cured.

Blockage of the tear drainage pathway in adult needs a bypass surgery called Dacryocystorhinostomy or DCR. By this surgery a new drain is created between the eye and nose. This can be done either through skin side or through nose using endoscope (DOORBIN). Surgery through nose gives absolutely scarless (bina daag/nishan) operation.

Accident, injury or trauma can affect any part of the body including face & eyes. After injury, patient’s life should be stabilized first. Once life threatening conditions are taken care of (mostly in multi-specialty hospitals), attention needs to be given to the face, and particularly the eye region. Injury can affect any structure of the eyelid, eyeball and the surrounding bones (fractures) depending upon the mechanism and force of injury.

Eyelid is a delicate and important structure, and if injured, needs meticulously repaired to preserve its normal shape and function. Also to prevent post-operative ugly looking scar and malposition of facial structures, the surgeon needs to put appropriate stitches (materials & thickness).

Injury to the tear ducts (canaliculus) within the eyelids require special placement of silicone tubes within them to keep them open while the injured eyelid heals.

Fractures of the bone surrounding the eye (orbital walls) may cause the eyeball to sink back into its socket. It can also lead to facial deformity, poor eye movement, or loss of vision.

Apart from thorough ocular examination, imaging (CT or MRI) is often required to know the extent of injury and plan management accordingly.

Management of oculo-facial trauma needs multidisciplinary (oculoplastic surgeon, maxillofacial surgeon) approach and often staged procedures. The outcome of trauma repair entirely depends upon extent and severity of injury.

Thyroid eye disease is a condition wherein one or both eyes bulge forward and the eye aperture gets widened giving a frightening and staring look to the individual. The eye condition may or may not be associated with abnormal thyroid hormone level in the body (hyper or hypo thyroidism). In this disease, there is swelling of the soft tissues around eyeball (muscle, fat). This can lead to ocular discomfort such as watering, redness and bulging of eyeball leading to corneal dryness and even frank infection (ulcer). Swelling of the muscles of eye can lead to double vision and in severe cases loss of vision due to pressure on nerve.

The initial (active) phase of thyroid eye disease involves frequent swelling of tissues around the eyes and is treated with medications (commonly Steroids). Fortunately, the active phase of most thyroid eye disease patients lasts for 18-24 months. However, the deformities (prominent eyeball, raised eyelids, or squint) may persist, and require surgery in the second (inactive) phase.

Decompression surgery is typically done first to sink the prominent eyeball into bony orbit. This may need to be followed by eyelid surgery to reduce eye aperture. Finally, if the patient has persistent double vision, squint surgery may need to correct that.

The muscles of facial expression and the eyelid are normally under our voluntary control. Facial spasm is a condition in which these muscles function abnormally and are no longer under the direct control of the brain. It can affect the entire face, or just the area around the eyes.

Four distinct forms of facial spasm are known:

Benign Essential Blepharospasm – In this condition there is involuntary contraction of muscles around both eyes. It may result into rapid fluttering of eyelids, difficulty in opening eyelids, or forced contraction of the lids & brows.

Meige syndrome – When the contraction also involves all facial muscles and neck muscles, it’s called Meige syndrome.

Hemifacial spasm – It is uncontrolled contraction of the muscles on one side of face, usually including the eyelids.

Myokimia - It is a more localized form of spasm, that typically involves a single eyelid or periocular area.

Treatment of blepharospasm & hemifacial spasm with medications is difficult. The benefits are variable and short lasting with often undesirable side effects. The most common and effective treatment of these conditions are with Botulinum Toxin injections. Botulinum toxin A is approved by FDA for treatment of these disorders. The toxin is injected into the muscles at several sites around the eyelids, brows and face to prevent unwanted contractions.

Injection procedure is performed as an out patient procedure. Application of anesthetic cream an hour before the procedure makes it almost painless. The effect takes 7-10 days to come, and can last for 3-4 months.

Botulinum toxin controls the spasm, and does not treat it. Therefore, repeated injections are required for continued effect. This treatment is safe and effective. Side effects are uncommon and transient, and may include droopy eyelids and double vision.

Some patients may be non-responsive to Botulinum toxin injections, and would need surgical procedure to control spasm.