Ophthalmic Plastic Surgery and Orbitofacial Aesthetic Surgery Dr. Savari Desai Ophthalmic plastic surgery is a branch of ophthalmology that deals with disorders and diseases of the eyelid, socket, lacrimal (tear drainage) system and orbit. It is fast emerging as a well-demarcated subspeciality and has carved a niche for itself, and requires that the ophthalmologist be well trained in it. The field of ophthalmic plastic and reconstructive surgery represents a perfect blend of science and art. It is an optimal amalgamation of time-tested reconstructive techniques and modern day aesthetically oriented approaches. There has been a shift in focus from merely 'removing lesions' to removing them 'aesthetically', with minimally invasive techniques. Harnessing the fine microsurgical skills acquired from ophthalmology, the ophthalmic plastic surgeons have ventured into the exciting field of Orbit and Facial Aesthetic Surgery. Recent paradigm shifts in this field have extended the clinical spectrum from simple eyelid problems to complex surgery. This update will focus on new developments in this subspecialty that have most significantly affected patient care. Eyelid Lesions Chalazion Chalazion, the common eyelid nodule is as well known to the ophthalmologist as the common cold is to the general physician. A chalazion is often mistaken for a stye,
however it grows away from the eyelashes and follows a slow course at presentation, unlike a stye which presents acutely at the lid margin. For larger lesions, incision and curettage has been the standard practice in removing a chalazion in the operation theatre. Intralesional steroids and 5 Flurouracil are effective for small to moderate sized lesions with higher patient acceptance due to minimal discomfort and also since it is an OPD procedure. Intralesional 5 Fluorouracil, a well-known anti-fibrotic agent has also found to be safe and effective. Ptosis (drooping of the eyelid) Sling it! Ptosis, can present at birth (congenital), during childhood, or later in adult life. Surgeries such as levator resection or conjunctivomullerectomy are required in cases of mild to moderate ptosis. Severe ptosis is commonly seen in children may require a more versatile surgery. Severe congenital ptosis that obstructs the visual axis requires early correction to prevent amblyopia (lazy eye). Traditional sling surgery requires multiple incisions over the eyelid and forehead, often leading to unsightly scars. The sling also needs revision as the child grows up. Silicone rod sling surgeries have been reported to be effective for correcting ptosis. A silicone rod is a versatile, elastic band and can be adjusted, as the child grows. Its flexibility makes it a good choice in conditions of severe myogenic ptosis, where minimal lagophthalmos (eye exposure) is desirable. The end cosmetic results are excellent. Following the surgery, the child does need a regular detailed ophthalmic evaluation. This is required to routinely monitor the progress in visual growth. Facial Palsy and Lagophthalmos Gold Weight implants Lagophthalmos or incomplete closure of the eyes results from permanent facial nerve palsy such as Bells palsy, post acoustic neuroma surgery. It is can be managed with eyelid gold weight implants rather than a tarsorrhaphy (suturing the eyelids
together). The implant is inert to the body and hence remains well placed. The implant provides dynamic mobility to the eyelids and the outcome is cosmetically aesthetic. Vascular Eyelid Lesions Various types of complex lesions such as vascular malformations can arise on the eyelids, due to its anatomical structure and vascular pattern. These tend to bleed profusely during surgery. We can combine surgical removal of these lesions with a medical grade glue known as cyanoacrylate glue, allowing the lesion to be excised precisely without excessive bleeding, hence providing a near scar free surgical outcome. Other eyelid lesions such as hemangiomas, lymphangiomas, cysts are removed with small, hidden incisions so as to practically make the surgery free of scars. Plexiform Neurofibromas of the Eyelid Neurofibromatosis is a multisystem genetic disorder that is commonly associated with skin, neurological, and orthopedic manifestations. Neurofibromas are amongst the most common facial hamartomas. Most patients born with this condition often suffer from a social stigma due to the grotesque appearance of the eyelids and the facial lesions. Due to the nature of neurofibromas, which infiltrates tissues, these lesions are very vascular. They are not circumscribed or encapsulated and are difficult to remove completely. A technique involving debulking of the lesions, by matching it to the opposite eyelid shape achieves near normal facial symmetry. The surgery is usually done in two or more stages to achieve mobility of the eyelids. Socket Rehabilitation of a disfigured blind eye: Ocular Prosthesis and Implants. Disfigured blind eyes, intraocular malignancy or eyes with severe trauma often need to undergo destructive procedures such as enucleation and evisceration. In the
empty socket the placement of an orbital implant restores volume, and enhances the cosmetic correction provided by a well matched ocular prosthesis. The myoconjunctival technique of enucleation using non integrated silicone or PMMA implants is a unique and inexpensive surgical technique, which allows life like movements of the prosthetic eye. Over the years, the 'stock eye' which is a poorly matched and poorly tolerated ocular prosthesis, has paved way for a custom ocular prosthesis. The fabrication of a custom ocular prosthesis is a blend of science and art resulting in an artificial eye with perfect fit and comfort. Lacrimal Surgery Watery eyes A patient with a watering eye, finds it difficult to constantly keep wiping away the excess tears. Blockage of the tear duct is a common condition, occurring in newborns as well as older patients. Since its introduction, Dacryoscystorhinotomy (DCR) has been constantly evolving. It works by making a new drainage system through a small near hidden incision. External DCR remains the gold standard for the treatment of nasolacrimal duct obstruction. Endonasal DCR, a minimally invasive procedure is gaining popularity because of its potential to avoid an external scar. This technique however is yet to evolve to match the success rates of an external DCR which is as high as 95 to 98%. Congenital nasolacrimal duct obstruction in children, often presents with discharge, watering and swelling near the medial canthus of the eye. This is due to in the incomplete opening of the nasolacrimal duct at the time of birth. Hydrostatic massaging taught to the parents, will help relieve the condition. In more resistant cases, nasolacrimal duct probing done under a short general anaesthesia helps in opening the blocked duct. Lacrimal Punctal stenosis :The tears, which are formed in the eye, are removed by a well-formed drainage system in the eye. The tears drain through the lacrimal puncta (a small opening on the eyelid margin) into the canaliculus and nasolacrimal duct. In older people, watering can be due to narrowing of the lacrimal puncta and this is
known as punctal stenosis. This small but important finding is often over looked in most cases. This can be treated by making the punctual opening larger by means of a punctoplasty. Orbital Surgery Irrespective of the surgical indication, placement of incisions for orbitotomy itself has shown a drastic shift to 'transconjunctival' and hidden 'eyelid crease' incisions over the classical skin approach. Conditions such as orbitopalpebral cysts and lymphangiomas are treated with minimally invasive sclerotherapy rather than surgical excision. Thyroid Eye Disease Prominent bulging eyes, eyelid retraction, double vision, difficulty in moving the eyes, decrease in vision, puffiness of the eyelids and dryness of the eyes are just some of the manifestations of thyroid eye disease. Every patient who is undergoing treatment for a thyroid condition should have a complete ophthalmic examination with special examination for 'thyroid eye disease'! It is a complex disease, which requires treatment in the form of oral or intravenous steroids. Prominent bulging eyes, causing cosmetic and functional impairment of vision require orbital decompression. Orbital decompression for Thyroid Eye Disease too is performed through hidden sub-centimeter eyelid crease incisions, and has become a lot safer than before. Aesthetic Eye The skin loses its elasticity and tone, allowing wrinkles to form easily as we age. Rejuvenation is a combination of non-invasive procedures such as Botox, fillers, along with surgical procedures such as blepharoplasty, browplasty and midface lift. The concepts have changed from reversing aging to slowing the process of aging thereby enhancing your natural features. Critical aging changes in the periorbital
area include glabellar frown lines, horizontal forehead lines, crow's feet and tear trough deformity. Botulinum Toxin Ophthalmologists first introduced botulinum toxin to the medical community in the 1980s as a treatment for squint and blepharospasm. Oculoplastic surgeons have begun using botulinum toxin for aesthetic purposes since the early 1990s. Botulinum toxin treatment is probably the single most important advance in aesthetic facial surgery of the last decade because it offers a non-invasive technique with more predictable and reversible results. Botox, is a simple procedure. The patient can just walk in and out of the outpatient department after getting the treatment. Local anesthetic creams aid in the process of making the injection of botox relatively painless. Facial Dystonia Undo the spasms Dystonias are abnormal involuntary sustained muscle contractions and spasms, often characterized by blepharospasm, which manifests as abnormal blinking, eyelid tics or twitch resulting from any cause. You may have seen a person walking in the crowd who appears to be winking or grimacing his face. This condition is known as hemifacial spasm or benign essential blepharospasm. Both of these are a part of a spectrum of facial dystonias or involuntary muscle contractions. These conditions not only result in social stigma but also prevent the person from doing normal dayto-day activities such as reading, crossing the road, or simply opening their eyes. Botox given in various quantities, helps relieve these spasms. In severe cases of benign essential blepharospasm, surgery may be required, which removes the source of the contracting muscle and provides the patient with immense relief! Thyroid eye disease lid retraction
Eyelid retraction presents with the classical staring look of a thyroid patient. Botox can be used to decrease this lid retraction temporarily, allowing the patient to appear less frightening! Soft Tissue Fillers While Botulinum toxin works well for dynamic wrinkles, static wrinkles and soft tissue volume loss requires a filler. In the periorbital area, focal loss of volume along the orbital rim unveils the contours of orbital fat bound by the arcus marginalis. There are three periorbital hollows of importance to the ophthalmologist while planning periorbital soft tissue augmentation and include the orbital rim hollow, the zygomatic hollow and the septal confluence hollow. Hyaluronic acid is the most commonly used filler, and can typically last for up to a year. It is also used for reformation of the brow fat pads, and to recreate the lower eyelid orbicularis roll. Recently, soft tissue fillers have been reported as a successful non-surgical option for the management of mild to moderate eyelid cicatrix/scars or lower eyelid retraction. Soft tissue fillers cause the lower eyelid to stretch and expand the tethered anterior lamellae, correcting the pathology without actually performing a surgery. The Future In conclusion, the extremely interesting field of ocular plastic surgery is in a state of constant flux with rapidly changing thought processes and approaches allowing the transition from traditional to advanced, from more extensive to more refined, and from invasive to minimally invasive. The bottom line appears to be less is more.
How to instill eyedrops The patient is asked to look up and tilt the head slightly back. The lower eyelid is pulled down slightly while the patient keeps looking up and only one drop should be put in the space created by pulling the lower eyelid. The patient then closes the eye and the excess drop fallen out of the eye can be wiped away. To avoid the absorption of the eyedrop into the systemic circulation the patient should apply a firm pressure with his index finger for about two minutes in the area between the nose and the inner corner of the eye.