“Every mountain top is within reach if you just keep climbing.”
— Richard James Molloy
What is it ?
Oculoplastics, or oculoplastic surgery, includes a wide variety of surgical procedures that deal with the orbit (eye socket), eyelids, tear ducts, and the face. It also deals with the reconstruction of the eye and associated structures.
Oculoplastic surgeons perform procedures such as the repair of droopy eyelids (blepharoplasty), repair of tear duct obstructions, orbital fracture repairs, removal of tumors in and around the eyes, eyelid reconstruction.
What is Oculoplasty ?
Oculoplasty is surgery with relation to the eye and surrounding structures. Oculoplasty surgery may be performed in order to improve function, comfort and appearance for the following conditions: tear drainage problems, eyelid malposition, skin cancers of the eyelid, problems of the orbit (eye socket).
What is DCR ?
If the blockage occurs further in the drainage system pathway (nasolacrimal duct), you may require surgery to bypass the blockage and create a new pathway for tears to drain into the nose. The surgery, called DCR (dacryocsytorhinostomy)’)
Why is my doctor recommending surgery for watering of eyes ?
With age and/or trauma and scarring, the lids may stretch and pull away from the surface of the eye, and turn in (entropion) or turn out (ectropion). This results in eye irritation and watering. Surgery is used to restore the normal position of the eyelid. In case you have watering due to a nasolacrimal duct block, you will need a DCR.
Tears are produced by the lacrimal gland located in the upper outer portion of each eye. They normally drain from the eye through small tubes called tear ducts or nasolacrimal ducts( NLD) that stretch from the eye into the nose. A blocked tear duct occurs when the opening of the duct that normally allows tears to drain from the eyes is obstructed or fails to open properly. If a tear duct remains blocked, the tear duct sac fills with fluid and may become swollen and inflamed, and sometimes infected.
What causes a NLD Block ?
In babies, the most common cause of NLD Block is the failure of the thin tissue at the end of the tear duct to open normally.
Other less common causes of NLD Block in children include:
- Abnormal growth of the nasal bone that puts pressure on a tear duct and closes it off.
- Closed or undeveloped openings in the corners of the eyes (puncta) where tears drain into the tear ducts.
In adults, tear ducts may become blocked as a result of a thickening of the tear duct lining, nasal or sinus problems, injuries to the bone and tissues around the eyes (such as the cheekbones), infections, or abnormal growths such as tumors.
What are the symptoms?
Usually, the first symptom of NLD Block is excessive tearing, ranging from a wet appearance of the eye to tears running down the cheek. Babies who have blocked NLD usually have symptoms within the first few days to the first few weeks after birth. If infection occurs in the eye’s drainage system , you may see redness and swelling (inflammation) around the eye or nose. Also, yellow mucus can build up in the corner of the eye, and the eyelids may stick together. In severe cases, infection can spread to the eyelids and the area around the eye.
The symptoms of a blocked tear duct may get worse after an upper respiratory infection, such as a cold or sinus infection. Also, symptoms may be more noticeable after exposure to wind, cold, and sunlight.
How is NLD Block diagnosed?
A blocked tear duct is diagnosed based on a medical history and a physical exam. Also, tests may be used to measure the amount of tears or to see whether tears are draining normally from the eyes. Other tests can help your doctor find out where the blockage is or how it was caused?
Diagnosis is based on symptoms. The cause of the tear duct blockage must also be identified. Tests are determined by the patient’s age and symptoms. To determine the presence and extent of tear duct blockage, a fluorescein eye stain is used to observe the drainage of tears. An orange dye is placed in the eye using a dropper or blotting paper. After it covers the surface of the cornea, a blue light is shone on the eye to detect abnormalities on the cornea, including delays in tear drainage.
An internal examination of the nose may be indicated, especially if an injury has occurred. Imaging tests and x-rays also may be warranted to rule out other causes, such as a tumor. In adults, a fluid is irrigated through the nasolacrimal drainage system to locate and determine the extent of the blockage.
Treatment depends on the symptoms, the cause, and the age of the patient. If an infection is present, it is treated first. Antibiotic eye drops or ointment are usually prescribed.
A blocked duct in an infant is treated by gently massaging the area between the eye and nose several times a day. This treatment is usually successful in opening a blockage or helping to move a blockage that is in the process of self-resolving. If tearing is persistent beyond 1 year of age or if the affected eye is infected, a surgical procedure is performed.
In adults, the cause of the blockage must be determined. If an infection clears and the duct remains obstructed, or if an infection recurs, further treatment may be necessary. In children and adults, a duct can sometimes be reopened by placing a small probe into the duct. If this does not remove the obstruction, a silicone tube can be inserted to maintain an opening. In children, the tube usually must remain in position for 6 to 12 months, until the tear duct stays open by itself. The drawback to this method is that a second procedure may be necessary to remove them.
If conservative measures fail, patients may require a procedure called dacryocystorhinostomy, the creation of a new passage for tears to flow. This is performed in a hospital, under general anesthesia. The procedure is more than 90% successful in relieving the blockage.
If the tear duct is damaged beyond repair due to chronic infection or injury, an artificial duct can be surgically implanted. The artificial tear duct, called a Jones tube, is placed behind the inner corner of the eyelid to drain tears into the nose.
Tumors or nasal polyps that cause obstruction usually are removed surgically.
In many cases, tear duct obstruction cannot be prevented. Safety precautions should be taken when playing contact sports and performing other types of physical activities (e.g., wearing helmets and face masks) to prevent trauma to the face. Prompt and adequate treatment for nasal and eye infections may also reduce the risk.
What is Ptosis?
Ptosis (pronounced toe’ sis), or drooping of the upper eyelid, may occur for several reasons such as: disease, injury, birth defect, previous eye surgery and age. In most cases, it is caused by either a weakness of the levator muscle (muscle that raises the lid), or a problem with the nerve that sends messages to the muscle Children born with ptosis may require surgical correction of the lid if it covers the pupil. In some cases, it may be associated with a crossed or misaligned eye (strabismus). Left untreated, ptosis may prevent vision from developing properly, resulting in amblyopia, or lazy eye. Patients with ptosis often have difficult blinking, which may lead to irritation, infection and eyestrain. If a sudden and obvious lid droop is developed, an ophthalmologist should be consulted immediately
Signs and Symptoms
The causes of ptosis are quite diverse. The symptoms are dependent on the underlying problem and may include:
- Drooping lid (may affect one or both eyes)
- Irritation: Difficulty closing the eye completely
- Eye fatigue from straining to keep eye(s) open
- Children may tilt head backward in order to lift the lid
- Crossed or misaligned eye
- Double vision
Detection and Diagnosis
When examining a patient with a droopy lid, one of the first concerns is to determine the underlying cause. The doctor will measure the height of the eyelid, strength of the eyelid muscles, and evaluate eye movements and alignment. Children may require additional vision testing for amblyopia.
Ptosis does not usually improve with time, and nearly always requires corrective surgery by an ophthalmologist specializing in plastic and reconstructive surgery. In most cases, surgery is performed to strengthen or tighten the levator muscle and lift the eyelid. If the levator muscle is especially weak, the lid and eyebrow may be lifted. Ptosis can usually be performed with local anesthesia except with young children.
Patients with ectropion have a sagging lower eyelid that leaves the eye exposed and dry. It is caused by a lack of tone of the delicate muscles that hold the lid taut against the eye. Excessive tearing is a common with ectropion, but wiping the tears away only causes the lid to sag more. Ectropion is most common among people over the age of 60.
Signs and Symptoms
- Gritty, sandy feeling
- Excessive tearing
- Red, irritated eyelid
Detection and Diagnosis
Ectropion can be diagnosed with a routine eye exam.
The irritation can be temporarily relieved with artificial tears and ointments to lubricate the eye; however, surgery to tighten the lid is usually necessary to correct this problem.
Entropion, an eyelid that turns inward, is a problem that typically affects the lower lid. It usually stems from a muscle spasm; however, it can also be caused by scarring from trauma or inflammation from certain diseases that involve the eyelids. When the eyelid turns inward, the lashes rub against the eye, resulting in irritation, scratchiness, tearing and redness. Surgery is often required to correct the problem.
Signs and Symptoms
- Sandy, gritty feeling
- Red eye
Detection and Diagnosis
Entropion can be detected during a routine eye exam. A slit lamp microscope is used to examine the effects of the in-turned eyelashes on the surface of the eye.
The most effective treatment for entropion is surgery, although some patients find temporary relief by pulling the lower lid down with a piece of tape. Artificial tears are also helpful to ease the irritation caused from the lashes rubbing against the eye.
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