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Overview
Oculoplastic surgery is the cosmetic, corrective,
and reconstructive surgery of the eye. It manages
and repairs problems primarily related to the
tissues or structures surrounding the eye, rather
than the eyeball itself. These structures include
the eyelids, the tear ducts, and the orbit (bony
socket surrounding the eye). Ophthalmic plastic
surgeons are board-certified ophthalmologists who
have completed several years of additional, highly
specialized training in plastic surgery.
Cosmetic Surgery
Blepharoplasty,
also known as an eyelift, removes excess skin and
fat in the upper eyelids and excess fat in the
lower lids. The procedure can also be done on just
the upper or lower eyelids. It may be accompanied
by an eyebrow lift and cheek lift as well.
This procedure is done for cosmetic reasons. Over
time, the eyelids become baggy or droopy because
the skin stretches and fat pockets become more
prominent. This is most commonly a result of
aging, but sagging eyelids also run in families.
When eyelids droop, it may give the impression of
being tired or appearing older.
Eyelid plastic surgery is usually done under local
anesthesia in a plastic surgeon’s office. The
surgeon makes incisions in the natural creases of
the upper lid and removes the excess fat and skin.
The incisions are closed with fine stitches, and
scarring is often completely unnoticeable because
the incisions are hidden in the creases.
Lower lid surgery is performed much the same way.
Incisions are made on the inner or outer surface
of the eyelid, excess fat is removed, and the
incisions are sutured. Inner incisions are not
visible, and outer incisions are barely visible
and fade over time.
Complications
Swelling and bruising is common after surgery and
normally heals within a few days. Blepharoplasty
is sometimes performed in conjunction with facial
resurfacing, in which lines around the eyes are
removed with a laser or a chemical peel.
Corrective Surgery
Ptosis
is a drooping upper eyelid that is often treated
with a corrective procedure. In this condition,
the border of the eyelid (part that contains the
lashes) falls too low and may partially block
vision. In severe cases, the lid may completely
cover the pupil and the patient has to tilt his or
her head back to see. Mild ptosis does not always
require treatment. However, it seldom improves
over time and usually requires corrective surgery.
Ptosis may be a congenital condition (present at
birth) or the result of an injury or neuromuscular
disease (e.g., myasthenia gravis). Ptosis that
develops in adults is usually related to the
long-term effects of gravity and aging, which
cause the tendon that attaches the levator
(lifting) muscle to the eyelid to lose elasticity.
In adults, the underlying cause is determined and
treated, if possible. Corrective surgery shortens
or tightens the levator muscle and lifts the upper
eyelid. In cases where the levator muscle is
especially weak, the eyelid and the eyebrow may be
lifted. The procedure is usually performed under
local anesthesia that numbs the area around the
eye. It is preferable for the patient to be awake
to help the surgeon gauge how high to lift the
lid.
Young children are usually given general
anesthesia. If ptosis is not too severe, surgical
correction is generally performed between the ages
of 3 and 5. Ptosis that interferes with vision is
corrected at a younger age to help avoid amblyopia.
Complications
As the lid heals, it sometimes becomes evident
that it was under- or overcorrected and a second
procedure is necessary. In undercorrection, the
lid remains too low. In overcorrection, which is
less common, the lid has been lifted too high. A
small amount of overcorrection may resolve
spontaneously, but sometimes it results in the
inability to close the eye completely, requiring
additional surgery. Ointment is used to prevent
eye dryness, if the eye does not close during
sleep.
Repair of Eyelid Malpositions
Entropion
is the turning inward of the upper or lower
eyelid. It develops as a result of weakened
structures that support the eyelid. It occurs in
people of all age groups, but is most prevalent in
older people. It often occurs as a result of
aging, infection, or scarring inside the eyelid.
Rarely, it is congenital (present at birth).
When the eyelid turns inward, the eyelashes and
skin rub against the cornea, causing severe
irritation, redness, and pain. If untreated, it
can cause eye infections, corneal abrasions, or an
eye ulcer. These conditions can threaten vision.
Surgical correction involves rotating the lid
margin to a normal position and tightening the
muscles. It is usually effective and is generally
performed under local anesthesia in an outpatient
setting.
Ectropion
is the turning outward of the margin of the lower
eyelid and the eyelashes. It occurs most
frequently in older people, due to relaxation of
the tissues as a result of aging. Other causes
include skin cancer of the eyelid, trauma, eyelid
scarring, and previous eyelid surgery.
The source of tear drainage is a small opening on
the lower corner of the eye. As the lower lid
turns outward, this opening may pull away from its
normal location, disrupting the normal tear
drainage process. This can lead to excessive
tearing, mucous discharge, eye irritation, and
chronic conjunctivitis (infection or inflammation
of the inner membrane of the eyelid).
Lubricating ointments or artificial tears can be
used to relieve symptoms in mild cases, but
surgery is necessary to correct the problem. The
procedure is usually performed under local
anesthesia in an outpatient setting. During the
operation, the eyelid and underlying muscles are
tightened. After surgical correction, most
patients no longer have symptoms.
Reconstructive Surgery
Surgical removal of skin cancer of the eyelid is
standard therapy. Depending on the size, depth,
and location of the lesion, this can cause
substantial loss of eyelid skin that may affect
its function and appearance.
Surgeons attempt to preserve as much skin as
possible and minimize scarring, while making sure
that all of the cancer cells are removed. Moh’s
technique, (link) or frozen section control, for
example, enables the surgeon to excise the tumor
while leaving more healthy tissue intact. Some
very small tumors may heal on their own, through a
process called granulation.
A large tumor may require reconstructive surgery.
Two methods used are skin flaps and skin
grafts. Both procedures “borrow” skin away
from the immediate operative area. In a skin flap,
the tissue is borrowed from a nearby area and
attached to the face. The incision is made to
create a flap that will cover or partially cover
the wound, once the tumor is excised.
When a skin flap is not possible due to location
or size of the lesion, a skin graft is performed.
This involves removing skin from another part of
the body and using it to create a partial or
entirely new eyelid. Skin grafts can be split
thickness (i.e., just the surface layer of skin)
or full thickness (i.e., includes underlying
muscles and blood supply), depending on the
individual case. Most skin grafts are successful,
but repeat grafting may be needed if they do not
heal well.
Orbital Decompression
Graves' ophthalmopathy
produces a condition called exophthalmos or
proptosis (protrusion of the eyeball). The muscle
tissues around the eyes swell, causing significant
vision loss and disfigurement. This condition can
often be treated with medication and radiation,
but orbital decompression is sometimes needed to
make more space for the eye and prevent vision
loss.
In orbital decompression, bone tissue between the
orbit (eye socket) and the sinuses is removed to
provide more room for the eye, reducing the
protrusion. The procedure is performed under
general anesthesia and often requires a short
hospital stay.
Complications
Following surgery, some patients experience
numbness in the cheek, upper teeth, and lip on the
affected side, which can last several months.
Also, double vision may develop.
Enucleation
Enucleation is the removal of the eye. Intentional
removal is a drastic measure, resulting in
complete and permanent blindness. Reasons for this
surgery include a malignant tumor in the eye,
uncontrollable pain in an eye that has lost its
sight, or traumatic injury that is beyond repair.
Surgery is performed under general anesthesia. The
procedure involves making an incision around the
cornea and detaching the eye from the surrounding
structures. The eyeball is removed in one piece,
along with part of the optic nerve. The eye
muscles are preserved, if possible, to enable the
movement of a prosthesis.
Implantation
An ocular prosthesis is an artificial
implant that is placed in the empty eye socket.
The implant is not visible and maintains the
natural structure of the orbit and supports the
cosmetic prosthesis that fits over it. The
substance of choice is hydroxyapatite. It is
derived from a species of ocean coral, closely
resembles human bone, and has been used for nearly
20 years. Because of its composition, it can be
used as an integrated orbital implant (i.e., it
essentially becomes a “living” part of the body).
The prosthetic eye is the visible structure
that is handcrafted by an ocularist, a highly
skilled specialist. The eye is crafted to match
precisely the natural eye and is made of plastic
or glass. It fits over the implant and under the
eyelids, much like a large contact lens. It moves
as the implant moves, resembling natural eye
movement. To achieve greater motility, the
prosthetic eye can be attached to the implant by
drilling a hole in the front surface of the
implant and inserting a peg. The peg is then
attached to the back of the artificial eye.
A child born without an eyeball (congenital
anophthalmos) usually has a small eye socket
(orbit) because normal development did not take
place in utero. The empty orbit does not grow as
the child’s face matures, making it impossible to
use an implant and prosthetic eye as an adult. To
counteract this, an expander or a dermis fat graft
is used to encourage normal growth of the socket.
A conformer is made of a soft, synthetic
material that can be expanded inside the orbit,
like a balloon to help keep the orbit open and
help it grow.
The orbit can also be expanded surgically, if the
conformer fails. One procedure involves going
through the scalp to raise the top (roof) of the
orbit. Another type of surgery expands the orbit
by dividing it into three parts. Surgery is
performed under general anesthesia in a hospital.
Complications
Rarely, a person who has undergone enucleation is
unable to wear a prosthesis. Cosmetic procedures
for children with congenital anophthalmos are
sometimes unsuccessful. In some cases, the eyelids
are too short and cannot be adequately lengthened,
even with skin grafts. The orbits may not expand
sufficiently, even with expanding devices and
surgery. There may also be facial or bone
deformities that do not allow for a
natural-looking prosthesis. |
