- Understanding Refractive Errors
- Refractive Surgery Techniques
- Candidates for Refractive
Surgery
- Important Facts
- Cataracts
- Blocked Tear Ducts
- Droopy Eyelids (Ptosis)
- Eyelid
Reconstruction
- Blepharoplasty
for Baggy Eyelids
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Botox Therapy
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Oculoplastic Surgery
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Eyelid Cancers
A cataract is clouding of the natural lens that can affect the vision. The lens situated inside the eye can become more and more cloudy, preventing light from reaching the retina.
The natural ageing process is the main cause of cataracts. Conditions such as Diabetes, eye injury, inflammations, prolonged use of drugs like steroids etc. can also result in formation of cataracts.
Cataracts develop over a period of years and commonly affect both the eyes, although not necessarily at the same time. Distance vision is the first to be affected and as the lens becomes progressively more cloudy and rigid, near vision can also deteriorate.
Symptoms of cataract are cloudy or filmy vision; changes in the way you see colours; glare at night, from lamps or sun; frequent changes in spectacle prescription, temporary improvement in near vision in longsighted people and rarely double vision.
Surgery is the only effective treatment when cataract starts affecting the quality of vision and life. Cataract removal is one of the most frequently performed operations and is considered one of the safest and most effective. During cataract surgery the natural cloudy lens is removed and replaced with an artificial lens. This procedure is usually done under local or topical anaesthetic and patients can return home in a couple of hours. The technique used for cataract removal is known as phacoemulsification which requires a small incision and no stitches. Most artificial intraocular lens implants are rigid and cannot change shape like a natural lens. Modern methods of cataract surgery allow adequate near or distance vision without resorting to spectacles. In selected patients, multifocal or accommodative lenses are implanted and which allow both near and distance objects to be seen in clear focus without resorting to spectacles. These lenses give relative freedom from spectacles in majority of patients.
Benefits of cataract surgery: Successful cataract surgery improves quality of life and vision. It results in improvements in safer driving, reading and better mobility. This translates into greater self confidence and more independence. Social activities and hobbies can be enjoyed much better.
Potential complications: Cataract surgery has a success rate of 95% in patients with otherwise healthy eyes. Like any other operation, cataract surgery also is not risk free.
Sight threatening complications are quite uncommon. Possible complications include high pressure in the eye, swelling or cloudiness of the cornea, drooping eyelid, migration of part of lens at the back of the eye, displacement of artificial lens, bleeding inside the eye, infection inside the eye, retinal detachment and rarely total loss of eye sight.
Watering Eye with Blocked Tear Ducts:A blocked tear duct results in a watering eye, as the tears cannot drain normally into the nose. This may be associated with repeated infections of the lacrimal sac, which is situated between the inner part of the eye and nose.
Several tests are done to confirm the diagnosis and nature and site of blockage. These may include syringing of the lacrimal passages, Jones dye test, X-rays, Dacryocystogram and rarely lacrimal scan using a gamma camera. It may also be necessary to request a consultation from an Ear, Nose and Throat surgeon before deciding about the surgery
In adults, the corrective operation of Dacryocystorhinostomy (DCR) is performed. This is carried out under general anaesthetic. The operation involves creation of an alternate channel for drainage of tears between the tear sac and nose, bypassing the blocked duct. At times, a silicone tube may be placed in the newly created passage to ensure its patency till it heals which may take 6-9 weeks. This tube is subsequently removed.
An alternative technique called Endonasal Dacryocystorhinostomy with silicone intubation (Endonasal DCR) is at times undertaken in association with an ENT surgeon. The advantage of this technique includes shorter procedure, avoidance of general anaesthetic, no skin incision or stitches.
The success rate of conventional DCR is 85-90% with slightly lower rates in Endonasal DCR and cases with partial or canalicular blocks.
In small children and infants who are born with blocked tear ducts, the treatment is usually conservative. This involves massage of the lacrimal sac with intermittent use of antibiotic drops for 3-6 months. With time, majority of children are relieved of watering of eyes with spontaneous relief of the tear duct obstruction. Syringing and probing of the tear ducts may be required in cases not responding to sac massage and antibiotic drops. This is a short procedure done under general anaesthetic as a day case.
Other causes of watering from the eyes include inflammation of eyelid margins (blepharitis), ingrowing eyelashes (trichiasis), inturned lower eyelid (entropion), drooping of lower eyelid away from eye (ectropion), or narrowing of tear duct opening (punctal stenosis). Entropion, ectropion, trichisis and punctal stenosis require surgical intervention and can be performed under local anaesthetic.
Ptosis is drooping of the upper eyelid. If severe, it can interfere with vision by covering the pupil of the eye.
Usually, ptosis is benign in nature and amenable to surgical treatment. The type of operation depends on how weak the muscle lifting the eye is. This muscle is called the levator. Occasionally, ptosis is due to more serious causes, mainly diseases affecting the muscles or the nervous system.
There are four main procedures that can be employed to correct ptosis.
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Levator resection or plication: This technique is used if the levator muscle is weak (children) or due to slippage of the tendon from its attachment to the eyelid (older people).
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Brow suspension: When the levator muscle is very weak, suspending it from the eyebrow using silicon rod or mesh can lift the eyelid up. Patient then controls the height of the eyelid by moving the eyebrow up or down.
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Fasanella-Servat procedure: Used infrequently in milder degree of drooping of the eyelid.
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Muellers' muscle resection (modified Putterman procedure)- This procedure is done from the undersurface of eyelid. This technique involves removing Muellers' muscle in patients with mild ptosis. A positive phenyl-epherine test is essential for this method to achieve the desired results
Potential side effects
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Poor closure: The eye may remain partially open on falling asleep and can become dry. This may require lubricating drops and ointment at night for about three months.
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Unsatisfactory lid height: Further surgery may become necessary to raise or lower the eyelid.
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Bruising and swelling: Occurs occasionally after surgery but settles down in a couple of weeks with cold packs and propped up position while asleep.
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Hang up: On looking down, the eyelid may not follow the eye and may remain in the same position especially after correction of severe ptosis.
In a child with ptosis, surgery is normally deferred to allow proper evaluation and tissue development. Surgical correction may have to be performed earlier if the droopy eyelid is causing amblyopia or laziness.
Eyelid Retraction: Some patients with Thyroid gland abnormalities develop eye changes like upper eyelid retraction, resulting in a staring appearance. This can be surgically corrected by recessing levator or Muellers muscle, resulting in marked cosmetic improvement of eyes.
Eyelid reconstruction is necessary after all or part of the eyelid has been removed. This occurs after removal of tumours like Basal cell carcinoma, following injuries or burns.
The techniques for eyelid reconstruction depend on age and the skin type, the size of the area to be repaired and whether is the lower or upper eyelid which is affected.
The process involves repair of two layers.
On the front surface of the lid, skin cover can either be provided by a) sliding or rotating grafts from adjoining areas like one of the other lids, cheek or temple region and b) free skin grafts from the upper eyelids of the same or opposite side or from behind the ear.
On the back surface of the lid, there must be a smooth, moist surface to slide over and protect the eye. Suitable materials include conjunctiva from the same or opposite eye or occasionally lining of the cheek inside the mouth.
In most cases the reconstruction can be accomplished as a single procedure. In other situations, the procedure may be divided into two stages. During the first stage, the eye may require closure, especially if tissues of the upper or lower lid of the same side have been used to cover the gap. After the graft has healed and has become viable which can take 6-9 weeks, the flap is divided during the second stage.
It is not always possible to determine the best procedure for lid reconstruction before the procedure has begun. If the tear duct is removed as part of tumour resection, a watering eye results. With repeated surgery, it is always possible to achieve a reasonable good result, but it is never possible to make an eyelid as perfectly formed as the original one.
Blepharoplasty for Baggy Eyelids:With age, skin around the eyelids loses its elasticity and muscles tend to slacken. This results in accumulation of folds of loose skin on the upper eyelid and puffiness and swelling of the lower lids. Slackening of muscles also allows the fat that normally cushions the eyes in the bony socket, to protrude forward and which in turn accentuates the baggy appearance of eyelids.
This can be an inherited feature. Baggy eyelids often appear worse in the mornings due to fluids settling in areas with loose skin. In severe cases, the folds of loose skin hang over the lashes in the upper eyelid, obstructing the vision and give a sensation of shadows in the upper part of the visual field. Baggy eyelids may be associated with drooping of the lids or the eyebrow, which are also signs of ageing.
The operation of blepharoplasty aims to cosmetically improve the lid by removal of excessive skin and /or protruding fat. The operation is usually done under local anaesthetic. In the lower lids it can be performed via the external skin approach or preferably by trans-conjunctival approach. Occasionally, the procedure of blepharoplasty may be combined or preceded by brow lift (browpexy) or ROOF sculpting procedures. Blepharoplasty may be combined with ptosis correction if there is associated droopiness of upper eyelid. At times, supplementary procedures like mid face lift, SOOF lift are required to achieve a good result especially if there is sagging of the tissues in mid face region.
After the operation, there may be slight bruising and swelling which takes a couple of weeks to settle down with ice packs. Radio-frequency surgical technique for this operation minimises the postoperative inflammation, thereby reducing discomfort and results in relative less scarring with faster healing. Continuous ageing may necessitate a repeat procedure after several years. Benefits of the procedure include a less fatigued, more vibrant and youthful appearance. An ideal patient for this procedure is the one with a good level of self esteem and who has realistic, limited objectives and expectations of cosmetic surgery.
Facial rejuvenation with IPL, lasers or fillers can further improve the appearance following a successful Blepharoplasty procedure.
Potential complications are rare and include mild asymmetry, bleeding, scarring, retraction of the lower lid, exposure of the cornea, worsening of dry eye symptoms etc.
Botox Therapy: Botulinum toxin injections are useful in treatment of various conditions like hemifacial spasm, idiopathic blepharospasm, squint,nystagmus, non healing corneal ulcers, excessive watering from eyes, post Bell's palsy synkinesis. Cosmetic indications include removeal of wrinkles on face inclding Crows feet around eyes, frown lines on the forehead and bridge of nose, wrinkles on nose, upper lip rhytids, Vermillion border, pebbly chin, Nasolabial folds and scar management. Repeat Botox injections are usually required at 3 monthly intervals.
Radio-frequency Technique for Oculoplastic Surgery:
Radio wave surgery offers laser like outcomes in facial cosmetic procedures with precision cutting and a faster healing process. It is a completely different concept from electrocautery or diathermy machines. This technique reduces bleeding while cutting, causing less bruising and reduces operating time. There is no lateral heat generated during cutting and hence there is no tissue damage or charring. After surgery, there is minimal swelling and healing time is significantly reduced. This consequently translates into superior healing and better cosmetic results.
This page was last updated on 22/Feb/2010
