Part II

Ophthalmic, plastic and reconstructive surgery is a specialized area of ophthalmology which deals with the management of deformities and abnormalities of the eyelids, lacrimal (tear) system, orbit (the bony cavity around the eye) and the adjacent face. An ophthalmic, plastic and reconstructive surgeon is an ophthalmologist (medical doctor and eye surgeon) who has completed additional training in plastic surgery as related to the eyes and the surrounding structures.

Since such surgery can affect a persons ability to see, ophthalmic plastic surgeons are best qualified to perform this delicate surgery and also to provide any care that the eye itself may need.

INJURY TO THE EYELIDS

Trauma may result in injury to the eyelids. Precise evaluation and repair of injuries are necessary to insure the best possible function and appearance, especially when it involves the eyelid. The eyelid has a skeleton called the tarsus. This must be perfectly aligned to insure that the inside of the eye is lined with conjunctiva and that the lashes are also precisely aligned so that they do not rub on the eye. Any trauma to the eyelids necessitates an eye examination to make sure that there is no damage to the delicate structures of the eye.

EYELID TUMORS

Eyelid tumors are very common and are usually of a benign nature. Most eyelid tumors can be simply excised, many times not requiring any patching or sutures. Cryotherapies (freezing), or hyfrecation (burning) are other ways that these tumors can be removed. Eyelid cancer (malignancy) is common and is increasing in frequency. All new eyelid bumps or sores that will not heal must be evaluated to insure that they are not cancer. These types of tumors are more common in patients who are fair skinned and have a history of previous skin cancers. The most common skin cancer is basal cell carcinoma, however, other types of skin cancers can occur on the eyelids. Early diagnosis and surgical removal offers the best probability of permanently eliminating the tumor. Currently, the best available treatment options are surgical excision with standard frozen section control of the lid margins to insure that the tumor is removed. Reports reveal five year cure rates over 95% using this treatment. The ophthalmic reconstructive surgeon has many special methods to surgically rebuild the affected eyelids so that it has an almost normal appearance.

BLEPHAROSPASM

Patients with essential blepharospasm has bilateral, spasmodic contraction of the orbicularis muscles of unknown etiology which result in prolonged eyelid closure or significant visual disability. Local injected botulism (botulinum) neurotoxin A has proven to be effective for many patients affected with this condition achieving significant benefit for 70% to 90% of individuals. The ocular side effects of ocular botulinum injections include ptosis, droopy eyelid, diplopia (double vision), lagophthalmos, drying out of the eye, reflex tearing and pain in the injection sites. However, side effects are usually minimal and are reversible. Duration of action of the injections ranges from 6 to 18 weeks and repeat injections are frequently needed to maintain clinical relief. Other alternatives include drug therapy which is usually less effective. Surgical myectomy is reserved for blepharospasm patients for whom medical therapy with botulinum toxin has failed. The objective of a facial myectomy is to selectively remove the periocular muscles while preserving the blood supply and functional integrity of the eyelids.

LACRIMAL SYSTEM

In order for the eye to remain healthy, it must remain moist. The lacrimal gland is a specialized gland located under the outer one-third of the upper eyelid that makes tears. Each time that you blink, the eyelid spreads the tears over the surface of the eye and pumps excess tears into the tear ducts that drain the tears into the nose. This is why your nose runs when you cry. The upper and lower eyelids, near your nose, on the eyelid margin contain a small tear duct that can be seen when the eyelid is everted (turned out).

DRY EYES

If the lacrimal gland fails to produce enough tears to properly wet the eye, the surface of the eye begins to dry out. An eye that is too dry, burns, stings and feels that there is sand in it. Patients who have rheumatoid arthritis, an autoimmune disease or with the normal aging process have decreased tear production. Artificial tears and lubricating ointments will help to control the drying and irritation that occurs when too few tears are produced. Artificial tears that "take the red out" are useful for short term use, but when used long term, are not good for the eyes because the vasoconstriction effect wears off with time. When adding lubricants to the eye does not adequately relieve this discomfort, other options are available. Small plugs may be placed in the tear ducts on the upper eyelid or lower eyelid to block the drainage of the fluid and give the eyes more normal tears that build up on the eye. These tears contain all the normal chemicals and antibiotics which are secreted from the lacrimal gland. These plugs are usually made of silicon which is permanent, or collagen, which is dissolvable. The plugs are not felt and, if excessive tearing results, can be easily irrigated out of the tear duct. Surgery may also be easily performed to close the tear ducts. This usually requires cauterizing the small opening of the tear duct on the eyelid.

WET EYES (EPIPHORA)

If the lacrimal gland is producing tears properly and the duct that drains the tears from the eye into the nose becomes nonfunctioning, the tears will back up and spill over the eyelid and cause the tears to run down the face. Usually, there is no known cause for the tear duct blocking up. It most commonly occurs in middle-aged females. A plugged-up tear duct can cause an infection with a painful swelling in the inner corner of the eyelids. Surgical elimination of the obstruction is necessary to eliminate the tearing and infection. A new tear duct is created surgically by either making a skin incision or going through the nose and connecting the tear duct to another place in the side of the nose. External skin incision remains the standard procedure for treating required obstruction of the tear ducts in adults and older children. Frequently, achieving operative success rates are 90% to 100%. The external incision is made between the eyelid and nose, measures only about one-half inch and usually heals without any scarring. Recently, endoscopic tear duct surgery has become a subject of interest as a treatment alternative. The surgery can be performed through the nose and no skin incision is required. Occasionally, the tear duct obstruction can be beyond repair. When this happens, it is necessary to surgically implant an artificial pyrex glass tube behind the inner corner of the eyelid to drain the tears directly into the nose. This pyrex glass tube is called a "Jones Tube."

Children are frequently born with an obstruction in the tear duct. This usually occurs at the junction of the tear duct which empties into the nose, and usually only involves a small membrane. When this occurs, tearing results. The stagnant tears within the tear duct often become infected, causing pus to collect between the eyelids. Most obstructions dissolve on their own within the first few months of life. At least 95% dissolve by 12 months of age. Usually topical antibiotics and massaging of the tear duct can help clear these obstructions. If these obstructions do not resolve they can be eliminated with a simple probing of the tear duct which involves passing a small, firm wire through the tear duct into the nose.

ORBITAL TUMORS

Tumors may affect the structures within the orbit. The orbit is the bony socket that surrounds the eye. The orbit contains the eye, muscles that move the eyes, arteries and the nerves with which you see- the optic nerves. All of these structures are involved in and cushioned by an intricate system of supporting membranes and fat. Numerous medical and surgical problems can affect the orbit. Anything that causes swelling and enlarging the orbital structures behind the eye will push the eye forward (proptosis) and may restrict its movement. Double vision results from an eye that does not move properly.

As tumors slowly enlarge, the eyes bulge forward and movement may be limited. Management of these tumors usually results in a sophisticated diagnostic evaluation and surgical exploration. Ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI) remain the mainstay of imaging modalities and diagnosis of orbital disease. The diagnostic accuracy of these tests have allowed them to supplant invasive orbital arteriography and venography (injections of dye into the arteries or veins). Fortunately, most orbital tumors are not malignant and can be treated surgically.

THYROID EYE DISEASE

Thyroid eye disease is a medical problem that causes enlargement of the muscles which move the eye and open the eyelids too wide. This is an autoimmune disease of unknown origin which seems to be more common in patients who smoke cigarettes. As the muscles of the eye slowly enlarge, the eyes push forward and the movement is restricted. Bulging eyes (proptosis) move poorly and have a wide stare (eyelid retraction). The swelling of the muscles can become so severe that the blood flow to the optic nerve is strangled, resulting in slow loss of vision. Double vision can also result. Surgical rehabilitation is usually reserved after the eyelid abnormalities have stabilized for at least four months. Acute surgery may be needed to prevent loss of vision from swelling around the optic nerve. Other modalities tried first are Prednisone, Cyclosporin or x-ray therapy. Surgical rehabilitation needs to be individualized and performed in stages. If decompression of the optic nerve or orbit is required, it should be done first, followed by eye muscle surgery (strabismus surgery), then eyelid surgery. The most common method of orbital expansion to relieve compression of the optic nerve is a two wall decompression which involves removing the bone of the floor of the orbit.

ORBITAL INJURIES AND FRACTURES

Trauma of the orbit may cause fractures of the bones surrounding the orbit. The two most common fractures are a tripod zygomatic (cheek bone) fracture or orbital floor fracture (blow-out fracture). When the inferior, orbital rim is struck with any object, the floor is deformed with resultant fracture with entrapment of tissue. This entrapment of tissue can include eye muscles which results in double vision. Also, with fractures of the floor, the volume of the orbit can expand and the eye can sink back also. This can be corrected by repairing the fracture and placing an implant on the floor of the fracture to reapproximate the floor. Sometimes eye muscle surgery is required to correct the double vision. Tripod surgery usually results from trauma to the cheek, especially a fist, with sinking in of the cheek, difficulty chewing and many times a fracture of the orbital floor is associated with this. This can be precisely repaired with bone plates or steel wires.

LOSS OF AN EYE

At times, it becomes necessary to surgically remove an eye that has become severely damaged by disease or injury. Many times, the eye is removed because it is blind and painful. Sometimes, when the eye is deformed, it does not require being removed and if it is shrunken, can be covered with a specifically made artificial prosthesis. This is like a large contact lens that can cover the eye surface and is painted and especially molded to look just like the other eye. In many instances, it is difficult to tell that the patient has an artificial eye. There are two main ways used to remove the eye. The first is called evisceration in which the cornea (front of the eye) is removed and the intraocular contents are removed. However, the sclera (white part, muscles and orbit) are left in position. A ball is placed in the eye and the eye is sewn up.

The other more commonly used method is to remove the entire eye itself. However, this is a more invasive procedure and involves surgery, deep within the orbit. This is called enucleation. Good movement of an artificial eye is obtained when an evisceration is performed. In the past, good movement of an artificial eye was seldom obtained, however, with enucleations, new surgical procedures have been developed that may enable the ophthalmic reconstructive surgeon to achieve acceptable movement of the artificial eye even if the eye was removed years ago. Hydroxy appatite (coral) and Medcor (polyethylene) implants have now been developed. These are placed in the sclera of the eviscerated eye or the pocket remaining after the enucleation and the muscles are well attached. Blood vessels and tissue grow into these implants so that they move very well. They are incorporated into the body and are associated with less infection and are in a more anatomic and functional position.

back to Part I of Surgery of the Eyelids, Lacrimal System, and Orbit 

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