Lagophthalmia is the inability to completely close the eyelids. Multiple conditions can lead to the appearance of lagophthalmia, but most often it occurs as a result of damage to the facial nerve or as a result of eyelid conditions. The facial nerve can be damaged as a result of trauma, a stroke, a facial paresis, as a result of tumours or as a result of autoimmune diseases. Eyelid diseases that can cause lagophthalmia are burns, injuries, eyelid surgery. The symptoms of lagophthalmia are foreign body sensation, tearing, pain. Incomplete closure of the eyelids over a longer period of time can result in the formation of scars on the cornea and thus in the impairment of visual acuity.
If lagophthalmia is caused by a temporary condition, the surgical treatment consists of tarsorrhaphy. This represents the stitching of the eyelids, either partially or completely. After the cause that triggered the appearance of lagophthalmia has passed, the suture thread (s) at the level of the eyelids are removed, without leaving any marks or scars.
If the lagophthalmia is permanent, the solution is to implant a gold plate at the level of the upper eyelid, so that when the blinking reflex is initiated, under the weight of the gold plate the upper eyelid manages to lower and protect the eyeball. For the insertion of the implant, a small incision is made in the natural fold of the eyelid, and the gold plate is deeply anchored at the level of the eyelid, it is not felt and is not uncomfortable. Additionally, it may be necessary to correct the ectropion of the lower eyelid by an intervention called “tarsal strip” which consists of lifting the lower eyelid and fixing it to the periosteum. Recovery is rapid and takes about 3 weeks, and postoperative treatment consists of eye drops and ointments.
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Eyelid ptosis is a lowering of the upper eyelid and can be congenital or acquired, unilateral or bilateral. Depending on the severity of the ptosis, the drooping eyelid may cause a decrease in visual acuity by the partial or the complete blocking of the visual axis. While in adults the blockage of the visual axis does not determine repercussions on the development of vision and visual acuity, in children things are a little different. In the case of congenital ptosis, the muscle which lifts the eyelid (levator muscle) is underdeveloped, so the visual axis is obstructed, either partially or completely, the effect being that of disrupting the process of normal vision development resulting in the installation of amblyopia, the so-called “lazy eye”. That is why in the case of congenital ptosis that covers the visual axis it is very important that the release of the visual axis be achieved without delay so as not to disturb the physiological process of vision development.
The treatment is strictly surgical, the function of the muscle that lifts the eyelid being evaluated preoperatively to decide the type of intervention necessary for the correction of ptosis. If the function of the muscle is <4mm the intervention necessary to correct the ptosis is called frontal suspension. During this intervention, 5 small incisions of approximately 3 mm are performed: 2 incisions at the level of the eyelid fold, 2 incisions at the level of the eyebrow and an incision above the eyebrow. Through these small incisions, a Gore-tex thread is inserted that allows the eyelid to be anchored to the eyebrow, therefore through the contraction of the frontal muscle the eyelid can be raised. The Gore-tex thread is well tolerated, does not cause side effects from the body, is durable, and by its deep anchoring cannot be felt on the outside.
If the function of the levator muscle is> 4mm the surgery required to correct ptosis is called external levator resection. An incision is made in the eyelid fold, and through this incision the aponeurosis of the levator muscle is anchored to the tarsus, thus forming a much better torque for the lifting of the drooping eyelid.
Postoperatively, in both types of interventions, the eyelids will not close completely for a period of a few weeks to a few months, therefore the postoperative treatment is very important, which consists of intense lubrication of the eye surface with artificial tears and ointments until complete closing of the eyelids. In both types of interventions, the incisions heal after about 2-3 weeks, the aesthetic result being very good, and the scars minimal.
Orbital decompression is the surgery by means of which bone tissue and sometimes fat from the orbit is removed. Most frequently this intervention is practiced in Graves Thyroid Orbitopathy, which is most commonly manifested by: exophthalmia, inability to completely close the eyelids, double vision, dry eyes, increased orbital pressure due to inflammation of the extraocular muscles, facial asymmetry. The purpose of the orbital decompression intervention is to create more space in the orbit, thus facilitating the mobility of the eyeball and the repositioning of the eyeball in the orbit. Depending on the degree of exophthalmia, several types of decompression can be performed:
- Lateral orbital decompression +/- fat: a small incision is made in the outer part of the fold of the upper eyelid, through which the lateral wall of the orbit is exposed and the sphenoid bone is milled. Depending on the degree of exophthalmia, the fat in the orbit can be excised too.
- Medial orbital decompression: a transcaruncular incision and dissection to the posterior lacrimal ridge are made, the papyraceous lamina is fractured, followed by the excision of the bone from the posterior lacrimal ridge to the top of the orbit, orbital fat is herniated at the level of the ethmoid sinus.
- Lower orbital decompression: an incision is made in the lower conjunctiva, through which the lower orbital border is reached and the partial fracturing of the floor of the lower orbital wall and the herniation of orbital fat in the maxillary sinus are performed.
Postoperative treatment consists in the application of antibiotic drops / ointment, artificial tears, ophthalmic ointment, and depending on the severity of the exophthalmia, the recovery can take from a few weeks to a few months. In the case of medial and inferior orbital decompression, no scars remain, and in the case of lateral decompression, a fine scar of approximately 2 cm remains hidden in the fold of the eyelid.
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The tears are secreted by the lacrimal gland, then lubricate the surface of the eyeball, and finally drain through 2 small holes located in the nasal part of the eyelids. These small holes are called lacrimal points, and from this level the tears are taken by 2 tear ducts that open at the level of the lacrimal sac, reaching the nose after through the nasolacrimal duct.
Dacryocystorhinostomy is a surgical procedure that establishes a new communication between the tear sac and the nose. When there is an obstruction in the nasolacrimal duct, the tears can no longer follow the physiological path and thus can no longer reach the nose. DCR surgery can be performed either endoscopically or externally.
- Endoscopic DCR: a small incision is made near the middle nasal concha, after which part of the lacrimal bone is excised to form a new communication with the nasal mucosa. After the lacrimal sac is exposed, it is incised, and a silicone two-channel stent is inserted through the lacrimal points and fixed at the nose level.
- External DCR: a skin incision of approximately 1.5 cm is made located in the paranasal area near the anterior lacrimal ridge, the lacrimal sac is exposed, the bone from the lacrimal sac is excised, the lacrimal sac and the nasal mucosa are incised some flaps being formed. The silicone stent is inserted in a similar manner as in the case of endoscopic DCR, and the flaps in the tear sac are anastomosed to the flaps of the nasal mucosa.
In both types of interventions, the silicone stent is kept for about 6 weeks, after which it is sectioned and removed in the practice. Postoperative treatment is represented by a nasal spray, eye drops, and nose blowing = is prohibited for 6 weeks.
The retractor muscles of the eyelids determine the eye opening. The retractor muscles of the upper eyelid are represented by the muscle which lifts the eyelid and the Muller muscle, and those of the lower eyelid are represented by the capsulopalpebral fascia and the lower tarsal muscle.
Eyelid retraction is the ascent of the upper eyelid or the lowering of the lower eyelid, multiple mechanisms being involved. The main causes that can determine eyelid retraction are acute or chronic inflammatory processes, surgery or trauma that can cause tissue shortening, neuromuscular disorders, by mechanical effect, congenital diseases, pseudoretraction following a contralateral ptosis. The most common cause of unilateral or bilateral eyelid retraction is thyroid orbitopathy.
The correction of the eyelid retraction is performed by means of a surgery with the aim of weakening the retractor muscles of the eyelid. Retraction of the upper eyelid can be corrected by Mullerectomy, which consists of transconjunctival excision (through the inside of the eyelid) of the Muller muscle. Another intervention that allows the correction of the retraction of the upper eyelid is represented by Blepharotomy. An incision is made in the natural fold of the eyelid through which the lateral wing of the levator muscle was disinserted. Retraction of the lower eyelid can be corrected by means of a lateral canthoplasty or by disinsertion of the retractors. To perform the lateral canthoplasty, a small incision is made in the lateral canthal region, followed by the sectioning of the inferior division of the lateral canthal tendon and its anchoring at the level of the periosteum of the orbit, resulting in the extension of the inferior eyelid and the diminution of the retraction.
Postoperatively, it is necessary to apply drops and ophthalmic ointments, the recovery lasting depending on the intervention from a few days to a few weeks.
Blepharoplasty is a surgery that improves the appearance of the eyelids and may involve excision of excess skin, muscle or fat. As we age, the eyelids become looser, and the muscles that support them lose their tonus, resulting in the lowering of the eyebrows, eyelids and the formation of dark circles. The blepharoplasty intervention aims to eliminate the appearance of tired eyes, drooping eyelids, dark circles and to make you look more rested, younger, without changing the shape of your eyes.
Upper blepharoplasty involves the conservative excision of excess skin from the upper eyelid, muscle stretching, and repositioning or transposition of fat as appropriate, through a localized incision in the natural fold of the eyelid.
Lower blepharoplasty aims to restore the volume lost in the lower eyelid. A transconjunctival incision is made, inside the eyelid, through which the transposition of fat at the level of the dark circles is performed. If the herniated fat is not sufficient for transposition, the restoration of the volume at the level of the lower eyelid can be corrected by means of an Augmentation Blepharoplasty which consists in the injection of autologous fat. If there is excess skin on the lower eyelid, it is excised conservatively through an incision located below the lash line.
In both types of blepharoplasty, recovery takes about 2-3 weeks, and postoperative treatment consists of drops and ophthalmic ointments.
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Evisceration is the removal of the contents of the eyeball while preserving the scleral wall and extraocular muscles. The procedure is usually performed to reduce pain in the blind eye or to improve the cosmetic appearance in case of unrecoverable injuries.
To perform the evisceration, a 360-degree incision of the conjunctiva is made, followed by a 360-degree excision of the cornea. The contents of the eyeball are then removed and an implant is inserted – a PMMA ball in the scleral cavity to preserve the volume, the scleral wall and conjunctiva are sutured, and at the end a conformer is placed to preserve the conjunctival sac bottoms and a temporary tarsorrhaphy is performed. It is very important to completely cover the implant in order to reduce the possibility of its extrusion and the formation of an infection.
Postoperative treatment consists of the administration of antibiotics, analgesics and ophthalmic ointments, and the recovery lasts about 6 weeks, after which the conformer can be replaced with an eye prosthesis.
Enucleation is the complete removal of the eyeball, keeping the extraocular muscles and the contents of the orbit intact. This type of intervention is indicated for some eye tumours, in case of a blindly painful eye, in case of sympathetic ophthalmia or in case of severe traumas.
To perform the enucleation, a 360-degree incision of the conjunctiva is made, followed by the identification and anchoring of the upper, lower, medial and lateral straight muscles, followed by the sectioning of the optic nerve. An implant is inserted in the orbit cavity, and the previously anchored muscles are attached to it. At the end, the conjunctiva is sutured and a conformer is placed to keep the conjunctival sac bottoms.
Postoperative treatment consists of the administration of antibiotics, analgesics and ophthalmic ointments, and the recovery lasts about 6 weeks, after which the conformer can be replaced with an eye prosthesis.
The most common fractures involving the orbit are the fracture of the orbital floor and the fracture of the orbit medial wall. The typical situation that results in a fracture in the orbital floor is represented by the sudden increase in orbital pressure following an impact with an object that has a diameter larger than the orbit opening, so the eyeball absorbs the force of the impact and transmits it. As the orbit lower wall is thinner it yields under the pressure exerted on it. Fractures of the orbit medial wall appear relatively isolated, most often being associated with the fracture of the floor.
Orbital fractures can cause enophthalmia, bruising, local edema, infraorbital nerve damage, double vision, limitations of eyeball movements. Fractures involving more than half of the orbital floor, associated with severe enophthalmia, double vision, limitations of eyeball motility, or muscle attachment to the fracture site, require surgical treatment to repair the fracture. Most often orbital fractures are repaired using a titanium osteosynthesis material, with a very good tolerability from the body – Medpor Titan Barrier. Depending on the type of fracture, to perform the surgery, either a lower transconjunctival incision or a transcaruncular incision is performed, both incisions being made inside the eyelids, without any incision in the skin. After the tissues are thoroughly dissected and the periosteum detached, the focus of the fracture is exposed and the implant is positioned.
Postoperative treatment consists of the administration of antibiotics, drops and ophthalmic ointments, and recovery varies depending on the severity of the fracture and can last up to several months.
Orbital & eyelid tumors
Tumours located in the orbital cavity can cause clinical manifestations even at very small sizes, because the orbital cavity is inextensible and the effect of a tumour growth is to compress the adjacent orbital tissues. Orbital tumours can be benign or malignant and can be primary or metastatic. Some orbital tumours are most common in children, while some other tumours are found mainly in adults. The most common benign tumour is cavernous hemangioma, which develops mainly in middle-aged adults. Most orbital tumours found in children are benign, with cystic formations accounting for half of the cases, and capillary hemangiomas come next. The most common malignant tumour in children is rhabdomyosarcoma. Other types of orbital tumours are represented by: meningiomas, neurofibromas, optic gliomas, osteomas, hemangiomas and lymphangiomas, sarcomas, histiocytomas.
Regarding benign palpebral tumour formations there is a great variability of tumours that can occur in the eyelids. It is very important to differentiate between benign and malignant tumours. The main benign tumours of the eyelids are cysts and pigmented tumours, and the latter can be associated with malignant tumours. The most common malignant tumour eyelid formations are basal cell carcinoma, squamous cell carcinoma and sebaceous carcinoma.
Depending on the presumptive diagnosis in the case of orbital tumour formations, the surgical treatment may be to excise the formation or to perform a tumour biopsy. Taking into account the location of the formation, a transconjunctival or transcaruncular incision is made (both incisions being made inside the eyelid) through which the tissues are thoroughly dissected, and the tumour is highlighted and carefully manipulated for excision or biopsy.
The treatment of eyelid tumours can also be performed for the purpose of a complete excision of the formation or for the purpose of harvesting a biopsy. In the case of small lesions, their excision is made through a small incision in the eyelid, and in the case of larger tumours, their excision is followed by eyelids reconstruction, customized according to the location of the formation.
Postoperative treatment is represented by drops and ophthalmic ointments, and recovery is dictated on a case-by-case basis by the type of tumour formation.
Entropion is a condition that involves the turning of the eyelids inward, so the eyelashes and the free edge of the eyelid come in contact with the eye surface. Prolonged contact and mechanical effect cause eye discomfort, conjunctival hyperemia, pain, sensitivity to light and wind, excessive tearing, mucous secretion, crusts at the base of the eyelashes, which can result in corneal erosions, and in severe cases in the formation of corneal ulcers. The eyelids can be turned inwards permanently or only when blinking or squeezing the eyelids. Entropion occurs more frequently in the adult population and usually affects the lower eyelid. The causes that can determine the appearance of entropion are represented by: the weakening of the muscles at the level of the eyelids, scars or previous surgeries at the level of the eyelids, eye infections,
The type of surgery to correct entropion depends on the condition of the eyelids and on the situation that led to its occurrence. If the entropion is caused by the loss of tissue elasticity, several types of corrective interventions can be performed: applying sutures in order to flush the eyelid, reinsertion of the lower eyelid retractors, lateral edge strengthening procedures or combined procedures. In case of scar caused entropion, a palatine mucosal graft may be required to support the tarsus.
Postoperative treatment in most types of interventions consists of drops and ophthalmic ointments, postoperative scars being minimal, with recovery lasting about 2-3 weeks.
Ectropion is a condition in which the eyelids turn outwards, and therefore the inner surface of the eyelids remains exposed and predisposes to inflammation and eye discomfort. Ectropion is more common in adults and generally affects only the lower eyelid. By turning the eyelid outwards, the lacrimal points through which the tears flow also turn outwards, and the tears no longer drain properly leading to excessive tearing, dry eye, permanent discomfort and sensitivity to light. The causes that can determine the appearance of ectropion are: weakening of the muscles of the eyelids, facial paresis, scars or surgery on the eyelids, especially if a large amount of skin has been excised, eyelid formations that by gravitational effect can result in the outward turning of the eyelid.
The type of surgery to correct ectropion depends on the cause that resulted in its occurrence. In case of involutional ectropion, the most common intervention is called lateral canthoplasty, which allows the lower eyelid to be stretched. A small incision is made in the lateral canthal region, followed by the sectioning of the lower division of the lateral canthal tendon and by its anchoring to the periosteum of the orbit, having the effect of stretching the lower eyelid and correcting its outward turn. When there are scars with a retractile effect on the lower eyelid, skin grafts harvested from either the upper eyelid or the retroauricular level may be needed to correct the ectropion.
Postoperative treatment in most types of interventions consists of drops and ophthalmic ointments, postoperative scars being minimal, and recovery lasts about 2-3 weeks.
Botulinum toxin in oculoplastic diseases
Botulinum toxin is a neurotoxin produced by the bacterium Clostridium botulinum. The effect of the toxin is to block the release of a neurotransmitter called acetylcholine at the neuromuscular junction by the axonal terminations. The toxin causes a disease called botulism, but it can be used for both medical and aesthetic purposes.
Botulinum toxin is used to treat many medical conditions, but ophthalmologically it is used to treat the following conditions:
- Benign essential blepharospasm
- Oromandibular dystonia
- Meige syndrome
- Hemifacial spasm
- Eyelid opening apraxia
- Treatment of tics, tremor, myokymia
- Eyelid retraction
- Spastic entropion
Before administration of Botox injections, a cream with an anaesthetic effect is applied, so that the discomfort is minimal. Depending on the pathology, a specific number of units are injected at the level of the muscles involved. The effect begins to be seen after about 3-5 days and becomes maximized after 7-10 days. There are no restrictions after the injection, and the average duration of the effect is 3 months.