What is oculoplastic surgery?
Oculoplastic surgery is plastic surgery around the eye. This is a surgical field which deals with all the pathologies around the eye. It starts with the forehead along the hairline extend into the cheek area below and laterally it extend to the temporal area. In general, they are divided into eyelid, lacrimal system (drainage system of tears), orbit (structures surround the eyeballs), aesthetics, abnormal eye movement, facial nerve palsy and socket (structures and bony cup surround the eyes when the eyes are removed).
Eyelid pathologies involves the following:
a) Trichiasis of eyelid or misdirected eyelashes. The cause ranges from blepharitis (inflammation of eyelid), malposition of eyelid (entropion or ectropion) or congenital. The ingrowing eyelashes cause eye irritation as the cornea is supersensitive. If left untreated, chronic irritation to the cornea can cause cornea vascularisation and corneal scarring.
The treatment ranges from epilation which needs to be repeated every six weeks, electrolysis which also required repeated sessions, cryotherapy and surgical excision.
b) eyelid lumps or bumps. It can range from benign but annoying or unsightly lesion such as chalazion, papilloma or warts and sebaceous cyst. The malignant lesions include sebaceous cell carcinoma, squamous cell carcinoma, basal cell carcinoma and melanoma. If the lesion keeps on recurring despite surgical removal, then it raised a suspicion that it may be malignant and need to seek oculoplastic surgeon help to remove and surgically reconstruct the eyelid.
c) malposition of eyelid such as ectropion or entropion. Ectropion refers to out-turning of eyelids. It can be due to aging with of lost of attachment of retractor holding onto eyelid, paralytic orbicularis muscle secondary to facial nerve palsy or cicatrical changes with there is a scar pulling the eyelid outwards. It can lead to watery eyes besides being unsightly. Entropion, in contrary, refers to rolling in of the eyelids, bring in the lashes together with it and hence irritate the cornea.
d) Ptosis or drooping of the eyelids. It can sometimes associate with dermatochalais which is excess skin in the upper eyelid. People either describe as eye drooping down or eyelids become heavy or saggy. It usually occur when one becomes older. However, contact lens wear can associate with it due to its constant rubbing with the levator muscle (the muscle which lift up the eyes). Ptosis can also occur in children too. It can occur unilateral or bilaterally. If it is unilateral or affect central visual axis, there is a risk of developing ambloypia (eyes structures are normal but the vision is reduced) and hence need early intervention. The treatment for ptosis is invariably surgery. Depending on levator muscle function, surgery can be in the form reattachment or shortening of muscles (levator resection or advancement), frontalis sling with silicon rod or autogenous fascia lata.
Lacrimal system pathologies
a) Blockage of nasolacrimal duct or blockage of tear duct. Patients usually present with teary or watery eyes, with occasional mucusy discharge. In adult, it is usually due to aging changes in which the nasolacrimal duct (the drainage ‘ pipe’ which connect the lacrimal sac to the nose )got blocked. If the blockage become chronic , it may form a bump in the inner corner of the eye by the side of the nose (mucocele) or get infected (dacryocystitis). It commonly occurs in the elderly lady. Except for the antibiotics used during the infection, there is no eye drops or medicine to get rid of the blockage except surgery. The surgery, namely dacryocystorhinostomy, is an one hour surgery which opens a passage in the nasal bone to the tears pass down directly into the nose. In a newborn baby, the opening of nasolacrimal duct (valve of Hasner) may got blocked and present with persistent watery eyes which some doctors may mistaken it as recurrentconjunctivitis. No antibiotics are required but firm massage will usually suffice. Most will settle by age of 1 despite some may require probing or dacryocystorhinostomy.
b) Canalicus pathlogy: Canaliculus is a passage connect between punctum and lacrimal sac. Sometimes it can get severed during trauma. The repair of canalicus injury required expertise of oculopastic surgeon as failure to repair primarily will lead to epiphora or watery eyes for life.
Orbit refer to space between eyeball and its socket. There is muscle, fat , connective tissue, vessels and nerves. The commonest problems that we see is thyroid eye disease in which there is increase in volume in both orbital fat and extraocular muscles. This leads to proptosis (eyes protruding out), double vision (diplopia) and even reduced vision. The treatment includes control of hyper or hypothyroidism, selenium, steroid in various form and surgery such as orbital decompression to increase volume of the orbit, eyelid lowering surgery to make it look less protruding and squint surgery to make it looks straighter.
Orbital tumor which sometimes appear as eyelid mass or tumor is another possible pathology. It can be benign or malignant. Recent study in Malaysia showed that lymphoproliferative lesions is one of the common cause of orbital tumor. The universal use of steroid for orbital tumor or lump should be avoided as it may confuse the diagnosis. An incisional biopsy should be taken instead by oculoplastic surgeon to identify the nature of lesion.
Socket usually refer to the orbital space with the eyes removed. Patients have eyes removed due to injury, diseases or tumors. Many wear prosthesis , however, with time, they find the prosthesis no longer fits. This may be due to the fat resorption which made the socket larger and hence heavier prosthesis is being replaced. The larger and heavier prosthesis can lead to laxity of lower eyelid. While some patients can be treated by fixing a better prosthesis, many may require surgery. Do consult an oculoplastic surgeon if the ocular prosthesis keep on falling out or produce excessive ocular discharge.
Hemifacial spasm or blepharospasm
Hemifacial spasm refers to involuntary closing and twitching of one eyes and part of face including the mouth twitching. Blepharospasm refers to sustained , forced, involuntary closing of the both eyelids. Both causes significant social embarrassment, functional blindness as eyes are closed rather than open and see. The causes are multifactorial. It can due to dry eyes to Tourette’s syndrome to tardive dyskinesia. Most of them are benign which is not life threatening and cause unknown. In hemifacial spasm , it can be due to vascular loop pressing onto facial nerve and sometimes nerve decompression can alleviate the symptoms. Otherwise , the common treatment is botulinum toxin. It is important to address other causes such as dry eyes in order to get better control. Whilst many says that botox is for life, I have seen some patients achieve botox free when all the aggravating factors are addressed. In those who continue to have symptoms despite botox, then they need a surgery myomectomy in order for the eyes to be open again. Usually this group of patient has apraxia of eyelid opening.