Blepharoplasty

What is Anophthalmia?

Anophthalmia

( A medical term used to describe the absence of the globe and ocular tissue from the orbit ) can be congenital (present at birth) or acquired later in life. Congenital anophthalmia can occur alone or along with other birth defects. Cases of Anophthalmia may result from inherited genetic mutations, sporadic genetic mutations, chromosome abnormalities, prenatal environmental insult or unknown. True or primary anophthalmos is very rare. Only when there is complete absence of the ocular tissue within the orbit can the diagnosis of true anophthalmos be made. Extreme microphthalmos is seen more commonly. In this condition, a very small globe is present within the orbital soft tissue, which is not visible on initial examination. Anophthalmia and microphthalmia may occur secondary to the arrest of development of the eye at various stages of growth of the optic vesicle. It is important to recognize microphthalmia because the development of the orbital region, as well as the lids and fornices, is dependent on the presence of a normal-sized eye in utero. Anophthalmia is sometimes a clinical characteristic of Trisomy 13 which is a Gross Chromosomal Abnormality. (Anophthalmia is very rare but the exact incidence is unknown. One report from a prospective study of 50,000 newborns found an incidence of microphthalmia of 0.22 per 1,000 live births)


There are three classifications for this condition:
- Primary anophthalmia is a complete absence of eye tissue due to a failure of the part of the brain that forms the eye.
- Secondary anophthalmia the eye starts to develop and for some reason stops, leaving the infant with only residual eye tissue or extremely small eyes which can only be seen under close examination.
- Degenerative anophthalmia the eye started to form and, for some reason, degenerated. One reason for this occurring could be a lack of blood supply to the eye.



Surgical Techniques

There are three types of eye removal and many different options for implant. Orbital implants and ocular prostheses are used by the surgeon to restore a more natural appearance.


Evisceration

Removal of the internal eye contents, but the sclera is left behind with the extraocular muscles still attached. Either generalor local anesthetics may be used during eviscerations, with antibiotics and anti-inflammatory agents injected intravenously An ocular prosthetic can be fit over the eviscerated eye in order to improve cosmesis.
Only the contents of the eye (iris, lens, vitreous, retina, and choroid) are removed The leaves behind a pocket of sclera.
Improved motility: because the muscles that control eye movement remain attached to the sclera Sclera is filled with an orbital implant or sphere.
The sphere may be made of MEDPOR®, PMMA or hydroxyapatite material.
This orbital sphere or implant remains permanently A prosthetic eye can be made 6-8 weeks later by an ocularist


Enucleation

removal of the eyeball, but the adjacent structures of the eye socket and eyelids remain. An intraocular tumor excision requires an enucleation, not an evisceration.
Enucleation is removal of the eye, leaving the eye muscles and remaining orbital contents intact.
This type of ocular surgery is indicated for a number of different ocular tumors, in eyes that have suffered severe trauma, and in eyes that are blind and painful due to other disease.
Auto-enucleation (oedipism) and other forms of serious self inflicted eye injury are an extremely rare form of severe self-harm which usually results from serious mental illnesses such as schizophrenia
The entire eye (iris, lens, vitreous, retina, and choroid) AND SCLERA are removed
Muscles are detached from the sclera and may be re-attached to the implant
The implant may be made of MEDPOR®, PMMA or hydroxyapatite material, or may be a dermis fat graft
This orbital sphere or implant remains permanently
A prosthetic eye can be made 6-8 weeks later by an ocularist


Exenteration

removal of the contents of the eye socket (orbit) including the eyeball, fat, muscles and other adjacent structures of the eye.
The eyelids may also be removed in cases of cutaneous cancers and unrelenting infection.
Exenteration is sometimes done together with Maxillectomy which is removal of the maxilla or the upper jaw bone/cheekbone An exenteration removes the entire ORBITAL contents, the eye, the muscles which control eye movement, and generally the eyelids.
Since the orbit is empty, implants are more difficult to create some may be attached to eyeglasses, others to the orbit with the help of magnets
Note there is no soft tissue within the orbit.




Side Effects / Complications of Enucleation or Evisceration surgery

When an eye is removed, the patient loses all vision and the cosmetic use of the globe. Reported complications include hemorrhage, infection and extrusion of the implant.
Most patients with post-operative hemorrhage are either on blood thinners (e.g coumadin, plavix, heparin or aspirin) or are known to have a bleeding disorder. Such hemorrhages can be painful, but intervention is rarely helpful. Patients are typically treated with analgesic medications (pain-killers).

Orbital Infections are very rare, but are more common with integrated orbital implants. Most secondary orbital infections can be managed with antibiotics, covering or surgical removal of the orbital implant.
Implant extrusions can be managed by surgical replacement of the orbital implant
Normal Volumes of the Orbit:
- Adult orbital volume ranges from 24 to 30 ml
- Female orbital volume is approximately 2 mm less than male adults
- Each orbit contains approximately 10 ml of fat; extraocular muscles account for 5 ml of volume and the normal eyeball accounts for approximately 7 ml.
- Following enucleation there is a decrease in volume as well as changes in structure which give rise to what has been termed “post-enucleation socket syndrome.”

This involves enophthalmos, a deep upper eyelid sulcus, lower eyelid laxity with shallow fornix with possibly Ptosis or lid retraction. When an eye is removed, recall there is a 7 ml volume loss; however, the most commonly used 18 ml sphere replaces a volume of approximately 3 mm while a 16 mm sphere replaces a volume of 2 ml. A 20 mm sphere provides 4.1 ml of volume.
The situation is made worse by orbital fat atrophy of up to 3 ml.

It is unclear whether fat atrophy recurs as a result of reduction of blood supply or due to mechanical manipulation during surgical enucleation.
Bony orbital volumes are also noted to be smaller in patients who have had long-standing enophthalmia.



Procedures
Anophthalmos
- Anophthalmia is a medical term used to describe the absence of the globe and ocular tissue from the orbit. - This was first reported more than 400 years ago, yet it is only recently that significant reconstructive options became available. - There are many reasons why one might lose an eye. - Surgeries which result in anophthalmos
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Blepharoplasty
What is Blepharoplasty?
- Your eyes including your eyelids, are perhaps one of the first things people notice in you. This makes your eyes and eyelids one of the most important components for an appealing facial expression and aesthetic appearance. Any visible change in the shape or size of the orbital or periorbital region can spoil the look of your face.
- As you age and grow older, your eyelids may become ‘droopy’ or ‘baggy’ due to the stretching of your eyelid skin and gradually decreasing tone of your eyelid muscles. Your droopy eyelids and brow together cut a sorry figure for your face making you look tired, sleepy and haggard, further leading to eyelid or brow straining or both. In extreme cases, your saggy, baggy eyelids can even obstruct your vision, particularly peripheral vision causing difficulty in reading or driving.
- Blepharoplasty ensures cosmetic or functional corrections to the area around your eyes to enhance your look or to correct any abnormalities in function.
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Blepharospasm
- Blepharospasm is defined as an abnormal, involuntary, sustained and forceful closure or twitching of the eyelids. It is derived from the Greek word ‘blepharon’ which means eyelid, and ‘spasm’ which is an uncontrolled muscle contraction. Blepharospasm is usually associated with headache, eyebrow strain and occasionally loss of vision.
- Isolated blepharospasm is rare and represents a minority of patients presenting with blepharospasm. Blepharospasm is commonly associated with lower facial spasms as part of a syndrome or disease complex. Some examples are:
   - Meige Syndrome: Characterized by spasm of the eyelids and midface.
    - Brueghel’s Syndrome: Presents with blepharospasm and marked spasms in the lower face and neck.
    - Segmental Cranial Dystonia: In addition to the usual spasms of the eyelids and facial muscles it is associated with spasms along distribution of various cranial nerves, most frequently involving the Facial Nerve.
    - Generalized Dystonia: Presents with spasms across various body parts in addition to blepharospasm and facial spasms.
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Brow Lift
A forehead lift, also known as a browlift or browplasty, is a cosmetic surgery procedure used to elevate a drooping eyebrow that may obstruct vision and/or to remove the deep worry lines that run across the forehead and may portray to others anger, sternness, hostility, fatigue or other unintended emotions
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Congenital
Congenital anomolies include :
- Eyelid Disorders
- Orbital Disorders
- Congenital Ptosis
- Congenital Nasolacrimal Duct Obstruction

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Dry Eye
What is Dry Eye?
- Dry eye is a reduction in your eye’s ability to produce sufficient natural tears.
- Insufficient tear production can lead to irritation and pain, and even scarring of the cornea (the transparent part of the eye that covers the pupil and iris).
- Many people will experience dry eye symptoms at some point in their lives.
- Often due to environmental factors such as indoor heating or air conditioning, it can also be caused by occupational factors such as prolonged computer use.
- Dry eye symptoms can affect anyone.
- Some of the symptoms of dry eye include a burning sensation or gritty feeling in the eyes. You may also experience decreased tolerance to contact lens wear or sensitivity to light.
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Eyelid Laxity
- Eyelids protect your eyes from any foreign bodies while keeping them lubricated throughout. Any alteration in the shape, position or function of your eyelids can predispose your eyes to a plethora of ailments or interfere with our vision.
Our eyelid is a complex structure consisting of three theoretical layers:
   - Anterior Layer contains the skin and orbicularis muscle
   - Middle Layer contains the orbital septum and eyelid retractors
   - Posterior Layer contains tarsus and conjunctiva.

- Eyelid malpositions include any unnatural or incorrect positioning and orientation of eyelids due to various factors that influence any of the three layers of the eyelids. They may be caused due to ageing, trauma, scarring, birth defects or medical disease involving any or all of the three layers.
- The most common forms of eyelid malposition are eyelid retraction, ptosis, entropion and ectropion.
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Face
The world of cosmetic surgery has advanced tremendously over the last two decades. New procedures have emerged that can make an individual look and feel younger in a matter of a few minutes. Amongst the vast number of cosmetic procedures currently available, the face lift is a commonly performed one that is sought after by both men and women. Here we shall take a look at this procedure in a little more detail.

- What is a face lift?    - A face lift is called a rhytidectomy in the world of medicine. It involves tightening the muscles of the face and smoothening of the skin so that the face appears younger.    - However, it must be remembered that a face-lift is not an anti ageing solution.
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Lacrimal System
- The lacrimal gland produces tears which enter into the "duct" that drain the tears from the eye into the nose. The most common symptoms are If one has a plugged up "tear duct," not only will tears spill over the eyelids and run down the face, but the stagnant tears within the system can become infected.    (1) excess tearing (tears may run down the face) and    (2) mucous discharge - This may lead to recurrent red eyes and infections. - The excessive tearing can also produce secondary skin changes on the lower eyelids.
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Lagophthalmos
Patients with lagophthalmos have an inability to close eyelids. This may occur, for instance, in patients with Thyroid eye disease.
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Latisse
LATISSE® makes lash growth possible because of its active ingredient: bimatoprost. Although the precise mechanism of action is not known, research suggests that the growth of eyelashes occurs by increasing the percent of hairs in, and the duration of, the anagen (or growth) phase. Lashes can grow longer, thicker and darker because bimatoprost can also prolong this growth phase.
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Orbital Tumors
- Orbital Tumor is any tumor that occurs within the orbit of the eye. The orbit is a bony housing in the skull about 2 inches deep that provides protection to the entire eyeball except the front surface. It is lined by the orbital bones and contains the eyeball, its muscles, blood supply, nerve supply, and fat.
- Tumors may develop in any of the tissues surrounding the eyeball and may also invade the orbit from the sinuses, brain, or nasal cavity, or it may metastasize (spread) from other areas of the body. Orbital tumors can affect adults and children. Fortunately, most are benign.
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Ptosis
- Ptosis is an abnormally low position (drooping) of the upper eyelid
- Ptosis occurs when the muscles that raise the eyelid (levator and Müller's muscles) are not strong enough to do so properly.
- It can affect one eye or both eyes and is more common in the elderly, as muscles in the eyelids may begin to deteriorate.
- Compare with dermatochalsis (extra skin and fat)
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Skin Rejuvination
A radiant, smooth, youthful skin is the essence of beauty and trendy looks. Skin care routine highly contributes in the slowing down of rate of aging of the skin. Choosing the right skin care products for your skin type enhances your beauty keeping the skin cleansed, moisturized and well toned. Use of superficial skin resurfacing treatments to counter fine lines and wrinkles, acne scars and blemishes before they deepen ensures skin rejuvenation.
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Skin Tumors
Cancer of the eyelid, like any other cancer, can be a worrying thing. Treatments are variable and depend on the type of cancer. In this article, we shall take a brief look at the different kinds of eyelid tumors.
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Symblepharon
A symblepharon is a fibrous tract that connects bulbar conjunctiva to conjunctiva on the eyelid.
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Thyroid
Graves' disease is an autoimmune disease.
It most commonly affects the thyroid, causing it to grow to twice its size or more (goiter), be overactive, with related hyperthyroid symptoms such as increased heartbeat, muscle weakness, disturbed sleep, and irritability. It can also affect the eyes, causing bulging eyes (exophthalmos).
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Trauma
Eye injuries are extremely common with over 2 million cases reported every year that require medical treatment. Blindness in one eye is most commonly due to cataract and this is followed closely by eye injuries. In addition, in children, injury to the eye is a recognized as the most common cause of blindness in one eye that is not due to a birth defect.
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