Blepharoplasty

What is 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.




Epidemiology and Statistics of blepharospasm

Blepharospasm typically affects women in the age group of 40 to 60 years, with 2 to 4 women afflicted for every man affected by the disease. In the US, 2000 cases of blepharospasm are diagnosed every year with a prevalence of 5 per 100,000 people. Currently, there are around 50,000 diagnosed cases of blepharospasm in the United States.

Although mortality due to the disease is almost non-existent being a benign condition, it can be severely disabling with eye pain and functional blindness. There are also reported cases of severe depression and even suicides associated with severe and disabling blepharospasm.



Types of Blepharospasm

Etiologically, blepharospasm occurs in two forms:

Essential or spontaneous blepharospasm is a rare focal dystonia without any known cause and affects individuals between 45 and 65 years of age. Although idiopathic in nature, essential blepharospasm is commonly associated with stress, fatigue or an irritant. The symptoms may be benign and transient or might cause significant lifelong challenges to the individual and even cause functional blindness in those rare cases.

Reflex blepharospasm is due to reflex sensory stimulation through branches of the Trigeminal nerve and is common in conditions like phlyctenular conjunctivitis, interstitial keratitis, corneal foreign body, corneal ulcers and iridocyclitis. Excessive stimulation of the retina by dazzling light, stimulation of facial nerve due to central causes, and some hysterical patients also present with reflex blepharospasm. It is due to any pain in and around the eye.



Pathophysiology of Blepharospasm

Although still in the dark, it is understood that blepharospasm is a neuropathologic disorder and not due to some psychopathology as was believed in the past. The aetiology of blepharospasm is multifactorial cannot be pin-pointed to a central regulatory area somewhere in the basal ganglia, midbrain or brainstem.

The current view is that blepharospasm occurs due to a defective circuitry and not just a defective focus. To understand this better we need to understand the circuit that controls blinking. The circuit consists of a sensory limb, a control center located in the midbrain, and a motor limb.

Various stimuli such as corneal or eyelid irritation, pain, emotion, stress and other nerve stimulants trigger the sensory limb of the circuit.
This sensory stimuli are transmitted to a defective control center in the midbrain which is weakened by age, injury or genetics. This defective center results in a failure to regulate the positive feedback mechanism.

The abnormal positive feeback signals are unregulated in the motor pathway which causes uncontrolled contractions of various muscles in the distribution of facial nerve and its nucleus. The muscles commonly involved are orbicularis oculi, corrugator superciliaris and procerus of the eyelids and other muscles of facial expression ultimately resulting in contortion of the face and blepharospasm.




Clinical Presentation of Blepharopasm

The diagnosis of blepharospasm is a clinical one and investigations are futile as there is no specific observable pathology. The onset of blepharospasm is marked by a gradually progressive increase of blinking in response to innocuous stimuli like wind, polluted air, sunlight, noise, movements of the head or eyes, or exposure to any stressful environment. They also present with dry eye symptoms such as photophobia and eye irritation. These symptoms are however relieved by sleep, relaxation, gazing downwards, artificial tears, traction on eyelids, talking, humming or singing.


The following symptoms occur during the early stages of blepharospasm:

- Dry eyes
- Increased rate of blinking
- Spasms of the eyelids
- Irritation of the eyes
- Eye pain
- Midfacial or lower facial spasm
- Brow spasm
- Eyelid tic


Following anatomic changes are seen with long-standing blepharospasm:

- Ptosis or drooping of the brow and eyelids
- Dermatochalasis otherwise called as “baggy eyes” due to loose skin
- Entropion or inward turning of the eyelids
- Canthal tendon abnormalities


Differential Diagnosis of Blepharospasm

Due to its rarity and its similarities with other diseases, blepharospasm is often misdiagnosed. Following conditions should be considered in the differential diagnosis while evaluating a suspected case of blepharospasm:

Bells Palsy
Allergic conjunctivitis
Dacryocystitis
Eyelid myokymia
Keratoconjunctivitis sicca
Non-granulomatous anterior uveitis



Treatment Options for Blepharospasm

Patient education, membership in various support groups, pharmacotherapy, botulinum toxin injections, and surgical intervention constitute the best conventional treatments for a patient with blepharospasm. Various unconventional remedies that have found takers include faith healing, herbal treatment, hypnosis and acupuncture.
In reflex blepharospasm, the causative disease should be treated to prevent recurrences.
Blocking or reducing sensory stimulation constitutes the first line of management of a patient with blepharospasm. Wearing tinted sunglasses with ultraviolet blocking to decrease painful light sensitivity called photo-oculodynia is a simple yet effective measure. Improved light sensitivity, blink frequency, and functional limitations is noted with grey and FL-41 tinted lenses.
Irritation of the eyes, dry eyes and blepharitis associated with blepharospasm are ameliorated by lid hygiene, frequent application of artificial tears and occlusion of the punctum.




Medical Treatment of Benign Essential Blepharospasm


The goals of medical treatment are to reduce morbidity, possibly to halt progress, and to prevent complications. Pharmacotherapy however provides little to no relief for most patients with blepharospasm. Results with various pharmacologic agents are erratic and variable providing only marginal or transient relief of symptoms.

Tricyclic antidepressants provide symptomatic relief by treating the underlying depression that worsens the symptoms of blepharospasm. Lorazepam, clonazepam and Artane have been used with variable efficacy.

The most effective treatment of choice for achieving early yet temporary relief of symptoms is Botulinum toxin A with over 95% patients reporting significant improvement.

The toxin acts by interfering with acetylcholine release from nerve terminals, causing temporary paralysis of the associated muscles. After injection, Botulinum toxin A produces peak effect after 5 to 7 days and provides pain relief as early as 2 days and lasts for up to 3 months.

Complications of botulinum toxin injections are ptosis, corneal exposure, dry eye symptoms, entropion, ectropion, photophobia, diplopia, ecchymosis and lower facial weakness.

Failure of Botox or Xeomin therapy is due to eyelid malposition, aesthetic concerns, apraxia of eyelid opening, or photo-oculodynia. These conditions deserve surgical intervention.

It is commercially available in two forms - onabotulinumtoxinA (Botox) and incobotulinumtoxinA (Xeomin).






Surgical Treatment of Benign Essential Blepharospasm


Surgical treatment is considered only when there is poor response to a completed trial of Botox Injections. Spasm of the orbicularis oculi is best treated with myectomy. Frontalis suspension and limited myectomy with complete removal of the pretarsal orbicularis is preferred for patients who are visually disabled by apraxia of eyelid opening.

1. Myectomy
Myectomy is done in stages starting with upper eyelid surgery, followed by the lower eyelid surgery if symptoms persist. Chronic lymphedema is a common complication of simultaneous upper and lower eyelid myectomy, hence it is avoided. Myectomy may be limited myectomy or extended myectomy.
Limited myectomy: Consists of surgical extirpation of eyelid protactors, including pretarsal, preseptal, and orbital portions of orbicularis oculi muscle.
Extended myectomy: In addition to the above, it involves removal of the procerus and corrugator muscles.

2. Superior Cervical Ganglion Block
For patients who complain of debilitating light sensitivity (photo-oculodynia) intervention by a pain clinic may be beneficial to the patient. Superior cervical ganglion blocks reduce photo-oculodynia by chemical denervation of the orbital sympathetics, thus numbing the afferent loop of the disease and providing symptom relief.

- What is botulinum toxin A?
It is a toxin produced by the bacteria Clostridium botulinum which weakens muscles by blocking nerve impulses transmitted from the nerve endings of the muscles.

- Is botulinum toxin A safe?
Botulinum toxin is an approved treatment for Blepharopspasm and hemifacial spasm. Long-term follow-up studies have shown it to be a very safe and effective treatment, with up to 90 percent of patients obtaining almost complete relief of their Blepharopspasm .
Side effects include Ptosis, blurred vision, and double vision (diplopia), Lagophthalmos, ectropion, sagging of the mouth, brow droop, epiphora.

- How is botulinum toxin A used?
It is used to treat Blepharopspasm (Blepharospam refers eyelid muscles around the eye which close involuntarily. This may cause loss of vision, especially while reading, headaches, and eyebrow strain. The early symptoms of blepharospasm include increased blink rate (77%), eyelid spasms (66%), eye irritation (55%), midfacial or lower facial spasm (59%), brow spasm (24%), and eyelid tic (22%) with injection of tiny doses of botulinum toxin several sites above and below the eyes.
The sites of the injection will vary slightly from patient to patient and according to physician preference.
The injection is usually given on the eyelid, the brow, and the muscles under the lower lid. The injections are carried out with a very fine needle

- How long does it take to work?
Benefits begin in 1 - 14 days after the treatment and last for an average of three to four months.

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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