Blepharoplasty

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.


Patients with "dry eye": often complain of symptoms

   - feeling of dryness
   - gritty or foreign body sensation
   - burning sensation and stinging
   - soreness
   - tired eyes
   - paradoxically, watering eyes
   - Tearing is reflex tearing from the irritated cornea stimulating the lacrimal gland. Your eye may be red as a sign of irritation



Anatomy of the Tear Film

The normal tear film has three layers and several key functions. The layers are :
   - Lipid which is the top most layer. This helps tears from evaporating and is made by meibomian glands.
   - Aqueous which is in the middle. It is made from the main and accessory lacrimal glands
   - Mucin which is next to the cornea, and allows the tear film to spread over the ocular surface; it is made from goblet cells
The tear film is critical as it is the first surface that light hits as it enters your eye. It provides the cornea with nutrients, oxygen and protection from infection.


Causes of Dry Eye

Many different things can cause dry eye syndrome. The normal aging of tear glands, as well as specific diseases and disorders, may cause changes in the amount and condition of tears produced.

   - Congenital (born with) - Riley-Day Syndrome (familial dysautonomia)
   - Acquired
     1- Medications
       -decongestants
       antihistamines
       diuretics
       beta-blockers
       sleeping pills
       pain-relievers
       alcohol
     2- Trauma to lacrimal gland
     3- Neuroparalytic hypo secretion
     4- Inflammation of the lacrimal gland due to mumps, sarcoid
     5- Contact Lens Wear
     6- Milkulcz's syndrome
     7- Smoking
     8- Eye strain due to prolonged computer use
     9- Wearing contact lenses for long periods of time

   - Sjögren's syndrome is an immune system disorder which is characterized by inflammation and dryness of the mouth, eyes, and other mucous membranes. Tear production may be limited as the the lacrimal gland is affected. (Primary SS, young middle aged women, severe aqueous tear deficiency, HLA B8 association in 90% of patients

   - Excessive evaporation of tears can also cause dry eye syndrome. Such evaporation may be caused by "meibomitis," which results from infection and inflammation of the meibomian glands in the eyelids. Patients with thyroid disease (Thyroid or Grave's disease results from overative thyroid which affects the eyes, may cause proptosis, loss of vision and dry eye. Please see the Thryoid page for more details), may also experience dry eye syndrome caused by excessive evaporation.

   - Decreased sensitivity of the cornea can also lead to insufficient production of tears.

   - Hormonal changes can also affect secretions from the tear glands.


What You Can Do to Prevent or Minimize Dry Eye Symptoms

   - Avoid drafts from heating or air conditioning vents, especially in cars and airplanes.
   - Take frequent breaks to relieve eye strain during periods of prolonged computer use.
   - Remove your contact lenses and keep them especially clean when your eyes are feeling dry.
   - After LASIK surgery, use artificial eye drops to soothe and comfort your dry eyes during recovery.
   - Be aware that certain over-the-counter medications and prescription drugs can contribute to dry eye symptoms.
   - Use a humidifier at home and in your workplace.





Evaluation & Workup

Dry eyes can usually be diagnosed by the symptoms alone.Tests can determine both the quantity and the quality of the tears.
A slit lamp examination can be performed to diagnose dry eyes and to document any damage to the eye.
Dry eyes can usually be diagnosed by the symptoms alone.Tests can determine both the quantity and the quality of the tears.
A slit lamp examination can be performed to diagnose dry eyes and to document any damage to the eye


Diagnosis of Dry Eye

   - Dry eyes can usually be diagnosed by the symptoms alone.Tests can determine both the quantity and the quality of the tears.A slit lamp examination can be performed to diagnose dry eyes and to document any damage to the eye.
   - A Schirmers test can measure the amount of moisture bathing the eye. This test is useful for determining the severity of the condition. A five-minute Schirmer's test with and without anesthesia using a Whatman #41 filter paper 5 mm wide by 35 mm long is performed.For this test, wetting under 5 mm with or without anesthesia is considered diagnostic for dry eyes.
   - If the results for the Schirmers test are abnormal, a Schirmer II test can be performed to measure reflex secretion. In this test, the nasal mucosa is irritated with a cotton-tipped applicator, after which tear production is measured with a Whatman #41 filter paper.For this test, wetting under 15 mm after five minutes is considered abnormal.
   - A tear breakup time (TBUT) test measures the time it takes for tears to break up in the eye.The tear breakup time can be determined after placing a drop of fluorescein in the cul-de-sac.
   - A tear protein analysis test measures the lysozyme contained within tears.In tears, lysozyme accounts for approximately 20 to 40 percent of total protein content.
   - A lactoferrin analysis test provides good correlation with other tests.
   - The presence of the recently described molecule Ap4A, naturally occurring in tears, is abnormally high in different states of ocular dryness. This molecule can be quantified biochemically simply by taking a tear sample with a plain Schirmer test. Utilizing this technique it is possible to determine the concentrations of Ap4A in the tears of patients and in such way diagnose objectively if the samples are indicative of dry eye.


Mucin Tear Deficiency

   - may be due to decreased Vitamin A, alkali burns, Cicatricial pemphigoid, SJS
   - increased tear break-up time

Dry Eye Tests

Tests for evaluation of dryness
   - basic secretion test
   - Schirmer I
   - Schirmer I
   - Tear meniscus
   - Tear breakup time

As part of our eyes' normal function, tear film is produced, spread over the eyeball, and continually washed out through tiny holes on the edges of the upper and lower eyelids. Our impulse to blink is due to the tear film thinning out and evaporating, giving us the automatic impulse to blink and refresh the tear film. The process of the tear film thinning out is called tear film break-up.
When not enough tear film is being produced to keep the eye moist between blinks, or when the tear film composition is abnormal, tear film break-up can occur too quickly—before our impulse to blink. This causes dry spots to appear on the eye's surface (cornea).
Even if tear film is fairly normal, dry spots can still appear if the cornea has been compromised in some way. The cells on the corneal surface have very delicate structures that allow the tear film to stick to the eye, and if compromised, tear film can break-up too quickly



Treatment

What Are the Purposes of Tears?

As you know, the symptoms of dry eye are caused by a reduction in your eye’s ability to produce sufficient natural tears. Tears are important because they serve several functions for keeping the eye healthy. The following are just a few:

  • Tears moisturize the surface of the eye. Tears lubricate the inside of the eyelids to make blinking smooth and comfortable. Without them, the surface of the eye can become irritated, which can potentially cause damage to the cornea.
    • This prevents the cornea (the transparent front portion of the eye that covers the iris, pupil, and anterior chamber) from drying. If the cornea dries, it can potentially become damaged.
    • Pain, blurred vision, and even loss of sight may result in particularly severe cases.
  • Tears nourish the eye by transporting oxygen to the eye and removing carbon dioxide. Without tears, a malnourished cornea can lead to damaged vision.
  • Tears clean and protect the eye by washing away foreign particles. Tears contain antibacterial and antiviral substances that help defend the eye against infection.


How Are Dry Eye Symptoms Treated?

  • If you suspect you have dry eye symptoms, see your doctor. He or she can determine which treatment is appropriate for you. Depending on the severity of your condition, tear replacement is the most commonly recommended therapy—this involves the use of lubricant eye drops. The primary goal of treatment is to keep the eye moist and comfortable and to protect the eye’s delicate surface.
  • In addition to making changes to your environment, you may want to also use artificial tears to ease your symptoms.
  • You should also try to eliminate the factors that exacerbate or contribute to dry eye: Contributing eye abnormalities (such as blepharitis, an inflammation of the eyelids) should be treated.
    • Schedule regular breaks from reading, television viewing, and computer use.
  • Try to avoid excessive heat, air conditioning, and low humidity — they can aggravate dry eye symptoms as can being close to air conditioning ducts or heating vents.
  • Lower your computer screen so that you are looking down at it. This may decrease some of the discomfort that is often associated with prolonged computer use.
  • Avoid or eliminate those elements that are known to cause or aggravate dry eye symptoms.
  • The use of antihistamines or diuretics should be decreased as much as possible. However, it is important that you talk to your doctor before adjusting the dosage of or stopping any medications.


Treatment with artificial tears/lubricants



Preserved Artificial Tears
  • Artificial tears are a common treatment for dry eye symptoms.
  • They provide moisture, surface wetting, and comfort for people who suffer from dry eye symptoms.
  • Preserved artificial tears are typically recommended for those with mild dry eye symptoms.
    • Systane


Preservative-Free Artificial Tears
  • As your symptoms become worse, you may increase the use of artificial tears.
  • Preservative-free tears are often recommended for those with moderate or severe dry eye symptoms.
  • People with sensitive eyes may also prefer nonpreserved tears.
    • Celluvisc
    • Refresh


Thicker Artificial Tears and Ointments
  • Thicker artificial tears or ointments may be substituted if you use artificial tears more frequently.
  • An ointment may be preferred for nighttime use
  • Artificial lubricants such as tears and ointment


Drops with Omega-3 - Thera-tears
  • Omega-3s are essential fatty acids. “Essential” means that, because they cannot be produced by the body, their inclusion in the diet is essential for good health. The two best sources of omega-3s are dark, oily, cold-water fish, and flaxseed. They are known to have a multitude of health benefits, yet, as a population, Americans are omega-3 deficient—it has been estimated that 83% of Americans are deficient in omega-3s.1,2 North Americans have among the lowest dietary intake of omega-3s in the world (Figure 1).


    Omega-6s are another group of essential fatty acids. Americans obtain an excess of these through their consumption of beef, dairy, vegetable cooking oils, and vegetable shortenings (i.e. cookies, potato chips, snacks etc.). Unfortunately, while the recommended ratio of omega-3s to omega-6s is 1:2.3, the existing ratio of omega-3s to omega-6s consumption has been estimated to be as low as 1:10.

  • Omega-3s in the diet, once consumed, are elongated by enzymes to produce anti-inflammatory prostaglandin E3 (PGE3) and anti-inflammatory leukotriene B5 (LTB5)
  • Even more importantly, eicosapentaenoic acid (EPA), a long-chain omega-3 provided directly by fish oils, blocks the gene expression of the pro-inflammatory cytokines tumor necrosis factor alpha (TNF-a), interleukin-1 alpha (IL-1a), interleukin-1beta (IL-1b), proteoglycan degrading enzymes (aggrecanases) and cyclooxygenase (COX-2)
  • There is an abundance of clinical evidence that ingestion of omega-3s decreases the inflammation seen in the joints in rheumatoid arthritis 3-6 and in the skin in dermatitis as well. 7These anti-inflammatory effects go a long way to explain why omega-3s have been useful in helping patients with symptoms of posterior blepharitis or meibomitis. 8 In my practice, omega-3s have been displacing my use of systemic tetracyclines as treatment for the eye irritation that my meibomitis patients experience upon awakening in the morning. But the effects of omega-3s only begin with their effects on meibomitis.
  • The effects of suppressing pro-inflammatory cytokines don't stop here. We now know that the pro-inflammatory cytokines TNF- a , IL-1 a , and IL-1 b , impair tear secretion in lacrimal gland disease-based dry eye by inhibiting the release of neurotransmitters from neural synapses, and interfering with the secretory response of lacrimal gland acinar cells to stimulation. This is probably the main mechanism by which tear secretion decreases in dry eye.
  • Meibomian glands use essential fatty acids to synthesize oil (meibum). Dietary intake of omega-3s in general, and EPA and DHA in particular, have recently been shown to affect the polar lipid profiles of meibum as observed by HPLC. 25 Indeed, Boerner has observed the clearing and thinning of meibomian gland secretions with omega-3 supplementation. 8 Further studies are needed to determine whether these effects are sufficient to bolster the oil layer and retard evaporation.


Stimulation of tear production
  1. - Oral pilocarpine
  2. - Restasis
    • Restasis ® Ophthalmic Emulsion is the only prescription eye drop indicated to increase tear production which may be reduced by inflammation on the eye surface in patients with Chronic Dry Eye.
    • Increased tear production was not seen in patients using topical steroid drops or tear duct plugs. The approved treatment is one drop in the morning and one drop at night in each eye, every day
    • Unlike artificial tears, Restasis® Ophthalmic Emulsion helps increase your natural ability to produce tears which may be suppressed by inflammation due to Chronic Dry Eye.
    • Indeed, many patients using Restasis® report a noticeable increase in tear production with continued use.
    • What to Expect
      • Restasis® Ophthalmic Emulsion works gradually to increase tear production. Individual results may vary.

      Initial Results

      • You may first notice you're using artificial tears less and less. Over the course of time, you may be able to discontinue their use altogether.

      After Three Months

      • By the end of the third month many users can experience a significant difference in tear production.

      Continue Using Restasis®

      • As shown in six-month clinical studies, the benefits of Restasis® Ophthalmic Emulsion depend upon continuous use of the product.


Punctal Occlusion
  • Punctum and intra-canalicular occlusion are appropriate for certain patients with aqueous abnormalities, and it is important that a correct diagnosis is made to allow selection of suitable patients for the procedure.

Collagen plugs

  • These are "temporary" ; that is they dissolve over 4 to 7 days. This allows them to be useful for diagnostic and prognostic purposes. In other words, they may be used to predict the likelihood of benefit.
  • Plugs are available in a range of diameters (0.2mm, 0.3mm, 0.4mm, 0.5mm, and 0.6mm) and lengths (a "standard" 2mm and a shorter 1.6 mm).

Silicone plugs

These are "permanent" in that they do not dissolve. However they can be removed if necessary.


Treatment with Restasis

What is RESTASIS®?


  • RESTASIS® is the only prescription eye drop that helps increase your eyes’ natural ability to produce tears, which may be reduced by inflammation due to Chronic Dry Eye. RESTASIS® Ophthalmic Emulsion did not increase tear production in patients using topical steroids or tear duct plugs.
  • Research has shown that Chronic Dry Eye (keratoconjunctivitis sicca, also known as Dry Eye Syndrome) may be the result of a functional problem in the tear-producing glands of the eyes. This reduces tear production, resulting in an insufficient amount of tears to lubricate or nourish the eye

How does it work?


  • RESTASIS® Ophthalmic Emulsion is the first prescription eye drop indicated to increase tear production which may be reduced by inflammation on the eye surface in patients with Chronic Dry Eye.
  • RESTASIS® did not increase tear production in patients using topical steroid drops or tear duct plugs.
  • The approved treatment is one drop in the morning and one drop at night in each eye, every day.
  • RESTASIS® Ophthalmic Emulsion helps increase your natural ability to produce tears, which may be reduced by inflammation due to Chronic Dry Eye.
  • RESTASIS® is believed to work on the inflammation to relieve it and enable greater tear production over time.

What are the side effects?


  • The most common side effect reported by 17% of patients was ocular burning. 
  • Other side effects reported by 1% to 5% of patients included conjunctival hyperemia, discharge, epiphora, eye pain, foreign-body sensation, pruritus, stinging, and visual disturbance (most often blurring). 
  • RESTASIS® is contraindicated in patients with active ocular infections and has not been studied in patients with a history of herpes keratitis.
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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