Faq Oculoplasty

Specialised Oculoplasty Services

Orbit and Oculoplasty is a newly emerging sub-speciality in the field of Ophthalmology. The focus of the Orbit and Oculoplasty services is on the evaluation and management of Orbital and adnexal disorders. The blemish created by lid abnormalities and socket deformities are corrected.

  • Correction of Inturning(Entropian)/Outturning(Ectropion)/eyelids
  • Electrolysis for misdirected eyelashes(Trichiasis)
  • Ptosis Surgery
  • Surgical resection of growths on lids
  • DCR (Dacryocystorhinostomy), DCT(Dacryocystectomy), Probing
  • Enucleation/Evisceration with implant
  • Socket reconstruction with or without AMG/MMG
  • Rehablitation of patients of Exentration with Orbital Prosthesis (Facial+Prosthetic eye)
  • Management of Anophthalmia (Absent eyeball since birth or after surgery)
  • Management of Shrunken eyes (Phthisis & Atrophic Bulbi) with Custom Made Artificial Eye Botox treatment for facial twitches & frown lines

Botox treatment for facial twitches & frown lines

 

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Common EyeLid Problems

1. Stye (External Hordeolum)
2. Hordeolum Internum
3. Chalazion
4. Blepharitis
5. Entropion
6. Ectropion
7. Trichiasis
8. Ptosis
9. Lid tumors

Stye (External Hordeolum)

What is Stye (External Hordeolum)?
A localized infection or inflammation of the eyelid margin involving hair follicles of the eyelashes or meibomian glands.

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Stye (Upper Eyelid)

What are Symptoms of Stye?
• Severe pain which is sharp throbbing, feeling of fullness or heaviness and feeling of heat
• Tenderness (increase in pain on touching swelling/affected area)
• Pain subsides on escape of pus

What are signs of Stye?
• Starts usually as edema of the lids with chemosis
• Yellow pus point appears on the lid margin around the root of a lash at the most prominent part of the swelling
• Starts usually as edema of the lids with chemosis
• Yellow pus point appears on the lid margin around the root of a lash at the most prominent part of the swelling

What is the treatment of Stye?
1) Systemic
• Antibiotic
• Anti-Inflammatory Analgesic
• Supportive
• Treatment of associated systemic predisposing cause
2) Local
• Hot Fomentation
• Local broad spectrum antibiotic drop and ointment
• Evacuation of pus when pus points, sometimes epilation may be required before evacuation of pus (lid margin/ lesion should never be squeezed).

Hordeolum Internum

What is Internal Hordeolum?
• Hordeolum Internum is a suppurative inflammation of meibomian gland.
• It may be due to secondary infection of meibomian gland or it may start to begin with as suppurative infection of meibomian gland.
• This condition is more symptomatic than stye, the gland is larger and is located in fibrous tarsal plate.

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Internal Hordeolum

What are symptoms of Internal Hordeolum?
• Pain, which may be severe throbbing
• Swelling, which is away from lid margin
• Pus pointing either at the lid margin or on the palpabral conjunctiva.

What are signs of Stye?
• Swelling of affected lid, due to associated cellulitis
• Swelling is more marked about 4-5 mm from lid margin.
• Tenderness
• Palpabral conjunctiva over the swelling is congested a pus point may be visible
• Pus point may be visible at the lid margin

What is the treatment of Intertnal Hordeolum?
Medical treatment is similar to treatment of Hordeoulm externum i.e.
1) Systemic
• Antibiotic
• Anti-Inflammatory Analgesic
2) Local
• Hot Fomentation
• Local broad spectrum antibiotic drop and ointment
Sometimes it turns into chronic granuloma i.e. Chalazion

Chalazion

What is Chalazion?
• Chalazion is also called tarsal cyst or meibomian cyst
• Chalazion is chronic inflammatory inflammatory granuloma of meibomian gland
• Seen in adults more often as multiple lesions occurring in crops

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Chalazion

What are symptoms of Chalazion?
• Hard painless swelling little away from lid margin
• Swelling increases gradually in size without pain
• Small chalazia are better felt than seen
• Multiple lesions and large chalazion may be associated with inability to open eye fully.

What are signs of Chalazion?
• Painless swelling 4-5 mm away from lid margin. Swelling is hard
• On conjunctival side it appears red or purple. In long standing lesions it appears grey. In old lesion granulation tissue turns into jelly-like mass
• Chalazion may become smaller over the period of time , but complete resolution may occur only rarely
• Sometimes the granulation tissue is formed in the duct and project at the intermarginal strip as a reddish grey nodule.

What is the treatment of Chalazion?
• Intralesional injection of Triamcinolone Acetonide may help in resolution of chalazion
• Supportive
• Incision & curette of chalazion is indicated in cases when it causes disfigurement and mechanical ptosis due to its weight.
• Swelling remains for few days after surgery as the cavity is filled by blood.
• Post-operatively analgesic may be needed systemically. Local antibiotic drop and ointment for 1 to 2 wks

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Blepharitis

What is Blepharitis ?
Blepharitis is chronic inflammation of lid margin occurring as true inflammation or as simple hyperaemia.

1) Anterior

  1. Squamous
  2. Ulcerative

2) Posterior

  1. Meibomian Seborrhoea
  2. Meibomianitis
 
What are the symptoms and signs of Anterior Blephritis?
It occurs in two clinical forms:-
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A. Seborrhoeic or Squamous Blepharitis:-

  • Is a form of anterior blebharitis characterized by deposition of white scales among the eye lashes. Eye lashes fall and replaced by undistorted eyelashes.
  • On removal of scales, lid margins appear hyperaemic. Ulcers are absent.
  • Condition is metabolic associated with dandruff of the scalp
  • Usually associated with seborrhoeic dermatitis involving scalp, nasolabial folds and retroauricular areas

Symptoms:-

  • Burning, deposits / crusting along lid margins, grittiness, redness of lid margins, photophobia
  • Symptoms are worse in the morning

Treatment:-

  • Skin condition also requires treatment.
  • Cleaning of lid margin with baby shampoo. In case of bacteria infection, local antibiotic drops and ointment. Associated tear film dysfunction, if present is treated with artificial tear drops.
  1. Staphylococcal or Ulcerative Blepharitis:-
  • Ulcerative blepharitis is infective condition commonly due to staphylococcal infection.
  • Lid margins are covered with infective material (yellow crusts or dry brittle scales) matting eyelashes.
  • On removal of discharge small ulcers which bleed are found along lid margins around bases of the eyelashes.

Symptoms:-

  • Redness of lid margins, burning, itching, watering and photophobia.

Signs:-

  • Small ulcers at lid margins on removal of discharge, this features differentiate it from conjunctivitis.

Treatment:-

  • Discharge/crust is removed from lid margins with 1:4 dilution baby shampoo or luke warm 3% soda bicarbonate lotion. The loose discharge is then cleaned cotton
  • Diseased eyelashes are epilated
  • Appropriate antibiotic drops are used
  • After control of infection, daily cleaning of lid margins with blend lotion Improvement of local hygiene (rubbing of eyes and touching of eyes with dirty hand should be discouraged)
 
What are the symptoms, signs & treatment of posterior Blephrites?
It is inflammation of meibomian duct opening at intermarginal strip

It occurs in two clinical forms:-

  1. Meibomian Seborrhoea – characteristic appearance of oil droplet at the opening of meibomian duct opening at intermarginal strip. Tear film is oily and foamy. Frothy discharge accumulate on the lid margin. Foam like discharge can be expressed from these lesions.
  2. Meibomianitis – There is inflammation and obstruction of meibomian glands. Characterized by diffuse thickening of posterior border of lid margin which becomes rounded. On lid massage toothpaste like thick material can be expressed out. Due to duct blockade cyst formation may be present.

Treatment:-

  • Warm compresses
  • Systemic – Doxycycline 100 mgm twice x 1 week then once daily for 6 -12 weeks or Tetracycline 250 mgm 4 times x 1 week then twice for 6 -12 weeks
  • Associated tear film abnormality is treated with artificial tear drops.

Entropion

What is Entropion?
It is the medical term used to describe sagging and inward turning of the lower eyelid and eyelashes. The margin of the eyelid and the eyelashes invert (turn in)

What are the symptoms of Entropion?
Inturn eyelidmargins and eyelashes rub against the cornea. This rubbing can lead to excessive tearing, crusting of the eyelid, mucous discharge, irritation of the eye, chronic redness and corneal damage.

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What are the causes of Entropion?
• Age related: Most cases of entropion are due to relaxation of the tissues of the eyelid as a result of aging.
• Some cases result from scarring of the conjunctiva caused by chemical and thermal burns, trauma, conjunctival cancers, or previous eyelid surgery.
• Rarely entropion can be present at birth if the eyelids do not form properly.

What is the Treatment of Entropion?
• Prior to surgery, the eye can be protected by taping the lower lid down and using lubricating drops and ointment.
• Entropion should be repaired surgically before the rubbing damages the cornea by causing infection and scarring.
• In some cases, sutures can be placed through the lower eyelid until more definitive surgery can be performed.
• In rare instances a special injection(BOTOX) may injected to bring the lid into its normal position.

Please tell me something about surgery and post-op care?
• The surgery to repair entropion is usually performed under local anesthesia .
• In most cases, your doctor will tighten the eyelid and its attachments.
• You may have a patch overnight and then will commonly use an antibiotic ointment for about a week.
After your eyelids heal, your eye will feel comfortable and you will no longer have the risk of corneal scarring, infection, and loss of vision.

Ectropion

Ectropion

What is Ectropian?
It is the medical term used to describe sagging and outward turning of the lower eyelid and eyelashes. The margin of the eyelid and the eyelashes evert (turn out).

What are the symptoms of Entropion?
Turn out margin of the eyelid and the eyelashes can lead to excessive tearing, crusting of the eyelid, mucous discharge, irritation of the eye and chronic redness.

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Ectropion of Lower Eyelid

What are the causes of Ectropion?
• Age related- Most cases of ectropion are due to relaxation of the tissues of the eyelid as a result of aging
• Some cases result from scarring of the eyelid skin caused by chemical and thermal burns, trauma, skin cancers, or previous eyelid surgery.
• Paralysis of the face is another common cause of ectropion.
• Rarely ectropion can be present at birth if the eyelids do not form properly.

What is the treatment of Ectropion?
• Prior to surgery, the eye can be protected by using lubricating drops and ointment
• Ectropion should be repaired surgically before the rubbing damages the cornea by causing infection and scarring.
• When ectropion is due to scarring of the eyelid then skin grafting is required.
• In some cases, sutures can be placed through the lower eyelid until more definitive surgery can be performed.

Please tell me something about surgery and post-op care?
• a. The surgery to repair ectropion is usually performed under local anesthesia .
• b. In most cases, your doctor will tighten the eyelid and its attachments.
• c. You may have a patch overnight and then will commonly use an antibiotic ointment for about a week.
After your eyelids heal, your eye will feel comfortable and you will no longer have the risk of corneal scarring, infection, and loss of vision.

Trichiasis

What is Trichiasis?
Trichiasis means misdirected eyelashes .In this position of the lids are normal.

What are the symptoms of Trichiasis?
Misdirected eyelashes rub the cornea. This rubbing can lead to excessive tearing, irritation of the eye, chronic redness and corneal damage.

What is the treatment of Trichiasis?
a. Electrolysis for misdirected eyelashes.
b. In severe cases lid surgery may be required.

Ptosis

What is Ptosis?
Ptosis is the medical term for drooping of the upper eyelid, a condition that may affect one or both eyes.The ptosis may be mild – in which the lid partially covers the pupil; or severe – in which the lid completely covers the pupil.

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When does Ptosis occur?
Ptosis can occur at any age.

  • When present since birth it is called congenital ptosis.
  • When present in the elderly it is called acquired ptosis.
 
What are the causes of Ptosis?
  1. While the cause ofcongenital ptosisis often unclear, the most common reason is improper development of the levator muscle. The levator muscle is the major muscle responsible for elevating the upper eyelid.b. In adults (acquired) ptosis is generally due to
  • Weakening / dehiscence of the levator muscle.
  • Following injury to the muscle as after lid injuries and eye surgeries.
  • Rarely it may be due to myasthenia gravis (a condition where there is progressive weakness of muscles)
 
What is the treatment of Ptosis?
Ptosis is treated surgically, with the specific operation based on the severity of the ptosis and the strength of the levator muscle.

Congenital Ptosis :

  • If the ptosis is not severe, surgery is generally performed when the child is between 3 and 5 years of age (the “pre-school” years).
  • However, when the ptosis interferes with the child’s vision, surgery is performed at an earlier age to allow proper visual development.
  • Ptosis repair is usually completed under general anesthesia in infants and young children.

Acquired Ptosis:
It can be done according to the need of the patient.

  • Ptosis repair is usually completed under local anesthesia in adults.
  • The elevation of the eyelid will often be immediately noticeable, though in some cases bruising and swelling will obscure this finding.
  • Most patients will have sutures that need removing about a week following surgery.
  • In children, absorbable sutures are often used.
  • The bruising and swelling associated with the surgery will usually resolve in two to three weeks.
  • Some patients may need adjustment of the sutures to better align the lid height. This may or may not require additional anaesthesia or a trip to the operating room.

Lid Tumors

Watering from the eye.

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What are the causes of watering from eyes?
1) Emotions

2) The common causes are either due to increased production of tears or deficient drainage of tears.

  • Increased production is due to dryness of the surface of the eyes, infections of the conjunctiva or cornea, allergies or a small foreign body on the eye.
  • The drainage may be hampered either due to a block along the course of the drainage system or due to a failure of pumping mechanisms.

The eye has its drainage system called the lacrimal drainage system. A block along the drainage system is referred to as nasolacrimal drainage obstruction (NLDO).
1) When this passage is blocked since birth then it is called congenital NLDO.

What is thetreatment in acute dacryocystitis?

  • As there is a high spontaneous rate of remission (60-90%) in the first year of life, probing should be delayed until 10-12 months of age.
  • Parents can be instructed to undertake lacrimal sac massage during the intervening period.
  • Earlier probing is only justified if their is severe recurrent infection. Probing of the naso-lacrimal duct is the first line of treatments
  • With persistent epiphora and recurrent infection, it may be necessary to perform a dacryocystorhinostomy (DCR).
  • Bicanalicular silicone incubation with Crawford, Juneman or Ritleng tubes can be carried out.

2) Following a block the accumulated tears may be a nidus for infection and when infected the condition is called acute dacryocystitis.

What is thetreatment in acute dacryocystitis?

Systemic

  • Antibiotic
  • Anti-inflammatory analgesic

Local

  • Hot fomentation
  • Local broad spectrum antibiotic drop.

3) When the infection is low grade then there are changes within the walls of the lacrimal system and a chronic dacryocystitis occurs.

What is the treatment of chronic dacryocystitis?

Treatment options:-

  1. Conventional external DCR
  2. Nasal endoscopic DCR
  3. Laser assisted endoscopic DCR
    • Conventional external DCR where an incision is made near the inner end of the eye and a bony window is made by cutting a circular opening in the nose bone and communication is made to the nose.
    • Nasal endoscopic DCR where an endoscope is used to make the opening in the nose.
    • Laser assisted endoscopic DCR where a fine fibre optic cable with laser is used to make an opening in the bone.

Which procedure to choose?

Every procedure has its own merits and demerits.

  • External DCR has the highest success rate among all procedure and is still the gold standard procedure for NLD blocks. However the drawbacks is that it is a longer procedure, will have an incision over the inner aspect of the lid though inconspicuous and will need overnight hospitalization.
  • Nasal Endoscopic DCR is a “no scar “procedure and is a little faster than external DCR. The drawbacks are that the failure rates are a little more than conventional surgery, overnight hospitalization is essential and repeated visits to the hospital is mandatory.
  • Laser assisted Endoscopic DCR is the latest technique and is the fastest to perform with no scar or hospitalization. However the failure rates are the highest and repeated follow-ups are mandatory.

However your consultant will assist you in selecting the best procedure suited for you.
What are the types of NLDO?