What is oculoplasty?
Oculoplasty is the art and science of plastic surgery around the eye. The eyeball is a delicate structure, protected from harm by eyelids in front and the bony cup (socket) behind. Behind the eyeball run the nerves , arteries and muscles, which carry messages to the brain, move the eyeball, and provide nutrition to the eye. Oculoplasty deals with all these structures surrounding the eyeball.
Why should an eye surgeon do plastic surgery?
Oculoplastic surgeons first train as ophthalmologists, when they learn in details about the eye. During further higher training, they start to handle plastic surgery. They have the best knowledge about the eye and its surrounding; as eye surgeons, they are also ready to handle the most delicate of structures. This combination of skills makes the oculoplastic surgeons the best to do plastic surgery around the eye.
Ptosis– Ptosis is drooping of the upper lid. It may be present by birth, or appear later in life. Ptosis is usually corrected by surgery.
Entropion– Entropion is in-turning of the eyelid. The eyelashes rub on the eye and cause pain and watering; treatment is by surgery.
Ectropion– Ectropion is turning outwards of the eyelid margin, causing redness and watering (Link to gallery)Lagophthalmos- where the patient cannot close his eye; this can cause danger to the eye, pain and infection.
Eyelid tumors– Entropion is in-turning of the eyelid. The eyelashes rub on the eye and cause pain and watering; treatment is by surgery.
Lid tearrepairs with grafts and flaps–
Orbital fractures–A fracture in the bones around the eye can cause double vision, and a sunken small appearance of the eye. The fracture is repaired with an implant or plate. The best results are obtained in surgery within 2 weeks of injury, but surgery can also be done later.
Enucleation/ evisceration–A highly damaged eye may be replacedwith an orbital implant; this restores the comfort and appearance.
Socket reconstruction–where the eye has been removed for a serious disease, the socket of the eye may get shrunken. The socket is reconstructed to improve comfort and appearance.
Lacrimal –(eye watering) DCR, probing, intubations.
Blepharoplasty–Correction of eyelid bags
Thyroid eye disease–Thyroid disease can have a serious effect on the eye. The eye develops a bulging look; the patient can have itching and burning, discomfort, corneal ulcers, double vision, and even loss of vision.
Our thyroid eye disease clinic monitors the eye health regularly, so that any danger to the eye is prevented. By injection and surgery, the changes done by the disease can be reversed back to normal. (Add on link to information sheet for thyroid patients)
Botox clinic –hemifacial spasm, essential blepharospasm, wrinkle treatment. Due to over-action of muscles around the eye, the eyes can go into spasm – where the face and eyes twitch; patient is not able to open the eyes comfortably. This can be treated safely and effectively by injection of botulinum toxin.
Botulinum toxin can also be used to treat wrinkling and aging around the eye.
Trauma–Eyelid tear repairs (link to lid tear repairs under eyelid), orbital fracture (link to orbital fractures under orbit)
Ocularistry–When an eye has been removed due to disease, it may have a serious impact on the psychological and social well-being of the patient. Ocularistry is the art and science of manufacturing an artificial eye. For customised prosthesis (tailor-made artificial eye)measurements are taken from the patient’s own eye, and colour match is done. Thus the prosthesis fits well, is very comfortable, and looks similar to the patient’s own eye.
Pediatric oculoplasty–Probing, Ptosis
- Modern operating theatre
- Operating microscope
- Radio frequency Surgical Unit
- Diode laser for transcanalicular laser DCR
- Mechanized Microdrill for bone surgery
- Head-mounted focussed light
- Nasal endoscopy
- Vacuum aspirator
- Cryopexy machine
- Ultrasound B scan, UBM
- Grafting of donor sclera, amniotic membrane
- Stitch-less surgery with tissue glue
Ptosis is drooping of the eyelid. The eye appears smaller, there is difficulty opening th e eye. Ptosis may occur in one eye or both eye. There is obstruction of vision and a sleepy and tired appearance.
There is a muscle in the upper lid, called the levator- the function the levator is the lift the eyelid open. If the levator is not working well, the eyelid droops.
In many patients who have ptosis since birth, the levator muscle is weak since birth.
In patients where ptosis starts later in life, there may be multiple causes : injury, age, use of contact lens for many years, some neurological diseases.
- Do we need to consult a neurologist?
A small proportion of ptosis stems from neurologic diseases. Usually the oculoplasty surgeon is able to differentiate these on examination. They will then refer you to a neurologist.
- How important is it to correct ptosis?
For an adult, a ptosis can block part of the visual field, obstructing the vision. There can be strain by lifting the brow muscles to compensate. More and more people opt for ptosis correction to avoid looking tired, sleepy and unhappy.
In a child, the ptosis may cause delay in the development of vision, and a lazy eye (amblyopia). This has to be corrected at a young age, and appropriate glasses and exercise started. Once the patient is older, vision correction cannot be achieved. It is extremely important to have an accurate assessment of vision in a child with ptosis.
- What are the methods of correction of ptosis?
The oculoplasty surgeon assesses the measurements of the eye. If the natural muscle can be strengthened with stitches, that is the method of choice. If the natural muscle levator is too weak for correction, an implant (most commonly silicone) is places to connect the forehead muscles and the eyelids. The patient can then effectively use the forehead muscle to lift the eyelid.
Some neurologic diseases such as myasthenia can be treated by oral medicines.
Rarely, there are some ptosis patients where it is not safe to do surgery. These patients are recommended crutch glasses, spectacles which prop the eye open.
- What are the outcomes with ptosis surgery?
After ptosis surgery, the final outcome is known at 6 weeks .This is because each person’s body heals in a slightly different way, and a small percentage of uncertainty remains. Eight of ten patients have the eyelid set exactly at the correct height, two may be little higher or lower.
Usually the eyelid height is equal when the patient looks forward, but some difference is seen when the patient looks upward or downward. In a few patients, when the patient sleeps after surgery, a small gap may remain open in the eyelids. A silicone sling when used, has greater flexibility, allows natural blinking, and can be re-adjusted if required.
- What is ocularistry? What is a customised prosthesis?
When an eye is lost due to disease or injury, an artificial eye (prosthesis) can be fitted in its place. The prosthetic eye cannot see, but can give a natural appearance to the patient. A customised prosthesis is manufactured for the patient, taking measurements from his socket, and matching the colouring exactly. So a customised prosthesis fits well, is comfortable, and looks very similar to the natural eye. Ocularistry is the art and science of manufacturing such an eye.
- Is the prosthesis fitted directly?
The oculoplastic surgeon first assesses the damaged eye or socket. In some cases, prior surgery is required to make adequate space for the prosthesis to be fitted. In other cases, it can be fitted directly.
- Will the artificial eye move and blink naturally?
The movement and eyelid closure depends on the pre-existing condition of the eye socket. Usually the oculoplastic surgeon will be able tell by examining you. Most patients gain conversational movement of the eye, though the prosthesis may not move into the furthest corners.
- Is the prosthesis permanent?
If an implant is placed deep in the socket during surgical correction, that is permanent. The prosthesis has to be removed and cleaned once in one or two weeks. This is a very simple procedure, and done very easily by the patent.
- Can we do all activities with a prosthesis? Can a child be fitted with a prosthesis?
Yes, a child can be fitted with a prosthesis; in fact, it is recommended to stimulate the growth of the socket. It is very safe, and will not damage the other eye. A patient can do all usual activities except swimming. For a child, the prosthesis will need to be changed as the child grows.
- What special care is needed for a prosthesis?
The prosthesis is to cleaned periodically. Once a year, come for a check-up to your oculoplastic surgeon and ocularist. The socket will be examined to make sure it is healthy, and the prosthesis will be polished. If well maintained, the same prosthesis can be used many years. A protective glass of unbreakable fibre is recommended to be used – this is for the protection of the good eye.
- What is congenital dacryostenosis? Why is my child’s eye watering?
Every eye has a fine pipe leading from the eye into the nose. This is like a drain-pipe, and the tears go into the throat through this pipe . This is called the nasolacrimal duct. A child may be born with a block in the naso-lacrimal duct; this condition is called congenital dacryostenosis. The water and sticky material come out of the eye, and the chil’d eyes appear to the tearing all the time. This condition is seen within a few weeks after birth.
- What are the treatment options available?
Many of the children with congenital dacryostenosis will heal only with antibiotic drops and sac massage. The oculoplastic surgeon will show you the correct technique of sac massage for your child. If the condition has not healed by 9 to 12 months, it will probably not respond to further massage and a surgery will be required.
- What surgical options are there for the tear duct block?
The first step of surgery is called probing. It is very safe, can be done as a day-care procedure (night stay in hospital not required). There is no external wound or stitches, no bandage required, and normal activities can be continued from the next day.
- How effective is probing?
The best results are achieved at about one year of age. Nine out of ten babies have the problem corrected if probing is done within this time. As the child grows older, success chances decrease to about 7 or 8 out of 10.
- If the watering does not improve with probing, what is the next step?
A probing can be repeated 3 months later, putting silicone intubation in to prop open the nasolacrimal duct. For children older than 3-4 years, we recommend using silicone intubation routinely at the time of probing. If this too does not resolve the watering, the next step is a bigger surgery (see DCR) where a new nasolacrimal duct is constructed. But do not worry, the vast majotity of children will recover only with probing.
Each eye has a fine pipe which drains the tears from the eye. This is a nasolacrimal duct (drain-pipe of the eye). If it gets blocked, the tears and stickiness come out of the eye. The treatment is by dacryocystorhinostomy (DCR). This is a technique by which a new passage is created from the eye into the nose, and the tears can drain out.
- Is it necessary to undergo DCR?
When a nasolacrimal duct is blocked, the dirt and discharge accumulate in the lacrimal sac next to the eye. There is the risk of severe eye infection if the condition is left untreated. There may be swelling, pain, and watering. If a cataract surgery is planned, a blocked nasolacrimal duct increases the risk of dangerous infection; a DCR should be done before the cataract surgery.
- How is DCR performed? What are the outcomes?
DCR can be performed in three ways- externally, through a small (less than half inch) line next to the nose; endonasally- through the nose; and trans-canalicular using Laser DCR.
The external DCR leaves a fine mark near the eye; it has the highest success rates, more than 95 out of 100 patients have the problem completely solved after external DCR. An endo nasal DCR is done through the nose, so there is no mark outside. The success rates are a little lower; all nose space inside is not suitable for endonasal surgery, and it can be done well in selected patients only. Trans-canalicular Laser DCR is a very rapid procedure, with hardly any pain and swelling. However, some of the DCR done with laser may close down again.
- I have had a DCR done already. The eye is still watering. Why?
As mentioned, about 5 out of 100 patients find that their DCR has closed down again. This may particularly happen in a patient who had multiple attacked of infection earlier, with a history of injury near the nose, or a patient who has frequent nasal allergies and colds. The DCR can be repeated, with addition of silicone intubation to prop the passage open. A typical oculoplastic surgeon will often see patients sent over from elsewhere after the DCR did not work; most such patients can be re-operated successfully.
Scar Management Clinic
Post operative & post traumatic scar management using fractionated photothermolysis offers a unique opportunity to alter and improve scar tissue through the mechanisms of collagen remodeling, impact on scar microvasculature and reduction of abnormal pigmentation. The 1540 nm mid infrared erbium glass laser with its ability to produce deep coagulation with minimal ablation represents this genre of systems. The use of Fractionated Radio Frequency is another approach in the same direction.
A series of 3 – 6 treatment sessions with a fractionated laser can bring about significant improvement in scar architecture. The procedure is quick, produces little discomfort and does not entail downtime.
Treatment using state of the art laser platforms helps to ameliorate scars and improve the quality of life indices.
Thyroid Eye Clinic:Thyroid Eye Clinic
The Thyroid Eye clinic offers coordinated, multidisciplinary care by subspecialists dealing with Orbital and Eyelid Surgery, Eye Motility Disorders, Dry eye Specialist, Endocrinologist and ENT Surgeon. Collectively, the team provides each patient with individualized treatment, helping patients with functional and cosmetic problems that can result from this disease. The clinic offers surgical options such as orbital decompression to place the eye back in its socket, alleviation of retracted eyelids, loosening of the eyelid muscles and muscle surgery to correct diplopia and even Botox therapy for upper lid retraction and eye alignment disorders.