EYELID SKIN CANCER

Ninety percent of all basal cell skin cancers occur on the head and neck, and approximately 10% of these will involve the eyelids.   Squamous cell skin cancer less frequently effects the eyelids.  These neoplasms are related to sun exposure and ultraviolet light damage to skin and are more common in fair haired, blue eyed patients.  A "typical" basal cell cancer will have a raised, "pearly," firm border and a central depression.  Fine superficial blood vessels will be present on its surface and the patient may complain of bleeding or crusting from the lesion.  Many basal cells do not fit this characteristic appearance, and any enlarging mass around the eyelids should be evaluated and biopsied.

Skin cancers around the eyelids are best treated by excision with frozen section and microscopic examination of the tumor margins to ensure complete removal.  Often times the tumor may extend significantly beyond its apparent visible margins.  Following removal, reconstruction of a cosmetically and functionally satisfactory eyelid is carried out with the use of various procedures including donor grafts of skin, cartilage, and mucous membrane, skin-muscle flaps, and various "sharing" procedures from the opposing eyelid.

THYROID EYE DISEASE

Thyroid eye disease (Graves disease) is an autoimmune disease which tends to effect the thyroid, leading to hyper thyroidism, as well as involving the soft tissues of the orbit, the eyelids, and the muscles responsible for eye movement. Involvement of the eye muscles causes swelling which pushes the eyeball forward out of the orbit. Contraction of the muscles causes the lids to retract above and below the cornea producing a "bug eyed" appearance. This contraction of the eye muscles may also cause misalignment of the eyes and resultant double vision. Rarely the thickened muscles may com press the optic nerve producing visual loss.

Appearance of a patient with severe thyroid eye disease with marked
retraction of the upper and lower lids.

Same patient after eyelid surgery to drop the upper eyelids
and raise the lower eyelids.

A number of surgical options exist to treat problems of the eyelids and orbit in Graves disease.  Various eyelid surgeries can be performed to reposition the eyelids, and surgery can also be done to remove the bony floor and walls of the orbit, thus allowing the protruding eyeballs to settle back more normally.  Surgical removal of the orbital walls is also indicated in cases of visual loss to relieve compression of the optic nerve by the swollen muscles.

PTOSIS

Drooping of one or both eyelids is referred to as ptosis.  This may occur as a congenital defect or be acquired as part of a neurologic disease process, as a normal aging change, or as a result of trauma.  Drooping of the eyelid is usually secondary to problems related to the muscle which attaches to the eyelid and is responsible for its mobility.

This may interfere with visual function on the involved side.  This is particularly
important in congenital ptosis cases where a permanently "lazy eye" may develop.   In addition, ptosis may be the presenting sign of neurologic disorders such as myasthenia gravis or intracranial aneurysms and tumors.

Preoperative appearance of a patient with left upper lid ptosis
obscuring the field of vision.

Appearance of same patient after surgical correction.

Evaluation of the ptosis patient is directed toward determining the cause of the condition, the degree of visual handicap, and to best determine which surgical procedure will result in a good postoperative result.   Surgery is usually performed upon the defective eyelid muscle and its attachments, but in those cases in which the muscle has little function (such as in severe congenital ptosis or acquired neurologic ptosis), surgery may be performed to raise the drooping eyelid by connecting it to the muscles at the brow.  Most operations have a high rate of success, although incomplete closure of the eyelid after surgery is sometimes a problem which may require the use of lubricating ointments.

A patient with severe ectropion of the right lower lid and
moderate ectropion of the left lower lid.

Same patient after surgical correction of both lower eyelids.

Patient with severe orbit disease.

CT Scan showing the tumor behind the left ball.

Patient following removal of the orbital tumor.

TEAR DRAINAGE SYSTEM DISORDERS

Tears are produced by the lacrimal gland in the upper, outer portion of the orbit and flow across the lids to drain through small openings at the inner corner of the eyelids.  From there, tears flow into the tear sac and down into the nose.  Blockage of the tear
drainage system results in a watering eye and may also lead to infection in the tear sac. Blockage may be caused by a congenital defect in the tear drainage system or may be acquired as a result of inflammation, infection, or trauma.

A commonly performed operation is a dacryocystorhinostomy (DCR) in which bone is
removed from the side of the nose and a new drainage passageway created by opening the lacrimal sac with nasal mucosa. This is performed through a small incision in the angle of the nose which usually heals with a minimally visible scar. It may be performed under either local or general anesthesia, and usually requires hospitalization overnight to guard against postoperative bleeding or other complications. This surgery is usually 95% effective in relieving tearing problems caused by nasolacrimal duct obstruction.

Congenital nasolacrimal duct obstruction is a fairly common problem and will often times spontaneously resolve over time. In those cases in which tearing or infection persists beyond 9-12 months of age, probing of the nasolacrimal system may be carried out to open up in the nasolacrimal duct. On occasion, surgery on the nose may also be performed as well as placement of fine silicone tubes to maintain patency. This surgery is usually performed on an outpatient basis with or without general anesthesia as dictated by the patient's age.

COSMETIC EYELID & EYEBROW SURGERY

Of the various elements which combine to give a pleasing appearance to the face, the eyes have a primary role. Unfortunately, because the eyelid skin is the thinnest skin in the body, it is often times here that age-related loss of elasticity, sagging, and redundancy will first occur. Cosmetic oculoplastic surgery is performed on the forehead, eyebrows, and eyelids to correct these undesirable aging changes or to
enhance the baseline contour and appearance of the patient's eye tissues. The indications for this surgery are usually cosmetic. In those patients in whom the sagging eyelid skin and prolapsed orbital fat droop down to the point that they overhang the eyelashes and cause irritation or obstruct the visual field, then the surgery may be considered functionally necessary and should be reimbursed by third party carriers.

Patient with excess skin and fat in the upper lids which has
obliterated the upper eyelid crease.

Same patient following upper eyelid blepharoplasty with removal of skin,
muscle, and fat, and reformation of the eyelid crease.

Blepharoplasty is surgery performed on the eyelid to tighten the eyelid skin and reduce or eliminate the bulges caused by orbital fat. Surgery in the upper eyelid is performed through an incision hidden in the crease of the eyelid and is usually barely visible after healing. Lower eyelid surgery is performed through an incision just below the eyelashes and then following surgery the eyelashes usually hide the scar quite nicely.

Some patients will require only blepharoplasty surgery but in other patients, drooping and sagging of the eyebrows may also be contributing to the excess tissues in the upper lids. In these patients, elevation of the eyebrows is also desirable and may be performed through an incision hidden in the upper eyebrow hairs. If the forehead skin is also sagging, then the forehead and eye brows may be tightened and raised through an incision in the scalp or forehead.

Cosmetic eyelid surgery is usually performed on an out patient basis. The operation usually lasts 1 -2 hours, depending upon what exactly needs to be done.