Wednesday, July 29, 2015

Doc, why do I have so many lines along my double eyelid?

This 36 year-old woman with a history of allergy underwent double eyelid (Asian blepharoplasty) 2 years ago. Initially the double eyelids in both eyes were symmetrical and well-defined. However, in the last 6 months, she noticed the appearance of extra lines in her right upper eyelids which got worse over time (see Figure 1). History revealed she often rubbed her eyelids due to itchiness.

Figure 1. Poorly defined double eyelid 
in the right upper eyelid with extra lines. 

The lost double eyelid (skin crease) was caused by dehiscence (loss of attachment) between the skin and the underlying tissue mainly the levator aponeurosis (the muscle that's responsible for opening the eye). The dehisence was likely to arise from constant eyelid rubbing. Indentation of the eyelid skin showed that the double eyelid can be restored and the extra lines eliminated (Figure 2).

Figure 2. The top picture shows the right eye had well-defined double eyelid
(white arrow) which disappeared towards the corner of the eye (black arrow). 
Indentation of the skin using a paper clip shows the double eyelid 
can be restored with elimination of the extra line. 

There are many ways of correcting this problem. However, the easiest way with a short down-time is to indent the skin with a non-absorbable suture (Figure 3). The principle is similar to the suture technique for Asian blepharoplasty. 

Figure 3. Steps showing how the skin crease was restored. 
a. two marks are made along the original double eyelid near the corner of the eye; 
b. stab incisions were made at the sites marked; 
c. a non-absorbable suture was passed deep through the incisions catching the tarsal plate; 
d. the suture was then passed back through the incision this time just below the skin; 
e. the two ends of the suture were tied; 
f. at the end of the procedure.

At the end of the procedure, there was some puffiness. However, the patient was able to return to work. The recovery could be sped up with ice compress. 

Figure 4. Picture taken one hour after the procedure showing 
well-defined double eyelid despite the swelling. 

Wednesday, July 22, 2015

Doc, can you stop tears from running down my face?

This 68 year-old has been troubled by constant watering of the right eye for the past three years. She has seen many eye doctors but despite applying different eyedrops the condition fails to improve. Syringing of the nasolacrimal duct reveals blockage of the nasolacrimal duct. This condition typically affects elderly woman and thought to be a type of degeneration.  

Figure 1. Normal tear drainage system.

Figure 2. Diagram showing blocked nasolacrimal duct 
causing watering eye. 

Figure 3. Diagram showing how the blockage can be by-passed 
by creating an alternative passage for the tear. 

To bypass the blockage, an alternative passage is created by creating a connection between the lacrimal sac and the nasal cavity. The procedure is called dacryocystorhinostomy (DCR). The steps of the procedure done on this patient are shown in the photos below. The procedure is carried out under general anaesthesia.

Figure 4. a. Marking is done nasal to the right eye; 
b. incision is made and the skin and muscle are pulled away; 
c. an incision is made along the periosteum and peeled away from the bone; 
d. a hole is created by breaking the bone of the nose (rhinostomy); 
e. once the bone is removed the underlying nasal mucosa can be seen; 
f. the nasal mucosa is cut to create an anterior flap; 
g. the lacrimal sac is identified by inserting the lacrimal probes through the nasal puncta; 
h. the lacrimal sac is also cut to create an anterior flap; 
i. to improve the success rate of DCR, silicone tubing is inserted; 
j. the tube is passed from the punta through the lacrimal sac and nasal cavity and out through the nostril; 
k. after the tubing is passed, the anterior flaps of the lacrimal sac and nasal cavity are sutured; 
l. at the end of the procedure, the tubing is removed 6 weeks later. The new passage allowed the tear to bypass the blocked nasolacrimal duct. 

Monday, July 20, 2015

Doc, what are these swellings in my upper eyelids?

This 60 year-old woman is bothered by swellings in her upper eyelids near the nose. Examination shows these swellings were soft to the touch and can be pushed inwards (see figure 1). The features suggest these swellings were caused by prolapse of the medial fat pad. 

Figure 1. The patient is concerned by the swellings in her upper lids 
near the nose (areas circles in blue).

Anatomically, the upper eyelid contains two fat compartments: medial and central and the lower eyelids three: media, central and lateral (see figure 2). In young people, the fats are not visible but with age, the fat may become protruded due to weakness of the overlying structures such as muscles and septum (the fibrous tissue that separates fat from the muscles). 

Figure 2. Picture showing the right eye of a 70 year-old man with severe fat prolapse.
A = medial fat pad; B = central fat pad; 
1 = medial fat pad, 2 = central fat pad and 3 = lateral fat pad.

The swellings are easily removed through a limited incision along the skin creases (double eyelids). To get to the fat pad, the incision needs to go to through 3 layers namely: skin, orbicularis oculi muscle and the orbital septum. The fat needs to be handled with care to avoid bleeding into the back of the eye. After enough fat was taken the wounds are closed with sutures which are removed in one week.  
Figure 3. The patient shown in figure 1 undergoes fat incision under local anaesthesia.
a. marking along the skin crease (double eyelid); 
b. the fat is teased out from the medial fat compartment; 
c. the fat was clamped with a pair of artery forceps to prevent bleeding; 
d. the fat is excised and cauterized (burnt); 
e. at the end of the fat excision; 
f. the wound is sutured with 6/0 nylon. 

Sunday, July 12, 2015

Postoperative Review

Just done clinic including reviewing 12 operations I did yesterday. Some of the pre-and post-operative pictures are shown below with patients' permission. 
The top picture shows a patient with right ptosis preoperative which was corrected with posterior approach conjunctivomullerectomy. The swelling is minimal. 
The second picture shows a patient who had had suture technique for double eyelids some years ago, a limited incision techniques and epicanthoplasty were done to widen and lengthen the eyes. 
The last picture shows a patient who developed right ptosis following cataract surgery 10 years ago. Again the right ptosis was done with posterior approach conjunctivomullerectomy with minimal swelling.