Oculoplasty or ocular plastic surgery deals with all the alterations that may appear around the eyes (eyelids, eyebrows, etc.), both aesthetic and functional. Some of the most common pathologies that can be solved with eyelid surgery are: excess skin, bags, drooping eyelid (eyelid ptosis), inverted eyelid (Entropion), everted or drooping eyelid (Ectropion), alteration of the eyelashes (Distichiasis), eyelid tumours and various sequelae.

Treatment for Palpebral Ptosis

Ptosis is the medical term describing drooping of the upper eyelid. It can affect one or both eyelids. In some cases, it may obstruct part of the eye’s field of vision if the drooping of the eyelid is significant. Ptosis can be mild or moderate, covering only the upper part of the pupil, or severe where the entire pupil may be covered by the drooping eyelid. Ptosis from birth is called congenital ptosis.

In children, the most common cause of ptosis is imperfect development of the levator muscle of the eyelid, which is largely responsible for eyelid elevation.

In adults, the causes may be advanced age, trauma, disease of the muscle or neurological disorders. Over the years, the tendon that attaches the levator muscle to the eyelid weakens and stretches, allowing the eyelid to lower and obstruct the pupil. It is common for this process to accelerate after cataract surgery.

There are also other conditions that can cause eyelid ptosis such as myasthenia gravis, a condition where the muscles weaken and fatigue easily. The eyelid may droop on one side only in Horner’s syndrome, a neurological condition that indicates damage to the sympathetic system.

The most common symptom of ptosis is the inability or difficulty in keeping the eyes open, resorting to excessive use of the forehead to raise the eyebrows and eyelids.

Sometimes the head is tilted back or the eyelid is lifted with the fingers in order to see clearly.

Children born with ptosis may also develop lazy eye, strabismus and blurred vision.

The purpose of ptosis surgery is to lift the upper eyelid to allow normal visual development, preserve the upper field of vision and make both sides look symmetrical. Sometimes, where a diseased muscle is operated on, it is not always possible to achieve a perfect result and function. Ptosis is treated with different surgeries depending on the degree of severity and the degree of strength of the levator muscle.

Surgery involves adjusting the levator muscle to open the eyelid to the desired position. In severe cases where the levator muscle is very weak, an internal cable suspension is used to tie the upper eyelid to the inner part of the muscle that raises the eyebrows.

Treatment for Ectropion

What is an ectropion? Ectropion is the outward eversion (drooping) of the lower eyelid margin, resulting in exposure of the inner surface of the lower eyelid and loss of contact with the eyeball. It usually affects both eyelids at the same time.

There are many causes, but the most frequent are:

  • Senile: This is the most frequent cause; ageing and laxity of the eyelid connective tissue causes the eyelids to turn outwards.
  • Cicatricial: As a result of the contraction of scar tissue caused by burns, trauma, etc.
  • Paralytic: Due to loss of orbicularis oculi muscle support. Occurs for example in facial paralysis.
  • Spastic: Produced by spasm of the orbicularis oculi.
  • Mechanical: Due to the presence of some type of pathology that generates weight on the lower eyelid such as tumours, inflammatory or infectious processes.

The decrease in the horizontal tension of the lower eyelid causes the palpebral margin to tilt outwards.

This tilt causes dryness, thickening and hyperemia of the tarsal conjunctiva. It also hinders the drainage of tears at the inner corner, leading to lacrimation (epiphora). The mucosa loses contact with the eye and becomes a thicker, stiffer layer that no longer adapts to the curve of the eyeball.

Dryness of the cornea and irritation can predispose the patient to eye infections, corneal abrasions or corneal ulcers.

To relieve dryness and keep the cornea lubricated, artificial tears can be used as a lubricant. Surgery to tighten the muscles that hold the eyelids in place is usually effective and can be performed as outpatient surgery under local anaesthesia. Treatment of ectropion in any of its varieties is surgical.

Trichiasis and Distichiasis Treatment

Trichiasis is the abnormal growth of the eyelashes towards the inside of the eye, causing continuous rubbing against the surface of the eye. In addition to being very annoying, this can cause damage to the cornea and even loss of vision.

Distichiasis is the growth of new eyelashes from the meibomian glands. The meibomian glands are glands in the eyelids very close to the surface of the eye that do not normally harbour eyelashes. Distichiasis is usually caused by chronic inflammatory processes as in trichiasis. Distichiasis can also be congenital. Treatment is the same as for trichiasis.

There are multiple causes of trichiasis, although in many cases no causative process is identified. Any scarring of the eyelids can cause the eyelashes to grow inwards.

It is important to distinguish between trichiasis and entropion, as both involve contact of the eyelashes with the ocular surface. In trichiasis it is the eyelashes that grow inwards while in entropion the eyelashes grow normally but it is the eyelid that is rotated towards the eyeball.

Although the result for the patient is the same (eye irritation due to the eyelashes), the treatment of these two pathologies is quite different. In trichiasis the treatment aims to eliminate the hair follicles of the abnormal eyelashes and in entropion we correct the position of the eyelid surgically.

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