Learn more about oculoplastics and cosmetic surgery options

Ptosis is the medical term for drooping of the upper eyelid, a condition that may affect one or both eyes. When the edge of the upper eyelid falls, it may block the upper field of your vision. The drooping may be mild, with the lid only partially covering the pupil, or severe, with the lid completely covering the pupil. Ptosis present at birth is called congenital ptosis.

In children, the most common cause is improper development of the levator muscle, the major muscle responsible for elevating the upper eyelid. With adults, it may occur as a result of aging, trauma, or muscular or neurologic disease.

As you get older, the tendon that attaches the levator muscle to the eyelid can stretch and allow the eyelid margin to fall and cover part of the eye. It is not uncommon for a patient to develop upper eyelid ptosis after cataract surgery.

Ptosis can also be caused by injury to the oculomotor nerve (the nerve that stimulates the levator muscle), or the tendon connecting the levator muscle to the eyelid.

Symptoms of ptosis include difficulty keeping your eyes open, eyestrain, forehead aching from the increased effort needed to raise your eyelids, and fatigue, especially when reading. In severe cases, it may be necessary to tilt your head back or lift the eyelid with a finger in order to see out from under the drooping eyelid(s).

Children with ptosis may also develop decreased vision in one eye (amblyopia or “lazy eye”), strabismus (eyes that are not properly aligned or straight), refractive errors, astigmatism, or blurred vision.

The condition may be the first sign of myasthenia gravis, a disorder in which the muscles become weak and tire easily. Ptosis is also present in people with Horner’s syndrome, a neurologic condition that affects one side of the face and indicates injury to part of the sympathetic nervous system.

Treatments

Eyelid ptosis may be bothersome enough to warrant surgical repair. The main goals of ptosis surgery are elevation of the upper eyelid to improve the field of vision, permit full visual development in children, and to establish more symmetry with the opposite upper eyelid.

Ptosis surgery usually involves tightening the levator muscle in order to elevate the eyelid to the desired position. Your surgeon will discuss with you whether the incision and stitches will be on the outside or inside of your eyelid. If the levator muscle is extremely weak, then a “sling” operation may be performed, enabling the forehead muscles to elevate the eyelid(s). Congenital ptosis is also treated surgically. The specific operation is based on the severity of the ptosis and the strength of the levator muscle.

It is important to realize that completely normal eyelid position and function may not be possible to achieve.

Children with ptosis should be followed closely, before and after surgery, with eye exams on a regular basis to ensure that their vision is developing properly.

Ptosis surgery is an outpatient procedure. Young children are put under general anesthesia while older children and adults will often receive “twilight” anesthesia. Some surgeons will perform ptosis surgery in an office setting. Your doctor can discuss the options available in your situation.

Risks & Complications

Bleeding and infection, which are potential risks with any surgical procedure, are very uncommon. Be sure to tell your surgeon if you are on blood thinners as their use may put you at increased risk for bleeding complications. Most of these procedures can be performed under mild sedation or under local anesthesia.

Important: Your surgeon cannot control all the variables that determine the final position of your eyelid. There is ALWAYS a possibility that the lid will be higher or lower than desired or the curve and shape of the lid can be different. Touch up surgery to improve lid position may be necessary. While perfect symmetry between the two eyelids can never be guaranteed, the vast majority of patients see an improvement in their lid position and are happy with their results. As with any medical procedure, there may be other inherent risks that should be discussed with your surgeon.

Entropion is a condition where the upper or lower eyelid turns inward, rubbing the lashes against the eye, causing the eye to become irritated, red, and sensitive to light and wind. If it is not treated, the condition can lead to pain, tearing, discharge, and irritation. If entropion is severe or left untreated for a long period of time, it can lead to corneal damage and decreased vision. Entropion can be diagnosed with a routine eye exam. Special tests are usually not necessary.

Entropion can be caused by muscle weakness. As we age the muscles around the eyes tend to weaken. Laxity of the eyelid tendons, combined with weakening of these muscles result in the eyelid turning in. Some patients have eyelid spasms, forceful blinking, squeezing, or other neurological conditions that cause the eyelid to roll inward. Entropion may also occur as a result of trauma, scarring, or previous surgery.

When the lid turns inward, the lashes and the skin rub on the eye. There may be a foreign body sensation in the eye, or excessive tearing, crusting of the eyelid, or discharge. Irritation of the cornea may develop from lashes rubbing on the eye.

A chronically turned-in eyelid can result in acute sensitivity to light and wind, and may lead to eye infections, corneal abrasions, or corneal ulcers. If entropion exists, it is important to have a doctor repair the condition before permanent damage occurs to the eye.

Treatments

Entropion usually requires surgical treatment. Prior to the surgery, the eye is protected by applying tape to the lower eyelid and using lubricating ointment.

There are a number of surgical techniques for successful treatment and each surgeon will have a preferred method. The usual treatment for entropion involves tightening any laxity of the eyelid and its attachments to restore the lid to its normal position.

An excellent treatment for patients who are not able to have surgery is the Quickert procedure. This procedure requires two or three strategically placed sutures that will turn the eyelid in temporarily.

The definitive surgery to repair entropion is most commonly performed as an outpatient procedure under local anesthesia with or without sedation. Antibiotic ointment may be prescribed for about a week following the surgery.

Most patients experience immediate resolution of the problem once surgery is completed with little, if any, postoperative discomfort.

Patients with entropion from forceful eyelid blinking, spasms, or squeezing may benefit from a non-surgical treatment option. Botulinum toxin injections into the overactive eyelid squeezing muscles can weaken them for several months, allowing the eyelid to roll back into its natural position. This may also be a good option for patients who cannot have surgery.

Risks and Complications

Bleeding and infection, which are potential risks with any surgical procedure, are very uncommon. As with any medical procedure there may be other inherent risks including but not limited to anesthesia risks, swelling, scarring, or further surgery needed. Minor bruising or swelling may be expected and will likely go away in one to two weeks. Be sure to tell your surgeon if you are on blood thinners as their use may put you at increased risk for bleeding complications.

An ectropion is an outwardly turned, loose, or sagging eyelid. The lower lids are more commonly affected, but ectropion may occur in an upper lid as well. The sagging lower eyelid leaves the eye exposed and dry, and as a result, excessive tearing is common with ectropion. If it is not treated, the condition can lead to crusting of the eyelid, mucous discharge, and irritation of the eye. Serious inflammation could result in damage to the eye. Ectropion can be diagnosed with a routine eye exam. Special tests are usually not necessary.

Generally, the condition is the result of tissue relaxation with aging, although it may also occur as a result of facial nerve paralysis (Bell’s palsy), trauma, scarring, or other surgeries. Ectropion may also be associated with conditions like obstructive sleep apnea.

The wet, inner, conjunctival surface of the eyelid can flip outward, becoming exposed to the air. Normally, the upper and lower eyelids close tightly, protecting the eye from damage and preventing tear evaporation. If the edge of one eyelid turns outward, the two eyelids cannot meet properly, and tears are not spread over the eyeball. This may lead to irritation, burning, a gritty, sandy feeling, excess tearing, visible outward turning of the eyelid, and redness of the lid and conjunctiva.

Corneal dryness and irritation may lead to eye infections, corneal abrasions, or corneal ulcers. Rapidly increasing redness, pain, light sensitivity, or decreasing vision should be considered an emergency in a person with ectropion.

Treatments

The irritation can be temporarily relieved with artificial tears and ointments to lubricate the eye. Surgical treatment for an ectropion often depends on the underlying cause. In the type of ectropion associated with aging, most surgeons elect to shorten and tighten the lower lid. This typically is completed with an incision of the skin at the outside corner of the eyelid and reattachment of the eyelid to underlying tissues and the upper eyelid. Sometimes, there are scars from chronic sun exposure, following trauma, or the surgical removal of skin cancers. Your surgeon might need to use a skin graft taken from the upper eyelid or from behind the ear to repair the ectropion. Both the donor site for the graft and the surgical site will usually heal nicely within a few weeks following the surgery. The surgery to repair ectropion is usually performed as an outpatient procedure under local anesthesia, with the patient lightly sedated with oral and/or intravenous medications. You may have a patch overnight and then you will likely use an antibiotic ointment for about a week. After your eyelids heal, your eye will feel comfortable again.

Many patients experience immediate resolution of the problem once surgery is completed, with mild postoperative discomfort. After your eyelids heal, your eye will feel more comfortable and you will no longer have the risk of corneal scarring, infection, and loss of vision.

Risks and Complications

Bleeding and infection, which are potential risks with any surgical procedure, are very uncommon. Be sure to tell your surgeon if you are on blood thinners as their use may put you at increased risk for bleeding complications. In addition to the removal of the sutures, minor bruising or swelling may be expected and will likely go away in one to two weeks.

Important: Your surgeon cannot control all the variables that may impact your final result. The goal is always to improve a patient’s condition but no guarantees or promises can be made for a successful outcome in any surgical procedure. There is always a chance you will not be satisfied with your results and/or that you will need additional treatment. As with any medical decision, there may be other inherent risks or alternatives that should be discussed with your surgeon.

Thyroid eye disease is a disorder of the immune system. It is not understood why our body’s protective defenses begin to attack the body’s own tissues. In thyroid eye disease the tissue around the eye is attacked by inflammatory cells and the result is inflammation, swelling, and bulging of the eye.

Thyroid disease and thyroid eye disease both come from the immune system attacking healthy tissue. We now know one disease does not directly cause the other. The immune system will attack both the thyroid and the tissue around the eye. The timing and severity of these two diseases is variable depending on the individual.

Common symptoms of thyroid eye disease include swelling around the eyes, bulging of the eyes, irritation, redness, and a pressure sensation associated with headache. There can be pain with eye movement, and/or restriction of eye movements causing double vision. If the inflammation involves the muscles, or if the swelling is severe enough, the pressure in the orbit (eye socket) can become extremely high. This can cause compression of the optic nerve, resulting in progressive loss of vision, and possibly blindness if the condition is not treated promptly.

There are two phases of thyroid eye disease. The first phase is the inflammatory phase, which typically lasts six months to two years. The second phase is the stable phase when active inflammation is quiet. Many patients will be left with some degree of protrusion of the eye, eyelid retraction, or double vision that may require additional treatment.

Chronic eye exposure from protrusion or lid retraction can lead to severe drying of the eye and corneal scarring. Double vision can be severe and disabling. Depending on the severity of the thyroid eye disease, all patients should be followed closely by an expert.

Treatments

For many, the discomfort from thyroid eye disease can be treated with topical lubricants, wrap-around tinted glasses, sleeping with eye shields or by elevating the head of the bed at night.

When there is active inflammation, certain treatment modalities have been tried including steroids, anti-inflammatory medicines, and radiation. Promising new drugs and other treatments may improve the treatment of active thyroid eye disease in the near future. The function and appearance of the eyes can usually be improved by reconstructive eyelid or orbital surgery. The particular surgical technique used will depend on the type and severity of the eye problems, but typically progresses in three stages. Not all patients with thyroid eye disease will require all of these treatments.

Stage one of surgery is orbital decompression (removing part of the bony orbit and fat behind the eye to relieve pressure in the eye socket). This can prevent damage to the optic nerve and allow the eye to move back into a more normal position in the eye socket.

Stage two is eye muscle surgery to correct misalignment of the eyes and double vision.This is achieved by repositioning the enlarged muscles that control eye movement.

Stage three is eyelid surgery to adjust the position of retracted lids in order to improve eyelid closure and restore eyelid function. Removal of excessive fat from the eyelids can also improve their appearance.

While it may not be possible to completely eliminate all of the consequences of thyroid eye disease, surgery to correct these conditions is generally successful in satisfactorily restoring function, comfort, and cosmetic appearance.

Risks and Complications

Minor bruising or swelling may be expected and will likely go away in one to two weeks. Bleeding, infection, anesthesia risks, and scarring, which are potential risks with any surgery, are very uncommon. Be sure to tell your surgeon if you are on blood thinners as their use may put you at increased risk for bleeding complications.

Important: Your surgeon cannot control all the variables that may impact your final result. The goal is always to improve a patient’s condition but no guarantees or promises can be made for a successful outcome in any surgical procedure. There is always a chance you will not be satisfied with your results and/or that you will need additional treatment. As with any medical decision, there may be other inherent risks or alternatives that should be discussed with your surgeon.

The outer layer of skin is called the epidermis. Epidermal cells include flat squamous cells, round basal cells, and pigment producing melanocytes. The dermis is the deeper layer of skin and contains the hair follicles, oil and sweat glands, and blood vessels. Skin cancers can arise from any of these skin cells. A biopsy is usually required to confirm the diagnosis of skin cancer.

What are the causes? Excessive exposure to sun is the single most important factor associated with skin cancers of the face, eyelids, and arms. Fair-skinned people develop skin cancers far more frequently than darker-skinned people. Skin cancers may also be hereditary.

The most common types of periocular (eye area) skin cancers are basal cell carcinoma and squamous cell carcinoma. Either may appear as a painless nodule, or as a sore that won’t heal. The skin may be ulcerated, or there may be bleeding, crusting, or the normal eyelid structure may be deformed. The eyelashes may be distorted or missing.

Melanomas arise from the pigment-producing melanocytes. This is a less common but more serious form of skin cancer. A mole that bleeds or becomes tender, or one that changes is size, shape, or color, should be evaluated by a physician.

Sebaceous gland carcinoma arises from the oil glands in the skin. This is also a more serious form of skin cancer. It may appear as a thickening of the eyelid, or as persistent eyelid inflammation.

Basal cell skin cancers enlarge locally and rarely spread (metastasize) to other parts of the body. Left untreated, they will continue to grow and invade surrounding structures. Squamous cell carcinomas, melanomas, and sebaceous gland carcinomas can metastasize to other parts of the body through the bloodstream or lymphatic system. Prompt, aggressive treatment is necessary because of the risk of early spread.

Treatments

Surgical excision is the most effective treatment for periocular skin cancers. There are two very important principles in treating skin cancers — complete removal and reconstruction. Complete removal of the skin cancer is necessary to reduce the chance of recurrence. Reconstruction of the resulting defect is tailored to preserve eyelid function, protect the eye, and provide a satisfactory cosmetic appearance.

Your doctor may recommend Mohs surgery, which is a technique where the lesion is removed layer by layer with same-day microscopic confirmation. A dermatologist specially trained in the technique performs Mohs surgery, and the oculofacial plastic surgeon repairs the area once the cancer is removed. Alternatively, your surgeon may elect to remove the cancer using frozen sections. In this instance, the surgeon removes the lesion with a small margin of normal tissue. The specimen is quickly frozen and the pathologist examines the tissue to determine if the entire tumor has been removed. Once this is confirmed, the area is repaired.

How the area where the skin cancer was removed is reconstructed depends on the size of the defect left behind. Smaller defects can be repaired by suturing the edges together. Larger areas may require local flaps or free skin grafts to close them. Radiation may be useful for patients who cannot tolerate surgery, or in addition to surgery in more aggressive types of skin cancers.

Early and complete removal of eyelid skin cancers is vital to reduce the chance of a recurrence, and to reduce the risk of spread to other parts of the body. Careful follow-up after surgery is necessary to look for recurrence and to look for new cancers so they can be treated promptly.

Risks and Complications

Recurrence is rare but may occur even after complete excision of a skin cancer. Recurrence is much more common if the lesion is not completely excised. If the skin cancer involves the tear drainage system, the eye may tear afterwards. These conditions can usually be treated with additional surgery. Bleeding and infection, which are potential risks with any surgical procedure, are very uncommon. Be sure to tell your surgeon if you are on blood thinners as their use may put you at increased risk for bleeding complications.

Important: Your surgeon cannot control all the variables that may impact your final result. The goal is always to improve a patient’s condition but no guarantees or promises can be made for a successful outcome in any surgical procedure. There is always a chance you will not be satisfied with your results and/or that you will need additional treatment. As with any medical decision, there may be other inherent risks or alternatives that should be discussed with your surgeon.

Myokymia is an uncontrolled contraction (or quivering) of muscles along the lower and/or upper eyelids of one or both eyes. This usually results from anxiety and stress, fatigue, and caffeine. The contractions are often so small that they are not visible to others. Fortunately, this resolves on its own over several weeks.

Benign essential blepharospasm (BEB) is uncontrolled contraction of muscles around the eyes. The condition affects both sides and may result in a variety of problems including difficulty opening the eyes, rapid fluttering of the eyelids, or forced contraction of the lids and brows. When the mouth and neck are involved with the spasms, the condition is called Meige syndrome. The initial symptoms may be excessive blinking with progression to more forceful and frequent muscle contraction. The spasms disappear during sleep and may be made worse with bright lights, fatigue or emotional stress.

Aberrant facial nerve regeneration may occur after an episode of facial paralysis (e.g. Bell’s palsy) as an attempt by the body to reinnervate the paralyzed area. This rewiring can lead to eyelid twitching, drooping, and even tearing when other muscles of facial expression are activated (e.g. smiling, chewing).

Hemifacial spasm (HFS) is uncontrolled contraction of the muscles on one side of the face, usually including the eyelids. The initial symptom may be twitching of the eyelids, with progression to involve the muscles on one entire side of the face. The severity of symptoms may vary from mild fluttering to forceful contraction. Unlike blepharospasm, this condition occurs during sleep.

The cause of BEB is unknown. The diagnosis may be made by your physician examining you and observing your facial movements. Blepharospasm is a benign condition that requires no further diagnostic testing.

HFS is sometimes caused by irritation of the facial nerve at the base of the skull. This irritation may be the result of an abnormal blood vessel pulsating against the facial nerve. When the facial nerve is irritated, it causes the facial muscles to contract and spasm. Less than 1% of cases are caused by a tumor. Therefore, your physician may recommend magnetic resonance imaging (MRI).

Treatment

Myokymia will stop on its own, particularly if the underlying cause is addressed. Oral medications are rarely effective in treating blepharospasm or HFS. The benefits are variable and short-lasting. These medicines may have undesirable side-effects, with patients complaining of fatigue or “clouding” of their thoughts.

The most common treatment of BEB, aberrent facial nerve regeneration, and HFS is with botulinum toxin injections. Botulinum toxin is FDA approved for the treatment of these disorders. The toxin is injected into the muscles at several sites around the eyelids and brow to prevent unwanted contractions. The effects of botulinum toxin last an average of two to four months, and injections may be repeated as needed. This treatment has been found to be safe and effective. Side effects are uncommon and last only for a short time, and may include droopy eyelids and double vision.

Surgery may be recommended for BEB if botulinum toxin therapy is not successful. Protractor myectomy surgery removes the eyelid muscle responsible for eyelid closure. This surgery is successful for some but not all patients. Many patients still require botulinum toxin injections after myectomy surgery. Surgery for HFS may be contemplated if an aberrant blood vessel is found to be the cause. The surgery involves microvascular decompression of the vessel near the brainstem to relieve pressure on the facial nerve.

Dark glasses are a mainstay of supportive therapy, and serve two purposes. They block the bright lights (which worsen spasms), and they hide the eyes from other people. As stress makes these conditions worse, stress management intervention may be helpful.

The facial nerve is a branching nerve that travels from the brainstem to the face and controls movement involved in smiling, frowning, closing the eyes, and raising the eyebrows. Trauma, surgery, stroke, Bell’s palsy or infection may cause temporary or permanent paralysis (“palsy”) of the facial nerve. When this occurs, patients may have trouble closing their eyes, raising their eyebrows or managing tears on that side of the face. Symptoms may include an eye that waters, an eye that is dry and scratchy, a droopy brow or upper eyelid, or a saggy lower eyelid. Some patients will experience paralysis of the lower half of the face leading to drooling, change in speech quality, sagging of the corner of the mouth.

Although function of the affected nerve may improve in some patients over time, that function does not always return to normal. The previously paralyzed muscles of the face or eyelids may begin to relax and contract in unusual ways or in synchrony with other, distant, muscle groups (“synkinesis”). Symptoms of synkinesis include eyelid spasms, squinting when chewing foods, and drooping of the upper lid from over-action of the eyelid closing muscles. These changes are usually permanent.

Treatments

When the facial nerve is injured from trauma, stroke, infection or after Bell’s palsy, improvement can sometimes be seen over several months. During this time, some patients will find lubrication of the eye with over-the-counter tears and ointment all that is necessary. Others whose eyes don’t close well may be advised to use moisture chambers or tape the eye shut at bedtime to avoid dryness overnight. Some patients may require lid surgery to help protect or close the eye. This might involve placing a weight under the skin to help close the upper lid, tightening a saggy lower lid against the eye, or partially sewing the lids shut at the outside corner. Some of these procedures can be reversed if the function of the facial nerve improves.

If facial nerve palsy is permanent, patients usually need to continue lubricating the eye indefinitely. Surgery to lift the brow or lower face can be considered to help improve facial symmetry. There may be a role for rewiring the paralyzed muscles through facial reanimation surgery. Though most oculofacial plastic surgeons do not do reconstructive surgery for paralysis of the lower face, your surgeon can discuss the options that may be available to you.

Treatments for problems related to synkinesis are also available. Many patients benefit from physical therapy, which can help improve facial function and symmetry, especially during active movements. Eyelid spasms and drooping lids may be reduced with oral medications or even strategic use of botulinum toxin injections (e.g., Botox®). In some cases, surgery may be an option. It is important to discuss your concerns and goals with your physician in order to develop a treatment plan that works for you.

Risks and Complications

In the setting of paralysis, it is sometimes necessary to repeat surgery as the effects wear off over time. Bleeding and infection are potential risks of any surgery. Be sure to tell your surgeon if you are on blood thinners as their use may put you at increased risk for bleeding complications.

Important: Your surgeon cannot control all the variables that may impact your final result. The goal is always to improve a patient’s condition but no guarantees or promises can be made for a successful outcome in any surgical procedure. There is always a chance you will not be satisfied with your results and/or that you will need additional treatment. As with any medical decision, there may be other inherent risks or alternatives that should be discussed with your surgeon.

The orbit, or eye socket, is a bony opening that contains the eyeball and the muscles, blood vessels, nerves and fat that help support it. Blunt force trauma to the head or around the eye can break the bones of the orbit, leading to a “blow-out” fracture. The areas along the inside wall (the wall between the eye and the nose) and floor are the thinnest and fractures are more likely to occur here. A CT scan is usually obtained to confirm the presence and exact location of the broken bone(s). Soft tissue may sometimes be trapped in the fracture site. Symptoms of a blow out fracture may include pain, swelling, bruising, double vision, nausea, numbness of the cheek or upper teeth. After swelling subsides, the eye can appear sunken. It is important that the eyeball is carefully examined, as it can also be damaged as a result of the trauma.

Treatment

Not all broken orbit bones need to be fixed. If the fracture site is not too big, if there is no bothersome double vision and if the eye doesn’t look sunken, many patients can be allowed to heal without the need for surgery. Right after the injury, it is not always clear if a patient will need surgery. Your surgeon will follow you closely and may prescribe cold compresses, antibiotics or a short course of anti-inflammatory pills. During this time you should avoid sneezing or blowing your nose and should not fly in an airplane or go deep-sea diving. These activities may allow air to enter the orbit, causing further discomfort and damage.

Your surgeon will usually determine whether an operation is needed within two weeks after injury. The most common reasons to consider surgery are bothersome double vision, nausea or severe pain with eye movement, or a visibly sunken eye. Your surgeon can describe the plans for your surgery based on your symptoms. Patients are put to sleep for the operation and depending on the situation, may go home after surgery or stay overnight in the hospital for observation.

Most patients are swollen and bruised for several days after the operation. Though the eye is not usually bandaged, vision may be blurry for several days. Cold compresses, antibiotic or anti-inflammatory pills may be prescribed. Some patients may have double vision or numbness across the cheek that usually improves over time. Most patients may return to work or school within a week, though many surgeons prefer to limit full strenuous activity, airplane travel and deep sea diving for several weeks after the operation.

Risks and Complications

Bleeding and infection are potential risks of any surgery. Be sure to tell your surgeon if you are on blood thinners as their use may put you at increased risk for bleeding complications. In rare circumstances, surgery in the orbit can lead to loss of vision that may be permanent. Surgery for blow-out fractures may not always achieve the desired results and some patients may have persistent double vision, numbness or asymmetry in the appearance of the two eyes.

Important: Your surgeon cannot control all the variables that may impact your final result. The goal is always to improve a patient’s condition but no guarantees or promises can be made for a successful outcome in any surgical procedure. There is always a chance you will not be satisfied with your results and/or that you will need additional treatment. As with any medical decision, there may be other inherent risks or alternatives that should be discussed with your surgeon.

A chalazion is a swollen lump on the eyelid. Chalazia arise from oil glands located near the eyelashes. If an eyelid gets inflamed, for any reason, these oil glands can get congested with very thick oil. The thick oil not only flows and functions poorly, but can also lead to more inflammation. When the patient’s immune system walls-off or isolates the inflamed oil gland tissue into a nodule, this is called a chalazion.

The most common symptom of a chalazion is a non-tender or mildly tender lump on the eyelid. The lump is usually visible, red, and noticeable to the touch. Chalazia may develop over days to weeks, sometimes at the site of a recent stye (eyelid infection). A chalazion might go away if its contents drain, either through the skin surface or onto the eyeball surface.

The oil glands in a chalazion normally help keep the eye surface moist and comfortable. When these glands malfunction, the eye can feel uncomfortable, dry, irritated, or itchy. Some patients complain of a foreign body sensation under the eyelids, and some have watery eyes. The eyelashes can also develop flakes that look like dandruff. All these problems can lead to blurry vision.

Treatments

Applying warm moist compresses with gentle pressure to the affected eyelid several times daily may treat a chalazion. This process is sometimes referred to as performing “lid hygiene.” The heat of the compress can help the thick oil in a chalazion become thinner, allowing it to flow out of its gland or drain better. Baby shampoo is sometimes added to the compress for the same reason and to help wash away eyelid dandruff. The heat also improves blood flow in the area, which can help clear away the inflamed chalazion tissue. The heat should not be so hot that it scalds the skin.

Your physician may prescribe drops or ointment in addition to the warm compresses. Since chalazia are usually not infected, oral or topical antibiotics may not be totally effective. Your physician may recommend an injection of steroid medicine or even surgical drainage. Although these procedures can be very effective, bleeding, bruising, infection, scar tissue formation, and recurrence are possible. As with any medical procedure, it is important to ask your surgeon about the risks and possible complications.

Risks and Complications

Bleeding and infection, which are potential risks with any surgical procedure, are very uncommon. Be sure to tell your surgeon if you are on blood thinners as their use may put you at increased risk for bleeding complications.

Important: Your surgeon cannot control all the variables that may impact your final result. The goal is always to improve a patient’s condition but no guarantees or promises can be made for a successful outcome in any surgical procedure. There is always a chance you will not be satisfied with your results and/or that you will need additional treatment. As with any medical decision, there may be other inherent risks or alternatives that should be discussed with your surgeon.

Eyes that water or tear uncontrollably are one of THE most common complaints eye doctors hear from their patients. There are several reasons why eyes can water and the treatment depends on the underlying cause. In most cases, your oculofacial plastic surgeon will have an idea of why your eyes water based on your symptoms and physical exam. Unfortunately, it is not always clear why eyes tear and there are people who may not find relief despite their doctor’s best efforts to treat them. It may be reassuring to know that in the vast majority of cases, tearing — while extremely bothersome to the patient — is not harmful to the eye.

To understand why eyes can water, it is helpful to understand how and why tears are made and how they ultimately drain away from your eye.

“BLINK” Tears: The surface of your eye and insides of your eyelids are mucous membranes similar to the inside of your mouth. Mucous membranes by definition should be moist at all times. In the mouth, that moisture is provided by saliva. In the eye, this moisture is provided by tears that are made by numerous tiny glands that dot the surface of the eye and insides of the eyelids. Throughout the day when you blink, this moisture is spread across the eye and slowly pushed toward the inside corner next to your nose.

Tear Drainage: On the inside corner of each eyelid is a small drainage hole called a punctum. You can see this opening if you look closely in the mirror and gently pull your lid away from your eye. Once the tears disappear down this hole, under normal conditions, they wind their way through various channels down to your nose.

“CRY” Tears: In addition to the numerous glands that make “blink” tears, everyone has a large gland (“lacrimal gland”) under the outer upper eyelid that, in addition to being responsible for tears of joy and sorrow, also makes the tears that soothe the eye when it’s irritated from things like allergies, cutting an onion, a stray eyelash. However, the most common reason the lacrimal gland may flood the eye is because there aren’t enough blink tears to keep the eye properly moist and the eye starts to dry out.

A dry eye can result from things like a dry or windy environment; hormonal changes associated with pregnancy, breast feeding or menopause; inflammation of the eyelid edges (“blepharitis”); or lids that don’t properly cover and protect the eye. Probably the most common cause of a dry eye are aging changes that decrease the amount of the “blink” tears. This dryness in turn triggers the “cry” tears to start flowing. There are so many tears made in these situations that they overflow the normal drainage pathway to the nose and instead spill onto the cheeks. Treatment for overflow tearing is directed at the underlying cause and commonly includes over-the-counter supplemental “blink” tear drops (yes, a watery eye is often treated, paradoxically, with tear drops), lid scrubs and warm compresses for blepharitis. Some people with severe and long-standing dry eye may benefit from prescription drops that help the body make more of its own “blink” tears.

Tear Drainage Problems

If there is a narrowing or blockage anywhere along the pipes from the eye to the nose, even blink tears can overflow onto the cheeks. Your doctor can perform tests to determine if there is a blockage and if so, where between the eye and nose the problem lies. The exact location of the blockage will determine what treatment options are available to you. In most cases, a surgical procedure will be required to either alleviate or bypass the obstruction.

Another less common type of drainage problem happens when there is a problem with blinking. If the lids are weak or loose from age, paralysis or injury, they may not blink as well. Without a proper blink mechanism, the tears have a hard time finding their way to the drainage hole at the inside corner. In this situation, your doctor may advise an eyelid tightening procedure to improve the drainage mechanics. There can be no guarantee that this type of procedure will be effective or won’t need to be repeated as the lid loosens over time but it can provide relief in some patients.

When All Else Fails

In some cases, your doctor may not be able to pinpoint the exact cause(s) of your tearing. When no other options for relief are available, there may be a role for botulinum toxin (e.g., Botox®) injections into or partial surgical removal of the lacrimal gland. Your doctor can give you more information on these options. You may ultimately decide to live with this aggravating, but not generally harmful condition.

Summary

Tearing eyes are a major source of discomfort for many people. In most cases, the tearing does not significantly harm the eye. Treatment for this condition is directed at the underlying cause. Overflow problems (of which dry eye is a the most common and paradoxical cause) are commonly treated with over the counter or prescription eye drops, or lid hygiene. Drainage problems may be treated with a handful of surgical procedures directed at correcting or bypassing the underlying obstruction or improving blink strength. Your doctor can advise you of your treatment options.

The tear drain starts with two small openings called puncta; one punctum is in your inner upper eyelid and the other is in the inner lower eyelid. You can see them with the naked eye if you look up close. Each of these openings leads into a small tube called the canaliculus which in turn empties into the lacrimal sac between the inside corner of your eye and nose. The lacrimal sac narrows into a tunnel called the nasolacrimal duct that passes through the bony structures surrounding your nose and then empties tears into your nasal cavity.

When you blink, your eyelids push tears evenly across the eyes to keep them moist and healthy. Blinking also pumps your old tears into the puncta and lacrimal sac where they travel through the nasolacrimal duct and drain into your nose.

The most common symptoms include mucous buildup at the inside corner of the eye and/or along the lashes, excessive watering and distorted vision. Depending on where along the passageway from the punctum to the nose the blockage occurs, you may also have redness, tenderness and swelling between the inner corner of the eye and the side of the nose. A skillful history and examination by your doctor can usually identify if a narrowing or blockage exists and if so, where along the passageway it is.

Treatments

Your surgeon may recommend a number of treatments based on the analysis of your symptoms and the findings on your exam. In some cases, it may be as simple as applying warm compresses and antibiotics but often, surgery is the most effective treatment.

Narrowing of the punctum or canaliculus may respond to minor office procedures to reopen these passageways — snip punctoplasty or stenting procedures. A common location of blockage is the nasolacrimal duct. This causes tears to be trapped in the lacrimal sac and sometimes become stagnant and infected (as shown on the cover of this brochure). If the nasolacrimal duct is narrowed (also known as “stenosis”) but still partially open, your surgeon may recommend placing temporary stents through your nasal passageways. If this is not effective or if the nasolacrimal duct becomes completely blocked, a dacrocystorhinostomy (DCR) is the gold standard surgery to correct this problem.

To perform the procedure, your surgeon will create a new drainage opening from the blocked sac directly into your nose to bypass the obstruction in your nasolacrimal duct. (Unlike children in whom a blocked nasolacrimal duct can often be opened with a sharp probe, adults are not able to be treated in this same way.) A small incision is made either in the skin or inside the nose. A fine, soft silicone stent may temporarily be left in the new tear drain for a few weeks to keep the duct open while healing occurs.

A DCR is an outpatient procedure that may be done under “twilight” sedation or general anesthesia. You may have a bit of nose bleeding for a couple days after the procedure. Most people recover in less than a week.

A less common site of complete blockage is at the level of the canaliculus. In this situation, a prosthetic Pyrex glass prosthesis (often referred to as a Jones or Gladstone-Putterman tube) may be placed to connect the surface of the eye directly to the nasal cavity in a procedure called a conjunctivodacryocystorhinostomy (CDCR). Unlike a DCR that requires virtually no maintenance after surgery, living with a glass tube can create challenges for many patients. While some patients may choose to simply live with their tearing in this situation, your surgeon can provide more details to help you make your decision.

Most patients experience improvement in their tearing and discharge once the appropriate procedure has been done to address the blockage in their tear drainage system.

Risks and Complications

Bleeding and infection, which are potential risks with any surgical procedure, are very uncommon. Be sure to tell your surgeon if you take blood thinners as special arrangements may need to be made to prevent major wound and nose bleeding during and after your operation. Minor bruising and swelling between the eye and nose should be expected and will likely go away in one to two weeks. passageways may narrow again or scar tissue may grow around the new opening made in a DCR or CDCR. Further surgery may be required.

Important: Your surgeon cannot control all the variables that may impact your final result. The goal is always to improve a patient’s condition but no guarantees or promises can be made for a successful outcome in any surgical procedure. There is always a chance you will not be satisfied with your results and/or that you will need additional treatment. As with any medical decision, there may be other inherent risks or alternatives that should be discussed with your surgeon.

The tear (lacrimal) glands produce tears constantly during the day to keep the eyes lubricated. The tears drain away from the eyes through the lacrimal drainage system. Approximately 7% of infants are born with congenital obstruction of the tear drainage system in one or both eyes. This percentage is even higher in premature infants.

The tear drain system starts at tiny openings in all four eyelids called puncta. Each punctum leads into a small tube called a canaliculus, which in turn empties into the lacrimal sac, located between the inside corner of the eye and nose. The lacrimal sac leads into a canal called the nasolacrimal duct. The nasolacrimal duct passes through the bony structures surrounding your nose and empties tears into the nasal cavity.

With each blink, the eyelids push tears evenly across the eyeballs to keep them moist and healthy. Blinking also helps get old tears into the lacrimal drain system. Once tears are inside the drain system, blinking acts like a pump to push those tears from the lacrimal sac down through the nasolacrimal duct and into the nose.

The most common symptoms of a blocked tear drain are excessive watering, mucous discharge, eye irritation, and painful swelling in the inner corner of the eyelids. Newborns with congenital nasolacrimal duct obstruction may have a blockage anywhere along the tear drain system. Usually, the blockage occurs at the end of the nasolacrimal duct, where a thin membrane can block the tears from emptying into the nose. If the nasolacrimal duct is blocked, tears will back up, spill over the eyelids, and run down the cheek.

Tears can also be trapped in the lacrimal sac, leading to an infection. A skillful history and physical examination can usually pinpoint the cause of tearing.

It is important that children with excessive tearing be examined by an ophthalmologist to determine the cause of the problem. In some children, excessive tearing may be due to causes other than tear duct obstruction.

Treatments

congenital lacrimal obstructionInitial treatment involves massaging the area around the affected lacrimal sac to force the tears down the nasolacrimal duct, and to push open the membrane causing the obstruction. The physician may also prescribe oral antibiotics, drops, or ointment.

If massage does not relieve the tearing, additional treatments might be necessary. Your child’s physician may be able to open the blockage by inserting a thin metal probe through the punctum and down the nasolacrimal duct into the nose. This outpatient procedure may take place in the office if the child is less than one year of age, otherwise in the operating room.

For severe or recurrent cases, additional options include physically dilating the nasolacrimal duct with a balloon, propping the nasolacrimal duct open with a temporary silicone stent, or surgically creating an alternative drainage pathway for tears to pass into the nose.

Most patients experience resolution of their tearing and discharge after treatment is completed, with little if any postoperative discomfort.

Risks and Complications

Bleeding and infection, which are potential risks with any surgical procedure, are very uncommon. Minor bruising or swelling may be expected and will likely go away in one to two weeks. Occasionally, the body may form scar tissue that blocks the drain again, which may require additional procedures.

Important: Your child’s surgeon cannot control all the variables that may impact your child’s final result. The goal is always to improve a patient’s condition but no guarantees or promises can be made for a successful outcome in any surgical procedure. There is always a chance you will not be satisfied with the results and/or that your child will need additional treatment. As with any medical decision, there may be other inherent risks or alternatives that should be discussed with your child’s surgeon.

Botulinum toxin injection is the most popular cosmetic medical treatment in the US, and is a favorite among men and women looking for non-surgical facial rejuvenation.

Botulinum toxin has a long history in ophthalmology, and most ophthalmologists have many years of experience in its use. Oculofacial plastic surgeons are among the foremost specialists in use of botulinum toxin for lines, wrinkles, and facial reshaping at the eyebrows, jawline, lips, and neck. It has proven to be safe, effective, and economical.
Botulinum toxin is a safe, naturally occurring substance that causes muscle relaxation typically lasting three to four months. In high doses, botulinum toxin will weaken muscles substantially, while in lower doses, the relaxation and weakening are subtle. These effects can be harnessed by your physician to improve frown lines between the brows, crow’s feet at the outer corners of the eyes, horizontal lines in the forehead, and eyebrow height and shape. Botulinum toxin can also be used to treat vertical lip lines, down-turn at the lips, and twitching or spasm of the eyelids, cheeks, and face.

Your physician will review your specific concerns and medical history and advise you about the best uses for botulinum toxin in your situation. It is injected with a tiny needle directly into the muscle(s) causing wrinkles, spasm, or facial aging. Mildly uncomfortable, the injections take only a few seconds. Effects begin to be visible at two to three days and are usually fully evident by one week. Bruising rarely occurs and fades naturally. Improvements in facial appearance and muscle relaxation typically last three to four months.

Facial Fillers

Facial fillers are also a popular alternative in non-surgical facial rejuvenation. They are sometimes employed alone, but can also be an adjunct to botulinum toxin. Commonly used facial fillers include naturally-occurring hyaluronic acid products, as well as synthetic microsphere products.

Fillers work by safely restoring lost volume under the skin thereby smoothing out wrinkles and sagging from aging. For many years they have often been used to improve the shape and fullness of the lips and creases around the mouth. They also work well to improve contour and fullness at the cheeks, eyebrows, earlobes, and to partially hide dark circles under the eyes. Recent advances in technology have resulted in longer-lasting and more natural improvements than ever before.

Your physician will review your specific concerns and medical history and advise you about the best uses for facial fillers in your situation. Fillers are injected with a tiny needle directly into the area of concern, sometimes with ice, anesthetic cream, or anesthetic block injections to minimize discomfort. Effects are visible immediately, but mild local swelling occurs rapidly and lasts for a few days. Bruising may occur and fades naturally. Improvements in facial appearance last six to eighteen months with hyaluronic acid; shorter with collagen, and longer with synthetic microspheres.

Risks and Complications

Bleeding and infection, which are potential risks with any procedure, are very uncommon. Bruising can occur with any injection. Be sure to tell your surgeon if you are on blood thinners as their use may put you at increased risk for bleeding complications. Botulinum toxin injections can rarely induce weakness in a nearby muscle, causing asymmetry, or a droopy eyelid or lip. To minimize this risk, your physician will recommend that you avoid touching the injected areas for several hours so that the botulinum toxin will bind to the intended muscles only. Facial fillers can also cause asymmetry, and rarely, a local sensitivity reaction.

Important: Your surgeon cannot control all the variables that may impact your final result. The goal is always to improve a patient’s condition but no guarantees or promises can be made for a successful outcome in any surgical procedure. There is always a chance you will not be satisfied with your results and/or that you will need additional treatment. As with any medical decision, there may be other inherent risks or alternatives that should be discussed with your surgeon.