Ectropion

Ectropion means that the lower eyelid is “rolled out” away from the eye, or is sagging away from the eye. The sagging lower eyelid leaves the eye exposed and dry. If ectropion is not treated, the condition can lead to chronic tearing, eye irritation, redness, pain, a gritty feeling, crusting of the eyelid, mucous discharge, and breakdown of the cornea due to exposure.

What Causes Ectropion

Generally the condition is the result of tissue relaxation associated with aging, although it may also occur as a result of facial nerve paralysis (due to Bell’s palsy, stroke or other neurologic conditions), trauma, scarring, previous surgeries or skin cancer.

What are the Symptoms?

The wet, inner, conjunctival surface is exposed and visible. 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 evenly over the eye. Symptoms may include excessive tearing, chronic irritation, redness, pain, a gritty feeling, crusting of the eyelid and mucous discharge.

Can Ectropion be Repaired?

Yes, ectropion can be repaired surgically. Most patients experience immediate resolution of the problem once surgery is completed with little, if any, post-operative discomfort. After your eyelid heals, your eye will feel comfortable and be protected from corneal scarring, infection, and loss of vision.

Entropion

Entropion means the the lower eyelid in "rolled in" toward the eye. This allows the eyelashes to rub on the cornea, the most sensitive part of your eye. It can cause eye irritation, pain, tearing, and could lead to a corneal abrasion and ulcer, which can permanently damage your vision.

What Causes Entropion?

Entropion is generally caused by laxity of the skin and support tissues of the lower eyelid, as well as a loss of support from the muscles within the eyelid. It may also be caused by scarring of the inside of the eyelid.

What Are The Symptoms?

The eyelashes rubbing on the cornea cause tearing, pain and irritation, which is temporarily relieved by pulling down on the eyelid, rolling it back out. Usually the lid will roll back in with blinking. Occasionally, people with put tape on the lid to keep it from rolling in.

Can Entropion Be Repaired?

Yes, entropion can be repaired surgically. Immediate relief of symptoms generally follows surgery, and post-operative discomfort is minimal. After your eyelid heals, your eye will feel comfortable and be protected from corneal scarring, infection, and loss of vision.

Dry eye

What Makes Up Our Tears?

The tears are made up of three key components. The outermost layer of oil is secreted by tiny glands along the edge of your eyelids. The middle layer is mainly water mixed with numerous enzymes and other protective molecules like antibodies that help to protect against infection. The innermost layer is mucus, which helps the tears to stick in a smooth layer on the cornea (see video at upper left). If any one of these layers is absent or out of balance, the tear film will not adequately lubricate or moisturize the eye and dry eye can result.

Can Dry Eye Be Treated?

There are many things you can do for dry eye. The first line therapy is to replace missing tears with artificial tears. These need to be given often as tears are constantly evaporating or draining away. Avoiding situations that cause more rapid evaporation will also help, like not sleeping under a ceiling fan, or letting the air conditioner blow in your face while driving. If the oil layer is the problem, you can encourage oil release from the glands by using hot compresses on the eyelids once or twice daily along with lids scrubs (wash along the eyelashes with baby shampoo mixed with warm water). Additionally, taking omega-3 (fish oil) tablets has been shown to improve tear oils. When these treatments aren't enough, we next turn to stopping drainage of the tears with tiny silicone plugs (see video at lower left). These are either temporary or semi-permanent and will keep your natural tears in place longer. When dry eye is severe, we can permanently block the tear drains by cauterizing them. Other treatments include wearing moisture retaining glasses or goggles an using tear ointments. If the problem is due to an eyelid abnormality, surgery is often required to reposition the eyelids against the eye.

Where Can I Get More Information?

You can call our office at (801)264-4420 and schedule an appointment for a consultation. We will examine your eyes, tear film and eyelids and help you find a solution for your dry eye problem. You can also find more intormation on the American Academy of Ophthalmology's Get Eye Smart website.

Tearing

The tear film on the surface of the eye is a critical component of maintaining vision. Tears nourish and lubricate the surface of the eye as well as wash away debris. A smooth, balanced tear film (consisting of water, oil and mucus) also allows light to enter the eye in an optimal fashion. If there is a disturbance of the tear film, patients will often experience tearing, burning, irritation and most importantly blurred vision. Patients who experience tearing either have a problem with tear production or tear drainage.

Increased Tear Production and Dry Eyes

The eye has two sets of structures that produce tears. Smaller tear glands help maintain a baseline level of moisture on the surface of the eye. Unfortunately, inflammatory conditions like rheumatoid arthritis, Sjogrens disease as well as aging and menopause lead to decreased tear production. As tear production diminishes, the surface of the eye starts to dry out. Further, inflammation of the oil glands along the edge of the eyelid, common in patients with roseacea, also causes early breakdown and evaporation of the tear film. The brain senses the eye is both dry and irritated and in turn signals the main tear gland to flush the eye. As a result, the dry eye tears and becomes watery. Patients with dry eyes note intermittent tearing of the eyes during activities like reading, driving, watching TV, using a computer or going outside on a windy day. These all cause the eye to dry out because the eye blinks less during these activities. The treatment for dry eyes includes 1) replacing tears with artificial lubricants which can be bought over the counter, 2) medications like Restasis that decrease inflammation in tear glands and encourage natural tear production to resume and finally 3) plugging of the tear drain. Other causes of increased tear production exist like allergies, infections and eyelashes poking the eye. These conditions can often be found during examination.

What Are the Causes of Obstructed Tear Ducts?

An obstruction of the tear ducts may occur for numerous reasons (aging, trauma, inflammatory conditions, medications and tumors) and cause numerous signs and symptoms ranging from wateriness or tearing to discharge, swelling, pain and infection. These signs and symptoms may result from the tear drainage system becoming obstructed at any point from the puncta to the nasal cavity.

What Are the Symptoms of Obstructed Tear Ducts?

If the tear passageways become blocked, tears cannot drain properly and may overflow from the eyelids onto the face as if you were crying. In addition to excessive tearing you may also experience blurred vision, mucous discharge, eye irritation, and painful swelling in the inner corner of the eyelids. A thorough examination by an ophthalmic plastic surgeon can determine the cause of tearing and recommend treatment.

How is an Obstructed Tear Duct Treated or Repaired?

Depending on your symptoms and their severity, your specialist will suggest an appropriate course. In mild cases, a treatment of warm compresses and antibiotics may be recommended. In more severe cases, surgical intervention to bypass the tear duct obstruction (dacryocystorhinostomy or DCR surgery) may be recommended. A DCR is performed by creating a new tear passageway from the lacrimal sac to the nose, bypassing the obstruction. A small silicone tube called a stent may temporarily be placed in the new passageway to keep it open during the healing process. In a small percentage of cases, the obstruction is between the puncta and the lacrimal sac. In these cases, in addition to the DCR procedure, the surgeon will insert a tiny artificial tear drain called a Jones Tube. A Jones Tube is made of Pyrex glass and allows tears to drain directly from the eye to the nose.

Where Is The Surgery Performed?

DCR surgery is usually performed as an outpatient procedure. Patients usually have some bruising and swelling on the side of the nose that subsides in one to two weeks. In general, surgery has a greater than 90% success rate and most patients experience a resolution of their tearing and discharge problems once surgery and recovery are completed.

Styes & Blepharitis

Blepharitis is inflammation of the eyelids, usually along the margins, with oily particles, crusting and bacteria stuck to the eyelashes near their base. It can cause irritation, itching, redness, and burning or stinging of the eyes. Blepharitis is often seen in patients with rosacea, but most of the time the cause is unknown.

How do you treat blepharitis?

Lid hygiene is the primary treatment, including hot compresses once or twice daily along with eyelid scrubs using a gentle soap. This helps to remove bacteria and built up oils as well as aids in the flow of oils from the meibomian glands along the eyelid margin. These glands supply the oily layer of your tear film, which is important to maintain to avoid dry eye. In more severe cases, we often prescribe topical ointments, anti-biotic/anti-inflammatory eyedrops, or even oral medications.

Can blepharitis be cured?

There is no definitive cure for blepharitis and most people who suffer from it must treat it on a daily basis. The intensity of the symptoms can wax and wane for various reasons.

Styes & Chalazia

A stye (hordeolum) is an infected eyelash follicle. This will often drain on its own with warm compresses, but may need topical antibiotics or occasionally incision and drainage. More common is a chalazion, which is a painless, red, swollen nodule within the eyelid that is caused by a blocked oil gland. These can resolve by using hot compresses twice daily followed by cleaning the eyelid margins with mild soap and warm water. If they don't resolve after a few weeks of treatment, incision and drainage is also an option.
The danger in a recurring stye is that it may not be a stye at all, but a type of cancer called sebaceous cell carcinoma. You should definitely have a recurring stye checked out by an ophthalmologist.

Where Can I Get More Information?

You can call our office at (801)264-4420 and schedule an appointment for a consultation. We will examine your eyes, tear film and eyelids and help you find a solution for your eyelid problem.

Thyroid Eye Disease (Graves Disease)

Thyroid eye disease (also known as Graves’ Disease) is an autoimmune inflammatory disorder of uncertain cause that affects the tissues of the eye socket (i.e. eyelids, muscles and other soft tissues surrounding the eyes). Patients with this disorder often have a thyroid abnormality, which may manifest either before, during or after the eye related signs and symptoms. However, a small percentage of patients may have eyelid and eye socket manifestations of the disorder without developing a thyroid abnormality.

Disease Characteristics

Thyroid eye disease can develop and affect patients in different ways. The disease can begin suddenly and progress rapidly over days to weeks or start slowly and progress gradually over a long period of time. The majority of patients have mild inflammation, the most common signs and symptoms of which are retraction of the upper and/or lower eyelids and bulging of the eyes (also known as proptosis). In cases of moderate inflammation, patients may also have varying degrees of double vision and eyelid swelling as well as visible redness of the lids and eyes. A small percentage of patients with thyroid eye disease develop severe inflammation, which can result in compression of the optic nerve and permanent vision loss. In most cases, the inflammatory process is self-limited and runs a course lasting 6 months to a few years before "burning out". After the inflammatory phase of the disease ends, scarring of eyelid and orbital tissues may result in the persistence of eyelid retraction, bulging eyes and double vision.

Evaluation and Management

It is important to be evaluated by an ophthalmologist to assess the eye-related manifestations of the disease as well as by an endocrinologist to manage thyroid problems. Patients with mild eye disease are usually seen regularly to monitor progression of the disease and manage eye-related symptoms. Patients with moderate to severe eye disease may require medical or surgical intervention to reduce inflammation or improve vision. Once the inflammatory phase of the disease has ended, patients with eyelid abnormalities, double-vision or bulging eyes may be eligible for surgical correction to improve their function and appearance. Cigarette smoking has been associated with development of worsening thyroid eye disease, therefore stopping smoking is always recommended for these patients.

Skin Cancer

The eyelid skin is the thinnest and most sensitive skin on your body. As a result, this is often the first area on your face to show change from sun damage and aging. Unfortunately, sun damage and other environmental toxins not only cause the skin to age but can cause serious damage. Skin cancer of the eyelids is relatively common and several types exist. The presence of a bump or growth on the eyelid that is enlarging, bleeds or ulcerates should be evaluated. This involves examination and sometimes a biopsy.

Basal Cell Carcinoma

Basal cell tumors represent ninety percent of eyelid tumors. These skin cancers grow slowly over months and years. They most often appear as a pearly nodule or bump that eventually starts to break down and bleed or scab up. Despite being a cancer, these tumors don't spread to distant areas but rather just continue to grow and infiltrate the surrounding tissue. They typically can be cured by simple surgical removal followed by reconstruction of the defect left behind.

Squamous Cell Carcinoma and Melanoma

These types of tumors are less common but are more aggressive and require more involved care to ensure complete treatment. Again, primary treatment involves removing the tumor, but care must also be taken to ensure the tumor has not spread anywhere, causing larger health problems. Your surgeon will help coordinate this as part of your treatment depending on the size and circumstances of the tumor at presentation.

Treatment

Skin cancer needs to be removed surgically by a skilled individual who cannot only remove the tumor but reconstruct the eyelid or area where the tumor was removed. We often perform small tumor removals in the clinic, but of must use a surgical facility with an on site pathologist who can immediately examine the specimen to ensure the whole tumor was removed. Other times, the help of a dermatologic surgeon specializing in Mohs surgical excision will be utilized. This procedure is completed in two steps, the first in the dermatologist’s office with immediate examination of the tumor to ensure its complete removal followed by the reconstructive surgery in our operating room.

Orbital (Eye Socket) Infections, Trauma and Tumors

Orbital infection, or orbital cellulitis, is an aggressive, sight threatening process. Usually arising from a nearby sinus infection, this situation must be treated swiftly and aggressively with antibiotics and often surgery. Close follow up and monitoring is required to treat these infections, but is typically successful. Of note, not all infections occur as an extension of sinusitis. This can also occur after trauma to the eyelid, eye or eye socket as well as in patients whose immune system is challenged.

Facial injuries often result in fractures to the eye socket and cheek bones, along with lacerations involving the eyelids. Careful reconstruction of these injuries is important to restore the natural shape and symmetry of the face, as well as ensure the normal functioning of the eyelids.

In both children and adults, a variety of tumors can occur in the eye socket. Some grow slowly, and go unnoticed while others can grow rapidly; impairing vision and causing even greater problems. CT scans and MRI’s are the best method for detecting and differentiating these growths prior to having surgery. Once the location is identified, along with the general characteristics of the lesion, a treatment plan can be created. In some instances we can treat these tumors on their own, often as an outpatient. On the other hand, aggressive tumors may require the help of other surgical specialists and inpatient hospital treatment.

Who Should Treat Orbital Disease?

The orbit is a small, compact and complex structure. Oculo-Facial surgeons have undertaken the extra training to deal with the nuances of treating eye socket disease and injuries. When choosing a surgeon to evaluate and treat your orbital problem, look for an ophthalmic facial plastic & reconstructive surgeon who specializes in the eyelid, orbit, and tear drain surgery.

Pediatric Eye Socket and Tearing Problems

Children are wonderful joys in our lives and have a unique perspective of the world. Unfortunately they are not immune from medical disease and therefore often need expert care. Specifically, children can be burdened with problems of the eyelid, tear drain system and eye socket such as a traumatic injury, a tumor or congenital birth defect. Ophthalmic plastic surgeons are experts in treating many of these disorders and are available to assist in caring for your kids.

Tearing

Excess tearing from the eye is not uncommon in children. The tear drain is located in the inner corner of the eyelids and runs into the nose. Unfortunately about 5% of infants are born with a congenital blockage of the tear drain. When this is present, babies will develop excess tears dripping from the eye along with occasional discharge from the eye and crusting along the lashes. The good news is 90% of these blockages open spontaneously during the first year of life. During this time period conservative treatment with massaging the tear system and topical antibiotics are the mainstay of treatment. If the problem continues beyond the first year of life or if a severe infection occurs during the first year of life, a surgical procedure can be performed to open up the tear drain, which is highly successful. Sometimes extra procedures are needed like placing a stent or stretching the tear drain with a balloon to help establish normal flow down the drain.

Eyelid Abnormalities

The eyelids function to protect the health of the eye. However if an eyelid does not form properly it can have an effect on visual development. A congenital droopy eyelid, Ptosis, most commonly occurs because the muscle inside the eyelid that lifts the lid did not former properly. The weakness in the eyelid muscles can be mild and often observed or it can be profound and need urgent surgery to prevent significant visual problems. The only viable treatment for a droopy eyelid is surgery to lift the eyelid. Multiple surgical techniques exist to accomplish this and are tailored to meet the needs of the child based on the severity of the droopy eyelid and the amount of function the muscle inside the eyelid has.

In addition to ptosis of the eyelid, other problems can affect the eyelid and its function. This includes in turning or out turning of the lid, misdirected eyelashes, congenital defects of the eyelid and even growth in the lid or superficially in the skin of the eyelid. Again, the importance of treating these problems and restoring normal eyelid function is to ensure the health of the eye and development of normal vision.

Orbital Disease

Thankfully, orbital problems are not that common in children. The orbit is the boney socket in the skull that houses the eye and all the associated structures that help the eye function. The most common problem to affect the eye socket in children is acute bacterial infections, most commonly spreading from an adjacent sinus infection. These serious infections require aggressive treatment with antibiotics and sometimes surgery. In addition, tumors of the eye socket occur as well. Hemangiomas are an over growth of blood vessels that grow rapidly in the first year of life then slowly regress. When present in the orbit or eyelids, it can seriously affect visual function and development. In addition, some cancers can occur around they eye in children. A combination of surgery, chemotherapy and sometimes radiation is used to treat these life threatening problems.

Finally, kids love to have fun but sometimes at the cost of injuring themselves. Injury to the eye, orbit and surrounding structures often heals with careful observation and rest. However more serious injuries may necessitate surgery to repair the damage.

Who Should Perform Pediatric Oculoplastic Surgery?

When choosing a surgeon to evaluate and treat pediatric oculoplastic problems that involve the eyelid, tear drain or orbit, look for an ophthalmic facial plastic & reconstructive surgeon who specializes in the eyelids, orbit, and tear drain surgery. Dr. Call and Dr. Harris have the extra training required to care for these problems in children and adults. They are not only board certified ophthalmologists who know the anatomy and structure of the eyelids and orbit, but also have expertise in ophthalmic plastic reconstructive surgery to appropriately care for your child.