Ptosis is a drooping of the upper eyelid. It is more than just having
an excess of eyelid skin drooping downward. The drooping is caused by a weakening of the muscle in the upper eyelid,
called the levator. In advanced cases, this can actualy obstruct the upper portion of the peripheral field of vision.
Activities such as reading, driving or watching television may be compromised by a droopy upper eyelid. While some are
born with this condition, most people gradually develop ptosis with increasing age. Surgery corrects this condition
by reattaching a loose muscle or shortening a weak muscle. It can be combined with removal o excess skin or fatty tissue
at the same time of surgery.
Ectropion is an outward turning of the eyelid. As a result of this
condition, the eyelid and the eye itself are exposed to the air, causing irritation, light sensitivity and tearing.
The inside of the eyelid becomes visible and is often quite red. There are many causes of ectropion, but the most common
is associated with a gradual loosening of the eyelid tendons with age. Surgery is performed to tighten and reattach
the eyelid tendon, returning it to a more normal position.
Entropion is an inward turning of the eyelid. This condition results in the
eyelashes of the lower eyelid scratching the eye itself, causing severe irritation, tearing, light sensitivity and pain. If
left untreated an ulcer may form. A muscle typically pulls loose inside the eyelid causing this problem. Surgery involves
reattachment of the loose muscle, and tightening of the eyelid tendon. This returns the eyelid to a normal position.
There are many types of growths which can be found on the eyelids. Most of
these are benign (non-cancerous), but several types of malignant (cancerous) growths can occur. They are most commonly associated
with sun exposure. Because it is difficult to differentiate between benign and malignant growths, it is best to have these
examined. A biopsy sometimes is necessary to establish the diagnosis. Surgical removal is often required for growths that
are suspicious in nature or increasing in size. Biopsies are often performed as an office procedure, or may be removed in
an outpatient surgical setting if more extensive. A word
of caution: skin cancer can affect the eyelid area, so if you have a new or suspicious-appearing growth, please have
it checked by a specialist.
Dry eyes are a common problem in the Arizona desert. Gritty, foreign-body
sensation, burning, and blurring vision are all symptoms of dry eye. Artificial tears is the first line of treatment.
Tears are available over-the-counter, and are used at least 4 times daily. A lubricating gel also can be used at night.
Punctal plugs are used to prevent tears from draining away from the eye, thus helping it retain moisture. Plugs are
inserted into the punctum (the tear duct drain opening) in the office setting. Recently, the drug Restasis gained
FDA approval. It is the first drug specifically aimed at treating the inflammation and irritation associated with dry eye,
thereby reducing the gritty, foreign-body sensation. It is especially helpful for more severe forms of dry eye, such as Sjogren's
Epiphora (tearing) can be caused by a variety of problems. Often, dry eye and allergies
can cause eye irritation, producing "reflex" tearing. Using allergy drops and artificial tears can help this problem.
Occasionally, tearing may be caused by excess tear production, but more often it is caused by decreased drainage or obstruction
of the tear duct drainage system. Punctal stenosis or narrowing of the tear duct opening can prevent tears from entering the
drainage system. This can be corrected by an office procedure called a punctoplasty, where the tear duct opening is enlarged
to facilitate tear flow.
Dacryocystitis is an inflammation of the lacrimal or tear sac. It is often caused by blockage
of the nasolacrimal duct (the duct connecting the tear sac to the inside of the nose. Common symptoms of dacryocystitis include
tearing and mucous discharge from the eye. The eyes may be matted together in the morning. Occasionally, a hard, tender and
swollen area will appear on the inner corner by the nose.
Treatment of dacryocystitis often involves antibiotics
taken by mouth. Although this will alleviate some of the symptoms, it will not relieve the blockage. Therefore a patient will
be subject to repeat infections unless definitive surgery is performed. The surgery, termed a DCR, involves making a new connection
between the tear sac and the inside of the nose, bypassing the obstructed area. Many surgeons are now performing the DCR with
an endoscope (a fiber optic light attached to a video camera). Dr. Chen is among a handful of surgeons with at least 25 years
of experience in performing endoscopic DCR.
Orbital trauma can result in fractures of the bones
surrounding the eye. Various forms of trauma can contribute to these fractures known as blowout or tripod fractures depending
on which bones are involved. Not all orbital fractures need to be repaired. A careful examination helps determine when surgery
is necessary. Symptoms can include double vision and a sunken appearance of the eye.
When necessary, surgery releases any tissue which may be entrapped within a fractured bone.
A thin plate is frequently placed to take place of the fractured bone. At times, small metal plates are needed to hold bones
together. Surgery will usually eliminate double vision and keep the eye in its proper position.
Although rather uncommon, the orbit (eye socket) is susceptible to a variety of
diseases. These include tumors, infections, various inflammatory conditions and thyroid related problems. Symptoms can include
pain, double vision and protrusion of the eye. They are too numerous and extensive to list here.
Prompt investigation of orbital problems is important. This can include a CT or MRI scan as well as a detailed office
examination. At times a biopsy is necessary. Treatment can range from the use of antibiotics to oral steroids to surgical
Enucleation is the surgical removal of the eye. It is performed when an eye
has poor or no vision and has become painful. Occasionally, enucleation is performed to remove an eye with a malignant tumor.
The eye is removed and replaced by a round implant which fills the volume of the orbit. The eye muscles are often attached
to the implant, which allows for movement of the prosthetic eye. Evisceration is a less invasive alternative to enucleation,
whereby the cornea and the eye contents are removed, leaving the scleral shell behind. A round implant is placed to
fill the volume of the orbit, much like enucleation. Once complete healing has occurred an ocularist fits a prosthetic
eye. Usually, the patient is comfortable and a remarkably good fit is obtained with the prosthesis.
Thyroid Eye Disease
Most individuals with thyroid disease do not experience eye problems. However,
some may experience changes with the eye known as thyroid ophthalmopathy, thyroid eye disease (TED), Grave's ophthalmopathy
or Thyroid related orbitopathy. Although TED is seen in all types of thyroid disorders, it is most common in patients that
are or were hyperthyroid. TED occurs in about 1 out of 20 people that are hyperthyroid. It can also rarely occur in those
who are hypothyroid and even when there is an absence of thyroid abnormalities in the body. Thyroid disease can cause
many different eye problems. These include redness and swelling, double vision, decreased vision, eyelid retraction and a
protrusion of the eye itself. A patient may experience one or more of the above symptoms. Eye problems will usually
occur and frequently change in type or severity for between 6 months and 2 years. Once stabilized, it is unusual for the eyes
to start changing again. In some patients the eyes return to normal. Others are left with permanent changes including exophthalmos
(bulging of the eye) eyelid retraction, exposure of the eyes and double vision. A great deal can be done to improve these
problems, but this may require surgery.
Medical Aspects of Thyroid Eye Disease
Graves' disease is caused by what is described as an autoimmune process.
Autoimmune disease may be understood as a process by which the body sees some part of itself as being foreign and reacts to
it much the same way that it would with any bacteria or virus. In the case of Graves' disease, the body sees the thyroid gland
as the foreign object and produces antibodies that attack the thyroid gland. This will often (but not in all cases) cause
the thyroid gland to become over active.
TED is currently believed to be due to a similar autoimmune reaction.
However, in the case of TED, different antibodies attack the muscles associated with eye and eyelid movement. Although the
thyroid gland and the eye may be under attack by the same immune system, it is felt that both conditions remain independent
of one another. The antibodies that attack the eye can cause inflammation and swelling of the muscles around the eye, which
is what can eventually cause protrusion of the eyes, double vision and retraction of the eyelids.
The Thyroid Puzzle
Even after decades of research there are mysteries
associated with thyroid disease that we still don't understand. One of the more puzzling is the relationship between TED and
thyroid disease. A common misconception is that once your medical doctor treats your body's thyroid problem the eyes would
go back to normal. In fact, treatment of TED involves controlling the autoimmune disease.
Often, this does not occur. In some patients the eyes
worsen in the months and years after medical treatment despite stable thyroid function levels. We have seen patients whose
eyes first showed sighs of TED as long as 30 years after being stabilized medically. Even though good medical treatment may
not prevent or cure TED, it is extremely important to treat the thyroid disease and maintain normal thyroid function levels.
Smoking and Thyroid Eye Disease.
are more likely to develop TED and also are at more risk for developing more severe forms of the condition. They are also
at increased risk for vision loss (blindness) from TED. Surgery to restore vision loss is more successful if the patient stops
smoking. All patients with thyroid eye disease are advised to stop smoking.
The Role of the Eye Specialist
An Ophthalmologist specializing in TED (usually an oculoplastic surgeon) has several roles
in treating a patient that has eye problems. The first is to help the patient deal with the time when the eyes are changing
and provide simple solutions to the irritation, tearing and swelling often associated with TED. Often this involves something
as simple as using artificial tears frequently during the day and lubrication ointment at night. Additionally , elevating
the head at night, by using several pillows, will often help decrease swelling around the eyes. Additionally, the eye specialist
can help determine when the eyes have stopped changing so that corrective or cosmetic surgery can be performed, if necessary.
Finally, the eye specialist will watch for signs and symptoms of serious eye disease which can lead to vision loss.
New treatments for TED:
In 2020, the FDA approved Tepezza for patients with TED. This medication is a biologic agent that helps to reduce
the inflammation in the orbit, and can reduce proptosis (bulging of the eye). This drug may be covered by insurance,
and is given as a series of infusions. Please discuss whether you are a candidate for this medication with your physician.
Additional Educational Resources