Oculoplasty

Oculoplastics is a subspecialty within ophthalmology that deals with structures surrounding the eyeball like orbit (eye socket), eyelids, tear ducts and their reconstructive procedures.

Oculoplasty surgeons imbibe the finest skills of ophthalmic microsurgery and plastic surgery as they first train as ophthalmologists and later specialise in plastic surgery making them highly skilled surgeons.

The Oculoplasty department follows a holistic approach with comprehensive care available under one roof including reconstructive surgery, aesthetic surgery, lacrimal disorders, anaesthesia care, ocular prosthesis centre, physician care, laboratory facilities including pathology, microbiology thereby working towards novel treatment techniques.

Ptosis

What is Ptosis?

Ptosis is drooping of the eyelid. The eye appears smaller, there is difficulty opening the eye. Ptosis may occur in one eye or both eyes. There is an obstruction of vision and a sleepy and tired appearance.

Why does Ptosis Occur?

There is a muscle in the upper lid, called the levator, the function of levator is to lift the eyelid open. If the levator is not working well, the eyelid droops. In many patients who have ptosis since birth, the levator muscle has been weak since birth. In patients where ptosis starts later in life, there may be multiple causes: injury, age, use of contact lenses for many years, and some neurological diseases.

Do we need to consult a neurologist?

A small proportion of ptosis stems from neurologic diseases. Usually, the oculoplastic surgeon is able to differentiate these on examination. They will then refer you to a neurologist.

How important it is to correct Ptosis?

For an adult, ptosis can block part of the visual field, obstructing the vision. The patient will have a strain on lifting the brow muscles to compensate. More and more people opt for ptosis correction to avoid looking tired, sleepy and unhappy.

In a child, the ptosis may cause a delay in the development of vision, and a lazy eye (amblyopia). This has to be corrected at a young age, and appropriate glasses and exercise started. Once the patient is older, vision correction cannot be achieved.

What are the methods of correction of Ptosis?

The oculoplasty surgeon assesses the measurements of the eye. If the natural muscle can be strengthened with stitches, that is the method of choice. If the natural muscle/ levator is too weak for correction, an implant (most commonly silicone) is placed to connect the forehead muscles and the eyelids (silicone sling). The patient can then effectively use the forehead muscle to lift the eyelid. Another option is to use the patient’s own tissue from the leg (fascia lata sling).

Some neurologic diseases such as myasthenia can be treated by oral medicines.

Rarely, there are some ptosis patients where it is not safe to do surgery. These patients are recommended crutch glasses, and spectacles which prop the eye open.

 

Lacrimal

Blockage of the tear drainage system often leads to watering and discharge and at times, acute infection of the lacrimal sac among patients of all age groups ranging from infants (congenital) to the elderly, and can be cured by probing, intubation and surgery. Blockage can be complete or partial or at any site from the lacrimal puncta to the nasolacrimal duct.

Probing

Every eye has a fine pipe leading from the eye into the nose. This is like a drain pipe, and the tears go into the throat through this pipe. This is called the nasolacrimal duct. A child may be born with a block in the nasolacrimal duct; this condition is called congenital dacryostenosis. The water and sticky material come out of the eye, and the child’s eyes appear to be tearing all the time. This condition is seen within a few weeks after birth.

Many children with congenital dacryostenosis will heal only with antibiotic drops and sac massage. The oculoplasty surgeon will show you the correct technique of sac massage for your child. If the condition has not healed by 9 to 12 months, it will probably not respond to further massage and surgery will be required.

The first step of surgery is called probing. It is very safe and can be done as a day-care procedure (night stay in hospital not required). There is no external wound or stitches, no bandage required, and normal activities can be continued from the next day.

Dacryocystorhinostomy (DCR)

When there is a nasolacrimal duct (drain-pipe of the eye) blockage the tears and sticky discharge come out of the eye. The eye can be red and feel irritated. In the early stages, there will be pain and swelling around the nasal part of the eye, associated with pain – this stage is called Acute Dacryocystitis. When the disease persists for a long duration the pain will subside but blockage and associated discharge persist- this stage is called Chronic Dacryocystitis. The treatment for the acute stage is oral antibiotics (medical management) and for the chronic stage, dacryocystorhinostomy (DCR) (surgical management) is needed. This is a technique by which a new passage is created from the eye into the nose, and the tears can drain out.

 

Ocular Prosthesis

For a patient who unfortunately loses an eye to disease or trauma, the pain extends beyond the loss of the function itself. The continued suffering of a painful or disfigured eye and the social stigma, all lead to psychological setbacks for the patient.

 

What is Ocularistry? What is a customised prosthesis?

When an eye is lost due to disease or injury, an artificial eye (prosthesis) can be fitted in its place. The prosthetic eye cannot see but can give a natural appearance to the patient. A customised prosthesis is manufactured for the patient, taking measurements from his socket, and matching the colouring exactly. Ocularistry is the art and science of manufacturing such an eye.

Is there any prior assessment before fitting the prosthesis?

Before fitting the custom prosthesis, the socket is assessed to ensure it is healthy. There should not be any active infection or inflammation, excessive tenderness or sensitivity. The space available must be adequate, and the fornices well formed to support the prosthesis.

Will the artificial eye move and blink normally?

The movement and eyelid closure depends on the pre-existing condition of the eye socket. Usually, the oculoplastic surgeon will be able to tell by examining you. Most patients gain conversational movement of the eye, though the prosthesis may not move into the furthest corners.

Is the prosthesis permanent?

The implant is placed deep in the socket during the surgical correction. The implant is permanent. The prosthesis has to be removed and cleaned once a week or two, which can be done easily by the patient.

What special care is needed for the prostheses?

The prosthesis is to be cleaned periodically. Once a year, the patient needs to come for a check-up with the oculoplastic surgeon and ocularist. The socket will be examined to make sure it is healthy, and the prosthesis will be polished. If well maintained, the same prosthesis can be used for many years.

 

Thyroid eye disease

Thyroid dysfunction is a commonly encountered condition which can affect the eyes ranging from bulging of eyes and retraction of the lids, leading to facial asymmetry to sight-threatening complications. Both medical and surgical modalities of treatment are available for this condition.

Thyroid eye disease (TED) is a disease marked by swelling of muscles and fatty tissues surrounding the eyeball within the eye socket. It is also known by other names such as Thyroid Related Ophthalmopathy (TRO), dysthyroid eye disease, Grave’s Ophthalmopathy or Ophthalmic Grave’s disease.

The swelling of the muscles and soft tissue pushes the eyeball forward, causing double vision. In severe cases, there is loss of vision due to compression of the nerve connecting the eye to the brain. When the eye is pushed forward the clear window of the eye (cornea) loses its protection provided by the eyelids and may get damaged.