The skin loses its elasticity and our muscles slacken with age. For the eyelids this results in an accumulation of loose skin which collects as folds in the upper lids and forms deepening creases in the lower lids. At the same time there is slackening of the muscle beneath the skin allowing the fat, which cushions the eyes in their sockets, to protrude forward to give the appearance of bagginess. In some families there is an inherited tendency for bags to develop during early adulthood before any skin changes.

The problem often seems worse in the morning particularly with prolonged stress and lack of sleep. Fluid that is normally distributed throughout the upright body during the day, tends at night to settle in areas where the skin is loose, such as the eyelids. Drooping of the eyelids is also an effect of the ageing process and aggravates the accumulation of the skin in the upper eyelids. Sometimes so much skin accumulates in the upper lids that it hangs over the eyelashes to obstruct vision.

What can be done?

An eyelid reduction (blepharoplasty) removes the surplus skin and protruding fat to produce a more alert appearance and reduces the morning swelling. Sometimes it is only necessary to reduce the skin, sometimes the skin and the fat and sometimes just the fat. If only the fat is being removed from the lower eyelids, then this can be removed from the inside of the lower eyelid avoiding an external excision (transconjunctival blepharoplasty)

What are the consequences?

People who have the familial problem of bags beneath the eyes may well undergo surgery in their 20s. Ageing effects of the skin are apparent earlier in the eyelids than elsewhere. A reduction of the skin can be carried out from the age of 35. Patients with thyroid disease often develop eye signs which can be helped by surgery. Where there is reduced secretion of thyroxin (hypothyroidism) there is an increase in fat and where there is an increase in thyroxine (hyperthyroidism) there is often so much increase in fat that the eyes protrude. An extended eyelid reduction (Olivari’s procedure) can treat this satisfactorily.

What are the limitations?

It is important for you to understand that only the wrinkles which are in the skin which is cut away will be removed. We are only treating the eyelids within the bony margin of the orbit (eye sockets). Folds of skin extending on to the cheek (festoons) will not normally be improved. Wrinkles in the area of the crow’s feet will remain and although the skin is much tighter it is still necessary to be able to open and close the eyes freely. The skin has less elasticity with age and for proper closure of the eye the upper eyelid will need to have surplus skin when it is open. Descent of the eyebrow can be helped by endoscopic brow lift and an extension of this, the deep facelift, can be used to not only lift the eyebrow and the upper eyelid, but also lift and open the outer angle of the eye.

Sometimes residual or recurrent wrinkles are suitable for treatment by chemical peeling or laser resurfacing. The operation has no effect at all on the dark colour of the lower eyelid.

The operation

Both upper and lower eyelid surgery can be carried out under local anaesthesia or under general anaesthesia in a hospital.

In a typical procedure the surgeon makes incisions following the natural lines of your eyelids; in the creases of upper lids and just below the lashes in the lower lids (see illustration). These incisions are extended a little way into the crow’s feet or laughter lines at the corner of the eyes. Through this incision surplus fat is removed and excess skin and sagging muscle removed.

If you have a pocket of fat beneath your lower eyelids without surplus skin then the fat may be removed through the inside of the lower eyelid.

The resurfacing laser can be used at the same time as a transconjunctival blepharoplasty to tighten the external skin and reduce wrinkles, although there is no external scar there is residual redness in the skin which will last a few months.

Following surgery it would be best to keep your head elevated for a few days to reduce swelling. Cold compresses can also help. The surgeon will normally apply some suture strips or Steri-Strips® as support to the eyelids after surgery and if these become crusted they can be replaced. Cleaning the eyes with water is useful and the surgeon may advise the use of eye drops or ointment.

The sutures are usually removed after 3 to 5 days and soon after you will be able to use make-up. Sometimes you will be advised to use the suture strips or Steri-Strips® as support to the lower eyelids for a week or so.

The closure of the eyes appears tight after surgery because of the swelling and because skin has been removed. If closure is not complete at night the patient should apply some eye ointment before going to sleep. This sensation will settle as the swelling goes down.

The eyes appear watery after surgery, partly because of swelling under the conjunctiva (chemosis) and partly because the tear ducts are swollen and do not drain as readily. This will last a few weeks. Although there is bruising it can quite readily be disguised with make-up and dark glasses. The scars will be pink for a few months, but eventually they become almost invisible.

Dacryocystitis

Dacryocystitis is an inflammation of the lacrimal sac, often as a result of infection. It may be acute or chronic. For anatomical reasons, it occurs more frequently on the left side. An ocular origin for inflammation of the lacrimal system is less common than a nasal origin.

Rarely, congenital dacryocystitis can occur. One study reported a birth prevalence of 1 in 3,884.This is a serious condition because the orbital septum is poorly formed in infants and there is a significant risk of spread (orbital cellulitis and its complications).

Epidemiology

It is more common in females. It tends to occur either in infants (uncommon) or in adults (much more common) over the age of 40 years, peak age 60-70 years.

Presentation

Acute dacryocystitis

  • Symptoms and signs are over the region of the lacrimal sac (but may spread to the nose and face with teeth pain being experienced by some). Therefore, look just lateral and below the bridge of the nose for:
    • Excess tears (epiphora) – almost invariably.
    • Pain
    • Redness
    • Swelling

The patient may complain of decreased visual acuity owing to the excess tears and an abnormal tear composition.

Examination will reveal a tender, tense, red swelling (± preseptal cellulitis in severe cases). Mucopurulent discharge can be expressed from the punctum. There may be a fever and an elevated leukocyte count too.

Chronic dacryocystitis
This may present with a history of chronic or recurring epiphora and may have persistent redness of the medial canthus. There may be a painless or recurring swelling over the lacrimal sac, and pressure over this will result in reflux of mucopurulent material through the lower punctum.

Differential diagnosis

  • Orbital or facial cellulitis(discharge cannot be expressed from the punctum).
  • Acute ethmoid or frontal sinusitis.
  • Dacryocystocele (mild enlargement of a non-inflamed lacrimal sac in an infant).

Investigations

  • In severe or atypical cases (eg, non-responsive to antibiotics), culture the expressed contents of the sac.
  • CT scan of the orbit and the paranasal sinuses can be useful.
  • A dacryocystography (DCG) may be performed where structural abnormalities are suspected.

Associated diseases

This is most commonly associated with nasolacrimal duct obstruction which results in stasis of the lacrimal sac contents. Less commonly, it is associated with anatomical abnormalities of the lacrimal sac or with nasal or sinus surgery. Nasal disease may be found in a number of these patients – eg, various forms of rhinitis, trauma or the presence of a foreign body. Rarely, there may be a lacrimal sac tumour.

DCR
This is a procedure that creates a drainage passage between the lacrimal sac and the nasal mucosa of the middle meatus so preventing accumulation of material in the lacrimal sac. It is indicated in adult patients who have a nasolacrimal duct obstruction that either causes symptoms or that results in infection of the lacrimal sac. It is carried out under general anaesthetic. It may be done externally by the ophthalmologists or – increasingly – endoscopically by an ophthalmology/ear, nose and throat team.

Prognosis

This is good if managed promptly and surgery is not delayed once the acute phase has resolved. However, congenital dacryocystitis can be very serious and is associated with significant morbidity and mortality if not treated promptly and aggressively.

Chronic canaliculitis

This is an uncommon condition where the canaliculi become chronically infected. Common pathogens reported are Staphylococcus spp., Streptococcus spp., Actinomycesspp. and Propionibacterium spp.

Presentation

Symptoms

  • Unilateral epiphora.
  • Chronic mucopurulent conjunctivitis (refractory to usual treatment).

Signs

  • Oedema of the canaliculus: look for a swelling at the medial end of the upper or the lower lid.
  • ‘Pouting’ punctum: this is turned out and is prominent.
  • Gentle compression of the canaliculi results in expression of concretions: solid, pale-yellow fatty material.

Investigation

High-resolution ultrasound biomicroscopy may be helpful.

Differential diagnosis

Canalicular obstruction

Obstruction of the lacrimal canaliculi may be congenital (see separate Congenital Nasolacrimal Duct Obstruction article) or acquired. Acquired causes include trauma, scarring, inflammatory conditions, local tumours, Bell’s palsy, radiotherapy and certain drugs – eg, docetaxel.

Presenting features are excess tearing ± sticky discharge and irritation.

Investigations

  • Syringing and probing to identify the site of obstruction.
  • The Jones’ fluorescein dye test.
  • may be well tolerated and a good alternative to CDCR.[22]

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