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Aesthetic Fillers and Botulinum Toxin for Wrinkle Reduction

Definition The use of neuromodulators to adjust the power of muscles of facial expression has become the most popular aesthetic treatment worldwide. Changing the contours of the aging face with the use of three-dimensional fillers is a powerful adjunctive treatment. Key Features The functional and aesthetic importance of the periorbital region. Mechanisms of action of neuromodulators. Soft tissue augmentation mechanisms. As in surgery, knowledge of anatomy…

Cosmetic Blepharoplasty and Browplasty

Definition Surgeries to correct changes in the eyelids and forehead area that are secondary to aging and manifest by redundancy and displacement of tissues. The most important procedures include upper and lower eyelid blepharoplasty and brow elevation. Key Features Facial aging results in bone remodeling with changes in soft tissue draping and midface fat atrophy. Any aesthetic eyelid or brow surgery must evaluate the patient’s complaints…

Orbital Infection and Inflammation

Definition: Inflammation or infection of the orbital contents. Key Features Signs of inflammation include redness (eyelids and/or conjunctiva), swelling (proptosis, eyelid swelling, and conjunctival chemosis), pain (not always), and loss of function (reduced ocular motility, loss of vision). Differentiating infection from noninfective inflammation and establishing the nature of any noninfectious inflammation are important. Introduction Orbital infections and inflammations are relatively common. The commonest, Graves’ orbitopathy, is…

Thyroid Eye Disease

Definition: Thyroid eye disease (TED) is an orbital autoimmune process associated with autoimmune thyroid disorders that causes inflammation and expansion and fibrosis of orbital fat and striated muscle, resulting in cosmetic and functional morbidity. Key Features Approximately 50% of patients with Graves’ disease may develop orbitopathy. The orbital target of the immune response is the pluripotential orbital fibrocyte. Common clinical features of the orbitopathy are eyelid…

The Lacrimal Drainage System

Definition The tear drainage system of the eye consists of the lacrimal puncta, canaliculi, lacrimal sac, and nasolacrimal duct. It serves to transport tears from the eye and conjunctival sac to the nose. The eyelids also form an important component of this system by serving as a physiological pump, propelling tears to the medial canthus. Key Features The orbicularis muscle and eyelids act as a lacrimal…

Enucleation, Evisceration, and Exenteration

Definitions: Enucleation: surgical removal of the entire globe. Evisceration: surgical removal of the entire contents of the globe, leaving a scleral shell. Exenteration: removal of the entire orbit, including the globe, eyelid, and orbital contents—usually performed for malignant tumors. Key Features Indications for enucleation, evisceration, or exenteration surgery. Careful preoperative patient evaluation and counseling. Detailed presentation of specific surgical techniques for enucleation, evisceration, and exenteration. Postoperative…

Orbital Diseases

Definition The orbit is the bony cavity that contains the eye, eye muscles, lacrimal gland, and other structures that serve eye functions. Numerous diseases affect the orbit and can involve any of these tissues, including neural, muscular, vascular, lymphatic, and connective tissues. The pathology can sometimes be determined by a combination of clinical and imaging characteristics, but in many cases will require a biopsy for histopathological…

Evaluation and Management of Periorbital Soft Tissue Trauma

Definition Injuries varying from simple skin abrasions to more complex cases with extensive tissue loss and underlying fractures of the facial skeleton caused by blunt or penetrating facial trauma. Key Features Partial-thickness eyelid injury. Eyelid margin lacerations. Eyelid injuries with tissue loss. Full-thickness eyelid injury. Introduction Periorbital soft tissue injuries, including blunt and penetrating trauma to the eyelids and lacrimal apparatus, are common presentations to emergency…

Eyelid Malignancies

Definition: Cutaneous cancers that arise from the epidermis, dermis, or adnexal structures of the eyelid. Rarely, they may be metastatic from distant sites. They include a number of histologically distinct tumors from diverse skin cell types. Key Features Flat, eroded, or elevated lesion on the eyelid margin, eyelid skin, or brow. Nodular and well circumscribed or irregular with indistinct borders. Ulcerated with a central crater or…

Benign Eyelid Lesions

Definition: Benign eyelid lesions can arise from epithelial or dermal adnexal elements. These include epithelium, hair follicles, apocrine and eccrine glands, blood vessels, and nerves. Some may appear aggressive and must be differentiated from malignancies. Key Features Three to six times more common than malignant neoplasms. Can occur on any skin surface; some occur most often or exclusively on the eyelids. May reflect local pathology or…

Ectropion

Definition Ectropion is an outward rotation of the eyelid margin from the eye. Key Features Ectropion may result from progressive age-related eyelid laxity, vertical skin shortening, orbicularis muscle weakness from facial nerve palsy, or mechanical force on the eyelid from a scar or tumor. Lower-eyelid ectropion results in epiphora, palpebral and conjunctival surface irritation and keratinization, and corneal exposure with potential corneal ulceration and scarring. Surgical…

Entropion

Definition Entropion: a commonly encountered inward rotation of the tarsus and eyelid margin ( Fig. 12.5.1 ). Key Features Symptoms and signs include ocular foreign body sensation, secondary blepharospasm, ocular discharge, tearing, superficial keratopathy, and corneal scarring. The natural course often is progressive; early signs and symptoms may be intermittent. Numerous corrective techniques for this eyelid malposition are reported; early publications reflected the failure to appreciate…

Blepharoptosis

Definition Ptosis is defined as the upper eyelid resting in a droopy, abnormally low position while the eye is in primary gaze. Key Features Blepharoptosis (ptosis) is caused by a weakness in one or both of the eyelid retractors, the levator muscle, and Müller’s muscle, which position the upper eyelid. Ptosis can be broadly categorized into common and unusual types. Common types are acquired involutional ptosis…

Orbital Imaging

Definitions Computed tomography: An imaging technique where contrast differences are based on tissue density based on the passage of X-rays through tissues. Magnetic resonance imaging: An imaging technique where density differences are based on tissue proton density and their resonance characteristics determined by their biochemical relationships within the atomic lattice. Orbital pathological processes often have characteristic features that can help narrow the diagnostic possibilities when considered…

Clinical Anatomy of the Orbit

Definition The orbit is the anatomical space bounded by seven orbital bones and enclosed within the multilamellar periorbita. It is separated above from the intracranial compartment and medially and inferiorly from the paranasal sinuses. The orbit contains the eye and numerous anatomical tissue systems that subserve visual function. Key Features Anteriorly, the orbit is limited by the orbital septum, which represents the anteriormost layer of the…

Clinical Anatomy of the Eyelids

Definition The eyelids are mobile, flexible, multilamellar structures that cover the globe anteriorly. They protect the ocular surface, spread the precorneal tear film, and help propel tears into the lacrimal drainage system. Anatomically, the eyelids are composed of an anterior lamella of skin and orbicularis muscle and a posterior lamella of tarsus and conjunctiva. Between the two are the eyelid retractors that elevate the upper eyelid.…

Techniques of Strabismus Surgery

Definition Strabismus surgery is physical manipulation of the extraocular muscles with the goal of therapeutic benefit. Key Feature The ideal strabismus surgery needs to merge fusional potential garnered through preoperative testing with education about realistic patient expectations and excellent surgical technique. Introduction Strabismus can lead to frank diplopia, visual shadowing, visual confusion, asthenopia, headaches, dizziness, anomalous head position, decreased visual field, impaired stereopsis, and a large…