Oculoplastic Consultants of Arizona, P.C.

RECONSTRUCTIVE SURGERY Many general health conditions also can affect the health of your eyes, and should be evaluated by a specialist. While we see many patients with these problems, not all of them require surgery. Also, the treatment of these medical problems may be covered by your insurance.

PTOSIS 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 weakening of the attachment of a muscle in the upper eyelid, called the levator. In advanced cases, this can actually 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 of excess skin or fatty tissue at the same time of surgery. ECTROPION 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 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.

EYELID TUMORS 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.

DRY EYES 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 Syndrome. TEARING PROBLEMS 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 10 years of experience in performing endoscopic DCR.

ORBITAL FRACTURES 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. ORBITAL DISEASES 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 removal. ENUCLEATION (PROSTHETIC EYES) 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. 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, Grave's ophthalmopathy or Thyroid related orbitopathy (TRO). Although TRO is seen in all types of thyroid disorders, it is most common in patients that are or were hyperthyroid. TRO 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. TRO is currently believed to be due to a similar autoimmune reaction. However, in the case of TRO, 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 TRO 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. 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 TRO as long as 30 years after being stabilized medically. Even though good medical treatment may not prevent or cure TRO, it is extremely important to treat the thyroid disease and maintain normal thyroid function levels. SMOKING AND THYROID DISEASE At the present it is not believed that smoking will lead to the development of TRO. However smokers are at increased risk for developing more severe forms of the condition. They are also at increased risk for vision loss from TRO. Surgery to restore vision loss is more successful if the patient stops smoking. THE ROLE OF THE EYE SPECIALIST An Ophthalmologist specializing in TRO 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 TRO. 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.