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Evaluation and Management of Age-Related Eyelid Problems Craig Lewis, MD

Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

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Page 1: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Evaluation and Management of Age-Related Eyelid Problems

Craig Lewis, MD

Page 2: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Disclosure Statement• Speaker, Craig Lewis, M.D. has a financial

interest/agreement or affiliation with Lansing Ophthalmology where he is a shareholder and employed as an oculoplastic specialist.

• I have no financial interest in any of the products discussed.

• Off-label use: I will discuss off-label use of botulinum toxin products.

Page 3: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Oculoplastic Specialist

• What is oculoplastics?– Specialized field of

ophthalmology:•Eyelids•Tear drain•Orbit

– Medical problems– Cosmetic concerns

ASOPRS

Page 4: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Age-Related Eyelid Problems

Page 5: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Age-Related Eyelid Problems• Droopy upper eyelids

• Extra eyelid skin • Ptotic upper eyelid• Droopy eyebrow

• Droopy (loose) lower eyelids• Inward turning (entropion)• Outward turning (ectropion)• Floppy eyelid syndrome

• Eyelid surgery basics• Q & A

Page 6: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Upper Eyelid Changes

Page 7: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

• Extra upper eyelid skin: Dermatochalasis– Blocks vision– Heavy, tired sensation

Extra skin

Eyelid height normal

Droopy upper eyelids

Page 8: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Droopy upper eyelids• Extra upper eyelid skin: Dermatochalasis

– Problem: Extra skin hangs over eyelid– Cause: Time + gravity + movement of eyelids– Treatment: Blepharoplasty surgery

Page 9: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Droopy upper eyelids• Blepharoplasty surgery

– Treats extra skin hanging over eyelid

– Removes redundant skin and extra fatty tissues

Page 10: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

• Steps:– Mark skin– Remove flap of skin and orbicularis muscle– Open orbital septum to remove fat if needed– Close skin

Blepharoplasty

Page 11: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Blepharoplasty

Page 12: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Blepharoplasty

Page 13: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Potential Benefits of Surgery• Side vision improved• Reading vision better (more light)• Less strain by not lifting brow• Rested appearance

Page 14: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

• Hemorrhage• Lagophthalmos• Retraction• Under-correction• Over-correction• Ptosis• Web• Crease

Possible Complications

Page 15: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Before After

Blepharoplasty

Page 16: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

After

Before

Blepharoplasty

Page 17: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Upper Eyelid PtosisDrooping of eyelid due to weakness of the lifting muscle.

Excess skin Weak lifting muscle

Page 18: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Upper Eyelid Ptosis

• Ptotic upper eyelids– Blocks vision– Tired sensation, often worse in evening– Brow aches

Eyelid not open

enough

Page 19: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Upper Eyelid Ptosis• Droopy upper eyelids

– Problem: Eyelid does not open far enough to see well

– Cause:• Most common: gradual

stretch or dehiscence of levator palpebrae superioris or Muller’s muscle

• Other causes, some serious

Page 20: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Levator palpebrae superioris

Muller’s muscle

Page 21: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Upper Eyelid Ptosis• Potential serious causes:

– Muscle disorders• Myasthenia Gravis, Lambert-Eaton Syndrome

– Nerve disorders• Multiple sclerosis, compression from mass (lung cancer)

– Blood vessels problems• Aneurysm (CNIII palsy), Diabetes

– Orbital disease• Orbital mass, Graves Eye Disease

Page 22: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

• Potential serious causes:– Warning signs:

• Droopy lid + double vision• Droopy lid + pain/headache• Suddenly droopy lid

Upper Eyelid Ptosis

Page 23: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Upper Eyelid Ptosis• Ptotic upper eyelids

– Most common cause: stretching levator muscle

– Treatment: Eyelid ptosis repair surgery

• Eyelid ptosis repair surgery– May be done from under

the eyelid or through the skin

BEFORE

AFTER

Page 24: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Blepharoptosis surgery• Internal approach: CML

– Conjunctivo-mullerectomy-levator resection– All from inside, no skin incision– Advantages: natural contour, no skin scar, more

predictable• External approach: ELR

– External levator resection– From outside through bleph-type incision– More powerful for very droopy eyelids

Page 25: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Blepharoptosis surgery: CML

Page 26: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Blepharoptosis surgery: CML

Page 27: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Blepharoptosis surgery: CML

Page 28: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Blepharoptosis surgery: CML

Page 29: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Blepharoptosis surgery: CML

Page 30: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Blepharoptosis surgery: CML

Page 31: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Blepharoptosis surgery: CML

Page 32: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Blepharoptosis surgery: CML

Page 33: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Blepharoptosis surgery: CML

Page 34: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Blepharoptosis surgery: CML

Page 35: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

AfterBefore

Ptosis repair: ELR

Page 36: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

AfterBefore

Ptosis repair: CML

Page 37: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Ptosis repair: CML

Page 38: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

AfterBefore

Ptosis repair: CML

Page 39: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Ptosis surgery: Complications• Bleeding• Retrobulbar hemorrhage: rare after CML

– Orbital septum not violated• Lagophthalmos• Retraction• Under-correction: most common complication• Over-correction: rare

Page 40: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Congenital Ptosis• Causes:

– Poor development of levator muscle

– Horner’s syndrome– Many others

• Problems:– Amblyopia– Abnormal head

position

Photo from: http://www.aapos.org/terms/conditions/90

Page 41: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Congenital Ptosis• Challenges:

– Poor levator muscle function cannot be directly improved

– Lagophthalmos may worsen after ptosis repair

– Cosmetic concerns

Photo from: http://www.aapos.org/terms/conditions/90

Page 42: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Eyebrow Position• Determine normal for each individual• Maintain facial expression• Proportional to face

Page 43: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Eyebrow ptosis• Droopy eyebrow skin

– Blocks vision, especially to the side– Heavy sensation

Page 44: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Eyebrow ptosis• Droopy eyebrow skin

– Problem: Extra tissue from eyebrow hangs over eyelid

– Cause: Time + gravity – Treatment:

• Eyebrow ptosis repair surgery

• BOTOX® brow lift

Page 45: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

BOTOX®• BOTOX®

– Purified BOtulinum TOXin– Temporarily weakens muscles

• 3 month effect per treatment– Indicated for wrinkles between

brows (glabellar area)– Black-box warning 2009– Other similar drugs:

• Dysport®, Myobloc®, Xeomin®

Page 46: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Eyebrow Surgery• Above eyebrow • Above hairline• Hairline• Forehead Crease• Internal (through eyelid

surgery opening)

Page 47: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Before

After

Eyebrow Surgery

Page 48: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Before

After

Brow Surgery

After

Page 49: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Before

After

Eyebrow and Upper Lid Surgery

Page 50: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Eyebrow and Upper Lid Surgery

Before After

Page 51: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Before

After

Eyebrow and Upper Lid Surgery

Page 52: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Before After

Eyebrow and Upper Lid Surgery

Page 53: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Age-Related Eyelid Problems• Droopy upper eyelids

• Extra eyelid skin • Ptotic upper eyelid• Droopy eyebrow

• Droopy (loose) lower eyelids• Inward turning (entropion)• Outward turning (ectropion)• Floppy eyelid syndrome

• Eyelid surgery basics• Q & A

Page 54: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Droopy Lower Eyelids• Eyelid entropion

– Lower eyelid that rolls in– Problem: Irritation as

lashes rub against eye– Cause: Loose eyelid with

spasm of orbicularis oculi muscle

– Treatment: • Usually surgery• BOTOX® (FDA approved)

Page 55: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Eyelid Problems• Eyelid ectropion

– Lower eyelid that turns out– Problem: Irritation or tearing

as eyelid doesn’t protect eye– Causes:

• Usually loose eyelid (time and gravity)

• Mechanical (ex: tumor)• Cicatricial (ex: dermatitis,

post-surgical)

– Treatment: Drops or ointment, often surgery

Page 56: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Cicatricial Ectropion

Lower eyelid blepharoplasty complication

Page 57: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Cheeklift

Loose lower

eyelids

Page 58: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Cheeklift and Upper Eyelid Blepharoplasty

1 month afterBefore

Page 59: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

1 year afterBefore

Cheeklift and Upper Eyelid Blepharoplasty

Page 60: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Eyelid Problems• Floppy eyelid syndrome

– Chronic eye irritation due to extremely loose eyelids

– Often worse on ‘downhill’ side

• Eyelid turns over while sleeping– Strong association with

obstructive sleep apnea– Treatment: Shield eyes at

night, surgical eyelid tightening, identify and treat OSA

Page 61: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

FAQs and Eyelid Surgery Basics

Page 62: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

FAQs

•Will insurance cover surgery costs?•Where is surgery performed?•What type of sedation is used?•How long does surgery take?•How long is recovery?

Page 63: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

FAQs

• Does insurance cover eyelid surgery?– Lower eyelid malpositions: Yes– Upper eyelid/eyebrow surgery: Maybe...

• Must meet criteria• Varies by insurance carrier

Page 64: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

FAQs• Medically necessary upper eyelid

surgery criteria:1. Causes problem with comfort or vision

• Blocks vision, heavy, tired feeling• No good: Hard to put on make-up, looks bad

in mirror2. Blocks vision by visual field test3. Photos: Eyelid skin drapes over

eyelashes OR eyelid crosses near pupil

Page 65: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Eyelid Surgery Basics• Out-patient surgery

at surgical center or hospital

• Monitored anesthesia care most common

• ~1/2 hour per eyelid surgical time

Page 66: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Eyelid Surgery Basics• Comfort/recovery

– Most patients have some discomfort/pain for a few days after surgery

– Usually patients feel fine within 2-4 days after surgery

– Bruising/swelling universal

Page 67: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

• Scars– Any skin incision will leave a scar– Eyelid skin is thin & scars are usually minimal

• Follow-up– 1 week post-op

• Remove any stitches– 6-8 weeks follow-up visit

Eyelid Surgery Basics

Page 68: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Eyelid Surgery Basics• Down time

– Plan for two week recovery– Vision may be blurry for

several days– Swelling/bruising for 1-3

weeks– During recovery: read, watch

TV, listen to music, chat on phone all OK

Page 69: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

• Inactivity for 2 to 3 days• Ice packs for 2 days • Ointment to suture line • Can usually drive in 2-3 days• Avoid strenuous activity for 2 weeks

Eyelid & Eyebrow SurgeryEarly Recovery

Page 70: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

• “Tight” sensation in eyelid area• Incision line blends after 3-5 months• Some swelling in upper & lower lid area

Eyelid & Eyebrow SurgeryLate Recovery

Page 71: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Questions and Answers

Page 72: Evaluation and Management of Age-Related Eyelid Problems...Upper Eyelid Ptosis Drooping of eyelid due to weakness of the lifting muscle. Excess skin Weak lifting muscle Upper Eyelid

Thank you!