Eyelid Malposition: Ptosis, Entropion, and Ectropion

There are several common types of eyelid malpositions. This is a general medical term for eyelids that don’t sit and do what they are supposed to do. Normally the eyelids are firmly held against the eye. Tears lubricate the eyelid movements and the eyelids themselves function like the windshield wipers of the eyes. This is the result of a delicate balancing act between the eyelid position and tension of the eyelid ligaments. In the lower eyelid the muscle that helps close the eyelids functions like a muscular hammock to hold the lower eyelid against the globe.

In the upper eyelid the levator palpebra superioris muscle is responsible for opening the eyes by elevating the upper eyelids. The action of this muscle is transmitted to the upper eyelid by a broad fan like tissue called the levator aponeurosis. Individuals may be born with a droopy eyelid and the levator muscle may not work as effectively as a normal muscle. Under the microscope, the muscle may look incompletely developed with fat and connective tissue replacing the muscle that should be present. Crowell Beard, M.D, has referred to this as “developmental dystrophy”. As the levator muscle does not effectively lift the lid, there may also be insufficient traction on the skin by the same muscle to generate a crease in the affected upper eyelid. It is not uncommon to see a heavy eyelid and an absent eyelid crease. Occasionally the heavy eyelid is associated with other eyelid abnormalities such as the blepharophimosis syndrome. This syndrome has a heredity basis and can run in families. A less common form of congenital ptosis called Marcus-Gunn jaw-winking ptosis: movement of the jaw causes a fall in the position of one of the eyelids. Treatment of these conditions is based on the degree the levator muscle is able to lift the eyelid. This measure is called the levator function.

In adults, congenital ptosis is seen but the most common cause of upper eyelid ptosis in the adult is acquired ptosis. There are several causes of acquired ptosis. The most common cause appears to be attenuation of the levator aponeurosis, which becomes stretched out over time. This is also referred to as levator dehiscence ptosis but it is controversial if the levator actually “dehisces,” a medical term for separates, or if the attenuated tendon gets cut in the process of performing the surgical repair. Other causes of acquired ptosis include four broad categories: neurogenic, myogenic, traumatic, and mechanical. It is helpful to classify and properly diagnosis the basis of the droopy eyelid because this has a bearing on the choice for repairing the upper eyelid ptosis.

There are two principle approaches to repairing acquired upper eyelid ptosis. For small amounts of ptosis (1-2 mm) a simple test is performed during the preoperative assessment. An eye drop is instilled into the eyes and the response to the drops is measured. If the drop raises the eyelids to the desired height, the lid position is very likely to respond to a surgery referred to as a Conjunctival Muellerectomy. This surgery is performed from behind the upper eyelid using a special clamp called a Putterman ptosis clamp. If the eyelid does not respond to the eye drops or if the degree of ptosis is too large a second type of ptosis surgery is indicated. This type of surgery is called an anterior levator resection ptosis surgery. This surgery is performed through an incision at the eyelid crease on the outside of the eyelid. The levator aponeurosis is dissected and sutures are tied to effectively shorten the aponeurosis. Surgery is performed under local anesthesia. This facilitates repositioning of the eyelid. The patient is asked to open and close the eye. The sutures can be repositioned to adjust the eyelid position. Once this is satisfactory, the sutures are permanently tied and the eyelid is closed. Skin sutures are removed within a week. Swelling and bruising usually resolves in 10-14 days. A personal consultation with Dr. Steinsapir will determine if you are a candidate for upper eyelid ptosis surgery.

Laxity of the lower eyelid can present as either a turning in or turning out of the lower eyelid. These malpositions usually occur in older individuals. The type of lower eyelid malposition is determined by the nature of which structure have become weak in the eyelid. When the lower eyelid retractors become attenuated, the forces on the eyelid tend to favor an inward rotation of the lower eyelid. This is called entropion. This causes the eyelashes to rub against the eye and cause severe irritation. There are various approaches to address these issues. Typically the lower eyelid retractors are reattached and the lower eyelid is shortened. When the lower eyelid is lax and there is contraction of the lower eyelid skin or weakening of the orbicularis oculi muscle as occurs with Bell’s palsy, the lower eyelid rotates away from the eye. This is called ectropion. In this situation, the lower eyelid does not rub against the eye. However, the lid does not protect the eye and this can also cause irritation. Surgery is directed at lengthening the lower eyelid and resuspending the lid back against the globe. In both cases, an assessment of the midface support is essential. With entropion and ectropion, failure to address midface ptosis can lead to an unsatisfactory result. Swelling and bruising usually resolves in 10-14 days. A personal consultation with Dr. Steinsapir will determine if you are a candidate for repair of entropion or ectropion.

Lacrimal Surgery

Abnormal tearing is a common problem. This is seen in newborns who have incomplete opening of the tear duct system and in older adults. However individuals of all ages can present with this problem. In adults, tears well up in the eye on an all too regular basis. This necessitates constant wiping of the eye with tissue. The tears can blur vision and the perpetual tears running down the cheek is a source of embarrassment. Even loved ones have difficulty grasping the debilitating nature of this problem.

In the inner corner of the eyelid are small openings called puncta that are the openings to the tear drainage system. Below the skin the puncta continue as the canalicui, small lined tubes that are stiffened with elastin and drain the tears into a sac that lies deep in the bone on the side of the nose. This sac drains into the nose. At birth, some of the valves that help direct the tears to drain to the nose may not be open and functional. Many babies rapidly out grow this problem. When the problem does not resolve Dr. Steinsapir will recommend massage of the tear system. If this fails to improve the situation, a probing of the tear ducts by 12 months of age is generally recommended. Some pediatric ophthalmologists will perform this procedure without anesthesia in the office. Dr. Steinsapir feels that this is traumatic and recommends a brief general anesthesia to permit a more optimal probing of the tear ducts with a higher likelihood of success. For some infants, the tearing will persist and placement of tubes and additional procedures may be needed.

In adults, probing of a blocked tear duct is unlikely to improve the tearing. A different approach is needed. A diagnostic irrigation of the tear duct system leads to a working diagnosis of the anatomic blockage and a recommendation for the appropriate surgery. For many adults with tearing the surgery recommended is called a dacryocystorhinostomy. This surgery involves bypassing the blockage in the lacrimal sac. Bone between the lacrimal canal that contains the lacrimal sac and the nose is removed. The lacrimal sac above the blockage is opened, as is the corresponding nasal mucosa, which lines the other side where the bone was removed. These edges are sewn together creating a new passageway for tears to drain from the eye to the nose. The surgery can be performed on an outpatient basis under sedation. Recovery takes about 7-10 days. Typically when tubes are placed, these are removed 6 months after surgery. A personal consultation with Dr. Steinsapir will determine if a dacryocystorhinostomy is right for your tear problem.

Orbital Surgery

Dr. Steinsapir is highly trained in orbital skull based surgery. Care of the eye changes associated with thyroid eye disease benefit from this range of skills. The management of this condition is discussed in the section on thyroid eye disease. Other orbital conditions include orbital tumors such as cavernous hemangiomas, mucoceles, lacrimal gland tumors, and the repair of orbital fractures. These conditions require careful assessment and detailed imaging to determine the optimal treatment plan. Many of the incisions used to address these conditions are inconspicuous and hide in the eyelid crease, or are approached from behind the eyelids. Orbital fractures can occur from mild or severe facial trauma. Orbital fractures should be repaired promptly to prevent the eye from healing with compromised function or appearance. A personal consultation with Dr. Steinsapir is necessary to determine the best approach to address the orbital changes you are experiencing. You are encouraged to bring copies of any imaging studies that have been performed to your initial consultation.

Anophthalmic Socket

Trauma and disease can necessitate the removal of an eye. Often this is recommended when the eye has lost all useful vision and has become a blind, painful eye. This may follow soon after a sudden trauma, the discovery of an intraocular tumor, or after a long fight to preserve a diseased eye. The removal of an eye is the option of last resort. A second opinion is advisable if there are any questions about the best course of action. Generally, it is not recommended to remove a blind eye that is otherwise comfortable. In this circumstance, if there are cosmetic issues, a custom contact lens or scleral shell can be fabricated by an ocularist with good cosmetic results. When a blind eye becomes painful, removal by enucleation or evisceration is generally recommended. Enucleation means the removal of the entire eye. The extraocular muscles may be reattached to the intraconal implant that is placed in the orbit to make up the volume lost when the damaged eye is removed. Once the socket has healed, an ocularist then fabricates an acrylic prosthetic piece to fit behind the eyelids, referred to as a “glass eye.” An evisceration involves the removal of the cornea and the contents of the eye, but leaves most of the eye wall or sclera intact. The advantage of this procedure is that it is less disruptive to the orbital tissues and leads to more natural movement of the acrylic prosthetic. Generally, an evisceration is preferred if there are no reasons that might favor an enucleation in a particular circumstance. There has been a push toward integrated intraconal implants made of hydroxyapatite. Unfortunately, these implants are often not well tolerated resulting in exposure of the implant and the need for revisional surgery. The anophthalmic socket (socket without an eye) often requires revisional surgery due to a number of factors. One of the common issues is related to inadequate replacement of orbital volume because too small of an implant was chosen at the time the eye was removed. The ocularist attempts to compensate for this by making a larger prosthesis. However, over many years, the weight of the oversized prosthesis can stretch the eyelids leading to secondary issues, including chronic discharge and difficulty retaining the prosthesis. A consultation with Dr. Steinsapir is needed to determine the best options for rehabilitation of the anophthalmic socket.

Cancer Reconstruction

Skin cancer can affect the eyelids. Basal cell carcinoma is the most common of the skin cancers that affect the eyelids. Others include squamous cell carcinoma, sebaceous cell carcinoma, and melanoma. All skin cancers have the potential to damage eyelid structures. The lower eyelids are more commonly involved but all portions of the eyelids can be affected. Lesions typically present as a slowly growing mass. Other signs include break down of the skin with raw and crusting areas, and bleeding. Basal cell carcinoma tends to have a heaped and pearly edge with central ulceration. Squamous cell carcinomas can present as a rough red patch of skin that slowly expands. Sebaceous cell carcinoma can grow insidiously along the eyelid and even experienced doctors sometimes confuse this with chronic inflammation of the eyelid margin. Melanomas are often pigmented, grow irregularly and may demonstrate a range of color or even be without pigment. In addition to local behavior, several of these skin cancers have the potential to spread to other parts of the body and can be life threatening. This includes squamous cell carcinoma, melanoma, and sebaceous cell carcinoma. Basal cell carcinoma is unlikely to spread to other parts of the body but it causes local destruction if not surgically excised.

Treatment of these eyelid skin cancers starts with a formal diagnosis established by sampling the lesion. This is done as a biopsy performed by your dermatologist, general ophthalmologist, or by Dr. Steinsapir. This is comfortably done with a little local anesthesia and the removal of a small punch of tissue. Generally the biopsy site, which is quite small, is left to heal on its own. If the biopsy does prove that the lesion is a skin cancer, the next steps for managing the lesion very much depend on the type of skin cancer. In virtually all cases, surgical excision is indicated to cure the cancer or maintain local control if there is evidence that the lesion has spread. Early diagnosis and treatment greatly increases the likelihood of a cure.

The key with managing eyelid cancers is their complete surgical excision. Their removal must be the primary concern over the aesthetic and functional consequences of removing the skin cancer. However, how the excision is performed can make a big difference both for the ultimate success of treating the skin cancer and preserving eyelid aesthetics and function. Traditionally, eyelid skin cancers were removed by the reconstructing eye plastic surgeon. A pathologist then examines the edges of the tissue removed using frozen sections. This method is still used today and has a relatively high rate of success. However, there is a more optimal method of excising eyelid skin cancers. This involves a team approach where a dermatologist surgeon trained in Mohs’ cancer surgery excises the tumor and the eyelids are reconstructed by Dr. Steinsapir. There are numerous advantages to this approach. First, the rate of success in excising the cancer is much higher than frozen section control. In some published series success approaches a 99% cure rate. This is because the method lets the Mohs’ surgeon map and sample 100% of the surgical margin. Secondly, the method is very economical in preserving normal surrounding tissue. Since the eyelids and tear duct system represent very precious real estate, preserving this tissue means a better aesthetic and functional result without compromising the goal of removing the skin cancer. Recovery is also faster. Once the Mohs’ surgeon has completed removal of the lesions, a dressing is placed over the area and Dr. Steinsapir then examines the area. The closure may be performed in the office if the defect is small or on an outpatient basis at UCLA that day or the next day based on the circumstances. A personal consultation with Dr. Steinsapir will determine which approach is right for you.

Post-Cancer Surgery Reconstruction

It is the goal of the primary surgeon to make the best closure of the area after the removal of the skin cancer. However, for a number of reasons, the initial closure often represents the best compromise at the time. It is quite common that more than one stage of reconstruction will be necessary to obtain the best aesthetic and functional results. Dr. Steinsapir has found that for a variety of reasons, people do not always get the best advice regarding the value or need of having further reconstruction. The message can sometimes be that the patient is being vain, or ungrateful in asking for a better reconstructive result. In some cases, the reconstructive surgeon has made their best effort and really doesn’t have any idea how to make the compromised area functionally or aesthetically better. Dr. Steinsapir prides himself on providing innovative approaches to improve eyelids compromised by prior reconstruction. A personal consultation with Dr. Steinsapir will determine what options are available to improve your appearance and the function of your eyelids.

Bells Palsy and Facial Nerve Injury

Bell’s palsy causes facial weakness or frank paralysis. Typically people awake to find that they have a weakness on one side of the face. Symptoms may progress over several days. Facial weakness may be the only sign. A viral infection in the canal that transmits the facial nerve is thought to be the cause. Studies suggest that the most common virus that produces this syndrome is the Herpes Simplex Type 1 virus, which is also responsible for cold sores. Recovery of the facial nerve occurs partially or completely in over 80% of cases. Unfortunately, this means the eyelid function can be significantly impaired resulting in severe corneal exposure and drying. For a given individual it is impossible to know at the time that the weakness develops whether the symptoms will persist for a few months or a lifetime. Treatment is initially directed at supportive measures including frequent artificial tears and bland ophthalmic ointment. If needed temporary partial closure of the eyelid may be necessary. This procedure is called a tarsorraphy. Long-term solutions may also include the placement of a gold weight in the upper eyelid to facilitate eyelid closure, midface lift with placement of a hard palate graft, and permanent lateral tarsorraphy. Some advocate the placement of a spring closure of the upper eyelid. Unfortunately, these appliances are not stable in the eyelid, are prone to infection, and often require a commitment to multiple surgeries to maintain function. Surgery to address acoustic neuroma, a benign brain stem tumor, is another cause for facial nerve injury. Frequently the tumor is intimately involved with the facial nerve, which is injured in the process of removing the tumor. Weakness of eyelid closure is managed in a fashion similar to Bell’s palsy because in many cases function will recover in time. When recovery does not occur, definitive steps are needed to protect the cornea. A personal consultation with Dr. Steinsapir will determine the best options for your situation.

Reconstructive Midface Surgery

Many lower eyelid problems benefit from midface surgery. The lower eyelid is intimately related to the cheek mass that tends to fall over time. When lower eyelid abnormalities are the result of midface ptosis, failure to surgically address the midface ptosis will result in a compromised surgical outcome. Dr. Steinsapir is frequently called upon to correct these types of problems. How do you know if you need this type of help? Virtually any lower eyelid situation that has not responded to more traditional techniques needs to be carefully assessed to determine if midface ptosis or maxillary hypoplasia are contributing to the anatomic challenges. If you have had more than one revisional surgery on the lower eyelid without obtaining the surgical result you and your surgeon had hoped for, you will benefit from a consultation with Dr. Steinsapir. Contact the office to schedule you personal consultation.

Scar Revision

The initial repair of a facial laceration is often performed under less than ideal conditions. Tissue swelling can compromise the alignment of the tissues even when the repair was performed by a plastic surgeon, facial plastic surgeon or eye plastic surgeon. It is often possible to achieve a much more acceptable result after the initial repair. In many cases, the body can heal remarkably. For this reason, Dr. Steinsapir advises waiting 6 to 12 months before considering having an unacceptable scar revised. An exception to this rule is sometimes made if it is clear that for whatever reasons the reapproximation of the wound edges is clearly inaccurate. Scar revision involves excising the old scar tissue using a W-plasty tissue rearrangement. The fresh wound edges are carefully reapproximated using magnification. These procedures are generally performed under local anesthesia in the office procedure suite. The revised scar is always more visible while it is healing. The sutures are all removed within one week after the procedure. As the wound heals, the redness quiets and over the course of several months the wound matures. The technique is very effective for highly visible scars. A personal consultation with Dr. Steinsapir will determine if the scar you are concerned with will benefit from scar revision.

Will Dr. Steinsapir accept my insurance?

Dr. Steinsapir does not accept insurance including, but not limited, to Medicare, Medi-Cal, and Medicaide. You are directly responsible for Dr. Steinsapir’s surgeon’s fee. Depending on the details of your coverage, you insurance may cover a portion of the fees charged by the hospital for surgery.

I don’t find Dr. Steinsapir listed as a provider for my health plan. Can I still use my health insurance for reconstructive surgery?

Dr. Steinsapir does not participate as a network provider for any health plan. You health insurance may cover some of the cost for surgery at UCLA for the hospital, anesthesia, and pathology fees. The office is happy to answer specific questions regarding insurance coverage.

I am a school teacher and I am thinking of having reconstructive surgery with Dr. Steinsapir during my winter break. How much notice do I need to give the office?

Generally, the office is scheduling non-emergency surgeries 6-9 months ahead. Occasionally, cancellations occur making it sometimes possible to have surgery on shorter notice. However, we encourage you to plan ahead, especially for busy times of the year like the winter break when it seems that everyone wants elective surgery.

I had a cancer removed from one of my eyelids and a reconstruction at the same time. I am very discouraged by my appearance but my current doctor does not seem to take my concerns seriously. I am grateful that the cancer was successfully removed but I am wondering if anything can be done for my appearance?

This is a common situation. Your doctor may simply feel that your reconstruction was the best that could be done under the circumstances. We find that a fresh set of eyes is sometimes very helpful. A personal consultation with Dr. Steinsapir will reaffirm your current doctors management or provide you with a new direction to improve your appearance following cancer reconstruction. Most patients find this a very helpful and informative visit.