Oculoplastic 1

Oculoplastics assesses the structures around the eyes, the eyelids, the orbits (bony cavity where the eyes are located) and the tear ducts.

Oculoplastics recommends and carries out the appropriate therapeutic actions, either medical or surgical. These include the treatment of pathologies and also those of an aesthetic nature, related to ageing or reconstruction, due to trauma or tumour removal. The aesthetic aspects of the periocular area are a very important area of action, from the prevention of signs of ageing to the restoration of volumes and the harmonious restructuring of the upper face.

The eyelids are structures with a cartilaginous skeleton covered by a very thin layer of skin (the thinnest in the whole organism), and their main functions are to protect the eyeball and help with the secretion, distribution and drainage of tears. The eyelashes, located on the edge of the eyelids, also provide protection to the eye, as they serve as a barrier to the entry of dust and microorganisms. It is in this area that the sebaceous glands responsible for the production of lipids that make up the lipid layer of the tear are located, including Meibomius and Zeiss glands.

Another of the structures evaluated is the Orbit. It corresponds to the bony cavity where the eyes, the extraocular muscles, nerves, including the optic nerve, blood vessels and the retrorbital fat are inserted.

The pathology of the eyelids is vast. Many changes may be age-related, while others may be associated with inflammatory, infectious, traumatic agents or even tumours.

Among the anatomical alterations we can find ptosis, entropion, ectropionand eyelid retraction.

  • Ptosis corresponds to a change in the position of the upper eyelid, which is drooping, and may affect the visual axis. It has different causes - congenital, senile, traumatic, associated to systemic or autoimmune pathologies, such as myasthenia gravis, among others.
  • Entropion is a change of the eyelid that curls inwards (usually the lower eyelid) causing lesions on the ocular surface due to constant rubbing of the eyelashes against the surface.
  • In ectropion the lower eyelid turns outwards, exposing the palpebral conjunctiva, leaving the eye unprotected and with difficulties in lubrication. It can be related to age due to loss of tonicity of the eyelid muscle (the orbicular), trauma, tumours. Since in this case the eyelid does not close the eyelid crevice completely and correctly, there is a deficit of lubrication, with dystrophic and inflammatory changes both in the eyelid and on the ocular surface.

Another common pathology that affects the eyelid is cysts with or without inflammation, which include chalazia and hordeolus (aka pinkeye or pinkeye).

Trichiasisand dystikiasisare pathologies that affect the eyelashes, the former growing inwards and the latter growing in an abnormal location. In both cases there can be friction of the lashes on the ocular surface, causing uncomfortable and potentially damaging corneal lesions.

The tears produced by the main lacrimal gland, located in the lacrimal fossa, on the superolateral wall of the orbit and are spread by the movements of the eyelid (the blink) on the ocular surface. Subsequently they pass to the lacrimal points, from there to the lacrimal canaliculi and to the lacrimal sac, where they accumulate. They are later finally eliminated through the nasal tear duct into the nasal cavities. The tear consists of water, minerals, proteins, lipids and antibacterial enzymes (lysozyme, destroys the cell wall of many bacteria). Any alteration in the tear production/drainage balance will have repercussions on the comfort and health of the ocular surface.

Alterations in the lacrimal ducts cause epiphora (tearing), when there is difficulty or even impediment in draining the nasal cavities, caused by inflammatory or mechanical processes.

The impossibility of draining the lacrimal sac due to occlusion of the nasal tear duct leads to an accumulation of tears and bacteria carried by them. The bacterial proliferation ends up causing an acute and very painful infection of the sac, the dacryocystitis.

Dacryocystitis is an infection of the lacrimal sac. It can form an abscess, requiring systemic antibiotic therapy, which does not always resolve and sometimes has to be drained by puncture. When they are very repeated, they sometimes end with the definitive ablation of the lacrimal sac(dacryocystectomy). When there is an obstruction of the nasal tear duct, with an epiphora, it is necessary to perform a surgery, nowadays simplified by the use of a laser, which re-establishes the passage, avoiding the obstruction(dacrocistorhinostomy).

Oculoplastic surgery also allows for the assessment and treatment of situations in which it is necessary to empty or remove the eyeball (evisceration/ enucleation) due to atrophy, tumours or severe chronic pain (e.g. neovascular glaucoma ) in eyes without useful vision, and the respective aesthetic reconstruction.

In general, the observation of the external ocular aspects under the biomicroscope, by the ophthalmologist during the consultation, will be sufficient for the diagnosis of some of the pathologies mentioned above.

In the pathology of the lacrimal pathways, of the orbit (fractures and tumours) it is often necessary to resort to imaging with the injection of contrast, such as dacryoscystography (studies the tear excretion pathways, to identify obstructions and their location), performed with X-rays. In cases of tumours or fractures of the orbit, CT and MRI are common.

The pathologies which encompass the study area of Oculoplastics are very varied and, consequently, so is the therapy used. As already mentioned, it may be medical or surgical, depending on the cases. The former refers mainly to situations of an infectious nature such as dacryocystitis, the use of lubricants as tear aids, anti-inflammatory drugs, in eye drops or in oral form.

In reconstructions due to trauma or tumours it is always necessary to resort to surgery, which in more difficult cases can be several.

With a cosmetic nature, Oculoplastics playsan important role in terms of facial rejuvenation, with the application of Botulinum Toxin,Hyaluronic Acid or bio-stimulators , with the objective of preventing or treating the appearance of signs of ageing such as facial and peri ocular wrinkles, replacement of lost volumes, removal of bags of fat from the eyelids (commonly known as "puffiness"), etc.

In other cases, surgery is necessary, such as blepharoplasty to treat eyelid folds, entropion and ectropion, dacryocystectomy and dacryocystorhinostomy (the first to remove the lacrimal sac, the second to re-establish the nasal tear duct).

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