DR. AMJAD AHMAD - OCULOPLASTIC AND RECONSTRUCTIVE SURGERY

Conditions Treated

(This page under construction)

• Ptosis surgery for both adults and children

Eyelid ptosis is defined as drooping of the eyelid margin. This condition is different than dermatochalasis which is redundant skin on the eyelids. Drooping of the upper eyelid can cause obstruction of the patients superior visual field. Ptosis of the upper eyelid can be caused by many conditions. Some children are born with congenital ptosis. This is caused by maldevelopment of the lifting muscle of the eyelid (levator aponeurosis) and can be either unilateral (more common) or bilateral. Adult onset ptosis has many different etiologies including disinsertion or thinning of the levator muscle, weakening of the lifting muscle or even loss of nerve signals to the upper eyelid muscle. There are multiple different types of surgical procedures to repair upper eyelid ptosis. The type of procedure chosen depends on the underlying cause of the ptosis and the current function of the lifting muscle (levator aponeurosis).

If the lifting muscle of the eyelid has good function an eyelid approach can be used to lift the eyelid. This can be done either thru an incision in the upper eyelid crease or can be done thru an internal approach which requires removal of tissue on the undersurface of the eyelid.

If the lifting muscle has no function or minimal function a frontalis sling may be necessary to elevate the eyelid. This procedure requires incisions in the upper eyelid as well as above the eyebrow. Using either a piece of fascia lata(tendon from the thigh) or silicone the eyebrow is essentially connected to the upper eyelid. When the patient lifts his forehead the upper eyelids will elevate.

The risks of ptosis surgery include asymmetry of the eyelids, undercorrection or overcorrection of the eyelid position, infection, bleeding and even ocular irritation. Opening the upper eyelid will improve the peripheral visual field and patients who have had ptosis surgery will often comment on how much brighter their world appears compared to their pre-operative level. Patients with underlying dry eye are at risk for worsening of their irritation after eyelid ptosis surgery. 

• Graves eye disease - medical and surgical management

  Thyroid eye disease is an autoimmune disease which is often associated with systemic thyroid dysfunction(usually hyperthyroidism). The eye disease affects the tissues surrounding the eye including the extraocular muscles, fat and eyelids. The hallmark findings are eyelid retraction and bulging of the eye. Some patients can develop double vision or even loss of vision from compression of the optic nerve.
  
  Supportive care including ocular lubricants, avoidance of smoking, and medical management of any systemic thyroid dysfunction will be all that is needed for most patients. A number of surgical options exist to treat problems of the eyelids and orbit in Graves disease. Orbital decompression is removal of the bones relieves pressure around the swollen orbital tissues. This surgery not only moves the eye back into the eye socket but also can relieve any pressure on the optic nerve. Eye muscle surgery is sometimes needed for patients who have double vision. Multiple different eyelid surgeries may need to be performed including dropping the upper eyelid, raising the lower eyelid, closure of the corners of the eyelids(tarsorraphy), and blepharoplasty.

  Please see picture examples below.

  Classic Graves eye disease	Classic Graves eye disease

• Eyelid reconstruction after skin cancer removal

  There are multiple different type of skin cancers that affect the eyelids with Basal cell cancer being the most common. The good majority of these cancers are locally invasive but do not usually spread to distant areas. Commonly involved areas in the eye region include, lower eyelid(most common), outer and inner corners(lateral and medial canthus) and upper eyelid. In some cases the skin cancer can involve the tear drainage system which is located in the corner of the eyelid(near the nose). There are two stages of treatment, the first is excision of the cancer and the second stage is reconstruction of the eyelids.

  • Excision Stage:
    Hospital based - Dr. Ahmad can excise the cancer with the assistance of a pathologist. The pathologist is a doctor who will examine the edges of the removed cancer to make sure that all the cancer has been removed. Once the pathologist confirms that the cancer has been removed, Dr. Ahmad will start to reconstruct the eyelids.  A Mohs surgeon is a specialized dermatologist who not only removes the skin cancer but also examines the tissue edges to make sure that all the cancer has been removed. In certain circumstances a Mohs surgeons assistance can be extremely helpful in tumor removal.

   

  • Reconstruction Stage:
    After the pathologist has confirmed that all the cancer has been removed, Dr. Ahmad will reconstruct the eyelids and tear drainage system(if needed). If a Mohs surgeon is removing the skin cancer the patient will be scheduled for reconstruction of the eyelids in advance either in the office or in the hospital.

  
  The eyelids are highly specialized soft-tissue structures whose main purpose is to protect the eye and while blinking spread moisture evenly over the cornea (the front of the eye). There are three layers of the eyelid, the inner layer is moist much like the inside lining of the mouth, the middle layer is made up of tarsal plate (gives eyelids stiffness), and the outer layer is skin.
  
  Depending on the hole in the eyelid after skin cancer removal you may require either tissue grafts or a local flap. A graft is a piece of tissue that is removed from one area of the body and transferred to another area without a blood supply. A flap is a piece of tissue that is moved but still has a blood supply running thru it.
  
  The inner layer of the eyelid can be reconstructed with tissue grafts from the cheek, hard palate, ear cartilage and even tarsal plate from the opposite eyelid. Skin grafts are used to reconstruct the outer portion of the eyelids and are harvested from behind the ear, in front of the ear, above the clavicle, inner arm and even from the inner thigh.
  
  The inner layer can sometimes be reconstructed with a flap from the upper eyelid called a Hughes tarsoconjunctival flap. This flap is used in cases where the good majority of the lower eyelid has been removed. Skin flaps are commonly used to reconstruct the outer portion of the eyelids.
  
  The choice of grafts or flaps to reconstruct the eyelids depends on the size of the eyelid defect, age, health of the patient, and even the health of the eye itself.

  Please see picture examples below.

  Common eyelid Basal Cell Cancer	Common eyelid Basal Cell Cancer

   

• Eyelid malpositions (Ectroprion and Entropion)

Ectropion:
Turning outwards of the upper or lower eyelid margin is called ectropion. There can be many underlying etiologies of ectropion but the most common is laxity of the eyelid ligaments. Surgical repair is usually focused on tightening the lax eyelid. Cicatricial ectropion is caused when scar tissue pulls the eyelid margin outwards. Skin grafting is usually necessary to repair this specific form of eyelid ectropion.

Entropion:
Turning inwards of the eyelid margin. This is a common eyelid malposition that is usually seen in the elderly. Patients who have had intraocular surgery like cataract surgery may be at more risk for this condition. Laxity of the eyelid ligaments and disinsertion of the lower or upper eyelid retractor muscles are the usual culprits that cause eyelid entropion. This condition usually causes eye discomfort because of the eyelashes that are rubbing against the cornea or conjunctiva. Conservative options include eye ointment and taping of the eyelid outwards.

Please see picture examples below.

Entropion of lower eyelid with lashes hitting the eye	Ectropion of right lower eyelid

• Orbital fractures and surgery

Trauma to the eye area can cause fracture of the bones that surround the eye. The most common fracture type involves the orbital floor. This is the bone the eye sits on above the maxillary sinus. Patients with fracture of the orbital floor will commonly have double vision and pain with movement of the eye. Large fractures can cause the eye to sink into the socket. Surgical repair of the orbit is usually not performed for 2-3 weeks because many of the symptoms (double vision, and pain) will improve by themselves.

• Lacrimal (Tear duct) surgery

Our eyes make tears thru out the day to keep our corneas moist and clear. The tears are made from glands that surround the eye and are drained in the corner of the eye nearest to the nose. Patients who complain of watery eyes or of tears running down their cheek often complain of blurry vision especially when they read. The reasons for tearing are often multifactorial especially in the elderly. The most common reason for intermittent tearing is dry eye. When the ocular surface is dry or irritated the lacrimal gland will increase tear production causing the patient to have watery eyes.

 

• Pediatric and adult tearing

• Eyebrow elevation

• Upper and lower eyelid blepharoplasty

• Midface lift (cheek lift)