When it comes to eye problems, we often tend to think of areas like the lens, cornea and retina.
But some common eye complaints are caused by issues outside the eyeball – conditions such as droopy eyelids, in-turning or out-turning eyelids, eyelid lumps and tumours, problems with tear ducts and issues involving the eye socket. This is where oculoplastics can help. Oculoplastic surgeons are specialised ophthalmologists (eye doctors) who perform a range of eyelid and facial plastic operations to treat and improve conditions around the eyes.
Oculoplastics is a specialist form of eye care that deals with all the structures around the eye, including the eyelids, the lacrimal (or tear) system and orbit (the bone cavity around the eye). Various problems can affect these structures, and to some extent they are becoming more common; many more people are having eyelid surgery, for example, as the general population ages. Oculoplastic surgeons (also known as ophthalmic plastic and reconstructive surgeons, or oculo-facial surgeons) are eye doctors who have been specially trained to treat these important structures around the eye. The procedures they use range from simple eyelid malpositions to more complex reconstructions involving the eyelids and the surrounding forehead, temporal and cheek areas. Oculoplastic surgeons are experts at understanding the delicate anatomy and function of the eyelids and their surrounding structures. The goal of oculoplastic surgery is to correct either functional or cosmetic problems, and in some cases both.
An epiretinal membrane behaves like scar tissue. As the tissue contracts, it “puckers” the underlying macula. This can cause distortion and visual loss.
Oculoplastic surgery provides treatment for a number of different problems. The most common ones include:
Eyelid ptosis (drooping upper eyelids)
This is a condition where one or both of the upper eyelids hangs lower over the eye than it should do. Sometimes this is a minor cosmetic issue; if it progresses, however, it can affect a patient’s visual field, and may also cause a brow ache. There are many reasons why it might happen, and an oculoplastic surgeon will be able to assess the exact cause and recommend the appropriate treatment during a consultation. In some cases this will mean surgery, which is often performed as a day case under local anaesthetic. During the operation, the surgeon makes a small incision in the skin of the upper lid. The eyelid tissues are then adjusted to lift the lid back to its natural height.
Ectropion / Entropion (in-turning or out-turning eyelids)
Ectropion and Entropion are conditions where the lower (or sometimes upper) eyelid turns outwards (ectropion) or in towards the eyeball (entropion). It commonly happens to patients as they get older, due to age-related stretching of the tissues that support the lid; but there are other possible causes, and an oculoplastic surgeon will be able to assess these and provide an appropriate management plan. Though surgery is often required for ectropion and entropion, it can be done as a day case under local anaesthetic. During the operation, the surgeon makes incisions either to the skin of the lower lid just below the eyelashes, or inside the eyelid. Through these incisions, the structures of the eyelid are repositioned so the eyelid returns to its natural position.
Blepharoplasty (cosmetic surgery for eyelids)
Blepharoplasty is the medical term for plastic surgery that corrects problems with the eyelids. It can be used to reduce excess skin and sometimes fat from the upper or lower eyelids either for aesthetic reasons, or if the excess skin is having an effect on your peripheral vision (visual field). An oculoplastic surgeon should be the first choice for anyone considering cosmetic surgery to the eyelids, as they are best placed to make a full assessment of the eyelids and eyes to advise the correct treatment. They are able to properly assess the surface health of the eyes, and the function of the eyelids, prior to plastic surgery.
Watery eyes can be due to either an excessive production of tears or a problem with tear drainage, and they can cause quite a lot of distress. An oculoplastic surgeon will be able to assess the reason for the watering and provide an appropriate management plan to treat the problem. Though simple treatments can make a big difference to patients with a watery eye, occasional surgery may be helpful. On assessment, your oculoplastic surgeon will be able to advise when and what type of surgery would be suitable.
Eyelid lumps and tumours
Many types of benign lumps can affect the eyelids, as well as some types of cancer. If you’re worried about a lump and want to have it properly looked at, the oculoplastic surgeon will be able to assess the situation, offer a diagnosis and then provide treatment if necessary. Removal of benign eyelid lumps is often not possible on the NHS, but it can be done privately. It is often a quick, office-based procedure, carried out under local anaesthetic.
Facial palsy is a condition where the nerve that supplies the muscles on one side of the face is damaged. An oculoplastic surgeon is often involved because it affects the ability of the eyelids to close, which puts the eye at risk of exposure. The oculoplastic surgeon will be able to assess the extent of the damage to eyelid function and advise on appropriate management. This may involve simple conservative measures such as lubricant eyes drops, though it could also require surgery.
If you’re having eyelid surgery with us, your operation will take place under a local anaesthetic, so you should be able to go home soon after the surgery. This involves a small injection under the surface of the eyelid to make it numb, a bit like the injection you might get at the dentist.
Preparing for surgery
When you arrive at the hospital a member of staff will be there to welcome you. They will make sure everything is OK, perform a few routine checks and then take you to the operating theatre. We use a reclining seat for surgery. This allows you to lie back in a fairly flat position. Don’t worry if you’re unable to lie completely flat; we will help you get into a comfortable position that works for you.
The surgical team will then introduce themselves and make a few final checks. The surgeon may need to make some marks with a soft pen on the skin of your eyelids. After that he will give you the anaesthetic injection. This does sting (a bit like a bee sting) for a few seconds, but that quickly passes and then your eyelid will be numb. You may still experience the feeling of soft touch and pressure, but you won’t feel anything sharp or painful. After this the team will clean part or all of your face with an antiseptic solution. They will then carefully place a drape around your head. The drape simply rests under your chin. It doesn’t cover your face.
During the operation
During surgery we may ask you to open your eyes or look in certain directions at times, but for most of the operation you can just lie back with your eyes closed and relax. You won’t be able to see what is going on as the surgeon will be working very close to your face. If you find that the operating lights are too bright, we can cover your other eye with a soft cloth to help you feel more comfortable.
Most unilateral (single-eye) procedures usually take about 30 minutes. Bilateral (both eyes) operations can take 45-60 minutes. After the surgery we will clean and wipe your face. In some cases we may apply an eye pad, which will stay in place for between 24 and 48 hours. In most cases, however, an eye pad isn’t necessary. Immediately after the operation, we often advise patients to apply an icepack to the eye for 20 minutes, to minimise any post-operative bruising. You can do this as soon as you get into the recovery area; the nurses will have a pack ready for you to use when you get there. In the recovery area the nurses will also explain how you can best manage your eyes in the post-operative period. Once all this has happened, you’ll be free to go home.
Every patient responds to surgery in different ways and heals at different speeds. As a rule of thumb, though, you can expect some swelling and bruising in the first week after eyelid surgery, which will be visible to other people. In the second week this begins to settle and it’s usually not very apparent that surgery has taken place. Any scars from the operation are designed to blend into the normal creases of the skin around your eyelids.
We see all our patients a week after their surgery so that we can review the healing process and remove any sutures. We will see you again for a final check after about two to three months.
For patients who work, we usually recommend taking at least one week off to recuperate after surgery. Some people prefer to allow a fortnight, but we can review this when you come in for your post-operative appointment at the end of the first week.
The effects of the local anaesthetic usually begin to wear off after an hour. In practise, most patients rarely experience much discomfort after the operation. But if your eyes do feel painful, it’s fine to take some paracetamol (assuming you don’t have an allergy to this medication). Eyelids have an excellent blood supply. This is good because it means they heal very quickly, but by the same token they can also become bruised and swollen following surgery. The amount of bruising and swelling you experience can be quite variable and difficult to predict. But there are some things you can do to help reduce them.
Using ice and gentle pressure on the eyelids after surgery can help to reduce the swelling. The simplest way to do this is with a bag of frozen peas wrapped in a tea towel. Press this gently onto your closed eyelids for 20 minutes. You can repeat this at regular intervals, ideally five to six times a day for the first three days.
Eyelid swelling can be affected by the position of your head relative to your body during the healing process. Keeping your head up and above the rest of your body during the first few days may help to ease some pressure on the lids. Sleeping with a few extra pillows, or putting a few books under the head of your bed, can keep your head a little higher when you are asleep and reduce any extra swelling overnight.
It’s important to give your body time to heal and recover, so we always recommend that you avoid any strenuous activity for at least two weeks following your surgery. Light exercise such as walking is fine, but try to avoid anything that raises the heart rate too much or involves putting your head below your body. You should avoid swimming for the first two weeks as well. You can wash your face and take showers, but try to avoid getting the eyelids too wet.
Studies have shown that smoking affects the healing process after eyelid surgery, which is why we ask patients to stop smoking in advance of their procedure. If you do smoke, we recommend you avoid it for at least two weeks before your operation takes place, and for the first few weeks afterwards.