Botulinum and Facial Fillers

There are many options to treat facial wrinkles, including botulinum toxin and facial fillers. Botulinum toxin, a substance that helps to relax muscles, is often used to treat the dynamic wrinkles that result from muscle contraction. In contrast, facial fillers (a sugar-like substance found in skin) are often injected into areas of static wrinkles to help restore the volume loss stemming from the aging process.

The most common areas where botulinum toxin is used include the outer corners of the eyes (crow’s feet), areas between the eye brows (glabellar frown lines), or in the forehead to improve the horizontal lines. It can also be used to reshape and elevate the eyebrow or treat vertical lip lines or down turning of the lips, as well as fixing any pre-existing facial asymmetries.

The most common areas where facial fillers are used on the face include the smiles lines or parentheses (nasolabial folds), hollowness in the lower eyelids (tear trough area and nasojugal fold), the lines below the corners of the lips (marionette lines), and the cheeks and lips. The effect of botulinum toxin typically lasts for 3-4 months whereas fillers may last for 6 months to 1 year.

Additional information:

Eye & Brow Lift

Droopy eyebrows or forehead typically results from the aging process, but can also arise from Bell’s palsy, stroke, tumors, infections, or trauma resulting in facial nerve injury. When the brow and forehead droops, it may crowd more skin down over the upper eyelids. In addition to causing the upper eyelids to block part of the superior visual field, the droopy brows may also make you look tired or angry. If significant visual field loss exists, insurance companies may cover the procedure.   

For mild cases of droopy eyebrows, non-surgical treatment can be performed with botulinum toxin and fillers to lift the brow. For more significant cases, outpatient surgery is often performed. It is sometimes combined with upper lid blepharoplasty or upper eyelid ptosis repair, depending on its contribution to the superior visual field obstruction.

Lower lid blepharoplasty may also be performed to remove puffiness or bags under the eyes. Overall, excess fat, muscle, and skin from both the upper and lower eyelids to redefine the shape of the eye.

Additional information:

Eye Lash Enhancement (Latisse®)

Latisse®, (bimatoprost ophthalmic solution) is a FDA-approved prescription treatment for inadequate or not enough eyelashes. This treatment allows the lashes to grow longer, fuller, and darker. Topical solution is applied to the upper eyelashes each night and full results are seen after 12-16 weeks. If you stop using Latisse®, your eyelashes are expected to return to the original appearance after several weeks to months.

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Ptosis (Droopy Eyelids)

Ptosis (pronounced “toe-sis”), is the term for droopy eyelids. Droopy eyelids are usually due to the normal aging process, whereby the pulley muscle that opens the lid becomes stretched out and the eyelid falls, covering part of the pupil. In children, the pulley muscle may develop abnormally, causing blockage of the vision.  On occasion, droopy eyelids may be signs of a more serious medical condition, such as muscular problems (i.e. myasthenia gravis or other neurological problems (third-nerve palsy) or Horner’s syndrome. Patients with ptosis often have problems keep the eyelids open, and constantly raise the forehead or arch the eyebrows, or even tilt the head back in order to see, leading to fatigue. When severe, the droopy eyelids can block the upper part of your vision and interfere with daily activities.

Untreated children with ptosis may develop amblyopia (lazy eye), astigmatism, or blurred vision, leading to developmental delay. If the droopy eyelid is significant, insurance companies will often cover the surgical procedure. Ptosis repairs are very successful in improving visual field function. The surgery is typically performed under local sedation on an outpatient basis.

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Procedures & Treatments

Chalazion (Stye/ Hordeolum)

A chalazion is a persistent inflammation or swelling of the upper or lower eyelids. A chalazion is caused by a blockage of one of the oil glands in the eyelid. Swelling may also occur in other parts of the eye due to a secondary infection. Symptoms of a chalazion include:

  • a small bump which can usually be felt in the eyelid
  • a gradual swelling of the eyelid
  • discomfort in the eye or difficulty with seeing if the chalazion is large (swelling of the eyelid is usually not painful)

If the initial chalazion becomes infected, the entire lid may become swollen and painful.

Treatment of a chalazion:

A small chalazion may go away on its own without treatment in a couple of months. However, treatment of a secondary infection or larger chalazion may include:

  • applying warm, wet compresses around the eyes for approximately 15 minutes, several times throughout the day
  • antibiotic drops for the eye
  • if symptoms do not improve, surgery may be needed to drain the chalazion or injection of steroids for larger or recurrent lesions. ,
  • If there are other associated conditions such as blephariits or acne rosacea, additional treatment may also be necessary.

Additional information:

Stye/Chalazion - American Society of Ophthalmic Plastic and Reconstructive Surgery

Ectropion (Out-turned Eyelid)

The eyelids are delicate structures integral to protecting and maintaining the health of the eye.  As we age, the skin thins out, tissue stretches and sags.  As a result, the eyelids can often turn away from the eye (ectropion), causing redness, irritation, and tearing.  Treatment may involve ocular lubrication and surgical repair.

Additional information:

Ectropion (Out-turned Eyelid) - American Society of Ophthalmic Plastic and Reconstructive Surgery

Ectropion Photos - American Society of Ophthalmic Plastic and Reconstructive Surgery

Entropion (in-turned eyelid)

The eyelids are delicate structures integral to protecting and maintaining the health of the eye.  As we age, the skin thins out, tissue stretches and sags.  As a result, the eyelids can often turn in towards the eye (entropion), causing redness, irritation, and tearing.  Treatment may involve ocular lubrication and surgical repair.

Additional information:

Entropion (in-turned eyelid) -  American Society of Ophthalmic Plastic and Reconstructive Surgery

Eye and Lid Tumors

Cancer of the eyelid skin and eyeball is relatively common and there are several types that exist, such as basal cell carcinoma, squamous cell carcinoma, melanoma, and sebaceous gland carcinoma. If you notice the presence of a bump that grows, bleeds, ulcerates or is associated with blood vessel growth, color change, asymmetric boarders, and persistent irritation or itching, the lesion should be evaluated. A biopsy is usually required to confirm the diagnosis of cancer.

Typically, complete removal is needed to decrease the risk of recurrence. The area is then reconstructed in order to maintain proper eye and lid function and to optimize the cosmetic appearance.

Additional information:

Eyelid Skin Cancer - American Society of Ophthalmic Plastic and Reconstructive Surgery

Eyelid Skin Cancer Photos- American Society of Ophthalmic Plastic and Reconstructive Surgery

Eye Removal (Enucleation & Evisceration)

The eye is sometimes removed due to severe trauma, infection and various conditions such as cancer and uncontrolled eye pressure causing pain and poor vision. The purpose of surgery is to remove the tumor or relieve the pain.  Most patients elect to have a ocular prosthesis made with an ocularist and it typically leads to a good cosmetic outcome.

Additional information:

Eye Removal (Enucleation & Evisceration) - American Society of Ophthalmic Plastic and Reconstructive Surgery

Enucleation/Evisceration Photos - American Society of Ophthalmic Plastic and Reconstructive Surgery

Eye Lash Misdirection (Trichiasis)

Trichiasis is misdirected eyelashes which cause them to rub against the surface of the eye ball. Symptoms may include ocular irritation, foreign-body sensation, eye redness, and persistent tearing. Causes of this condition include chronic blepharitis, and eyelid scarring from trauma, prior surgery, or trachoma, and systemic disorders such as cicatricial pemphigoid.

In another related condition called distichiasis, an abnormal row of lashes arises from the Meibomian oil gland opening (from either congenital or inflammatory causes) and may result in similar symptoms.

Treatment options may include epilation of abnormal lashes or electrolysis, cryotherapy or surgery for more diffuse, severe or recurrent cases.

Management of any underlying blepharitis or inflammation of the eyelid is also important to prevent recurrence.

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Facial Spasms / Tics

There are many causes of periocular and facial spasms, including myokymia, benign essential blepharospasm, hemifacial spasm, and facial nerve misdirection syndrome.

In benign essential blepharospasm, there is uncontrolled forced contraction of the eyelids and brows, due to involuntary contraction of the muscles around the eyes. The condition affects both sides and may be accompanied by difficulty in opening eyes or abnormal movements of the mouth, and neck. The spasms are usually worse with bright lights, fatigue, and stress. The spasms usually disappear during sleep.

Hemifacial spasm typically involves twitching of both the upper and lower eyelids with progression to the entire face on one side. This condition may be associated with anatomical compression of the facial nerve. The spasms often do not dampen with rest or sleep.

Myokymia is twitching of one eyelid, usually associated with fatigue. These spasms are usually self-limited and resolves with rest.

Facial nerve misdirection syndrome occurs when the facial nerve makes the wrong muscle connections after prior injury or palsy. As result, stimulation of the facial nerve results in contraction of the wrong muscles, such that when the patient closes the eyes, it cause the mouth to move, or when the patient smiles or purses the lips, the patient closes the eyes.

The most common treatment of blepharospasm, hemifacial spasm, and facial nerve misdirection syndrome is Botulinum toxin is a substance that helps to relax muscles and help prevent uncontrollable muscle contractions. For facial nerve misdirection syndrome, selective injection of Botulinum toxin into muscle groups helps to block the aberrant contractions. For blepharospasm, tinted glasses and oral sedatives may also help and surgical excision of the contractile muscles can also be performed in severe cases. In hemifacial spasm, if an aberrant blood vessel was detected, decompression surgery may also be performed to help relieve pressure on the facial nerve.

Additional information:

Facial Spasm - American Society of Ophthalmic Plastic and Reconstructive Surgery

Benign Essential Blepharospasm - North American Neuro-Ophthalmology Society

Hemifacial Spasm - North American Neuro-Ophthalmology Society

Facial Nerve Palsy

There are several conditions that may not allow full closure of the eyelid, leading to significant dryness of the eye surface.     Treatment options may include use of ocular lubricants, moisture chambers or tape to avoid excessive dryness.  There are also various surgeries that may be performed to allow better protection of the ocular surface, such as lower or upper eyelid malposition repair and upper lid weight placement.

Additional information:

Facial Paralysis - Facial Nerve Palsy- American Society of Ophthalmic Plastic and Reconstructive Surgery

Ocular trauma and orbital fractures

Trauma to the eye and orbit may result in a multitude of significant injuries, leading to severe vision loss. Bleeding may occur inside the eye (hyphema) or within the eye socket (orbital hemorrhage) and cause irreversible blindness. Eyelid or globe lacerations as well as retained foreign body materials may also incite severe vision-threatening infections. In addition, persistent ocular inflammation (iritis), swelling of the retina (commotion retinae), detachment of the retina, optic neuropathy, and even glaucoma may occur as a result of the injuries.

Fractures of the bones of the eye socket may also cause persistent double vision, pain with eye movement, and sinking-in of the eye (enophthalmos), and typically needs to be repaired in a timely manner. Eyelid or nasolacrimal injuries may also need to be reconstructed to avoid excessive tearing or eyelid closure problems. For the severely damaged non-repairable eye or the functionally blind and painful disfigured eye, then removal of the eye may be necessary as well.

Additional information:

Orbital “Blow Out” Fractures - American Society of Ophthalmic Plastic and Reconstructive Surgery

Orbital Disease (Tumors and Infections)

There are many disorders that affect the orbit (the soft tissues that surround the eye ball).  Infections of the orbit (orbital cellulitis), which may cause serious irreversible blindness, typically result from adjacent sinus infections (sinusitis). Orbital cellulitis can also occur from infections the lacrimal gland (dacryocystitis), dental abscess, or found in patients who are immunocompromised or have suffered a traumatic injury. Symptoms may include eyelid swelling, pain, redness, blurred vision, headaches, double vision, and prominence of eye (proptosis). Antibiotic treatment is typically required to treat these infections, although surgical drainage of the infection is sometimes needed as well.

Orbital tumors may cause symptoms of double vision (diplopia), pain, pressure sensation, decreased vision, and prominence of eye (proptosis). These tumors may be benign and primarily localized in the eye socket. However, it may also be malignant and arise from other parts of the body in cases of tumor metastasis.

Imaging and lab testing are often needed to characterize the lesion and biopsy and/or surgical removal may be needed as well. 

Watery Eyes

There are many causes of tearing, including overproduction of tears from allergies or dryness, and poor drainage from lower lid malposition or blocked tear drain system. A tear duct blockage may lead to infection and chronic pink eye. Various procedures, such as tear duct probing, balloon dilation, stent placement, or tear drain bypass surgery may be performed to help alleviate the blockage and reduce the risk of recurrent infections.

Additional information:

Adult Tearing- Causes and Treatment- American Society of Ophthalmic Plastic and Reconstructive Surgery

Blocked Tear Ducts-Kids - American Society of Ophthalmic Plastic and Reconstructive Surgery

Blocked Tear Duct Surgery -Dacryocystorhinostomy (DCR)- American Society of Ophthalmic Plastic and Reconstructive Surgery 

Thyroid (Graves’) Eye Disease (Protruded Irritated Eyes)

Graves’ disease, or thyroid orbitopathy is an autoimmune inflammatory disorder, in which there is overproduction of abnormal antibodies that attack the thyroid gland. These abnormal antibodies also affect the tissues of the eyelids, extraocular muscles, and soft tissues around the eyeball. Consequently, the eyes may bulge and appear protruded and the eyelids may become retracted, resulting double vision (diplopia), in inability to close the eyes (lagophthalmos), dry eyes, ocular surface scarring, as well as vision loss.

In most cases, the orbital inflammation is self-limited, but in some cases, steroids and even radiation treatment may need to be used to reduce the swelling. In severe cases with vision loss, surgery may need to be done to decompress the eye socket in order to relieve the pressure and prevent damage to the vision.

After resolution of the inflammation, which may take up to 6 months to a few years, orbital decompression can be done to allow the eyes to return back to a more normal position in the eye socket. Double vision can also be treated with eye muscle surgery or prism glasses. Surgery to correct retracted eyelids may also be performed in order to restore normal eyelid closure to improve appearance.

Of note, cigarette smoking typically prolongs the course of disease and worsens the inflammatory process so avoidance of smoking is strongly recommended.

Additional information:

Thyroid Eye Disease - American Society of Ophthalmic Plastic and Reconstructive Surgery

Thyroid Eye Disease Photos - American Society of Ophthalmic Plastic and Reconstructive Surgery

Thyroid Eye Disease - North American Neuro-Ophthalmology Society