Medical conditions and diseases like cancer, injuries and trauma can cause lid repair and reconstruction surgery to be necessary for some patients. Whether it is an eyelid malposition like ectroption or entropion, oculoplastic reconstruction after cancer removal and treatment, post-Mohs procedure reconstruction, or a medically necessary tarsorrhaphy, Dr. Magauran is skilled in rebuilding lids and lacrimal systems to improve function, vision and aesthetics.
Eyelid Malpositions – Ectropion, Entropion
The most common lid repair surgeries are to correct the positioning of eye lids. Ectropion (where the eyelid turns outward and away from the eye) and entropion (where the eyelid turns inward and towards the eye) are two such examples.
Ectropion is a progressive outward rotation or turning of the eyelid margin. Patients may experience symptoms due to ocular exposure and inadequate lubrication. Symptoms-such as blurry vision, severe discomfort, redness, watering, burning, itching, corneal defect are caused by continual overexposure to air and environmental factors without lubrication and protection from the lids and blinking. Temporary treatment includes frequent lubrication with artificial tears, artificial tear gel, or ophthalmic ointment, wiping lids up and in versus down and away from the eye and taping even patching to keep eye closed and covered. Surgical intervention is the only permanent resolve for ectroption.
Entropion is a progressive inward rotation or turning of the lower eyelid margin. This causes continual irritation of the
ocular surface from the misdirected lashes. Symptoms—such as blurry vision, severe discomfort, foreign body sensation, redness, itching, burning, excessive tearing, and discharge—are caused by cilia and keratin rubbing against an unprotected globe. This may result in a persistent epithelial defect, corneal ulceration, and in the worst cases, globe perforation. Although conservative treatment with ocular lubricants (over the counter and prescribed drops, gels and ointments are typically used), taping, or botulinum toxin injections can produce temporary relief, surgical intervention is required to permanently restore proper anatomic positioning.
Tarsorrhaphy is a surgical procedure in which the eyelids are partially sewn together to narrow the eyelid opening. It may be done to protect the cornea in cases of corneal exposure. It is one of the safest and most effective procedures for healing difficult-to-treat corneal lesions. Tarsorrhaphy is most commonly performed to protect the cornea from exposure caused by inadequate eyelid coverage, as may occur in Graves disease or facial nerve (CN VII) dysfunctions such as Bell palsy. It can also be used to aid in the healing of indolent corneal ulceration sometimes seen with tear-film deficiency, herpes simplex or zoster, stem cell dysfunction, or CN V dysfunction (neurotrophic lesions), Möbius syndrome or after corneal graft surgery. Tarsorrhaphies may be temporary or permanent; in the latter case, raw tarsal edges are created to form a lasting adhesion. They may be total or partial, depending on whether all or only a portion of the lid is fused and which part of the eye is therefore is occluded.
Cancer Reconstruction, Post-Mohs Lid Reconstrution
The eyelids and skin around the eyes are not immune to skin cancers. Fortunately, most of the eyelid cancers we see are of the Basal Cell variety. Basal cell cancer spreads locally and once it is “out”, it is gone. For everything but the small localized growths, we utilize the services of a Mohs surgeon to completely excise the cancer using serial microscopic analysis. In upper eyelid reconstruction, an in-depth knowledge of the anatomy is an absolute prerequisite for success. As an oculoplastic surgeon, Dr. Magauran excels at post-Mohs reconstruction. Rebuilding eyelids sounds serious, and it is. For Dr. Magauran this is an incredibly rewarding task because at the end of the day, the outcomes are truly amazing. Sometimes we use skin muscle flaps, sometimes free skin grafts, sometimes we borrow from Peter to pay Paul. At the end of the day, it’s is not just a tender touch and healthy respect for tissue, most of the credit goes to the eyelids themselves – they are incredible structures at regenerating!
Lacrimal Surgeries, Tearing Disorders and Chronic Dry Eye Treatment
There are plenty of causes of tearing, but did you know the most common cause is dry eye? From Restasis to flaxseed, punctal plugs to endoscopic dacryocystorhinostomy, we can help understand what is happening and what can be done to solve these problems. We’ll walk you through the various options to improve your dry eye problem or rebuild the tear duct system if you need it, so you can live your life comfortably.
Non-surgical treatments include:
- Lubrication with Artificial Tears, Artificial Tear Gel or Ophthalmic Ointments
- Prescription ocular medications like: Restasis and Xiidra
- Addition of supplements including Omega 3 Fatty Acids to improve quality tear film like Flaxseed Oil
- Punctal Plugs: Disolvable and Permanent
Lacrimal surgery repairs dysfunction in the tear ducts system that normally drains tears from the eye surface. This may include the exploration and reconstruction of any portion of the system depending the location of the closure (stenosis) or obstruction. Dilation of the punctal opening, and attempt at irrigation of the lacrimal system can help diagnose blockages and aid in assessment and treatment. Treatment can be as simple as using eye drops, a minor procedure in the clinic, or may require surgery in the operating room.
Surgical treatments include:
- DCR and Endo-DCR (tear duct bypass surgery)
- C-DCR (tear duct bypass with implant)
- Punctal Stenosis and Cauterization
- Punctal Stents
Dacryocystorhinostomy (DCR) surgery is a procedure that aims to eliminate fluid and mucus retention within the lacrimal sac, and to increase tear drainage for relief of epiphora (tears running down the face). This allows tears to drain directly into the nasal cavity from the from the eye through a new low-resistance pathway.
Thyroid Disease Ocular Correction
Thyroid eye disease, or Graves’ ophthalmopathy, is a potentially vision-threatening autoimmune disease that presents in most in hyperthyroid patients. Aapproximately 30 to 50 percent of patients with thyroid disease have ophthalmic manifestations, but only 3 to 5 percent of the patients have vision-threatening forms of the disease. Patients will commonly present with complaints of diplopia (double vision), changes in the appearance of their eyes or symptoms related to corneal exposure, such as foreign body sensation, photophobia, redness and tearing. The most common and specific clinical finding for TED is eyelid retraction, occurring in about 91 percent of the patients. This is followed by 62 percent with proptosis; 43 percent with motility dysfunction; 30 percent with pain; 23 percent with epiphora (excessive watering); and only 6 percent with compressive optic neuropathy.
It is recommended that surgical intervention be postponed until the patient is in the inactive phase or symptoms are stable for at least three to six months. Exceptions to this apply when the vision is threatened by compressive optic neuropathy or severe proptosis with corneal ulceration or stretch optic neuropathy. In this case, orbital decompression surgery is often the first-line of therapy to preserve vision. In general, removal of one or two orbital walls and/or orbital fat is performed to decompress the optic nerve and allow the globe to retract. Once stability is achieved, strabismus surgery, if necessary, can then be performed, followed by eyelid surgery to correct the retraction if needed.
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