Ocular trauma & Oculoplastics
Update on oculoplastic surgery

Minimally invasive procedures, a greater understanding of etiology, comanagement, and formal recognition are but some of the advances in this subspecialty

A patient with bilateral medial and lateral wall orbital decompressions and upper lid Mullers muscle resection and lateral tarsorrhaphies
Source: Sang Hong, M.D.




This patient had bilateral medial, lateral, and inferior wall orbital decompressions and lateral tarsorrhaphies. Postoperatively, the patient regained all visual functioning
Source: Sang Hong, M.D.

Newer techniques in oculoplastic surgery that reduce visible scarring, coupled with improvements in imaging and fillers and formal recognition by the Accreditation Council for Graduate Medical Education (ACGME), are all rapidly changing the oculoplastics landscape.
The American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) is celebrating its 40th anniversary this year, said current president Stuart R. Seiff, M.D., emeritus professor of ophthalmology, University of California, San Francisco.
“ASOPRS has been the oversight group that has accredited oculofacial plastic surgery fellowship training programs,” Dr. Seiff said. To become a member of the prestigious society, surgeons must pass both an oral and written exam. “We never called ourselves board-certified in deference to the parent ophthalmic community, but as of [mid-September], the ACGME has given us accreditation, which will likely lead to board-certification over the next decade,” he added.
Dr. Seiff expects formal accreditation of programs to take effect by July 2010. The ASOPRS is also working with the American Academy of Ophthalmology to “begin an exploratory/joint meeting with our own subspecialty day beginning at next year’s meeting in Chicago.”
Additionally, more oculofacial plastic surgeons are realizing the aggressive treatment of even a few years ago is no longer sufficient. “If you’ve been aggressive, it’s hard to go back and replace what you’ve removed in cases of blepharoplasty, for instance,” said Kami Parsa, M.D., Beverly Hills, Calif. “It used to be commonplace to take out a lot of fat from the eye, or remove a lot of skin. This led to patients looking unnatural and ‘operated on.’ Newer techniques rely on minimalism where the recovery is faster and results more natural-looking.”
Over the past few years, “the biggest advances have been in the cosmetic realm and dermal fillers, where doing less is more; and we’re doing more minimally-invasive surgeries,” said Sang Hong, M.D., department of ophthalmology, The Eye Institute, Medical College of Wisconsin, Milwaukee.
The advances in the specialty aren’t limited to just the U.S. For the British Oculoplastic Surgery Society (BOPSS), “training and patient safety are very much the leading agenda for the next few years,” as they have been since its inception in 2001, said Brian Leatherbarrow, F.R.C.S., F.R.C.Ophth., consultant oculoplastics and orbital surgeon, Manchester Royal Eye Hospital, Manchester, England.

The current outlook

Newer techniques and a better understanding of anatomy and how tissue heals are advancing the overall oculofacial plastics arena, Dr. Parsa said. “If I divide my practice: I do 50% cosmetics and 50% reconstructive or revisional surgery.”
The emergence of revisional oculoplastics surgery “is huge and getting bigger,” he said. “One-third of the procedures I do is fixing other people’s problems” Typically, he said, patients complain about not being able to close their eyes after what should have been “simple blepharoplasty, but it was done by someone without the proper training,” Dr. Parsa said.
At Wills Eye Hospital, Philadelphia, the oculoplastics division is comprised of four surgeons, said Robert B. Penne, M.D., director of oculoplastics, Wills Eye Hospital. One focuses mainly on cosmetic surgery, but Dr. Penne concentrates on functional oculofacial surgery, with cosmetic-only comprising about 10% to 20% of his practice.
Likewise, at the Medical College of Wisconsin, the three oculofacial plastic surgeons “mostly see functional eyelid, orbital, periorbital and nasolacrimal diseases—versus cosmetic cases—because of the nature of the patients referred to us,” Dr. Hong said. “Nevertheless, these are exciting times in oculofacial plastic surgery. There has been a trend for more minimally invasive procedures and increasing popularity of the use of filler agents such as hyaluronic acid gel and botulinum toxin. We have been using newer technologies such as ultrasonic bone emulsification and intraoperative CT/MRI image guidance systems in our orbital surgeries to allow us to perform more complete and effective surgeries and yet achieve a higher level of safety during surgery for the patient at the same time.”

Blepharoplasty, ptosis, and others

Blepharoplasty of the lower eyelid has “always presented a challenge and new techniques and approaches have increased the options available for patients,” Dr. Leatherbarrow said. “The problem of the post-blepharoplasty syndrome with lower lid retraction and a hollowed look to the lower lid is now much reduced by techniques that reposition fat over the inferior orbital margin, avoiding the removal of fat wherever possible.
This is often combined with an orbicularis suspension technique or a mid-face lift to better address the problem of the lower eyelid ‘tear trough’ defect. Coleman fat injection techniques for the mid-face and tear trough fat or filler injections have also been embraced over recent years with improved results for patients.”
With ptosis patients, “we’ll see them once, do the surgery, have one or two quick follow-up visits, and then they’re done,” Dr. Penne said. “Other diseases, such as a bad thyroid eye disease, those patients mandate one or two visits a month, for several months.”
Today’s blepharoplasty surgery is more than “just taking out fat or skin,” Dr. Seiff said. “It’s truly moved to restoration of the entire mid-face structure. There are a lot of techniques and devices out there to improve lower lid surgery. I’m not entirely convinced the ‘best’ one has been developed yet.”
Dr. Hong agreed, “There has been a changing paradigm in blepharoplasty from simply removing fat to repositioning it and/or using fillers instead. With involutional periorbital changes, it’s not that there is more fat, but that it’s malpositioned. We’re more concerned now about trying to restore a more youthful look by repositioning the fat and facial soft tissue or by using fillers to inflate the deflated areas.”
To that end, Dr. Hong said although he has a special interest in the management of Graves eye disease, performing brow lifts, mid-face lifts, blepharoplasty, ptosis repair, ectropion/entropion repair, tear duct surgery, and reconstructive surgery after Mohs resection are really the more “bread and butter” procedures of our specialty.
At Wills, the most common oculofacial plastic surgery is ptosis, said Dr. Penne. “Most of these patients also have excess skin, so they’ll have some sort of blepharoplasty. Those two often go together,” Dr. Penne said. He also performs a significant amount of ectropion/entropion, as well as other functional surgical procedures but does not focus on the facial fillers.

Thyroid eye disease

“Orbital decompression surgery for the management of thyroid eye disease has seen changes which have led to improved patient outcomes,” Dr. Leatherbarrow said. “Most surgeons now adopt a minimally invasive approach leaving the patient with a barely perceptible scar in a laughter line at the lateral canthus or lateral aspect of the upper eyelid. In the past many different approaches have been used, including a bicoronal flap approach which was much more invasive and daunting for the patient.”
Combining a medial and an extensive lateral orbital wall decompression reduces the patient’s eye protrusion and has a low risk of complications, Dr. Leatherbarrow added.
Thryoid eye disease is difficult, Dr. Penne said, because the autoimmune disease attacks the extraocular muscles and the orbital fat. Typically, those with hyperthyroidism are likely to develop thyroid eye disease.
“Thyroid eye disease can happen years after the patient’s been treated for hyperthyroidism,” he said. “In the eye, the disease course can range from a few months to two years, and for people who smoke it’s much worse. There’s just not a lot of good treatments available other than long-term steroids. Injecting steroids into the orbit—pulse injection of steroid for short course over long term—may stop the inflammatory process.”
Dr. Penne added, research from the Mayo Clinic “about five years ago” questioned if radiation could provide a viable alternative to steroids. “We don’t think so, but it doesn’t make it worse, either,” Dr. Penne said. “Once their disease has burned out, then they may have double vision and need surgical rehabilitation. If left alone, it could become vision threatening.”
Over the past few years, “medicine as a whole has come around to what we have known for a long time—eye disease associated with thyroid disease is not something brought on by thyroid hormone levels, but by an autoimmune disease,” Dr. Seiff said. In the past three years, ASOPRS provided a significant amount of seed money to form a coalition between oculofacial plastic surgeons, endocrinologists, and neuro-ophthalmologists to jointly fund research projects on thyroid eye disease.
“The goal is to get National Institutes of Health funding down the road,” he said.
For mild cases of thyroid eye disease, lubricating drops or ointments is “all that is needed to control the symptoms of dry eyes,” Dr. Parsa said. “For pain or swelling, a short course of steroids is usually sufficient. Some doctors recommend orbital radiation, which can be successful in some patients. Patients with thyroid eye disease need to be followed closely for the development of compressive optic neuropathy, which occurs in a small percentage of patients. In this condition, the swelling in the orbit or eye socket can compress the optic nerve, which is responsible for vision, and cause the patient to become permanently blind. For these patients, orbital decompression surgery should be performed to prevent blindness.”
Exciting research in the molecular biological pathophysiology of Graves eye disease is ongoing around the country, Dr. Hong said. “One day, we’ll actually understand it enough to be much more effective at treating it at different levels and different cellular receptors with a battery of precisely-orchestrated medications rather than using the current mainstay of treatment, systemic steroids, which is more of a “shot-gun” approach, which is effective but has significant limitations and side effects..”

Cosmetic surgery

Many academic centers tend to see much more functional vs. cosmetic cases, Dr. Hong said. “Academic centers generally cannot be as financially competitive in cost and pricing for cosmetic procedures. The private centers can often offer cosmetic procedures for less out-of-pocket cost for the patient,” he said.
That being said, the most radical changes recently have occurred in the realm of cosmetic surgery, Dr. Penne said. “How to use fillers around the eye is still being figured out,” he said. “We’re still evolving our resurfacing procedures, although a lot of that applies to the face more so than just the orbital region.”
Mid-face lifts have uses outside of cosmetic surgery, Dr. Leatherbarrow said.
“They’re being used more frequently for the management of patients with a facial palsy. The introduction of new devices such as the biodegradable Endotine implant (Coapt Systems, Palo Alto, Calif.) have improved the results of such surgery. Mid-face lifts can now be undertaken with small incisions in the lower eyelid alone,” he said.
“The Coleman fat injection technique has also been adopted by many surgeons over recent years to address a residual volume deficit in an artificial eye patient, an appearance often referred to as an anophthalmic socket syndrome,” Dr. Leatherbarrow said.

Reconstructive surgery

Radical changes in reconstructive surgery include newer implants and technologies, Dr. Parsa said. He cited one patient in whom “we just performed a customized 3-D orbital reconstruction. The patient was from Arkansas and had been in a car accident about 15 years earlier. Reconstructive surgery had been done at home, and part of the problem was the left orbit was about 7 cm lower than the right one,” he said.
“With the use of 3-D computerized tomography scan we were able to duplicate the contralateral orbital floor to reconstruct an orbital implant that was a perfect match,” he said.

Comanagement

In some areas of oculofacial surgery, comanagement with other surgical specialties may be beneficial, said Dr. Hong. For instance, Graves eye disease tends to affect younger people.
“One day they look fine; and over a period of 6 to 18 months, the orbit and periorbital area undergo swelling and enlargement, resulting in the classic ‘bug-eyed’ appearance,” he said. “It’s cosmetically and functionally deforming.” In its most severe form, vision loss can occur from optic nerve compression. First-line treatment is steroids, then followed by surgery, if necessary, to try and save the vision.”
In his practice, he performs the surgery in conjunction with a sinus surgeon, who performs the medial wall decompression endoscopically, which obviates a separate incision and allows the sinus surgeon to perform a formal ethmoidectomy which allows an unobstructed, fuller medial wall decompression and decreases the risk of postoperative sinusitis. Also, the endoscopic medial wall decompression can be performed without the need for surgical retraction on the orbital soft tissue which would increase orbital and intraocular pressure in an already swollen and tight orbit; and when the medial wall decompression is performed first, the necessary surgical retraction during the subsequent lateral and/or inferior wall decompression is more effective—because the orbit is less tight and there is more room—and cause less rise in orbital and intraocular pressure.
“I decompress the lateral bony orbital wall using an ultrasonic bone emulsification system that preferentially emulsifies the immobile bone tissue over the more pliable soft tissue, therefore much safer for soft tissue,” Dr. Hong said. “I also use an intraoperative CT-image-guidance system—which was first used by ENT surgeons during sinus surgery for better localization during surgery, and we’ve adopted its use in orbital surgery. We do a pretty good job of optimizing the bony decompression while maintaining the safety of the anterior and middle cranial fossae dura. It’s been great to apply this relatively new technology to orbital surgery to improve both surgical efficacy and safety.”
For patients with the most severe form of the disease, this type of comanagement is relatively common, Dr. Hong said. Recently, orbital decompression has been offered even “to patients who might not have vision loss from optic nerve compression, but have significant, recalcitrant (i.e., unresponsive to or intolerant to steroids) retrobulbar pain and pressure because of orbital congestion and proptosis ... Select patients with milder disease severity but with significantly debilitating symptoms have clearly benefited from orbital decompression also,” he said.

What the future holds

According to Dr. Leatherbarrow, endoscopic dacryocystorhinostomy for the management of the watering eye “has undergone improvements over the course of the last few years with improved patient outcomes. The endoscopic equipment now available has also improved. This means that fewer and fewer patients are undergoing open surgery with a resultant permanent facial scar, medial canthal ligament disturbance and an impaired blink reflex,” he said. “Other materials used in oculoplastic surgery have seen improvements e.g. Medpor Titan has been recently introduced and offers the oculoplastic surgeon major advantages in the management of patients who have suffered large orbital wall blowout fractures.”
Dr. Seiff said he is most excited about some of the new neuromodulators that have been introduced in an effort to compete with Botox (onabotulinumtoxinA, Allergan, Irvine, Calif.).
“There was some competition a few years ago from Myoblock, but it wasn’t nearly as cost-effective or user-friendly as Botox,” he said. Another product introduced recently—Dysport (abobotulinumtoxinA, Ipsen, Wrexham, Wales)—needs to have a price breakthrough at this point.” At this point, Botox and the hyaluronic acid fillers remain the workhorses for minimally invasive facial rejuvenation, he said.

One important event for

ASOPRS has been its participation in coalition for injectable safety (Patient Coalition for Injectable Safety), Dr. Seiff said.
“ASOPRS is very proud to participate in this coalition with aesthetic plastic surgeons, facial plastic surgeons, and dermatologic surgeons. The emphasis here is we’re all standing together to guarantee patient safety,” he said.
Dr. Penne believes improvements in the treatment of thyroid eye disease will continue to dominate the specialty. “Thyroid eye disease is not like cataract, where millions are done every year. There’s not as big a commercial investment in treating thyroid disease,” he said. Different material choices being used to try to reconstruct lids, bovine and human dermus, are all potential areas of interest, he said.
Dr. Seiff also believes the specialty will see additional advances in endoscopic surgery.
“Endoscopic surgery in experienced hands is an equally efficient option for many patients when compared to external surgery,” he said. “There are some individual advantages and disadvantages, but endoscopic brow lifts are becoming standard.”

Editor’s note: Drs. Seiff, Parsa, Hong, and Penne have no financial intersets related to their comments. Mr. Leatherbarrow’s text, Oculoplastic Surgery, 2nd edition, is being published this fall.

Contact information

Hong: 414-456-7989, shong@mcw.edu
Leatherbarrow: +44 08458 332233, brianleatherbarrow@faceandeye.co.uk
Parsa: 310-777-8880, kamiparsa@gmail.com
Penne: 215-928-3250, dpenne1@comcast.net
Seiff: 415-254-7227, SSeiff@gmail.com