BASICS

DESCRIPTION

• Dermatochalasis refers to excess eyelid skin associated with the aging process.

• Blepharochalasis is a rare eyelid disorder that often presents in childhood, characterized by recurrent episodes of idiopathic painless edema of the upper and occasionally lower eyelids.

• Steatoblepharon describes the herniation of orbital fat.

EPIDEMIOLOGY

Incidence

• Data unavailable

• Frequently occurs by the age of 40 years and progresses with age.

• May develop by age 20 years in those with family history.

Prevalence

Data unavailable

RISK FACTORS

• Advancing age

• Smoking

• Sun exposure

• Facial trauma

• Positive family history of dermatochalasis

Genetics

Unknown

GENERAL PREVENTION

• Avoid smoking

• Avoid eyelid rubbing

• UV protection-hat, sunglasses, and sunscreen advised

PATHOPHYSIOLOGY

• Consistent with normal aging changes of the skin

• Loss of elastic and reticular fibers of the dermis, thinning of the epidermis with resultant skin redundancy

ETIOLOGY

• Age

• Family tendency

• Chronic manipulation of eyelids

COMMONLY ASSOCIATED CONDITIONS

• Blepharoptosis

• Herniated orbital fat

• Eyelid laxity

• Dry eye syndrome

• Chronic blepharitis

• Chronic dermatitis

• Thyroid eye disease

• Chronic renal insufficiency

DIAGNOSIS

HISTORY

• Excess skin of the upper lids and/or lower lids

• Brow ache

• Ocular fatigue when reading

• Difficulty applying eye make-up

PHYSICAL EXAM

• Brow ptosis

• Horizontal forehead creases

• Excess upper eyelid skin

• Excess lower eyelid skin

• Descent of retro- orbicularis oculi fat (ROOF)

• Descent of suborbicularis oculi fat (SOOF)

• Herniated orbital fat

• Prominent bony orbital rim

• Low or absent eyelid crease

• Prominent nasojugal fold

• Prominent nasolabial fold

DIAGNOSTIC TESTS & INTERPRETATION

Lab

Initial lab tests

• In most cases, none is needed

• Tensilon test, if associated with ptosis

• Schirmer test, for tear function

• Visual field, for functional defect(surgery)

• Pre-op external photography

• Serum TSH if thyroid disease is suspected

• C1-esterase inhibitor, if hereditary angioedema is suspected

Follow-up & special considerations

• If positive tensilon test, need to rule out Myasthenia Gravis

• If low tear film, conservative skin excision is advised to avoid lid lagophthalmos.

• If superior visual field loss, surgery is functional and may be covered by insurance.

• External pre-op photography is essential for documentation.

Imaging

Initial approach

• In most cases, none needed.

• CT scan or MRI of orbit and midbrain if associated third nerve palsy or proptosis

Follow-up & special considerations

Treat underlying condition if present

Pathological Findings

• Atrophy of eyelid skin, actinic elastosis, and basophilic degeneration of dermal collagen

• Attenuation of orbital septum

DIFFERENTIAL DIAGNOSIS

• Blepharoptosis

• Blepharochalasis

• Floppy eyelid syndrome

• Prolapsed lacrimal gland

• Entropion

TREATMENT

MEDICATION

First Line

• Skin care products (Retin-A, Alpha-Hydroxy Acids)

• If blepharitis, consider lid hygiene, topical antibiotics, and topical steroids.

• If dry eye, consider appropriate topical lubricant and/or punctual occlusion.

Second Line

• Fractional CO₂ laser treatment

• Infra-brow botulinum toxin injections

ADDITIONAL TREATMENT

Issues for Referral

• Underlying eyelid ptosis

• Dry eye syndrome

• Corneal pathology

• Brow ptosis requiring brow lift

• Laxity of lower lid requiring lid tightening procedure

• Prolapsed lacrimal gland

COMPLEMENTARY & ALTERNATIVE THERAPIES

• Vitamin supplements

• Fish oil and alpha omega–3 supplements

SURGERY/OTHER PROCEDURES

• The upper and lower lid blepharoplasty has undergone numerous refinements in recent years. These refinements include techniques to elevate and re-inflate descended and deflated tissues, as well as ethnic considerations. The technique is essentially the same whether surgery is for functional or cosmetic reasons.

• Primary treatment is surgical

IN-PATIENT CONSIDERATIONS

Initial Stabilization

Most are outpatient

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Slit-lamp evaluation for corneal health

Patient Monitoring

1 day, 1 week, 1 month post-op, and as needed.

DIET

• Low salt diet

• Fruits, berries,

• Leafy green vegetables

• Fish (salmon, sardines)

PATIENT EDUCATION

See risk factors

PROGNOSIS

Excellent in most cases

COMPLICATIONS

• Undercorrection

• Overcorrection (lagophthalmos)

• Exposure keratopathy

• Hollow superior sulcus (excess fat removal)

• Asymmetry of lid crease, fold or arch

• Medial canthal web

• Brow ptosis

• Blepharoptosis

• Complete loss of vision

ADDITIONAL READING

• Ancona D, Katz BE. A prospective study of the improvement in periorbital wrinkles and eyebrow elevation with a novel fractional CO2 laser-the fractional eye lift. J Drugs Dermatol 2010;9(1):16–21.

• Grant D Gilliland, Md Dermatochalasis Emedicine ophthalmology from WebbMD emedicine.medscape.com/article/1212294-printup Feb 25 2010.

• Korn BS, Kikkawa DO, Cohen SR. Transcutaneous lower eyelid blepharoplasty with orbitomalar suspension: Retrospective review of 212 consecutive cases. Plast Reconstr Surg 2010;125(1):315–323.

• Mack WP. Complications in periocular rejuvenation. Facial Plast Surg Clin North Am 2010;18(3):435–456.

CODES

ICD9

• 374.34 Blepharochalasis

• 374.87 Dermatochalasis

CLINICAL PEARLS

• Determine and address the patient’s main concern. Treatment is surgical if symptoms warrant treatment

• The patient needs to understand the true risks and have realistic expectations before surgery is undertaken

• Thorough preoperative evaluation and meticulous surgical technique are necessary to obtain satisfactory results