Dermatochalasis

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


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Nov 9, 2016 | Posted by in OPHTHALMOLOGY | Comments Off on Dermatochalasis
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