Reconstructive Procedures

Blepharoptosis or Droopy eyelid

This patient had a droopy left upper lid, as seen in the first photo below. She is seen after surgical repair performed from the inside of the eyelid (lower photo). Sometimes the lid is too high or too low following this surgery, and further operations may be needed. Notice that the left upper lid is slightly higher than the right upper lid in the lower (postoperative) photo.


Thyroid Related Eye Disease

Pictured here is a patient with Graves' ophthalmopathy (thyroid related eye disease) preoperatively in the upper photo and following an orbital decompression surgery by Dr. Hawes and strabismus (double vision) repair (lower photo).

Many problems result from Graves' eye disease, including:

  • lid retraction (upper lid too high or lower lid too low)
  • double vision
  • bulgy eyes
  • swelling of the eyelids and eyeballs
  • blurry vision or loss of vision
  • trouble closing the eyelids and dryness of the eyes/watering of the eyes

The photos below show a patient with marked upper lid retraction and bulging of the eyes. The top photo is prior to surgery and the lower photo is one year following orbital decompression surgery.

Sometimes these problems resolve with time and medical management, but other times surgery is necessary or helpful. Steroids (for example, Prednisone) may help on a temporary basis. Radiation therapy may help. Surgeries include orbital decompression (removal of the bone and/or fat of the eye socket to allow the eye to settle back into the socket), repair of double vision, lowering of the upper lids, raising the lower lids, and blepharoplasty. Several operations may be needed to obtain the best result.


Skin Cancers

The most common skin cancer involving the eyelids and face is basal cell carcinoma. Sun exposure combined with a fair complexion often results in this tumor. The best treatment for these tumors is surgical excision, followed by reconstruction of the defect.

These tumors may vary in appearance, but do have some common characteristics:

  • firm nodule that won't heal
  • ulcerated or crusted surface that bleeds when you pick at it
  • loss of eyelash
The best treatment for these tumors is surgical excision, followed by reconstruction of the defect.

The patient pictured has a skin cancer located in the center of his lower eyelid.


Trauma

Injuries can cause bothersome eye problems. The patient pictured at right (top) has sustained facial fractures and a blocked tear duct, but also has a deformity of the inner corner of his right eye, in which the inner corner is moved laterally (telecanthus) and downward. He was referred to Dr. Hawes by a general plastic surgeon for repair of the telecanthus after four previous surgeries.

Pictured at right (below) is a dog bite injury patient referred to Dr. Hawes for repair. He has a laceration involving his tear ducts, which can result in excessive tearing unless it is properly repaired.


Eyelid turned in

The patient pictured here has a right lower eyelid entropion, or a rolling inward of the eyelid margin. This results in the eyelashes rubbing the eye, and is very irritating to the eye. Surgery is the best treatment, with a successful repair achieved by Dr. Hawes 95% of the time after one operation.

Eyelid turned out

The patient at right has both lower lids turned outward. This is an example of a lower lid ectropion, which also predisposes the eye to irritation and infections, and is treated with surgery.


Excessive Tearing

Below is a sketch of the tear ducts, which normally drain tears away from the eye and into the nose. When there is a blockage of the ducts, the tears cannot drain properly and instead accumulate by the eye. This can be a nuisance and sometimes may result in infections of the tear sac and a recurring pink eye. Surgery is usually necessary when the tear ducts are completely blocked. This can often be done on an outpatient basis in about one hour with local anesthesia and sedation. The success rate for dacryocystorhinostomy (DCR) is 90-95% with a single operation. Dr. Hawes has performed more than 2000 of these operations. The operation can sometimes be performed without a skin incision, though it is more often done with a small (1/2 inch) incision. Dr. Hawes also places and repairs Jones tubes, which are permanent indwelling Pyrex glass tubes placed to drain the tears when other procedures fail to provide sufficient relief.

Shown at right is the location of the skin incision and the appearance of the scar eight months after the surgery. The scar is minimal in this patient, as is typically the case.


Orbital Tumors

The orbit and its contents (right) consist of the bones of the eye socket and the soft tissue contents, including the eye and its associated muscles, vessels, nerves, and other soft tissue contents. Diseases and tumors may occur in this space.

Common problems include inflammatory, cancerous, structural, and vascular or blood vessel disorders. These can manifest with bulging or displacement of the eyeball, double vision, loss of vision, swelling of the eye and eyelids, pain, tearing, or pulsation of the eye.

Can you see the tumor in the CT scan pushing the right eye forward?

Pictured at right is a patient with an orbital tumor pushing her right eye forward in the first photo and then following removal of the tumor by Dr. Hawes in the second or lower photo. The tumor was derived from a nerve and was quite large.


Fractures

Fractures or broken bones of the eye socket and face are a frequent result of trauma. The most common object causing a "blowout" fracture of the orbit is a fist, although baseballs, racquet balls, golf balls and motor vehicle accidents can also do this. Below is a drawing of how these fractures occur (the drawing is from a textbook chapter authored by Dr. Hawes).

Signs of a blowout fracture include:

  • numbness of the cheek, side of the nose, upper teeth, lip, or gum on the side of the injury
  • double vision
  • sunken eye, which may not be apparent for weeks to months
Seen at right is a patient with double vision after a blowout fracture repaired by a general plastic surgeon. Notice the left eye does not elevate very well. In the second or lower photo, the patient is seen following repair by Dr. Hawes. The patient still has some double vision.

Some fractures heal without surgery, but the more severe ones are best treated with surgery. Dr. Hawes can usually perform the repair from inside the lid, avoiding a skin scar. Dr. Hawes has successfully repaired fractures for several professional athletes.


Loss of an Eye

Trauma, disease, or cancer may require removal of an eye.  The psychological injury to the patient from such a loss can be much worse than the physical disability.  See this link for helpful information on many issues related to the loss of an eye.

Surgery to remove an eye includes the options of enucleation (removal of the entire eye) and evisceration (removal of the eye contents with preservation of the outer white portion). Dr. Hawes is now performing more eviscerations than enucleations when possible, as the evisceration surgery often gives a better cosmetic result.

Removal of an eye is usually done under general anesthesia on an outpatient basis. An implant is placed in the eye socket at the surgery, typically with the eye muscles attached to it. This is important in preserving movement. About 6 weeks after the surgery, an ocular prosthesis is fit by an ocularist, who works  closely with Dr. Hawes to get the prosthesis looking and moving like a real eye. Most often, Walter Johnson is the ocularist for Dr. Hawes' patients. Walter has the skills of an artist, is a fine craftsman, and is nationally known for his work. He can be reached at 303-649-9494.

There have been many advances in implants and prostheses over the last twenty years. The new motility implants allow for blood vessels to grow into the implant and offer the potential for placing a motility peg. While it usually does improve fine movements of the prosthesis, a peg is not essential. in most cases and sometimes a peg can cause additional problems. Dr. Hawes has been using motility implants since 1985 and is very familiar with their implantation and management.

The patient pictured at right had his left eye removed by Dr. Hawes, with placement of a motility implant. He is seen wearing an ocular prosthesis made by Walter Johnson.

A book is available that many patients have found helpful in dealing with the loss of an eye. Order your copy of A Singular View, written by airplane pilot Frank Brady, who lost an eye in an accident. The book gives accurate descriptions of the problems encountered, and suggests methods of coping with the problems.


Birth Defects

Children sometimes are born with eyelid, tear duct, or eye socket problems. These may include blocked tear ducts, droopy eyelids, hemangiomas (benign blood vessel tumors), and syndromes such as Goldenhar's syndrome.

Pictured at right (top) is a child with a hemangioma. The little girl was treated by Dr. Hawes with steroid injections. The first photo shows the preoperative photo and the lower photo shows the result several years later. Even though the tumor is not completely gone, the patient has a much improved appearance. These tumors do tend to improve with time. Surgery can speed the improvement.

Another example of a congenital or birth problem is pictured below. This baby girl has a somewhat unusual syndrome known as Goldenhar's syndrome. She has a coloboma or defect in her left upper eyelid, which has failed to form properly. Also notice the skin tag in front of the ear. The first photo shows the preoperative photo with Saran wrap over the eye to protect it from dryness and the lower or second photo shows the result following reconstruction of the left upper eyelid by Dr. Hawes. Notice the white spots on the outer aspect of each eye, which are limbal dermoids, commonly found as part of this syndrome.


Blepharospasm

Benign essential blepharospasm  consists of involuntary spasms of forceful eyelid closure and is more common than previously believed.  The cause of the disorder is not yet known, although research continues. Botox or botulinum toxin therapy is helpful in most patients. This drug is given by injection into the muscles causing eyelid closure. It usually works within a few days or weeks and lasts 3-4 months. Contact the Benign Essential Blepharospasm Foundation for support groups, a newsletter, research information, and audio tapes describing BEB and its treatment.

Sometimes surgery is used to treat this condition, especially when all other treatments have not succeeded. Pictured below is a patient who had a limited myectomy surgery performed by Dr. Hawes. He no longer requires Botox injections, although most patients still do need Botox after myectomy surgery.