Oculoplastics involves the diagnosis and treatment of the eyelid, periocular area, lacrimal system, and orbit. This field includes various surgical procedures such as blepharoplasties, repair of orbital fractures and nasolacrimal duct obstructions, and excision of intraorbital and periorbital lesions. It can also include facial rejuvenation procedures like laser skin resurfacing and brow lifts.
Oculoplastic treatments can have both functional and aesthetic benefits. Here we will discuss updates in eyelid and periocular aesthetic treatment options.
Overview of conditions treated by oculoplastic specialists
| Condition | Features |
|---|---|
| Ptosis | Characterized by drooping of the eyelid. Associations: Aging, systemic disease, genetic disorders, trauma, long-term contact lens wear, and chronic eye rubbing. Can cause superior visual restriction. Can be cosmetically unappealing. |
| Dermatochalisis | Characterized by loose and redundant eyelid skin. Risk factors: Genetic predisposition, aging, high body mass index, light skin complexion, and smoking. Can affect superior and lateral vision. Typically evident in the upper lids, known as “hooding.” In the lower lids, it gives the appearance of “bags” under the eyes. |
| Eyelash thinning/loss | Risk factors: Age, recurrent blepharitis, ocular rosacea, dermatitis, autoimmune conditions, chemotherapy, laser treatment, trichotillomania, and repeated use of false lashes. |
| Periorbital wrinkles | Periocular skin around our eyes, being the thinnest on the body, is predisposed to wrinkles, fluid retention, dark circles, and the increased appearance of older age, making it an important area for rejuvenation. |
| Ocular Rosacea | More than half of patients with rosacea have ocular involvement. Consists of fine telangiectatic vessels along the eyelid margin leading to the appearance of pink lid margins. Associated with meibomian gland dysfunction, Demodex, and dry eye. |
Table 1: Courtesy of Maria Canellos, MS
Topical pharmaceutical agents used in oculoplastics
Upneeq
In 2020, Upneeq (Oxymetazoline hydrochloride) 0.1% ophthalmic solution was FDA approved for ptosis. Oxymetazoline is an alpha adrenergic agonist. It is a once-a-day ophthalmic drop that can improve eyelid positioning in patients with acquired blepharoptosis. Via its alpha agonism, the drop stimulates levator palpebrae muscle contraction and upper eyelid lift. Patients can experience 1 to 2mm of eyelid lift, lasting 6 to 8 hours.1
Due to Upneeq’s mechanism of action, caution should be taken when prescribing to patients with conditions such as cardiovascular disease and uncontrolled hypertension. In patients with narrow angles, Upneeq can potentially cause angle-closure glaucoma. Potential side effects of this drop may include conjunctival redness, superficial keratitis, dry eye, and headache.
This prescribed eye drop is a good nonsurgical option for those patients who may not be ready for ptosis surgery. Although the eyelid lift is milder than surgical eyelid lift results, it is a reasonable temporary solution. Upneeq can treat various causes of acquired ptosis, including Botox-induced ptosis. However, congenital causes of ptosis may still require blepharoplasty.
Latisse
We are familiar with Lumigan (bimatoprost 0.03% solution), which is prescribed to decrease intraocular pressure in glaucoma. Bimatoprost is a prostaglandin analog. Latisse is an eyedrop containing a different concentration of bimatoprost ophthalmic solution (0.3%). Latisse is the only prescription solution that is FDA-approved to lengthen and thicken eyelashes. A sterile applicator is applied to the upper eyelash and lid margin each evening.
Eyelash results are typically seen after 8 to 10 weeks of use. Side effects can include redness, dryness, itching, and darkening of the periorbital skin. Although unlikely, Latisse can cause hyperpigmentation of the iris. Caution should be taken when prescribing this to patients with uveitis, glaucoma, and dermatitis of the eyelid.2 If a patient stops using Latisse, their lashes will return to their original state.
Lumify
Lumify (brimonidine tartrate), 0.025%, is an ophthalmic solution used to decrease redness in the conjunctiva. There are many causes of conjunctival injection, which Lumify can be considered for. These include transient causes, such as acute irritation, and chronic causes, such as the use of glaucoma medications. However, it is important to note it is not used to treat infectious causes of conjunctivitis.
Brimonidine is an alpha 2 agonist which constricts blood vessels, alleviating conjunctival erythema. Brimonidine is found in other medications that lower intraocular pressure in glaucoma. Lumify does not require a prescription. Improvement can be seen within minutes, and it can be used every 6 to 8 hours. Side effects may include itching, dry mouth, blurred vision, and drowsiness.3 Drug interactions may be involved if taking opioids, antidepressants, and antihypertensives.
Light and thermal devices for the eyelids and periocular area
Intense pulsed light therapy
Intense pulsed light (IPL) is known to have many uses, including the treatment of facial rosacea, fine wrinkles, and skin pigmentation. In the eye, it is used for ocular rosacea, Demodex, chalazion, dry eye disease, and periorbital wrinkles. It is important to note that IPL is not a laser; it's light. A broad spectrum light is emitted through a filter and ultimately absorbed by the oxyhemoglobin in the telangiectatic vessels of the skin. The light is converted to heat and causes the ablation of these fine vessels.4
The wavelength of the light emitted, the pulse frequency, and energy density can be adjusted to treat different sizes of blood vessels and different skin complexions. This treatment targets dry eye disease because the ablation of these vessels along the lid margins decreases inflammatory mediators. This warming effect also allows for easier meibum expression in the meibomian glands. IPL also can help decrease the number of Demodex mites associated with ocular rosacea.
IPL can now be used to treat chalazion, making it a great nonsurgical alternative. This treatment helps to address the inflammatory nature of chalazia. Advantages include the comfort of the procedure, no incision, no injection, and no downtime. Because IPL addresses the underlying condition, it reduces the incidence of future chalazia.
There are many other in-office devices available to us that involve heat and mechanical expression of the meibomian glands. These can be used alone or in conjunction with the IPL. These include Lipiflow, iLux, TearCare, and low light therapy (LLT). In addition, radiofrequency involves electrical currents delivered to the skin for dry eye treatment and wrinkles.5 These currents are converted into heat, similar to IPL.
Injectable treatments used in oculoplastics
Neurotoxins
Botox and Dysport are commonly used intramuscularly injected agents in the United States that contain purified botulinum toxin approved for treatments in oculoplastics. The toxin’s mechanism of action involves inhibiting acetylcholine release at the neuromuscular junction. This leads to paralysis of the targeted muscle and decreases the appearance of dynamic wrinkles.
The effects of botulinum toxin can last about 3 to 4 months, with peak effects seen at 2 to 6 weeks. In oculoplastics, it is FDA-approved for hemifacial spasm and blepharospasm. For patients with blepharospasm, the purified extract is injected into the preseptal orbicularis oculi muscle.6 For hemifacial spasms, the location of injection varies depending on the muscles involved.
In addition, these injections may decrease the appearance of mild dermatochalasis. By lifting the eyebrow, the redundant and loose skin is elevated. As with all products, these do not come without their complications. The most common side effects are bruising, swelling, headache, and ptosis. Incomplete closure of the lids and a widened aperture may result, causing dry eye. Side effects resolve when the botulinum toxin wears off.
Fillers
As we age, the periocular skin becomes looser as collagen decreases. Periocular fillers are injections used to replace this lost volume to create a more youthful appearance. Some fillers even stimulate the synthesis of new collagen. There are various filler types, each involving different components, which include bovine collagen, human collagen, porcine collagen, and hyaluronic acid (HA).
The HA fillers are a particularly good choice for patients who would like the option of dissolving the filler, which is made possible by using hyaluronidase. Typically, their effects last 6 to 24 months in the periocular area. The outcome of filler placement is largely affected by the injection technique. For instance, fillers placed too superficially can lead to an irregular appearance.
The appropriate technique differs depending on the type of filler used. By putting filler in the upper cheek, it can help elevate the position of the lower eyelid giving a more youthful appearance in patients with lid laxity. Although fillers are often used for aesthetic purposes, they can be used for defects after cancer or trauma. Benign complications include redness, bruising, and the Tyndall effect; which is blue-gray discoloration.7
Other, more severe complications include allergic reactions and rarely skin necrosis and vascular occlusions. Although rare, there are reports of blindness due to retinal and ophthalmic artery occlusion after improper filler injections.8
Laser resurfacing
In oculoplastics, ablative laser resurfacing is a nonsurgical procedure that uses a laser to improve the appearance of skin around the eye. These lasers can be used for periocular photoaging, scars, and wrinkles. The light from the laser is absorbed by the epidermal water, removing this layer of skin. Once this heat reaches the underlying dermal layer, collagen formation and remodeling occur, leading to “skin tightening.”
Ablative laser resurfacing types differ depending on the type of laser used, which include fractional and non-fractional lasers. Fractional ablative lasers involve multiple narrow columns emitted in alternating locations, while non-fractional lasers target the entire surface. Therefore, fractional lasers allow for areas of undamaged skin to re-epithelialize, and the treatment area can recover more quickly. Both fractional and non-fractional lasers can also be subdivided into carbon dioxide lasers, Er:YAG (erbium) lasers, and more.
Research has shown that CO2 lasers may lead to an increased level of collagen remodeling. In addition, CO2 lasers can also be used during blepharoplasty to make an incision instead of using a scalpel. This technique leads to decreased bruising and bleeding.9 When considering laser resurfacing treatment, caution should be taken in patients with herpes, scleroderma, ectropion, and other cutaneous disorders. Complications of these lasers include redness, scarring, discoloration, and infection.
Advantages of this procedure include no incisions, no anesthesia required, minimal discomfort, and less recovery time than surgery. The number of treatments is dependent upon the depth of the scarring or wrinkles, and effects may last for years.
In closing
Oculoplastic procedures are often medically necessary to repair structural abnormalities that impair ocular function. In addition, many of these procedures have cosmetic utility.
We currently have many exciting treatment options for ocular and periocular conditions. As pharmaceuticals and technology continue to advance, the oculoplastics space will continue to be in high demand.
