By: Richard O. Gregory, MD
As a plastic surgeon, most of the inquiries I receive about the eyelids are concerning the appearance. However, it is important to remember that the eyelids are what protects our eyes and, therefore, our eyesight. It is a serious mistake to overlook, or perhaps even override the functional aspects in favor of a certain appearance. The purpose of this paper is to examine the anatomy, physiology, and common complaints regarding the eyelids. Persons with eyelid problems should consult their plastic surgeon or ophthalmologist to better understand their problem and what steps may be taken to safely correct it.
To better understand common complaints about the eyelids, it is important to understand their function. While much of the coverage of the eyeball is provided by the upper eyelid, the lower eyelid is more dedicated to protection and, therefore, more likely to be a problem for the patient. In particular, the function of the lower eyelid is to provide coverage and a tear film for the eyeball in order to lubricate the eye and prevent corneal ulceration, and perhaps blindness.
The lower eyelid acts like a windshield wiper to wipe the tear film across the corneal surface to lubricate it. This is done by the blink reflex when your eye is irritated. In order for an appropriate tear film to be provided, the eyelid must be against the eyeball. To assist in this process, there is a natural tilt to the eyelid called a canthal tilt which runs from the outer corner towards the inner corner of the eye. On very few patients is this tilt absent or negative, thereby impairing the tear drainage.
A common disorder occurs when the eyelid sags. As we age, there is a natural laxity that develops in the lower eyelid. In fact, the lower eyelid is designed somewhat like a hammock. A piece of fibrocartilage, attached by tendons to the inner and outer corner of the eye, stiffen the eyelid approximating it to the eyeball. Due to age and other factors, these tendons get stretched much like stretching the ropes on the hammock which then sags. For individuals suffering from this problem, there are operations designed to restore support for the lower eyelid.
Another cause of a sagging eyelid may be the shortening of the lower eyelid structures. This then results in ectropion, or increased scleral show, which reveals more of the white of the eye. This not only impairs the distribution of the tear film when we blink, but can also cause additional tearing. The tears tend to gather in the sagging portion of the eyelid and thus drain on the cheek. The shortening of this lower eyelid tissue can be aggravated by surgery. While difficult, grafting tissue into the lower eyelid to improve coverage can be done for some patients.
Commonly, patients complain of dry eye. Individuals with this issue often experience scratchy, irritated eyes in the middle of the night. As we sleep, the muscles around the eye relax and our natural blink reflex is gone. The eye then pops open. Overhead fans, air-conditioning, and the like blow across the eye causing dryness and irritation which can awaken the patient. A simple, but commonly overlooked, remedy for this is to cover the eyes at night to protect them. Although a number of devices have been invented and marketed for this purpose, a simple piece of clear, plastic kitchen wrap can be extremely helpful. Sleep masks may also work if they can achieve a good barrier seal around the eye.
While surgery can done to correct some of these anatomical problems, it also is possible that surgery on the eyelid can cause some of the problems. Following surgery, there is always some minor swelling around the eye. It is important that steps are taken to protect the eye during this phase of swelling. Head elevation, cool packs to the protect the eye, and loads of artificial tears or lubricants are all helpful. Usually, as the swelling abates, the eyelid function will gradually return although this may require a long time. Occasionally, additional surgery is necessary to further protect the eye. Treatments to improve eyelid and periorbital appearance will be discussed in another paper.
Finally, to extract a portion of the Hippocratic Oath that should serve as a warning to both the patient as well as the surgeon planning eyelid surgery, “Primum non nocere”, or “First, do no harm.” Always remember that the function and health of your eye is paramount to any concern of appearance.
About Richard O. Gregory, MD
An internationally known board-certified plastic surgeon, Dr. Richard Gregory has developed an outstanding reputation locally for his unparalleled surgical technique, excellent service, and integrity. While skilled in all areas of plastic surgery, his passion is in facial rejuvenation, utilizing surgical procedures, non-surgical options, and laser technology to achieve the desired result. Dr. Richard Gregory is a world renowned expert welcoming patients and surgeons from around the world who seek his expertise.
Year over year, Dr. Richard Gregory is voted “Best Plastic Surgeon in Orlando” by Orlando Magazine, recognized in America’s Best Doctors list, and chosen as “Best of the Best” by SELF Magazine. Dr. Richard Gregory is dedicated to helping his patients look and feel their best.
