Tears are produced by the lacrimal and the eyelid glands and are responsible for protecting and keeping the eye moist. When the ducts responsible for allowing the tears to drain, which are different from the lacrimal gland ducts, become clogged, excessive tearing occurs (watery eyes). Abnormal tearing occurs because of blockages in one of three areas:

• Blockage of the tear drain in the nose (nasolacrimal duct obstruction)
• Blockage of the tear drain in the eyelid (canalicular obstruction)
• Blockage of the tear drain opening on the eyelid margin (punctal stenosis)

Treatment for tear duct obstruction

Tearing is fairly common and can be caused by conditions, such as allergy or medication, that only temporally lead to tear duct blockage.

Tear duct obstruction in infants is usually caused by a thin membrane blocking the opening of the tear duct in the nose and typically resolves itself before the child is one year old. If the problem persists, it may be necessary to open the blocked tear duct surgically. If the child is born with a blockage, the condition is classified as congenital nasolacrimal duct obstruction.

A blocked tear duct in adults rarely resolves itself if not caused by infection, medication or allergy and it may be necessary to have surgery to open the blocked tear duct. Tear duct surgery options include:

• Tear duct opening (punctoplasty) – If the punctum (tear duct opening on the eyelid margin) is narrow, a minor, painless procedure can be done in the office under local anesthesia to open it.
• Tear duct intubation (stenting) – For narrowed but not completely blocked tear ducts (usually related to medication), tubes (or stents) can be placed in the tear ducts for a couple of months to prevent further or permanent scarring. This procedure can be done either in the office or in the operating room under minor sedation. Tube removal is performed in the office and is painless.
• Dacryocystorhinostomy (DCR) – If damage to the tear duct is irreparable, a bypass communication needs to be created between the tear duct and the nose to allow the tears to drain. This procedure, called dacryocystorhinostomy, is performed in the operating room under general anesthesia or deep sedation and also involves placing tubes (or stents) in the lacrimal ducts for a couple of months. Tube removal is performed in the office and is painless.
• Jones Tube placement (cDCR) – when there are no lacrimal canaliculi left in the eyelids, a rigid plastic tube (the Jones tube) is placed, after a DCR surgery is performed, from the inner corner of the eye into the nose. The tube in this case will stay in place permanently, although occasionally it needs to be replaced.

There are a few occasions where it becomes necessary to remove all or part of a patient’s eyeball and/or eye socket. While this surgery is used as a last resort, reasons to have all or part of the eye or eye socket removed or modified include:

• Trauma – A severely damaged eye sometimes cannot be repaired and has to be removed in order to prevent infection and sympathetic ophthalmia (a rare disease where the immune system attacks not only the damaged but also the normal eye).
• Pain – A blind eye commonly becomes painful and has to be removed for comfort, in addition to cosmetic reasons
• Cancer of the eye – If cancer is present within the eye itself, it is sometimes necessary to remove the entire eye
• Orbital tumors – While tumors can grow inside the eye, they may also grow within the eye socket (the orbit) which surrounds and protects the eye
• Sunken eye (enophthalmos) – Usually refers to a sunken appearing prosthetic eye and can be treated by various procedures that increase the volume of the eye socket to bring the prosthetic eye forward, in line with the normal eye.

Surgical procedures for eye removal

Our oculoplastic surgeons will help determine if partial eye removal will be more beneficial, or if removing the entire eye is the only option. These procedures are used only when absolutely necessary. The three main surgical techniques for partial or complete eye removal are:

• Evisceration – Evisceration surgery involves removing the eye contents, while leaving the sclera (the white part of the eye) and the muscles responsible for the eye movements intact. This is the least traumatic procedure for the eye socket and usually yields the best cosmetic result.
• Enucleation – Enucleation surgery involves the removal of the entire eye (including the sclera), but leaves the eye muscles and the orbit intact
• Exenteration – The most radical of the three procedures, exenteration involves removing the entire eye, the eye muscles, most of the orbital soft tissues and occasionally part of the orbital bones. This procedure is reserved for severe cancers or life-threatening infections.

Eye and eye socket reconstruction

Evisceration, enucleation, and exenteration surgery will change the appearance of your eye, making reconstructive surgery necessary. Because the procedure is carefully selected based on individual needs, our oculoplastic surgeons will discuss which reconstructive options might be best for you.

Several facial and eyelid squeezing disorders are treated by our oculoplastic surgeons. These disorders include:

• Blepharospasm (BEB) – Blepharospasm is characterized by bilateral involuntary eyelid spasms, which sometimes affect other facial muscles as well. The cause for blepharospasm is unknown but is thought to be a neurodegenerative disease such as Parkinson’s.
• Hemifacial spasm (HFS) – Hemifacial spasm is characterized by involuntary twitches occurring on one side of the face. This can be sometimes caused by compression of the facial nerve (the seventh cranial nerve – responsible for movement of the eyebrows, eyelids and mouth) by tumors or vascular lesions. However, hemifacial spasm is fairly rare and in most patients a direct cause cannot be identified.
• Meige syndrome (lower facial dystonia) – A rare disorder characterized by involuntary muscle contractions in the jaw, tongue and eyes, Meige syndrome is a combination of two forms of dystonia: oromandibuar dystonia (OMD) and blepharospasm.
• Aberrant regeneration (AR) – AR is similar to hemifacial spasm in that it is usually unilateral and can involve both the upper and the lower face. Occurs after recovery from Bells’ or other forms of facial nerve palsy when the facial nerve function is abnormal with miswiring and excessive stimulation of the facial muscles.   

Treatment for eyelid and facial squeezing disorders

Many disorders that cause spasms of the face can be treated with Botox® injections, but severe cases of belpharospasm, especially those associated with apraxia of lid opening, require surgical intervention. Myectomy surgery is the procedure of choice for severe squeezing not responding to Botox® injections, although surgery is sometimes needed to correct the associated droopy eyelids and brows and improve the dry eyes by tightening the lower lids.

Various diseases can affect the eyelids, making vision difficult or altering one’s physical appearance. The eyelids are responsible for protecting the eyes. When working correctly, they spread moisture over the surface of the eye (keeping it from drying out) and act as natural barriers to outside particles. However, when eyelids do not function properly, they can irritate the eye and cause vision problems. The following eyelid problems are addressed by the oculoplastic surgeons at the Wilmer Eye Institute:

• Ptosis – Ptosis (drooping of the upper eyelids) generally affects an individual’s line of sight. Caused by age, nerve damage or trauma, ptosis can affect adults and children and is treated surgically by lifting the eyelid.
• Dermatochalasis – Defined as an excess of skin in the eyelids, dermatochalasis is typically treated by blepharoplasty. Upper eyelid dermatochalasis is sometimes covered by insurance if severe enough to block vision. Discuss this with your doctor at the time of your appointment.
• Brow ptosis – Brow ptosis is a drooping or sagging eyebrow. Brow ptosis repair is sometimes covered by insurance companies and involves an internal brow elevation (browpexy), a direct brow lift or an endoscopic forehead lift. Discuss these options with your doctor at the time of your appointment.
• Ectropion – Defined as outward turning of an eyelid (typically the lower eyelid), ectropion exposes the inner portion of the eyelid as well as the eye to the air, exacerbating the dry eye symptoms: blurry vision, tired, burning eyes, red eyes, red eyelids and sometimes tearing. 
• Entropion – Defined as inward turning of an eyelid (typically the lower eyelid), entropion causes the eyelashes to rub against the surface of the eye. This leads not only to severe irritation and decreased vision but, if left untreated, to permanent scarring and vision loss.
• Eyelid retraction – Various conditions (scarring, prior surgery, Graves disease) can shorten the eyelids vertically, which exposes the eye to the air and leads to decreased vision and irritation. This in turn affects not only the quality of vision but also the health of the eye.

Accidents often result in dramatic alterations to one’s appearance. Our oculoplastic surgeons are experts in those reconstructive procedures that repair facial or eyelid lacerations, as well as facial or orbital fractures.

Each case is unique and treatment is typically performed on an urgent basis. Any alterations to the normal anatomy of the face and orbit (the eye socket) can be addressed by our physicians. The goal of treatment is always to return the face and the eyes to their original appearance and function.

In addition to emergency treatment, our oculofacial plastic surgeons work to counter long-term effects of traumatic injuries, such as scarring, excess tearing, and double vision.

Orbital tumors

The orbit (the eye socket) and the eyelids work in conjunction to protect the eye and its muscles. Various tumors may grow or spread to the eye socket or the eyelids and must be removed in order to protect our patient’s vision. Your surgical team will make recommendations based on the size and location of the tumor.

Graves' Orbitopathy

Graves' orbitopathy is an autoimmune condition characterized by swelling of the tissue in the orbit (the area around the eyes), creating bulging of the eyes. 

Learn more about Graves' orbitopathy.

Orbital decompression surgery

Orbital decompression surgery is the name given to those procedures designed to enlarge the eye socket, thus reducing the pressure on the optic nerve and the bulging of the eye (proptosis). It involves removing orbital fat, bone or both. It is done under general anesthesia and can be performed at the same time with certain eyelid procedures designed to reduce the corneal exposure and dryness. Although a reconstructive procedure covered by insurance, it has a dramatic effect on the patient’s appearance, as well.

More new cases of skin cancer are diagnosed every year than the combined cases of breast, prostate, lung and colon cancer. Skin cancer is commonly caused by excessive sun exposure. Some common early signs of skin cancer include:

• Red splotches
• Scale-like or flaking skin
• Dark spots
• Bumps or raised areas of skin

Cancer of the eyelids is very dangerous and needs to be treated urgently. If skin cancer forms around the edge of the eyelids, it often causes the eyelashes to fall out. The following are types of skin cancer known to affect the eyelids and skin:

• Basal cell carcinoma – The most common type of skin cancer, basal cell carcinoma can present itself as a white or red bump or nodule
• Squamous cell carcinoma – The second most common type of skin cancer, squamous cell carcinoma often presents itself as an scaly lesion (squamous means “scale”)
• Sebaceous cell carcinoma – The third most common form of eyelid cancer can be very aggressive with metastasis occurring early in the course of the disease. 
• Melanoma – Least common but most deadly among all forms of skin and eyelid cancers, melanoma often presents itself as a growing, changing, irregularly colored splotch on the skin or the eye.

Skin cancer diagnosis

To diagnose skin cancer, the physician will take a biopsy of the suspected lesion in clinic for examination under the microscope by a trained pathologist. If the biopsy confirms the lesion to be cancerous, further treatment will be needed.

Skin cancer treatment

One of the most successful methods for skin cancer removal is Mohs surgery. Mohs surgery involves the removal of skin cancer, layer by layer.

Learn more about Mohs surgery.

On the same or subsequent day, our oculofacial plastic experts perform the reconstructive surgery to restore your normal appearance following the removal of skin cancer lesions from the face or the eyelids.

Trichiasis is the official name for a condition characterized by misdirected or abnormally positioned eyelashes. Trichiasis, sometimes caused by entropion causes discomfort and irritation to the eye, and can lead to permanent damage to the cornea and vision loss. Symptoms of trichiasis include:

• Constant eye irritation
• Eye pain, redness and/or irritation
• Excessive or abnormal tearing
• Excessive sensitivity to light

Treatment for trichiasis

Treatment for trichiasis depends on the number of eyelashes affecting the surface of the eye. For temporary relief, the eyelashes can be plucked out (called epilation), but they usually grow back.

For more severe cases and for recurrent disease, our team of oculoplastic surgeons may recommend permanent removal of only the affected eyelash follicles using a special radiofrequency device. If entropion is the cause, or if the cornea has been damaged, corrective eyelid surgery may be necessary.