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EYE CARE AND EYE CARE ANDEYE CARE AND
QUALITY OF LIFE QUALITY OF LIFEQUALITY OF LIFE

Prior to this point in the procedure, an auricular graft is harvested (2) remove only fat, not including orbital septum, for shortening of
from behind each ear under a posterior skin and subcutaneous tissue the dense orbital septum will produce an internal retraction phenom-
flap. An approximate 4 mm by 20 mm rectangular cartilage graft is enon; (3) avoid fat removal via the cul-de-sac conjunctival approach
then fleshed and stored in saline. Then a lateral canthotomy, inferi- in the lower lid; proptosis usually makes the orbital fat pads extrude Eye Allergies: Symptoms and Relief
or cantholysis and inferior cul-de-sac conjunctival incision is made more anteriorly into the lid, but the operative space is very tight due
just under the inferior edge of the tarsus. The lower lid retractors are to proptosis, and the orbital septum is difficult to dissect from the
stripped or incised to release the lid from its posterior imbrication. The posterior approach; (4) maintain corneal protection at all time with
graft is sutured with a running, interlocking suture of 6-0 Vicryl using either a corneoscleral protective shield or ocular lubricants such as car- By Priyanka Gupta, MD
a spatula eye needle to the superior edge of the tarsus and the lower boxymethylcellulose sodium (Celluvisc, a long lasting lubricant drop).
lid retractor stump. The cartilage graft chosen for each eyelid is placed It is extremely important before embarking on this procedure to
with the convex surface toward the skin, which gives a nice curvilinear verify that this is a patient with euthyroid Graves’ Disease. A full med- pring is in the air, but so is a yellow-green colored pollen from age but is not a good long-term solution. Nasal decongestants also
shape to the lower line. The posterior surface of the graft is covered ical and ophthalmologic workup should be performed first to ascertain Live Oak trees here in San Antonio. You might have noticed only relieve symptoms temporarily and should not be used on a regu-
with conjunctival overgrowth within one week as the sutures dissolve. that this is a stable condition. Sthis pollen clogging your pool filter, covering your car wind- lar basis. Antihistamine/mast-cell stabilizers are available in both eye
The conjunctival edges are not sutured together over the graft, because shield or coating your outdoor table. This heavy pollen can linger drops and nasal sprays — most over the counter. They tend to work
this will only vertically shorten the lid posteriorly. The inferior arm of William R. Thornton, MD, FACS, is certified by the American in the air for weeks depending on whether or not it has rained. The with less efficacy compared to nasal corticosteroids and nasal antihis-
the lateral canthal tendon is sutured with a double- armed 5-0 Vicryl, Board of Ophthalmology and University Fellowship trained resulting allergy and asthma symptoms can be miserable. tamines. They are a good option when there may be a contraindication
and the canthotomy is closed with 6-0 silk. in the subspecialty of Ophthalmic/Facial Plastic/Orbital to being on antihistamines or topical corticosteroids. Corticosteroid
If it is necessary to narrow the lateral commissures for improve- Reconstructive Surgery. Dr. Thornton is a member of the Bexar Classic Spring “Hay Fever” Symptoms Can Include: nasal sprays are now available over the counter, and should be started
ment in cosmesis, a small lateral tarsorrhaphy of 3 mm will complete County Medical Society. • Rhinorrhea two weeks before the allergy season and continued for the duration of
the procedure nicely. The lateral tarsorrhaphy is performed in the usual • Nasal congestion leading to mouth breathing/snoring at times the season for maximum effectiveness. Linking the nasal corticosteroid
fashion with denuding of the lid margin with a Bard-Parker 15 blade, • Postnasal drip with a nasal antihistamine is a superior combination than just taking
suturing the cartilage with a double-arm 5-0 Vicryl suture, and exter- • Sneezing (can be repetitive and severe in some cases) an oral antihistamine as it targets the nasal mucosa and ocular areas
nalizing the knot through the skin and then interrupted 6-0 silk in • Itchy nose, eyes, ears and mouth locally giving good local effects. There are several prescription nasal
the skin. References: • Red and watery eyes steroid/nasal antihistamine combinations that are available, and can
1. Baylis HI, et al. Autogenous auricular cartilage grafting for lower • Swelling around the eyes be an excellent preventative strategy during Live Oak pollen season.
Discussion eyelid retraction. Opthalmol Plast Reconstr Surg 1985; 1:23 • Moody and irritable
One of the most grateful patients in a cosmetic surgery practice 2. Chlafin J, Putterman AM. Mueller’s muscle excision and leva- • Tired When all the efforts above fail, or leave a patient with suboptimal
is the thyroid ophthalmopathy patient with improved cosmesis and tor recession in retracted upper lid. Arch Ophthalmol 1979; • Disturbed sleep results, it’s time to call your allergist to consider allergen immunother-
function after upper and lower lids retraction surgery. Patients with 97:1487 (see also Ophthalmology 1981;88:507) apy. Immunotherapy can help build the body’s tolerance. With immu-
extreme proptosis so that eyelid closure is impossible should be consid- 3. Converse JM, Krupp S. Exopthalmos. In: Converse JM (ed) The ocular manifestations can be pronounced during March and notherapy, you get shots containing tiny amounts of the allergen. The
ered for orbital decompression first, then eyelid surgery. If strabismus Reconstructive plastic surgery. 2nd ed, vol 3 (Philadelphia: WB April here in San Antonio, causing itching, watering, swelling and ery- dose gradually increases over time to help your body become immune
(usually vertical heterotopia) is present, extraocular muscle surgery is Saunders, 1977:972-8) thema. For patients with asthma, there may be an upswing of asthma to the allergens. A board-certified allergist can prescribe more inten-
indicated before eyelid retraction surgery, for obvious reasons. 4. Cooper WC. The surgical management of the lid changes of symptoms: hacking cough, shortness of breath, chest tightness and sive remedies to bring your current symptoms under control and devel-
Cartilage shims may be used in both upper and lower lids, but most even wheezing leading to asthma exacerbations every spring. op a preventative plan using allergen immunotherapy that can help you
have found it unnecessary in the upper lid. I avoid any cartilage or Graves’ disease. Ophthalmology 1979;86:2071 avoid the misery of seasonal allergies in the future. Rather than reduc-
preserved sclera in the upper lid due to the possibility of extrusions of 5. Dixon R. Surgical management of the thyroid related upper eye- Some Tips to Help Battle the Spring Allergy Season Include: ing symptoms after they have started, allergen immunotherapy (“aller-
suture or implant, which would have serious complications involving lid retraction. Ophthalmology 1982;89:52 1. Limiting your outdoor exposure as much as possible. Maybe gy shots” or “allergy drops”) helps your body develop resistance to the
the cornea, and the thickening of the preseptal area, which is a signifi- 6. Frueh BR, et al. Lid retraction and levator aponeurosis defects exercise temporarily indoors, use more air-conditioning while in pollen particles so that your symptoms are significantly reduced and
cant cosmetic shortcoming. in Graves’ eye disease. Ophthalmol Surg 1986;17:216 your car and consider wearing a mask. much less severe. Allergy injections are the traditional immunothera-
Cartilage in the lower lid is well tolerated by the cornea because 7. Harvey JT, Anderson RL. The aponeurotic approach to eyelid 2. Be sure to wash after every outdoor activity. That pollen can py treatment and are widely recognized as being quite effective. Oral
the graft is inferior to the cornea, and closure of the lids does not bring retraction. Ophthalmology 1971;88:513 collect on hair and clothing so taking a shower and changing into allergy drops are now available and offer a convenient, safe and effec-
them into contact. Some surgeons have insisted on closing the con- 8. Henderson JW. Relief of eyelid retraction-a surgical procedure. clean clothing after outdoor activities will reduce your exposure to tive option for patients who don’t want to take allergy injections in the
junctival pocket overlying the graft. In eyes of the patient with thyroid Arch Ophthalmol 1965;74:205 the pollen. Also consider taking your shoes off outside to not track doctor’s office. Regardless of whether you choose shots or drops, an
disease this will only shorten the lid posteriorly and produce some 9. Leone CR. Management of ophthalmic Graves’ disease. Oph- pollen indoors. individualized extract prescription is prepared for each patient based
recurrence of retraction. thalmology 1984;91:770 3. Wipe off pets before they enter your home. on the results of specific allergy testing.
Lateral tarsorrhaphies can be used judiciously to narrow the lat- 4. Begin taking your preventative medications now and defi-
eral palpebral fissures in patients with persistent temporal flare of the 10. Putterman AM, Fett DR. Mueller’s muscle in the treatment of nitely a couple weeks before the allergy season in the future. Priyanka Gupta, MD, is board-certified in Allergy-Immunology.
lids. A unilateral tarsorrhaphy can bring asymmetrical lid retraction upper eyelid retraction: a 12 year old study. Ophthalmol Surg Dr. Gupta received her BS from the University of Michigan
patients. 1986’17:361 Several Categories of Medications Can be Helpful: and her MD at Michigan State University College of Human
The important aspect of the blepharoplasty to remember are: (1) 11. Schimek RA. Surgical management of ocular complication of Artificial tear drops help relieve eye allergies temporarily by Medicine. Her internal medicine residency was completed
avoid aggressive skin removal; leaving some redundant skin is a better Graves’ disease. Arch Ophthalmol 1972;87:655 washing allergens from the eye. A daily nasal saline rinse is very in Houston at Baylor College of Medicine. Her Allergy-Immunology
cosmetic result, for too much skin removed will produce lagophthal- 12. Waller RR. Lower eyelid retraction: management. Ophthalmol effective at helping keep nasal passages open naturally. Oral antihis- fellowship took her to Chicago at Northwestern University Feinberg
mos and compromise the improved lengthening of the lid anteriorly; Surg 1978;9-41 tamines may be somewhat helpful in relieving itchy eyes, but they School of Medicine, where she trained in both adult and pediatric allergic
can make eyes dry and even worsen eye allergy symptoms. Adding an and immunological diseases. Dr. Gupta is a member of the Bexar County
oral decongestant PRN can temporarily relieve sinus pressure/drain- Medical Society.

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