Adnexal Disease & Oculoplastics

Q: What is an adnexal disorder in ophthalmology?

A: The adnexal (tissues around the eye) subspecialty is one of several within the field of ophthalmology and it encompasses disorders of the eyelids, tear drainage, orbital tissues, and socket problems.

Some of the conditions diagnosed and treated within this subspecialty are:

• Eyelid Cyst

• Droopy Eyelid (Ptosis)

• Watery Eye

• Orbital Conditions

• Thyroid Eye Disease (TED)

Q: What is an eyelid cyst, and how is it treated?

A: There are various types of eyelid lesions, most common of which is a chalazion.  A chalazion is a common lump on the eyelid that is caused by inflammation of a tiny gland within the skin that produces oil. When this gland becomes blocked, it can rupture and the inflammation process begins. A chalazion is not a stye, which is an infection in the eyelash hair follicle root on the surface of the skin.

No treatment may be necessary as up to half of people get better without any treatment. This can take between two and six months but if the chalazion is not causing you any problems, it is probably best just to watch and wait.

Hot compresses help to ease discomfort. Hold a clean flannel that has been in hot water gently but firmly against the closed eye for 5-10 minutes, 3-4 times a day. Sometimes this warmth and slight pressure is enough to soften the contents of the fluid-filled swelling (cyst), helping it drain more easily. (The water should be hot but comfortable and not scalding.)

Antibiotic ointments, drops and medicines are not recommended as they do not make any difference – the contents of the cyst are infection-free (sterile).

A small operation is an option if it is troublesome or persistent. The operation is usually done under local anaesthetic, although children and some adults may not tolerate this and may require general anaesthetic. The eyelid is numbed and a small cut is then made on the inside of the eyelid to release the contents of the cyst and it is scraped out. After surgery, antibiotic drops or ointment are commonly prescribed.

Q: What are droopy eyelids (ptosis), and how are they treated?

A: Ptosis, or drooping of the upper eyelid, can happen in one or both eyes. Ptosis can interfere with vision by affecting the upper field of vision. It may also cause eye strain, eyebrow ache or cosmetic concerns.

Treatment of Ptosis is surgery to lift one or both of your upper lids. It is usually performed under local anaesthetic, although occasionally some sedation can be given during the procedure to help with relaxation.

The surgery takes approximately 45 minutes per eye. A patient may feel some light tugging on the eyelid during surgery, and may be asked to look up and down. At the end of the surgery, the skin wounds are closed with sutures (stitches), ointment is applied and a pressure dressing is placed over the eyelids. If both eyes are done then one of the eye pads will be removed after about an hour.

Q: What are watery eyes, and how are they treated?

A: Tears are constantly being produced by the eye; these usually drain out through the normal tear drainage system arising from the inner corner of the eyelid, down the tear duct into the nose. The tear duct narrows with age, resulting in the system overflowing and tears rolling down the cheeks. 

This would be treated through a surgical procedure to improve tear drainage by forming a new tear duct into the nose bypassing any existing blockage. It is usually performed under a general anaesthetic as a day case procedure. 

Q: What are orbital conditions, and how are they treated?

A: The orbit of the eye, or the eye socket, is the bony hollow structure which houses the eye as well as the associated anatomical structures. Various disorders can affect the eye. The orbit can get infections, inflammation, fractures, tumours etc. Various diseases like Grave’s disease can also affect the eye orbit.

Diseases of the eye orbit are treatable and can be completely cured if diagnosed in time. Since the eye area is very delicate and complex, the treatment should only be done by an ophthalmologist. Any delay in the treatment may result in permanent vision loss. Therefore, any changes in the eye, even if minute, should be taken seriously and a doctor should be consulted.

Q: What is thyroid eye disease, and how is it treated?

A: Thyroid eye disease is an autoimmune condition. ‘Autoimmune’ means that your own white blood cells or antibodies are causing damage to parts of your own body in addition to their normal role of protecting you against infections. In the case of thyroid eye disease, the damage is directed to fatty tissue and muscles behind the eye. Swelling of the damaged tissues behind the eyes can cause the eyes to become red and swelling to occur above and below the eyes. It may also cause the eyes to be pushed forward (‘starey eyes’, ‘proptosis’, ‘exophthalmos’). In more severe cases, the damage at the back of the eye causes swelling and stiffness of the muscles that move the eye, causing double vision especially when you look from side to side, as the muscles cannot keep the eyes exactly in line with each other. Occasionally, the swelling behind the eyes is bad enough to press on the nerve from the eyes to the brain, affecting your vision.

The commonest symptoms are mild soreness and grittiness of the eyes. Surprisingly, one eye is usually affected more than the other. There may also be increased watering of the eyes, a dislike of bright lights and a feeling of discomfort behind the eyes, especially when looking up or side-to-side. Puffiness of the upper eyelid or around the eyes (‘baggy eyes’) is also common and is worst first thing in the morning. The eyes often appear ‘starey’ and drying of the eyes or too many tears can cause blurry vision, which may come and go.

When double vision is getting worse or the accuracy of vision is deteriorating, stronger treatment may be used to calm down the immune system (immunosuppressive treatment) and reduce the swelling behind the eyes. Some specialists use low dose radiotherapy to the eyes. This is often effective and side effects (in experienced hands) are minimal. Currently, standard ‘immunosuppressive treatment’ involves steroid tablets at high dosage. This treatment is effective but can cause swelling of the face, increase in weight, thinning of the bones, sleeplessness and diabetes. It is therefore reserved for severe cases and must only be used under specialist supervision. Once the thyroid eye disease reaches the stable uninflamed state, these treatments are not effective.