Dermatochalasis Clinical Presentation

The patients who complain of dermatochalasis frequently report visual difficulties.

• The most common visual difficulties encountered include loss of the superior visual field, difficulty in reading, and loss of peripheral vision when driving.
• In addition, patients with moderate-to-severe dermatochalasis chronically elevate their brows to improve their visual field. This frequently is associated with frontal headaches.
• Ocular irritation, dry eyes, and dermatitis also may be the presenting signs of dermatochalasis.

Patients should be questioned about a history of periorbital trauma, thyroid disease, recurrent edema, dry eye syndrome, dry mouth, kidney disease, and dermatologic conditions.

The physical examination in patients with dermatochalasis should begin by measuring the patient's distant visual acuity with best-corrected lenses. Once this is complete, the examination should proceed in an orderly fashion as described below.

• The eyelid skin should be evaluated carefully. The amount of eyelid skin redundancy, the thickness of the skin, skin inflammation, and skin lesions should be noted carefully.
• The amount of excess skin in the upper eyelid can be assessed by the pinch technique, as shown in the image below. The pinch technique can be used in the lower eyelid when the patient maintains a sustained upgaze with the mouth open. This stretches the lower eyelid skin and helps ensure that overresection of lower eyelid skin is not completed. Pinch technique for measuring redundant skin in upper eyelid blepharoplasty.
• The presence of an upper eyelid crease should be noted and measured.

  • The normal upper eyelid crease falls 8-12 mm above the lid margin and is generally higher in women than in men.
  • Some patients may be noted to have a double eyelid crease or epiblepharon, which commonly is seen in Asian patients.
  • Some patients may not have an eyelid crease. In addition, the presence of a nasojugal fold and inferior tarsal eyelid crease should be noted.
• The orbital fat should be assessed in persons with dermatochalasis.

  • Orbital fat herniation can be accentuated by gentle ballottement on the eye.
  • There are 2 fat pads in the upper eyelid and 3 fat pads in the lower eyelid. The presence and amount of fat pad herniation should be noted.
• Lateral bulging in the upper eyelid frequently results from lacrimal gland prolapse, which should be noted preoperatively, in that lacrimal gland resection can cause serious complications.
• The eyelid margin position also should be noted. The normal upper eyelid margin position should fall approximately 1 mm below the superior limbus.

  • This distance also can be measured with the marginal reflex distance (MRD) test. The normal distance from the eyelid margin and the light reflex is at least 4 mm.
  • MRD is associated closely with superior visual field defects. The smaller the MRD, the more the visual field loss. Some authors have suggested that the MRD can be substituted for visual field measurement in assessing the functionality of a patient's dermatochalasis.
• It is critical to recognize lid ptosis preoperatively. Occasionally, the blepharoplasty surgery can be complicated by postoperative ptosis.

  • The position and the contour of the brow must be noted and any ptosis of the brow identified. This frequently plays a role in patients' expectations.
  • Many patients with dermatochalasis also have brow ptosis. To correct the dermatochalasis and visual field loss adequately, brow surgery should be performed concomitantly with blepharoplasty surgery. Blepharoplasty surgery performed alone has not been shown to change the brow height.
• The ocular surface should be assessed in all patients considering blepharoplasty surgery. Patients with a significant history of dry eyes should be evaluated carefully. This evaluation should include biomicroscopic examination of the ocular surface, evaluation of the tear film, position of the puncta, and, in some patients, measurement of the tear-breakup time (BUT) or basic secretor testing.

  • Many studies confirm that tear BUT, Schirmer testing, and basic secretor testing are inaccurate and inconsistent measures of a dry eye syndrome. Instead, the patient's constellation of findings should be viewed in the light of their history.
  • Other important findings to note include the presence of conjunctival filtering blebs, superior limbic keratitis, pterygia, pinguecula, corneal dystrophies and scarring, and corneal dellen.
• Bell phenomenon also should be assessed. A normal Bell phenomenon involves the rolling of the eyeball up and out upon eyelid closure. This is important in patients with a dry eye syndrome and/or lagophthalmos.

  • Some patients may be noted to have no Bell phenomenon or a reverse Bell phenomenon where the eye rolls down upon eyelid closure.
  • Lagophthalmos should be evaluated carefully. Blepharoplasty frequently can be associated with postoperative lagophthalmos. This resolves in most cases once the eyelid edema subsides. The presence of lagophthalmos can be used to judge the amount of skin to be resected.
• Proptosis and enophthalmos must be noted in all the patients with dermatochalasis. The position of the eyeball can affect the position of the eyelid on the globe and cause a pseudoptosis.
• Hypertrophic orbicularis muscle must be noted preoperatively. Most commonly, it is noted in the lower eyelid pretarsal region. The treatment is directed toward resection of the hypertrophic orbicularis muscle.
• Scleral show must be noted preoperatively. When present in the upper eyelid the etiology must be identified. The frequent etiologies include the following: thyroid eye disease, proptosis, amyloidosis, and postblepharoplasty surgery.
• Scleral show in the lower eyelid may be due to the above mentioned causes, plus the following: horizontal eyelid laxity, anterior lamellar shortening or posterior lamellar shortening, and scarring.

The most common cause of dermatochalasis is the normal aging phenomenon, which is associated with a loss of elastic tissue and resultant eyelid skin and muscle redundancy. Other causes may include the following:

• Trauma can be associated with dermatochalasis.
• Patients with severe periorbital edema may develop redundancy of the eyelid skin and muscle. This can be severe enough to cause a functional visual field defect.
• Chronic dermatitis can be caused by dermatochalasis, or it can be the cause of dermatochalasis. Chronic inflammation of the eyelid skin can lead to recurrent edema and redundancy of the eyelid skin.
• Thyroid eye disease frequently can be associated with dermatochalasis and steatoblepharon. It is associated with infiltration of the orbital fat and extraocular muscles with immunoglobulin complexes. Clinically, this is seen as steatoblepharon and resultant dermatochalasis.
• Chronic renal insufficiency can be associated with periorbital edema. When chronic, this edema can result in stretching of the eyelid skin and redundancy of the eyelid skin and muscle.
• Amyloidosis rarely can be associated with extracellular deposition of glycoproteins in the orbicularis oculi muscle. This can result in ptosis and dermatochalasis.
• Blepharospasm is a disorder of unknown etiology whereby the patients experience uncontrolled, sustained, and severe spasm of the orbicularis oculi muscles. This disorder frequently is associated with hypertrophy of the orbicularis muscle and resultant dermatochalasis.
• Floppy eyelid syndrome is a disorder of the eyelids that is associated with severely redundant and lax eyelids. Both the skin and the muscle are affected, and the tarsal plate develops a rubbery consistency and is significantly redundant and lax. When chronic, this leads to markedly redundant and lax eyelid skin and orbicularis muscle.
• Genetics may play a role in some patients who develop dermatochalasis. These patients frequently develop early signs of dermatochalasis in their 20s.