eMedicine Specialties > Ophthalmology > Lid

Dermatochalasis

Author: Grant D Gilliland, MD, Private Practice, Texas Ophthalmic Plastic, Reconstructive and Orbital Surgery Associates
Contributor Information and Disclosures

Updated: Nov 2, 2007

Introduction

Background

Redundant and lax eyelid skin and muscle is known as dermatochalasis. It is a common finding seen in elderly persons and occasionally in young adults. Gravity, loss of elastic tissue in the skin, and weakening of the connective tissues of the eyelid frequently contribute to this lax and redundant eyelid tissue. These findings are more common in the upper eyelids but can be seen in the lower eyelids as well.

Some systemic diseases also may predispose patients to develop dermatochalasis. These include thyroid eye disease, renal failure, trauma, cutis laxa, Ehlers-Danlos syndrome, amyloidosis, hereditary angioneurotic edema, and xanthelasma. Genetic factors may play a role in some patients.

Dermatochalasis can be a functional or cosmetic problem for the patients. When functional, dermatochalasis frequently obstructs the superior visual field. In addition, patients may note ocular irritation, entropion of the upper eyelid, ectropion of the lower eyelid, blepharitis, and dermatitis. When cosmetic, patients note a fullness or heaviness of the upper eyelids, "bags" in the lower eyelids, and wrinkles in the lower eyelids and the lateral canthus.

Steatoblepharon describes the herniation of the orbital fat in the upper or lower eyelids. It is associated frequently with dermatochalasis. However, some patients may present with isolated steatoblepharon. Herniation of the orbital fat in the eyelids is because of a weakening of the orbital septum, usually because of age. Most commonly, it is noted in the medial upper eyelid but can give the appearance of "bags under the eyes."

Blepharochalasis syndrome is separate and distinct from dermatochalasis and is a rare disorder that typically affects the upper eyelids. It is characterized by intermittent eyelid edema, which frequently recurs. This results in relaxation of the eyelid tissue and resultant atrophy. In approximately 50% of patients, it is unilateral.

This syndrome can be separated into early and late phases. The early phase is divided further into hypertrophic and atrophic forms. The cause is probably a localized form of angioedema. Sequelae include conjunctival edema and injection, entropion, ectropion, steatoblepharon, ptosis, and excessively thin skin. Blepharochalasis rarely can be associated with agenesis of the kidney, vertebral abnormalities, and congenital heart defects.

Pathophysiology

The pathophysiology of dermatochalasis is consistent with the normal aging changes seen in the skin. This includes loss of elastic fibers, thinning of the epidermis, and redundancy of the skin. When associated with dermatitis, a nonspecific chronic infiltrate is seen. The pathology of blepharochalasis typically shows loss of elastic fibers, lymphedema, epithelial atrophy, and vasculitis.

Frequency

United States

Dermatochalasis most frequently occurs in elderly persons and is very common; the severity is quite variable. The age of onset most frequently is noted in the 40s and progresses with age. Some patients have a familial tendency and develop dermatochalasis in their 20s.

Mortality/Morbidity

• Visual field loss is the most frequent sequelae of dermatochalasis. In severe cases, patients can lose more than 50% of their superior visual field. Patients with a purely aesthetic deformity may not have any visual field defects.
• Blepharitis frequently is seen in patients with moderate-to-severe dermatochalasis. It is characterized by eyelid skin edema and erythema; scurf; meibomian gland inflammation and plugging; and, occasionally, hordeolum.
• Eyelid deformities, such as upper eyelid entropion and lower eyelid ectropion or retraction, can be seen with redundant upper or lower eyelid skin. The redundant upper eyelid skin overhangs the lashes, causing lash ptosis and entropion with resultant keratitis. In patients with severe lower eyelid dermatochalasis, laxity of the lower eyelid develops with resultant eyelid retraction or ectropion.

Race

Race does not seem to play a role; however, patients of Asian origin frequently note fullness in the upper eyelid. This is due to the difference in eyelid anatomy. The Asian patient's orbital septum fuses with the levator aponeurosis low above the eyelid margin or not at all. This allows the preaponeurotic fat to prolapse anteriorly in the eyelids.

Sex

Dermatochalasis occurs with equal frequency in males and females.

Age

• Dermatochalasis most commonly occurs in elderly persons, and its presence and severity increase with age.
• Blepharochalasis is a disease of young persons, especially seen at puberty.

Clinical

History

• The patients who complain of dermatochalasis frequently complain of 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.

Physical

• 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. 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.
• 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.
• 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.

Causes

• 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.
• 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.

• Search for CME/CE on This Topic »

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