Blepharochalasis is an ophthalmic disease characterized by atrophy of the skin of the upper eyelids with the formation of excessive folds over the palpebral margin. The main clinical manifestations: “bag-like” overhanging of the upper eyelids, visual impairment, increased lacrimation, conjunctival hyperemia. For the diagnosis of blepharochalasis, physical examination, visometry, biomicroscopy, tonometry, computer refractometry, perimetry are performed. Treatment tactics are reduced to performing upper blepharoplasty in combination with lacrimal point plasty and resection of “fatty” hernias.
Blepharochalasis is a pathological overhang of the skin folds of the upper eyelids. The disease was first described in 1937 by Australian ophthalmologist Ida Mann. There are no statistics on the overall prevalence of the disease. Cases of anomaly development in three generations of the same family are described, which suggests a genetic predisposition to blepharochalasis. The disease is most often detected in elderly women. Among the patients, persons of the Caucasian race prevail, which is due to the peculiarities of the histoarchitectonics of the skin.
The etiology of the disease is not fully known. As a rule, sporadic cases of the disease are observed. Less often, the drooping of the eyelid becomes one of the manifestations of half atrophy of the face. Scientists are studying the role of vascular and endocrine factors. Pathology can develop against the background of angioedema in patients with a burdened allergic history. The main causes of blepharochalasis:
- Individual features of the skin structure. Persons with reduced elasticity of the skin are at risk of the disease. The hydrophilic properties of the skin are determined by the composition of the intercellular matrix and connective tissue fibers.
- Prolonged edema. Frequent edema of the periorbital region is caused by kidney pathology (chronic renal failure, glomerulonephritis), allergic reactions. The development of the disease is promoted by the peculiarities of nutrition (excessive consumption of salt and liquid, protein starvation).
- Involutional changes of the century. With age, the manifestations of senile elastosis and atrophic changes in the skin increase in patients, the tone of the circular muscle of the eye decreases.
- Laffer-Asher syndrome. In persons with this genetic syndrome, in addition to blepharochalasis, there is an increase in the thyroid gland and a duplicate of the mucous membrane of the upper lip. The first symptoms are detected at a transitional age.
- Application of accessories. The likelihood of the disease is significantly increased when using eyelid piercings, as well as decorative elements (rhinestones, sequins, false eyelashes). The application of permanent makeup potentiates the development of blepharochalasis only in allergic edema.
- Iatrogenic effects. The cause of the disease may be a violation of the technique of performing cosmetic manipulations in the ocular region. Rapid progression of blepharochalasis is associated with laser skin rejuvenation.
Involutional changes play a key role in the mechanism of development. The initial signs of aging of the eyelids are revealed already from the age of twenty. According to morphohistological studies, the pathogenesis is based on the thinning of collagen fibers in combination with a relative increase in the volume of connective tissue in the structure of the circular muscle. Single elastic fibers are visualized among chaotically arranged collagen fibers. In many cases, they are completely absent. Atrophic changes affect all layers of the skin. The use of accessories leads to stretching of the skin and the development of a unilateral form of pathology.
In patients with blepharochalasis, the process of neuromuscular regulation of vascular tone is disrupted, which leads to vasodilation. An increase in blood flow and a decrease in microcirculatory pressure contributes to the progression of chronic congestion. Only the upper eyelids are usually involved in the pathological process, however, when using specific diagnostic methods, secondary disorders are also detected on the skin of the lower eyelids. Thinning of the tarzoorbital fascia causes the appearance of fatty “hernias”. Atrophic changes are often combined with chronic blepharitis, which aggravates the course of the disease.
The first symptoms of the disease develop in people 20-40 years old. The clinical picture is most pronounced in old age. Patients note that the onset of symptoms was preceded by edema of the eyelids or a chronic course of blepharitis. An early sign of the disease is the formation of a pronounced skin fold on the upper eyelid during the tension of facial muscles (when smiling). It is most noticeable when observing a person in profile. Patients complain of a “bag-like” overhang of the eyelid folds, which partially or completely cover the upper eyelashes. At the initial stages, patients are only concerned about a cosmetic defect.
With the progression of blepharochalasis, pathological changes are detected even at rest. The skin becomes thinned, stretched, vessels shine through it. Specific protrusions resembling fat “hernias” are visualized. Vision worsens when the skin overhangs, which initially cover only the lateral corner of the eye. With a complicated course, the skin fold reaches the middle of the pupil. Irritation of the skin with eyelashes leads to their redness and swelling. Age-related changes in the auxiliary apparatus of the eye lead to increased lacrimation, photophobia. The lesion of the eyelids is symmetrical.
The most common complication of blepharochalasis is secondary blepharitis. In most patients, excessive overhanging of the skin contributes to the formation of ectropion. Patients are at high risk of infectious lesions of the anterior eye (conjunctivitis, keratitis, blepharoconjunctivitis). It is often possible to diagnose xerophthalmia. Pathological lacrimation provokes irritation of the skin in the periorbital region. In severe cases, amblyopia develops. All patients with this disease have a history of suffering from “tired eye syndrome”.
To make a diagnosis, a physical examination and instrumental research methods are used. During visual inspection, the overhang of the eyelid is determined. The direction of the fold is oblique, from the medial edge to the lateral. The outer edge of the eye slit is covered with overhanging skin. The elasticity of the skin is reduced, blood vessels shine through the thinned skin. Specific diagnostic methods include:
- Visometry. A decrease in visual acuity is observed only with pronounced overhanging of the eyelid. During the test, the patient squints and tries to lift the skin fold.
- Computer refractometry. Patients have secondary amblyopia. The appointment of the study to elderly patients makes it possible to diagnose presbyopia. In persons under 40 years of age, the myopic type of clinical refraction is more often detected.
- Biomicroscopy of the eye. Examination of the anterior segment of the eyes reveals injection of conjunctival vessels and single foci of corneal ulceration caused by irritation of the membranes of the eyeballs with the palpebral edge and eyelashes.
- Perimeters. The technique makes it possible to diagnose an uneven narrowing of the visual field. The upper and, less often, the upper lateral areas fall out of sight. In some cases, photopsies are detected.
- Contactless tonometry. Violation of the outflow of watery moisture provokes an increase in intraocular pressure. With additional electronic tonography, minor changes in intraocular hydrodynamics are detected.
Differential diagnosis in ophthalmology is performed with blepharoptosis and blepharophimosis. A distinctive feature of blepharophimosis is a combination of ptosis with shortening and narrowing of the eye slit. Isolated blepharoptosis is caused by a myogenic or neurogenic mechanism. The patient is unable to open the eye slit independently. When forming an overhanging skin-muscle fold on the eyelid, we are talking about pseudoblepharochalasis.
Patients with this disease are shown cosmetic correction of the defect using blepharoplasty. Surgical intervention is performed on an outpatient basis under regional anesthesia. The first stage of the operation is the removal of excess skin of the eyelid with their further tightening. Patients with increased lacrimation require additional plastic surgery of the tear point. To prevent postoperative drooping of the eyelid, elderly patients undergo cantopexy. If necessary, plastic surgery of the tendon of the muscle that raises the upper eyelid is performed. Detection of orbital hernias requires their resection. Removal of skin sutures is performed on 5-7 days after surgery. A modern method of eliminating blepharochalasis using a combination of microwave and laser radiation is under development.
Prognosis and prevention
The prognosis with timely elimination of the cosmetic defect is favorable. Specific preventive measures have not been developed, non-specific ones are aimed at observing the rules of eye hygiene. To prevent the disease, you should not wear makeup for a long time with specific decorative elements on the eyelids (rhinestones, sequins). Ophthalmologists do not recommend piercing on the eyelids, because under the weight of accessories, the skin gradually stretches and loses its former elasticity. People with early signs of the disease need to monitor their diet and skin condition.