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Upper-Eyelid Wick Syndrome Association of Upper-Eyelid Dermatochalasis and Tearing

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Upper-Eyelid Wick Syndrome Association of Upper-Eyelid Dermatochalasis and Tearing CLINICAL SCIENCES Upper-Eyelid Wick Syndrome Association of Upper-Eyelid Dermatochalasis and Tearing Inbal Avisar, MD; Jonathan H. Norris, FRCOphth; Dinesh Selva, FRACS, FRANZCO; Raman Malhotra, FRCOphth Objective: To highlight a case series of patients mani- tially obscured by upper-eyelid skin (type 2). Five patients festing epiphora and misdirection of tears laterally or along (56%) had linear excoriation of skin in the lateral can- the upper-eyelid skin crease. This association has been thus. All patients underwent upper-eyelid blepharo- termed upper-eyelid wick syndrome. We describe the clini- plasty, 3 combined with ptosis repair and 3 combined cal features and outcomes of management of these pa- with eyebrow-lift. All patients achieved 80% to 100% im- tients. provement in epiphora following surgical intervention to the upper eyelid. The mean (range) follow-up was 2.8 Methods: A retrospective review of patients referred to (1-6) years. 2 oculoplastic centers during a 6-year period for epiphora, who were considered to have misdirection of tears re- Conclusions: We defined upper-eyelid wick syndrome as lated in some way to upper-eyelid dermatochalasis. the misdirection of tears laterally or along the upper- eyelid skin crease causing epiphora, related in some way Results: Nine patients (7 women and 2 men; mean [SD] to upper-eyelid dermatochalasis. In all cases, epiphora age, 61.2 [11.3] years, range, 41-76 years) with bilateral improved with treatment of upper-eyelid dermatochala- epiphora and lateral spillover (100%), occasionally com- sis. Although recognized among physicians, this has never bined with upper-eyelid wetting (n=2). All patients had been formally described in the ophthalmic literature, to upper-eyelid dermatochalasis. Five patients had upper- our knowledge. eyelid skin obscuring and in contact with the lateral can- thus (type 1), and in 4 the lateral canthus was only par- Arch Ophthalmol. 2012;130(8):1007-1012 PIPHORA IS OFTEN ETIOLOGI- lids.3,4 Epiphora is not frequently ad- cally multifactorial, ranging dressed as a symptom related to derma- from hyperlacrimation (su- tochalasis. However, patients with pranuclear, infranuclear, and dermatochalasis often report symptoms reflex tearing due to evapo- such as burning, itching, and epiphora. Al- Erative dry eye) to pump failure to outflow though the impact of upper-eyelid derma- dysfunction, including lower-eyelid mal- tochalasis has been recognized by physi- position or stenosis at the level of the puncti, cians, the role of the upper eyelid as a canaliculi, lacrimal sac, or nasolacrimal duct. causative factor in epiphora is not well de- Addressing a single factor in multifactorial scribed. epiphora may lead to only a moderate im- We describe a series of patients mani- provement in symptoms.1,2 festing epiphora and misdirection of tears Bothersome upper-eyelid dermatocha- laterally or along the upper-eyelid skin Author Affiliations: lasis typically causes symptoms of gradual crease. All patients had a degree of upper- Corneoplastic Unit, Queen increasing heaviness of the upper eyelid, eyelid dermatochalasis, some with skin- Victoria Hospital, East a tired or worn appearance, puffy or swol- fold contact to the lower-eyelid margin, and Grinstead, England (Drs Avisar, len eyes, and diminution of peripheral up- epiphora improved or resolved in all cases Norris, and Malhotra); and per visual fields. Severe dermatochalasis following interventional treatment to re- Discipline of Ophthalmology may overhang the eyelid margin to exac- duce upper-eyelid dermatochalasis. This as- and Visual Sciences, University of Adelaide, and South erbate lash ptosis and cause ocular dis- sociation has been termed upper-eyelid wick Australian Institute of comfort and corneal irritation. Female pa- syndrome. We highlight the clinical fea- Ophthalmology, Adelaide, tients often report difficulty in applying tures and outcomes of management of pa- Australia (Dr Selva). eyeliner and mascara to the upper eye- tients with upper-eyelid wick syndrome. ARCH OPHTHALMOL / VOL 130 (NO. 8), AUG 2012 WWW.ARCHOPHTHALMOL.COM 1007 ©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Table. Case Series of Patients Manifesting Upper-Eyelid Wick Syndrome Case No. 123456789 Sex/age, y F/63 F/65 F/61 F/41 M/71 F/65 F/64 M/76 F/45 Frequency of wiping, 5 20 120 30 120 60 180 60 60 min Spillover Lateral Lateral Lateral and Lateral and Lateral Lateral Lateral Lateral Lateral upper upper eyelid eyelid Typea 121212211 Ptosis Yes Yes No No Yes No No No Yes Brow ptosis Yes No No No Yes Yes No Mild Mild Associated symptoms of Yes Yes No No No No No No No reflex tearing Horizontal lower-eyelid No No No No Yes No No Mild Mild laxity Lacrimal syringing PPPPPPPP90%P FDRT result Neg Bilateral pos Neg Bilateral pos Bilateral pos Neg Neg Bilateral pos Bilateral pos Lateral canthus linear No Yes No Yes Yes No No Yes Yes excoriation Other examination No No No No No No No Angular No findings blepharitis Management Ptosis; Ptosis; Bleph Bleph Bleph; Bleph; Bleph Bleph Ptosis; bleph; bleph DBL EBL bleph EBL Resolution, % 100 100 90 100 80 100 100 100 90 Abbreviations: bleph, upper-eyelid blepharoplasty; DBL, direct brow lift; EBL, endoscopic brow lift; FDRT, fluorescein dye retention testing; neg, negative; P, patent; pos, positive; ptosis, posterior approach ptosis repair. a Type of dermatochalasis and relation to lateral canthus: type 1 (lateral canthus obscured and in contact) or type 2 (lateral canthus partially obscured and not in direct contact). METHODS For the purpose of categorization, upper-eyelid dermato- chalasis was retrospectively graded on the basis of standard pho- tographs as either type 1 (lateral canthus in direct contact) or This was a retrospective case series of patients referred to 2 spe- type 2 (lateral canthus partially obscured but not in direct cialist oculoplastic centers from January 1, 2004, through De- contact). cember 31, 2010, for epiphora, considered to have misdirec- The main outcome measures were subjective improve- tion related in some way to upper-eyelid dermatochalasis ment in symptoms (percentage of improvement), objective im- (“wicking of tears”), in whom interventional treatment to the provement in wetting of upper-eyelid skinfold and skin crease, upper eyelid improved epiphora. Institutional review board– improvement in lateral canthus excoriation, and cessation of approval was obtained for this retrospective study. Clinical rec- misdirection of tears using the FDRT with no misdirection of ords were reviewed and patient demographic characteristics, the upper-eyelid skinfold and crease. preoperative frequency of wiping, site of tear spillover (lateral Patients were excluded if during this period their symp- or medial aspect and/or upper-eyelid wetting), and associated toms improved with conservative measures only (without any dry-eye symptoms related to reflex tearing were recorded. Pres- intervention to the upper eyelid), if they underwent addi- ence of lateral canthus skin excoriation, upper-eyelid derma- tional surgery for epiphora to the lower eyelids or lacrimal sys- tochalasis, ptosis, horizontal lower-eyelid laxity including lower tem, or if preoperative symptoms of epiphora were reported eyelid lateral sag, patency to lacrimal syringing, and results of only retrospectively following upper-eyelid surgery. Conser- fluorescein dye retention testing (FDRT) were also recorded. vative measures included ocular lubricants and warm com- Management and postmanagement resolution were docu- presses for evaporative dry eye causing reflex tearing, for ex- mented. ample. All patients were given conservative measures at the time Upper-eyelid wick syndrome was defined as symptoms and of listing for upper-eyelid surgery to exclude this as a signifi- signs of epiphora and upper-eyelid dermatochalasis with evi- cant cause. dence of tear misdirection based on symptoms of lateral spill- Our surgical technique of upper blepharoplasty and posterior- over with or without upper-eyelid wetting and objective signs approach aponeurotic ptosis correction has been previously de- of staining with misdirection of fluorescein on FDRT. The FDRT scribed.5 This was performed under local anesthesia. Our sur- demonstrates misdirection of tears not only laterally but also gical technique of endoscopic eyebrow-lift is based on a standard along the upper-eyelid skinfold and even along the upper- technique and has been previously described.6 Our surgical tech- eyelid skin crease (evident when the upper-eyelid skinfold or nique for direct eyebrow-lift has been previously described.7 eyebrow is lifted). This was performed under local anesthesia. During assessment, the eyebrow was gently elevated with a thumb or finger placed over the eyebrow hair to reduce the de- gree of apparent dermatochalasis and lateral canthus skin con- RESULTS tact. The FDRT was then repeated to demonstrate a reduction in misdirection and lateral spillover and show the potential ben- efit of upper-eyelid treatment for dermatochalasis as a cause Nine patients (7 women and 2 men; mean [SD] age, of misdirection before recommending surgery. 61.2[11.3] years, range, 41-76 years) were identified. All ARCH OPHTHALMOL / VOL 130 (NO. 8), AUG 2012 WWW.ARCHOPHTHALMOL.COM 1008 ©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 A B A C D B E F C Figure 1. Examples of dermatochalasis with lateral hooding causing wick syndrome. A and B, Type 1 lateral canthus obscured and in contact. C and D, Case 1 shows type 1 hooding before and after levator advancement, upper-eyelid blepharoplasty, and endoscopic eyebrow-lift. E, Type 2 lateral canthus partially obscured and in contact. F, Fluorescein tracked into the upper skin crease. had symptoms of epiphora with lateral spillover, occa- sionally combined with upper-eyelid spillover or wet- Figure 2. Case 4. A, Lateral and upper spillover of fluorescein along the ting (2 patients [22%]). Clinical details of each patient upper eyelid shown by fluorescein tracking along the right upper eyelid are included in the Table.
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