Dermatochalasis is a term that is defined as excess upper and/or lower eyelid skin. The eyelid skin is thin and prone to fine wrinkling. Redundant skin is often associated with fat herniation, descent of eyebrows, and descent of mid-face. Fat herniation is most common in the superomedial region and in the inferomedial and central part. In addition, variable puffiness due to eyelid oedema and discolouration from venous leakage (black circles under eyes) develop with age. It is a common condition and is seen in elderly persons, but occasionally in young adults also. It is more common in the upper eyelid but may be seen in the lower eyelids as well.
Common factors which contribute to this lax and redundant eyelid tissue are:
- Ageing.
- Loss of elastic tissue in the skin.
- Weakening of the connective tissue of the eyelid.
- Effect of gravity.
- Solar and age-related degeneration of collagen.
- Descent of brow complex (retro- orbicularis oculi fat or ROOF) and malar complex (suborbicularis oculi fat or SOOF).
- Actinic exposure and smoking hasten the development of changes.
Symptoms :
Dermatochalasis may be asymptomatic. It is usually a bilateral condition.
It may present with
- Redundant upper eyelid skin that may be associated with herniation of orbital fat (steatoblepharon) through a weak septum.
- Obstruction of superior visual fields due to excess lid skin.
- Irritation of eyes.
- Blepharitis.
- Ectropion of the lower eyelid.
- Entropion of the upper eyelid.
- Dermatitis.
- Fullness or heaviness of upper eyelids.
- ‘Bags’ in lower eyelids.
- Wrinkles in lower eyelid and at lateral canthus.
Causes
Dermatochalasis is due to age-related loss of skin elasticity and weakening of the connective tissue of the eyelid, usually seen in elderly.
Pathophysiology
The pathophysiology of dermatochalasis is consistent with the normal ageing changes of the skin of eyelids. This includes loss of elastic fibers, thinning of the epidermis, and redundancy of the skin. Chronic infiltrate may be present when it is associated with dermatitis.
Histologically, epidermis appears thin and smooth. Dermis shows some loss of elastic and collagen tissue, along with an increase of capillary vascularity. There is often basophilic degeneration of the collagen (actinic elastosis), and a mild lymphocytic inflammatory reaction.
Systemic associations
Systemic diseases which predispose patients to develop dermatochalasis are
- Thyroid eye disease.
- Hereditary angioneurotic oedema.
- Trauma.
- Renal disease.
- Amyloidosis.
- Cutis laxa.
- Ehlers-Danlos syndrome.
- Xanthelasma.
Genetic factors may also have role in some patients.
Diagnosis
Diagnosis depends upon the clinical features.
It produces cosmetic problem such as wrinkles in lower eyelid and at lateral canthus, ‘bags’ in lower eyelids, and fullness or heaviness of upper eyelids.
Functionally, it may cause blepharitis, dermatitis, upper eyelid entropion, ectropion of lower eyelid, irritation of eyes, and obstruction of superior visual fields.
Evaluation
- Identify pre-existing blepharoptosis, brow ptosis, lacrimal gland prolapsed, or horizontal lid laxity.
- Lateral bulging of the upper lid should be recognised as lacrimal gland prolapse and should be distinguished from pad of fat.
- Coexistent dermatochalasis of the eyelids and browptosis may be tested by elevating the eyebrows.
- The interpalpebral fissure and levator function, as well as the marginal reflex distance from the upper and lower eyelids, should be documented.
- The eyelid crease should be measured in millimetres.
Differential diagnosis
Dermatochalasis may be differentiated from conditions like
- Congenital or acquired ptosis.
- Eyebrow ptosis.
- Floppy eyelid syndrome.
- Oedema of eyelid/blepharochalasis.
- Prolapse of lacrimal gland.
Management
Management should be carried out under medical supervision.
Management of dermatochalasis is mainly surgical.
Medical therapy
- Lid hygiene and topical antibiotics may be required for blepharitis.
- Topical steroids are helpful in dermatitis.
- Topical lubricants are helpful in patients developing dry eyes.
Surgical therapy
- Procedure like upper eyelid blepharoplasty to remove excess eyelid skin and orbital fat, with reconstruction of the upper eyelid crease, is helpful.
- Patients with associated ptosis (drooping of eyelid) may require ptosis surgery.
- Placement of temporary collagen punctal plugs, permanent punctal plugs or punctal cautery may be done in patients with dry eyes.
Prognosis
Results are usually good with proper diagnosis and surgical blepharoplasty.
Complications
Prevention
Smoking and eyelid rubbing should be avoided.
References
Stein Harold A, Stein Raymond M, Freeman Melvin I. The Ophthalmic Assistant- A Text for Allied and Associated Ophthalmic Personnel Ninth Edition. Elsevier Saunders 2013. P 406.
Gold Daniel H, Lewis Richard Alan. Clinical Eye Atlas Second Edition. Oxford University Press 2011. P 14- 15.
Denniston Alastair KO, Murray Philip I. Oxford Handbook of Ophthalmology Third Edition. Oxford University Press 2014. P 161.
http://emedicine.medscape.com/article/1212294-overview
http://eyewiki.aao.org/Dermatochalasis
http://www.nature.com/eye/journal/v18/n1/full/6700527a.html