Hering’s law of equal innervation states that eye muscles or eyelid muscles of each eye are equally innervated. Therefore, in the presence of a marked ptosis on one side, the equal innervation will result in an artificially elevated opposite eyelid. If the ptotic eyelid is lifted, the opposite eyelid will usually fall because the stimulus that lifts the ptotic eyelid is lifted and the same will apply to the opposite side.
​

The patient has no history of thyroid disease or any other neuromuscular diseases. There is no history of trauma. She notes that the left upper eyelid “is much worse when I am tired and at the end of the day”.

Clinical examination shows a corneal reflex-eyelid margin distance of less than zero on the left side and 1 mm on the right. She has a high and poorly formed left upper eyelid skin crease with a deep superior sulcus. Her levator function is normal at more than 12 mm on both side. The right side shows a slightly raised upper eyelid skin crease which is more defined and there is early hollowing of the superior sulcus. Her left brow is higher than the right brow by 4 mm.

Note the subtle prominence of the left medial fat pad which becomes revealed as the medial levator aponeurosis becomes “lateralized” with disinsertion. The orbital septum is weakest medially and this allows the medial fat pad to become more prominent. This is seen in many involutional ptosis cases. The lateralization of the levator aponeurosis also caused medial flattening of the upper eyelid as is obvious here. These are subtle signs that should be noted preoperatively and corrected surgically.
​
The common questions a surgeon may be faced with when encountering such a patient are as follows:

1. If I have a droopy eyelid on one side, should I have surgery on one side or both sides?
2. If I have surgery on one side because the Herring’s test did not show my “good” eyelid coming down, is there still a chance that the lid would become lower after one-sided surgery?
3. What is the best option for me?
4. When should one-sided droop of an eyelid be repaired? Should I wait until both sides droop?​

Q 1. If I have a droopy eyelid on one side, should I have surgery on one side or both sides?

1. 1. When the Hering’s is positive, it makes sense to operate upon both upper eyelids at the same time. It should be remembered that when the Hering’s test is done (by lifting the droopy lid and watching the “normal” eyelid for drooping), the relaxation of the “normal” side may not always be obvious or dramatic. Subtle changes can be easily missed. So a careful, and, if necessary, a repeat examination is vital to help make a decision.

Q 2. If I have surgery on one side because the Hering’s test did not show my “good” eyelid coming down, is there still a chance that the lid would become lower after one-sided surgery?

A 2. Absolutely. The preoperative Hering’s law test is usually predictive, but there can be a mild ptosis on the unaffected side which can become manifest after unilateral surgery. Swelling, bruising, etc after surgery will make the operated eyelid look persistently droopy for some days (even weeks) and therefore, it is important to give the body a chance to heal and the neurological responses (Hering’s in other words) to manifest themselves. We will generally not make any judgement about the final lid height for at least two months after surgery, sometimes longer.
Q3. What is the best option for me?

A3. How many different shades of grey are there? Horses for courses. One should not just assess the eyelids. The relationship of the eyelids to the brows (depending upon racial characteristics, sun exposure, contact lens wear, age, etc) has to be considered. Asymmetry of the face (we all have asymmetric faces) becomes slowly-but-surely more apparent as we age and this applies to the periorbital area and eyelids as well. People forget to look at the position of the lower eyelids when addressing a droopy eyelid or eyelids. We will all have one lower lid a little different (lower, fuller, etc) when compared to the other. So, after an assessment of all these factors, and with the help of a full-face photograph, options can be discussed.
Q 4. When should one-sided droop of an eyelid be repaired? Should I wait until both sides droop?

This is simple. If a slightly droopy eyelid does not bother you functionally or cosmetically, leave it well alone. Mild and even moderate asymmetry of the face and the eyelids is common. If you choose to have surgery on the droopy upper eyelid only, be prepared to see asymmetry after surgery with the operated side looking higher than the unoperated side.
​
This patient underwent an anterior approach left upper eyelid ptosis repair. The orbital septum was opened and the fat released but no fat was removed. The fat was advanced to fill the deep superior sulcus and attached to the orbicularis to provide a fullness above the eyelid skin crease. The eyelid skin crease was recreated with imbrication sutures which picked up the levator aponeurosis in the eyelid skin closure

Note the following:

1. The left brow that was higher than the right brow has relaxed and is about the same height as the right brow.
2. The left ptosis is corrected with an improvement in the skin crease and an improvement in the left deep superior sulcus.
3. The right upper eyelid now looks ptotic. However, the corneal reflex-lid margin distance is only slightly smaller.
4. Note that the right superior sulcus is now deeper and the skin crease appears much higher. With Hering’s law, when the stimulus to keep the opposite eyelid up is removed, the levator will relax and any underlying levator disinsertion may become manifest with a difference in the skin crease (which will be higher) and the sulcus (which will be deeper as the disinserted levator and the attached septum pull back revealing the deeper superior sulcus. It is important to remember that this type of apparent deepening of the superior sulcus with Hering’s law is frequently missed and the patient my wrongly assume that the surgeon caused this quite dramatic difference.
5. Note the correction of the prominent medial fat pad on the left and also the correction of the medial flattening of the upper eyelid.
6. By recreating the skin crease, we can also evert the ptotic eyelashes as was done here.

This particular patient was still not bothered visually by the right upper eyelid so she elected not to have any surgery on the right side. However, other patients may choose to have the now apparent droop of the right upper eyelid corrected. The surgeon should aim to give the patient a symmetrical skin crease, and fill the superior hollow (sulcus) to achieve as much symmetry as possible. This surgery may be performed at any time the patient wishes.

For Residents, Fellows, Oncologists, Ophthalmologists, Plastic Surgeons, Dermatologists

Squamous cell carcinoma of the conjunctiva is at the advanced spectrum of ocular surface neoplastic disease termed "ocular surface squamous neoplasia" (OSSN).

Risk factors for OSSN: 

• Ultraviolet light
• HIV/AIDS
• Human papilloma virus
• Allergic conjunctivitis
• Smoking

Africa has the highest incidence of OSSN in the world because of the high levels of ultraviolet light radiation and also because of the higher incidence of HIV/AIDS. OSSN affects 1.3 out of 100,000 people per year. This is X10 higher than the incidence elsewhere in the world. 

In equatorial Africa, OSSN affects younger adults and proportionately more women are affected than in other parts of the world. The age of presentation in Africa is 40 years compared to 60 years in other parts of the world. In Africa, 2/3rds of the tumors are seen in females whereas 70% are males elsewhere in the world. 

Dr. BCK Patel MD, FRCS

For patients, residents, fellows, surgeons

While there are several medical indications for botulinum toxin injection in the face and/or the neck, we are concentrating on the safe areas where judicious injection with botulinum toxin gives a pleasing result. 

For residents, fellows, plastic surgeons and oculoplastic surgeons

Temporary tarsorrhaphy sutures are often needed at the end of surgical procedures on the orbit, the eyelids, after repair of facial fractures and after reconstruction of eyelids and facial structures. A tarsorrhaphy may be needed when treating or preventing the occurence of chemosis and also when one wants to protect the cornea in the postoperative period.

Some of the common indications for a temporary tarsorrhaphy are:

• at the end of a cosmetic procedure like a lower blepharoplasty or cheek lift
• after surgery on a patient with thyroid orbitopathy
• after a skin graft to the upper or lower eyelid
• after eyelid reconstruction following tumor removal from an eyelid
• after a corneal transplant
• to retain a socket symblepharon ring after fornix reconstruction
• after pterygium surgery
• after an enucleation or evisceration to retain the conformer and reduce chemosis
• in a patient with an acute facial palsy to protect the cornea
• when treating a recalcitrant corneal erosion or infection
• in the presence of an anesthetic cornea
• at the end of an orbital tumor or trauma case

In this video, Dr. BCK Patel MD shows the eyelid margin anatomy and show how temporary tarsorrhaphy sutures are placed at the gray line to appose the eyelids. A lateral third suture will close the lateral third, an additional central suture will generally give protection of the whole cornea. Only rarely is a third, medial suture needed.

For physicians and patients

How to manage herpes zoster and its complications, with considerations for COVID-19 and the COVID vaccine. Christine Kanownik

BCK Patel MD, FRCS
For Residents, Fellows, Plastic Surgeons, Oculoplastic Surgeons

Conjunctival chemosis is the collection of fluid under the conjunctiva, resulting in a blister-like swelling of the conjunctiva.

A chalazion is initially a painless mass that develops on the eyelid. It is caused by a blockage of the Meibomian gland. The blocked gland allows the contents (lipogranulomatous material) to expand and will eventually allow the material to spread into the surrounding tissues, causing local inflammation. 

Initially, the chalazia are soft or rubbery but go on to become firm. Inflammation or secondary infection will lead to tenderness of the lesions. Does an initial infection of the Meibomian gland cause a chalazion to develop or is it a blocked Meibomian gland that secondarily becomes inflamed and can become infected? The exact sequence is probably both of the above in different lesions. 

​There are many devices now available which emit light in the blue, red and infrared wavelengths. These devices may be used by medical practitioners but many home-use devices which apply the light at more conservative levels are available.

One or more creases along the lower eyelid that start at the medial canthus and progress outwards and slightly further down from the eyelid margin. There may be one or more of such lines and when they are occur in the presence of atopic dermatitis, they are called Dennie-Morgan lines.