Jane Styche

Good evening everyone. I hope you're all well and welcome to our webinar on oculoplastic surgery. My name is Jane, and I'm the Eye Unit sister here at Benenden Hospital. Our expert presenter is Miss Elizabeth Hawkes, Consultant Ophthalmologist.

Her presentation today will be followed by a Q&A session. If you'd like to ask her a question, please do so via the Q&A icon which is at the bottom of your screen. This can be done with or without giving your name.

Just to remind you all that the webinar is being recorded, although other attendees won't know that you're taking part unless you give your name when asking a question. If you prefer not to be recorded now is your opportunity to leave.

I'll now like to hand you over to Miss Hawkes and you'll hear again from me soon. Thank you.

Miss Elizabeth Hawkes

Great, thank you, Jane; that was a very nice introduction.

So hi, good evening everyone. My name is Dr Elizabeth Hawkes and I'm a Consultant Ophthalmologist and Oculoplastic Surgeon at Benenden Hospital and I also have a practice in London at the Cadogan Clinic.

I qualified from Imperial College, London and I'm a member of various oculoplastic societies in the UK, Europe and in America. I have various roles in addition to my clinical work, such as I'm on the advisory board for the Aesthetics Journal, I'm an examiner for the College of Ophthalmologists and I have an interest in safety in cosmetic surgery and cosmetic injectables. I also used to be the lead for the emergency eye care service for the county of Berkshire.

So firstly, what is an Oculoplastic Surgeon? So, we are all Ophthalmologists - that means we are doctors who have trained in eye surgery. We've then all taken advanced training in order to specialise in eyelid plastic surgery. Then I've taken additional training in order to specialise in cosmetic eyelid surgery and non-surgical facial injectable techniques.

I've spoken to various journalists and leading journals on oculoplastic surgery and tips and tricks in order to keep the eyelid skin rejuvenated and I hope to share some of that information with you this evening.

So just to give you a brief overview of the talk; so, the first minute or two will be a very brief description of the anatomy of the eye, which is very important to understand first. I'll then briefly just discuss the different terms such as Optometrist, Optician and Ophthalmologist - what does it all mean?

I'll go on to discuss eye health and then talk briefly about false eyelashes and eye makeup and I really encourage the men listening to listen, because there are some tips on eyelid hygiene. And then finally we'll be talking about how to keep the eyelid skin youthful and rejuvenated.

So, eye anatomy. So, I have my model eye here and as you can see, what happens is light enters here - this structure here - which is the cornea, which is the clear part of your eye on the front of the eye. And the light travels back through the lens and then hits the back of the eye, which is your retina, and then processes images by the optic nerve up to the brain in order for us to see.

Looking at the eye at the front you may have heard a lot of terms that have been described. So, the pigmented part of the eye is called the iris; and in the centre of the iris is a small opening which is called the pupil, which allows the light to travel through to enter the eye and hit the retina.

The eyeball’s hard shell is called the sclera and there is a transparent membrane that covers that which is called the conjunctiva. Then the eyelids we describe as the upper and lower eyelid. And this layer here is called your eyelid margin where you have the meibomian glands that secrete the outer layer of your tear fill and have a key role in dry eye disease.

And then, importantly this is the eyebrow as well. When you're dealing with oculoplastic surgery we're dealing with the region from the eyebrow to the lower lid to the top of the cheek.

And they're the basics. So, moving on to terminology.

So, in the community we have Opticians and Optometrists and they are able to perform eye checks, examine the back of the eye and perform screening with very advanced imaging and scans. But mainly they're known for refraction as well.

In the hospital setting you have Ophthalmologists and we are all doctors and surgeons as well. And we're very lucky to have primary and secondary care integration here in ophthalmology.

So, moving on to eye health. So obviously this is a very biased lecture but, in my opinion, vision is the most important sense. And everyone wants to know this: we're saying now that 60s is the new middle age, so everyone wants to know how to protect their eye health into the future and into the later on in life.

These are the leading causes of loss of vision that we will not be covering in this talk (this is an oculoplastic webinar) but they are cataract, diabetic eye disease, glaucoma and age-related macular degeneration.

So, in in keeping with general health, prevention is better than cure. So when you're thinking about your heart health, eye health is very, very similar and it's the usual things: don't smoke, limit processed foods and foods that contain high levels of sugar and salt, get your five portions of fruit and veg, limit alcoholic intake, do your steps every day or runs in the week and eat lots of high fibre foods.

And that's sort of the basics for prevention.

Going further than that, specifically thinking about your eye health; it’s extremely important to go for regular eye checks. Amazingly, now the technology has moved on so much, this is a picture of a macular OCT scan and we're actually able to image the ten layers of the retina, which is incredible. So, we're able to detect disease years before you start to actually have any visual symptoms.

So that's why it's very important to go for regular checks with your Optometrist or with your Ophthalmologist, particularly if you have any family history of eye disease such as the four I just mentioned.

Moving on to sunglasses. So obviously the summer's just around the corner and UV rays are actually extremely damaging - not just for the delicate eyelid skin and UV rays are the number one cause of aging around the whole face, also they can cause the development of small skin cancers - particularly around the eye region. And that's a very high-risk area. And we'll cover that a bit later

But also inside the eye as well UV damage has been shown to accelerate the formation of cataracts and also cause damage to the retina, so it's really important that when you're buying your sunglasses you don't want to just them to look good - that's obviously very important - but they have to have a functional role as well.

So, what do you need to look for? All you need to do is look for a sticker that says UV400. And if it says UV400 you know that it's going to filter out the harmful UVA and UVB rays. The bigger the better, because the more coverage you get the more you're going to protect the eyelid skin as well - and that region from the brow to the upper cheek as discussed.

There's obviously lots of other types of lenses; you can get polarised lenses and specific tinted glasses for sports, but the key thing is really UV400

This is something I get asked about a lot in consultations. Blue light: what is the evidence out there?

So blue light from your smartphone is not making you blind and it's not going to cause harm. What the real concerns are - so firstly, blue light is involved with our circadian rhythm, which is the sleep/wake cycle in our brain. So, if you're using your iPhone, your laptop, and it's emitting blue light that can disrupt your sleep pattern.

So, it's sort of bad for sleep hygiene. So, the advice would be to avoid screen work one or two hours before bedtime.

There is some very, very limited evidence that - if you do have a history of macular degeneration - you want to reduce the amount of blue light, but it's very limited. But what is actually bad about excessive screen time if you have dry eye disease. So, if you have dry eye disease, your eyes - the surface of the eye - is dry. The eye is gritty and very uncomfortable and when you're staring at your screen it you will naturally reduce the amount of times you blink.

And the function of a blink is to sweep your tears from the upper outer corner to drain into the punctum. So, if you're not blinking as much these, the ocular surface is not getting the lubrication it needs.

So, you may have all heard of the 20/20/20 rule, which is essentially every 20 minutes you want to look away an object 20 feet away in the distance for 20 seconds

So, moving on to eating for eye health. So obviously, don't start supplements without consulting your GP, Optometrist or Ophthalmologist first.

So, when you think about eating for eye health the first thing that springs to mind for most people – carrots! So, carrots; they are very important and that's true they have a role for night vision and they’re a good source of vitamin A.

Not just carrots, sweet potato and melon, and they have a role in night vision and also to keep the surface of the eye clear.

But it's not just Vitamin A.

Moving on to antioxidants. So, Vitamin C and also Vitamin E, not to forget that too. They have been shown that they can delay the onset of cataract formation and macular degeneration and they have a crucial role in eye health.

Omega-3. So specifically, if you have dry eye disease which affects about one in four of the population and the number one cause for it is a condition called blepharitis where the glands between the lashes are clogged up and they secrete the oily layer of your tear film.

Omega-3 has been shown (if you take one gram a day) after six to 12 weeks it would improve the quality of the secretions from the meibomian glands and improve the symptoms of dry eye disease.

So, if you're on a desert island with dry eye disease the one supplement you want to be taking would be Omega-3 and you know you can get it naturally from salmon, tuna etc.

Now Lutein and Zeaxanthin are nutrients that maybe not everyone who knows about but they are not made naturally by the body and they have a key role in macular function.

So, in the back of the eye and the retina, your macular has the highest concentration of cells that enable us to process light cone cells. So, it's very important.

And these cells are functioning to protect sight and essentially these two nutrients have been shown to help that region and essentially, they're in kale and leafy greens. And if you don't feel like you're eating enough this is the recommended dose that you should be taking for macular health.

Selenium, so that has a very important role in thyroid function; so, if you do have a history of thyroid eye disease or any type of thyroid dysfunction you may want to start taking selenium - either supplements or brazil nuts have quite a high concentration.

So, zinc. This has a high concentration in oysters and again has a very important role in eye health - so you may want to think about that too.

Vitamin D is interesting. So, there has been a lot of evidence to show that Vitamin D is very important for general health and there's very little bad advice coming out with Vitamin D.

So, it's not a surprise that it also has a key role in eye health particularly for dry eye disease.

So overall the key thing really is to follow a Mediterranean diet, and this is actually being published to reduce the risk of advanced macular degeneration and this is a large multi-centre study internationally.

So, if you if you were thinking of starting some supplements for eye health when you go to a pharmacist, Boots, essentially have a look around all this. There's a lot of different brands out there but the key thing is just to turn the package over and check that they're actually following the AREDS-2 formula because that is the very large study and then you can start taking them.

Okay, so that was eye health. Just to give you a brief overview of the foods that are quite good.

So, moving on to false eyelashes and eye makeup. And I get asked this all the time but like I said at the beginning, men please do stay tuned because there is some other important information in this section.

So, mascara. So, this is what mascara looks like on the outside, but actually under the microscope it doesn't look so glamorous as you can see in these two pictures here.

But does that mean you should stop wearing mascara? No, of course not. But what it does mean is you need to be performing lid hygiene and you need to be removing your makeup thoroughly every evening.

So, lid hygiene is just a term that we use as eye specialists to describe cleaning the lids properly, and if you don't perform regular lid hygiene you can get a condition called blepharitis which is essentially inflammation of the eyelid margin. And it looks a bit like this under the microscope.

So, it's a form of (it doesn't sound very pleasant) dandruff of the eyelashes and that's the debris that can cause dry eye, can make the eyes very gritty, foreign body sensation can cause infections - particularly if you wear contact lenses.

And without treatment it can lead to lash loss and also recurrent style formation and this is all due to the build-up of bacteria. So, the main way to treat it is eyelid hygiene. Essentially, every evening - ideally morning and evening - get into a routine like when you're brushing your teeth and either get a cotton pad or, if you want to get a reusable pad, you can boil some hot water, let it cool down so it's warm but not scalding and clean the lids.

So, you need to massage down for the upper lids and up for the lower lids with a cotton pad. You can also even get a cotton bud, or you can take it a step further and buy medicated lid care wipes. I have no financial interest but Blephaclene or Ocusoft are very good

And that's how you can keep blepharitis at bay.

Unfortunately, there is no cure, but if you do regular lid hygiene then you can keep your eyes very comfortable, particularly if you have a history of styes.

So, I get asked a lot as well about eyelash extension facts and safety. So, the key thing with this is, you know, if you are thinking about using eyelash extensions, is to make sure the salon that you go to has a good reputation.

If you're prone to allergies or allergic eye disease, then you'd want to look a little bit closer at the glue that they're using. Make sure it's not expired and make sure you know – maybe - do a patch test elsewhere on the body to make sure you're not going to have a reaction.

But really, do good lid hygiene. Don't think “I've got lashes in, I don't want to do the lid hygiene in case they fall out”, because the priority is really lid hygiene.

So, moving on to the last section of the talk: how to keep the eyes and eyelid skin looking youthful and rejuvenated.

And that's a big part of cosmetic oculoplastic surgery or cosmetic ophthalmology. So, the eyes are getting a lot of attention at the moment; with the covered area we're all wearing masks.

The only feature of our face that's on show is our eyes and the eyes are very important; they can show emotion, whether you're angry, if you're happy, if you're sad, it's all in the eyes.

So, the eyes are very important; not only to see clearly but also how they look as well. Now the depressing thing is actually the eyes are the first part of the face to show the signs of aging so why does this happen?

Firstly, I'm going to explain what happens and why. Then we'll go on to the various treatment options in order to help this.

So firstly, eyelid skin is one of the thinnest in the body. It's unique to the rest of the face. So, around the face you have skin and then a cushion of fat before you get to the muscle. However, in the eyelid you have skin and muscle so there is no cushion of fat there. Furthermore, over about the age of 30, we start to lose our collagen and elastin and skin in general starts to become thin and loose.

And for this reason, without that layer of fat eyelid skin you're prone to sort of getting hooded eyes and the medical term is dermatoclasis.

Also, the muscle that's underneath the eyelid (the orbicularis oculi) which encircles the eye and is responsible for blinking. So, we blink 12 times a minute, so this muscle is the most active muscle on the face. And that again can accelerate the formation of fine lines.

Moving onto the lower lid. It's very common to start to get volume loss and, if you look back at photos of, say, children around sort of five to ten - what you'll find is there's a very smooth continuation from the lower lid to the upper cheek - there's no distinction.

However, as we get older and time goes on they start to separate and that can cause the formation of a tear trough deformity and then you can also get eye bags, which is the orbital fat that starts to bulge forward. And we're going to come on to that in a bit.

These changes are all accelerated by smoking, sun, exposure and they can also run in the family.

So firstly, moving on to non-surgical options to rejuvenate the eyelid skin.

First thing I want to talk about is Botox. So it has quite a bad reputation in the media and in celebrities where it's been done badly but actually what's fascinating about it is it was first discovered by accident by an ophthalmologist - an oculoplastic surgeon - so it was used for patients with a condition called blepharospasm. That's when you have uncontrollable blinking of the eye and the treatment for that has always been Botox, from a medical point of view.

And what these this power couple (an Oculoplastic Surgeon and a Dermatologist in Vancouver), what they noticed is that patients coming back for their blepharospasm treatment were also looking less angry. So even though their symptoms of blinking were improved, they wanted to keep coming back because they looked less angry.

And that's how they pioneered aesthetic and cosmetic Botox! So, it's been around for a long time and, if it's done properly, it's safe. It's not permanent, it doesn't last forever. It temporarily blocks muscle contraction and then you metabolise it after about three months.

And that will help the appearance of fine lines developing. Particularly it's most popular around the frown complex (the cabela region) and also the smile lines or the crow's feet.

So that's Botox and, of course, there's time at the end of the session for any questions.

Moving on now to dermal filler which has probably even got even worse of a reputation. So, when people think filler, I think everyone just thinks “Oh I just want bigger lips”, but it can do so much more than that.

So firstly, is hyaluronic acid which is a naturally-occurring substance that is found in our skin, in our eyes actually. It is the highest concentration the body is actually in the eye and our joints so it's a naturally occurring substance that gives its skin is plumpness. Plus, it tracks water so it can add volume and that's where it has loads of benefits.

And again, it's not permanent; it can last anywhere between six to eighteen months, depending on how much you use and what type of filler you use.

This is just an example where you can soften the nose to mouth lines and reduce the tired appearance of the face, but it can be used anywhere: tear trough, cheek, temple, brow, nose to mouth lines, lips, jaw, chin, noses, it can do a lot.

And the key thing is to see someone qualified who knows what they're doing with it and where to put it to enhance your natural features - not make you look different.

But the scary thing is actually you don't have to be a doctor to buy dermal filler and you may have seen in the news that actually during lockdown when you weren't able to get Botox and filler, the patients were so distressed they were buying filler themselves watching videos on YouTube and trying to inject themselves.

And this can lead to the very devastating complications of filler where you can actually occlude a vessel and have skin compromise. And actually, the worst risk you can have is a loss of vision, but this is very, very rare in safe hands.

So that's why it's an unregulated market.

So, it's important to ensure whoever you're seeing has appropriate qualifications and that's why I've really developed an interest in safety and aesthetic practice. It's something I feel quite strongly about.

Okay, moving on so skin boosters now. So, skin quality treatment.

So Profhilo really is the big thing at the moment. It's hyaluronic acid but what's different is it's the highest concentration of hyaluronic acid that you can buy and it's a skin bioremodeling treatment.

So, how it works is the evidence shows that it actually stimulates collagen and elastin production. It's different to dermal filler, even though it's the same substance, but it's injected very superficially, and it will stimulate collagen and elastin production. And you need to have a course.

It's very natural very, very popular. It doesn't change your face; it just improves skin quality in men and women.

And then I briefly wanted to talk about P-R-P which is coined ‘The vampire facelifts’ by the Kardashians. Essentially this is where you use your own blood, and it's a form of regenerative medicine.

So, you use your own growth factors that are found in your own blood to stimulate collagen, elastin production that we all lose after about the age of 30.

So you may have seen the old videos where blood is just poured and smeared all over the face. That's not actually how it's done. Now it's done in a very controlled way with a cannula in two points on each side of the face, so four points in total.

And you have to have it regularly, but it will work over time. It's based on the quality of your own blood - your platelets - because you fractionate off the platelet-rich plasma which has the growth factors. So, you have to be healthy and what was I was saying before in the talk, your general health is very, very important because if you're injecting your own blood it has to be healthy blood.

And you know, regenerative medicine is the future.

So, moving on now to the surgical approaches to enhance the appearance of the eyes.

So, blepharoplasty. So blepharon means eyelid and plasti means to mold and upper and lower blepharoplasty surgery is the most commonly performed cosmetic procedure in the UK now. And it's done by us as Oculoplastic Surgeons.

We are registered with BOPS - the British Oculoplastic Surgical Society. Plastic surgeons also do this operation too. And what does - so we're going to go on to discuss that - but essentially it can help with excess upper eyelid skin, so hooded eyes particularly if it starts to affect your peripheral vision. And in the lower lids it can reduce the appearance of eye bags.

So, I just wanted to explain eye bags because as I mentioned before, aging around the eyelid area is very, very complex and it's very delicate.

So, what you can see here is - in your lower lid - you have three fat pads; your medial, central and lateral. And this is what they look like. So, these fat pads are held in place by a structure called your septum.

So, you want to think about it as like the guard of your lower lid and the fat and also there is a section of the upper lid as well. Unfortunately, again, over time, everything gets a bit loose and the eye bags start to bulge forward - prolapse forward - and that's how you get the formation of eye bags.

And particularly in the upper lid this fat pad (the medial fat pad; you don't have an outer fat pad in your upper lid you have a lacrimal gland there) starts to bulge forward there in the inner corner. And then we mentioned about the brow dropping and hooded eyes and excess skin and you start to lose an eyelid.

And the good thing is that these age-related changes can be easily addressed with an operation, which is safe if done in safe hands. So lower eyelid blepharoplasty, just to give you an idea: men and women.

This gentleman was lower eyelid blepharoplasty eye bag removal and they approached the eye bags by the inside, so there's no external scar. Or it can be addressed by an external scar. And this gentleman had inside the eye scarless eye bag removal.

This lady again had eye bags removed and a technique called fat repositioning. So you take your own fat and you use it to fill the small groove there, a bit like a teardrop filler but it works as permanent. And it's your own fat again, done from the inside This is an example of an upper lid.

So, what I wanted to say as well is that there's been a huge surge in the number of inquiries of blepharoplasty surgery; again we're staring at ourselves more - it's called the Zoom effect. So, you know, right now, we're on Zoom - you know we're looking at ourselves and you start to see things that perhaps you didn't see before. And that's led to a huge surge in cosmetic surgery, eyelid surgery and facial plastic surgery.

And here is an example of the results you can expect to achieve from upper eyelid blepharoplasty. So, the key here is you can see this lady has an eyelid back. It's just sort of restoring symmetry of the upper lid here as well and it's all done by natural lines, natural smile lines, natural creases around the eye.

And again, in men, and the key thing is that you'll look like you've come back from a holiday - you won't look different.

Tips for healthy eyelid skin, just to wrap, summarise, sleep on your back. It's very important. It's difficult but you start on your back. Don't smoke, always wear a high factor sun cream even in the winter and - when you're applying sunscreen - you can go right up to the eye and on the upper and lower lid as well. It's a high-risk area for formation of skin cancer because we forget to put sun cream around the eye particularly in this inner corner.

Always wear sunglasses. There's lots of creams that you can start to use to help the appearance of fine lines around the eye, including a retinal cream.

Follow a healthy diet rich in leafy greens, kale, Omega-3, zinc.

Dark circles; you can check your iron levels if you're worried about that.

Non-surgical and surgical options are available.

So, thank you for listening and I hope you found that useful. I'm going to start with some questions now and these are my details if you want to get in touch.

Jane Styche

Thank you so much for that, Elizabeth, it was really interesting.

I do have a couple of questions for you so I'm just going to fire them over to you now.

Our first question is: what causes red veins to appear on my eyelid?

Miss Elizabeth Hawkes

So, the eyelid is very, very vascular. It probably has the densest vascular network on the face. So, everyone has those blood vessels. Why are they more apparent? Well, like I was saying, in the upper eyelid skin and the lower eyelid skin you lack that cushion of fat. So, blood vessels become more obvious there and it may be if you've got quite fair skin that they are more obvious.

But it's normal to have blood vessels around the upper and lower eyelid.

Jane Styche

Thank you okay I have a question here. I have a chalazion inside my eyelid. What is the treatment for this?

Miss Elizabeth Hawkes

So, the first thing, as mentioned in the talk, is to do lid hygiene morning and evening with warm water. And if you do develop a chalazion, where the glands get clogged up, you need to do hot compress four times a day.

You can buy over-the-counter chloramphenicol; if that's not enough you could consider a surgical incision. And it sounds scary, but it's all done from inside. You know there is no external scar, the eye is completely numb to pain and it's a very safe procedure and only takes about 5-10 minutes.

Jane Styche

Thank you and our final question - oh no I've got another one come through - do you provide treatment for ingrowing eyelashes?

Miss Elizabeth Hawkes

Yes, we can we can target ingrowing lashes. So the first thing to do is identify the cause: why are the lashes in growing? And then there's lots of different treatment options from simple things such as just removing them at the slit lamp to more permanent solutions such as eyelash electrolysis or cryotherapy.

Jane Styche

What can cause eyelid pain and how can I treat it?

Miss Elizabeth Hawkes

Eyelid pain, well I think you to explore that a bit more; you know, why is the eyelid painful? We need to take more of a thorough history really.

I guess the most important thing would be to make sure your vision is okay and if your vision's okay then we can target that, but I don't know.

If I was to guess, I'd probably say the most common reason for eyelid pain is something like blepharitis which we've spoken about a lot in this talk. It's very, very common and can cause a wide range of symptoms.

So, I'd start doing lid hygiene or seek a consultation, but primarily if you have reduced vision or eye pain itself you should seek specialist help fairly soon.

Jane Styche

Absolutely! A couple more for you. So, what's the treatment for a twitching eyelid?

Miss Elizabeth Hawkes

So, this is very common. I'd probably say every member of the population has suffered from a twitchy lid at some point.

The most common causes are fatigue, excess caffeine, stress. They're the most common causes. And blepharitis is a big cause as well. Back to blepharitis - it's so common and just a little spasm that's the main cause.

Dry eye disease can cause it as well and more aggressive involuntary eyelid closer is blepharospasm which it doesn't sound that you're what's being described from the question. So i hope that helps.

Jane Styche

Okay, final question which actually I'll probably be able to answer.

I'd be interested in a blepharoplasty and how quickly could I get to see somebody?

So usually here at Benenden, our Consultants - particularly Miss Hawkes - works with us every week, so you would be able to see Miss Hawkes relatively quickly - within two weeks, I expect.

And then within two weeks after that, should you need to have treatment, and that's what you're listed for we can get that arranged for you.

Okay so that's all of the questions. So, I'd like to thank Miss Hawkes for all of her presentation and answering the questions for us.

You'll now receive a short survey and I'd be grateful if you could spare a few minutes to let me have your feedback on today's webinar.

Our next webinar is on Tuesday the 4^th of May at 7pm with Mr Chipperfield and Mr Oliver and this webinar will be relating to hips and knees.

So, on behalf of Miss Hawkes, myself and the team at Benenden hospital I would like to say thank you very much for joining us today and we look forward to seeing you at our next webinar.