There are a multiple reasons people get dark circles underneath their eyes, including genetics, lower eyelid position, lower eyelid bags, allergens, sun exposure, previous trauma, and loss of volume in the cheeks.  Identifying the underlying cause is the most important and effective way to treat them.  During the initial consultation Dr. Parsa will identify the cause and will come up with the needed treatment. If a specific eye cream is needed he will recommend it for you.

How does the mid face age?
The triangular area formed between the two corners of the eye and the corner of the mouth makes up the mid face. The mid face is an essential component of an attractive face. With the aging process, two processes occur: 1) sagging of the fatty tissue that normally drapes over the cheekbones, and 2) loss of tissue volume from fat and muscles. This results in less prominent cheekbones and a droopy fold of skin and fat between the nose and the cheek (the nasolabial fold). The tear trough (the area between the lower lid and the cheek) becomes more prominent with aging, causing more apparent and prominent lower eyelid bags.
What can a cheek lift achieve?
Using minimally invasive cheek and mid face lift techniques with limited incisions, the droopy cheek tissue can be lifted up over the cheekbone, thereby restoring the more prominent youthful contour, improving the tear trough and bagginess of the lower lids, and softening the undesirable cheek fold.

What are different techniques used for a mid face or cheek lift?

• Endoscopic Mid face Lift
As with the endoscopic brow-lift , an endoscope is used after making small incisions at the temple and inside the mouth. Dr. Parsa uses the sub-periosteal approach to the mid face tissue, a deep technique where all the tissues are lifted from the cheekbones and re-suspended in a higher place. Suspension can be achieved by sutures or Endotine, which is an absorbable implant that aids in maintaining the position of the tissues after a cheek or mid face lift.
• Endoscopic Mid face Lift
As with the endoscopic brow-lift , an endoscope is used after making small incisions at the temple and inside the mouth. Dr. Parsa uses the sub-periosteal approach to the mid face tissue, a deep technique where all the tissues are lifted from the cheekbones and re-suspended in a higher place. Suspension can be achieved by sutures or Endotine, which is an absorbable implant that aids in maintaining the position of the tissues after a cheek or mid face lift.
•SOOF lift
The SOOF (sub-orbicularis oculi fat) is an acronym for the fatty tissue of the uppermost part of the cheek. The incision to reach the SOOF can be made through a transconjunctival lower lid approach, or a transcutaneous lower lid approach. This mid-face lift technique typically has less swelling associated with it.
 
What is cheek augmentation?
Cheek augmentation can help restore the well-formed cheekbones you used to have when you were young, or if you have never had well-defined cheekbones, may give your face the desired contour of higher cheekbones. Cheek implants are made in various shapes and sizes, depending on the area to be augmented. They are made out of permanent solid materials that have been used successfully for years. These implants are typically inserted through hidden incisions inside the mouth, between the upper lip and the gums. A pocket is created over the bone and the proper size and shaped implant is placed. After healing, the implant generally feels as if it is part of your own cheekbone.

What material is used for cheek augmentation?
Dr. Parsa uses Gore-Tex, Medpore or Silastic (medical-grade Silicone rubber) implants. These implants are stable and they do not reabsorb, so the result is permanent.

What type of anesthesia is used?
Both cheeklift and cheek augmentation can be performed under Monitored Anesthesia Care (MAC). This type of anesthesia is performed by an anesthesiologist. The main advantages of this anesthesia are: (1) it does not require putting a breathing tube in the throat, (2) it does not require a breathing machine, (3) the recovery is much faster, (4) there is less nausea after surgery. All of these elements translate into greater comfort and safety.
During MAC anesthesia an intravenous needle is placed into one of the veins of the arm or hand. Relaxing medication is given to make the patient fall asleep. The amount of medication is adjusted as needed. After the patient is asleep, numbing medicine is also placed in the skin of the area that is being operated on. During the procedure the patient is unaware of anything going on and cannot hear anything, yet he or she is breathing normally.

What is recovery like?
For a midface or cheek lift, most patients experience minimal discomfort after the procedure. Most swelling will generally improve over one week, however it will take several weeks for all the swelling to resolve. Most individuals will return to work and social activities within 7 to 10 days, although some swelling will still be present.
With the cheek augmentation procedure the cheeks may feel tight, and chewing may be uncomfortable in the first few days. Movement of the mouth and hard chewing should be limited. Pain medication can lessen discomfort. Stitches in the mouth dissolve in approximately 7 to 10 days. Most swelling subsides within 2 weeks, although the results of the surgery may not be fully visible for as long as 3 to 4 months.

I am interested! How should I proceed?
If you are considering this procedure we encourage you to schedule a private consultation with Dr. Parsa. During this visit he will listen to your concerns and, after a comprehensive evaluation, will discuss the best management for you. If you are a suitable candidate you will be informed of all potential risks of the procedure. Depending on your gender, ethnicity, and age, a customized procedure will be tailored for you.

If you are an out of town patient visiting our Beverly Hills Office, please do not hesitate to contact us to help arrange your travel plans.

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Before and After Fat Injection Photo: The following images are actual patients of Dr. Kami Parsa.

Botox®

Watch this video

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Historically many cultures consider fuller lips a sign of fertility. Today they are a symbol of sexual vitality, youth and health. In some people thinner lips can be a family trait. Also, most people with age develop thinner lips, and the corners of the mouth drop giving a sad appearance to the face. Lip augmentation creates fuller, plumper lips and reduces fine wrinkles around the mouth. There are a number of non-surgical and surgical options available to enhance the volume and shape of the lips.

• Temporary Fillers
Today the most common techniques for lip augmentation involve placement of fillers. Collagen products such as CosmoDerm and CosmoPlast, hyaluronic acid products like Restylane and Hylaform , and fat are some of the examples of temporary fillers. Filler techniques for lip augmentation are performed in the office under topical (ice or numbing cream) anesthesia or local anesthesia (small injections to numb the lips). The recovery is quite brief and, depending on the product used, the longevity of the results is typically 3 to 4 months.

• Surgical Implants
A more dramatic degree of lip augmentation can be achieved by surgically placing implants. These implants typically last longer than fillers. The most common lip implants are Alloderm and Gore-Tex (also known as Softform or Advanta) implants. The procedure is performed under local anesthesia or using IV sedation. Patients usually require a few days of recovery because there will be moderate amount of lip swelling for the first 2-3 days.

• Alloderm implant
Alloderm is made from human collagen, thus it has a soft and natural feel, making it a suitable implant for lips. It has been used as an implant on the face with great success for many years. The results are generally long-lasting, although some of the initial volume will be lost over the first 6 to 8 months.

• Gore-Tex implant
Gore-Tex (or ePTFE) is a synthetic implant that has been used in the face and body for many years. The main advantage is that it does not get absorbed over time and the results are permanent. Gore-Tex lip implants are also marketed as Softform or Advanta.

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Introducing Lattice the worlds first FDA approved solution for eyelash growth.

What is LATISSE™ (bimatoprost ophthalmic solution) 0.03%?

LATISSE™ solution is a prescription treatment for hypotrichosis used to grow eyelashes, making them longer, thicker and darker. What is hypotrichosis of the eyelashes?

Hypotrichosis is another name for having inadequate or not enough eyelashes.

How does LATISSE™ work?

The active ingredient in LATISSE™ is bimatoprost. Although the precise mechanism of action is not known, research suggests that the growth of eyelashes occurs by increasing the percent of hairs in, and the duration of, the anagen (or growth) phase. Lashes can grow longer, thicker and darker because bimatoprost can also prolong this growth phase.

How do I apply LATISSE™?
LATISSE™ is a once-a-day treatment you apply yourself each evening to the base of the upper eyelashes. See the full instructions in How to Apply.

How soon will I see results?
LATISSE™ users may see results starting at 4 weeks with full results after 16 weeks. The growth is gradual overnight, over time.

Is LATISSE™ a replacement for mascara?
No, LATISSE™ does not work in place of mascara. However, mascara is a nice complement to LATISSE™ to help make your new longer eyelashes look even more attractive.

Is LATISSE™ different from nonprescription products that indicate eyelash growth?
LATISSE™ solution is the first and only prescription treatment approved by the FDA for inadequate or insufficient eyelashes, growing them longer, fuller and darker.

What if I forget to apply one night? Or a few nights?
If you miss an application or a few, don't try to catch up. Just apply the LATISSE™ treatment the next evening and stay on schedule.

What happens if I stop using LATISSE™?
If you stop using LATISSE™, your eyelashes are expected to return to their previous appearance over several weeks to months.

Do I need to get a prescription for LATISSE™?
You need to be examined by Dr. Parsa before he prescribes you LATISSE™. Dr. Parsa is an oculoplastic & cosmetic eyelid surgeon. He can examine you and assess if you are a candidate for Lattise.

What are the possible side effects of LATISSE™?
The most common side effects after using LATISSE™ solution are an itching sensation in the eyes and/or eye redness. This was reported in approximately 4% of patients. LATISSE™ solution may cause other less common side effects which typically occur on the skin close to where LATISSE™ is applied, or in the eyes. These include skin darkening, eye irritation, dryness of the eyes, and redness of the eyelids.

What should I do if I get LATISSE™ in my eye?
LATISSE™ solution is an ophthalmic drug product. If any gets into the eye, it is not expected to cause harm. The eye should not be rinsed.

Who should NOT use LATISSE™?
Do not use LATISSE™ solution if you are allergic to one of its ingredients.

What are the ingredients in LATISSE™?
Active ingredient: bimatoprost. Inactive ingredients: benzalkonium chloride; sodium chloride; sodium phosphate, dibasic; citric acid; and purified water. Sodium hydroxide and/or hydrochloric acid may be added to adjust pH. The pH during its shelf life ranges from 6.8 — 7.8.

What is skin hyperpigmentation?
This is a common, usually harmless condition in which patches of skin become abnormally darker than the surrounding skin color. This occurs when an excess of melanin, the brown pigment that produces normal skin color, forms deposits in the skin. Hyperpigmentation is a possible side effect of LATISSE™, but may be reversible after you discontinue use.

What is elevated intraocular pressure (IOP)?
This is a condition where the pressure inside the eye is higher than normal. LATISSE™ may decrease IOP. So make sure you let Dr. Parsa know if you have any ocular condition. Concurrent administration of LATISSE™ and certain IOP-lowering medications in ocular hypertensive patients should be closely monitored for changes in intraocular pressure.

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LATISSE Before and After pictures:

Bell's palsy, also known as 7th nerve palsy, is a result of temporary weakness or permanent paralysis of the facial nerve. This nerve controls muscles of facial expression, eyelid movement, and muscles of the forehead and neck. Most of the time Bell's palsy involves one side of the face, however bilateral cases have been reported. Dr. Parsa is a member of the Institute for Facial Paralysis . This is a multi- disciplinary team approach to treating patients who have been affected by this disabling disorder. His surgical skills have been featured on the Discovery Health Channel and multiple media outlets around the world. In this section we hope to be able to answer some of your questions about Bell's palsy. If you need further assistance or have other questions or comments please feel free to contact us.

Is Bell's Palsy the same thing as Facial Paralysis?

Yes.

How do I know if I have Bell's Palsy?

The 7 th cranial nerve is normally responsible for facial expression. This means that every time you smile, laugh, blink, wink, close your eyes, raise your brows, frown, blow a whistle, and make funny faces you are using this nerve to stimulate your facial muscles. If suddenly or progressively you can't do any or some of these things, this could be a sign that you have Bell's palsy.

What causes Bell's palsy or facial paralysis?

A lot of times a definitive cause is hard to find. Viral infections such as herpes simplex virus (HSV) have been associated with Bell's palsy. Other causes include: 1) birth trauma, 2) temporal bone fracture, 3) facial trauma, 4) diabetes, 5) pregnancy, 6) acute or chronic otitis media (middle ear infection), 7) other infections such as mumps, mononucleosis, Lyme disease, and tuberculosis, 8) toxicity from Thalidomide, tetanus, or carbon monoxide, 9) tumors such as acoustic neuroma, facial nerve neuroma, fibrous dysplasia, or metastatic tumors from other parts of the body, 10) multiple sclerosis, 11) myasthenia gravis, 12) sarcoidosis, 13) amyloidosis, 14) Wegener's Granulomatosis, and 15) Kawasaki disease. There are other causes not listed, so we recommend a comprehensive evaluation by someone who is an expert in this field.

How common is Bell's Palsy?

In the United States the rate of Bell's palsy is about 20 to 30 cases per 100,000 population. Worldwide the rate is approximately 10 to 30 cases per 100,000 population.

Are male and females affected equally?

The male-to-female ratio is approximately equal.

Is there a specific age that people are affected more often?

Facial paralysis or Bell's palsy can affect patients at any age. The mean age of onset is early to mid forties. Higher predominance is seen in patients older than 65 years of age, and a lower rate of incidence is observed in children younger than 13 years old.

What are some of the functional and aesthetic impairments associated with facial nerve paralysis?

There is facial asymmetry, depression of eyebrows, inability to close the eyelids (lagophthalmos), paralysis of the lower eyelid (ectropion), decreased tear production, corneal damage, mid-face drooping, nasal airway obstruction secondary to external valve collapse, inability to smile (asymmetry), oral incompetence and drooling, and lower lip deficit.

Why can I open my eyes but not close them?

Cranial nerve 7 is responsible for closing the eyes. This is why patients affected by Bell's palsy will have trouble closing their eyes. Opening the eyes involves the use of your 3 rd cranial nerve which should not be affected by Bell's palsy.

Why do my eyes tear?

There are a multiple reasons why most patients with Bell's palsy complain of tearing. For one thing, the affected eye is not blinking as often, resulting in exposure of the eye to air and thus dryness. When this occurs, the brain will sense that the eyeball is dry and will command the lacrimal gland to produce more tears. Another reason one tears constantly is that the blinking mechanism is needed to help drain the tears into the nose. That's right, into the nose (this is why we get a runny nose every time we cry). If this process is interrupted, the produced tears will run down the face. The third reason there is excessive tearing is due to lack of tone of the lower eyelid.

Why do I feel like there is something constantly in my eyes?

The affected eye is not blinking as often, and the eye gets dry. This is sensed by the brain as if there is something constantly in the eyes.

What other things can happen if I am not blinking?

The worse thing that can happen if you are not blinking often is that the affected eye will get dry and an ulcer or infection can occur on the cornea. This is a serious problem because it can lead to blindness. Aggressive lubrication with artificial tears and ophthalmic ointments is necessary to prevent this from happening. In severe cases the eyelids may need to be patched or taped shut at night.

I use artificial tears and ointments all the time. Are there any surgical procedures that can help?

Yes. Once you have been evaluated by Dr. Parsa, he will customize a treatment protocol for you individually. This may include the use of Gold weights to help close your upper eyelid, correction of your loose lower eyelid, or surgical correction of everted lower eyelids.

Why and how is a Gold weight placed?

A gold weight is placed to help close the upper eyelid better. During your initial consultation, Dr. Parsa will determine the size of the gold weight needed to be inserted to help close your eye. The surgery is an outpatient procedure (you go home the same day), and it is done under local anesthesia. As can be seen in the above figure, the gold weight is inserted under the muscle and over the tarsal plate.

I am embarrassed to eat or talk in public places because of Bell's palsy. What can be done for me?

At the Institute for Facial Paralysis, Dr. Kami Parsa and Dr. Azizzadeh, a Harvard trained Facial plastic surgeon, along with a team of sub-specialists such as an otolaryngologist, ophthalmologist and physical therapist, will work closely with you to restore aesthetics and function.
After your comprehensive evaluation, any of the following surgical procedures may be recommended. For the brow and eyelid region: Gold weight placement to help with upper eyelid closure, surgical tightening of the lower eyelid, and browlift to improve eyebrow position and symmetry. For the mid-face region: creation of a dynamic smile, facelift to improve symmetry and aesthetics of the face, mid-facelift, static suspension of nasal ala to improve nasal breathing, and creation of the nasolabial fold. For the lower face and lips: lower lip wedge excision, asymmetric facelift, and dynamic lip.

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Before and After Bells Palsy Photos: The following images are actual patients of Dr. Kami Parsa.

Revisional left lower eyelid surgery

Note the shape of the left lower eyelid on the left pre-operative photo compared with the right post-operative photo. There is more symmetry after the hard palatal graft reconstruction of the lower eyelid.

There are multiple names one can find for the autoimmune eye condition that can be seen with thyroid disease. These include thyroid eye disease, sometimes abbreviated as TED, Graves' ophthalmopathy, thyroid-associated orbitopathy (TAO), and Graves ' orbitopathy. This autoimmune eye condition, while separate from thyroid disease, is often seen in conjunction with Graves' disease. The condition can be seen in people with no other evidence of thyroid dysfunction, and is occasionally found in patients who have Hashimoto's disease. Most thyroid patients will not develop thyroid eye disease, and if so, only mildly. Depending on the severity, patients may complain of the following symptoms: 1) pain in the eyes, especially when looking up, down or sideways, 2) itchy, dry eyes, 3) swelling of the eyes and its surrounding tissues, 4) swelling in the orbital tissues which causes the eye to be pushed forward, referred to as exophthalmos, giving thyroid eye disease sufferers a wide-eyed or bulging stare, 5) red eyes, 6) diplopia or double vision, 7) loss of vision.


Treatment
In mild cases of thyroid eye disease, lubricating drops or ointments is all that is needed to control the symptoms of dry eyes. For pain or swelling, a short course of steroids is usually sufficient. Some doctors recommend orbital radiation, which can be successful in some patients. Patients with thyroid eye disease need to be followed closely for the development of compressive optic neuropathy, which occurs in a small percentage of patients. In this condition, the swelling in the orbit or eye socket can compress the optic nerve, which is responsible for vision, and cause the patient to become permanently blind. For these patients, orbital decompression surgery will be performed to prevent blindness. Orbital decompression can also be performed on patients who have severe proptosis (extruded eyes). Patients who complain of double vision, depending on the severity of symptoms, can either wear prisms on their glasses or have surgical correction to reposition the eye. TED can at times cause the upper eyelids to be drawn up and give a “stared” look. This can be corrected surgically by repositioning the upper eyelids.

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Eyelid Malposition (ectropion, entropion, post trauma, congenital defect)

The eyelids can be malpositioned for a variety of reasons. It could be congenital, meaning the person was born with it, or it could be secondary to aging, trauma, burn or tumors. A malpositioned eyelid not only aesthetically looks unappealing, but more importantly, it can cause severe irritation, burning, tearing and in some instances compromise vision. Here are a few reasons for eyelid malposition.

Ectropion is an outward turning of the eyelid. This condition is most often associated with aging, however it could also be caused by facial nerve paralysis (Bell's palsy) or scarring of the skin around the eyes from previous injury or burn. Most patients with ectropion complain of constant tearing and a burning sensation. Depending on the cause, the surgical correction varies. If the ectropion is secondary to aging, the lateral aspect of the lower eyelid is tightened and thus repositioned. If the ectropion is secondary to scarring, a skin graft from the upper eyelids or behind the ear will be harvested to correct the defect.


Entropion is an inward turning of the eyelid, typically involving the lower lid. It is usually caused by a loose lower lid, however it can also be caused by scarring from trauma or inflammation from certain ocular diseases. Because of this inward turning the patient complains of constant irritation, tearing and a burning sensation. Depending on the cause, either a lower lid tightening procedure, or the release of scar tissue and placement of a mucus membrane graft will be needed. Both of these operations are performed on an outpatient basis.

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Eyelid skin cancer and trauma are two of the most common reasons a person may need eyelid reconstruction. As an oculoplastic surgeon with experience in both ophthalmology and plastic surgery, Dr. Parsa is an expert in eyelid reconstruction. Even if the entire upper and lower eyelids were damaged from trauma or tumor, Dr Parsa can reconstruct the eyelids by harvesting tissue from other parts of the body. This task is always accomplished by keeping these important goals in mind: preserve vision, prevent blindness, maintain eyelid function and improve cosmesis.

• Eyelid cancers:

Basal cell carcinoma: more then 90% of all malignant eyelid tumors are basal cell carcinoma. It usually presents as a small, firm and raised nodule with an ulcerated center and fine telangiectatic blood vessels. Although these tumors do not metastasize to lymph nodes or distant organs, they can cause extensive local destruction.

Squamous cell carcinoma: although less common than basal cell carcinoma, squamous cell carcinoma is much more aggressive. Most of the time it is locally invasive, but it can metastasize to regional lymph nodes and even produce systemic metastatic cancer. Wide surgical excision of these tumors is the primary treatment. Sometimes when there is extensive involvement or adequate margins are not obtained, radiation therapy or other treatment modalities may be used.

Malignant melanoma : melanoma is a relatively rare cancer of the eyelid and accounts for less then 1% of all eyelid malignancies. The tumor thickness should first be identified via a biopsy to determine the required margin of resection. The thicker the tumor (on biopsy), the higher the likelihood of local recurrence and distant metastasis. Complete surgical excision of these tumors with 5-10 mm clear margins is recommended. At the time of diagnosis, a systemic evaluation should be undertaken to assess distant metastasis. These patients need to be followed closely.

Sebaceous cell carcinoma: this is a rare type of cancer involving the eyelids. These tumors primarily originate from the meibomian glands, sebaceous glands of the eyelids that normally produce the oily layer of the tear film. These tumors can be mistaken for some more benign conditions, such as a chalazion or “sty.” Any “sty” that does not heal and resolve with medical treatment or surgical drainage should be biopsied to rule out sebaceous cell carcinoma. The treatment consists of surgical excision and long-term monitoring for regional lymph node or distant metastasis.

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Enucleation is the surgical procedure in which the eyeball is removed and replaced with an implant. There are several reasons that an enucleation is performed. It could be removed to eliminate a malignant tumor that has developed within the eye, to alleviate uncontrollable pain in a blind eye, or to reduce the risk of “sympathetic” inflammation of the remaining eye when one eye has been severely injured and blinded.

Evisceration is a procedure identical to enucleation with an exception in that the sclera (the white part of the eye) is not removed in the former. In conditions where an intraocular tumor is suspected and the entire globe (eyeball) needs to be removed, an evisceration is not recommended.

Although many patients who require either enucleation or evisceration surgery have little to no vision in their eye, it must be made clear that the enucleation procedure will result in instantaneous, permanent, and total blindness of that eye. The procedure can be performed under general anesthesia or local anesthesia with mild sedation. All patients who undergo this procedure will require an artificial eye (ocular prosthesis) as a cosmetic substitute for their natural eye. The ocular prosthesis is made by an ocularist, an artist, who will try to match the exact color, shape, and texture of the other eye. The prosthesis is usually made 4 to 6 weeks after the surgery. American Society of Ocularist

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When one or more bones around the eye are broken, the condition is called an orbital fracture. This may involve the roof, floor, lateral or medial walls of the orbit. An orbital fracture usually occurs after some type of injury or secondary to some blunt trauma to the face. Depending on the severity of the trauma, it can involve other facial bones as well. Orbital fractures can be associated with severe eye injury or damage, so a full ophthalmic exam should be undertaken.
Symptoms of orbital fracture can include swelling of the eyelids, pain in the eye, double vision, bruising around the eye, sunken eye, numbness of upper teeth and decreased movement of the affected eye.
The diagnosis of facial and orbital fractures is based on an initial comprehensive clinical exam followed by imaging studies, such as a CAT scan. It is possible that one of the extraocular muscles (the muscles which move the eye) may be entrapped in the fracture, in which case the surgical repair should be undertaken as soon as possible within a few days. If there is no entrapment of the muscles, most ophthalmologists wait one or two weeks for the swelling to subside before proceeding with a surgical repair.

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The orbit is defined by all the structures that are contained within the bones of the eye socket. This includes the eyeball, extraocular muscles, optic nerve and the fat that fills the spaces in between. Any of these structures can be affected by a tumor. In addition, cancer of the surrounding sinuses, brain, and nasal cavity may grow through the bones and invade the orbit. Metastatic tumors may also travel to the orbit. Orbital tumors can affect both adults and children. Fortunately, in both age groups most orbital tumors are benign.

In children most tumors are the result of developmental abnormalities. The most common benign tumors in children are dermoids (cysts of the lining of bone) and hemangiomas (a blood vessel tumor). Children also commonly suffer from orbital cellulitis, an infection that usually starts as a severe sinusitis and secondarily invades the orbit, resulting in prominence of the eyeball. Malignancies in childhood are unusual (most common is rhabdomyosarcoma), but any rapidly growing mass is cause for concern.

In the adult population the most common benign tumors are also blood vessel tumors (hemangioma, lymphangioma and arteriovenous malformation). Tumors of the nerves (schwannoma), fat (lipoma), as well as those that evolve from the surrounding sinuses (mucocele) occur less commonly. Frequently, pain and prominence of the eyes can be mistakenly attributed to the growth of a tumor. Further evaluation often reveals a benign non-infectious inflammatory process termed pseudotumor (as an indication of the diagnostic confusion associated with this entity). Alternatively the inflammation may result from a systemic process such as Graves ' thyroid disease. The most common malignant orbital tumors in adults are lymphomas. Often they are initially confined to the orbit without any systemic manifestations. Metastatic tumors most frequently arise from the breast and prostate. Direct invasion of the orbit from the surrounding skin and sinus cavities can occur from squamous and basal cell cancers. Other malignancies that arise from tissues within the orbit are less common (hemangiopericytoma, chondrosarcoma, malignant neurofibroma).

The evaluation of a patient with a prominent eye begins with a careful history and examination by a specialist trained in the field of orbital diseases. In addition to progressive prominence of one or both eyes, troubling symptoms include pain, loss of vision or double vision, redness and swelling of the eyelids and the presence of a palpable mass. Most often either a CAT scan or MRI will be ordered to more carefully define the condition. If suspicious, a diagnostic biopsy may be required. Some conditions require no treatment, whereas others are best treated medically or with the use of radiation therapy. The remainder require surgical excision. Fortunately, surgery has become safer with the use of CAT scans and MRI for preoperative planning, along with the intraoperative use of operating microscopes and surgical lasers. :: Read more

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Tears are produced by the lacrimal glands; each blink lubricates the globe and moves the tears medially towards the nasolacrimal ducts (tear ducts), which drain the tears into the nose. Tearing, also known as epiphora, can be caused by a number of reasons. A patient with tearing needs to have a comprehensive evaluation so the correct cause and treatment plan can be determined. Here are some common reasons for tearing.

• Blepharitis:this is inflammation of the eyelids, and is probably the most common cause of tearing. The oily layer of the tear film is produced by the glands around the eyelid. This layer plays an important role in preventing rapid evaporation of the tears. With inflammation, these oil-producing glands can get clogged. As a result, the tear film will lack this important component and thus evaporate rapidly, leading to dry eye syndrome. The irritated, dry feeling sends signals to the brain to produce more tears, thus the reason for excessive tearing in these patients. The treatment involves treating the underlying blepharitis and use of artificial tears.

• Eyelid malposition: As explained above, the blink dynamic is very important in the proper movement of tears across the eye surface and its drainage into the tear ducts. If the eyelids are malpositioned for whatever reason the patient will have excessive tearing. Previous trauma, tumors, congenital defects, ectropion and entropion are a few causes of eyelid malposition. The patient needs to be evaluated, and reconstructive surgery should be undertaken to correct the underlying cause.

• Nasolacrimal duct obstruction: Also known as the tear duct the nasolacrimal duct is responsible for draining the tears into the nose. This is why a person who is crying will also have a runny nose. If this passage is blocked, the patient will complain of excessive tearing. There are two types of nasolacrimal duct obstruction, congenital and acquired.

• Congenital Nasolacrimal Duct (NLD) Obstruction is a fairly common condition in children whom there is failure of the nasolacrimal duct to open into the nose. If this is the case, tears, mucous, and bacteria cannot be properly cleared from the eye, and as a result the child will have constant tearing. About 80% of congenital NLD obstructions will resolve spontaneously by one year of age. Thus if a child is younger then one, the parents are instructed to massage the nasolacrimal sac (the area near the nose on the lower eyelid) 4 to 5 times a day. If the child has persistent tearing after 12 months of age, a nasolacrimal probing procedure is performed. This procedure is done under general anesthesia. The procedure usually takes just a few minutes, and the infant or child will likely be entirely pain-free afterwards. NLD probing is about 90 to 95% effective and is an extraordinarily safe procedure. For those few infants in which NLD probing fails, a second probing may be attempted or silicone tubes may be placed in the NLD until an open passageway is secured about three to six months after placement .

• Acquired Nasolacrimal Duct Obstruction usually occurs in middle or late adulthood. These patients typically complain of persistent tearing and the tears run out of one eye. This condition is diagnosed by the clinician, who will check with a dye disappearance test or NLD irrigation. If the diagnosis of acquired NLD obstruction is confirmed, the patient may be offered a curative procedure known as dacryocystorhinostomy (DCR).

The DCR Procedure: 
Since the nasolacrimal ducts are blocked, the goal of this procedure is to create a new tear drainage path into the nose. There are two ways to perform this procedure. One is the external DCR, which involves making an incision outside the nose. This procedure has a better success rate then the endoscopic DCR, which has no external incisions. Once the new pathway is created, a tiny plastic stent is placed for 3 to 6 months to ensure proper healing of the new drainage system.

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