Excerpt from Dermatochalasis

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Background

Redundant and lax eyelid skin and muscle is known as dermatochalasis. It is a common finding seen in elderly persons and occasionally in young adults. Gravity, loss of elastic tissue in the skin, and weakening of the connective tissues of the eyelid frequently contribute to this lax and redundant eyelid tissue. These findings are more common in the upper eyelids but can be seen in the lower eyelids as well.

Some systemic diseases also may predispose patients to develop dermatochalasis. These include thyroid eye disease, renal failure, trauma, cutis laxa, Ehlers-Danlos syndrome, amyloidosis, hereditary angioneurotic edema, and xanthelasma. Genetic factors may play a role in some patients.

Dermatochalasis can be a functional or cosmetic problem for the patients. When functional, dermatochalasis frequently obstructs the superior visual field. In addition, patients may note ocular irritation, entropion of the upper eyelid, ectropion of the lower eyelid, blepharitis, and dermatitis. When cosmetic, patients note a fullness or heaviness of the upper eyelids, "bags" in the lower eyelids, and wrinkles in the lower eyelids and the lateral canthus.

Steatoblepharon describes the herniation of the orbital fat in the upper or lower eyelids. It is associated frequently with dermatochalasis. However, some patients may present with isolated steatoblepharon. Herniation of the orbital fat in the eyelids is because of a weakening of the orbital septum, usually because of age. Most commonly, it is noted in the medial upper eyelid but can give the appearance of "bags under the eyes."

Blepharochalasis syndrome is separate and distinct from dermatochalasis and is a rare disorder that typically affects the upper eyelids. It is characterized by intermittent eyelid edema, which frequently recurs. This results in relaxation of the eyelid tissue and resultant atrophy. In approximately 50% of patients, it is unilateral.

This syndrome can be separated into early and late phases. The early phase is divided further into hypertrophic and atrophic forms. The cause is probably a localized form of angioedema. Sequelae include conjunctival edema and injection, entropion, ectropion, steatoblepharon, ptosis, and excessively thin skin. Blepharochalasis rarely can be associated with agenesis of the kidney, vertebral abnormalities, and congenital heart defects.

Pathophysiology

The pathophysiology of dermatochalasis is consistent with the normal aging changes seen in the skin. This includes loss of elastic fibers, thinning of the epidermis, and redundancy of the skin. When associated with dermatitis, a nonspecific chronic infiltrate is seen. The pathology of blepharochalasis typically shows loss of elastic fibers, lymphedema, epithelial atrophy, and vasculitis.

Frequency

United States

Dermatochalasis most frequently occurs in elderly persons and is very common; the severity is quite variable. The age of onset most frequently is noted in the 40s and progresses with age. Some patients have a familial tendency and develop dermatochalasis in their 20s.

Mortality/Morbidity

• Visual field loss is the most frequent sequelae of dermatochalasis. In severe cases, patients can lose more than 50% of their superior visual field. Patients with a purely aesthetic deformity may not have any visual field defects.
• Blepharitis frequently is seen in patients with moderate-to-severe dermatochalasis. It is characterized by eyelid skin edema and erythema; scurf; meibomian gland inflammation and plugging; and, occasionally, hordeolum.
• Eyelid deformities, such as upper eyelid entropion and lower eyelid ectropion or retraction, can be seen with redundant upper or lower eyelid skin. The redundant upper eyelid skin overhangs the lashes, causing lash ptosis and entropion with resultant keratitis. In patients with severe lower eyelid dermatochalasis, laxity of the lower eyelid develops with resultant eyelid retraction or ectropion.

Race

Race does not seem to play a role; however, patients of Asian origin frequently note fullness in the upper eyelid. This is due to the difference in eyelid anatomy. The Asian patient's orbital septum fuses with the levator aponeurosis low above the eyelid margin or not at all. This allows the preaponeurotic fat to prolapse anteriorly in the eyelids.

Sex

Dermatochalasis occurs with equal frequency in males and females.

Age

• Dermatochalasis most commonly occurs in elderly persons, and its presence and severity increase with age.
• Blepharochalasis is a disease of young persons, especially seen at puberty.

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