These Eye Surgeons Help You Look Better

Oculoplastic specialists offer array of treatments to enhance appearance of eyes and face.

People get only one chance to make a first impression. Often, that impression is based largely on the appearance of their eyes and face. It’s no wonder people take special care of these delicate areas.

“Using a product such as JUVÈDERM, people not only get the benefit of a more youthful appearance, but the results are also very natural looking.”
– Dr. Applebaum

When age, genetics or sun exposure affects the eyes and face, fellowship-trained oculoplastic surgeons Robert J. Applebaum, MD, MBA, and Norberto Mancera, MD, at Florida Eye Specialists & Cataract Institute, spring into action. These physicians provide services designed to correct issues with or enhance the appearance of the eyes and face.

“Puffy or drooping eyelids can make people look old, tired or even mean,” Dr. Applebaum observes. “While puffy eyelids are often hereditary, they become more pronounced with age.”

To treat sagging eyelids, Dr. Applebaum and Dr. Mancera often recommend blepharoplasty, a safe, effective and cosmetically appealing eyelid surgery. By removing excess eyelid tissue, blepharoplasty can make a dramatic difference in the appearance of the face.

There are two types of blepharoplasties: upper and lower, Dr. Applebaum explains.

“Upper blepharoplasty is for removing excess skin and sometimes puffiness from the upper eyelids. It can be performed to create a more youthful appearance or to improve vision, because excess tissue can get in the way of vision and endanger the patient,” he informs.

Surplus skin on the upper eyelids can obstruct a patient’s peripheral vision.

“If you look in the mirror and see the skin of the upper eyelids approaching your eyelashes, that may well represent a loss of your visual field,” Dr. Applebaum warns. “Unfortunately, because the condition develops slowly, people may lose as much as 30, 40, even 50 percent of their visual field before they realize they need help.

“We measure vision loss by performing a visual field test. Peripheral vision is first checked with the eyelid in its natural position. Next, the eyelid is taped up and the vision is rechecked. If there is a difference of 12 degrees or more between the tests, the eyelid condition is considered a functional problem.”

Medicare and other insurance programs may cover the cost if the visual field is impaired due to excess skin. Whether motivated by cosmetic or functional issues, upper blepharoplasty is a relatively easy procedure performed at the institute, Dr. Applebaum reassures.

“We give our patients a derivative of Valium to relax them. With their eyes gently closed, we remove the excess tissue along the course of the upper lid and stitch the incision closed,” he details. “The scar is placed into the lid crease, so when the eyes are open, the scar is tucked away into the normal anatomical fold of the crease. The eyelid skin is the thinnest skin on the body; consequently, scarring is minimal.”

Realigning Fat Pads

Norberto Mancera, MD

Lower eyelid surgery, or lower blepharoplasty, is strictly a cosmetic procedure, Dr. Mancera notes.

“If we are operating on just the lower eyelids, the surgery takes approximately an hour. It takes longer than upper blepharoplasty, which takes about 20 minutes, because the lower lids have a more intricate anatomy than the upper lids,” the doctor explains.

There are two techniques for lower blepharoplasty.

“We can operate through the front and make an incision in the skin. Or we can do it from the back and make the incision in the conjunctiva, the membrane that covers the inside of the eyelid,” Dr. Mancera describes. “I prefer doing the procedure transconjunctivally because it eliminates visible scars and gives quick, easy access to the lower lid fat pads.”

During surgery, the physician may release the fat pads, reduce their size and/or reshape them to give the patient a more pleasant appearance.

“In some patients, we do what is called a fat pad transposition,” Dr. Mancera reports. “During a transposition, the fat pads remain in their original position, but we realign them and suture them to the cheek pad. This produces a better blending of the lower eyelid and cheek. It helps with any tear trough issues as well.”

The tear trough is the deep furrow between the lower eyelid and upper cheek. It may appear as a little divot or dark circle underneath the eyelid, which can give the eyes a sunken appearance. Moving the fat pads forward is like adding a permanent filler to the tear trough, improving the look of the eyes.

“Often, we perform upper and lower blepharoplasty in combination, which is a nice way to take years off the patient’s appearance,” Dr. Mancera proclaims. “And the effects of these procedures are subtle. Patients don’t look like they underwent significant plastic surgery.”

High-Intensity Light

Another technique for rejuvenating the skin of the face and around the eyes is intense-pulsed light, or IPL.

“Skin problems typically begin when people are in their 30s,” Dr. Applebaum reveals. “That is when production of collagen and elastin, the building blocks of skin, starts to decrease and skin cell turnover begins to decline. These conditions make it more difficult for the skin to recover from the effects of aging and injury caused by exposure to the sun and elements.”

These conditions result in the formation of brown age spots, discoloration of the skin, visible blood vessels on the surface, uneven skin tone, and fine lines and wrinkles. They also make small scars, such as those from acne, more visible. IPL can improve these concerns.

“IPL is not a laser-resurfacing technique,” Dr. Mancera stresses. “Instead of a laser, IPL uses high-intensity light at multiple wavelengths. The wavelengths and frequency of the light can be adjusted to address various skin conditions. IPL does not damage the surface of the skin, which can occur with laser techniques.”

While not a laser, IPL works on the same principles. Light is absorbed into specific skin cells, where it is converted into heat energy. The heat damages the walls of the targeted blood vessels and breaks up pigment cells. The affected vessels and pigment cells then rise to the surface, where they fade or are carried away by the lymphatic system.

“One of the biggest advantages of using IPL instead of lasers, which generally produce more noticeable results, is minimal downtime,” Dr. Mancera discloses. “Because IPL does not affect the surface of the skin, there is little redness following treatment. Patients can have an IPL treatment done over their lunch break and return to work afterward.”

Nonsurgical Services

In addition to surgical procedures, Dr. Applebaum and Dr. Mancera offer nonsurgical facial cosmetic services. These include BOTOX® Cosmetic injections and a variety of facial fillers. These options can help reverse changes associated with aging.

“BOTOX Cosmetic is a synthetic toxin that is altered so it is nontoxic to the body of a healthy person,” Dr. Applebaum informs. “It blocks the release of neurotransmitters that trigger muscle contractions and lead to wrinkles.”

Among the fillers used by the physicians are JUVÈDERM®, VOLUMA and Restylane®. Many fillers contain hyaluronic acid, a substance found naturally in the body that helps restore volume and hydration to the skin.

“Over time, materials in the skin, including the collagen and base membranes, break down, so the face begins to sag. We use fillers in the cheeks to add volume and give the face a nonsurgical lift,” Dr. Mancera describes. “We also use fillers in areas slightly lower on the face to decrease the appearance of fine lines and wrinkles around the nose and lips. Often, we use them in the lips to give the lips more fullness.

“Fillers can also enhance the appearance of the jawline, to give people a more angular jawline. For men, a jaw enhancement can really masculinize the face, and it can give women a slimmer appearance to the face and a more defined jawline.”

Another filler, KYBELLA®, is used to decrease the appearance of a double chin. It is injected into the fatty tissue of the chin, where it breaks down fat cells.

“Using a product such as JUVÈDERM, people not only get the benefit of a more youthful appearance, but the results are also very natural looking,” Dr. Applebaum assures. “Patients don’t look like they’ve had anything done.”

Contemplating Cataracts

Florida Eye Specialists & Cataract Institute’s eye specialists offer a vast selection of services using the most advanced technology. This includes the latest techniques and products for the treatment of cataracts.

Dilip “Dr. Samy” Rathinasamy, MD

“Cataracts are the gradual discoloration or clouding of the eye’s natural lens,” describes Dilip “Dr. Samy” Rathinasamy, MD, a board-certified ophthalmologist and cataract surgeon at the institute.

“Think of the lens as you would a window made of clear, thick, flexible plastic. As the elements take their toll on the plastic, it becomes discolored, distorting the images that can be seen through it. Eventually, the plastic becomes so discolored that you can’t see anything through it.

“A cataract develops in much the same way, which is why cataracts can cause blurry vision and even cause some people to notice more glare than usual, especially at night, with halos or starbursts around car headlights and lamps.”

Cataracts can also cause colors to appear faded or have a yellow or brownish tint. Reading may become more difficult as it becomes harder to distinguish the contrast between letters on the page and the background. Frequent prescription changes to eyeglasses or contact lenses may also signal the presence of cataracts.
Cataracts are treated during a surgical procedure in which the clouded lens is removed and replaced with an artificial intraocular lens, or IOL.

The goal at Florida Eye Specialists & Cataract Institute is to fit patients with an IOL that minimizes or eliminates their dependency on glasses. To help achieve that objective, the institute uses the LENSAR® laser system, a leading-edge femtosecond technology.

“The LENSAR’s functions and precise laser incisions enable surgeons to remove cataracts with increased safety and position the IOLs with greater accuracy,” explains Ana-Maria Oliva, MD, a fellowship-trained corneal and refractive surgeon with the institute. “These innovations lead to better vision following surgery.”

“Cataract surgery can be life-changing for patients. That’s one of the things I find so satisfying and rewarding about what I do.” – Dr. Oliva

The LENSAR automates certain aspects of cataract surgery that were traditionally done by hand, so the procedure is more efficient, more effective and safer.

“The laser makes the initial incision into the eye,” Dr. Oliva details. “It can also create the capsulotomy, which is the opening into the thin, fragile membrane, or capsule, that holds the cataract. And it does so with exceptional precision.

“A capsulotomy done by hand can be less than perfect. The importance of having a perfect capsulotomy is that the IOL can then sit in a more optimal position, which ultimately gives the patient better vision.”

The LENSAR is useful in other ways as well.

“To correct astigmatism, which is an irregular shape of the cornea that leads to blurry vision, surgeons sometimes make limbal relaxing incisions, which are tiny cuts in the cornea to reshape it,” Dr. Samy explains. “The corneal reshaping done by the LENSAR can reduce astigmatism and help people see more clearly after surgery.”

Toric Technology

Another advancement to the femtosecond laser is it enables even more precise placement of IOLs following cataract removal. This feature is designed for use with toric lenses.

“Toric lenses are another way to correct astigmatism.” Dr. Samy says. “They have different strengths in different parts of the lens, which make up for the asymmetric power of the misshapen cornea.

“Using the femtosecond laser technology, doctors are able to put markings on the capsule to better align the toric lens. This provides even more precise placement of the lens for correcting astigmatism.”

Dr. Oliva points out that the laser performs the most crucial portions of the surgery with unmatched precision within seconds of the click of a button. It is a nice adjunct to the surgeon’s skills and expertise.

“Cataract surgery can be life-changing for patients,” she reports. “That’s one of the things I find so satisfying and rewarding about what I do. I’m happy to be able to restore clear sight to patients with such a quick and easy surgery.

“Technology has advanced the treatment of astigmatism apart from cataract surgery as well. Doctors are able to perform imaging on the operative eye in the office using corneal topography and use the image as a guide on the day of surgery.

“We take a picture of the eye, then superimpose it on the eye during surgery and apply our measurements. When patients lie down, their eyes rotate. With this technology, we can adjust for any rotation. This enables more precise limbal relaxing incisions for correcting astigmatism.”

Latest Lenses

Technology has also led to vast improvements in IOLs, which are made of acrylic or silicone and are coated with special material to protect the eyes from the sun’s ultraviolet rays.

The IOL has two parts: the optic, or central area responsible for refraction, and side structures called haptics that hold it in position. Like contact lenses, IOLs are available in various focusing powers.

“The most commonly used IOLs are monofocal lenses, which correct for one focal range, typically distance vision,” Dr. Samy points out. “This results in excellent vision for driving and most daily activities, but people may require reading glasses for very small print. One way to get around that is the monovision approach, where the doctor corrects one eye for distance and one eye for reading.”

Then there are multifocal lenses.

“Most multifocal lenses are bifocals that correct either distance and intermediate vision or distance and near vision,” Dr. Samy educates. “They generally permit the patient to be less dependent on glasses.”

A trifocal lens, the Alcon PanOptix®, has different focusing powers on the optic to enable crisp, clear vision at all zones: distance, intermediate and reading, similar to progressive eyeglasses.

“The PanOptix became available in the United States in late 2019 and is the only trifocal lens approved for use in the US,” Dr. Oliva reports. “It has quickly become a popular lens choice because it virtually eliminates the need for glasses following cataract surgery.

“People have more active lifestyles and use their computers and smartphones with greater frequency. They want to be able to see at all distances following cataract surgery, and they do not want the hassle of glasses.”

The main drawback to multifocal lenses is they sometimes produce visual disturbances, such as rings and halos around lights at night. But a new multifocal lens, the Alcon AcrySof® IQ Vivity®, recently came on the market with a significantly lower risk of nighttime visual side effects.

“The Vivity is a new generation of multifocal lens that we refer to as an extended depth of focus lens,” Dr. Samy explains. “It uses innovative technology that bends light rays entering the eye, allowing light to focus properly on the retina. The retina converts light rays into electrical signals and sends those signals to the brain, which interprets them as images.”

The Vivity corrects blurriness and gives patients clear distance, near and intermediate vision, often eliminating the need for glasses. Another benefit is it can be used with patients who have other eye conditions.

“Most multifocal lenses are contraindicated in patients with eye disease, but people with eye conditions such as glaucoma, macular degeneration and diabetic retinopathy are still candidates for the Vivity,” Dr. Samy elaborates. “These patients would not be candidates for traditional multifocal IOLs.”

© FHCN article by Patti DiPanfilo. Photos by Jordan Pysz. mkb
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