Download Cosmetometry: Integrating Aesthetics into Optometric Practice

Cosmetometry: Integrating Aesthetics into Optometric Practice
Walter Whitley, OD, MBA, FAAO
Derek Cunningham, OD, FAAO
Sheila Barbarino, MD, FACS, FAAO, FAACS
This course will provide an overview of cosmetic surgery and optometry’s impact in this area. A review
of facial anatomy, testing protocols, available treatments and techniques, and future developments will
be covered. Implementation strategies will be discussed.
Learning Objectives:
Review facial anatomy
Gain a better understanding of available treatment options
Discuss pre-/post-treatment protocols
Discuss implementation within optometry practice
Discuss comanagement opportunities
I.
Introduction to Cosmetic Treatment
a. What is cosmetic eye care?
b. Where does optometry fit in?
c. Can we do this within our practice?
d. Comanagement opportunity
II. Colored Contact Lens
a. Opportunity - 19MM people are interested, but only 2.4MM currently wear color
contact lenses
b. What is the value of a colored CL wearer?
i. Acuvue Define
ii. Ciba Air Optix
III. Eyelash Enhancements
a. Latisse - Treatment for hypotrichosis (inadequate or not enough lashes) to grow
eyelashes longer, fuller, darker.
b. Zoria Boost
IV. Red Eye Treatments
a. OTC Products
i. Tetrahydrozoline HCl 0.05%
ii. Naphazoline hydrochloride 0.03%
b. Off-label treatments
i. Brimonidine - selective alpha-2 adrenergic receptor agonist
1. Vasocontrictor in diluted form <0.1%
2. Studies in LASIK surgery
ii. Topical anti-inflammatories
c. Surgical
i. Eye whitening conjuctivoplasty
1. Local conjunctival resection of those areas that have excessive or
dilated vessels, hyperplastic growths (such as pinguecula or pterygium)
or dense melanosis.
2. Tissue is removed down to the level of the episclera (including portions
of Tenon’s capsule).
3. Over the next few weeks, the tissue regenerates as a more pristine,
transparent tissue without the excessive vascularization or
discoloration.
4. Used with or without amniotic membranes and mitomycin C
ii. Pterygium surgery
1. Indications
a. Presence of benign thickening of the outer conjunctiva of the
eye that grows onto the cornea
b. Loss of clarity within visual axis
c. Increasing corneal astigmatism
d. Chronic irritation and inflammation
e. Cosmesis
f. Motility restriction
2. Review of the procedure
a. Abnormal tissue removed exposing bare sclera
b. Conjunctival autograft - transplant of tissue that has been
painlessly removed from underneath the upper eyelid
c. Stiches vs. No-stitch
d. Tisseel Glue - Fibrin tissue adhesive
3. Discuss post-operative care
4. Complications
a. Recurrence
b. Sub-epithelial scarring
c. Scleral melt (mitomycin-C)
d. Muscle insertion damage
e. Graft inversion
f. Dellen
g. Steroid complication
d. Future treatments
V. Skin Treatments - Cosmetic procedures used to remove the top layer of sun-damaged and dead
skin cells. Can be achieved in a number of ways, ranging from laser, light and other energybased treatments to chemical peels and other non-ablative methods.
a. Microdermabrasion / Skin rejuvenation / Facial Peels
b. Indications
i. Static wrinkles: These wrinkles are visible at all times and do not change in
appearance with facial movements
ii. Dynamic wrinkles: These are expression lines that may appear as folds when the
skin is not moving, and deepen with facial movements or expressions
iii. Pigmentation: Freckles, sun spots, or other darkened patches of skin result
mainly from sun exposure
iv. Scars: As the result of acne or injury to the skin, scars may be rolling (a wavy
appearance to the skin), pitted, discolored, or have raised borders
v. Vascular conditions: Blood vessels visible on the surface of the skin, vascular
lesions that appear as tiny blood-filled blisters or even a constant flush of facial
redness
vi. Loss of skin tone: Weakening of the supportive skin structures (collagen and
elastin fibers) that result in a loss of skin firmness or the development of
cellulite
VI. Injections and Techniques
a. Facial wrinkle treatments - Inhibits neurotransmission at neuro-muscular junction
(acetylcholine, others)
i. Leads to chemical denervation striated muscle
ii. Peaks at 2 weeks
iii. Neuronal sprouting heralds return of function @ 3 – 6 mos.
iv. Examples
1. Botulinum toxin
2. Dysport
3. Xeomin
v. On-label therapeutic uses in ophthalmology
1. Blepharospasm
2. Hemi-facial spasms
3. Strabismus
vi. Off-label therapeutic uses in ophthalmology
1.
2. Lag ophthalmos s/p acute Bell’s Palsy, exposure keratopathy, poorly
healing defect
3. Alternative to permanent tarsorrhaphy
4. Tx of filamentary keratitis with a blepharospasm component
b. Dermal fillers - Facial fillers provide needed filling in or contouring of the face. They are
used to minimize facial wrinkles and folds, such as lines from the nose to the corners of
the mouth (nasolabial folds), deeper frown lines, and shadows around the eyes.
i. Examples
1. Juvederm
2. UltraJuvederm
3. UltraPlus
4. Restylane
VII. Surgical Treatment
A. Blepharoplasty – Surgical treatment to repair droopy eyelids that may involve removing
excess skin, muscle and fat on upper or lower lids
a. Indications
i. Bilateral excess skin/fat weighing down on lashes
ii. Superior VF decrease
iii. Eyes seem ‘hooded’
iv. Brow ache & fatigue
v. Low MRD (<4mm), improved when skin lifted off lid
vi. Normal LF (10-15mm)
b. Relative contraindications
i. Unilateral ptosis
ii. Previous blepharoplasty
B. Brow Lift / Endotine brow lift - Reduces the wrinkle lines that develop horizontally
across the forehead, as well as those that occur on the bridge of the nose, between the
eyes. Improves frown lines, the vertical creases that develop between the eyebrows
and raises sagging brows that are hooding the upper eyelids
a. Indications
i. Ptosis due to eyebrow hanging below supraorbital rim
ii. Improvement in a visual-field deficit caused by overhanging eyebrow
skin
iii. Relief of ocular fatigue caused by compensatory overactivity of the
frontalis muscle
iv. Aesthetics
b. Relative contraindications
i. Unilateral ptosis (unilateral scar)
ii. More obvious incision line
C. External levator enhancement – procedure used to correct bilateral ptosis
a. Indications
i. Bilateral ptosis due to loss of levator tendon support attachment to lid
ii. Low MRD (<4mm) even when brow and skin are lifted off
iii. Decreased LF (measured to be <8mm while controlling frontalis)
b. Relative contraindications
i. Unilateral ptosis
ii. Smooth lid skin without dermatochalasis
D. Fasanella servat – Procedure used to correct mild to moderate ptosis
a. Indications
i. Ptosis corrected by Mullers muscle function
ii. Mild ptosis with good levator function
iii. Ptosis will decrease with 10% phenylephrine instillation
iv. Unilateral ptosis
v. Absent lid crease
b. Relative Contraindications
i. >2mm ptosis compared to other eye by MRD or IPF
ii. Ocular co-morbity: corneal transplant or bleb (stitches rubbing on
cornea)
E. Post-operative management / complications
a. Eyelid suture removal 5-7days
b. Post-operative hematoma
c. Ecchymosis
d. Edema
e. Allergic reactions
f. Infection
g. Unsatisfactory outcomes