Eye Care

In their daily practical work, dermatologists and dermatocosmetologists often have to deal with various cosmetic defects and dermatoses on the skin around the eyes. Knowledge of a number of anatomical and physiological features of the periorbital region can help in explaining the pathogenesis and features of the course of these conditions and diseases.

The orbital region contains the eye itself and its accessory apparatus, which provides protection and eye movement. The accessory apparatus includes the eyelids, the lacrimal apparatus and the eye muscles. The eyelids (palpebrae - Latin, blepharon - Greek) are a kind of "sliding screens" whose functional purpose is to protect the eyeballs. The upper eyelid is larger than the lower, and its upper border is represented by the eyebrow. When the eye opens, the lower eyelid is lowered only by its own weight, and the upper eyelid is raised actively due to the contraction of the muscle that raises the upper eyelid.

The skin of the eyelids is characterized by a smaller number of cell rows in the epidermis. Thus, the number of rows of cells in the spinous layer is 2-3, while in other areas of the skin - from 3 to 8-15. The granular layer is absent. A smaller thickness of the stratum corneum is also noted, it is about 9 microns.

There are a small number of individual fine vellus hairs and small single-lobed sebaceous glands, with a small cluster of sebaceous glands in the corners of the eyes and along the edge of the eyelids. It is known that the surface of the skin of the eyelids has a more alkaline index than other areas of the skin. There is evidence of greater permeability of the stratum corneum of the eyelids for medicinal and toxic substances. The listed structural features of the epidermis and its stratum corneum indicate imperfection of the barrier properties of the skin, on the one hand, and its high permeability, on the other. Thus, in practical work, caution should be exercised when prescribing high-concentration products, as well as topical glucocorticosteroids. In addition, all procedures that sharply disrupt its barrier properties, in particular brushing, etc., are extremely undesirable for the skin of the eyelids. When carrying out procedures that change the pH of the skin surface (for example, peelings), it is recommended to focus on individual tolerance. The structural features of the skin of the eyelids necessitate the use of special products adapted for this area for daily care (cleansing and moisturizing).

In addition, a distinctive feature of the composition of the skin of the eyelids is its tendency to increased hydration. An abnormal tendency to water retention is noted in various pathological processes accompanied by acute inflammation, such as simple and allergic dermatitis, herpes, streptococcal impetigo, etc. Edema is often present in this localization. Professionals usually take this feature into account when diagnosing these dermatoses. Edema of the eyelids, especially the lower ones, can also be associated with impaired lymph drainage. Thus, with the deforming type of aging, lymph drainage worsens due to a violation of the tone of the orbicularis oculi muscle. Persistent eyelid edema associated with lymphostasis can occur in a special form of rosacea (rosacea with persistent solid edema, or Morbigan's disease). Disruption of the outflow through the lymphatic vessels may occur with various tumor and metastatic processes in the orbital region and in other anatomically close localizations (for example, cancer of the lacrimal gland, etc.). In this case, persistent lymphostasis quickly becomes complicated by secondary fibrosis, and then a characteristic density of tissues appears in the lesion.

At the edges of the eyelids there are hair follicles of the eyelashes, deeply immersed in connective tissue. Eyelashes are bristly hairs, they are replaced every 100-150 days. In clinical practice, specialists deal with the so-called "barley". This disease belongs to the group of staphylococcal pyoderma and is a purulent-necrotic inflammation of the hair follicle of the eyelash. An analogue of such a process in the skin is a furuncle. Subcutaneous fat tissue in the area of the skin of the eyelids is absent. This is why the above-mentioned inflammatory process is more localized in nature, compared to a furuncle.

Directly under the skin are bundles of the orbicularis oculi muscle. The rigid base of the eyelids is the crescent-shaped tarsal plate, formed by dense connective tissue, and not cartilage, as is sometimes mistakenly believed. The tarsal plate covers special branched sebaceous glands (meibomian). These glands open outside the hair follicles behind the eyelashes and secrete a lipid-rich secretion, which, when mixed with tear fluid, creates a special emulsion on the surface of the eye. The analogue of such an emulsion on the skin is the water-lipid mantle, the purpose of which is to prevent the evaporation of tear fluid from the surface of the eye and maintain the barrier properties of the corneal epithelium. In a number of eye diseases, in particular in ophthalmo-rosacea, the composition of the described emulsion is disrupted, so it is recommended to use artificial tears. As is known, the anterior corneal epithelium is a multilayered flat non-keratinizing epithelium, it contains numerous nerve endings that provide high sensitivity of the cornea, has a high ability to regenerate, being renewed every 7 days. This period explains the duration of external use of most drugs in ophthalmology. The fascia of the eyelid is woven directly into the dermis and tarsal plate - the tendon of the muscle that raises or lowers the eyelid.

Cosmetic defects in the periorbital area include skin wrinkling, drooping of the upper eyelid and so-called "hernias" of the lower eyelid. These phenomena are characteristic of age-related skin changes. In particular, with constant contraction of the facial muscles of the eye circumference and with constant contraction of fibroblasts of the overlying dermis, typical oblique lines are formed in the projection of "crow's feet" on the skin in the area of the outer corners of the eyes. The listed changes are one of the first signs of premature skin aging. These phenomena are aggravated by hypertonicity of the muscles of the eye circumference, which is typical for people with visual impairment (myopia, astigmatism, etc.). In this regard, it is no coincidence that specialists recommend timely adequate correction of visual impairment, wearing sunglasses when in the sun, etc. Later, with a decrease in turgor and a violation of skin elasticity, another sign of age-related skin changes is formed - wrinkling of the eyelids and drooping of the upper eyelid. The appearance of characteristic changes in the lower eyelid area is caused by hypotonia of the orbicularis oculi muscle, which can occur with the deforming type of aging.

A special complaint of patients may be pigmentation under or around the eyes. In differential diagnostics of this phenomenon, it is necessary to take into account individual anatomical features of the periorbital zone, atopic dermatitis, and skin manifestations of a number of endocrine dysfunctions (for example, Addison's disease). Individual anatomical features include a thin stratum corneum in the area of the epithelium of the skin of the eyelids, especially the lower one, as well as venous stasis in the area of the superficial vessels of the dermis, giving a slightly bluish tint to the skin. This was intensified by overfatigue, short sleep, and anemia. For the childhood and adult phase of atopic dermatitis, pigmentation on the eyelids, especially the lower ones, is typical, combined with a characteristic deep fold on the lower eyelid (Denny-Morgan symptom). Periorbital pigmentation can also occur with melasma (chloasma), along with a typical localization in the centrofacial part.

In cases of periorbital erythema, the specialist should remember about allergic dermatitis of the eyelids, atopic dermatitis, toxicoderma, dermatomyositis. Allergic dermatitis is characterized by itching, the presence of erythema, vesicles and papules, unclear boundaries of the lesions, and extension beyond the skin of the eyelids. A certain allergological anamnesis is clarified; as a rule, patients indicate the use of external cosmetic care products or decorative cosmetics. In the case of exacerbation of atopic dermatitis, there is erythema, peeling of the skin of the eyelids, clearly visible on the Denny-Morgan folds. When questioning the patient, a characteristic "atopic" anamnesis, other signs of atopy (rhinitis, asthma) are revealed, and during examination - typical rashes on the trunk and limbs, atopic cheilitis. Dermatomyositis is characterized by an increase in symptoms associated with muscle weakness (difficulty raising arms, difficulty climbing stairs, etc.). There may be various non-specific rashes on the skin. In particular, persistent erythema (recurrent, bright red or purple-violet) is observed in the eyelid area, accompanied by periorbital edema.

In addition to the above diseases, the most common dermatoses of the skin around the eyes that patients seek help from a cosmetologist include seborrheic dermatitis, perioral (steroid) dermatitis, simple dermatitis, rosacea, milia, pyoderma, xanthelasma of the eyelids, fibropapillomatous malformation, and various neoplasms.

In case of diagnosis of neoplasms on the skin of the eyelids, consultation with an oncologist-dermatologist and an ophthalmologist-oncologist is necessary for an adequate diagnosis and decision on the tactics of further management. It is necessary to remove neoplasms located on the ciliary edge of the eyelids with special care, since further formation of a scar can lead to a change in the direction of eyelash growth. The consequence of this is constant trauma to the corneal epithelium. The most common neoplasms of the eyelids include syringomas and fibromas (they are often called papillomas).

Finally, thinning of eyebrows and eyelashes can also have an important diagnostic value. This phenomenon is observed in focal alopecia, secondary syphilis, atopic dermatitis. In focal alopecia, characteristic lesions are often found on the scalp, eyebrows and eyelashes may be affected (including unilaterally). There is no hair within the lesions, and at the periphery, in the progressive stage of the process, specially altered hair is found - in the form of an "exclamation mark". Small focal alopecia in secondary recurrent syphilis is more often observed on the scalp, less often - in the beard, moustache, pubis, eyebrows and eyelashes. It is considered a sign associated with damage to the nervous system. Hair loss in the form of small foci in the eyebrow area is called "omnibus" (A. Fonmier) or "tram" (P.S. Grigoriev) syphilid, i.e. a symptom that allows diagnosing syphilis even in a tram in a patient sitting opposite. The defeat of the eyelashes is characterized by their partial loss and successive fusion, as a result of which the eyelashes differ in uneven length: short eyelashes can be seen next to normal ones. Such eyelashes are called "stepped" (Pincus' sign). In severe cases of atopic dermatitis (childhood or adult), some patients, in addition to characteristic changes in the skin of the eyelids, erythema and swelling of the face, cheilitis, note thinning of the outer third of the eyebrows.

Thus, a number of anatomical and physiological features of the skin around the eyes determine the diagnosis of various cosmetic defects and skin diseases, and also dictate the choice of certain cosmetic manipulations by a specialist. It should be emphasized once again the importance of the most gentle approach when choosing procedures, as well as the need for a comprehensive and analytical approach when assessing the condition of the skin in the periorbital area.

Skin care around the eyes at home

Skin care at home consists of morning and evening procedures. Gentle cleansing with cosmetic milk, cream, foam, tonic liquids for eyelids that do not contain alcohol, specially designed for care of this area is necessary. Adequate moisturizing and photo protection are recommended. Moisturizing eyelid creams are used twice a day and are applied with superficial point movements on the upper eyelid from the inner corner of the eye to the outer one, while the product should not be applied below the natural fold of the upper eyelid. In the lower eyelid area, the cream is applied from the outer corner of the eye to the inner one, no closer than 5 mm from the edge of the eyelid. Special eyelid creams can be used to reduce swelling, remove "dark circles under the eyes", smooth out fine wrinkles (with a "botox" effect). The choice of a specific eyelid skin care product is decided individually, after diagnosing a particular condition.

General requirements for cosmetics for eyelids:

• eye cream should not be sticky or greasy, so as not to cause swelling and pastiness;
• Cosmetics for the eyelids should contain active components in small concentrations, since the skin in this area is characterized by a thin stratum corneum and an active rate of proliferation; the cosmetic product should not have a pronounced irritating effect when it comes into contact with the conjunctiva;
• Cosmetic products for eyelids must have proof of passing dermatological and ophthalmological tests.

To reduce eyelid swelling at home, masks made from freshly grated potatoes, chopped parsley, and lotions with astringent solutions can be recommended. The freshly prepared mask is applied to cleansed eyelid skin for 15-20 minutes. Then the mask is washed off with cool water or herbal infusions.

At home, it is advisable to perform gymnastic exercises for the eyelids, strengthening the oculomotor and facial muscles, improving the blood supply to the periorbital area and helping to prevent eye strain. The exercises are performed in a sitting position with a straight back and raised head. The movement is carried out by the eyes, and it is necessary to focus the gaze on the chosen point each time. This will improve the ability to focus.

Gymnastic exercises for the eyelids (by L. A. Kunichev, 1985)

1. Rotate your eyeballs up and down, up and down. Close your eyes. Repeat the exercise 3 times.
2. Look up, forward, down and forward. Repeat the exercise 3 times. Close your eyes.
3. Look left and right. Repeat 3 times. Close your eyes.
4. Look left, forward, right, forward. Repeat 3 times. Close your eyes.
5. Look diagonally up, then down: first to the upper right corner, then to the lower left corner. Repeat 3 times. Close your eyes. Change direction: upper left corner, lower right corner. Repeat 3 times and close your eyes.
6. Slowly make 3 circular movements with your eyeballs to the right. Close your eyes. Then do the same exercise in the direction of the eyeball movement to the left and close your eyes again.
7. Look at the tip of your nose, and then at some distant point. Repeat the exercise 5 times and close your eyes.
8. Look at the tip of one of your fingers, located at a distance of 30 cm, then at any point in the distance. Repeat the exercise 5 times and close your eyes.
9. Look at the selected object in detail for a long time without blinking.
10. Close your eyes and squeeze them tightly, then make several quick blinking movements. Repeat 3 times and close your eyes.

Skin care around the eyes in a cosmetology facility

It is important to emphasize that all manipulations are carried out along the lines of least skin stretching - from the inner corner of the eye to the outer along the upper eyelid, and in the opposite direction along the lower eyelid.

All procedures begin with cleansing the skin of the eyelids. The question of using peels in the eyelid area is decided individually. Glycopeels (25 and 50% solutions of glycolic acid) are indicated. The application of mechanical peeling creams is not recommended. When choosing eyelid masks, preference should be given to moisturizing masks on a cream and gel basis, collagen sheets or "glasses", alginate fillings. Currently, patches, napkins and pads with collagen and retinol are widely used.

The range of physiotherapeutic procedures for the skin around the eyes is very limited. Peeling-brushing, desincrustation and vaporization, cryomassage with liquid nitrogen and carbonic acid snow, vacuum massage are not indicated, and direct exposure to ultraviolet radiation is not recommended.

Darsonvalization of the eyelid skin is used to improve blood flow and lymph drainage, trophism and increase muscle tone. Indications are pastosity of the eyelids, fine wrinkles. Contraindications: dry and "sensitive" skin, rosacea and individual intolerance to the method. Darsonvalization of the eyelids is performed with a cylindrical or mushroom-shaped electrode that is moved along the closed eyelids, in a circular motion. The duration of the procedure is from 1 to 3-5 minutes for each eyelid, a course of 5-7 sessions, every other day. With the right parameters of exposure, the patient experiences a feeling of slight tingling and warmth. In the eyelid area, it is preferable to carry out the procedure with cream, since darsonvalization has a drying effect.

For. prevention of skin aging around the eyes, the myostimulation method is used. The procedure is carried out every other day, for a course of 10-15 sessions. Preventive courses are indicated 2 times a year. Patients under 35-40 years of age are not recommended to prescribe this procedure.

Microcurrent therapy is widely used, allowing to reduce the manifestations of puffiness and swelling around the eyes due to the lymphatic drainage effect (lymphatic drainage). Microcurrent lifting is also used, especially for the deforming type of aging.

Injection techniques are successfully used to eliminate expression wrinkles localized in the glabella area ("anger lines"), horizontal wrinkles on the forehead and "crow's feet" around the eyes. They use preparations made from botulinum toxin extracted from the botulism pathogen - Clostridium Botulinum type A - "Botox" and "Dysport". Apart from some differences in activity, "Botox" and "Dysport" have absolutely identical side effects. This can be temporary paralysis of other muscles if the injection points are incorrectly chosen. Most often, this is expressed in the formation of the so-called "Mephistophelean" eyebrows, ptosis of the eyelids. "Botox" and "Dysport" are combined with almost any cosmetic procedures. Deep laser skin resurfacing and dermabrasion are not recommended. There is no single point of view on the use of mesotherapy in the eyelid area.

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