The Eyes Have It

True confession: the impetus for this article came out of pure vanity.

The compelling TV ads from Allergan/AbbVie for Vuity, the first and only FDA approved eye drop for treating presbyopia, were literally an “eye opener” for me. I was fascinated and needed to dig a little deeper into what is trending now and on the horizon for treating the aging eye area.

I was not disappointed.

Eye treatments aimed at rejuvenating the upper and lower eyelid areas are in demand.

“We are seeing a lot of interest in patients’ eyelids and periorbital areas which has really stemmed from wearing masks on a daily basis,“ says Bryn Mawr, PA-based facial plastic surgeon Jason Bloom, MD. “Patients are paying more attention to their periorbital region because that is the first thing that people see. Whether it is using neuromodulators to raise the brows, microblading, brow shaping, eyelash extensions, or lash lifts, patients are showing much more interest in their eye areas.”

For these reasons, there’s a lot of innovation in this category. Thanks to a robust pipeline, a flurry of new products along with inspired uses of existing techniques and technology, new treatments for the eyelid area are having a moment.

Trouble spot: Under-eye bags

Troubleshoot: Peregrine Ophthalmic’s Lipolat

Status: Under investigation

Peregrine Ophthalmic is developing an injectable drug that seeks to reduce unwanted under-eye bag fat, which would improve the overall aesthetic appearance of patients’ treated eyes, says Steve Yoelin, MD, an ophthalmologist in Newport Beach, CA. He is also a strategic Advisor at Peregrine Ophthalmic, Chief Medical Strategist for DelNova, member of the Business Advisor Board and member of the Aesthetic Advisor Board at STRŌMA MEDICAL, and an advisor to AbbVie.

Currently, the only way to achieve this outcome is via costly incisional surgery, he says. “The company doesn’t think that results will be permanent as it expects the fat to return after the medication wears off,” Dr. Yoelin says. “However, it’s possible that over time with continued treatment, the results may remain to an extent even after treatment is eventually discontinued.”

Trouble spot: Complications after neuromodulator injections around the eyes

Troubleshoot: DelNova’s ReViVox

Status: Under investigation

If a patient is unhappy with the results of hyaluronic acid-based fillers, doctors can reverse the effects with hyaluronidase. There hasn’t been a way to do this with neuromodulators until now.

DelNova is developing a novel drug that would allow practitioners to reverse adverse events that are caused by neurotoxins, including ptotic eyelids, heavy eyebrows, and worsening mylar edema. The timing is right. “Drug companies and patients alike are looking for longer-lasting neurotoxins. These side effects may be particularly problematic for new neurotoxins in the pipeline due to their longer durations,” Dr. Yoelin says.

Trouble spot: Eye color change

Troubleshoot: STRŌMA Laser System

Status: Under investigation

STRŌMA Medical is developing a non-invasive laser system for permanent eye-color change, Dr. Yoelin says. Upon approval, this technology would be the first of its kind.”

The technology lightens eye color progressively with each treatment. It doesn’t darken eye color, he says. “The procedure is irreversible, but since the technology incrementally lightens eye color with each treatment, patients can observe the eye color change across procedures and discontinue treatments when they reach their targeted eye color.

Trouble spot: Eyelid ptosis

Troubleshoot: Upneeq (oxymetazoline hydrochloride ophthalmic solution), 0.1%

Status: Approved and available

Upneeq is a prescription eyedrop used to treat acquired blepharoptosis (low-lying lids) in adults that entered the market in 2020 from RVL Pharmaceuticals, Inc, “Most patients (and many well-trained aesthetic physicians) have a difficult time differentiating eyelid ptosis from eyebrow ptosis and upper eyelid dermatochalasis,” says Brian Biesman, MD an oculoplastic surgeon in Nashville.

“Upneeq is instilled as an eye drop and corrects mild to moderate eyelid ptosis,” he says. “The duration of effect is 6-8 hours, and the majority of patients in my experience will use it daily to maintain the results, although some use it twice daily.”

For decades, oculoplastic surgeons have used neosynephrine drops in the eye to predict the outcome of posterior approach (Muller’s muscle/conjunctiva) ptosis repair, he says. After seeing the results of a positive neosynephrine test, patients frequently asked if they could just use the eye drop until such time they were ready for surgery (or in place of surgery altogether).

Thanks to Upneeq, they have an option. What’s more, Upneeq has a much longer-lasting effect than neosynephrine. “Upneeq is extremely effective and well tolerated,” Dr. Biesman says. The key is to understand which patients are the best candidates for treatment. Mild ptosis is common. “A large percentage of the patients seeking blepharoplasty surgery have at least some degree of ptosis,” Dr. Biesman says. “Correcting even mild ptosis in conjunction with blepharoplasty can be the difference between good eyelid surgery and great eyelid surgery.”

Trying Upneeq can help patients better understand this. “It is also useful for patients who have asymmetric ptosis,” he says. “If both lids are low, but one is lower than the other, Upneeq should be placed in the droopier lid first. “

If the droopy lid responds to become higher than the other, patients may choose to use Upneeq in both eyes. “Nothing else does what it does except surgery. The patient can try it on for size and most of them will have an immediate response of Wow!”

For lid ptosis, Steven Fagien, MD, an oculoplastic surgeon in Boca Raton, FL, and the author and Editor of Putterman’s Cosmetic Oculoplastic Surgery, typically uses Jeuveau or Botox. “I like to use Jeaveau around the eyes because the field of effect is smaller; it works nicely for the eyelids because it doesn’t spread where you don’t want it to. Jeaveau has a smaller field of effect than Botox.”

“At least once a day I treat patients who present with lid ptosis. We can treat mild degrees of lid ptosis right above the lashes. The biggest fear of patients when having toxins is getting a drooping lid. We can also treat aperture asymmetries of the eyelids. The orbicularis muscle closes the lid at the lid margin towards the lashes. If you weaken the orbicularis, or the protagonists, the antagonists lift it up. It’s critical to respect the relationship between these two muscles,” he adds.

Trouble spot: Volume loss around the eyes

Troubleshoot: Fillers and PRP

Status: Approved and available

The recent FDA approval for Allergan Aesthetics’ Juvéderm Volbella XC for the improvement of infraorbital hollows in adults over the age of 21 was widely considered a milestone. “This is the first hyaluronic acid that is now on the label, so Allergan can promote it directly to consumers which is a very big deal,” says Dr. Biesman. “Contrary to what many believe, the infraorbital area is one of the safest areas to inject from a vascular adverse event perspective, especially with respect to vision loss, “ he says.

“My workhorse product in this area is Restylane-L, but I also use Restylane Lyft, Belotero Balance +, and have recently used RHA Redensity to treat this area. Patients sometimes ask about injection of platelet-rich plasma (PRP) in the infraorbital hollows as a substitute for soft tissue fillers and I do not find that the results of PRP injection can be compared to those achieved with fillers,” Dr. Biesman says.

Dr. Bloom uses a lot of the new RHA Redensity filler for infraorbital hollow/tear troughs. “That is a big change for me after using Restylane-L for about 12+ years for that indication,” he says. “I am finding that Redensity is soft, moldable, and doesn’t have a significant amount of swelling.” The company is now looking at pursuing this indication from the FDA.

“The most common complications around the eyelid are heavy eyebrows and droopy eyelids, and heavy eyebrows are more common than droopy eyelids. Dermal filler injections, particularly when injected into the glabella, the nasal bridge, and the forehead, carry a risk of blindness,” says Dr. Yoelin. “It’s important for practitioners to exercise caution when injecting fillers into the face, and especially when injecting them into these three anatomical regions.”

The ideal filler doesn’t hydrate and is easy to dissolve, says Julie Woodward, MD, Division Chief of Oculofacial and Orbital Surgery at Duke University in Durham, NC. “It should also be moldable and but not migrate, doesn’t create a tindle effect, and can be used to address fine lines. There is no perfect filler for every indication,” she says “From the hydration studies that we performed at Duke and published in Dermatologic Surgery, the lowest hydrators are NASHA, VYCROSS15, and Thiofix wet milling technology in Revanesse Versa.”

Trouble spot: Eyelid lines and wrinkles

Troubleshoot: Laser skin resurfacing, PRP

Status: Available

“In these settings, I believe laser skin resurfacing is the gold standard,” says Dr. Biesman. “However, PRP injections can produce meaningful improvement in some patients.” He frequently uses a 27g cannula and slowly injects PRP between the obicularus muscle and overlying skin. “Two to three treatments are typically required for best results, and in some patients, I may also combine this with laser treatment,” he says.

“Most recently, I have been using a new erbium fiber laser, UltraClear from Acclaro Medical,” Dr. Beisman adds. “It is unique in the way that it is engineered to produce minimal thermal effect which in turn minimizes treatment discomfort and healing time, yet you can cause enough change in the dermis to stimulate meaningful remodeling with negligible recovery time.”

Trouble spot: Vascular issues around the eyes

Troubleshoot: Lasers

Status: Available

“We can use several modalities to treat vascular issues around the eyes to brighten that area,” says Mira Kaga, MD, Founder of The Kaga Institute of Medicine and Aesthetics in Marlboro, NJ. “A lot of patients come in requesting fillers, yet they often don’t realize that they don’t actually have a deficit to fill. They may complain about the darkness that emanates from vasculature that is very superficial.”

For blue veins, Dr. Kaga will use the 1064nm on Cutera’s excel V+ platform. For more fine reticular vessels, she opts for the 532nm on the Dermastat handpiece. “The most important thing is contact cooling so we are protecting the skin from excessive heat, which can cause complications. We can decrease the spot size so we can target even tiny vessels,” she says.

For periorbital veins, we use an intraocular shield which is similar to a contact lens. This allows us to get close to the lash line without harming any of the anatomy in the area,” she says.

Trouble spot: Microblading complications

Troubleshoot: Lasers

Status: Available

Tattooed eyebrows are a common complaint for many of Dr. Kaga’s patients. “Poorly done microblading and similar procedures can lead to oxidized and discolored pigment,” she says. “What started out as brown ink can oftentimes develop into a red or orange color.” To address this problem, Dr. Kaga uses the enlighten laser to break down and eliminate any undesirable ink in just a few treatment sessions.

Trouble spot: Upper face aging

Troubleshoot: Surgery

Status: Available

For patients who seek a longer lasting option to address the signs of aging of the upper face, surgery is still widely considered to be the most reliable choice.

“The most common surgical procedure I do is what I call a ‘multi-layer blepharoplasty,’” says Dr. Bloom. “This is a transconjunctival lower eyelid blepharoplasty with a skin pinch and periorbital/midface fat grafting. By conservatively removing lower lid fat, I am taking out the puffiness of the lower lid bag, but it is important to now replace volume to the midface and periorbital areas to improve the lid-cheek junction,” he says. Additionally, the eyelid skin is tightened with a skin pinch to address the remaining layer of the eyelid, Dr. Bloom explains.