Eyelid Surgery

Threshold

General Principles

This policy is intended for referring clinicians from primary care (i.e. General Practitioners and Community Optometrists), hospital eye services and independent service providers.

Clinicians should assess their patients against the criteria within this policy prior to a referral and/or treatment.

Referring patients to secondary care without them meeting the criteria or funding approval having been secured not only incurs significant costs in out-patient appointments for patients that may not qualify for surgery, but inappropriately raises the patient’s expectation of treatment.

On limited occasions, Norfolk & Waveney Integrated Care Board (ICB) may approve funding for an assessment only to confirm or obtain evidence demonstrating whether a patient meets the criteria for funding. In such cases, patients should be made aware that the assessment does not mean that they will be provided with surgery and surgery will only be provided where it can be demonstrated that the patients meet the criteria to access treatment in this policy.

Patients should be advised being referred does not confirm that they will receive treatment or surgery for a condition as a consent discussion will need to be undertaken with a clinician prior to treatment.

Treatment should only be undertaken where the criteria have been met and there is evidence that the treatment requested is effective and the patient has the potential to benefit from the proposed treatment. Where the patient has previously been provided with the treatment with limited or diminishing benefit, it is unlikely that they will qualify for further treatment.

Inclusions:

Norfolk and Waveney Integrated Care Board will only fund surgical treatment of the following eyelid conditions if the inclusion criteria can be met as identified within table 1.0.

Exclusions:

The following procedures are not funded on cosmetic grounds alone.
The policy does not apply to patients with suspected malignancy who should continue to be referred under 2 weeks wait pathway rules for assessment and testing as appropriate.

Cases for Individual Funding Consideration (Patients who do not meet the policy criteria)

On a case-by-case basis, patients might be eligible for surgical intervention, in consideration of their exceptionality. The requesting clinician must provide information to support the case for being considered an exception, by submitting an individual funding request (IFR form).

Procedure	Inclusion Criteria and guidance notes
Ptosis Correction (Drooping of Eyelid(s)	There is evidence of significant functional impairment. AND/OR Patient has objective demonstration of visual field restriction within 20 degrees of fixation on visual field testing. There is abnormal compensatory head posture. There are symptoms related to ptosis e.g. headache, neck pain and back ache. Surgery will improve the vision of the patient. Guidance: Children with Ptosis should be routinely referred as the condition may cause amblyopia. Also, any rapid onset ptosis in adults and children where there is a suspicion of a neurological problem such as Horner’s Syndrome should not wait for a visual field test.
Blepharoplasty (Plastic Surgery of the Eyelid)	UPPER LID Documented patient complaints of interference with vision or visual field related activities such as difficulty reading or driving due to upper eye lid skin drooping, looking through the eyelids or seeing the upper eye lid skin. AND There is redundant skin overhanging the upper eye lid margin and resting on the eyelashes when gazing straight ahead. AND A visual field test by the hospital shows that eyelids impinge on visual fields reducing field to either 120° laterally and or by 40^overtically in the relaxed, non-compensated state. Fields should be assessed with the lid in its normal position and again with the lid taped up to demonstrate that it is the droopy lid causing the field defect. Exemptions – Removal of redundant skin of upper eyelids is considered medically necessary for the following indications: To repair defects predisposing to corneal or conjunctival irritation such as entropion or pseudotrichiasis. To treat periorbital sequelae of thyroid disease, nerve palsy, blepharochalasis, floppy eyelid syndrome and chronic inflammatory skin conditions. To relieve symptoms of blepharospasm or significant dermatitis on the upper eyelid caused by redundant tissue. Following skin grafting for eyelid reconstruction
Ectropion (lower eyelid turns outwards away from the eye)	Patient meets the threshold criteria for Surgical Treatment of Epiphora (please refer to separate NWICB Clinical Threshold Policy) OR Vision is impeded. OR There is exposure of the cornea (e.g. in paralytic Ectropion) and risk of keratopathy (urgent correction required).
Entropion (eyelid(s) fold inwards)	Routinely funded.
Chalazion (fluid filled swelling (cyst)	The cyst has persisted for 12 months or longer despite conservative management such as: Warm Compress Lid Cleaning Massage The above has been tried and one or more of the below symptoms are present: Presence of infection which is resistant to treatment. A single episode of pre-septal cellulitis The cyst impedes vision as experienced by reduced acuity (due to astigmatism) or visual field tests if causing a lid droop or causing amblyopia in a child. Causing mechanical changes such as secondary pull of the eye lid away from the eye, or epiphora. Patient is experiencing persistent pain. Guidance: If there are red flag signs or symptoms to suggest malignancy, arrange urgent referral under the two-week wait pathway for specialist assessment, biopsy (where appropriate), and any required management.