Excretory system Figure

The puncta on the medial aspect of the upper and lower lid margins mark the opening of the lacrimal drainage system. Each leads into a 2mm vertical dilatation of the canaliculus (ampulla) followed by an 8 to 10mm horizontal portion. It is important to recognise this canalicular configuration when performing tear sac wash-out and to hold the lid taut during the procedure. The superior and inferior canaliculus combine to form the common canaliculus which leads into the lacrimal sac. Its entry...

Radiation

Historically, irradiation enjoyed significant popularity among a large segment of the medical community for the treatment of epithelial malignancies, and a number of studies reported better than 90 cure rates for periocular basal cell carcinomas. More recently, however, investigators have observed that basal cell carcinomas treated by irradiation recur at a higher rate and behave more aggressively than tumours treated by surgical excision. The radiation dose used to treat patients varies...

Transconjunctival blepharoplasty

Transconjunctival blepharoplasty is indicated in patients with fat prolapse but without excess skin. The lower eyelid is infiltrated with local anaesthesia subcutaneously and trans-conjunctivally down to the orbital rim. A marginal traction suture is placed and the lid everted over a Desmarres retractor. The conjunctiva is incised 4mm below the inferior tarsal margin, extending the width of the eyelid, using scissors, cutting cautery or laser. The incision is carried through the deeper tissues...

Lasers in oculoplastic surgery

The use of lasers in oculoplastic surgery has become increasingly widespread of late. Two lasers are at present pre-eminent in the field the carbon dioxide and more recently erbium YAG lasers. The basic principle for all these lasers is that of delivering high laser energy in short pulses or bursts, thus maximising tissue ablation whilst minimising adjacent thermal damage and hence scarring. The current lasers produce these short burst effects either by the provision of a super or ultra pulse...

Treatment of dysthyroid eye disease

Most patients with thyroid eye disease will have relatively few symptoms and signs, and many will require only topical lubricants during the active phase of the disease and no long-term therapy. Patients without proptosis when the disease is inactive, but with persistent lid retraction or incomplete lid closure, may need eyelid surgery to protect the cornea (Chapter 7). Likewise, squint surgery may be needed when the eye disease has been shown to be stable and inactive for some months....

Dermis fat grafts

In certain circumstances, such as following implant extrusion, it may be inappropriate to reinsert a foreign body into the orbit. A useful autogenous graft to replace orbital volume, and if necessary to increase socket lining, is de-epithelialised dermofat. Dermofat grafts do not fare well in extensively traumatised sockets nor in severely contracted sockets with poor vascularity. De-epithelialised dermofat is harvested from a donor site, generally the upper outer quadrant of the buttocks....

Upper lid retractor recession

The anterior approach is suitable for larger amounts of retraction the posterior approach is better for smaller amounts. Since the posterior approach also results in a raised skin crease, it is preferable to restrict its use to bilateral cases. The principle is that the levator aponeurosis and Muller's muscle are separated from the tarsal plate and recessed. Their position may be maintained with a spacer or with sutures, or left free. The technique for the anterior approach is as follows...

Benign orbital inflammatory disease

Dacryoadenitis forms just one class of orbital inflammation, but any orbital tissue may become inflamed either due to a specific aetiology or without a known cause. Scleritis and episcleritis are other subgroups of orbital inflammation that are discussed elsewhere. Thyroid orbitopathy is a very specific form of orbital inflammation and is presented in Chapter 11. Bacterial orbital infections are common and the age of the patient and site of origin help to indicate the likely organism and guide...

Fractures of the orbital roof zygoma and midface

Fractures of the orbital roof are uncommon and usually accompany major head injury, larger fractures often being comminuted and involving the frontal sinuses, the cribriform plate or intracranial injury the ophthalmologist is, therefore, unlikely to be in charge of the primary management of these cases. Similarly, midfacial fractures are treated by maxillo-facial surgeons and the ophthalmologist's role is in the assessment of visual function, treatment of the ocular injury and in the late...

Principles of management for malignant eyelid tumours

The management of all malignant eyelid tumours depends on Correct histological diagnosis Assessment of tumour margins Assessment of systemic tumour spread Focal malignancy can be treated with The age and general health of the patient The clinician's relative expertise. The choice of treatment is particularly important in Tumour extension to bone the orbit Patients with a cancer diathesis for example, the basal cell nevus syndrome. A comprehensive examination of the patient is important with...

Canalicular lacerations

In discussing the controversy which surrounds the management of canalicular lacerations, it is important to remember that under normal circumstances, 30 of the tear drainage is via the upper and 70 via the lower canaliculus. Some authors, particularly in the USA, consider that all lacerations of the canaliculi should be repaired using the technique of intubation of the whole nasolacrimal apparatus. Other authorities point out that epiphora is rare unless both canaliculi are involved, and that...

Lower lid retractors

Although the upper and lower lids are analogous structures the main distinction is the lid retractors. While the upper lid gains tremendous mobility through the striated levator muscle, the lower lid gains most of its movement via a fibrous extension from the inferior rectus muscle with a range of only 3 to 5mm. The lower lid retractors consist of a sheet of fibrous tissue which extends from the inferior rectus sheath, splits to encapsulate inferior oblique and then runs forward to the inferior...

Signs of intraocular or systemic disease

Slit lamp bio-microscope examination of the ocular surface and the anterior and posterior segments should be performed conjunctival chemosis may be seen in inflammatory conditions, including thyroid related ophthalmopathy, and superior limbic kerato-conjunctivitis is typically related to thyroid orbitopathy. The pathognomonic Lisch nodules of neurofibromatosis are readily apparent in the postpubertal patient (Figure 10.6). Anterior or posterior segment inflammation may accompany the orbital...

Distal margin rotation mucous membrane grafting

If lid retraction is more severe the posterior lamella may need to be lengthened with a graft. Hard palate mucosa (Figure 4.8) is preferable as it is stiffer than labial or buccal mucosa and is wettable. Nasal septal cartilage with its mucoperichondrium is an alternative. The upper tarsus can be incised transversely and the graft inserted between the cut edges as for a lower lid cicitricial entropion repair. The terminal tarsus usually needs to be Figure 4.7 Lamella division with posterior...

Anterior approach blepharoplasty

Anterior approach blepharoplasty is indicated in patients with excess lower eyelid skin and fat prolapse. Technique - a subciliary incision is marked 1-2mm below the lash line starting inferior to the punctum, running across the lid to the lateral canthus and extending straight laterally for up to 1cm in the line of a natural skin crease (Figure 8.5). The skin is incised with a scalpel and deepened centrally on to the tarsus. A skin muscle flap is initially fashioned and elevated off the tarsus...

Sebaceous gland carcinoma SGC

SGCs are very rare, with a predilection for the periocular area. In addition, SGC of the eyelids has a tendency to produce widespread metastes whereas such tumours occurring elsewhere on the skin rarely metastasize. SGC occurs with increasing frequency with advancing age. The tumour has a predilection for the upper eyelid, but diffuse upper and lower eyelid involvement may occur in patients presenting with chronic blepharoconjunctivitis. This tumour is well recognised for its ability to...

Marginreflex distance MRD

Since palpebral aperture is not only affected by the degree of ptosis but also by the lower lid position (Figure 5.1b), it is sometimes more useful to get the patient to fixate a point light source in the primary position and to measure the distance from the corneal light Figure 5.1 Palpebral aperture measurement. (b) Same vertical measurement with left ptosis compensated by left lower lid retraction. (c) Margin reflex distance measurement. Figure 5.1 Palpebral aperture measurement. (b) Same...

Frontalis action

Frontalis overaction may mask ptosis to some degree and it is important to be aware of this when assessing patients. When considering a brow suspension procedure it is necessary to check that good frontalis action is present. A point on the brow is defined and its excursion measured with the brow relaxed and then raised, which should be about 10mm (Figure 5.3). If the patient finds it difficult to relax a habitually raised brow then he she should be instructed to frown and then relax. Figure...

Surgical trauma to the orbit

The orbital contents may occasionally be damaged due to inadvertent entry into the orbit during endoscopic sinus surgery and may result in devastating complications, such as severe motility restriction or blindness (Figure 14.13). Direct damage to the orbital fat, muscles and, more rarely, optic nerve, may occur, especially during power-assisted debridement of diseased sinus tissues. The most important point in the management of inadvertent orbital entry is recognition and immediate cessation...

Benign neural and osseous lesions

Neurilemmomas (Schwannomas) typically present like cavernous haemangioma and have a similar scan appearance, and neurofibromas usually form a mass in the supraorbital nerve, with slowly progressive proptosis and hypoglobus resection of these tumours, when causing loss of orbital function, is curative. In contrast, plexiform neurofibromas diffusely affect the anterior orbital tissues, especially in the upper eyelid and lacrimal gland, and resection is difficult and does not eliminate the...

Examination

Ask the patient to demonstrate what he she is unhappy with and or would like changed either in a mirror or with photographs. It is essential to note whether these concerns are appropriate and more importantly whether the expectations with regard to surgery realistic. Examine the whole face for asymmetry, scarring etc. before examining specific areas of the face. It is important to remember that there are certain differences in facial structure between the female and male, such as brow and upper...

Upper eyelid blepharoplasty

Excess upper eyelid tissue and or herniated orbital fat can be excised for functional or aesthetic reasons. In the former the excess tissues abut or overhang the lash margin, thus interfering with visual function. Significant coincidental brow ptosis must be repaired or it will be worsened by blepharoplasty. The incision is marked with the patient sitting up. A line is drawn along the skin crease starting above the superior punctum extending to the lateral canthus and then sloping upwards...

Exenteration

This involves the total excision of the orbital contents, with or without the removal of the eyelids. Indications for this surgery are advanced malignancy, either of the eyelid, the globe or surrounding adnexal structures. The extent of the procedure depends upon the size and extent of the tumour. If the tumour of the globe does not involve the eyelid skin the lids may be retained but they must be sacrificed in the presence of an extensive skin tumour. An elliptical incision is made through the...

Indications for primary removal of globe

Primary enucleation to prevent the development of sympathetic ophthalmia is no longer advocated. Where possible, the injured eye should undergo accurate primary repair until the intraocular damage can be assessed in detail. Modern intraocular surgery can often salvage severely damaged eyes. If there is no visual potential after an ocular perforating injury, the ocular inflammatory reaction does not settle down rapidly or the eye has been grossly disrupted, it is wise to carry out an enucleation...

Malignant orbital disease in children

Although very rare, the very aggressive malignancies of rhabdomyosarcoma or neuroblastoma tend to present under the age of 10 years, the acute haematological malignancies within the first two decades and primary lacrimal gland malignancy has a peak incidence in the fourth decade. Rhabdomyosarcoma, with a peak incidence at age 7, is the commonest primary orbital malignancy of childhood and arises from pleuripotent mesenchyme that normally differentiates into striated muscle cells. Although...

Entropion

Entropion refers to any form of inverted lid margin. The normal physiological position of the upper and lower eyelid margin is dependent on the relationship between the anterior and posterior lid lamellae (Figures 4.1 and 4.2). These are tightly bound together at the lid margin but elsewhere slippage can occur to cause either an entropion or ectropion. The lamella structure of the lids imparts rigidity and movement which has been well documented by Mustarde. The lids are opened by the lid...

Imaging

Enlarged extraocular muscles tendinous insertion often spared Orbital fat normal, diffusely increased opacity or increased in quantity Occasional slight bowing of the medial orbital wall (lamina papyracea) the Coca-Cola bottle sign Frequent inferior rectus enlargement on axial scan, the mass of which may simulate an orbital tumour Crowding of the optic nerve, at the orbital apex, by enlarged extraocular muscles Lacrimal gland rarely enlarged, but often prolapsed forwards Fat prolapse from the...

Congenital entropion

Congenital entropion is a relatively rare but usually benign condition. Surgical intervention requires to be modified for each case. Epiblepharon is more common and is present more frequently in the oriental races. Due to a variation in septal configuration and overall smaller orbital dimensions, the oriental lid displays overridings of the posterior lamella by a roll of skin and preseptal orbicularis.Time is often all that is needed to secure the integrity of the cornea as initially the lashes...

Lower lid retractor recession Figure 710

The principle here is that the lower lid retractors are separated from the lower border of the tarsal plate and recessed. Their position is maintained with a spacer. Place a stay suture through the lower tarsal plate close to the lid margin. Evert the lid over a Desmarres retractor. Make an incision through the conjunctiva close to the lower border of the tarsal plate. Carefully dissect the conjunctiva from the underlying, white, lower lid retractor layer, as far as the inferior fornix. Make an...

Accentuation

In any unilateral ptosis, but especially in acquired aponeurotic ptosis, an underlying asymmetrical bilateral ptosis may be present. The voluntary effort required to lift the more ptotic lid is associated with increased innervation to the less ptotic lid due to Hering's law, which may normalise its position. The patient is asked to maintain primary position without blinking and the ptotic lid manually lifted by the examiner. The normal lid is examined to see whether it shows a gradual droop...

History for patients with lacrimal disease

Apart from helping to elucidate the cause of the epiphora, the history (Box 10.2) allows assessment of the degree of functional disturbance to the patient. In some, epiphora is simply a mild nuisance, whereas in others it significantly interferes with their quality of life, often with a profound effect on reading and driving. In most cases tears spill over at the medial canthus, whereas lateral spillover usually occurs with lower lid laxity (Figure 10.11). The nature of the discharge, whether...

Further reading

A manual of systemic eye lid surgery. London Churchill Livingstone, 1989. Dutton JJ. Coralline Hydroxyapatite as an ocular implant. Ophthalmology 1991 98 370-7. Jones CA, Collin JROC. A classification and review of the causes of discharging sockets. Trans Ophthal Soc UK 1983 103 351-3. Jordan DR, Allen L, Ells A et al. The use of Vicryl mesh to implant hydroxyapatite implants. Ophthal Plast Reconstr Surg 1995 11 95-9. Jordan DR, Gilberg SM, Mawn L, Grahovac SZ. The...

Congenital myogenic dysgenetic ptosis

Congenital myogenic ptosis is a sporadic or more rarely inherited dysgenesis of the levator muscle resulting in reduced levator function and ptosis, either unilateral or bilateral. The levator function varies from good to poor and similarly the ptosis ranges from mild to severe. When levator function is poor there is also lack of a skin crease and lag of the lid on downgaze since the muscle both contracts and relaxes inadequately. Lagophthalmos may also be present. The initial priority is to...

Post operative management and complications

A topical steroid-antibiotic combination should be prescribed and the nose inspected LASER-ASSISTED and ENDONASAL LACRIMAL SURGERY Light LASER-ASSISTED and ENDONASAL LACRIMAL SURGERY Light Figure 16.3 a-16.7b Right endonasal surgical DCR Figure 16.3 a-16.7b Right endonasal surgical DCR 16.3a The light beam is visible in the middle meatus on the lateral nasal wall 16.3b view of light-pipe transillumination with 30 Hopkins endoscope, S septum, LR lacrimal ridge, MT middle turbinate, E endoscope....

Computed tomography

As the orbit and surrounding sinuses have tissues with naturally high radiographic contrast, thin-slice computed tomography is the most effective and economical tool for the initial imaging of the orbit (Figure 10.7). For a suspected orbital mass, a single run of axial scans with intravenous contrast (unless contraindicated), together with coronal reformats images, is generally sufficient to give a probable diagnosis and allow planning of surgery or medical therapy if needed, direct coronal...

Squamous cell carcinoma SCC

Squamous cell carcinoma in the eyelids is similar to that occurring elsewhere on the skin, with low metastatic potential and low tumour-induced mortality. It represents approximately 1-2 of all malignant eyelid lesions. The tumours tend to spread to Figure 6.4 Complex BCCs, (a) morphoeic (b) fixed to bone (c) medial canthal (d) orbital invasion (e) recurrent after irradiation. regional nodes but direct perineural invasion into the CNS is usually the cause of death in this group of patients.The...

Intraorbital foreign bodies

The site of entry of an orbital foreign body may be self-sealing and easily overlooked. Highspeed foreign bodies are more likely to penetrate the globe, whereas low-speed ones (such as twigs) are more likely to spare the globe. Failure to remove an unsterile foreign body is likely to result in an intraorbital or intracranial abscess, or an externally draining sinus (Figure 14.8). The prime investigation for localisation is thin-slice axial and direct coronal CT scan (Figure 14.9) and MRI should...

Wies procedure

A transverse skin incision is made below the level of the proximal margin of the tarsal plate and carried through into the fornix. The lid retractors are then identified and directly sutured from the lower fornix up the front of the tarsal plate and tied across the skin 2mm below the lash margin. This creates a fibrous barrier to any inappropriate action of anterior lamella across the posterior, thus stopping inversion of the lid margin. The traction sutures through to the skin keep the lid...

Benign cystic anomalies of the orbit

Orbital cysts generally arise from epithelium sequestered within the orbit during embryological development, by implantation after trauma or due to expansion of epithelial-lined sinus lesions into the orbit. These lesions arise from surface epithelium implanted at sites of embryological folding and, if situated anteriorly within the orbit, are commonly noted soon after birth. Due to the accumulation of epithelial debris and sebaceous oil in the lumen of the cyst, the cysts slowly enlarge and...

Orbital implants

When the globe is removed its volume cannot be replaced solely with an ocular prosthesis. By replacing orbital volume in the form of a orbital implant a light artificial eye can be fitted. Many shapes have been suggested but a sphere is routinely used as it has the maximum volume for a given surface area. An 18mm sphere has a volume of 3ml and when wrapped this increases to 4ml. Studies have shown that patients may require larger volume. More recently a conoid shape with a flat front surface...

Box 92 Classification of materials used in orbital implants

Synthetic - silicone, Medpor Naturally occurring - Hydroxyapatite Autogenous - dermofat graft Synthetic - Gortex, Vicryl mesh Homologous - fascia lata, dura, sclera Autogenous - temporalis fascia, fascia lata implants have led to a high extrusion rate. Hydroxyapatite, as it becomes fully integrated with fibro-vascular ingrowth, allows direct coupling of the orbital implant and prosthesis. Following implantation and integration of the Hydroxyapatite a drill hole is placed, into which a peg can...

Malignant orbital diseases in adults

As with all cancers, orbital malignancy is more common in middle age and in the elderly and may be either primary disease arising in the orbit, secondary to spread from the sinuses, or metastatic from remote sites. Adenoid cystic carcinoma, with a peak incidence in the fourth decade, is the commonest malignancy of the lacrimal gland and accounts for 30 of all epithelial tumours. Other, much rarer, carcinomas include primary adenocarcinoma, muco-epidermoid carcinoma, squamous carcinoma and...

Skin

Eyelid skin is thin allowing good mobility of the eyelids. In part due to this thinness, it has a tendency to stretch with age. The resultant excessive skin can be used for full thickness skin grafts. Such skin grafts take well as there is little subcutaneous fat. It should be noted that the lower lid has no vertical excess skin and one should excise lesions from the lower lid as vertically as possible to avoid a cicatricial ectropion. Figure 1.1 Sagittal view of the eyelid structures.

Diplopia

Eyes Cranial Nerve Palsy Images

Double vision arises from neurological deficit, muscle disease or due to distortion of orbital tissues.True binocular diplopia may be intermittent or constant, the images may be displaced horizontally, vertically or obliquely, and the diplopia may be worse in different positions of gaze. Thyroid orbitopathy and trauma are the commonest orbital cause of diplopia, although disease at the apex may cause multiple cranial nerve palsies. Anteriorly located tumours tend to displace the globe rather...

Sebaceous gland carcinoma

It is important to routinely examine for evidence of pagetoid spread multicentric origin by performing random conjunctival sac biopsies. It is appropriate to biopsy any areas of telangiectasia, papillary change or mass. The management of SGC consists of surgical extirpation of the tumour. With heightened appreciation of the clinical presentation of the tumour, early surgical excision significantly enhances the long-term prognosis. Numerous procedures for incision and drainage of suspected...

Surgical spaces

The orbit may be divided into three surgical spaces. The potential subperiosteal space lies between the bone and the periorbita. The intra and extraconal spaces are divided by the extraocular muscles and intermuscular septa. Orbital plate of greater wing of sphenoid Levator palpebrae Superior rectus superioris Lacrimal N Frontal N Sup. ophthalmic vein Levator palpebrae Superior rectus superioris Figure 1.5 Annulus of Zinn and related structures. Inf. division oculomotor N. Abducens N. Figure...

Procedure Figure

An anterior approach has the advantage that excess skin can be excised where patients have co-existing dermatochalasis. Sometimes a true disinsertion of the levator aponeurosis is identified and the lower edge of the aponeurosis can then be reinserted onto the tarsal plate. In aponeurosis stretching, the aponeurosis is advanced sufficiently to eradicate the ptosis. Since the vast majority of aponeurotic ptosis occurs in adults, this surgery should be performed under local Figure 5.5 Aponeurosis...

Surgical rehabilitation of the patient with dysthyroid eye disease

Compressive Optic Neuropathy

Severe conjunctival chemosis is self-perpetuating due to the throttling effect of the lower eyelid on the prolapsed conjunctiva and will, in some patients, prevent eyelid closure (Figure 11.3a). After subconjunctival injection of local anaesthetic with adrenaline, drainage of subconjunctival fluid and placement of Frost sutures in the upper and lower eyelids will typically allow closure of the eyelids under an occlusive dressing, with topical application of a steroidal ointment (Figure 11.3b)....

Lacrimal drainage scintigraphy

This study uses a gamma camera to follow the passage of a drop of radio-labelled fluid Figure 10.18 A typically dilated canaliculus in a patient with Actinomyces canaliculitis. Figure 10.18 A typically dilated canaliculus in a patient with Actinomyces canaliculitis. (usually Technetium 99) from the conjunctival sac to the nasal passages, and provides a measure of physiological tear clearance where there is a patent system on clinical Figure 10.19 Lacrimal scintigraphy showing a normal right...

Secondary orbital tumours

The orbit may be infiltrated by malignant tumours arising in the globe or in any of the surrounding structures, such as the eyelids and paranasal sinuses. If there is extensive orbital involvement, it may be necessary for orbital exenteration as part of the surgical rehabilitation. Tumours originating in the lids, particularly meibomian gland carcinoma and neglected basal cell or squamous carcinomas, can spread Figure 13.9 (a) Fungating melanoma in young patient with terminal disease, (b) the...

Blepharophimosis syndrome

Blepharophimosis syndrome is an autosomal dominant, inherited syndrome (gene on chromosome 3). Occasionally sporadic. A combination of features are seen bilaterally including phimosis on the palpebral aperture, telecanthus, epicanthus inversus, ptosis with poor levator function and cicatricial ectropion of the lateral part of the lower lid. If surgery for telecanthus and epicanthus inversus is required it should be performed at about 3 years of age, prior to ptosis surgery. A Y-V plasty with...

Direct brow lift Figure

The principle is to raise the brow by the excision of an ellipse of skin and frontalis plate and orbicularis muscle, (b) orbicularis muscle plate and orbicularis muscle, (b) orbicularis muscle Figure 7.7 Deep sutures inserted in direct brow lift. Figure 7.7 Deep sutures inserted in direct brow lift. muscle, fixing it to the periosium of the forehead. Mark the ellipse of tissue to be excised mark first the superior border of the brow across its full width. Now manually lift the brow to the...

Everting sutures

For the most benign form of entropion where there is incompetence of the lid retractors, all that is required are everting sutures. These can be 4 0 catgut double-armed sutures. It is possible to gain a similar Figure 4.6 Everting sutures for lower lid entropion. Figure 4.6 Everting sutures for lower lid entropion. effect using 6 0 gauge sutures. Three sutures per lid are average (Figure 4.6). Care must be taken that the most medial suture is not over tightened as this may well cause punctal...

Gold weight implantation Figure

The principle is that an implanted gold weight closes the lid when the levator muscle is relaxed with blinking and voluntary eyelid closure. Figure 7.6 (a) Gold weight placed between the sutured to tarsal plate over the gold weight. Figure 7.6 (a) Gold weight placed between the sutured to tarsal plate over the gold weight. Estimate the required weight of the implant with test weights stuck to the upper lid skin close to the lashes. The correct weight allows complete closure of the upper and...

Complications of levator resection and aponeurosis advancement

Overcorrections - if the lid is very high then immediate lowering is required. If the overcorrection is mild, instruct the patient to massage the lid with traction on the lashes regularly for up to three months. Wait six months and reassess. Undercorrections - if marked, immediate re-do surgery is indicated. If mild, wait six months and review. Abnormal contour - selective recession or advancement of the levator or aponeurosis. Lagophthalmos and exposure - regular lubricant drops and ointment....

Dacryocystography

Dacryocystography provides very good anatomical detail of the outflow system -revealing occlusion, stenosis or dilatation of the outflow tract and also, in some cases, diverticulae, stones, or tumour (Figure 10.17) -but does not give a true measure of the physiological function. However, where the system is patent during injection of contrast, the failure of spontaneous clearance of oil-based contrast media after the patient resumes Figure 10.16 Intranasal tumour causing epiphora. Figure 10.16...

Enucleation

This procedure (Figure 9.2) involves the removal of the entire globe by severing the attachments of the extra-ocular muscles and optic nerves. This is the technique of choice in the presence of an intra-ocular tumour as histological specimens are easily obtained. There is no associated risk of sympathetic ophthalmitis. The surgery requires care to Figure 9.1 Evisceration. (a) 360 peritomy, anterior chamber opened, cornea removed, two triangles of sclera excised at 3 and 9 o'clock (b)...

Proptosis and globe displacement

Whilst some patients may be aware of displacement of the globe, in some only relatives or friends will have noted these symptoms. Old photographs may be helpful in establishing the duration of displacement. Posteriorly located lesions cause axial proptosis, while anterior lesions tend to displace the globe away from the mass (Figure 10.1a and 10.1b). Enophthalmos may be seen with posttraumatic enlargement of the orbital cavity, orbital venous anomalies, scirrhous tumours (typically breast or...

Marcus Gunn jawwinking ptosis

Marcus Gunn jaw-winking ptosis is a developmental abnormality where the levator muscle co-contracts with stimulation of the trigeminal nerve supply to lateral pterygoid, medial pterygoid or both. Autosomal dominantly inherited or sporadic. There is ptosis of varying severity with related degree of levator function often associated with superior rectus underaction. Movement of the jaw causes elevation of the upper lid i.e. the wink. Abolition of the wink requires division of the levator muscle...

Upper lid retractors

These consist of three distinct parts forming one unit which lifts the eyelid. The levator palpebrae superioris is a striated muscle that arises from the lesser wing of the sphenoid directly above the Annulus of Zinn in the posterior orbit. It runs forward under the orbital roof for 40mm before changing direction and splitting into two elements, the anteriorly placed aponeurosis and a thin strip of smooth muscle (Muller's). The aponeurosis is a dense sheet of collagen fibres that runs towards...

Upper eyelid reconstruction

Reconstruction of upper eyelid tumour defects must be performed meticulously in order to avoid ocular surface complications. There are a number of surgical procedures which can be utilised to reconstruct an upper lid defect. It is important to select the procedure which is best suited to the individual patient's needs. Lagophthalmos following reconstruction may cause exposure keratopathy, particularly in the absence of a good Bell's phenomenon. The problem is compounded by loss of accessory...

Benign vascular anomalies of the orbit

Many vascular anomalies, such as varices, lymphangiomas and cavernous haemangiomas, are probably present from birth but may only become manifest in early adulthood. Capillary haemangiomas occur in 1-2 of infants and are more common in females and children of low birth weight most appear soon after birth, can enlarge dramatically and then undergo a spontaneous involution - with 75 resolving within five years. Involvement is usually unilateral and the intradermal eyelid lesions are bright red and...

Skin crease SC

Measurement The Upper Lid Crease

The anatomical distance from the upper lid margin to the eyelid crease is measured with the patient looking down (Figure 5.2). There may be more than one skin crease but generally there is a dominant one which becomes apparent when the patient moves their lid. Excess upper lid skin may overhang the skin crease and should be gently lifted out of the way, without stretching the skin, to enable the skin crease to be measured. In the primary position, the distance from the lid margin to the edge of...

Examination of patients with lacrimal disease

Careful examination of the eyelids and ocular surface should exclude causes of hypersecretion such as marginal blepharitis (Figure 10.12), Figure 10.12 Epiphora caused by severe blepharo-keratitis in a patient with acne rosacea. Figure 10.12 Epiphora caused by severe blepharo-keratitis in a patient with acne rosacea. trichiasis, dry eyes, pingueculum and corneal pathology. The normal punctum is directed into the tear lake and, although frank lower lid ectropion is easily recognisable, mild...

Injury to orbital soft tissues

Testicular Hammer

Avulsion of extraocular muscles is rare and usually results from a penetrating orbital injury with a hooking force, seen occasionally with deliberate attempts at enucleation during assault (Figure 14.11). CT scan allows an assessment of the state of the musculature, although repair is often difficult due to oedema, haemorrhage and retraction of the muscle into the orbit. When enucleation has been achieved, orbital oedema may be extreme and bacterial contamination likely in these circumstances...

Method for orbital exenteration

Exenteration, for certain pervasive malignant or benign orbital diseases, involves complete removal of the eyeball, retrobulbar soft tissues and most, or all, of the eyelids. Skin-sparing exenteration provides a very rapid rehabilitation and is particularly useful for benign disease, post-septal intraorbital malignancy and for the palliation of fungating terminal orbital malignancy (Figure 13.9a). The skin incision should be placed well clear of the malignancy, either near the orbital rim if...

Periorbital and eyelid signs

Swelling is the commonest eyelid sign of orbital disease, but lid retraction, lag or incomplete closure are also very common and hallmarks of thyroid orbitopathy (Figure 10.4). An S-shaped contour of the upper lid may be associated with a number of conditions plexiform neurofibroma of the upper eyelid, Figure 10.4 Signs typical of dysthyroid orbitopathy (a) bilateral proptosis and upper lid retraction (b) lid lag, best demonstrated by asking the patient to follow a slowly descending target (c)...

Ocular balance and ductions

Binocular patients should be examined for latent or manifest ocular deviations and the approximate extent of uniocular ductions in the four cardinal positions estimated. A forced duction (traction) test under topical anaesthesia will assist differentiation of neurological from mechanical causes of restricted eye movements. Likewise, retraction of the globe during an active duction suggests fibrosis of the ipsilateral antagonist muscle, this being a common sign with chronic orbital myositis....

Lower eyelid reconstruction

Hughs Flap

Defects of the lower eyelid can be divided into those that involve the eyelid margin, and those that do not. An eyelid defect of 25 or less may be closed directly. In patients with marked eyelid laxity, even a defect occupying up to 50 of the eyelid may be closed directly. The two edges of the defect should be grasped and pulled together to judge the facility of closure. If there is no excess tension on the lid, the edges may be approximated directly. The lid margin is reapproximated with a...

Complications of brow suspension

Overcorrection - release bands soon after initial surgery. Figure 5.8 Brow suspension - frontalis sling. Undercorrection - tighten bands in the early postoperative period. Redo surgery may ultimately be required. In mild cases a full thickness lid resection can be performed. Exposure - lubricants initially but may ultimately require release of bands. Late droop - redo brow suspension preferably with autogenous fascia lata to minimise risk of further late droop. Infection granulomas - systemic...

Eyelid trauma and basic principles of reconstruction

A doctor's first introduction to ocular plastic surgery is often being called upon to repair an acute eyelid laceration. The management of both acute and chronic or established eyelid injuries is laid out in this chapter. Surgical repair depends on a knowledge of eyelid anatomy and of the principles of eyelid reconstruction which are described here. The advanced trauma life support system (ALTS) was developed by the American College of Surgeons in 1993 as an algorithmic approach to the...

Basal cell carcinoma BCC

BCCs account for approximately 90 of malignant eyelid tumours. Ultraviolet light exposure is an important aetiologic factor in the development of eyelid epithelial malignancies. This tumour is prevalent in fair-skinned people. The effects of sun exposure are cumulative, as reflected in the increasing incidence of the tumour with advancing age. BCC may, however, occur in younger patients, particularly those with a tumour diathesis such as the basal cell carcinoma syndrome. In descending order of...

Medical canthal tendon

This supports the nasal aspect of the eye lids. The anterior limb inserts onto the anterior lacrimal crest and beyond to the frontal process of the maxilla. The common canaliculus enters the lacrimal sac behind the anterior limb. The posterior limb inserts onto the posterior lacrimal crest and contributes most to the stability of the medial canthus. An attempt should always be made to reform this component in eyelid reconstruction. The vertical component is a fascial support that extends from...

If

The lamina papyracea is infractured medially and the ethmoidectomy completed, keeping posterior to the posterior lacrimal crest and below the level of the anterior ethmoidal artery bone excision is continued inferiorly until the medial part of the orbital floor is removed. The periosteum is incised widely, to allow free prolapse of orbital fat into the areas of bone removal, and the anterior periosteal incision and superficial tissues closed in layers. Extended lateral canthotomy approach The...

Internal brow fixation browpexy

This is useful for the treatment of mild unilateral or bilateral, predominantly lateral, brow ptosis. It is often undertaken in conjunction with blepharoplasty. The amount of brow lift is determined as outlined above. After a standard blepharoplasty upper lid skin crease incision, dissection is continued superiorly and laterally in the submuscular fascia plane over the orbital rim. Deep to the plane of dissection the brow fat pad is identified overlying the lateral orbital rim.This is excised...

Skin grafting

Shaped Incision Skin Grafting

This is used to treat combined horizontal and vertical skin shortage. The lid is placed on upward traction. A subciliary incision is made and the skin reflected from the underlying orbicularis until the lower lid margin can lie in contact with the upper lid margin in its open position. This will produce an oversized graft bed to compensate for subsequent contraction. Figure 2.2 Z-plasty. The central limb of the Z is placed along the line of the scar. The limbs are equal in length. The optimal...

Medial canthoplasty Figure

The principle is that the margin of the upper and lower lids medial to the lacrimal puncta are joined to reduce the palpebral aperture and support the medial end of the lower lid. Place lacrimal probes in the canaliculi. Make incisions along the upper and lower lid margins medial to the puncta, staying anterior to the canaliculi, and join the incisions at the inner canthus. Undermine the skin to expose the orbicularis muscle above the below the canaliculi. Place one or two 6 0 absorbable...

Fractures of the orbital floor and medial wall

The indirect, blowout fracture of the orbital floor occurs when a major blunt blow is applied across the anterior orbital entrance, the fracture resulting from hydraulic collapse of the orbital floor and possibly by transmission of energy from a transient deformation of the inferior orbital rim. Typically one edge of the fracture involves the infraorbital nerve canal and a transient neuropraxia of this nerve is extremely common, with hypoaesthesia of the ipsilateral cheek, side of nose and...

Benign lacrimal gland disease

The lacrimal gland is liable to inflammation, cysts and benign tumours, but these conditions can present in a similar fashion to malignancy and this complicates the clinical management of these patients. Inappropriate management of benign conditions can lead to serious consequences - as with, for example, malignant recurrence after biopsy of a benign pleomorphic adenoma. Dacryocoele is a retention cyst of a gland ductule and often presents in young adults, with a variable swelling in the...

Total tarsal eversin

In this case the attachment of the lower lid retractors to the lower border of the tarsus is lax. The inflammation and oedema of the exposed conjunctiva is often sufficient to maintain the lid in an everted position. This can occur unusually as an isolated incident, Figure 3.9 Medial canthal resection. a canaliculus cut, lid to be resected. b marsupialisation and reattachment of resected canaliculus. Figure 3.9 Medial canthal resection. a canaliculus cut, lid to be resected. b marsupialisation...

Aberrant regeneration of seventh nerve

Aberrant regeneration of seventh nerve may occur following a facial nerve palsy in which the lower branches of the nerve can grow to re-innervate orbicularis oculi resulting in ptosis with movement or even resting tone of the muscles of facial expression of the lower face.The ptosis which develops following a facial palsy when the patient moves the lower facial muscles, for example, blows out the cheeks or simulates chewing, the upper lid droops. Abolition of the ptosis requires division of the...

Central ectropion

Patients are often diagnosed with conjunctivitis discharge and treated with topical antibiotics. The symptoms recur the moment these are stopped. This is probably because the dryness of the exposed conjunctiva is temporarily alleviated with the lubrication of the antibiotics, thereby stemming the apparent discharge produced to protect the exposure. While waiting for surgery, it is not unreasonable to sparingly lubricate the exposed tarsal conjunctiva with two to three times daily application of...

Direct brow lift browplasty

This procedure is particularly suitable for male patients with thick bushy eyebrows and receding hairlines thereby masking brow scarring and avoiding coronal scarring , patients requiring a less extensive procedure and those with unilateral brow ptosis secondary to facial nerve palsy. The extent of tissue excision is marked with the patient sitting upright aiming to position the scar within the upper row of brow hairs. The lower skin incision is made with the scalpel blade bevelled such that...

Lateral ectropion

These patients often complain of tear overflow laterally. When the lid margin is pulled forwards and medially, the lateral canthal corner seems to follow the pull and can be dragged to the extent that the laxity of the lower limb of the lateral canthal tendon will allow. In an intact lateral canthal tendon, there is an immediate resistant tug that appears to refuse to let go of the orbital wall. Lateral canthal laxity is often associated with tarsal sag and poor snap-back response these can be...

Sutures and needles

The main sutures used in oculoplastic repair are non absorbable polyamide synthetic fibre 10mm reverse cutting needle non absorbable protein fibre 10mm reverse cutting needle polyglactin 910 braided monofilament provides wound support for 30 days 8mm half-circle spatulated needle Figure 2.1 Technique for producing an everted skin wound. a The skin hook I pulls the entry site skin edge upwards.The needle trajectory II takes a greater bite of tissue in the midsection of the wound B than in the...

Closure of eyelid lacerations

The method of closure is detailed here. Place a lid guard to protect the globe. Align the grey line with 6 0 virgin silk. Leave the ends long and place the suture under light traction to bring the tarsal plates into alignment. Close the tarsal plate with 5 0 Vicryl. These are structural sutures and the bites must be tested for adequacy and placed just shallow to the conjunctival plane to avoid rubbing on the cornea. Close skin and orbicularis with 6 0 silk or nylon. Release the grey line suture...

Medial ectropion

Tarsoconjuntival Diamond Excision

Loss of lid margin apposition to the globe and resulting weakness of the physiological pump of blinking can lead to tear overflow. The repeated need to wipe aggravates the lid laxity. All patients with ectropion can present with epiphora, but this is more usual in those with mainly medial ectropion. The nasolacrimal outflow system should be syringed to elucidate any obstruction, as surgical correction of the ectropion alone will clearly not rid the patient of the symptoms in the presence of an...

Dacryocystorhinostomy indications

Dacryocystorhinostomy Scar

Dacryocystorhinostomy DCR involves removal of the bone lying between the lacrimal sac and the nose, with anastomosis between the lacrimal sac and nasal mucosa the lacrimal sac, with the internal opening of the common canaliculus, is incorporated into the lateral wall of the nose and provides a direct route for tears to reach the nose. The usual indication for DCR is complete or partial obstruction of the nasolacrimal duct such obstruction can cause skin excoriation, visual impairment, social...

Management of postenucleation socket syndrome

Each of the features of the post enucleation syndrome should be assessed Enophthalmos - evident clinically but may be quantified using exophthalmometry measurements. Ptosis - assessment of the degree of ptosis and amount of levator function is necessary. The margin reflex distance and skin crease should be recorded. The tarsoconjunctival surface should also be examined. Deep upper lid sulcus - evident as hollowing above the upper lid. Lower lid laxity - the degree of lower lid laxity and the...

Surgical options

Canaliculo-dacryocystorhinostomy CDCR Canaliculo-dacryocystorhinostomy is indicated where there is bicanalicular block with canalicular obstruction situated a minimum of 8mm from at least one of the puncta and for lateral common canalicular block, in which several millimetres of common canaliculus have been obliterated by scar tissue. The principle of the procedure is to excise the block of scar tissue and unite the medial end of one or both canaliculi to the nose, using the lacrimal sac mucosa...

Lateral tarsorrhaphy

The principle is to join the upper and lower lids laterally to reduce the palpebral aperture horizontally and improve the protection of the cornea. a Temporary tarsorrhaphy Figure 7.1a . Excise the lid margin tissues of the upper and lower lid laterally for the length of the intended tarsorrhaphy. Insert two vertical mattress sutures of 4 0 silk - as shown in the diagram. Tie the sutures over bolsters. Remove the sutures at one week. b Permanent tarsorrhaphy Figure 7.1b . Make an incision along...

Features of dysthyroid eye disease

Although Werner's early NOSPECS classification of dysthyroid eye disease Table 11.1 Assessment of common clinical features of dysthyroid eye disease after Thyroid 1992 2 235-6 . Figure 11.1 A 39-year-old woman with dysthyroid compressive optic neuropathy a before and b after orbital decompression. underlines the concept of a gradation of severity of the condition, it has largely been superseded by classifications based upon the degree of inflammation - such as that of Mourits or that of others...

Coronal brow lift

This procedure is ideally suited to patients with a combination of brow ptosis, excessive forehead skin and soft tissue and a low non-receding hairline. A bevelled high coronal incision is made within the hairline following the shape of the latter far enough posterior to position the subsequent scar 3-4cm posterior to the anterior hairline. The incision is angled to run parallel with the axis of the hair follicles down to periosteum. A forehead scalp flap is elevated using predominantly blunt...

Levator function LF

A measurement of eyelid excursion from extreme upgaze to extreme downgaze is recorded in millimetres which gives an estimate of levator function although true muscle function i.e. force, is not actually being measured . To eradicate the accessory elevatory input of frontalis muscle, it should be splinted against the forehead with a thumb. Normal levator function is about 15mm or more. It is arbitrarily divided into three grades good gt 10mm, moderate, 5-10mm and poor lt 5mm and is the most...