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A U E R S & T > Chapter 57 - Adnexal surgery - sx tx > Flashcards

Chapter 57 - Adnexal surgery - sx tx Flashcards

1
Q

What are the reconstruction blepharo plastic tx available?

A
  1. sliding skin flap
  2. conjuntival advancement flap
  3. full thickness eyelid graft
  4. rhomboid graft
  5. sliding z flap
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2
Q

What is a common cause of eyelid trauma in horses?

A

Exposure of the equine eye and hazards in confined environments.

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3
Q

Why is it essential to determine if an eyelid laceration is full or partial thickness?

A

To assess the extent of the injury and determine the proper treatment.

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4
Q

What is the benefit of using cold packs on an eyelid laceration?

A

Cold packs help reduce swelling if tolerated.

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5
Q

How should lacerations affecting the medial eyelid be managed?

A

By confirming nasolacrimal patency before closure.

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6
Q

What solution is recommended for flushing eyelid lacerations before closure?

A

A 1:50 dilution of 10% povidone-iodine solution followed by sterile saline.

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7
Q

Why is a two-layer closure preferred for eyelid lacerations?

A

To prevent abnormalities from proud flesh and scarring.

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8
Q

When can fresh eyelid lacerations be closed immediately?

A

If they are not long-standing or infected.

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9
Q

How are tissue-loss defects affecting less than one-third of the eyelid margin managed?

A

By direct apposition closure.

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10
Q

What is a common suture pattern used for palpebral conjunctiva closure?

A

Simple interrupted or simple continuous pattern.

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11
Q

What suture type is recommended for infected lacerations?

A

Nonabsorbable suture material, to be removed after 10-14 days.

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12
Q

What suture technique prevents corneal abrasion from suture tags?

A

A figure-of-eight suture pattern.

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13
Q
A

Figure 57-13. Repair of eyelid laceration. (A) Minimal débridement is performed. (B) Closure is performed in two layers, starting at the eyelid margin to ensure optimal alignment. (C) and (D) Skin closure is accomplished with simple interrupted sutures (4-0 or 5-0). A figure-of-eight suture pattern is useful for closure of the eyelid margin, as it allows suture placement on the eyelid margin, with placement of the knot away from the globe.

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14
Q
A
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15
Q

What is an aftercare recommendation to prevent postoperative rubbing?

A

Use of a protective eye mask with a hard cup.

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16
Q

When is reconstructive blepharoplasty indicated?

A

For lacerations or defects involving more than one-third of the eyelid margin.

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17
Q

Describe the sliding skin flap technique in blepharoplasty.

A

Vertical incisions are made, and small triangles (Burow triangles) are excised to close without dog ears.

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18
Q

describe the sliding technique

A

vertical incisions are made in the eyelid skin that extend in height approximately twice the width of the eyelid defect. Slightly diverging incisions will compensate for some expected wound contracture. Small triangular portions of skin (Burow triangles) are excised at the base of the vertical incisions (see Figure 57-16, A). These triangles allow closure without skin folds (dog ears) and help to distribute tension; they should approximate half of the full height of the vertical incision. The surrounding skin, skin flap, and conjunctiva are undermined using blunt dissection, and the skin flap is advanced to the eyelid margin (see Figure 57-16, B). Wound contracture should be anticipated, and a slight initial advancement and fixation of the flap past the eyelid margin may provide a better ultimate cosmetic result. The flap is sutured to the conjunctiva at the eyelid margin, and to the adjacent skin in a simple continuous pattern using 4-0 to 6-0 absorbable suture (polyglactin 910) (see Figure 57-16, C). A temporary tarsorrhaphy may provide additional support during healing.

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19
Q
A

Figure 57-16. Sliding skin flap to repair eyelid defects. (A) Proportions of incisions should be ab=b=cd=de. (B) Equilateral triangles of skin are excised, as is the affected portion of eyelid. The skin flap and adjacent skin are undermined with scissors. Adjacent conjunctiva is mobilized and closed with absorbable suture (polyglactin 910 [6-0 Vicryl]). (C) The skin flap is advanced, and the leading edge of the flap is sutured to the conjunctiva and skin.

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20
Q

What is the purpose of excising Burow triangles during sliding skin flap surgery?

A

To distribute tension and avoid skin folds.

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21
Q

How is wound contracture managed in sliding skin flaps?

A

By initially advancing and fixing the flap past the eyelid margin.

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22
Q
A

Figure 57-17. Tarsoconjunctival advancement flap. (A) A skin advancement flap is prepared as in Figure 57-16. (B) Conjunctiva of the upper eyelid opposite the defect is incised 3 to 4 mm from the eyelid margin and is undermined to create a flap. (C) The conjunctival flap is advanced and sutured into the defect.
(D) The skin flap is advanced and sutured in place. (E), A temporary tarsorrhaphy relieves tension on the flaps. The use of stents helps to distribute tension. (F) After 4 weeks, the tarsorrhaphy is removed and the conjunctival flap is severed at the level of the eyelid margin. The conjunctiva and skin are apposed with a continuous pattern of 6-0 or 7-0 absorbable suture.

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23
Q

What does a conjunctival advancement flap involve?

A

Advancing conjunctiva from the opposite eyelid to repair defects.

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24
Q

Why might a temporary tarsorrhaphy be necessary during conjunctival advancement flap healing?

A

To reduce tension on the conjunctiva.

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25
When is a full-thickness eyelid graft required?
For extensive eyelid skin lesions where sliding skin flaps are insufficient.
26
Where is the graft tissue usually taken from in a full-thickness eyelid graft?
From the upper eyelid for a lower eyelid defect.
27
What suture material is recommended for skin closure in a full-thickness eyelid graft?
Nonabsorbable monofilament nylon.
28
describe the tarsoconjunctival advancement flap
In cases of neoplasia or trauma with extensive conjunctival involvement, a conjunctival advancement flap from the opposing eyelid may be required (Figure 57-17). A sliding skin flap is created as detailed previously (see Figure 57-17, A). Palpebral conjunctiva from the opposing eyelid is incised approximately 2 to 3 mm from the eyelid margin measuring the same width as the eyelid defect, and vertical incisions are made towards the conjunctival fornix (see Figure 57-17, B). The conjunctival flap is sutured to the remaining conjunctiva in the eyelid defect (see Figure 57-17, C). Closure of the sliding skin flap is as previously described. A temporary tarsorrhaphy is required to alleviate tension on the conjunctiva. A second procedure is performed to transect the base of the conjunctival flap and remove the tarsorrhaphy, approximately 1 month following the initial surgery (see Figure 57-17, F). This procedure can generally be performed on the standing, sedated horse using local anesthesia.
29
tarsoconjunctival advancement flap is used when?
In cases of neoplasia or trauma with extensive conjunctival involvement
30
what is the full thickness eyelid graft technique? describe
This technique is easier to perform on a lower eyelid defect using the more mobile and extensive upper eyelid as the donor tissue. A sliding skin flap of the lower eyelid can provide partial closure of the defect to be grafted. The width of the graft should be 1 to 2 mm larger than the width of the defect in the opposing eyelid margin. The donor eyelid is incised approximately 5 mm from the eyelid margin (to spare the meibomian glands) (see Figure 57-18, B). The flap should be split into skin/muscle and tarsoconjunctival portions to aid mobility of the tissue. The tarsoconjunctival portion of the graft is sutured to the conjunctival defect in the lower eyelid using a simple continuous suture of 6-0 polyglactin 910 (see Figure 57-18, C). The skin portion of the graft is sutured to the lower eyelid skin defect using 4-0 nonabsorbable suture (e.g., monofilament nylon) (see Figure 57-18, D). The bridge in the upper eyelid is sutured to the graft to prevent retraction and a temporary tarsorrhaphy is placed. In a second procedure, following 4 to 6 weeks of healing time, the flap is transected along the new eyelid margin (see Figure 57-18, E), and the lower eyelid conjunctiva and skin are sutured using 6-0 absorbable suture material (polyglactin 910) in a simple continuous pattern (see Figure 57-18, F). The donor flap is sutured back within the upper eyelid.
31
Figure 57-18. Full-thickness eyelid graft. (A) The area of affected lower eyelid is excised. (B) The upper eyelid is excised 5 mm above the eyelid margin opposite the defect. (C) The graft is split into skin and tarsoconjunctival layers. The graft is advanced under the eyelid margin and sutured in place. (D) The bridging eyelid margin is sutured to the graft. A temporary tarsorrhaphy alleviates tension on the graft. (E) After adequate healing has occurred, the graft is severed along the intended eyelid margin. (F) The conjunctiva and skin are apposed along the eyelid margin with a continuous suture pattern. The skin flap is sutured to the bridge to complete the closure.
32
rhomboid graft flaps are used in which situations?
Rhomboid and modified rhomboid flaps are used to treat large periocular skin
33
describe the surgical procedure of a large rhomboid graft flap
A large periocular or eyelid margin defect can be grafted by generating a rhombus—an equal-sided parallelogram, which can be rotated to cover the eyelid defect (Figure 57-19). The rhombus can be constructed as a square or with sides at approximately 60 and 120 degrees. Once the defect is created, two incisions are made in the distal eyelid skin to form two further sides of the rhombus (see Figure 57-19, B). The skin is undermined using blunt dissection and the rhombus is rotated 90 degrees to fill the defect (see Figure 57-19, C). Conjunctiva from the distal palpebral or bulbar surfaces should be advanced to the new eyelid margin. Simple interrupted or simple continuous sutures of 4-0 to 6-0 absorbable suture material are used to suture the conjunctiva to the new eyelid margin and to suture the graft in place (see Figure 57-19, D).
34
Figure 57-19. Rhomboid graft flap. (A) The rhomboid is aligned with one side along the position of the eyelid margin. Sides of the rhomboid are equal. The replacement flap is incised on a line (A1) continuous with the diagonal of the rhomboid, for a distance equal to the sides of the rhomboid. The second incision (A2) is also equal in length, and is placed parallel to the side of the rhomboid. (B) The lesion is excised and conjunctiva is mobilized to cover the replacement flap. (C) The flap is dissected free from underlying tissue and rotated into position. (D) The flap is sutured in position with the leading edge forming the new eyelid margin. (Angles 1 and 2 are indicated on B and D to aid in orientation.)
35
when do you use the sliding Z flap?
Mass excision or tissue loss at the lateral canthus
36
Figure 57-20. Sliding Z flap. (A) Growths of the lateral eyelid can be removed en bloc. The triangular areas of skin to be removed adjacent to the defect are marked. Excision of these flaps facilitates skin mobilization. (The bases of the triangles align with the diagonal of the defect.) (B) Adjacent skin is undermined. (C) Equivalent triangles of skin are excised. (Cut edges A, A′, B, and B′ are shown to aid in orientation for advancement of the flap.) (D) The flap is advanced and sutured in place.
37
describe in detail the surgical tx of sliding z flap
The lesion should be fully excised or débrided, and the surrounding skin and tarsoconjunctiva should be separated using blunt dissection (see Figure 57-20, B). Triangles of skin are excised superior and inferior to the defect (see Figure 57-20, C). The skin is advanced to cover the defect. The new portion of eyelid margin is created by suturing skin and conjunctiva together using 4-0 to 6-0 absorbable suture material (polyglactin 910). The remaining skin is sutured in a similar manner (see Figure 57-20, D).
38
How is a rhomboid graft flap constructed?
By creating a rhombus that can be rotated 90 degrees to cover the defect.
39
What is the benefit of a rhomboid graft flap?
It fills large periocular or eyelid margin defects effectively.
40
When is a sliding Z flap typically used?
For reconstructing defects at the lateral canthus.
41
What additional support might be used during a third eyelid flap procedure?
A subpalpebral lavage device.
42
What causes the third eyelid to move over the eye?
Contraction of the retrobulbar muscle and globe retraction
43
What is the function of the nictitans gland in the third eyelid?
It contributes to the aqueous layer of the tear film.
44
What anatomical structure provides support for the third eyelid?
A T-shaped cartilage.
45
What is the role of the malar artery in third eyelid anatomy?
It supplies blood to the third eyelid.
46
How does loss of sympathetic tone affect the third eyelid?
It causes protrusion in cases like Horner syndrome.
47
What diagnostic procedures may be used for third eyelid abnormalities?
Cytology, biopsy, culture/sensitivity, and fine-needle aspiration.
48
What nerve provides sensory innervation to the third eyelid?
The infratrochlear nerve from the ophthalmic division of the trigeminal nerve.
49
When is a third eyelid flap indicated?
For corneal support or physical protection of the cornea.
50
Why are third eyelid flaps generally contraindicated for deep ulcerations?
They prevent medication penetration and can trap bacteria and inflammatory cells.
51
What are potential complications from improperly placed sutures in third eyelid surgery?
Skin ulceration and additional corneal damage.
52
What type of carcinoma commonly affects the third eyelid?
Squamous cell carcinoma.
53
How might squamous cell carcinoma initially present on the third eyelid?
As an area of hyperemia, raised and sometimes papillomatous.
54
Name two chemotherapeutics used as adjunctive treatments for third eyelid neoplasia.
Mitomycin C and 5-Fluorouracil.
55
What is the reported success rate for third eyelid excision alone?
Approximately 80-90%.
56
Why is cryotherapy discouraged for third eyelid squamous cell carcinoma?
It increases the risk of local tumor recurrence.
57
What are potential complications of third eyelid excision?
Orbital fat prolapse, keratoconjunctivitis sicca, and superficial keratitis.
58
What should be ensured when suturing third eyelid lacerations?
Proper apposition to avoid scarring and corneal trauma.
59
What are the three components of the preocular tear film?
Lipid, aqueous, and mucinous layers.
60
What glands produce the lipid layer of the tear film?
Meibomian and sebaceous glands of Zeis.
61
What is a major source of the aqueous layer in the tear film?
The lacrimal gland.
62
What cells produce the mucinous layer of the tear film?
Conjunctival goblet cells.
63
How often is tear volume recycled in a normal equine eye?
Approximately every 7 minutes.
64
What diagnostic tests are part of investigating corneal abnormalities?
Schirmer tear test, fluorescein staining, and Rose Bengal staining.
65
What Schirmer tear test value indicates abnormal tear production?
Less than 10 mm/min.
66
What is a simple method to assess nasolacrimal duct patency?
Passive drainage of fluorescein to the nasal ostium.
67
What instrument can be used for retrograde flushing of the nasolacrimal duct?
A 5-6 French gauge pliable urinary catheter.
68
What imaging technique is used for dacryocystorhinography?
Radiography with contrast medium or CT.
69
What is the primary purpose of endoscopic evaluation of the nasolacrimal duct?
To collect samples and remove foreign bodies or dacryoliths.
70
What is the most common nasolacrimal defect in horses?
Imperforate distal nasal punctum.
71
At what age are clinical signs of nasolacrimal defects usually first noticed?
From birth to 1 year of age.
72
What method is used to treat imperforate nasal puncta?
Filling the nasolacrimal duct with saline and incising the nasal mucosa over the fluid bleb.
73
What is a potential surgical alternative for nasolacrimal duct atresia?
Canaliculorhinostomy or canaliculosinostomy.
74
What condition may lead to epiphora in young horses?
Imperforate nasal puncta.
75
What technique allows visualization of the nasolacrimal system's duct walls?
CT dacryocystorhinography.
76
How long is a catheter left in place for treating imperforate nasal puncta?
2 to 4 weeks.
77
What is one risk of using an artificial stoma for nasolacrimal duct atresia?
Incomplete resolution of epiphora due to stricturing over time.
78
What is one risk of using an artificial stoma for nasolacrimal duct atresia?
79
What procedure may be performed to treat a lacerated nasolacrimal canaliculus?
Using a pigtail probe to place a silicone tubing stent.
80
What staining method aids in nasolacrimal patency assessment?
Fluorescein solution flushing.
80
Why are topical anesthetics important for nasolacrimal duct cannulation?
To provide local analgesia for the procedure.
81
What instrument is helpful in nasolacrimal punctal cannulation?
Sterile disposable or reusable cannulae.
82
Where do lacerations in the nasolacrimal system most commonly occur?
Near the eyelid margin.
83
What is the primary goal of surgically correcting nasolacrimal lacerations?
To prevent inappropriate healing or scarring that may block the canaliculus or punctum, leading to epiphora.
84
Why is retrograde cannulation preferred if possible?
It facilitates access to the canaliculus and ensures the stent or suture placement does not further damage the nasolacrimal system.
85
What type of suture material is recommended for retrograde cannulation?
2-0 to 3-0 nylon or polypropylene.
86
How is the silicone stent tube inserted when retrograde cannulation is successful?
It is passed over the suture through the nasolacrimal canaliculus and puncta from the unaffected side.
86
What tool is used to guide the suture through the nasolacrimal canaliculus?
A blunt-tipped, eyed Worst pigtail probe.
87
How is the silicone tubing secured if the duct is successfully cannulated?
It is sutured to the nose and eyelid skin using 6-0 polypropylene.
88
What is done if retrograde cannulation is not possible?
The probe can be passed through the opposing punctum of the lacerated canaliculus, and the suture is drawn through from this punctum.
89
How is the tubing secured at the medial canthus?
By tying the suture material in a circular pattern to maintain the tubing in place.
90
How long is the silicone tubing left in place for healing?
For 4 to 6 weeks.
91
Why is the silicone tubing left in place during the healing process?
To maintain patency of the canaliculus as it heals.
92
What are potential risks if lacerations of the nasolacrimal system are not corrected?
Blockage of the canaliculus or punctum, leading to excessive tearing or epiphora.
93
What is epiphora, and how can it be caused by nasolacrimal system lacerations?
Epiphora is excessive tearing, caused by blockage in the nasolacrimal canaliculus or punctum.
94
what type of stent material is used in the surgical correction of nasolacrimal lacerations?
Silicone tubing.
95
What is the function of a blunt-tipped, eyed Worst pigtail probe in the procedure?
It guides the suture through the canaliculus without causing additional trauma.
96
What is the benefit of securing the stent to the medial canthus?
It helps stabilize the tubing, ensuring the canaliculus remains open during healing.
96
Why is 6-0 polypropylene used for suturing in this procedure?
It is fine enough to secure the silicone tubing without causing excessive tissue irritation.
97
What would be a reason for choosing silicone tubing over other materials?
Silicone is flexible and well-tolerated, reducing irritation and allowing canaliculus healing with minimal risk of secondary damage.

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