Eye/Eyelid Flashcards
In an adult patient, which of the following physical findings is most likely to support a diagnosis of involutional blepharoptosis of the upper eyelids?
A) Excess upper eyelid skin
B) Eyelid margin-to-reflex distance of 4.5 mm
C) Higher than normal tarsal crease
D) Less than 8 mm of levator function
E) Upper eyelid eversion upon downgaze
The correct response is Option C.
Blepharoptosis occurs as a result of acquired or congenital causes. Among the former causes is the most common one, involutional (senile), as well as traumatic, mechanical, neurogenic, and myogenic. The latter category includes myogenic or neurogenic causes only. Because surgical correction is the only effective, definitive therapy for acquired ptosis, it is important for the clinician to be able to differentiate between the causes. The involutional variety is due to attrition or dehiscence of the levator aponeurosis from the anterior upper part of the tarsal plate. Diagnosis of ptosis is confirmed when there is less than 2.5 mm of distance between the upper eyelid margin and the papillary light reflex. Physical findings that support the diagnosis of involutional ptosis include a lid drop during downgaze, a higher than normal upper lid crease, visibility of the eye through the thinned upper eyelid, and preservation of good levator excursion (greater than 10 mm). Rating the degree of ptosis is based on the upper eyelid margin to pupillary light reflex distance: greater than 4 mm is considered normal. Excess upper eyelid skin can obstruct visual field; however, it is not indicative of involutional ptosis.
2018
A 65-year-old woman comes to the office because she is concerned about the appearance of her lower eyelid. A photograph is shown. Which of the following maneuvers is most critical to improve her periorbital appearance?
A) Botulinum toxin type A injections in the “crow’s feet” area
B) Fat injection limited to the lower eyelid
C) Orbital malar ligament release and fat repositioning
D) Skin resection and lateral canthopexy
E) Skin resurfacing using a phenol-croton oil peel
The correct response is Option C. The primary factor contributing to the patient’s concern is the relationship of the orbital malar ligament, orbital septum and retroseptal orbital fat. Release of the orbital malar ligament and fat repositioning offers the best option for improvement. The retroseptal fat compartments appear to be full so that fat injection alone would risk creating unwanted prominent fullness in the area. Skin resection should be conservative after fat repositioning to avoid lower lid malposition. Phenol-croton oil peeling is an effective treatment for aging changes but would not correct the anatomical relationships that underlie this patient’s chief concern. Botulinum toxin type A injections would not adequately address this patient’s concerns.
2018
A 50-year-old woman comes to the office seeking cosmetic improvement of the lower eyelids. Transposition of a pedicled postseptal fat graft from the central compartment is planned through a transcutaneous approach. A preoperative photograph is shown. Which of the following is the most appropriate structure to release for transposition?
A) Capsulopalpebral fascia
B) Inferior oblique tendon
C) Lockwood ligament
D) Lower slip of the lateral canthal tendon
E) Orbicularis retaining ligament
The correct response is Option E.
The orbicularis retaining ligament or the orbital malar ligament is a bilaminar membrane that spans from the periosteum of the inferior orbital rim to the fascia on the underside of the orbicularis. During aging, this ligament accentuates the orbital malar depression and restricts the orbital fat from blending with the sub oribularis oculi fat (SOOF). This patient presents with a prominent orbitomalar sulcus and tear trough deformity. Release of the medial portion of the orbicularis oculi muscle and the orbicularis retaining ligament allows fat transposition over the orbital rim, thus softening and improving this deformity. This procedure can be performed through either a transcutaneous or transconjunctival approach.
The capsulopalprebral fascia is a retractor of the lower eyelid. It is incised during a transconjunctival fat excision. It is not incised in a transcutaneous approach.
The inferior oblique tendon of the inferior oblique muscle should be protected during lower eyelid surgery. Lockwood’s ligament is a supportive structure of the globe. The inferior limb of the lateral canthal tendon is not released for fat transposition. It may be released for canthal support and repositioning.
2017
A 53-year-old woman is evaluated 6 weeks after undergoing blepharoplasty. Physical examination shows 1 mm of lagophthalmos with no dry-eye symptoms. The patient returns 8 months later for evaluation of dry eye, which began one month after undergoing laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following is the most likely reason for this patient’s dry-eye symptoms?
A) Blunted blink reflex secondary to decreased corneal reflex arc
B) Chronic use of vasoconstrictive eyedrops
C) Transient decrease in functioning of the orbicular muscle of the eye secondary to stretching from lid traction during surgery
D) Transient decrease in tear production caused by lacrimal gland pressure injury
E) Transient hypersensitivity of the cornea
The correct response is Option A.
Minimal lagophthalmos in the postoperative period following blepharoplasty is not uncommon and generally self-correcting. Minimal lagophthalmos may persist but is often asymptomatic owing to compensatory blinking and increased tear production, both of which are the result of the mild exposure and resulting corneal stimulation.
Laser-assisted in situ keratomileusis (LASIK) procedure involves creation of a corneal flap that interrupts the long ciliary nerves of the ophthalmic division of the trigeminal nerve. The interruption of these nerves results in decreased sensation to the cornea and a decreased corneal reflex arc. Patients with compensated exposure from blepharoplasty may lose the compensatory blink in reaction to corneal irritation following LASIK. This may cause dry-eye symptoms. With time, the corneal reflex arc improves, and the transient neurotrophic keratopathy and dry-eye symptoms improve. The other options are unlikely to cause her symptoms of dry eyes.
2016
A 45-year-old woman comes to the office to discuss aesthetic improvement of the lower eyelids. Physical examination shows lower eyelid pseudoherniation of fat and fine skin wrinkles. A postseptal transconjunctival approach with skin pinch excision is considered. The most significant advantage of this approach compared with a transcutaneous skin-muscle flap is a lower risk of which of the following complications?
A) Capsulopalpebral fascia injury
B) Corneal injury
C) Hematoma
D) Infection
E) Lid malposition
The correct response is Option E.
Transconjunctival blepharoplasty preserves the middle lamella, which includes the orbicularis oculi muscle. Preserving this layer significantly decreases the incidence of ectropion and lower eyelid malposition. Disadvantages of this technique include more difficulty with visualization and access. Many authors believe that a cutaneous skin muscle approach is more effective in blending the lid-cheek junction and transposing fat.
Some studies have shown minor reductions in hematoma and infection rates with the transconjunctival approach; however, the differences are small and not the most significant advantage.
The potential for corneal injury is greater with the transconjunctival approach. Most surgeons use corneal shields to prevent this complication.
The capsule palpebral fascia is routinely cut to access the fat compartments during a transconjunctival blepharoplasty.
2016
When skin excisions are designed for upper blepharoplasty, carrying the medial extent past the punctum is most likely to result in which of the following adverse effects?
A) Inadequate vertical skin excision
B) jury to the lacrimal system
C) Lagophthalmos
D) Retrobulbar hematoma
E) Webbing of the nasal skin
The correct response is Option E.
Extending the skin incisions too far medially can create a webbing of the nasal skin. Carrying the incision medially does not promote inadequate skin excision, lagophthalmos, or retrobulbar hematoma. Injury to the lacrimal system is unlikely to occur with a more medial incision
2016
A 61-year-old woman is evaluated 7 hours after undergoing bilateral lower blepharoplasty with septal release and fat repositioning. She reports pain and diminished vision in the right eye. Physical examination shows more swelling on the right side than on the left and tender proptosis of the right eye. Which of the following is the most appropriate treatment?
A) Administration of stronger pain medication
B) Head elevation and ice packs
C) Lasix administration and observation
D) Orbital decompression
E) Tarsorrhaphy
The correct response is Option D.
The most appropriate treatment is orbital decompression for retrobulbar hematoma. Most complications after blepharoplasty are correctable and minor. However, postoperative bleeding into the orbit causes a retrobulbar hematoma. With a large enough hematoma, orbital pressure increases, causing increased swelling, eye pain, and proptosis. With continued pressure, the optic nerve is compressed, leading to reduction in vision and ultimately blindness. The cause of a retrobulbar hematoma is bleeding within the orbit. As such, the blepharoplasty technique would be one in which the orbital septum was opened. Nevertheless, this complication must be considered in all blepharoplasty patients.
The treatment for retrobulbar hematoma is emergent orbital decompression. The incision needs to be opened and the orbital space accessed for the hematoma and soft tissues to decompress and alleviate traction or pressure on the optic nerve. A lateral canthotomy is done as well to ensure maximal decompression. In the past, mannitol has been given as a diuretic for reduction of edema, but also as a free radical scavenger in hopes of protecting the optic nerve from compressive ischemia. Lasix is often administered as a quick controllable diuretic to lessen edema.
This is a very rare complication of blepharoplasty. Mejia et al. surveyed plastic surgeons in the United States and Great Britain and derived data from over 750,000 blepharoplasties. In this study, 25 patients had permanent visual loss and 14 had temporary loss of vision. The overall incidence of visual loss due to retrobulbar hematoma was 0.0052% or one in 20,000 cases, with permanent loss occurring in 0.0033% or one in 30,000. Symptoms as noted above occurred in all patients within the first 24 hours, and hypertension was found to be the most common risk factor.
All patients will develop postoperative swelling and ecchymosis to varying degrees. Head elevation and ice packs are appropriate for standard swelling noted without findings of orbital pain, proptosis, or changes in vision. Tarsorrhaphy is useful for patients with lagophthalmos or ectropion but has no role in globe protection for acute proptosis in the above setting. Lasix infusion is part of the treatment for retrobulbar hematoma, but as a stand-alone therapy it is inadequate. Provision of more pain medication is inappropriate in the presence of pain and reduced vision and will only serve to mask some symptoms related to the hematoma.
2016
A 62-year-old woman is evaluated for lower blepharoplasty. On examination, negative vector is noted. Postoperatively, this patient is at increased risk for which of the following conditions?
A) Dystopia
B) Ectropion
C) Enophthalmos
D) Lagophthalmos
E) Proptosis
The correct response is Option B.
The finding of a negative vector places the patient at an elevated risk for lower lid malposition and ectropion. The negative vector refers to the anatomic relationship on lateral view of the maximum projecting point of the globe and the maximum projecting point of the infraorbital malar prominence. If the globe projects less than the malar prominence, a negative vector exists. Conversely, if the malar prominence projects more than the globe, a positive vector exists.
The negative vector finding indicates potentially deficient globe and lid support based on skeletal anatomy. Such patients will often have minor scleral show or lateral lid lag. It is important to recognize these findings prior to blepharoplasty surgery in order to surgically address the risks of ectropion via primary lid suspension during the blepharoplasty. Occasionally, lower lid blepharoplasty may be avoided if a negative vector is present and other conditions such as dry eye exist. Other findings or conditions that are associated with postoperative ectropion and lower lid malposition are: orbicular weakness, anterior lamellar shortage, inferior eyelid/orbital volume deficit, and eyelid laxity. Excessive or prominent middle lamellar scarring can occur after surgery, which can also lead to lid malposition.
Lagophthalmos is the inability to lower the upper lid fully and is a negative consequence of upper blepharoplasty due to excessive tissue resection or fibrosis. Enophthalmos is interior retraction or displacement of the globe related to increased orbital volume. This is unrelated to lower blepharoplasty surgery. Proptosis is an external displacement of the globe giving the appearance that the eyeball is extruding from the obit. This is most often associated with Graves disease, head trauma, and increased intracranial pressure. It can also be due to a retrobulbar hematoma after blepharoplasty, which is a surgical emergency due to the risk of blindness.
Dystopia refers to malposition of the globe related to skeletal changes of the orbit. This would not be a result of blepharoplasty, but can occur after facial trauma or facial tumor resection.
2016
A 60-year-old man comes to the office because he desires improvement in the appearance of his lower eyelid and upper cheek area. Physical examination shows a prominent tear trough. Which of the following is the anatomic basis of the tear trough?
A) Attachment of the orbital septum to the arcus marginalis
B) Cleft between the palpebral and orbital parts of the orbicularis oculi
C) Osteocutaneous ligament arising from the medial portion of the maxilla
D) Prominence of the orbital rim following descent of the malar fat pad
E) Triangular confluence of the origins of the orbicularis oculi, levator labii superioris alaeque nasi, and levator labii superioris
The correct response is Option C.
Recent articles have greatly improved our understanding of the anatomy of the lower eyelid, tear trough, pre-zygomatic space, and the ligaments in the orbital area.
The tear trough ligament is a true osteocutaneous ligament between the palpebral and orbital portions of the muscle. It extends inferolaterally from the medial canthus to approximately the mid-pupillary line, where is connects with the bilayered orbicularis retaining ligament. Recent anatomic dissection work has shown that this ligament is the anatomic basis of the tear trough deformity.
Fillers should be placed inferior to the tear trough ligament; placing them superiorly will only serve to emphasize lower eyelid fat, and will emphasize the tear trough deformity.
2015
A 32-year-old Korean woman undergoes bilateral upper lid blepharoplasty for creation of a supratarsal crease. A partial incision technique is used. Which of the following is the most likely complication of this procedure?
A) Asymmetry
B) Epicanthal webbing
C) Fold loss
D) Lagophthalmos
E) Suture extrusion
The correct response is Option A.
Blepharoplasty is the most common facial cosmetic procedure performed on people of Asian descent. Unlike blepharoplasty in Caucasian faces, the goal of Asian blepharoplasty is to create a supratarsal fold. Asian eyelids are characterized by several key elements including absent or low lid crease, shorter tarsus, descending pre-aponeurotic fat, and minimal or absent connection between the levator aponeurosis and the upper lid dermis. The mainstay of surgical correction is creation of a permanent fixation point between the levator muscle and the supratarsal dermis and subdermal structures.
The most common complication after Asian blepharoplasty is asymmetry. It is important to remember that unlike Caucasian blepharoplasty, the motivation for Asian blepharoplasty is less frequently rejuvenation. Rather, Asian patients are typically younger and desire creation of a supratarsal fold or correction of a preexisting fold asymmetry. Asymmetry is a common preoperative finding and should be well documented and discussed with the patient before surgery. Small differences in positioning of the newly created crease can be very obvious to both patient and surgeon. When recognized immediately after surgery, early revision should be considered.
Other complications unique to Asian blepharoplasty include fold loss, suture extrusion, and epicanthal scarring. Lagophthalmos, which most often results from overresection of upper eyelid skin, is less frequent in Asian blepharoplasty because skin excision is typically more limited, particularly in a younger patient undergoing a partial incision technique. Fold loss may result from a technical error in securing the layers of dermis, epidermis, or levator aponeurosis, or from placing too few sutures. Revisional surgery would be required to correct this problem. Suture extrusion is not uncommon, given that permanent sutures are used for fixation. Meticulous placement of clear 7-0 nylon and trimming of suture ends will minimize the risk of this complication. If a suture becomes exposed in the first few months postoperatively, removal should be deferred until scarring is mature and fixation is more tenacious. Epicanthoplasty is commonly used is Asian patients with epicanthal folds undergoing blepharoplasty. Various techniques, including Y, W, and modified Z-plasties, have been reported. The epicanthal region is prone to hypertrophic scarring, particularly in Asians who have thick dermis.
2015
Which of the following is the function of secretions of the meibomian glands?
A) Coats cornea as inner layer of tear film
B) Lubricates eyelid skin
C) Prevents evaporation of tear film
D) Promotes control of infectious agents
E) Promotes dispersion of tear film
The correct response is Option C.
Tears are a trilaminar fluid. The precorneal layer is formed by mucin-secreting goblet cells in the conjunctiva. This inner layer of the tear film covers the cornea and promotes the dispersion of the overlying aqueous layer.
The lacrimal gland secretes the middle layer. This aqueous layer is made of water and proteins. This layer promotes osmotic regulation and the control of infectious agents.
The meibomian glands produce the outer lipid layer. This oil layer helps to prevent the evaporation of the tear film. As a result, dysfunction of the meibomian glands can lead to dry eyes.
2014
In a patient with facial proportions within the normal ranges, which of the following measurements best approximates intercanthal distance?
A) Eyebrow length
B) Nasal bone width
C) Orbital fissure width
D) Stomion-to-menton distance
E) Subnasale-to-stomion distance
The correct response is Option C.
Intercanthal distance most closely approximates orbital fissure width. Normal facial values are often described as proportions rather than absolute numbers. Many texts describe normal intercanthal distance as between 30 and 35 mm, but some studies have shown intercanthal distances of up to 40 mm in healthy cohorts. Thus, using the facial features as referents can be helpful. The face is often divided into fifths for analysis of width, and the intercanthal distance represents one fifth, as does the orbital fissure width. The nasal bone width is narrower than the intercanthal distance, and the eyebrow length extends lateral to the lateral canthus, representing greater than a fifth of the facial width. Subnasale, stomion, and menton distances are most often used to calculate facial height proportions. Although there is no reason why, theoretically, a measurement of facial height could not correspond to a measurement of facial width, these values do not.
2014
A 65-year-old woman comes to the office for follow-up 6 days after undergoing bilateral upper eyelid blepharoplasty and repair of the right levator aponeurosis. Preoperatively, the patient had bilateral levator excursion of 13 mm and 4 mm of ptosis of the right eyelid. No ptosis of the left eyelid was noted. Physical examination today shows 2 mm of ptosis of the left upper eyelid. The right upper eyelid is well positioned. Which of the following is the most likely explanation for these findings?
A) Hering law
B) Horner syndrome
C) Müller maneuver
D) Todd paresis
E) von Graefe sign
The correct response is Option A.
Hering law describes equal innervation to the eyelids in that the signal to the levator is the same despite the potential need for each eyelid to work independently. In the scenario described, the patient had obvious ptosis of the right eyelid, and the signal to raise the eyelids was strong. When the right ptosis was corrected, the signal to raise the eyelids decreased, and the more mild ptosis of the left eyelid was uncovered. To help avoid this problem, a Hering test or a patch test can be performed. The Hering test is performed by elevating the ptotic eyelid and observing whether the other eyelid becomes ptotic. A patch test is when the ptotic eyelid is covered for a period of time (usually 15 minutes) and then observed for whether the non-ptotic eye becomes ptotic. The key to both tests is to decrease the excessive signal to raise the eyelids.
Horner syndrome includes ptosis of the eyelid, constriction of the pupil, and decreased sweating due to disease in the sympathetic system. This can be due to a tumor, congenital or iatrogenic.
von Graefe sign is lagophthalmos in downgaze. This is related to Graves disease. Müller maneuver is the reverse of the Valsalva maneuver. After a forced expiration, an attempt at inspiration is made with closed mouth and nose, thereby creating negative pressure in the chest and lungs. This maneuver is used to find weakened areas of the airway.
Todd paresis is focal weakness following a seizure. This can affect eye position.
2014
A 48-year-old woman comes to the office because of pain and tearing of the right eye 1 week after undergoing upper eyelid blepharoplasty. Fluorescein stain test result is positive for corneal erosion. On physical examination, absence of which of the following is most likely to put this patient at risk for corneal ulceration?
A) Accommodation reflex
B) Bell phenomenon
C) Ocular convergence
D) Oculocardiac bradycardia
E) Pupillary light response
The correct response is Option B.
Transient lagophthalmos during sleep is not uncommon following blepharoplasty. During the first few weeks of recovery, it is important to protect the eyes with lubricating drops and ointment. Bell phenomenon, an upward and outer movement of the eye when the eye is closed, is a protective mechanism which keeps the cornea protected behind the upper eyelid. Bell phenomenon is absent in 10 to 15% of the population. Accommodation reflex, oculocardiac reflex, ocular convergence, and pupillary light response do not place the cornea at risk after blepharoplasty.
2014
A 45-year-old woman comes to the office because of puffiness of both lower eyelids. Physical examination shows little lower lid skin excess, but prominent eyelid fat pads. Lid tone, snap back, and distraction test results show no abnormalities. Lid-cheek junction is smooth. A retroseptal transconjunctival approach of the lower lid is planned. Regarding the operative approach, which of the following statements is most accurate?
A) Fat pad reduction without violating the orbital septum is performed
B) Lower eyelid skin resurfacing with laser or chemical peel should not be performed concurrently with a retroseptal approach
C) The incision should be placed 1 to 2 mm below the tarsal border
D) The inferior oblique muscle will be noted between the central and lateral fat pad
E) The plane of dissection is deep to the orbicularis, but superficial to the orbital septum
The correct response is Option A.
The incision for a retroseptal approach is usually placed 4 to 5 mm below the tarsal border, or about 8 mm for the lid margin. The plan of dissection for a retroseptal approach is, by definition, deep to both the orbicularis muscle and septum. Because the fat pads are retroseptal, modification does not require entry through the septum when a retroseptal approach is used.
The preseptal approach is typically chosen for modification of the lid-cheek junction, and facilitates fat pad redistribution and access to the midface. The retroseptal approach is used for reduction of fat pads only. The inferior oblique muscle is located between the central and medial compartments of fat.
Multiple authors have shown that is it indeed safe to perform skin resurfacing with either chemical peel or laser simultaneously with a transconjunctival blepharoplasty.
2014
A 78-year-old man is evaluated because of superior visual field obstruction and drooping eyelids. Physical examination notes a levator excursion of 10 mm and a margin-reflex distance 1 of 2 mm. A photograph is shown. Phenylephrine eye drops do not significantly change the position of the eyelid margin. Which of the following procedures is most appropriate for this patient?
A) Direct brow lift
B) Frontalis sling
C) Levator advancement
D) Tarsoconjunctival Müllerectomy
E) Upper eyelid blepharoplasty
The correct response is Option C.
This patient has acquired aponeurotic blepharoptosis. This is the result of dehiscence or disinsertion of the levator aponeurosis from the tarsal plate. This is characterized by ptosis of the eyelid margin, a high or absent lid crease, good levator function, and thin eyelid tissue. This patient has the following criteria that support the diagnosis: a margin-reflex distance 1 of 2 mm, a high eyelid crease noted on the photograph, and good (10 mm) levator function noted on examination.
The most appropriate operation in this patient is levator advancement. This operation uses an external approach to advance the levator muscle onto the tarsal plate, addressing the dehiscence. The operation can be performed through the approach for an upper eyelid blepharoplasty.
Upper eyelid blepharoplasty could treat dermatochalasis. Brow lift could address the eyebrow position, but in this case there is no skin overlying the eyelid margin that would impact the visual field. However, both upper eyelid blepharoplasty and direct brow lift will not correct the underlying problem, which is the dehiscence of the levator muscle.
A frontalis sling uses either a tendon graft or alloplastic material to suspend the upper eyelid complex to the frontalis muscle. Thus, the eyelid is elevated when the frontalis muscle is activated. A frontalis sling is indicated in patients with severe ptosis and little to no levator function, as in the case of congenital or paralytic ptosis.
Tarsoconjunctival Müllerectomy excises a portion of the conjunctiva and Müller muscle through a posterior approach. Phenylephrine eye drops used preoperatively can predict the success of a Müllerectomy. After drops are instilled, one looks for correction of the eyelid margin to within 1 mm of the desired end result. In this patient, Müllerectomy is not indicated because the phenylephrine drops did not significantly change the eyelid position.
2023
