Eyelid Reconstruction 11-22 Flashcards
An otherwise healthy 72-year-old woman with right upper eyelid basal cell carcinoma undergoes full-thickness excision that involves 80% of the lid margin. Which of the following is the best option for reconstruction?
A) Full-thickness skin graft from the contralateral upper eyelid
B) Hughes tarsoconjuctival flap
C) Mustarde lower lid switch flap
D) Primary closure
E) Tenzel semicircular flap
The correct response is Option C.
Upper eyelid defects greater than 75% can be reconstructed with Mustarde lower lid switch, in which a large full-thickness portion of the lower eyelid is rotated based on the marginal vessels. It is necessary to delay the flap, and it sacrifices a portion of the lower eyelid.
Hughes tarsoconjuctival and Tenzel semicircular flaps are useful to reconstruct full-thickness defects greater than 25% and less than 75%. Full-thickness skin graft from the contralateral upper eyelid is used for partial thickness reconstruction of defects involving more than half of the eyelid, while primary closure is reserved for partial thickness and less than 50% defects, as well as less than 25% full-thickness defects.
A 47-year-old woman presents with concerns about a tired appearance of her upper eyelids. She notes that the lax quality of the skin makes it difficult to put her makeup on. Physical examination shows dermatochalasis with skin resting on the eyelashes and prominence of the medial fat pad. Margin reflex distance 1 is 4 mm. The patient has evidence of 13 mm of levator function. Which of the following is the most appropriate procedure for this patient?
A) Fasanella-Servat procedure
B) Hyaluronic acid injection into the upper eyelid
C) Lateral temporal brow lift surgery
D) Levator advancement
E) Upper eyelid blepharoplasty
The correct response is Option E.
The examination of the patient notes that there is no ptosis of the upper eyelid based on a normal margin reflex distance 1 of 4 mm. This measurement describes the lid margin to be 2 mm above the upper border of a 4-mm pupil. Additionally, the patient is noted to have normal levator muscle excursion. Thus, the Fasanella-Servat procedure (resection of a portion of the tarsus, conjunctiva, and Müller muscle) and the levator advancement procedures are not indicated in this patient.
Hyaluronic acid filler can be used to fill in for volume lost from the upper eyelids. However, this will not address the quality of the eyelid skin and the excess skin resting on the eyelashes.
The patient is noted to have lateral brow hooding, which can be addressed by lateral temporal brow lift surgery. This procedure will return brow skin to its appropriate position, but it will not address the patient’s main concerns and findings, which are limited to the skin of the upper eyelid (lax redundant skin of the upper eyelid which abuts the eyelashes). These concerns of dermatochalasis are best addressed by the skin-only upper eyelid blepharoplasty.
A 35-year-old woman undergoes a right dacryocystorhinostomy procedure with an incision in the inner canthus on the right side. Postoperatively, she has poor closure of the right upper eyelid. Which of the following is most likely responsible for the poor eyelid closure?
A) Interruption of the buccal branches of the facial nerve that supply the extracanthal orbicularis oculi
B) Interruption of the buccal branches of the facial nerve that supply the inner canthal orbicularis oculi
C) Interruption of the temporal branches of the facial nerve supplying the orbicularis oculi
D) Interruption of the zygomatic branches of the facial nerve that supply the extracanthal orbicularis oculi
E) Interruption of the zygomatic branches of the facial nerve that supply the inner canthal orbicularis oculi
The correct response is Option B.
The extracanthal orbicularis oculi is innervated by the zygomatic branch, which squeezes the eyelid, permits animation and expression, and protects the eye from debris and flying objects. The inner canthal orbicularis oculi is innervated by the buccal branches, which are responsible for blinking, eyelid closure, lower lid tone and position, and lacrimal pump function. Interruption of the buccal branches of the facial nerve that supply the inner canthus can profoundly affect blinking, eyelid closure, the tone and position of the lower lid, and the tear-pump mechanism. The temporal branches of the facial nerve do not supply any meaningful innervation to the orbicularis oculi.
A 72-year-old woman presents for evaluation of bilateral upper eyelid ptosis. Medical history includes cataract surgery 9 months ago. Repair of the dehiscence of the levator muscle is planned. During surgery, the levator aponeurosis is reattached to which of the following structures?
A) Gray line
B) Lockwood ligament
C) Müller’s muscle
D) Tarsal plate
E) Whitnall ligament
The correct response is Option D.
The Levator aponeurosis attaches to the tarsal plate. In patients with senile ptosis, the levator muscle becomes either detached or attenuated from its insertion into the tarsal plate. Similarly, during cataract surgery the muscle can become detached from the tarsal plate because of the placement of a retractor to hold the eye open for the procedure. Procedures performed to address this attenuation or detachment will suture the levator to the tarsal plate.
The gray line is a surface anatomical landmark on the eyelid margin that corresponds to the muscle of Riolan.
The Whitnall ligament is a structure of the upper eyelid. It attaches the superior aspect of the aponeurosis of the levator muscle to the orbital roof. This structure does not attach to Whitnall’s tubercle.
The Lockwood ligament is a structure of the lower eyelid. This corresponds to the Whitnall ligament of the upper eyelid. The Lockwood ligament is a fascial hammock that supports the globe. It is an expansion of the fascia of the inferior rectus and inferior oblique muscles and extends to the medial and lateral orbital walls.
Müller’s muscle is an accessory levator of the upper eyelid. It is located interior to the levator muscle.
A 3-year-old boy with minimal levator excursion of the left eyelid (2 mm) is scheduled to undergo ptosis repair. Which of the following materials has the lowest long-term recurrence and complication rate?
A) Autologous fascia lata
B) Polypropylene suture
C) Polytetrafluoroethylene (PTFE) strand
D) Silicone rod
The correct response is Option A.
Although all of the modalities listed have been used for congenital ptosis repair, autologous fascia lata (AFL) grafts have the lowest long-term recurrence rate and complication rates. Although studies have shown GORE-TEX to have a low recurrence rate compared to AFL, the complication rate of infection is higher with GORE-TEX. Grafting with irradiated fascia lata has a lower donor-site morbidity profile since it is allogenic tissue, but the long-term recurrence rate has been reported to be 50%. Polypropylene suture can be useful for temporary ptosis repair until AFL but has been plagued by recurrence secondary to slippage. Finally, silicone rods have been shown to have increased ease of adjustability since they do not incorporate, but they yielded higher complication rates than AFL.
A 68-year-old woman wants improvement of the appearance of her upper eyelids. She wears contact lenses daily without need for lubricating eye drops. When compared with the left eyelid, the right upper eyelid has a more elevated lid crease and the marginal reflex distance-1 (MRD-1) is 1.5 mm. The MRD-1 for the left eyelid is 3.0 mm. Levator excursion is 12 mm bilaterally. Which of the following eye tests is the most appropriate next step in this patient’s evaluation for surgery?
A) Phenylephrine test
B) Schirmer test
C) Tear breakup time
D) Visual acuity test
E) Visual field test
The correct response is Option A.
The patient presents with unilateral ptosis of the right eyelid. The elevated lid crease suggests levator aponeurosis attenuation or dehiscence as the mechanism for ptosis. This is known as senile ptosis and is the most common etiology. The challenge in these patients is to determine whether the contralateral eye is also ptotic and requires surgery. This phenomenon is explained by Hering’s law (equal and simultaneous innervation of both levator palpebrae muscles). When one eye has ptosis, the brain signals both eyelids to raise. The less ptotic contralateral eye can look normal. The problem occurs when only the more ptotic eye is surgically repaired. The impulse to raise the eyelids is decreased and the contralateral eyelid now descends and appears ptotic.
Evaluation demands a way to determine whether contralateral ptosis repair is required.
-Phenylephrine eye drops put into the more ptotic eye stimulate the Müller muscle to raise the eyelid. In turn, the afferent signals to raise the eyelids decrease. If the contralateral eyelid then falls over the next 10 to 15 minutes, the phenylephrine test is positive and suggests the need for bilateral ptosis repair.
-Other tests include patching the ptotic eye to decrease the afferent signals or manually raising the ptotic eyelid.
Marginal reflex distance-1 (MRD-1) is the distance in millimeters from the light reflex on the patient’s cornea to the level of the upper eyelid margin with the patient in primary gaze. Normal MRD-1 values are greater than 2.5 mm. Most of the population has MRD-1 values of 4 to 5 mm. The following tests are appropriate for evaluation of blepharoplasty patients, but they are not the most important next step in surgical planning for this patient with unilateral ptosis. Schirmer test evaluates tear production, and tear breakup time measures how quickly the tears evaporate. These tests are appropriate; however, dry eyes are unlikely in this patient because she is able to wear contact lenses without symptoms. Visual field tests are more important for insurance documentation than surgical planning. Visual acuity is for baseline information, not surgical planning.
A 12-year-old girl is evaluated for correction of congenital left unilateral upper eyelid ptosis. She demonstrates moderate left levator muscle function of 8 mm. Which of the following methods is most appropriate for correction of this child’s blepharoptosis?
A) Fasanella-Servat procedure with removal of the tarsus, conjunctiva, and Müller muscle
B) Frontalis muscle flap advancement
C) Frontalis suspension procedure with autogenous fascia lata
D) Müller muscle-conjunctival resection
E) Resection and advancement of the levator aponeurosis
The correct response is Option E.
The most appropriate method for correction of this child’s congenital ptosis is resection and advancement of the levator aponeurosis. This technique is appropriate in patients with greater than 5 mm of levator function. This child has 8 mm of levator function and is therefore a candidate for levator resection and advancement.
Frontalis suspension procedures are reserved for patients with poor levator function or congenital Marcus Gunn jaw-winking syndrome.
The Fasanella-Servat procedure is for correction of minimal ptosis and may alter eyelid contour.
The Müller muscle-conjunctival resection surgery is recommended for patients with fairly good levator function and does not allow for intraoperative adjustment of eyelid height. This child has unilateral blepharoptosis, and achievement of symmetry with the opposite eyelid is crucial.
The frontalis muscle flap is recommended for use in patients with severe ptosis with levator function of less than 4 mm.
A 2-year-old boy is brought to the office for evaluation of unilateral blepharoptosis. Examination shows a 2-mm eyelid ptosis of the right eye with 7-mm of upper eyelid excursion without visual obstruction. The left side shows no abnormalities. Which of the following is the most appropriate treatment in this patient?
A) Frontalis suspension
B) Lenticular skin excision
C) Levator palpebrae advancement
D) Tarsoconjunctival Müllerectomy (Fasanella-Servat procedure)
E) Observation and re-evaluation at age 3
The correct response is Option E.
Correction of mild to moderate eyelid ptosis in children should be delayed until the child can cooperate with the preoperative assessment and post operative care. This would not be reliably possible for a 2-year-old patient. Intervention before age 3 should be considered if there is significant obstruction of the visual axis. Levator advancement provides appropriate correction in pediatric patients with fair to good levator function. Frontalis suspension is generally reserved for instances when levator function is poor (less than 4 mm). Lenticular skin excision will have no reliable effect on lid position.
A 70-year-old man has a biopsy-confirmed squamous cell carcinoma of the upper eyelid. Excision of the lesion will produce a full-thickness defect of the central upper eyelid that is 70% of its width. Reconstruction of the defect with which of the following is most appropriate?
A) Cutler-Beard flap
B) Full-thickness skin graft
C) Hughes flap
D) Primary closure
E) Tenzel flap
The correct response is Option A.
The Cutler-Beard flap is the preferred flap for full-thickness defects of the upper eyelid that are greater than 66% of total eyelid width. This technique utilizes a full-thickness eyelid flap from the lower eyelid to provide a wide flap for eye coverage. In the first stage, the flap is raised and advanced into the upper eyelid defect. The flap is then inset, covering the eye. The inferior pedicle is divided in a second stage at 4 to 6 weeks and final flap inset is performed.
The Tenzel semicircular flap is an excellent technique for anterior lamellar defects of the upper or lower lid, but requires a second flap for posterior lamella reconstruction of full-thickness defects and is not generally the preferred technique for a large defect of the upper eyelid.
The Hughes tarsoconjunctival flap is a similar procedure to the Cutler-Beard flap, but is used for lower lid defects.
Full-thickness skin grafting would not restore the posterior lamellar defect, and direct closure would not likely be able to close a 70% defect of the upper eyelid properly.
A 30-year-old man comes to the physician 2 months after sustaining a deep laceration from forehead to cheek with medial canthal degloving in a motor vehicle collision. His initial workup included a CT scan that showed no facial fractures; the laceration was primarily repaired in the emergency department. Today, his vision is the same as his pre-injury vision. Which of the following is the triad of clinical sequelae that this patient is most likely to report today?
A) Exophthalmos, ptosis, and ophthalmoplegia
B) Lagophthalmos, ptosis, and eyes not closing at night
C) Miosis, ptosis, and anhidrosis
D) Strabismus and ptosis that worsen at night
E) Telecanthus, ptosis, and epiphora
The correct response is Option E.
A medial canthal degloving injury may or may not be associated with a naso-orbito-ethmoid fracture. In this scenario, CT scan showed no fractures.
These injuries can present as vertical lacerations from the forehead to the cheek, crossing the medial canthus. They usually present with the triad of telecanthus (from degloving of the medial canthal tendon, usually the posterior limb that is the weakest limb), ptosis (from avulsion or injury to the upper eyelid), and epiphora (from lacrimal or canalicular injuries). One suggested algorithm is to stage the initial repair of the telecanthus and lacrimal/canalicular repair, and then allow 3 to 6 months of healing before a second stage of ptosis repair.
The other choices are not as consistent with medial canthal degloving: miosis, ptosis, and anhidrosis are incorrect, as these are the triad in Horner syndrome. Exophthalmos, ptosis, and ophthalmoplegia may be seen in superior orbital fissure syndrome. Lagophthalmos, ptosis, and eyes not closing at night may be more associated with congenital ptosis. Strabismus and ptosis, which worsen at night, are suggestive of myasthenia gravis.
A 50-year-old woman is evaluated after undergoing Mohs micrographic surgery of the lower eyelid to remove a basal cell carcinoma 2 days ago. On examination, a 65% defect of the lower eyelid involving both the anterior and posterior lamellae is noted. Nether canthi are involved. Which of the following is the most appropriate reconstructive option for this patient?
A) Hughes tarsoconjunctival flap and Tripier lid switch flap
B) Local cheek V-Y advancement flap and buccal mucosal graft
C) Mustardé flap and hard palate mucosal graft
D) Tenzel semicircular flap and periosteal flap
E) Upper eyelid Cutler-Beard flap and buccal mucosal graft
The correct response is Option A.
Eyelid reconstruction is often a challenging endeavor, and depends upon thorough knowledge of the local anatomy, reconstructive options, and extent of resection. Eyelid defects are commonly classified into three categories—less than 25%, 25 to 50%, and greater than 50%—in order to help the surgeon choose the best reconstructive options. Whenever reconstructing an eyelid defect, it is important to identify the structures involved and be sure to reconstruct the lamellae that have been resected. In this patient, there is a defect that involves both the anterior (skin and orbicularis) and posterior (conjunctiva and tarsus) lamellae, and both must be addressed. Of the available options, the only one that appropriately provides the correct amount and quality of anterior and posterior lamellae for a greater than 50% defect is a Hughes tarsoconjunctival flap and Tripier lid switch flap.
A Tenzel semicircular flap would be appropriate for a 50% or less defect of the lower eyelid, but would not be the best option for a 65% defect.
Although a local cheek V-Y advancement flap and a buccal mucosal graft provides both anterior and posterior lamellar reconstruction, a local V-Y advancement flap of the appropriate size would likely create a cosmetically unappealing contour, and using buccal mucosa for the posterior lamella would not provide the amount of support needed for the lower eyelid to prevent ectropion postoperatively.
Although the combination of a Mustardé flap and a hard palate mucosal graft is a possibility because it provides both anterior and posterior lamellar reconstruction, the use of a hard palate mucosal graft would incorporate keratinized epithelium into the reconstruction, and, therefore, would be less desirable than the use of conjunctiva because it can cause corneal irritation.
The Cutler-Beard flap provides both anterior and posterior lamellar reconstruction and, therefore, the buccal mucosal graft is redundant and unnecessary.
A healthy 65-year-old woman is evaluated because of drooping of the upper eyelids. Examination shows high eyelid creases and 3 mm of ptosis. Levator excursion measures 10 mm. Which of the following is most likely to correct the blepharoptosis in this patient?
A) Brow lift surgery
B) Fasanella-Servat procedure
C) Frontalis sling
D) Levator advancement
E) Upper eyelid blepharoplasty
The correct response is Option D.
The patient described has moderate acquired blepharoptosis characterized by a high eyelid crease and 3 mm of ptosis. Her levator palpebrae muscle excursion is excellent (10 mm). The most likely cause is disinsertion of the levator aponeurosis from the tarsal plate due to chronic stretching of the levator muscle or involutional changes associated with aging. Surgical treatment most commonly involves advancing and reattaching the levator muscle to the tarsal plate.
An upper eyelid blepharoplasty alone or with a browlift would not correct the underlying cause of the ptosis.
The Fasanella-Servat (tarsoconjunctival mullerectomy) procedure classically excises a portion of mucosa, Müller’s muscle, and superior tarsus, thereby shortening the posterior lamella. This can address mild ptosis (1 to 2 mm) in a patient with otherwise excellent levator function.
The frontalis sling procedure uses autologous or alloplastic material tunneled from the brow to upper tarsus to accomplish upper eyelid elevation when levator function is poor. The cause of ptosis in these cases is likely congenital.
A 65-year-old woman comes to the office for consultation on blepharoplasty and rhytidectomy. She notes that her eyelid creases are asymmetric, with the right upper crease higher than the left. She also has difficulty seeing out of her right eye when she is tired. She notes that these symptoms have worsened progressively over the past 5 years. She has levator function of 11 mm with the brow and frontalis muscle in neutral position. This patient most likely has which of the following types of ptosis?
A) Involutional
B) Mechanical
C) Myogenic
D) Neurogenic
E) Traumatic
The correct response is Option A.
The most likely diagnosis is involutional or senile ptosis. In evaluating a patient requesting a blepharoplasty, one must also evaluate for blepharoptosis. If a blepharoplasty is performed without correction of ptosis, the patient will have continuing ptosis and potentially be dissatisfied.
The most common type of blepharoptosis is involutional or senile ptosis. A thorough history and physical examination should assess ophthalmologic and neurologic causes. On physical examination, there is a characteristic high skin crease (greater than 7 mm), thinned upper eyelid, and lid drop on downward gaze. The levator function (amount of lid excursion with the brow and frontalis muscle held in neutral position) should be assessed. Normal function is greater than 10 mm, moderate function is 5 to 10 mm, and poor function is less than 5 mm.
The etiology of ptosis can be classified into neurogenic (oculomotor nerve palsy, Horner syndrome, Marcus Gunn jaw-winking syndrome), myogenic (myasthenia gravis, myotonic dystrophy, mitochondriopathy), mechanical (edema or tumors), traumatic (birth trauma, muscle or nerve damage), congenital, or neurotoxic (such as in envenomation, snake bites, or botulism). None of these are likely, considering this patient’s history and physical examination.
A 60-year-old man undergoes Mohs micrographic resection of an upper eyelid squamous cell carcinoma. A photograph is shown. Which of the following reconstruction procedures will provide the most functional and aesthetically pleasing result in this patient?
A) Free nasoseptal grafting
B) Reconstruction with a forehead flap
C) Reconstruction with a free flap
D) Reconstruction with a glabellar flap
E) Reconstruction with a lid switch flap
The correct response is Option E.
A Cutler-Beard flap is a two-stage lid switch flap, taken from the lower lid.
Some of its disadvantages include two-stage reconstruction requiring eye occlusion for a number of weeks, sacrifice of lower lid tissue (and, commonly, a subsequent ectopion), and lack of intrinsic support. Many modifications have improved on its design including those that provide support. There are many reports of other types of flaps, but for a defect of this size and the anatomic requirements, the best choice is a lid switch flap.
A 50-year-old woman comes to the office 2 weeks after receiving botulinum toxin type A injections for forehead rhytids. She is pleased with the results but has developed unilateral eyelid ptosis. Apraclonidine 0.5% eyedrops are prescribed to improve upper eyelid function. Which of the following best describes the mechanism for improvement of upper eyelid ptosis in this patient?
A) Alpha-2 adrenergic stimulation of the Müller muscle of the upper eyelid
B) Beta-2 adrenergic stimulation of the levator palpebrae superioris
C) Muscarinic parasympathetic inhibition of the levator palpebrae superioris
D) Nicotinic parasympathetic inhibition of the Müller muscle of the upper eyelid
The correct response is Option A.
Apraclonidine is an alpha-2 receptor agonist and is believed to increase muscle tone of the sympathetically innervated Müller muscle located in the upper eyelid.
Beta-2 adrenergic stimulation of the levator palpebrae superioris is not appropriate because apraclonidine does not act as the beta-2 receptor, and it is not believed to stimulate contraction of the levator palpebrae superioris.
Muscarinic parasympathetic inhibition of the levator palpebrae superioris is not appropriate because apraclonidine does not act as the muscarinic parasympathetic receptor.
Nicotinic parasympathetic inhibition of the Müller muscle of the upper eyelid is not appropriate because apraclonidine does not act as the nicotinic parasympathetic receptor.
A 26-month-old boy is brought to the office for evaluation because of worsening congenital ptosis. A photograph is shown. Which of the following is the most appropriate next step in management?
A) Eye lubrication
B) MRI
C) Patching of the non-affected eye
D) Surgical correction
E) Observation only
The correct response is Option B.
A drooping eyelid is called ptosis or blepharoptosis. In ptosis, the upper eyelid falls to a position that is lower than normal. In severe cases of ptosis, the drooping eyelid can cover part of or the entire pupil and interfere with vision, resulting in derivational amblyopia. The eyelids are elevated by the contraction of the levator palpebrae superioris.
In most cases of congenital ptosis, a droopy eyelid results from a localized myogenic dysgenesis. Rather than normal muscle fibers, fibrous and adipose tissues are present in the muscle belly, diminishing the ability of the levator to contract and relax. Therefore, the condition is commonly called congenital myogenic ptosis. Most cases of congenital ptosis are idiopathic.
Surgical correction of congenital ptosis can be undertaken at any age depending on the severity of the disease. Earlier intervention may be required if significant amblyopia or ocular torticollis is present. If intervention is not urgent, surgery is often delayed until age 3 to 4 years. Waiting until this age allows for more accurate measurements preoperatively.
Congenital ptosis can also occur when the innervation to the levator is interrupted through neurologic or neuromuscular junction dysfunction. Nerve compression by external forces such as tumor must be ruled out. Specifically, when ptosis presents acutely or subacutely in a child over 1 year of age, compression of cranial nerve III is a concern.
Rhabdomyosarcoma is the most common primary malignancy of the orbit in children. MRI shows a well-circumscribed mass that typically enhances with gadolinium. On T1-weighted imaging, the tumor usually appears isointense to extraocular muscles but hypointense to orbital fat. On T2-weighted imaging, the lesion appears hyperintense to extraocular muscles and orbital fat. This tumor can grow rapidly and is treated with combined chemotherapy and radiation.
A history of difference in the size of the pupil may be helpful in diagnosing Horner syndrome. Patients with Horner syndrome have ptosis and miosis on the same side. Cervical or apical thoracic tumors can cause damage to the sympathetic chain and result in this condition. Neuroblastoma, which is one of the most common childhood cancers, should be ruled out with this presentation.
Intermittent patch therapy is indicated for strabismus to strengthen the weak rectus muscles.
A 55-year-old man comes for evaluation of epiphora in the right eye 6 months after sustaining a soft-tissue injury to the face in a motor vehicle collision. Physical examination shows that the punctum and lacrimal sac are open. A picture taken at the time of injury is shown. Results of Jones I and Jones II testing are negative. No other abnormalities are noted. Which of the following is the most appropriate next step in management?
A ) Botulinum toxin type A injections of lacrimal gland
B ) Conjunctivodacryocystorhinostomy
C ) Dacryocystorhinostomy
D ) Dilation of lacrimal apparatus
E ) Placement of lacrimal stent
The correct response is Option C.
Abnormalities of tear drainage may be subdivided into functional and anatomical. Functional failure is related to poor lacrimal pump function, which may be due to a displaced punctum, eyelid laxity, weak orbicular muscle of the eye, or cranial nerve VII palsy. Anatomical obstruction may occur at any point along the lacrimal drainage pathway and may be congenital or acquired. Primary acquired lacrimal duct obstruction occurs in the elderly as a result of fibrosis. Secondary acquired obstruction causes include neoplastic, traumatic, and mechanical mechanisms.
Conjunctivodacryocystorhinostomy is performed in cases of flaccid canaliculi, paralysis of lacrimal pump, and when the site of obstruction is proximal (punctum, canaliculi, lacrimal sac). It is not required when these structures are intact. The dacryocystorhinostomy procedure, which involves fistulization of the lacrimal sac into the nasal cavity, alleviates the symptoms of epiphora.
The lacrimal probe demonstrates that the punctum and the sac are intact. The negative result on both Jones I and II – failure of any fluorescein dye to show up in the nasopharynx – demonstrates complete obstruction distal to the lacrimal sac. Dilation or stent placement is not possible.
With a history of trauma and the laceration shown, this patient does not have epiphora secondary to excess tear production.
A 10-month-old boy is brought to the office because of the ocular defect shown in the photograph. Which of the following is the correct term for this anomaly?
A) Anophthalmia
B) Coloboma
C) Congenital cataract
D) Palpebral fissure
E) Tessier No. 6 cleft
The correct response is Option B.
Coloboma is a congenital ocular defect of the eyelid, iris, retina, choroid, or optic disk. The defects can range in size from a small notch to a large structural cleft. Palpebral colobomas are thought to arise from a localized growth disturbance, while colobomas of the iris, retina, and optic disk arise from defective closure of the optic fissure. Upper eyelid coloboma rarely affects vision; large defects of the lower eyelid can lead to corneal ulceration.
Anophthalmia is total absence of the eye. A congenital cataract is a lens opacity that is present in 1:4000 to 1:10,000 newborns. The size and location determine the effect on vision. The palpebral fissure is the natural opening between the upper and lower eyelids. A Tessier No. 6 cleft involves the inferolateral aspect of the lower eyelid, inferior orbital rim, and the zygoma. This cleft often has an associated lower eyelid coloboma and is related to Treacher Collins syndrome.
An otherwise healthy 72-year-old woman with right upper eyelid basal cell carcinoma undergoes fullthickness excision that involves 80% of the lid margin. Which of the following is the best option for reconstruction?
A) Full-thickness skin graft from the contralateral upper eyelid
B) Hughes tarsoconjuctival flap
C) Mustarde lower lid switch flap
D) Primary closure
E) Tenzel semicircular flap
The correct response is Option C.
Upper eyelid defects greater than 75% can be reconstructed with Mustarde lower lid switch, in which a large full-thickness portion of the lower eyelid is rotated based on the marginal vessels. It is necessary to delay the flap, and it sacrifices a portion of the lower eyelid. Hughes tarsoconjuctival and Tenzel semicircular flaps are useful to reconstruct full-thickness defects greater than 25% and less than 75%. Full-thickness skin graft from the contralateral upper eyelid is used for partial thickness reconstruction of defects involving more than half of the eyelid, while primary closure is reserved for partial thickness and less than 50% defects, as well as less than 25% full-thickness defects.
Mustardé’s technique of upper eyelid reconstruction using a laterally based full-thickness flap from the lower lid (after Beyer-Machule and Riedel 1993). a The full-thickness lower lid flap is outlined with a lateral pedicle. b The flap is swung into the upper lid defect, and the lower lid defect is closed. c A continuous suture line incorporates three interrupted sutures that close the defect and are taped to the skin. d, e About 3 weeks later, the pedicle is divided and the defects are closed.
