lids & malpositions Flashcards
paralytic lagophthalmos
usually 2/2 CN7 palsy.
Rx: gold weight sewn to anterior tarsus.
Medial ectropion
medial spindle procedure
involutional ectropion
tarsal strip (age related laxity)
Indications for orbital decompression
exposure keratoconjunctivitis or compressive optic neuropathy
softer indication: decompression to relieve orbtial pain assoc/w/venous congestion in TED or cosmesis
Pops on retrobulbar block
First pop: needle going through orbital septum
second pop: needle going through the intermuscular septum
Fasanella - Servat
(aka tarsoconjunctival mullerectomy)
- used to treat mild amounts of ptosis LESS THAN 2 mm
- controversial in that some tarsus is removed. Many argue that removing tarsus, which may be necessary in the future if the patient were to have an eyelid defect and need a tarsal graft, is inadvisable. However, the procedure can be used for small amounts of ptosis.
congenital myogenic ptosis
In congenital myogenic ptosis, the muscle belly is fibrous and fatty. The extra “bulk” to the muscle prevents the eyelid from looking down (eyelid lag) and sometimes from closing (lagophthalmos).
In congenital ptosis, the general rule is that < 4 mm of levator function usually means the patient will need a frontalis suspension, either with a synthetic material or autologous fascia lata grafts.
Immediate fracture repair
The recommendation is to fix the fracture immediately with any of the below findings.
1) Diplopia with CT or clinical findings of entrapment and an associated oculocardiac reflex
2) The “white-eyed blowout” fracture: relatively normal anterior exam in a young patient with marked motility restriction and CT evidence of an entrapped muscle or perimuscular tissue.
3) Early enophthalmos or significant facial asymmetry
Fracture repair after 2 weeks
Other indications for repair within 2 weeks of the fracture with a lower-quality evidence base include:
1) Symptomatic diplopia within 30 degrees of primary gaze with positive forced ductions.
2) Large floor fracture on CT > 50% of the floor in largest dimension (due to risk of enophthalmos)
3) Enophthalmos > 2 mm if cosmetically unacceptable to patient
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4) Hypoglobus
5) Progressive infraorbital hypoesthesia
6) Evidence of an entrapped muscle or perimuscular tissue on CT.
Important patient counseling points include sinus precautions (i.e. no nose-blowing) for at least two weeks to prevent orbital emphysema, and most practitioners prescribe a course of antibiotics to prevent infection given the communication between the orbit and the sinuses, although this does not have Level 1 evidence.
weakest part of maxillary bone?
The posterior medial part of the maxillary bone is the portion most likely to break with a blowout fracture.
LTS procedure
First, a lateral canthotomy and inferior cantholysis is performed.
Then, the eyelid is split at the gray line into the anterior and middle/posterior lamella. The lash follicles and anterior lamella (i.e. skin) is cut off in a triangular fashion over the desired length of the tarsal strip.
The palpebral conjunctiva on the back of the posterior lamella (i.e. on the forniceal side of the tarsal strip) is shaved, excised, or cauterized to destroy the mucus producing glands of the conjunctiva.
The tarsal strip is sutured to the lateral orbital periosteum.
The lateral canthotomy is closed.
Important to destroy the mucus-producing glands of the conjunctiva on the posterior lamella.
type of ptosis with high lid crease
The levator sends attachments to the skin to create the eyelid crease. A high crease indicates that the levator aponeurosis has slipped.
Ptosis surgery
In ptosis surgery, there are a few criteria one should use to evaluate which procedure is best suited to the patient.
If the patient has normal levator function, as this patient does, a frontalis sling is unnecessary.
In a patient with normal levator function, there are essentially three options for ptosis surgery:
1) An external levator resection or advancement, which is the traditional ptosis surgery most commonly performed, would require an upper eyelid incision and then direct plication or advancement of the levator aponeurosis to the tarsal plate. The only difference between a resection and an advancement is that in the former, the excess levator aponeurosis tissue is cut or resected instead of left in the eyelid. This is usually dependent on surgeon preference and does not affect the functional outcome appreciably.
2) A mullerectomy, which is an internal ptosis surgery in which Muller’s muscle in between the levator aponeurosis and the conjunctiva is removed (Muller’s muscle attaches to the superior portion of the tarsal plate), can usually improve milder amounts of ptosis
3) A tarsoconjunctival resection (Fasanella-Servat) is another internal ptosis surgery in which a small amount of tarsus is removed in addition to conjunctiva and Muller’s muscle to essentially shorten the middle and posterior lamella of the upper lid
In this patient with a history of skin cancer and a relative aversion to sunscreen, a Fasanella procedure would be a poor option because this patient has a reasonable chance of having an eyelid cancer. In that situation, she may need reconstructive surgery in which she would need a free tarsal transfer procedure and, therefore, one would want to preserve her native tarsus as much as possible. For this reason, the Fasanella procedure is not preferred by many ptosis surgeons although most would agree it is the fastest ptosis procedure among the available options.
Rx for cicatricial entropion
Tenzel procedure is also known as the tarsal fracture operation and involves making a posterior horizontal tarsal incision 2 mm inferior to the eyelid margin. The eyelid margin is then rotated away from the eye and this position is stabilized with everting sutures.
Eyelid repair (33-50% defect): Tenzel flap or FTSG
Closure of _% defects
Direct closure is used for defects that cover less than 33% of the upper eyelid margin.
Defect is in the 33-50% range: the eyelid can be freed with a lateral canthotomy and semicircular flap is rotated into the defect.
> 50%
Cutler-Beard procedure=upper eyelid defect
-A lower eyelid full thickness flap is advanced into the upper eyelid defect. This is then allowed to vascularize for 6 weeks and then the upper and lower eyelids are separated.
lower eyelid = modified Hughes procedure
-upper eyelid flap of conjunctiva and tarsus are sewn into the lower eyelid posterior lamellae and the anterior lamellae is filled in with free skin graft.
Ankyloblepharon
Ankyloblepharon is a partial failure of the eyelids to complete developmental separation with residual strands of tissue connecting the eyelid. Often they can be clamped and cut.
Epiblepharon
Epiblepharon is when pretarsal skin and orbicularis override the eyelid margin.
Often a benign condition that resolves on its own. The eyelashes may even touch the cornea but rarely does this cause keratitis.
Euryblepharon
Euryblepharon is a lengthening of the horizontal palpebral fissure and generally involves the lower lateral eyelid.
Associated with shortening of the vertical palpebral fissure and with blepharophimosis syndrome.
Epicanthus
Epicanthus is a prominent fold of eyelid skin perpendicular to and overlying the medial canthal tendon.
Congenital ectropion
Congenital ectropion 2/2 shortening of the anterior lamellae of the skin.
= mild condition that responds to conservative measures such as lubrication
What is a good rule of thumb for the amount of skin to be left behind for bleph?
Good general rule of thumb =10 mm from the incision to the eyebrow and 10 mm from the incision to the eyelid margin.
When removing skin and orbicularis in older patients, it can often appear that you are taking way too much. But often a large amount of skin and orbicularis removal is necessary to achieve the desired result.
MCC of ptosis in congenital blepharoptosis
Correct Answer: myogenic
MCC of congenital blepharoptosis = abnormal development of the levator muscle.
MCC acquired blepharoptosis is a weakening of the levator aponeurosis and its attachment to the tarsal plate.
3 main causes of involutional entropion
- overriding orbic
- eyelid retraction insertion
- horizontal lengthening of eyelid
A patient presents after getting hit around the eye with a baseball bat. He has a depressed superior nasal bridge, telecanthus, a right-rounded medial canthus, and epistaxis. Which of the following is the most likely diagnosis?
This patient has a naso-orbital-ethmoid fracture also known as a direct fracture. These fractures involve the frontal process of the maxillary bone, the lacrimal bone, and the ethmoid bones along the medial wall of the orbit.
The significance of identifying these fractures is important because their repair is drastically different.
Since this is a bony defect, bony repair with metal miniplate is necessary to reattach the bone to medial bony wall. If the clinician misdiagnoses this patient with having an avulsion of the medial canthal tendon, repair will likely be unsuccessful.
