Oculoplastics/Oculofacial surgery Flashcards
Les 2 conceptual layers des Eyelids
Anterior lamella : skin, orbicularis
Posterior lamella : tarsus, conjunctiva
Vrai ou Faux : le tarse est du cartilage
FAUX : not cartilage
Quel est le common landmark pour split la paupière during une eyelid surgery?
Grey Line (muscle de Riolan)
D’où arise les lashes?
Anterior lamella
Définir Trichiasis
Mauvais alignement anatomique des cils → frottement sur l’oeil
Définir Distichiasis
2e rangée de cils localisée a/n des glandes de Meibomius
Quel muscle s’occupe de la fermeture de l’oeil et par quel NC est-il innervé?
Orbicularis
NC7
Quels sont les muscles rétracteurs responsables de l’ouverture de l’oeil et quelle est leur innervation?
Releveur de la paupière supérieure (NC3)
Müllers (sympathique)
Upper versus Lower Eyelid : combien de fat pads?
Upper : 2
Lower : 3
The pre-aponeurotic fat is a useful landmark for the underlying levator.
In Asians without a lid crease, the pre-aponeurotic fat sits lower then Western lids.
Upper versus Lower Eyelid : suspensory ligament
Upper : Whitwalls
Lower : Lockwoods
Upper versus Lower Eyelid : longueur du tarse
Upper : 10 mm
Lower : 4 mm
Upper versus Lower Eyelid : arterial arcade
Upper : 2 (Marginal + Peripheral)
Lower : 1
Quelles structures s’attachent au Whitnalls tubercule?
Lateral palpebral ligament
Lockwoods ligament
Levator palpebral superioris
Lateral rectus check ligament
(Lacrimal gland fascia)
Which of the following can reveal an oculoplastics cause of « conjunctivitis »?
1. Ask patient to squeeze lids tight
2. The upper eyelid everts with just one finger
3. Pushing over the medial canthus
All of the above
Principales causes acquises d’un entropion (x3)
Involutional
Spastic
Cicatrix (conjunctiva/tarsus : ex. symblepharon causes conjunctival scar)
Principales causes acquises d’un ectropion (x3)
Involutional
Paralytic
Cicatrix (skin : ex. skin cancer causes scarring)
Présentation clinique entropion versus ectropion
Entropion :
Discomfort +++
Corneal abrasion
Tearing
Ectropion :
Some discomfort (plus léger)
Corneal exposure
Tearing
Quoi faire si on suspecte un latent ectropion?
Ectropion can be intermittent and mimic conjunctivitis.
If you suspect latent entropion, hold up the eyebrow and ask the patient to close their lids tightly.
Tx médicale et chirurgicale de l’entropion et de l’ectropion
Tx médical
- Entropion : lubrification, bandage contact lens/tape the lid, botox
- Ectropion : lubrification essentielle pour un NC 7 palsy, tape, message upwards
Tx chx
- Entropion : everting stich (MCS) → conjunctiva graft if cicatrix
- Ectropion : inverting stitch (Quickert) → skin graft if cicatrix
Mecanisms of involutional entropion
Horizontal laxity
Orbcuris override
Disinsertion of lower lid retractors
Enophtalmos
À quelles pathologies est associées le floppy eyelid syndrome?
Sleep Apnea
Keratoconus
Glaucoma
NAION
Floppy eyelid syndrome : eyelash point down aka « lashes ptosis »
Vrai ou Faux :
1. The normal location of the upper lid margin is above the superior limbus
2. Ptosis does not cause neck pain or headache
3. The most common cause of ptosis is involutional (age-related « wear and tear »)
4. An alternate cover test can be useful in the work-up of « ptosis »
5. Marcus Gunn jaw wink is usually an acquired problem
- FAUX : 1 mm sous le limbe environ
- FAUX
- TRUE
- VRAI
- FAUX
Où se situe la upper eyelid p/r à l’oeil?
The normal upper eyelid is 1-2 mm below the superior limbus
Quelle est la cause la plus fréquente d’une ptosis?
BlepharoPTOSIS : most common cause is involutional
Toujours r/o : CN3 palsy, Horners, myasthenia
Présentation clinique d’une ptose
Peripheral field loss
Neck pain
Headache
Changement IOL
Eyelid exam : différentes valeurs mesurées
BFS : Brow Fat Span
TPS : Tarsal Platform Show
MRD 1 : Margin Reflex Distance 1 = mi-pupille ad upper eyelid
MRD 2 : mi-pupille ad lower eyelid
Hauteur fissure palpébrale : MRD1 + MRD2
Qu’est-ce que la Marcus Gunn Jaw Wink?
Congenital ptosis associated with synkinetic movements of upper lid on masticating movements of the jaw
Usually unilateral but rarely presents bilaterally
Affects males and females in equal proportion
NC moteurs 3 et 5 (connexions aberrantes)
Vrai ou Faux : the degree of the ptosis determines the choice of surgery?
VRAI
Mild : muscle Müller avec drops sympathomimétiques
Moderate : aponévrose du releveur
Sévère : Frontalis muscle
Age-related (involutional ptosis) : Which of the following is/are expected?
1. Diplopia, Dyspnea, Dysphagia
2. Unequal pupils
3. Abnormal eye movements
4. Marked variability in lid height
5. None of the above
Réponse : 5. NONE of the above
An adult has constant, bilateral blinking. Which is FALSE?
1. This is a primary psychiatric problem 99% of the time
2. Artificial tears may help
3. Botox may help
4. FL-41 lens tint may help decrease ipRGC activity
Réponse : 1.
Caractéristiques d’un essential blepharospasm
Bilateral
Basal ganglia dz + Dry eye
Scan NOT essential
S’améliore durant la nuit
Caractéristique d’un hemifacial spasm
Unilateral
Blood vessel pounding(martelant) CN 7 nerve root
Scan de la FOSSE POSTÉRIEURE
Que faut-il fait avec un NC7 palsy avec inability to close the eyelid (lagophtalmos)?
Preserve the cornea
Que faut-il craindre dans un combined CN7 + CN5 involvement (ex. post acoustic schwannoma)
Beware neurotrophic ulcer
Concernant les eyelid tumors, which is/are FALSE?
1. Most surgery of eyelid cancer requires general anesthesia
2. Lash loss and skin ulceration are possible signs of malignancy
3. Sebaceous carcinoma may mimic chalazion
4. BCC may mimic chalazion
Réponse : 1. FAUX
Quel est le principale FdR de malignité?
Sun exposition
Signes d’une eyelid tumor BENIGN versus MALIGNANT
Benign :
- Smooth surface
- Lashes intact
- NO bleeding/Telangiectasia
Malignant :
- Ulcerated
- Lash loss
- Bleending + Telangiectasia
Quel est le cancer de paupière le plus fréquent?
Et quel est son Ddx?
BCC is THE MOST common eyelid malignancy
Other skin malignancies : squamous CA, melanoma, sebaceous CA, Merkel cell CA et parfois métastases
Qu’est-ce qu’un chalazion?
« Constipated » Meibomian Gland
Eyelid Potpourri. Which is/are TRUE?
1. Climate change has been implicated with possibly increasing : eyelid cancer, trachoma and CN 7 nerve palsy
2. Squamous cell carcinoma due to the polyoma virus
3. Most chalazia are infectious
4. Vismodegib is to BCC, as Cemiplimab is to squamous cell CA
Réponse :
VRAI : 1 et 4
FAUX : 2 et 3
La majorité des chalazions sont bénins, sans surinfx
Caractéristiques d’une suturing full-thicjness lid defects
Meticulous alignment to prevent notch
No full thickness stitches aka no stitches on conjunctival side
Imbricate tail of the margin stitch
Leave margin stitches for au moins 12 jours
Watery eyes (tearing). Which statement(s) is/are FALSE?
1. Dry eyes (unstable tear film) can cause reflex tearing
2. Horizontally loose lids may result in tearing
3. A blocked tear duct often results in p.m. tearing with burning sensation
4. Bogorad’s syndrome refers to « crocodile tears »
Réponse :
VRAI : 1, 2 et 4
FAUX : 3
Common causes of tearing
Unstable tear film
Lash/CÉ
Eyelid laxity
Nsaolacrimal blockage
Uncommon cause of tearing
Primary hypersecretion : pontine lesion
What factors would make you think nasolacrimal obstruction vs reflex tearing?
Reflex :
- Clear discharge
- Intermittent
- Worse when wind blows
- Often bilateral
- Causes : unstable tear film, lash corneal touch
Obstruction :
- Possible Purulent discharge
- Cosntant
- Prior Fx, nasal surgery
- Unilateral
- Causes : Mucocele, reflux on compression
Nasolacrimal duct obstruction (NLDO). Which is FALSE?
1. Pediatric NLDO often responds to nasolacrimal message and probing
2. Adult NLDO is usually at the valve of Hasner
3. Skin incisions for External DCR should NOT be 8 mm medial to the media canthus
4. Dacryoliths are stones in the lacrimal sac
Réponse :
VRAI : 1, 3 et 4
FAUX : 2
Localisation et Tx d’une obstruction nasolacrimal chez l’enfant versus chez l’adulte?
Enfant :
- Membrane of Hasner
- Message. Probe if not improved by 12 months of age.
Adulte :
- Sac-duct junction
- Dacryocystorhinostomy
Distance de chacun des EOMs par rapport au limbe
MR : 5,5 cm
IR : 6,6 cm
LR : 7,0 cm
SR : 7,8 cm
Structures passant through the orbital apex? Lesquelles sont intra-conal versus extra-conal?
Extra-conal : lacrimal nerve, facial nerve, trochlear nerve, superior ophtalmic vein
Intra-conal : nasociliary nerve, abducens nerve, oculomotor nerves (superior + inferior), sympathetics
Location of Nasolacrimal Duct?
Lateral wall
Tx dacryocystite
- Clavulin PO ou IV
- Other IV : ceftriaxone, vancomycine, moxifloxacine…
- DCR when inflammation settles
Medial orbital bones?
SMEL :
- S : sphenoid
- M : Maxillaire
- E : Ethmoid
- L : Lacrymal
Foramens du médial orbital wall et distance entre ceux-ci
Règle du 24-12-6
Ant Lacr Crest → 24 mm → Ant ethm. foramen → 12 mm → Post ethm foramen → 6 mm → Optic canal
Floor of the Orbit (bones)
Ma P Z
- Maxillaire
- Palatine
- Zygomatique
Roof of the orbit (bones)
RooF Less
- Frontal
- Less wing sphenoid
Lateral orbit bones
LATe-Great-Z
- Greater wing sphenoid
- Zygomatique
Quelles structures traversent la fissure orbitaire supérieure?
NC 3
NC 4
V1
NC6
+/- V2
Signs of orbital disease
Proptose
Displacement
DECREASED RETROPULSION
Lid retraction
Pulsation
The most common orbital disease are :
Orbital Fx
Orbital cellulitis
Thyroid associated orbitopathy
Lymphoma
Cause la plus fréquente d’une proptose UNI ou BILAT chez l’adulte?
Thyroid associated orbitopathy
Cause la plus fréquente d’une proptose chez l’enfant?
Cellulite orbitaire
Vascular orbit tumor la plus fréquente chez l’adulte et chez l’enfant?
Adulte : cavernous hemangioma
Enfant : hémangiome capillaire
Another common benign paediatric « orbital » tumour?
Dermoid cyst
Orbit malignancy le plus fréquent chez l’adulte et chez l’enfant?
Adulte : Lymphome NH
Enfant : Rhabdosarcome
Métastase orbitaire la plus fréquente chez l’adulte et chez l’enfant?
Adulte :
- H : Poumon
- F : Sein
Enfant : Neuroblastome (« ressemble à un child abuse » avec des racoon eye)
Entité orbitale qui augmente avec le froid
Lymphangiome
Entité orbitaire pulsatile?
Penser à une malformation AV
In patients woth Orbital flore Fx : Which is/are TRUE?
1. Fx patients should forcefully blow there nose to expel all blood be4 they leave the emergency room
2. Infraorbital anesthesia is an indication for floor Fx repair
3. Fx patients that faint on up gaze have hysteria and hypochondriasis
4. Children may have an orbital # but show very little periorbital bruising
Réponse :
VRAI : 4
FAUX : 1, 2, 3
Mechanisms of orbital floor fractures (x2)
Buckling : direct force to rim
Hydraulic : transmitted force from globe
Signs of Orbital Floor Fx
Enophtalmos
Infraorbital anesthesia/paresthesia
Vertical diplopia
Bradycardia (Syncope)
Large Floor Fx versus Small Floor Fx
Large Floor Fx (+ Medial Fx) : enophtalmos
Small Floor Fx : entrapment
Vrai ou Faux :
1. Kids can get small « trap door » floor Fx that need urgent repair if the muscle is entrapped
2. Kids may not be bruised from their trauma (white eyed blowout)
Réponse : VRAI pour les 2
Signs of a Roof Fx
Ptose
Upgaze diplopia
CSF leak
Kids may bet roof Fx from « face plant » injuries because the frontal sinus is not well developed
Pendant combien de temps un patient avec un Fx de l’orbite ne devrait-il pas se moucher?
2-3 semaines pour avoid emphysema s/c and augmentation PIO
Indications chx pour une Fx du plancher de l’orbite (x4)
Entrapment/Oculocardiac reflex
Non-resolving diplopia
Cosmetically objectionable enophtalmos
Conséquence d’une Hg rétrobulbaire
Syndrome du compartiment orbitale = may cause blindness
Tx de l’Hg rétrobulaire
Canthotomie et CANTHOLYSE (2e est la plus important pour libérer la pression)
Si High PIO ou DPAR : DON’T WAIT FOR SCAN
Complications d’une cellulite orbitaire
Abcès : lid, subperiosteal, orbital, brain
Thrombose sinus caverneux
Blindness
CN palsies
Mort
Tx d’un subperiosteal abscess (complication de la cellulite orbitaire) chez l’adulte versus chez l’enfant
Adulte : ATB, car souvent un seul germe
Enfant : Drainage, souvent polymicrobien
SUPERIOR subperiosteal abscess : more prone to brain abscess
ATB pour la cellulite orbitaire
Ceftriaxone + Vacomycin (MRSA) + Metronidazole (Anaérobes)
Présentation clinique et Tx de l’Orbital Inflammatory Syndrome (OIS) (variante de la myositis)?
Sudden onset painful proptosis that dramatically responds to 60 mg prednisone within 24-48h
Thyroid-associated Orbitopathy (TAO) : Which is/are FALSE?
1. The most common sign of TAO is superior scleral show (lid retraction)
2. Patient with TAO who require ophtalmic referral often have diplopia and conjunctival erythema/chemosis
3. Smoking cessation is advised in patients with TAO
4. Tepazza is an IL-6 inhibitors
Réponse :
VRAI : 1, 2 et 3
FAUX : 4, c’est un IGF
What is Thyroid Associated Orbitopathy (TAO)?
An A-I process that effects the orbit and thyroid gland
(L’une des atteintes n’est pas la cause de l’autre)
Vrai ou Faux : Dans la Thyroid Associated Orbitopathy (TAO), les muscles et les tendons sont atteints.
FAUX : the muscles are enlarged and tendon is often spared. Non-contrast CT is useful for surgical planning.
Thyroid-associated Orbitopathy (TAO) : Which is FALSE?
1. Radioactive iodine thyroid ablation may exacerbate orbitopathy, especially in patients who already have TAO
2. Surgical thyroidectomy can cure TAO
3. In patients with severe TAO, high dose glucocorticoid, orbital radiation and surgery are possible options
4. Teprotumumab is Health Canada-approved as of 2023, and costs less than 900$ US for a complete cycle of treatment
Réponse :
VRAI : 1 et 3
FAUX : 2 et 4
Active : medical therapy or radiotherapy
- Systemic steroids (pulse)
- Radiation
- Teprotumumab (IGF1 inhibitor)
- Tocilizumab (IL-6)
Quiescent : reconstructive surgery
- Décompression
- Strabisme
- Lid lengthening
- Bleph
Tx de Thyroid Associated Orbitopathy (TAO)
Active : medical therapy or radiotherapy
- Systemic steroids (pulse)
- Radiation
- Teprotumumab (IGF1 inhibitor)
- Tocilizumab (IL-6)
Quiescent : reconstructive surgery
- Décompression
- Strabisme
- Lid lengthening
- Bleph
