Periorbital Region and Blepharoplasty

Question 1

What is blepharochalasis?

Answer 1

Rare inherited disorder characterized by repetitive episodes of eyelid edema and subsequent levator dehiscence and ptosis.

Question 2

What is the best test for evaluating ptosis?

Answer 2

Marginal Reflex Distance (MRD1) test

Question 3

What is entropion?

Answer 3

Inward rotation of the eyelid margin

Question 4

What are the findings associated with Horner’s Syndrome?

Answer 4

Blepharoptosis, pupil miosis, and facial anhidrosis

Question 5

Where is the apex of the brow positioned?

Answer 5

Lateral limbus of the eye in forward gaze.

Question 6

What is the distance from the orbital rim to the apex?

Answer 6

40-45mm

Question 7

In the setting of normal facial proportions, what distance best approximates intercanthal distance?

Answer 7

Orbital fissure width

Question 8

What anatomical event happens during eyelid closure?

Answer 8

The lacrimal puncta closes. During eyelid opening, the puncta are open and in contact with the lacrimal lake at the medial aspect of the lower eyelid. The lacrimal sac is collapsed and empty at this stage and the canaliculi are patent.

Question 9

What are the layers of the eyelid?

Answer 9

Skin, orbicularis occuli, retro orbicularis oculi fat, orbital septum, orbital fat, levator muscle, Mueller’s muscle, conjunctiva.

Question 10

Which muscles contribute to medial brow retraction?

Answer 10

Corrugators, depressor supercilii (part of orbicularis), and minimal contributions from orbicularis occuli.

Question 11

What composes the anterior lamella?

Answer 11

Skin, orbicularis occuli.

Question 12

What composes the posterior lamella?

Answer 12

Lower lid: Tarsoligamentous sling consisting of the tarsal plate, medial and lateral canthal tendons along with the capsulopalpebral fascial and conjunctiva.
Upper lid: conjunctiva and Muller’s muscle.

Question 13

What separates the anterior and posterior lamella?

Answer 13

The orbital septum which originates at the arcus marginalis along the orbital rim.

Question 14

What is the tarsoligamentous structure of the eyelid?

Answer 14

1.) The tarsoligamentous sling creates the support structure for the posterior lamella
2.) The tarsal plates constitute the connective tissue framework of the upper and lower eyelids.
3.) The upper lid tarsal plate is approximately 30mm horizontal and 10mm vertical at its widest dimension. The lower lid tarsal plate is approximately 24mm horizontal and 4mm vertical in dimension. The tarsal plates of the upper and lower eyelid are attached to the orbital rim by the medial and lateral canthal tendons and retinacular support structures.

Question 15

What is the lateral canthus?

Answer 15

Complex connective tissue framework that functions as the fixation point of the lower lid. The lateral canthal tendon is 5mm in length and formed by the fibrous crura that connect the tarsal plate to Whitnall’s lateral orbital tubercle within the lateral orbital rim.

Question 16

What forms the lateral retinaculum?

Answer 16

Ligamentous structures from the lateral horn of the levator aponeurosis, lateral rectus check ligaments, Whitnall’s suspensory ligament, Lockwood’s inferior suspensory ligament that converges at the lateral canthal tendon.

Question 17

Describe the anatomy of the lower lid ligamentous system

Answer 17

Lower lid retractor system is composed of the capsulopalpebral fascia and the inferior tarsal muscle. Capsulopalpebral fascia originates from the inferior rectus fascia and encircles the inferior oblique muscle. The two portions of the capsulopalpebral fascia fuse anterior to the inferior oblique muscle to form Lockwood’s ligament which then inserts at the inferior tarsal border. The arcuate expansion of Lockwood’s ligament, Clifford’s ligament, inserts into the inferolateral orbital rim and fuses with the interpad septum between the central and lateral fat compartments of the lower eyelid.

Question 18

What is the function of Lockwood’s ligament?

Answer 18

To stabilize the lower lid on downward gaze while the lower lid retractors cause lid depression of the eyelid to increase the inferior visual field during down gaze.

Question 19

Describe the fat compartments of the upper eyelid

Answer 19

Central and nasal fat pads posterior to the septum and anterior to the levator aponeurosis. The interpad septum divides the two fat pads and is continuous with a septal fascial connection to the trochlea. Nasal fat pad is paler and more fibrous.

Question 20

Describe the fat compartments of the lower eyelid

Answer 20

Three fat compartments- nasal/medial, central, lateral. Nasal compartment has paler more fibrous fat. Central and lateral compartments are separated by an interpad septum and a fascial extension from Lockwood’s ligament, the arcuate expansion.

Question 21

What is the blood supply to the eyelid?

Answer 21

From the external carotid: facial artery, internal maxillary artery, superficial temporal artery.
From the internal carotid: dorsal nasal, supratrochlear, supraorbital, lacrimal, terminal branch of the opthalmic artery

Question 22

What is the preferred donor site for autologous reconstruction of the posterior lamella?

Answer 22

Hard palate mucosal graft

Question 23

What is the innervation to the eyelid?

Answer 23

Infraorbital nerve (V2): travels in the orbital floor and innervates the lower eyelid, cheek, and upper lip.
Lateral palpebral branch of the lacrimal nerve (branch of infraorbital n): innervates the superior lateral portion of the upper eyelid.
Lacrimal nerve (branch of opthalmic nerve, V1): provides sensation to the upper eyelid.
Infratrochlear nerve: innervates the medial aspect of the upper and lower eyelid.
Zygomaticofacial nerve: sensory innervation to the lateral fat pad of the lower eyelid.

Question 24

What structure lies adjacent to the sentinal vein?

Answer 24

Temporal branch of the facial nerve

Question 25

What is the arcus marginalis?

Answer 25

Periosteal thickening at the orbital rim where the orbital septum attaches.

Question 26

What is the inner/ pre-corneal layer of tear film composed of?

Answer 26

Formed by mucin secreting goblet cells located in the conjunctiva. Covers cornea and promotes dispersion of the overlying aqueous layer.

Question 27

What is the middle layer of tear film composed of?

Answer 27

Aqueous middle layer. Secreted by the lacrimal gland and is comprised of water and proteins. This promotes osmotic regulation and control of infectious agents. Dysfunction of the lacrimal gland leads to eye dryness and increased incidence of infections.

Question 28

What is the outer layer of tear film composed of?

Answer 28

Lipid layer produced by the meibomian glands; helps to prevent tear film evaporation. Dysfunction of the meibomian glands can lead to dry eyes.

Question 29

What is a tear trough deformity?

Answer 29

Attenuation/ laxity of the tear trough ligament; Tear trough ligament is an osteocutaneous ligament arising from the medial portion of the maxilla and extends inferolaterally from the medial canthus to the mid pupillary line where it connects with the orbicularis retaining ligament.

Question 30

What is the lymphatic drainage of the eyelid?

Answer 30

Medial: submaxillary lymph nodes
Lateral: parotid lymph nodes

Question 31

What is the procerus?

Answer 31

Muscle continuous with frontalis inserting into nasal bone to create horizontal wrinkles of the glabella.

Question 32

What are the oil secreting glands of the eyelid?

Answer 32

Meibomian, Zeis

Question 33

How is exopthalmos measured?

Answer 33

Use a Hertel exopthalmometer; distance between the anterior border of the globe and the most anterior point of the lateral aspect of the orbital rim is greater than 18mm. Enopthalmos is defined as less than 14mm, midrange is 15-18mm