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Collin - Plastic and Orbital Surgery 2001 PDF
Collin - Plastic and Orbital Surgery 2001 PDF
Ophthalmology
BMJ Books
Fundamentals of Clinical Ophthalmology
Neuro-ophthalmology
Edited by James Acheson and Paul Riordan-Eva
Paediatric Ophthalmology
Edited by Anthony Moore
Scleritis
Edited by Peter McCluskey
Uveitis
Edited by Susan Lightman and Hamish Towler
Forthcoming:
Cataract Surgery
Edited by David Garty
Cornea
Edited by Douglas Coster
Strabismus
Edited by Frank Billson
Fundamentals of Clinical Ophthalmology
Edited by
Richard Collin
Consultant Ophthalmic Surgeon,
Moorfields Eye Hospital,
London, UK
and
Geoffrey Rose
Consultant Ophthalmic Surgeon,
Moorfields Eye Hospital,
London, UK
Series Editor
Susan Lightman
Professor of Clinical Ophthalmology,
Institute of Ophthalmology/Moorfields Eye
Hospital, London, UK
BMJ Books 2001
BMJ Books is an imprint of the BMJ Publishing Group
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted, in any form or by any means, electronic, mechanical, photocopying,
recording and/or otherwise, without the prior written permission of the publishers.
www.bmjbooks.com
A catalogue record for this book is available from the British Library
ISBN 0-7279-1475-8
Contributors vii
Preface viii
3 Ectropion 15
Michle Beaconsfield
4 Entropion 24
Ewan G Kemp
5 Ptosis 32
Ruth Manners
8 Cosmetic surgery 78
Richard N Downes
9 Socket surgery 89
Carole A Jones
v
CONTENTS
Index 182
vi
Contributors
Michle Beaconsfield
Consultant Ophthalmic Surgeon, Moorfields Eye Hospital, London, UK
Richard N Downes
Consultant Ophthalmic Surgeon, General Hospital, St Helier, Jersey, CI
Carole A Jones
Consultant Ophthalmic Surgeon, Kent County Ophthalmic and Aural Hospital, Maidstone, UK
Ewan G Kemp
Consultant Ophthalmologist, Gartnavel General Hospital, Glasgow, UK
Carol Lane
Consultant Ophthalmic Surgeon, University Hospital of Wales, Cardiff, UK
Brian Leatherbarrow
Consultant Ophthalmic, Oculoplastic and Orbital Surgeon, Manchester Royal Eye Hospital,
Manchester, UK
Christopher J McLean
Consultant Ophthalmic Surgeon, Royal Surrey County Hospital, Guildford, UK
Alan A McNab
Consultant Ophthalmic Surgeon, Royal Victorian Eye and Ear Hospital, The Royal Melbourne
Hospital and the Royal Childrens Hospital, Melbourne, Australia
Ruth Manners
Consultant Ophthalmic Surgeon, Southampton General Hospital, Southampton, UK
Brett ODonnell
Consultant Ophthalmic Surgeon, Royal North Shore Hospital and St Vincents Hospital, Sydney,
Australia
Jane M Olver
Consultant Ophthalmic Surgeon, The Western Eye Hospital, London, UK
John Pitts
Consultant Ophthalmologist, Barts and the London NHS Trust, London, UK
Cornelius Ren
Consultant Ophthalmic Surgeon, Addenbrookes Hospital, Cambridge, UK
Fiona Robinson
Consultant Ophthalmologist, Kings College Hospital, London, UK
Timothy J Sullivan
Clinical Associate Professor and Head, Department of Ophthalmology, Royal Brisbane Hospital,
Brisbane, Australia
Anthony G Tyers
Consultant Ophthalmologist, Salisbury District Hospital, Salisbury, UK
Michael J Wearne
Consultant Ophthalmic Surgeon, Eastbourne District Hospital, Eastbourne, UK
vii
Preface to the
This book is part of a series of ophthalmic monographs, written for ophthalmologists in training
and general ophthalmologists wishing to update their knowledge in specialised areas. The
emphasis of each is to combine clinical experience with the current knowledge of the underlying
disease processes.
Each monograph provides an up to date, very clinical and practical approach to the subject so
that the reader can readily use the information in everyday clinical practice. There are excellent
illustrations throughout each text in order to make it easier to relate the subject matter to the
patient.
The inspiration for the series came from the growth in communication and training
opportunities for ophthalmologists all over the world and a desire to provide clinical books that
we can all use. This aim is well reflected in the international panels of contributors who have so
generously contributed their time and expertise.
Susan Lightman
Preface
This book covers the whole field of eyelid, lacrimal, orbital and socket surgery. As part of the
series of ophthalmic monographs it is written for ophthalmologists in training and general
ophthalmologists wishing to update their knowledge of oculoplastic surgery. It aims to provide a
practical guide to the management of basic oculoplastic problems. It does not try to give didactic
details of a systematic series of surgical procedures, but rather to present an outline of the
different options which are available to the surgeon with their advantages and disadvantages.This
is achieved by a team of contributors practising in different countries throughout the world who
have all worked at Moorfields Eye Hospital with the editors, but who have adapted their practice
to their current local circumstances. In this way we hope to have provided a surgical guide which
will be of value throughout the world.
Richard Collin
Geoffrey Rose
viii
CHAPTER TITLE
A sound understanding of the basic anatomy between conjunctiva which covers tarsus and
of the eyelids, lacrimal system and orbits is squamous epithelium which covers orbicularis.
essential in order to perform successful In plastic surgery, procedures are often
surgery.This chapter presents a basic overview described as involving the anterior or posterior
together with general considerations relative lamella.
to oculoplastic and orbital surgery. The upper lid margin lies 1 to 2mm below
the superior limbus, the peak lying just nasal
Whitnalls ligament to the centre of the pupil. The lower lid
Orbicularis Pre-Aponeurotic fat margin sits at the corneal limbus, its lowest
pad
portion lying slightly temporal to the pupil.
Orbital septum
The upper lid crease is 8 to 12mm above the
Levator palpebrae
Levator
superioris lashes and is formed by the subcutaneous
aponeurosis insertion of the terminal fibres of the levator
Post-
Aponeurotic
aponeurosis. The lower lid crease is more
space
Superior rectus
poorly defined as there are no subcutaneous
Mullers
muscle
insertions corresponding to those of the
upper eyelid. The nasojugal fold extends
Tarsus
inferior and laterally from the medial canthal
Inferior rectus
angle along the side of the nose and the
Tarsus angular blood vessels will generally be located
in this fold.
Orbital
septum
Inferior oblique
Pre-Aponeurotic fat pad
Skin
Orbicularis
Eyelid skin is thin allowing good mobility of
Figure 1.1 Sagittal view of the eyelid structures.
the eyelids. In part due to this thinness, it has
a tendency to stretch with age. The resultant
excessive skin can be used for full thickness
The eyelids skin grafts. Such skin grafts take well as there
The eyelids may be divided into anterior is little subcutaneous fat. It should be noted
and posterior lamellae. The anterior leaf is that the lower lid has no vertical excess skin
composed of skin and orbicularis and the and one should excise lesions from the lower
posterior of tarsus and conjunctiva. The grey lid as vertically as possible to avoid a cicatricial
line of the lid margin marks the separation ectropion.
1
PLASTIC and ORBITAL SURGERY
10mm
body of sac
} Lacrimal
sac
}
}
8mm
}
12mm
eyelid. The meibomian glands are found interosseous
part Nasolacrimal
within the tarsal plates. 5mm duct
} intramembranous
part
Inferior canaliculus
Secretory system
The lacrimal gland is an exocrine gland and The lacrimal sac leads into the nasolacrimal
lies in the anterior superolateral quadrant of duct. The duct has an upper intraosseous
the orbit in the lacrimal fossa. It measures (12mm) segment, the direction of which is
3
PLASTIC and ORBITAL SURGERY
inferior and slightly lateral and posterior. The apex and optic canal. The medial orbital walls
lower intramembranous segment (5mm) are approximately 1cm apart and parallel,
opens into the lateral wall of the nose beneath and the adult orbit volume is 30cc. Each orbit
the inferior turbinate. The ostium is covered wall has particular important relations. The
by a mucosal valve (of Hasner). The tear flow roof has the anterior cranial fossa and frontal
is actively pumped from the tear lake by the sinus above. The medial wall has adjacent
actions of the orbicularis muscle (Figure 1.3). nasal cavity, ethmoid sinuses and more
posterior sphenoid sinus. The maxillary
antrum is beneath the floor. The lateral wall is
located adjacent to the middle cranial fossa,
temporal fossa and pterygopalatine fossa. The
thinnest bone is in the medial wall (lamina
(a) (b) (c)
papyracea) adjacent to the ethmoid air cells.
The floor is also thin especially medially and
Eyelids Blinking Re-opening these are the areas most frequently
open of lids fragmented in blow out fractures. The
Figure 1.3 The lacrimal pump.
orbital walls are perforated by several
significant apertures. The Annulus of Zinn is a
fibrous ring formed by the common origin of
The orbit the four rectus muscles. The relationships of
the superior orbital fissure, inferior orbital
The bony orbit (Figure 1.4) fissure, Annulus of Zinn and optic foramen
The orbit lies behind the orbital septum. It and their contents are shown in Figure 1.5.
has four walls composed of seven bones;
ethmoid, frontal, lacrimal, maxillary, palatine, Surgical spaces
sphenoid and zygomatic. The walls (roof, The orbit may be divided into three surgical
lateral, medial, floor) taper posteriorly to the spaces. The potential subperiosteal space
lies between the bone and the periorbita. The
Lesser wing intra and extraconal spaces are divided by the
of sphenoid Body of
sphenoid
extraocular muscles and intermuscular septa.
Zygomatic
process Supraorbital
Frontal
notch Levator palpebrae
bone Superior rectus superioris
Optic foramen
Orbital plate Superior oblique
of greater Nasal Superior orbital Trochlear nerve
fissue Medial rectus
wing of bone
sphenoid Optic
Lacrimal N. nerve
Ethmoid
Lacrimal Frontal N. Ophthalmic
Superior artery
bone
Sup. ophthalmic vein
orbital Inferior rectus
Palatine Sup. divison
fissure
bone oculomotor N. Inf. division
Zygomatic oculomotor N.
Nasolacrimal N.
bone Abducens N.
Orbital
Inferior Maxillary plate of Inf. ophthalmic
orbital fissure maxilla vein
process Infraorbital Lateral rectus
foramen N. = Nerve
Figure 1.4 Bony right orbit. Figure 1.5 Annulus of Zinn and related structures.
4
ANATOMY and GENERAL CONSIDERATIONS
The subperiosteal space provides an easily careful handling of soft tissue. Appropriate
dissectable plane for surgical access and sutures and needle points lead to best wound
follows the contours of the orbital walls. The closure and healing.
most important structure in the extraconal
space is the lacrimal gland. Within the muscle
Anaesthesia
cone, i.e. in the intraconal space, lies orbital
fat, the optic nerve plus blood vessels and Anaesthetic options available to the patient
nerves. are local, local with sedation and general.
The choice is individual to each patient.
Local infiltration allows for patient co-
Blood supply, nerve supply and operation, rapid recovery time and accuracy
lymphatic drainage in lid surgery. It is reliable and rarely needs
the addition of a regional block although the
The internal and external carotid arteries latter is necessary in lacrimal drainage
supply blood to the eyelids and orbit with rich surgery. The anaesthetic agent may be short
anastomoses between the two. This good or long acting or a combination of both. The
blood supply accounts for rapid healing and addition of adrenaline gives vasoconstriction,
relative lack of infection. The venous drainage prolonged anaesthesia and better haemostasis
generally follows the arterial supply. There are if given 10 minutes to act. The injection
no identifiable lymphatic vessels in the orbit. is subcutaneous avoiding visible vessels
Medial lymphatics of the eyelids drain to the and penetration of muscle to minimise
submandibular lymph nodes, the lateral group haematoma formation.
to the preauricular nodes. The sensory Indications for general anaesthetic are
innervation of the eyelids and orbit is via the diminishing. It is usually reserved for more
ophthalmic and maxillary divisions of the invasive orbital procedures and eyelid surgery
Trigeminal nerve. on children.
Incisions
General considerations for
surgery All skin incisions result in scar formation.
Scars are less obvious if the incision is made in
or parallel to skin creases, for example an
Patient preparation and
upper eye lid incision in the upper lid crease
intraoperative care
for ptosis surgery
Proper patient selection, adequate pre- If this is not possible one should try to keep
operative assessment and meticulous surgical the incision parallel to the lines of minimum
techniques optimise surgical outcome. The skin tension (Figure 1.6). One exception to
patient should be properly informed as to the this is the vertical incision for lower lid lesions
type of procedure, benefit of procedure and to avoid cicatricial ectropion. The incision
potential complications. As far as possible should be as vertical as possible for the
the surgeon should decide pre-operatively the smallest scar and rapid healing. It is always
procedure of choice and obtain patient helpful to mark an incision before distortion
consent prior to the day of surgery. by local anaesthetic or stretching and it should
Intraoperatively, trauma to tissues is be made in a single steady motion. It is helpful
minimised by the use of specialised to cut down-hill to uphill to avoid blood
instruments (for example skin hooks) and obscuring the surgical field.
5
PLASTIC and ORBITAL SURGERY
Further reading
Collin JRO. A Manual of Systematic Eyelid Surgery (2nd ed).
London: Churchill Livingstone, 1989.
Jones LT, Wobig JL. Surgery of the Eyelids and Lacrimal
System. Aesculapius, 1976.
McCord CD, Tanenbaum M, Nunery WR. Oculoplastic
Surgery (3rd ed). New York: Raven Press, 1995.
McNab AA. Manual of Orbital and Lacrimal Surgery.
Edinburgh: Churchill Livingstone, 1994.
Zide BM, Jelks EW. Surgery Anatomy of The Orbit. New York:
Raven Press, 1985.
6
2 Eyelid trauma and basic principles of
reconstruction
John Pitts
A doctors first introduction to ocular plastic manipulations are carried out in the definitive
surgery is often being called upon to repair an repair of facial fractures, but it would be
acute eyelid laceration. The management of unreasonable to delay the treatment of
both acute and chronic or established eyelid torrential haemorrhage or severe neurosurgical
injuries is laid out in this chapter. Surgical injury in the same circumstances.
repair depends on a knowledge of eyelid
anatomy and of the principles of eyelid
reconstruction which are described here. Principles of soft tissue repair
The advanced trauma life support system
(ALTS) was developed by the American Antitetanus prophylaxis
College of Surgeons in 1993 as an algorithmic
Details are given in Table 2.1
approach to the management of patients with
life-threatening injuries. It is important that
Table 2.1 Guidelines for antitetanus prophylaxis.
everyone involved in the early resuscitation of
the injured patient has the same priorities Immunisation Clean wounds Tetanus-prone
status wounds
regardless of specialty.
ATLS can be stated simply as: Last injection of a Nil Nil or booster if
course or booster high risk of
within 10 years infection
rapid primary survey Last injection of a Antitetanus toxoid Antitetanus toxoid
simultaneous resuscitation course or booster and human
more than 10 years antitetanus
detailed secondary survey previously immunoglobulin
appropriate referral (inject at different
patient transfer sites)
the tissues scrubbed using a sterile hand scrub Start to remove sutures early (35 days).
brush. Larger fragments are removed Alternate suture removal is a useful
individually with forceps. The area is irrigated technique to avoid scarring. Support the
with saline and the process repeated until all tissues with Steristrips over tincture of
visible contaminants are removed. Adequate benzoin to promote adhesion.
retraction of wounds is important, and the Avoid complex procedures in primary
operating microscope is helpful in detecting repair.
smaller particulate contamination.
Sutures and needles
Preservation of tissues
The main sutures used in oculoplastic repair are:
Minimal surgical debridement is the rule in
facial and lid lacerations due to the superior nylon 6/0
healing characteristics of wounds in this area,
arising from its abundant blood supply. non absorbable polyamide synthetic fibre
10mm reverse cutting needle
IV
A IV
D
B
C
II
(a) III (b)
8
EYELID TRAUMA and BASIC PRINCIPLES of RECONSTRUCTION
Note: 6/0 Vicryl rapide, which is absorbed eikenella for human bites and pasturella for
in 42 days and which provides wound support animal bites.
for 10 days, is useful for skin closure in
children. Vicryl used for skin closure should Stab wounds
be undyed to avoid tattooing.
The dimensions of the weapon should be
used to give an idea of whether frontocranial
5/0 ethibond
perforation is likely and CT scans used
whenever this possibility is considered. The
braided polybutylate coated polyester
wound should be explored to identify
non-absorbable; remains encapsulated in
damaged structures. Superficial wounds
tissue
should be cleaned and primary closure
8mm half-circle spatulated needle.
obtained. Antitetanus prophylaxis should be
given according to the protocol.
If a weapon remains in position it should
Types of specific wounds not be removed until there are full
resuscitative and operative facilities available
Bite wounds
including cross-matched blood and
Bite wounds are always contaminated and neurosurgical expertise. Plain films in two
are often associated with tissue loss. Direct orthogonal planes and CT scanning are useful
closure should be attempted after thorough in demonstrating the position of the weapon,
cleaning and tetanus prophylaxis, metronida- but angiography may be necessary where
zole, and a broad spectrum antibiotic to cover damage to major vessels is suspected.
9
PLASTIC and ORBITAL SURGERY
When the instrument is removed there is a Close the tarsal plate with 5/0 Vicryl.These
period of initial brisk haemorrhage which then are structural sutures and the bites must be
subsides. Vascular clips, ties and cautery help tested for adequacy and placed just shallow
to control haemorrhage, and Surgicel can be to the conjunctival plane to avoid rubbing
packed along the track of the wound. There is on the cornea.
a risk of secondary haemorrhage when the Close skin and orbicularis with 6/0 silk or
blood volume is restored and the patient nylon.
begins to mobilise. Release the grey line suture from traction
and tie it down away from the cornea with
Eyelid lacerations the top skin suture.
Delay in repair is acceptable while more life- Remove skin sutures at day five.
threatening injuries are dealt with, but it is Remove the grey line suture at day ten.
important to ensure that the globe is protected
from pressure until penetrating injury is Lacerations parallel to the orbicularis
excluded, and the cornea is protected from fibres
dehydration until the lids can be repaired. One
should always check for penetrating injury These do not gape and can be left if small.
when the patient is under general anaesthetic Larger, slightly gaping wounds can be closed
before embarking on repair of eyelid with a subcuticular technique.
lacerations.
If the globe is intact, or when it has been Lacerations perpendicular to the
repaired, lid lacerations should be repaired. orbicularis fibres
This should be performed before repair of
other facial lacerations, because primary These have a tendency to gape and healing
closure in circumstances where tissue loss has by primary intention leaves an unsightly scar,
occurred elsewhere in the face may result in producing distortion of the eyelid margin and
stretching and difficult closure in the poor functional results. The obicularis should
periocular region. The upper lid takes priority be closed with interrupted 6/0 catgut sutures.
and should be repaired before the lower lid. The skin is closed with 6/0 silk or nylon using
Avoid excising tissue from the eyelids, as even an everting technique.
apparently devitalised tissues may regain
perfusion when anatomical relationships have Lacerations to the levator muscle
been restored. In repairing the lids, it is
important that the tarsal plates are accurately The levator can consistently be found under
aligned to prevent eyelid deformity, and the the pre-aponeurotic fat pad and the severed
eyelid margins must be smooth to prevent ends brought into apposition using 6/0 catgut
corneal damage. or Vicryl. Lacerations of the levator
aponeurosis will heal spontaneously if less
Closure of eyelid lacerations than half of its width is involved.
When the levator muscle is severely
The method of closure is detailed here.
damaged it may be easier to perform an
Place a lid guard to protect the globe. accurate primary repair of other lid structures
Align the grey line with 6/0 virgin silk. and repair the levator as a secondary
Leave the ends long and place the suture procedure under local anaesthesia, using the
under light traction to bring the tarsal movement of the muscle in upgaze to help
plates into alignment. identify the proximal end.
10
EYELID TRAUMA and BASIC PRINCIPLES of RECONSTRUCTION
repair which compromises the function of eye should undergo accurate primary repair until
the undamaged canaliculus should be the intraocular damage can be assessed in detail.
contemplated. If the decision is made to repair Modern intraocular surgery can often salvage
a single canalicular injury, then this should be severely damaged eyes. If there is no visual
carried out using the operating microscope. potential after an ocular perforating injury, the
8/0 Vicryl sutures are used to approximate the ocular inflammatory reaction does not settle
ends of the canaliculus over a 1mm silicone down rapidly or the eye has been grossly
stent, which is sutured to the lid margin and disrupted, it is wise to carry out an enucleation
removed after two weeks.The canaliculus must as a secondary procedure, preferably within two
be regularly dilated to keep it open. Although to four weeks of the trauma.
this method has the advantage of not involving
the uninjured canaliculus, Welham points out
that it is unlikely to remain patent and carries
the risk of producing lid distortion and Management of scarring
ectropion. In the light of these considerations, Healing wounds in the acute phase should
the following recommendations are made. be held in apposition with sutures to minimise
the blood clot and fibrin. After two weeks
Bicanalicular lacerations should be fibroblast activity increases and the wound
repaired using an intubation technique but enters the contraction phase which lasts about
the patient must be warned that post twelve weeks. It can be influenced by various
operative stenosis is likely and that this factors including pressure, massage, steroids,
may subsequently require conjunctivo- anti-mitotic agents such as Mitomycin C, and
dacryocystorhinostomy (DCR) with vitamins such as Vitamin E and C. After
placement of a Pyrex tube. twelve weeks the scar enters the phase of
Single canalicular lacerations can be dealt maturation and the fibroblasts become
with safely by accurately repairing the aligned. Activity can be monitored by the
eyelid, ensuring apposition to the globe, redness and thickness in the scar. If a wound
and marsupialising the distal segment of the is unsatisfactory it can be opened and re-
transected canaliculus in the wound using a sutured in the first two weeks. After that the
three-snip procedure. The marsupialised fibroblast activity is intense and any scar
area can be held open by placing 8/0 Vicryl revision is likely to be complicated by an
sutures. excessive response. The scars should be left
Common canalicular lacerations are dealt until they are judged to be mature which
with by carrying out a primary canaliculo- means they are no longer thick or red. This
DCR with intubation. will certainly take three months, even after a
Lacrimal sac lacerations are treated by clean primary surgical would, and after
a DCR (Dacryocystorhinostomy) with trauma it may take six to nine months or
intubation as a primary procedure. longer.
The principles of scar revision of a mature
scar are to excise the scar itself, preferably
Indications for primary removal to break up the line of the scar e.g. with a
Z-plasty or (Figure 2.2) multiple Z-plasties,
of globe
and to re-suture it as accurately as possible
Primary enucleation to prevent the with relief of all tension. Pressure, massage,
development of sympathetic ophthalmia is no steroids, etc. can be used post operatively to
longer advocated. Where possible, the injured modify the scar healing as desired.
12
EYELID TRAUMA and BASIC PRINCIPLES of RECONSTRUCTION
Cicatricial ectropion B A A
A
B
This is diagnosed by pushing the lower
eyelid upwards. Normally it will reach the
margin of the upper lid with the eye open.
Less severe degrees can be demonstrated by (a) (b)
asking the patient to open his/her mouth. The
tension in the lower eyelid skin will pull the lid
margin away from the globe.
A
The treatment of cicatricial ectropion B
Z-Plasty (Figure 2.2) Figure 2.2 Z-plasty. The central limb of the Z is
placed along the line of the scar. The limbs are equal
Z-plasty is used as follows to treat vertical in length. The optimal angle between the limbs is 60.
scars. Z-plasty produces a gain in length along the common
limb of the original Z. For 60 angles the gain is 75%.
The lid is placed on traction using a It also produces a 90 change in the orientation of the
common limb of the Z. In the example shown, the Z
mattress stitch over tarsorrhaphy tubing. can be designed to hide a scar in the upper lid skin
The scar is marked along its length. crease.
The upper and lower limbs of the Z are
marked.
A single Z can be converted to multiple Zs.
The skin flaps are raised and reflected on
skin hooks.
(b)
Underlying cicatrix is excised and
haemostasis obtained.
(a)
The flaps are transposed and sutured in
place A-stitches are useful at the apices
of the flaps (Figure 2.3).
The lid is placed on traction.
Pressure dressings are applied for 48 hours.
Skin grafting
This is used to treat combined horizontal
and vertical skin shortage. Figure 2.3 The A-suture for placing the apex of a
V-shaped wound. (a) shows the subcutaneous path
The lid is placed on upward traction. of the suture through the apex of the triangular flap.
(b) shows the tied suture approximating the apex of
A subciliary incision is made and the skin the flap in the V of the wound and subsequent
reflected from the underlying orbicularis everting sutures.
until the lower lid margin can lie in contact
with the upper lid margin in its open position. The graft bed is blotted with paper
This will produce an oversized graft bed to conveniently obtained from the suture
compensate for subsequent contraction. pack.
13
PLASTIC and ORBITAL SURGERY
The paper is trimmed around the blotted area Pressure dressings are applied and left in
to produce a template of the graft required. place for 48 hours.
The template is placed on the donor site
and a marker pen used to draw its outline. Dermis-fat grafting
Suitable donor sites include the pre-
auricular skin, the post-auricular skin and Dermis-fat grafts are useful in supplying
the supraclavicular fossa. subcutaneous bulk to scarred areas in the lower
The donor site is infiltrated with xylocaine/ lid/cheek and in the upper lid sulcus. The fat
adrenaline. cells inhibit further scarring and provide a more
The donor skin is raised using skin hooks natural antifibrotic effect than antimetabolites.
and a number 15 Bard Parker blade and Dermis-fat grafts can be obtained from the
wrapped in sterile saline soaked gauze. periumbilical and groin regions of the
The edges of the donor site may be abdomen or from the buttock. The graft is
undermined to allow closure without marked and xylocaine/adrenaline injected to
undue tension. obtain a peau dorange effect. The epidermis is
The donor skin is everted over the surgeons raised and excised using a blade in a manner
finger and subcutaneous fat trimmed off. similar to raising a split-skin graft, then
Trimming must not be excessive, to avoid discarded. The dermis-fat graft is excised and
damage to the vascular plexus. placed in sterile, saline-soaked gauze while the
Small horizontal incisions can be made to donor site is closed. The dermal element can
allow tissue fluid egress if desired. be sutured into the scarred tissues such that it
The graft is trimmed and sutured in place supports the fat element which comes to lie
with anchoring sutures; these can be left subcutaneously.
long-ended to support external bolsters if
desired. Further reading
The definitive graft sutures are placed; a Canavan M, Archer DB. Long term review of injuries to the
continuous Vicryl rapide or tissue glue can lacrimal apparatus. Trans Ophthalmol Soc UK 1979;
63:54955.
be used in situations where subsequent Collin JRO. Repair of eyelid injuries. In: Manual of systematic
suture removal may be problematic (in eyelid surgery. Edinburgh: Churchill Livingstone, 1989.
Dryden RN, Beyer TL. Repair of canalicular lacerations with
children, for example). silicone intubation. In: Levine MR. Manual of oculoplastic
Additional support can be achieved by surgery. New York: Churchill Livingstone, 1988.
passing double-armed sutures through the Mansour MA, Moore EE, Moore FA, Whitehill TA.
Validating the selective management of penetrating neck
lid and graft and tying these through wounds. Am J Surg 1991; 162:51721.
tarsorrhaphy tubing. Mustarde J. Repair and reconstruction in the orbital region: a
practical guide. Edinburgh: Churchill Livingstone, 1980.
The lid is placed on upward traction. Saunders DH. The effectiveness of the pigtail probe method
External bolsters are fashioned from gauze of repairing canalicular lacerations. Ophthalmic Surg 1978;
9:339.
to match the graft and tied in place with the Welham RAN. The lacrimal apparatus. In: Miller S. Clinical
long-ended anchoring sutures. ophthalmology. London: Wright, 1987.
14
3 Ectropion
Michle Beaconsfield
The term ectropion is derived from the Greek as a cicatricial ectropion, with shortage of
ek (away from) and tropein (to turn) and refers skin, may progress to include stretching of the
to any form of everted lid margin. tarsus and canthal tendons. Only correcting
The eyelid margin position is dependent on the skin shortage may in itself be insufficient:
the tension in the tarsus and the canthal a lid tightening procedure may be required, in
tendons (Figure 3.1), supported by the addition to addressing the skin shortage, to
orbicularis muscle. Spasm of the orbicularis, adequately correct the ectropion. The most
as may occur in new born infants, can cause important factors to establish in corrective
spontaneous eversion of the lids. Ageing surgery are where and how the lid should be
changes affecting the orbicularis muscle and tightened or supported. This forms the basis
the canthal tendons are the cause of of this chapter. The correction of other factors
involutional ectropion. This is aggravated by involved in ectropion repair is covered
the laxity of the lower lid retractors. Tumours, elsewhere, such as skin shortage (Chapter 2)
such as meibomian cysts, may cause and seventh nerve palsy (Chapter 7).
mechanical ectropion. Cicatricial ectropion is Ectropion is classified as:
caused by a shortage of skin. This may be
congenital, as in some patients with Downs Congenital
syndrome, or acquired following trauma; it Acquired
may involve the upper and/or the lower lid. In Involutional
seventh nerve palsy and paralytic ectropion, Mechanical
the support normally provided by the Cicatricial
orbicularis muscle is absent: the lower lid Paralytic
position is therefore dependent on the medial
and lateral canthal tendons which stretch
mechanically with time. Congenital ectropion
Although classifications are helpful, many This may be acute, as a result of spasm of
ectropia are multifactorial. Thus what started the orbicularis muscle as seen in the new-born
infant, or established by skin shortage such as
Medial Lateral
may occur in some cases of children with
Downs syndrome. Orbicularis spasm is
TARSUS managed by gently repositioning the everted
lids with a finger and lubricating the exposed
Figure 3.1 Lower lid margin elements. Tarsus and conjunctiva with antibiotic ointment. Rarely,
canthal tendons. inverting sutures are required (vide infra).
15
PLASTIC and ORBITAL SURGERY
Established congenital ectropion due to laxity, tarsal sagging, lateral canthal tendon
skin shortage may result in corneal exposure laxity, and the less common laxity/loss of
problems. These can usually be managed with attachment of the lower lid retractors to the
lubricants but if this proves insufficient then lower border of the tarsus. Initially the latter
skin grafting may be undertaken (Chapter 2). results in loss of the lower lid skin crease on
Lid tightening procedures may also be downgaze and ultimately leads to total tarsal
required (vide infra). eversion. What determines whether the lax lid
turns in or out is the movement of the preseptal
band of orbicularis muscle. This is still well
Acquired ectropion
tethered in ectropion and does not roll
Looking at the patient can often reveal signs upwards over the lower border of the tarsus, as
which will help to define the ectropion such as in involutional entropion (Chapter 4).
a mass pulling the lid down, or hemifacial
sagging with the inability to close the eye as Central ectropion
seen in seventh nerve palsy. In involutional Patients are often diagnosed with
medial ectropion, the lower punctum may be conjunctivitis/discharge and treated with
seen to evert and override the upper lid topical antibiotics. The symptoms recur the
margin only on blinking. moment these are stopped. This is probably
Palpation further indicates aetiology. because the dryness of the exposed
Pushing the cheek skin up to the lower orbital conjunctiva is temporarily alleviated with the
rim with a finger relieves skin shortage, lubrication of the antibiotics, thereby
thus confirming the suspicion of cicatricial stemming the apparent discharge produced
ectropion. In the absence of skin shortage and to protect the exposure. While waiting for
tumours, and with normal lid closure, the surgery, it is not unreasonable to sparingly
ectropion is likely to be due to lid laxity. lubricate the exposed tarsal conjunctiva with
The next point to establish is where the lid two to three times daily application of simple
is maximally lax (medially/centrally/laterally) eye ointment or equivalent. This will keep
and this is judged by gently pulling on the lid in the surface moist without contaminating the
the various directions to determine the possible corneal surface and fogging the vision.
amount and direction of displacement. It is Central ectropion describes a sag
worth noting if there is excess skin: this can be downwards and/or outwards of the lid
excised at the time of surgery. Finally, if the margin, without associated canthal tendon
conjunctiva has been exposed for any length of laxity.When the lid is pulled away and forward
time it may be inflamed or even chemotic.There from the globe it does not spring or snap back
may be crusting due to drying of secretions and to the globe as crisply as a taut tarsus. This
even keratinisation. It may be necessary to insert laxity is traditionally corrected with a full
temporary inverting sutures to pull the thickness pentagon excision. Bick originally
conjunctiva back down and into the fornix to described a pentagon excision at the lateral
restore its normal anatomical position: this will extremity of the tarsus with reattachment to
contribute greatly to improving its surface and the lateral canthus. The modified Bick
to reducing oedema. procedure of full thickness pentagon excision and
direct closure, just under a quarter of the way in
Involutional ectropion
from the lateral canthus, is now the standard
It is now understood that various factors correction for central ectropion. It is very
contribute to the generalised sagging of the successful in the absence of medial or lateral
lower lid including medial canthal tendon canthal laxity.
16
ECTROPION
The vertical incision through the tarsus lateral triangle from a blepharoplasty flap
should be made about 5 mm from the lateral and the pentagon excision to shorten the
canthal corner, so that the reconstruction does horizontal laxity is done under the flap.
not, even after resection, rub on the corner.
The amount of lid to be resected is Lateral ectropion
determined by overlapping the cut edges until These patients often complain of tear
the margin is taut. The tissue inferior to the overflow laterally. When the lid margin is
tarsus is excised as a triangle, thus completing pulled forwards and medially, the lateral
the pentagon (Figure 3.2a). The meticulous canthal corner seems to follow the pull and
apposition of the tarsal edges, with long acting can be dragged to the extent that the laxity of
absorbable sutures, dictates the appearance the lower limb of the lateral canthal tendon
and strength of the final result (Figure 3.2b). will allow. In an intact lateral canthal tendon,
Accurate marginal closure is secured with grey there is an immediate resistant tug that
line and lash line sutures; after tying, the appears to refuse to let go of the orbital wall.
trailing ends are kept long and secured in the Lateral canthal laxity is often associated with
tying of the first skin suture before trimming. tarsal sag and poor snap-back response: these
This avoids any cut ends, which may be too can be corrected with a lateral tarsal strip.
short, rubbing on the eye (Figure 3.2c). This procedure as described by Anderson is
If there is considerable excess skin, the itself a modification of Tenzels lateral canthal
above procedure can be combined with a sling. The lateral canthal corner is opened
lower lid blepharoplasty (Kuhnt-Symanovsky with a horizontal incision, and the inferior
type procedure): excess skin is excised as a limb of the lateral canthal tendon is exposed
and divided. The medial end of the wound is
lifted upwards and laterally to overlap the
surgical site and determine how much
horizontal shortening is required: this is where
the new medial wound edge and strip will be.
(a)
The strip is fashioned by clearing it of skin
and orbicularis anteriorly, lash margin
superiorly, and conjunctiva posteriorly.
Conjunctiva is usually quite adherent to the
tarsus and may need to be scraped off gently
with something like a D15 blade. The
inevitable venous ooze from this posterior
surface is best controlled by pinching the
(b) tarsal strip in a damp gauze between finger
and thumb for two minutes rather than
jeopardise the integrity of the strip with
aggressive cautery.
The newly fashioned strip is attached with a
(c) non-absorbable suture to the periosteum just
inside the lateral orbital rim at the mid
pupillary level (Figure 3.3), which places it
just under the upper limb of the lateral canthal
Figure 3.2 Modified Bick procedure.
(a) Pentagon excision, (b) Tarsal closure, (c) margin tendon. The mobilised anterior lamella is
and skin closure. lifted up and out, as for a blepharoplasty, and
17
PLASTIC and ORBITAL SURGERY
(a) (b)
(c) (d)
Figure 3.3 Lateral tarsal strip.
Figure 3.4 Lateral extent of punctal position in
the estimated excess resected. Two or three medial canthal laxity.
long-acting, absorbable sutures secure the cut
orbicularis: the long non-absorbable suture is
canthal tendon, can be corrected with a
thereby buried and the skin edges nearly
plication (Figure 3.4b); to the mid pupillary
apposed. Skin closure is standard.
line and needing posterior limb plication
(Figure 3.4c); or past the pupil and beyond
Medial ectropion
with obvious rounding of the previously
Loss of lid margin apposition to the globe pointed corner of the medial canthus: this
and resulting weakness of the physiological indicates loss of the posterior limb of the
pump of blinking can lead to tear overflow. medial canthal tendon which needs
The repeated need to wipe aggravates the lid reattachment to the posterior lacrimal crest
laxity. All patients with ectropion can present area (Figure 3.4d).
with epiphora, but this is more usual in Punctal ectropion without horizontal laxity
those with mainly medial ectropion. The can be corrected by a modified Lester Jones
nasolacrimal outflow system should be tarso-conjunctival diamond excision, taken from
syringed to elucidate any obstruction, as the internal, i.e. conjunctival surface of the
surgical correction of the ectropion alone eyelid. The lid is everted for surgery by gently
will clearly not rid the patient of the symptoms pulling on the 00 lacrimal probe that has been
in the presence of an obstruction; it will placed in the lower canaliculus. The tarsal
need to be combined with whatever lacrimal component is present in the lateral half of the
surgery is appropriate. Stenosis of the diamond (Figure 3.5a). A long-acting,
punctum only is common and secondary absorbable suture is used to close the wound
to drying and keratinisation. This usually by apposing the north and south corners of
resolves spontaneously over several weeks with the diamond. Before burying the knot, the
reapposition to the globe. lower lid retractors should be included in the
Punctal eversion can be difficult to assess if suture (Figure 3.5b). This will prevent
mild, but is obvious on blinking. This may be the punctum from pouting outwards on
observed as a single entity and repaired with a downgaze. The retractors are found by going
tarso-conjunctival diamond excision, or it may into the diamond with a fine pair of toothed
be associated with tarso-ligamentous laxity. forceps and grabbing the surface lying
The degree of medial canthal tendon laxity is anterior to the conjunctiva inferior to the
estimated by gently pulling the lid laterally lower border of the tarsus. The correct layer
and watching how far the punctum can be has been picked up if, on asking the patient to
dragged (Figure 3.4): not quite up to the look down without moving the head, a tug is
medial limbus of the cornea is best repaired felt through the forceps.
with a Lazy-T procedure (Figure 3.4a); past If punctual ectropion is accompanied
the limbus but not up to the pupil, indicating by tarsal laxity but the medial canthus is
laxity of the anterior limb of the medial essentially intact, which is often the case, a
18
ECTROPION
posterior surface of the medial end of the lax. The inflammation and oedema of the
tarsus, close to its superior border (Figure 3.8). exposed conjunctiva is often sufficient to
The knot is buried and the conjunctiva closed. maintain the lid in an everted position. This
Medial canthal resection is more appropriate can occur unusually as an isolated incident,
if the punctum can be pulled laterally beyond
the pupil. Here the horizontal shortening is
medial as well as lateral to the punctum. A
vertical incision is made perpendicular to the
lid margin, just lateral to the caruncle. This of
course necessitates cutting through the
inferior canaliculus (Figure 3.9a). An 00
(a)
Stitch
Canaliculus
Lacrimal sac
Figure 3.8 Medial canthal tendon plication Stitch Medial orbital wall
posterior limb.
(b)
lacrimal probe is maintained in the cut medial
end of the canaliculus. As before, the tip of
this probe can help in identifying the position
Figure 3.9 Medial canthal resection. (a) canaliculus
of the posterior lacrimal crest. It is the cut, lid to be resected. (b) marsupialisation and
periosteum just superior and posterior to this reattachment of resected canaliculus.
that is exposed with blunt dissection. The
globe is kept safely lateral to the surgical site
with small malleable retractors. where the possibility of a mechanical/
The degree of slack that can be taken up cicatricial element has to be excluded. More
is measured by overlap until the lid margin is usually, it presents as a long term result of
taut, as previously described. This portion is untreated progressive ectropia. In these cases,
resected. A non-absorbable suture is placed as surgical repair would therefore also need to
for posterior limb plication; however, before include correction of whatever horizontal
tying this, the cut medial end of the laxity was present.
canaliculus is secured by marsupialisation and Correction of the lower lid retractor laxity is
suturing to the top 1mm of the postero-medial achieved by reattachment of the retractors to the
corner of the newly shortened tarsus, with fine inferior border of the tarsus. A horizontal
long-acting, absorbable sutures (Figure 3.9b). incision is made along the inferior tarsal
The skin closure is standard. border and the lower lid retractors identified.
These can be resutured to the tarsal border as
part of the conjunctival closure.
Total tarsal eversion
Inverting sutures raise the anterior lamella
In this case the attachment of the lower lid relative to the posterior lamella and are
retractors to the lower border of the tarsus is very useful when the chronically exposed
20
ECTROPION
conjunctiva is in the way of proper apposition horizontal laxity, this should be surgically
of the lid to the globe, once the ectropion corrected at the same time.
repair has been otherwise correctly
completed. The redundant oedematous Cicatricial ectropion
conjunctiva can be stretched inferiorly and
A variety of conditions, congenital and
kept in that position by long acting absorbable
acquired, result in skin shortage which pulls
sutures pulled through from the anterior
the lid margin away from the globe. Both lids
surface of the fornix to the skin. The track of
may be affected, and the skin shortage causing
the sutures should run inferiorly and
the failure of normal lid closure may be
anteriorly so they exit at the skin surface at the
localised or diffuse.
level of the inferior orbital rim (Figure 3.10).
The assessment and management of
Here the sutures are tied over small bolsters,
cicatricial ectropion is covered in Chapter 2.
and can be removed after l4 days if they have
However it is worth emphasising that skin
not already fallen out.
shortage can be present with lid margin laxity.
It is not usually necessary to excise the
When the skin shortage is surgically repaired,
redundant conjunctiva. However, if its bulk is
the horizontal laxity needs to be corrected as
such as to prevent correct apposition of the
well to prevent recurrence of the lid malposition.
eyelid to the globe at the end of appropriately
carried out surgery, even with the help of
Paralytic ectropion
inverting sutures, then some of the
conjunctiva can be sacrificed. The failure of lid closure in this situation is
Inverting sutures may also be used as a due to seventh nerve palsy. Correction
temporary measure to control an ectropion, requires both support and lid tightening
while waiting for definitive surgery. procedures. The ectropion may have been
present long enough to be associated with skin
Mechanical ectropion shrinkage. All these aspects of facial palsy are
covered in Chapter 7.
If a growth or a cyst is responsible for
pulling the lid margin down, it should be
excised as vertically as possible.This will avoid Complications
a cicatricial ectropion. If the lesion has caused
Wound dehiscence and infection are unusual
with careful surgery and aseptic techniques,
but still occur with the latter commonly being
the cause of the former. Wound dehiscence in
the absence of infection is more likely to be
iatrogenic and due to poor apposition of
edges, lack of attention to anatomical layers,
and sloppy knot tying.
Bruising is an expected side effect of surgery
particularly in elderly patients, who form the
great majority of those undergoing ectropion
surgery. Nevertheless they should be warned
of this. Unless of vital medical importance,
chronic daily use of aspirin should be stopped
a minimum of 10 days prior to surgery to
Figure 3.10 Inverting sutures. allow platelet aggregation some recovery.
21
PLASTIC and ORBITAL SURGERY
Patients on anticoagulants, such as warfarin, clean finger very slightly greased with
should avoid lid surgery if the International antibiotic ointment, several times a day until
Normalised Ratio (INR) cannot be brought the lid resumes a normal position. If this has
down to between 2 and 22. not been achieved over 8 to 12 weeks, the
Haemorrhage tracking into the orbital cavity, lower lid retractors will need to be released
to the extent of raising intraorbital pressure and reattached to the tarsus, but on hang back
and potentially causing blindness secondary sutures. If the ectropion is as a result of too
to optic nerve compression, is rare but a well aggressive a removal of skin resulting in
recognised complication of lateral canthal shortage, this will need to be replaced with a
tendon surgery in particular. It is best avoided graft.
by ensuring that the surgical site is absolutely Consecutive entropion following ectropion
dry prior to closure. If the patient exhibits the surgery is unusual. Some internal marginal
above symptoms, the lateral canthal corner is rotation, rather than frank entropion, may be
reopened as a matter of emergency to allow noted during surgery: this is not uncommon
the sequestrated blood out, thereby relieving particularly in the reattachment of canthal
the pressure. tendons to periosteum. This rotation is caused
Ectropion repair hopefully results in long by the needle entries in the periosteum not
term success. However it is known that being mirrored by the direction of entry in the
recurrent ectropion occurs in some 10% of new tarsal edge. This is corrected by resiting
patients in the three years following surgery. of the suture at the time of surgery, rather
More often than not this is due to an than hoping it will settle down into the
underestimation of the horizontal shortening right position. Entropion as a long term
required: the repaired lid should be sufficiently complication of ectropion repair is often
taut at the end of surgery to just allow the associated with orbicularis override, and is
closed tips of a small blunt instrument, such treated accordingly.
as a Barraquer needle holder, under the lid An aggressive resection of the conjunctiva
margin. when repairing the laxity of the capsulo-
Recurrent ectropia should be assessed as if palpebral attachment of the lower lid
new and the anatomical cause addressed. A retractors will shorten the posterior lamella
pentagon excision will usually correct any and result in the equivalent of a cicatricial
laxity. If the remnant laxity is in the canthal entropion.This is best corrected with a mucous
tendons, either because they were not membrane graft to restore fornix depth. If the
accurately assessed preoperatively or because lid is still lax and there is excess lid skin, some
they became lax subsequently over time, then may advocate the easier to perform lateral
canthal tendon surgery is more appropriate canthal strip procedure and blepharoplasty;
than a pentagon excision. however this alone does not address the loss of
Ectropion consecutive to entropion surgery is fornix depth.
usually as a result of either undercorrection of Plication of the anterior limb of the medial
lid laxity (corrected as indicated above) or due canthal tendon can result in antero-
to overzealous reattachment or plication of the displacement of the canthal corner if the medial
retractors. If tarsal eversion is obvious at the canthal stitch is not placed superiorly and
time of surgery or immediately afterwards, it is posteriorly to the stitch in the tarsus. This
advisable to relax/replace the sutures attaching is best corrected at the time of surgery, but
the retractors to the tarsus. If the ectropion can be performed at a later date if the
becomes evident later, such as a week post anteroposition has not been noticed at the
operatively, the lid should be massaged with a time of the original operation.
22
ECTROPION
Involutional ectropion is not a pathological Bick MW. Surgical management of orbital tarsal disparity.
Arch Ophthalmol 1966;75:3869.
entity but a result of becoming less young. Danks JJ, Rose GE. Involutional lower lid entropion: to
Therefore it is not possible to promise a patient shorten or not to shorten? Ophthalmology 1998;105:
20657.
that surgery will guarantee a permanent cure: Jones LT. An anatomical approach to problems of the
as long as the ageing process continues so will eyelids and lacrimal apparatus. Arch Ophthalmol 1961;
tissue degeneration. Nevertheless, an accurate 66:13750.
McCord CD. Canalicular resection with canaliculostomy.
preoperative assessment of the various factors Ophthalmic Surg 1980;11:4405.
contributing to the lid malposition, together Smith BC. Lazy T operation for the correction of ectropion.
Arch Ophthalmol 1976;90:114950.
with an appropriate combination of procedures Tenzel RR, Buffam FV, Miller GR. The use of the lateral
as outlined above, are likely to result in success. canthal sling in ectropion repair. Can J Ophthalmol 1977;
12:199202.
Tse DT, Kronish JW, Buus D. Surgical correction of lower
Further reading eyelid ectropion by reinsertion of retractors. Arch
Ophthalmol 1991;109:42731.
Anderson RL, Gordy DD. The tarsal strip procedure. Arch
Ophthalmol 1979;97:21926.
23
4 Entropion
Ewan G Kemp
Yes No
No Yes Yes No
Rotation of
Lashes abrading Posterior
terminal tarsus Tarsal excision
cornea? lamella graft
No Yes
Figure 4.4 System for upper lid entropion. From: A Manual of Systematic Eyelid Surgery (2nd Edition),
Churchill Livingstone, 1989.
Conjunctival scarring?
No Yes
No Yes
Sutures
Transverse lid Transverse lid Tarsal fracture Post-lamellar graft
split + split, everting
everting sutures +
sutures horizontal
shortening
Recurrence Recurrence
Horiz. lid Plication lower
shortening lid retractors
Figure 4.5 System for acquired lower lid entropion. From: A Manual of Systematic Eyelid Surgery (2nd Edition),
Churchill Livingstone, 1989.
26
ENTROPION
Everting sutures
Spastic entropion
For the most benign form of entropion
Spastic entropion occurs as a primary event where there is incompetence of the lid
in essential blepharospasm. It is a term that is retractors, all that is required are everting
often incorrectly used to describe the sutures. These can be 4/0 catgut double-
overriding of the tarsal plate by preseptal armed sutures. It is possible to gain a similar
27
PLASTIC and ORBITAL SURGERY
Wies procedure
A transverse skin incision is made below the
level of the proximal margin of the tarsal plate
and carried through into the fornix. The lid
retractors are then identified and directly
sutured from the lower fornix up the front of
Figure 4.6 Everting sutures for lower lid entropion.
the tarsal plate and tied across the skin 2mm
below the lash margin. This creates a fibrous
barrier to any inappropriate action of anterior
effect using 6/0 gauge sutures. Three sutures
lamella across the posterior, thus stopping
per lid are average (Figure 4.6). Care must be
inversion of the lid margin. The traction
taken that the most medial suture is not over
sutures through to the skin keep the lid
tightened as this may well cause punctal
everted. The skin wound can be approximated
ectropion, creating epiphora where none
with three or four 6/0 silk or nylon sutures.
existed before. Excessive secondary ectropion
causing excessive exposure of the conjunctiva
allows secondary keratinisation of the Quickerts procedure
epithelium. Quickerts procedure is a more complicated
The ideal position post operatively is a lid surgical undertaking. The Wies operation is
margin which approximates the cornea. The combined with horizontal lid shortening. A
sutures should create a deep crease on Wies type transverse blepharotomy incision is
downgaze indicating that the lid retractors made. A section of full thickness lid is excised
have been re-attached to the anterior lamella. and the free edges approximated while the
Everting sutures, although used alone, can lower lid retractors are brought through to the
also be part of more elaborate procedures. If skin in a similar fashion to the Wies
they are used alone the effect can only be procedure. Any relative excess of skin and
guaranteed for about eighteen months to two orbicularis muscle below the transverse skin
years. Should the lid display not only wound can be excised.
incompetence of lid retractors but laxity at
canthal ligaments or even distortion of the
Jones procedure
tarsal plate, then further surgery is required
concentrating on these main areas. Distortion The lower lid retractors are plicated. A
of the tarsal plate will require either direct transverse lid incision is made through skin
shortening or dissection of excessive fibrosis. and orbicularis to expose the lower lid
Laxity of the canthal ligaments requires some retractors. This layer is dissected and
form of support or excision and shortening of shortened with sutures which connect it to
the tissue, particularly at the junction between the proximal margin of the tarsal plate. As
canthal ligament and tarsal plate. Care must the wound is resutured the deep layers are
be taken not to excessively shorten the lid or connected through to the skin. This is only
canthal ligaments, as this will prevent the lid going to be a success when there is little or no
from rising to its normal level and may well horizontal lid laxity; additional lid shortening
create a degree of overexposure of the inferior is necessary if this feature is present.
28
ENTROPION
Trichiasis
Trichiasis is the term used for distorted
eyelashes. They may arise from a normal
position i.e. from lash roots that are just
anterior to the tarsal plate (aberrant eyelashes)
Figure 4.8 Hard palate harvest for posterior lamella
or from an abnormal position (dysplastic
graft. eyelashes). Blepharitis and chronic external
eye disease are the commonest causes of
rotated away from the globe. Any keratinised aberrant eyelashes, but anything which leads
epithelium in contact with the cornea should to scarring of the lid margin can be
be excised. responsible e.g. trauma. Dysplastic lashes are
Ear cartilage (Figure 4.9) is not good as a caused by chronic ongoing external eye
posterior lamella graft in the upper lid as it disease conditions such as pemphigoid which
causes corneal irritation if it is not covered by may lead to eyelashes arising from the
conjunctiva or mucosa. Its main use in upper posterior lid margin.
30
ENTROPION
If the lid margin position is abnormal, this cryotherapy. The lid can then be reconstituted
must first be corrected as described in this with sutures leaving the posterior lamella a
chapter. If the eyelashes themselves are little proud to allow for any shrinkage after the
abnormal they must be destroyed. Various freezing.
methods have been described including An alternative treatment for distichiasis is to
electrolysis, cryotherapy, laser etc. evert the lid and cut the tarsus following the
course of each involved eyelash to its root.
Electrolysis This can then be treated under direct vision
with cautery or electrolysis. The disadvantage
This is the treatment of choice for one, two
of this is the time that it takes, but it can be a
or very few aberrant eyelashes. The
very effective treatment.
disadvantage is the difficulty of inserting
the needle accurately down the hair follicle
Further reading
to the root. If it comes out of the follicle it
Collin JRO. Congenital entropion. In: A Manual of
causes collateral damage which in its turn Systematic Eyelid Surgery (2nd ed). London: Churchill
creates more scarring and further trichiasis. Livingstone, 1989: 14.
El-Mulki S, Lawson J,Taylor D. A new and simple procedure
for correction of congenital tarsal kink. J Pediatr
Cryotherapy Ophthalmol Strabismus 1991; 35:1723.
Jones LT, Reeh MJ, Wobig JL. Senile entropion a new
This is the standard treatment for more concept for correction. Am J Ophthalmol 1972; 74:327.
Kemp EG, Collin JRO. Surgical management of upper lid
than a very few lashes. The lash follicles are entropion. B J Ophthalmol 1986; 20:5759.
sensitive to cold and are destroyed by a Liu D. Lower eyelid tightening: A comparative study. Ophthal
Plas Reconstr Surg 1997; 13:199203.
temperature of 20C. The destructive effect Mustarde J. Reconstruction of the upper lid. In: Repair and
is more marked if a double freeze-thaw cycle Construction of the Orbital Region (3rd ed). Edinburgh:
is applied. The disadvantage is that all the Churchill Livingstone, 1991: 191.
Quickert MH, Rathburn JE. Suture repair of entropion. Arch
lashes exposed to cryotherapy are destroyed Ophthalmol 1971; 85:304.
and it can cause depigmentation as Shorlin JP, Lemke BN. Clinical eyelid anatomy. In: Bosniak
S, ed. Principles and Practices of Ophthalmic Plastic and
melanocyte, are sensitive to 10C.This means Reconstructive Surgery. Vol 1. (1st Edition). London: W B
they are destroyed before the temperature is Saunders Company, 1996: 261.
Steel EHW, Hoh HB, Harrad R, Collins CR. Botulinum
cold enough to destroy the lash roots. toxin for the temporary treatment of involutional lower lid
entropion: A clinical and morphological study. Eye 1997;
11:4725.
Trabut G. Entropion trichiasis en afrique du nord. Arch
Distichiasis dOphthalmologie 1949; 9:701.
Tyers AG, Collin JRO. Involutional entropion In: Colour
This is the condition in which a second row Atlas of Ophthalmic Plastic Surgery (1st Edition). Oxford:
Butterworth Heinemann, 1995: 69.
of eyelashes grow out of the Meibomian gland Yang LLH, Lambert S, Chapman J, Stulting RD. Congenital
orifices. It can be treated by electrolysis, but entropion and congenital cornea ulcer. Am J Ophthalmol
1996; 121:32931.
there is a high failure or recurrence rate. If the Yaqub A, Leatherbarrow B. The use of autogenous auricular
lid is split into two lamellae with an extended cartilage in the management of upper eyelid entropion.
Eye 1997; 1:8015.
grey line split (vide supra), the terminal Wies F. Spastic entropion. Trans Am Acad Ophthalmol
posterior lamella can be treated with Otolaryngol 1955; 59:503.
31
5 Ptosis
Ruth Manners
History
The history should include the following
information: age of onset, family history, past (a)
ocular history (including previous intraocular 9 PA 9
or lid surgery), predisposing factors such as
contact lens wear or trauma, episodes of
lid swelling, whether the ptosis worsens
throughout the day, the presence of any
aberrant lid movements, whether eye (b)
9 PA 9
movements are impaired and if there is
diplopia.The past medical history and current
medications are also important when planning
surgery.
(c)
Palpebral aperture (PA) 4 MRD 4
5 5
With the eyes in primary position the widest
distance between the upper and lower lid Figure 5.1 Palpebral aperture measurement.
margins is measured in millimetres with a (a) Vertical measurement.
(b) Same vertical measurement with left ptosis
transparent ruler held directly in front of the lids compensated by left lower lid retraction.
(Fig. 5.1a). It is important to ensure there is no (c) Margin reflex distance measurement.
32
PTOSIS
iris pigmentation on the affected side if which the lower branches of the nerve can
Horners syndrome occurs congenitally or at a grow to re-innervate orbicularis oculi
very young age, and anhydrosis if the lesion is resulting in ptosis with movement (or even
below the superior cervical ganglion. resting tone) of the muscles of facial
expression of the lower face. The ptosis which
Diagnostic tests include: develops following a facial palsy; when the
Cocaine (4%) test. One drop is placed in each patient moves the lower facial muscles, for
eye. Over 30 minutes this prevents reuptake of example, blows out the cheeks or simulates
noradrenaline at the neuromuscular synapse chewing, the upper lid droops. Abolition of
causing pupil dilation on the normal side but the ptosis requires division of the levator
not on the affected side. muscle and brow suspension or levator
Hydroxyamphetamine (1%) test (presently transposition. The aberrant activity in the
unavailable). One drop in each eye facial nerves may be reduced with cautious
stimulates the release of noradrenaline botulinum toxin injections to the orbicularis
from the postganglionic nerve ending and muscle.
causes pupil dilatation in both eyes if the
lesion is preganglionic but only on the
normal side if the lesion is postganglionic. Mechanical
Ptosis can occur due to excessive lid mass or
The Fasanella-Servat procedure will treat bulk or to a scarring process in the lid.
the small degree of ptosis.
It may result from:
Marcus Gunn jaw-winking ptosis Lesions in the upper lid such as Meibomian
Marcus Gunn jaw-winking ptosis is a cyst, haemangioma, plexiform neuroma of
developmental abnormality where the levator neurofibromatosis or malignant tumours
muscle co-contracts with stimulation of the for example, basal cell, squamous cell and
trigeminal nerve supply to lateral pterygoid, Meibomian gland carcinomas.
medial pterygoid or both. Autosomal Cicatrising conditions in the lid such as
dominantly inherited or sporadic. conjunctival scarring.
There is ptosis of varying severity with Trauma which can cause scarring in the lid
related degree of levator function often which may act as a mass or as a splint
associated with superior rectus underaction. causing mechanical ptosis.
Movement of the jaw causes elevation of the Treatment is directed to the primary cause
upper lid i.e. the wink. such as removal of a lid lump or scar mass or
Abolition of the wink requires division of grafting to relieve cicatrised tissue.
the levator muscle and subsequent brow
suspension (unilateral, bilateral or levator Pseudoptosis
transposition). Treatment of the ptosis alone
should err towards undercorrection if there is It is vitally important to exclude pseudoptosis
a risk of post operatively accentuating the on examination of the patient and the following
wink by exposing more sclera. causes should be borne in mind:
Levator resection
(b)
Indications
Myogenic or neurogenic ptosis with
moderate or good levator function i.e. 5mm
or more, when the levator can be shortened to
lift the lid. Levator resection will not be
effective when levator function is poor i.e.
4mm or less.
Figure 5.4 Anterior approach levator resection. The
Procedure (Figure 5.4) levator muscle is resected after excising the
aponeurosis and Mllers muscle (a), and reopposed
The approach can be anteriorly through the to tarsus (b).
intended skin crease position or posteriorly
through the conjunctiva. The amount of
Aponeurosis surgery
levator resected is based on both the degree of
ptosis and the levator function. The levator is Indications
identified and freed from underlying tissues
Good levator function and evidence of
and shortened by between 12 to 30mm. In
aponeurotic ptosis. The choice of approach
larger resections the lateral and medial horns
and initial surgery are as for levator resections.
of the muscle are divided to allow the muscle
to be advanced sufficiently. The resected
Procedure (Figure 5.5)
muscle is then reattached with about three
sutures to the anterior, superior surface of the An anterior approach has the advantage
tarsus. The skin crease is reformed by that excess skin can be excised where patients
incorporating a bite of the lower edge of the have co-existing dermatochalasis. Sometimes
levator muscle in the skin wound. a true disinsertion of the levator aponeurosis
is identified and the lower edge of the
Internal Whitnall sling Where there is aponeurosis can then be reinserted onto
marked ptosis and levator function is not good the tarsal plate. In aponeurosis stretching,
(5mm or less) the levator can be slung over the aponeurosis is advanced sufficiently to
Whitnalls ligament which acts as an internal eradicate the ptosis. Since the vast majority of
suspension for the lid. This gives very little lid aponeurotic ptosis occurs in adults, this
movement post operatively. surgery should be performed under local
39
PLASTIC and ORBITAL SURGERY
(a)
Fasanella-Servat procedure
(tarsomllerectomy)
Indications
Small ptosis of 2mm or less with good
levator function, for example Horners
syndrome.
(a)
Procedure (Figures 5.9 and 5.10)
The lid is everted and the upper border of
the tarsus, together with the lower end of
Mllers muscle and the conjunctiva, are held
between clamps, excised and the free ends
resutured. The main effect is thought to
depend on the amount of tarsus excised. It is
important to place the clamps correctly
(Figure 5.10a) so that an equal amount of
tissue is excised along the eyelid, and to avoid (b)
excess removal centrally by incorrect
Figure 5.10 Fasanella-Servat procedure. Position of
placement of the clamps (Figure 5.10b), clamps, (a) correct; (b) incorrect.
which would result in a peaked lid. Some
surgeons prefer to preserve the tarsus and
suggest excising only Mllers muscle and Undercorrection redo the procedure if the
conjunctiva to correct the ptosis. indications for surgery are correct i.e. minimal
ptosis and good levator function.
Complications
Short tarsus generally results from over
Peaked lid avoid by correct positioning of zealous surgery for ptosis too severe to correct
clamps on everted lid. with a tarsomllerectomy.
42
PTOSIS
Corneal abrasion insert a protective soft Dortzbach RK, Sutula FC. Involutional blepharoptosis
a histopathological study. Arch Ophthalmol 1980;
contact lens for a few weeks post operatively. 98:10459.
Dryden RM, Fleming JC, Quickert MH. Levator
transposition and frontalis sling procedure in severe
Ptosis props unilateral ptosis and the paradoxically innervated levator.
Arch Ophthalmol 1982; 100:4624.
Very occasionally ptosis props fixed to Fasanella RM, Servat J. Levator resection for minimal ptosis,
spectacles are indicated for patients with another simplified procedure. Arch Ophthalmol 1961;
65:4936.
severe ptosis with both poor levator function Fox SA. Congenital ptosis II. Frontalis sling. J Pediatr
and poor frontalis action. In general, patients Ophthalmol 1966; 3:258.
Frueh BR. The mechanistic classification of ptosis.
will not tolerate ptosis props unless their Ophthalmology 1980; 87:101921.
orbicularis action is weak. Jones LT, Quickert MH, Wobig JL. The cure of ptosis by
aponeurotic repair. Arch Ophthalmol 1975; 93:62934.
LeMagne J-M. Transposition of the levator muscle and its
Further reading reinnervation. Eye 1988; 2:18992.
Liu D. Ptosis repair by single suture aponeurosis tuck.
Anderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch
Surgical technique and long-term results. Ophthalmology
Ophthalmol 1979; 97:11238.
1993; 100:2519.
Beard C. Complications of ptosis surgery. Ann Ophthalmol
McCord CD. Eyelid surgery: Principles and techniques.
1972; 4:6715.
Philadelphia: Lippincott-Raven, 1995.
Berke RN, Wadsworth JAC. Histology of levator muscle in
Neuhaus RW. Eyelid suspension with a transposed levator
congenital and acquired ptosis. Arch Ophthalmol 1955;
palpebrae superioris muscle. Am J Ophthalmol 1985;
53:41328.
100:30811.
Collin JRO. A manual of systematic eyelid surgery (2nd
Putterman AM, Urist MJ. Mller muscle conjunctival
Edition). London: Churchill Livingstone, 1989.
resection. Arch Ophthalmol 1975; 93:619.
Collin JRO, Beard C, Wood I. Experimental clinical data on
Sutula FC. Histological changes in congenital and acquired
the insertion of the levator palpebrae superioris muscle.
blepharoptosis. Eye 1988; 2:17984.
Am J Ophthalmol 1978; 85:792801.
Wilson ME, Johnson RW. Congenital Ptosis. Long-term
Collin JRO, ODonnell BA. Adjustable sutures in eyelid
results of treatment using lyophilised fascia lata for
surgery for ptosis and lid retraction. Br J Ophthal 1994;
frontalis suspensions. Ophthalmology 1991; 98:12347.
78:16774.
Crawford JS. Repair of ptosis using frontalis and fascia lata.
A 20 year review. Ophthalmic Surg 1977; 8:3140.
43
6 Tumour management and repair after
tumour excision
Brian Leatherbarrow
Eyelid tumours can be benign or malignant. It Slit lamp examination can highlight these
is not always easy clinically to differentiate various features that help to differentiate
between them. The consequence of failure to benign from malignant tumours (Figure 6.1).
identify a malignant tumour in its early stages
can be severe.
Malignant tumours
The appropriate management of malignant
eyelid tumours requires an understanding of
their clinical and pathologic characteristics.
Malignant tumours affecting the eyelids are
generally slowly enlarging, destructive lesions
that distort or frankly destroy eyelid anatomy.
Subtle features can help to differentiate
malignant from benign eyelid tumours (Box Figure 6.1 Eyelid BCC showing the malignant
6.1). Early diagnosis can significantly reduce features of loss of lashes, obliteration of eyelid margin
morbidity and indeed mortality associated and pearly telangiectatic change.
with malignant eyelid tumours. However,
malignant eyelid tumours are diagnosed early
only if a high degree of clinical suspicion is Box 6.2 Malignant eyelid tumours
applied to all eyelid lesions.
Epithelial
Basal cell carcinoma
Box 6.1 Clinical signs suggestive of Squamous cell carcinoma
malignancy Sebaceous gland carcinoma
Non-epithelial
A localised loss of lashes Lymphoma mycosis fungoides
Obliteration of the eyelid margin Merkel cell tumour
Pearly telangiectatic change Kaposi sarcoma
A new enlarging pigmented lesion Metastatic tumours
An area of diffuse induration Malignant sweat gland tumours
A scirrhous retracted area Melanoma
44
TUMOUR MANAGEMENT and REPAIR AFTER TUMOUR EXCISION
Benign tumours
Box 6.3 Benign eyelid tumours
Most benign eyelid tumours can be readily
diagnosed on the basis of their typical clinical A Benign lesions of the epidermis
appearance and behaviour. A number of lesions, Achrocordon (skin tag)
however, cannot be easily and reliably Seborrheic keratosis
differentiated from malignant eyelid lesion and Keratoacanthoma
require a biopsy for example, a keratoacanthoma. Inverted follicular keratosis
For small lesions an excisional biopsy serves two Cutaneous horn
functions: diagnosis and treatment. For larger
lesions an incisional biopsy is undertaken for B Benign lesions of the dermis
diagnostic purposes. Conversely, some malignant Dermatofibroma
lesions may appear relatively innocuous. Neurofibroma
It is important that biopsies are performed Capillary hemangioma
meticulously or errors in diagnosis will occur. Pyogenic granuloma
The tissue must be handled very carefully in Xanthelasma
order not to induce crush artefact. The tissue Xanthoma
sample should be of adequate size and depth Juvenile xanthogranuloma
and ideally should include adjacent normal
eyelid tissue. This is of particular importance C Benign lesions of the adnexa
with regard to biopsies of suspect Tumours of sweat gland origin
keratoacanthoma. If a sebaceous gland Syringoma
carcinoma is suspected it is important to alert Eccrine spiradenoma
the pathologist of this suspicion so that
appropriate stains are utilised. Some biopsy Tumours of hair follicle origin
material may need to be presented on filter Trichofolliculoma
paper because of the very small size of the Pilomatrixoma
samples for example, random conjunctival sac
biopsies in cases of suspected diffuse Tumours of sebaceous gland origin
sebaceous gland carcinoma. It is important to Sebaceous gland hyperplasia
orientate tissue for the pathologist where Sebaceous adenoma
biopsies are attempted excisional biopsies, in
case one or more edges are not clear of tumour D Benign pigmentary lesions
involvement. Sutures of various lengths can be Nevocellular nevi
employed as markers for this purpose. A Junction nevus
tumour excision map should be enclosed with Compound nevus
the pathology form to assist the pathologist. Intradermal nevus
Benign tumours of the eyelids may be derived Congenital nevus
from the epidermis, dermis, adnexa (sweat Blue nevus
glands, hair follicles, sebaceous glands), or Lentigo simplex
pigment cells. There are a large number of such Lentigo senilis
tumours. A few examples are shown in Box 6.3.
are cumulative, as reflected in the increasing non-tender, raised, pearly, telangiectatic, well
incidence of the tumour with advancing age. circumscribed lesion with an elevated
BCC may, however, occur in younger patients, surround and depressed crater-like centre
particularly those with a tumour diathesis (Figure 6.3).
such as the basal cell carcinoma syndrome.
In descending order of frequency, BCCs Clinical varieties of BCCs
involve the following locations (Figure 6.2):
Nodular
Lower eyelid Ulcerative
Medial canthus Cystic
Lateral canthus Morphoeiform
Upper eyelid. Pigmented.
(a) (c)
(b) (d)
Figure 6.2 Incidence of eyelid BCC (a) most common to (d) least common.
46
TUMOUR MANAGEMENT and REPAIR AFTER TUMOUR EXCISION
(a)
(b) (c)
(d) (e)
Figure 6.4 Complex BCCs, (a) morphoeic (b) fixed to bone (c) medial canthal (d) orbital invasion (e) recurrent
after irradiation.
47
PLASTIC and ORBITAL SURGERY
regional nodes but direct perineural invasion eyelids has a tendency to produce widespread
into the CNS is usually the cause of death in metastes whereas such tumours occurring
this group of patients.The tumour occurs with elsewhere on the skin rarely metastasize. SGC
increasing frequency with advancing age. occurs with increasing frequency with
Radiation therapy is a significant aetiologic advancing age. The tumour has a predilection
factor in the production of squamous cell for the upper eyelid, but diffuse upper and
carcinoma. lower eyelid involvement may occur in patients
There is no pathognomonic presentation. presenting with chronic blepharoconjunctivitis.
These tumours tend to appear as thick, This tumour is well recognised for its
erythematous, elevated lesions with indurated ability to masquerade as chronic blepharo-
borders and with a scaly surface (Figure 6.5). conjunctivitis or recurrent chalazion
Cutaneous horn formation or extensive (masquerade syndrome). Recurrent chalazion
keratinisation are the most consistent features. or atypical solid chalazions should alert the
When it occurs at the eyelid margin the lashes ophthalmologist to the possibility of underlying
are destroyed. Squamous cell carcinomas may sebaceous gland carcinoma (Figure 6.6).
be derived from actinic keratoses. With Histopathologic features of sebaceous gland
chronicity and cicatricial changes of the skin, carcinoma are characteristic and may be
secondary ectropion may occur. The clinical confirmed by lipid stains (oil red O) on fresh
features of the tumour are an exaggeration of tissue specimens. Multicentric origin is a feature
those found with actinic keratosis. of some SGCs. Clinical presentation of chronic
Benign tumours such as keratoacanthoma,
inverted follicular keratosis, and pseudo
epitheliomatous hyperplasia simulate features
of squamous cell carcinoma. The common
variable with these tumours is inflammation
that stimulates epithelial proliferation.
Clinically, rapid growth is characteristic of
these benign lesions.
(b)
Figure 6.6 Sebaceous gland carcinoma: (a) external
Figure 6.5 Squamous cell carcinoma. appearance, (b) following lid eversion.
48
TUMOUR MANAGEMENT and REPAIR AFTER TUMOUR EXCISION
Note: Classification:
Kaposis sarcoma
This tumour was first described in 1872.
Prior to 1981 most cases occurred in elderly
Italian/Jewish men or African children. It very
rarely involved periocular structures prior to
AIDS but is now a relatively common
manifestation of AIDS.
Clinical features
Lesions tend to be violaceous in colour
Figure 6.7 Nodular malignant melanoma. (Figure 6.8).The conjunctiva may be diffusely
involved and simulate inflammation.
Superficial spreading melanoma appears
typically as a brown lesion with shades of red,
white and blue it is initially flat but becomes
nodular with increase in vertical growth.
Nodular melanoma appears as a nodule or
plaque, is dark brown or black in colour but
can be amelanotic. It shows little radial growth,
but extensive vertical growth (Figure 6.7).
Surgery Surgery.
Irradiation.
The extent of tumour free margins does not
It is important to routinely examine for correlate with survival. It is therefore
evidence of pagetoid spread/multicentric appropriate to take relatively small tissue
origin by performing random conjunctival sac margins to preserve eyelid function wherever
biopsies. It is appropriate to biopsy any areas possible. If the tumour has extended to Clark
of telangiectasia, papillary change or mass. level IV or V or its thickness exceeds 15mm a
52
TUMOUR MANAGEMENT and REPAIR AFTER TUMOUR EXCISION
referral for lymph node dissection should be Although radiation therapy is not
considered. recommended as the treatment of choice for
Radiotherapy is rarely used in the periocular cutaneous malignancies, there are
management of eyelid melanoma. Doses occasionally patients who, for various reasons,
sufficient to destroy the tumour will destroy cannot undergo surgical excision and
the eye/ocular adnexae. reconstruction and for whom radiation may
be useful. However, it is important to continue
Metastatic eyelid tumours to look closely for evidence of recurrence well
The management of metastatic eyelid beyond the five-year post operative period
tumours is the realm of the oncologist and routinely utilised for surgically managed
usually involves chemotherapy and/or cutaneous malignancies.
radiation therapy. Surgical excision can be It is now generally accepted that basal cell
considered if the tumour is localised and carcinomas recurring after radiation therapy
unresponsive to other modalities. are more difficult to diagnose, present at a
more advanced stage, cause more extensive
Lymphoma destruction, and are much more difficult to
eradicate. The greater extent of destruction
The management of eyelid lymphoma is may be explained by the presence of adjacent
also the realm of the oncologist. radiodermatitis, which may mask underlying
tumour recurrence and allow the tumour
Kaposis sarcoma to grow more extensively before it can
Local control is usually easily achieved with be clinically detected (Figure 6.10). The
radiation. damaging effect of radiation on periocular
tissues poses another drawback to its use.
Note the potential complications associated
Specific therapies with the use of irradiation for treatment of
periocular malignancy (Box 6.4).
Radiation The most serious complications occur after
Historically, irradiation enjoyed significant treatment of large tumours of the upper eyelid
popularity among a large segment of the even when the eye is shielded.
medical community for the treatment of Although most surgeons would oppose the
epithelial malignancies, and a number of studies use of radiotherapy as the primary modality in
reported better than 90% cure rates for treating periocular skin cancers, it is felt to be
periocular basal cell carcinomas. More recently,
however, investigators have observed that basal
cell carcinomas treated by irradiation recur at a
higher rate and behave more aggressively than
tumours treated by surgical excision.
The radiation dose used to treat patients
varies depending on the size of the lesion and
the estimate of its depth.The treatments are
usually fractionated over several weeks. The
proponents of radiation therapy point to the
lack of discomfort with radiation treatment
and to the fact that no hospitalisation or
anaesthesia is required. Figure 6.10 Recurrent BCC post irradiation.
53
PLASTIC and ORBITAL SURGERY
the eye and restoration of good cosmesis. Of A smooth, nonabrasive eyelid margin free
these goals preservation of normal function is from keratin and trichiasis
of the utmost importance and takes priority In the upper eyelid normal vertical eyelid
over the cosmetic result. Failure to maintain movement without significant ptosis or
normal eyelid function, particularly following lagophthalmos
upper eyelid reconstruction, will have dire Normal horizontal tension with normal
consequences for the comfort and visual medial and lateral canthal tendon positions
performance of the patient. In general it is Normal apposition of the eyelid to the globe
technically easier to reconstruct eyelid defects A normal contour to the eyelid.
following tumour excision surgery than
following trauma. Large eyelid defects generally require
composite reconstruction in layers with a
General principles variety of tissues, either from adjacent sources
or from distant sites, being used to replace
There are a number of surgical procedures,
both the anterior and posterior lamellae. It is
which can be utilised to reconstruct eyelid
essential that only one lamella should be
defects. In general, where less than 25% of the
reconstructed as a free graft.The other lamella
eyelid has been sacrificed, direct closure of the
should be reconstructed as a vascularised flap
eyelid is possible. Where the eyelid tissues are
to provide an adequate blood supply to
very lax, direct closure may be possible for
prevent necrosis.
much larger defects occupying up to 50% of
the eyelid. Where direct closure without
undue tension on the wound is difficult, a Lower eyelid reconstruction
simple lateral canthotomy and cantholysis of Defects of the lower eyelid can be divided
the appropriate limb of the lateral canthal into those that involve the eyelid margin, and
tendon can effect a simple closure. those that do not.
In order to reconstruct eyelid defects
involving greater degrees of tissue loss, a Defects involving the eyelid margin
number of different surgical procedures have
been devised. The choice depends on: a) Small defects
An eyelid defect of 25% or less may be
The extent of the eyelid defect closed directly. In patients with marked eyelid
The state of the remaining periocular tissues laxity, even a defect occupying up to 50% of
The visual status of the fellow eye the eyelid may be closed directly. The two
The age and general health of the patient edges of the defect should be grasped and
The surgeons own expertise. pulled together to judge the facility of closure.
If there is no excess tension on the lid, the
In deciding which procedure is most suited edges may be approximated directly. The lid
to the individual patients needs, one should margin is reapproximated with a single armed
aim to re-establish the following: 5/0 Vicryl suture on a half circle needle. This
is passed through the most superior aspect of
A smooth mucosal surface to line the the tarsus, ensuring that the suture is anterior
eyelid and protect the cornea to the conjunctiva to avoid contact with the
An outer layer of skin and muscle cornea. This suture is tied with a single throw
Structural support between the two and the eyelid margin approximation checked.
lamellae of skin and mucosa originally If this is unsatisfactory the suture is replaced
provided by the tarsal plate and the process repeated.
56
TUMOUR MANAGEMENT and REPAIR AFTER TUMOUR EXCISION
Once the margin approximation is good, the the periosteum of the lateral orbital margin,
suture is untied and the ends fixated to the head with the lateral lid margin drawn up and
drape with a haemostat. This elongates the medially.
wound enabling further single armed Vicryl A semicircular flap (Tenzel flap) (Figure
sutures to be placed in the lower tarsus. These 6.13) is useful for the reconstruction of
are tied. The uppermost Vicryl suture is then defects up to 70% of the lower eyelid where
tied. Improper placement or tying of the suture some tarsus remains on either side of
or too great a degree of tension on the wound the defect, particularly where the patients
will result in dehiscence of the wound. Next, a fellow eye has poor vision. Under these
6/0 silk suture is passed in a vertical mattress circumstances it is preferable to avoid a
fashion along the lash line and a second suture procedure which necessitates closure of the
along the line of the meibomian glands. These eye for a period of some weeks. A semicircular
are tied with sufficient tension to cause eversion incision is made starting at the lateral canthus,
of the edges of the eyelid margin wound. A small curving superiorly to a level just below the
amount of pucker is desirable initially, to avoid brow and temporally for approximately 2cm.
late lid notching as the lid heals and the wound The flap is widely undermined to the depth
contracts. The sutures are left long and of the superficial temporalis fascia taking care
incorporated into the skin closure sutures to not to damage the temporal branch of the
prevent contact with the cornea.The conjunctiva facial nerve which crosses the midportion of
is left to heal spontaneously without suture the zygomatic arch. A lateral canthotomy and
closure.The skin sutures may be removed in five inferior cantholysis are then performed. The
to seven days but the eyelid margin sutures eyelid defect is closed as described above. The
should be left in place for 14 days. lateral canthus is suspended with a deep 5/0
Vicryl suture passed through the upper limb
b) Moderate defects of the lateral canthal tendon or the periosteum
Canthotomy and cantholysis where an eyelid of the lateral orbital margin to prevent
defect cannot be closed directly without retraction of the flap. Any residual dog ear is
undue tension on the wound, a lateral removed and the lateral skin wound closed
canthotomy and inferior cantholysis (Figures with simple interrupted sutures.
6.11 and 6.12) can be performed. The inferior
cantholysis is performed by cutting the tissue
between the conjunctiva and the skin close to
(a)
(a)
(b)
(b)
(c)
c) Large defects
The upper lid tarsoconjunctival pedicle flap
(Hughes flap) (Figure 6.14) is an excellent
technique for the reconstruction of relatively
shallow defects involving up to 100% of the (c)
eyelid. With defects extending horizontally
Figure 6.14 Hughes flap: (a) following excision of
beyond the eyelids it can be combined with lid lesion, (b) tarsoconjunctival flap raised from upper
periosteal flaps from the canthi to recreate lid, and (c) sutured to posterior lamella of lower lid.
58
TUMOUR MANAGEMENT and REPAIR AFTER TUMOUR EXCISION
massage the area in an upward direction for a canthal tendons, the free graft should be
few minutes, three to four times per day to anchored to periosteal flaps.
keep the tissues supple and prevent undue Periosteal flap for the repair of lateral lid
contracture. defects in which the tarsus and the lateral
The flap can be opened approximately six to canthal tendon have been completely excised,
eight weeks (or longer if necessary) after a periosteal flap provides excellent support for
surgery.This is done by inserting one blade of a the reconstruction. The periosteum should be
pair of blunt-tipped Westcott scissors just above elevated as a rectangular strip from the outer
the desired level of the new lid border aspect of the lateral orbital rim, at the
and cutting the flap open. It is unnecessary to midpupillary level, to provide upward
angle the scissors to leave the conjunctival edge support. The flap should be 4 to 5mm in
somewhat higher than the anterior edge. height, and the length can be judged based on
Traditionally this provides some conjunctiva the size of the defect to be reconstructed. The
posteriorly to be draped forward and create a hinged flap is elevated and folded medially
new mucocutaneous lid margin, but this leaves and secured to the edge of the residual tarsus
a reddened lid margin which is cosmetically or to the inner aspect of a myocutaneous flap
poor. It is preferable to allow the lid margin with 5/0 or 6/0 absorbable sutures.
simply to granulate as the appearance is far Mustarde cheek rotation flap with the
better. The upper lid is then everted and the development and popularity of other
residual flap is excised flush to its attachment. If reconstruction techniques and with the tissue
Mllers muscle has been left undisturbed in the conserving advantages of Mohs micrographic
original dissection of the flap, eyelid retraction is surgery, the Mustarde rotational cheek flap is
minimal and no formal attempt is needed to more rarely utilised than in the past (Figure
recess the upper lid retractors. The Hughes 6.17). It is reserved for the reconstruction of
procedure provides excellent cosmetic and very extensive deep eyelid defects usually
functional results for lower lid reconstruction. involving more than 75% of the eyelid.
Free tarsoconjunctival graft adequate tarsal A large myocutaneous cheek flap is dissected
support may be provided by harvesting a free and used in conjunction with an adequate
tarsoconjunctival graft from either upper lid. mucosal lining posteriorly.The posterior lamella
The upper lid is everted as described above. tarsal substitute is usually a nasal septal cartilage
The size of the graft needed is determined in graft or a hard palate graft. The important
a similar manner as well. Again, the tarsus is points in designing a cheek flap are summarised
incised across the width of the lid, 3 to 4mm by Mustarde in the following points.
above the lash line, to prevent upper lid
instability and lash loss.The flap is elevated by A deep inverted triangle must be excised
blunt dissection in the pretarsal space, and below the defect to allow adequate rotation.
vertical cuts are made to the tarsal base. The side of the triangle nearest the nose
The tarsus is then amputated at its base should be practically vertical. Failure to
and grafted into the recipient lower lid, as observe this point will result in pulling
described above. Because this graft is down the advancing flap because the
inherently avascular, it must be covered by a centre of rotation of the leading edge is too
vascularized myocutaneous advancement flap. far to the lateral side.
This technique is useful in lower lid The outline of the flap should rise in a
reconstruction for a monocular patient, curve toward the tail of the eyebrow and
because it does not occlude the visual axis. If hairline and should reach down as far as
the surgical defect extends to involve the the lobule of the ear.
60
TUMOUR MANAGEMENT and REPAIR AFTER TUMOUR EXCISION
closure for full-thickness defects of up to two tarsoconjunctival flap is useful for full-thickness
thirds of the eyelid margin (Figure 6.20a, b defects of up to two thirds of the upper lid
and c). An inverted semicircle is marked on margin. The residual upper eyelid tarsus is
the skin surface, beginning at the lateral bisected horizontally. The superior portion of
canthus and extending laterally approximately the tarsus is advanced horizontally along with its
3cm. The skin and orbicularis muscle are levator and Mllers muscle attachments. The
undermined under the entire flap, and a tarsoconjunctival advancement flap created is
superior cantholysis performed. The lateral then sutured in a side-to-side fashion to the
aspect of the eyelid may then be advanced lower portion of the upper lid tarsus and to the
medially to cover the defect. lateral or medial canthal tendon. The lower
The posterior surface of the advanced portion of the upper lid tarsus remains attached
semicircular flap may be covered by a to the orbicularis and skin tissue. After the
tarsoconjunctival advancement flap from the horizontal tarsoconjunctival advancement, the
lateral aspect of the lower eyelid. A vertical, full- external skin tissue is rebuilt by using full-
thickness, lower eyelid incision is made, and the thickness skin grafting or semicircular adjacent
tarsoconjunctival advancement flap is prepared tissue advancement.
by excising the lower eyelid skin tissue and lash A Cutler-Beard reconstruction is useful for
margin from the flap. The tarsus and upper eyelid defects covering up to 100% of
conjunctiva may then be advanced superiorly the eyelid margin. A three-sided inverted U-
into the lateral aspect of the upper eyelid flap. shaped incision is marked on the lower eyelid,
The lower eyelid defect may be repaired beginning below the tarsus. The eyelid is
primarily, anterior to the tarsoconjunctival flap. everted over a Desmarres retractor and a
The lateral tarsoconjunctival flap may be conjunctival incision is made below the tarsus.
released in four to six weeks. A conjunctival flap is fashioned and dissected
As an alternative to semicircular skin into the inferior fornix and onto the globe.
advancement, the advanced lower lid The flap is advanced into the upper eyelid
tarsoconjunctival flap may be covered with defect and sewn edge to edge with the
full-thickness skin tissue rather than a rotated, remaining upper fornix conjunctiva using 7/0
inverted semicircle. Vicryl with care being taken to avoid corneal
irritation (Figure 6.21a). The cornea is now
c) Large defects protected.
Sliding tarsoconjunctival flap horizontal Tarsal support to the upper eyelid is
advancement of an upper eyelid replaced by placing an autogenous auricular
Figure 6.20 Semicircular flap reconstruction (a) with superior cantholysis, (b) with lower lid posterior lamella
advancement flap, (c) final result.
63
PLASTIC and ORBITAL SURGERY
cartilage graft, which has been suitably other upper eyelid may be transplanted into
shaped, anterior to the conjunctival flap. The defects of the upper eyelid margin. The
edges are sewn horizontally to either tarsal resection of the normal eyelid should be
remnants or to periosteal flaps (Figure 6.21b). performed below the lid crease and should be
An incision is made through the lower eyelid done only when the remaining normal eyelid
horizontally below the tarsus and extended can be easily closed with direct closure. The
inferiorly to create a skin muscle advancement lashes of the transplanted lid rarely survive.
flap. The lower lid skin-and-muscle flap is The overlying skin and orbicularis are
then advanced to the upper lid to cover the removed and a rotation/advancement flap is
cartilage graft (Figure 6.21c). fashioned to cover the graft.
The lower lid tissue is advanced posteriorly Rotation and inversion of the lower lid margin
to the remaining lower lid tarsal and lid margin and tarsus into an upper lid defect provides
bridge. The bridge flap is left intact for at least good lid function as well as lashes for the
eight weeks prior to separation. When the upper eyelid. This procedure is best used,
bridge flap is separated, a full-thickness incision however, for large upper lid defects. It
should be made through the flap at a position necessitates complete reconstruction of the
inferior to the lower lid bridge margin (Figure lower eyelid margin, utilising a lateral
6.21d). The conjunctiva and skin are then Mustarde cheek flap reconstruction combined
sutured directly in the newly separated upper with a hard palate or nasal chondromucosal
eyelid tissue. The inferior margins of the lower graft for the reconstruction of the lower eyelid
lid bridge are freshened and reanastomosed to tarsus and conjunctiva. This technique is
the remaining lower lid skin and conjunctival particularly useful for reconstruction of upper
layers (Figure 6.21e). It is common for the eyelid colobomata.
lower lid to become very lax and to require a The lower lid margin needed for upper lid
wedge resection at the second stage. reconstruction is outlined laterally and a
Full-thickness composite graft a full- vertical full-thickness incision is made
thickness en bloc section of tissue from the inferiorly in the lower eyelid flap. The lateral
(d) (e)
Figure 6.21 Cutler-Beard reconstruction (a) conjunctival flap in place, (b) ear cartilage graft in place, (c) first
stage complete, (d) division of Cutler-Beard flap, (e) final stage.
64
TUMOUR MANAGEMENT and REPAIR AFTER TUMOUR EXCISION
aspect of the lower eyelid is then advanced reflected conjunctiva superiorly. This can
medially through the use of a lateral Mustarde then be covered with a full-thickness skin graft
flap. The lower eyelid margin is then inverted or a rotation flap from the lateral face or
and sutured into the upper lid defect. The mid-forehead. After maturation of the tissue, a
lower lid rotation is closed medially, and the small opening can be made to permit central
lateral aspect of the new lower lid margin is corneal vision. Because the upper and lower
backed with a nasal chondromucosal eyelids are immobile, only a small palpebral
composite graft or a hard palate graft. The fissure should be created to minimise the risk
bridge adjoining the upper and lower lids is of lagophthalmos and exposure.
separated after six to eight weeks. Although If available bulbar conjunctiva is insufficient
some surgeons use this technique with to cover the globe, full-thickness buccal
success, it is cumbersome and requires both mucous membrane may be grafted to the
lower eyelid construction and lateral facial posterior surface of the lateral cheek or
advancement. midline forehead flap to provide a mucosal
lining for the globe.
Eyelid defects not involving the eyelid margin When ample conjunctiva with a good blood
If a small skin defect can be closed directly supply is available, the reflected mucosal
this should aim to leave a vertical scar in order covering may be adequate to support full-
to prevent vertical contracture of the wound thickness skin grafting externally as an
and secondary lagophthalmos or eyelid alternative to larger flap rotations.
retraction. If direct closure of the tissue is
not possible, a full-thickness skin graft may
be placed over the defect to prevent Further reading
lagophthalmos. Abide JM, Nahai F, Bennett RG. The meaning of surgical
margins. Plast Reconstr Surg 1984; 73:4926.
Anderson RL, Ceilley RI. Multispeciality approach to
excision and reconstruction of eyelid tumours.
Full-thickness loss of upper Ophthalmology 1978; 85:115063.
and lower lids Collin JRO. A manual of systematic eyelid surgery. New York:
Churchill Livingstone, 1989.
Cutler NL, Beard C. A method for partial and total upper lid
Reconstruction of the upper eyelid becomes reconstruction. Am J Ophthalmol 1955; 39:1.
much more of a challenge when additional Gooding CA, White G, Yatsuhashi M. Significance of
periocular tissue and part of the lower eyelid marginal extension in excised basal cell carcinoma. N Engl
J Med 1965; 273:9235.
have been lost. The type of reconstruction will Hewes EH, Sullivan JH, Beard C. Lower eyelid
then depend very much on the age and reconstruction by tarsal transposition. Am J Ophthalmol
1976; 81:51214.
general health of the patient and the visual Hughes WL. Reconstructive surery of the eyelids (2nd ed) St.
status of the fellow eye. Frequently concerns Louis: CV Mosby, 1954.
Inkster C, Ashworth J, Murdoch JR, Montgomery P, Telfer
about cosmesis will have to be sacrificed to NR, Leatherbarrow B. Oculoplastic reconstruction
concerns about adequate corneal protection. following Mohs surgery. Eye 1998; 12:21418.
Leshin B, Yeatts P. Management of periocular basal cell
When a full-thickness defect includes the carcinoma: Mohs micrographic surgery versus
entire upper and lower eyelids, the goal of radiotherapy. I. Mohs micrographic surgery. Surv
reconstruction becomes preservation of the Ophthalmol 1993; 38:193203.
Margo CE, Waltz K. Basal cell carcinoma of the eyelid and
globe by complete coverage with mucous periocular skin. Surv Ophthalmol 1993; 38:16992.
membrane and skin tissue. Usually, sufficient Miller S. Biology of basal cell carcinoma. J Am Acad
Dermatol 1991; 24:113 (Part I), 16175 (Part II).
conjunctiva is available on the bulbar surface Mohs FE. Micrographic surgery for the microscopically
to allow undermining and reflection over controlled excision of eyelid cancers. Arch Ophthalmol
1986; 104:9019.
the corneal surface. The reflected bulbar Mustarde JC. Repair and reconstruction in the orbital region.
conjunctiva inferiorly is sutured to the Edinburgh: Churchill Livingstone, 1966.
65
PLASTIC and ORBITAL SURGERY
Pascal RR, Hobby LW, Lattes R, Crikelair GF. Prognosis of Salasche SJ, Amonette R. Morpheaform basal cell
incompletely excised versus completely excised basal cell epitheliomas: A study of subclinical extensions in a series
carcinomas. Plast Reconstr Sur 1968; 41:32832. of 51 cases. J Dermatol Surg Oncol 1981; 7:38792.
Patrinely JR, Marines HM, Anderson RL. Skin flaps in Tenzel RR, Stewart WB. Eyelid reconstruction by the
periorbital reconstruction. Surv Ophthalmol 1987; 31: 24961. semicircle flap technique. Ophthalmology 1978; 5:11649.
Putterman AM. Viable composite grafting in eyelid Von Domarus H, Steven PJ. Metastatic basal cell carcinoma.
reconstruction: a new method of upper and lower lid Report of five cases and review of 170 cases in the
reconstruction. Am J Ophthalmol 1978; 85:23741. literature. J Am Acad Dermatol 1984; 10:104360.
Rakofsky SI. The adequacy of surgical excision of basal cell Waltz KL Margo CE. The interpretation of microscopically
carcinoma. Ann Ophthalmol 1973; 5:596600. controlled surgical margins (abstract). Ophthalmology
Robins P, Rodriquez-Sains R, Rabinovitz H, Rigel D. Mohs 1991; 91:117.
surgery for periocular basal cell carcinoma. J Dermatol Wolf DJ, Zitelli JA. Surgical margins for basal cell
Surg Oncol 1985; 11:12037. carcinoma. Arch Dermatol 1987; 123:3404.
66
7 Seventh nerve palsy and corneal
exposure
Anthony G Tyers
ectropion and watering. Synkinesis, defined as eyelid closure. Many other techniques have
an involuntary movement of part of the face been proposed to reanimate the upper lid
other than that intended to move, can be but most of these have been abandoned
severe and distressing, causing a significant because of complications. The temporalis
cosmetic defect. Usually, closure of the eye transfer operation is effective and is still
also causes upward movement of the corner of widely used for severe exposure where
the mouth, and movement of the mouth also expensive options such as the use of gold
causes closure of the eye. weights are impractical.
Ectropion is treated with a lateral canthal
sling combined with a medial canthoplasty.
Management If, however, the medial canthal tendon is
Treatment in the early weeks is directed at very lax an alternative is a medial wedge
the painful red eye.Treatment for the watering resection. For severe and persistent ectropion
and the cosmetic defects can be deferred until the lower lid can be supported with a sling of
after six months when all likely recovery has autogenous fascia lata.
occurred. Reassurance and support of the Persistent watering, if severe, is effectively
patient is needed at every stage. treated with a Lester Jones tube.
Cosmetic improvement in seventh nerve
Early management the painful palsy is always challenging. In addition to the
red eye procedures mentioned above, the brow
position may be corrected, if necessary, with a
Topical lubricants and taping the eye closed direct brow lift. The scar heals well. However,
at night may be all that is required. A even less scarring follows brow lifts performed
temporary lateral tarsorrhaphy may be needed through a coronal incision or an endoscopic
to control severe exposure while the prognosis approach which is performed through several
for recovery is being assessed. Marked small incisions within the hair line. These are
ectropion of the lower lid may be treated early. more difficult and specialised procedures.
Simple lid shortening, as for an involutional Blepharoplasty of the lower lids may be
ectropion, may be effective but a better lid needed if laxity in the orbicularis muscle
position is achieved with a lateral canthal sling allows bags to appear and fluid to pool in the
(Chapter 3). lids. Synkinesis can be treated with botulinum
toxin injections if severe.
Management after six months
continuing exposure; watering
and cosmetic defects
Surgical techniques in seventh
Continuing exposure due to poor lid closure
or an inadequate blink may be treated by nerve palsy
lowering the upper lid, which is often slightly
Lateral tarsorrhaphy
retracted due to the unopposed action of the
levator palpebrae muscle. Mllers muscle may The principle is to join the upper and lower
be recessed or excised. The upper lid may be lids laterally to reduce the palpebral aperture
lowered further by recession of both Mllers horizontally and improve the protection of the
muscle and the levator muscle but this is cornea.
rarely needed in facial palsy. Alternatively, a The technique is as follows:
gold weight may be implanted into the upper
lid this allows a more natural blink and better a) Temporary tarsorrhaphy (Figure 7.1a).
68
SEVENTH NERVE PALSY and CORNEAL EXPOSURE
Lateral triangle of
upper tarsal plate
(a)
(b)
Figure 7.1 Lateral tarsorrhaphy (a) temporary, (b) permanent.
Excise the lid margin tissues of the upper lashes. This ensures the lashes do not point
and lower lid laterally for the length of the posteriorly to abrade the cornea.
intended tarsorrhaphy.
Insert two vertical mattress sutures of 4/0 Complications
silk as shown in the diagram. Tie the
sutures over bolsters. Temporary tarsorrhaphy the tarsorrhaphy
Remove the sutures at one week. often breaks down in places as soon as the
sutures are removed.
b) Permanent tarsorrhaphy (Figure 7.1b). Permanent tarsorrhaphy a fistula which
drains tears may appear at the lateral canthus
Make an incision along the grey line of the if the canthal skin is not carefully closed.
upper lid and lower lid laterally for the
length of the intended tarsorrhaphy.
Medial canthoplasty (Figure 7.2)
Deepen the incisions, staying on the
anterior tarsal surfaces for the full height of The principle is that the margin of the upper
the upper and lower lid tarsal plates. and lower lids medial to the lacrimal puncta
Make a vertical cut through the full height are joined to reduce the palpebral aperture and
of the upper and lower lid tarsal plates at support the medial end of the lower lid.
the medial ends of the grey line incisions.
This creates triangles of tarsal plate
laterally in the upper and lower lids.
Excise the triangle of the tarsal plate in the
lower lid. Cut skin edge
Insert a double armed 4/0 suture through
the tip of the triangle of the tarsal plate
in the upper lid. Pass both needles through
the apex of the bare area in the posterior
aspect of the lower lid and through to the
skin. Tie the sutures over a bolster. Orbicularis muscle
Close the skin of the lid margin with
vertical mattress sutures from above the
upper lid lashes to below the lower lid Figure 7.2 Medial canthoplasty.
69
PLASTIC and ORBITAL SURGERY
The technique is as follows: the medial canthus. Gently pull the lateral
edge of the wound medially to take up the
Place lacrimal probes in the canaliculi. slack in the lower lid margin and excise the
Make incisions along the upper and lower excess as a pentagon.
lid margins medial to the puncta, staying Place a probe into the cut end of the lower
anterior to the canaliculi, and join the canaliculus. Using blunt dissection with
incisions at the inner canthus. Undermine scissors, directed posteriorly and medially
the skin to expose the orbicularis muscle behind the canaliculus and staying lateral
above the below the canaliculi. to the lacrimal sac, identify the posterior
Place one or two 6/0 absorbable sutures lacrimal crest just posterior to the sac. A
from the muscle above the upper narrow malleable retractor placed laterally
canaliculus to the muscle below the lower will help visualisation of the posterior
canaliculus. lacrimal crest.
Tie the sutures to approximate the upper Insert a double armed, nonabsorbable 5/0
and lower lids of the inner canthus. suture into the periostium of the posterior
Close the skin with 6/0 sutures. Remove lacrimal crest, slightly above the level of the
the sutures at a week. inner canthus.
Pass the first needle through the tarsal
Complications the canthoplasty may stretch plate close to the lid margin, from posterior
with time. to anterior and the second needle 23mm
inferior to the first. Adjust the position of
Medial wedge resection (Figure 7.3) the two arms of the suture if necessary so
that when it is tied the lid is drawn medially
The principle is that stretched medial eyelid and posteriorly against the globe.
tissue, which includes the medial canthal Cut along the posterior wall of the cut
tendon and the proximal lower lid canaliculus, canaliculus for 23mm, place a 7/0
is excised and the tarsal plate is reattached to absorbable suture between the anterior lip
the posterior lacrimal crest to create a firm of the cut canaliculus and the conjunctival
support to the medial end of the lower lid. edge on the lower lid laterally. When this
The technique is as follows: suture is tied it will turn the lumen of the
Make a vertical cut through the full canaliculus posteriorly into the conjunctival
thickness of the lower lid, 45mm lateral to sac so that some tears will drain.
Before tying the 5/0 suspending suture,
carefully close the conjunctival wound with
a 6/0 absorbable suture to ensure that the
5/0 suspending suture is well covered
Cut
canaliculus posteriorly. Next, tie the canalicular suture.
Suture in posterior
Finally, tie the 5/0 suspending suture to fix
lacrimal crest the medial end of the lid.
Suture through
Close skin with 6/0 sutures. Remove these
tarsal plate at one week.
Insert a traction suture through the upper Follow the first two steps as for tarsotomy.
lid margin. Evert the lid over a Desmarres Pull down the lower wound edge this
retractor and incise the tarsal plate close to includes the narrow strip of the superior
its superior border. tarsal plate with Mllers muscle attached.
Extend the incision in the tarsal plate Dissect in the fine connective tissue
medially and laterally, parallel to the full between Mllers muscle posteriorly and
width of the superior tarsal border. the levator aponeurosis anteriorly until
Tape the traction suture firmly down to the junction of Mllers muscle and
the cheek, under the dressing, for 48 to aponeurosis is reached, after about 10mm.
72 hours. Carefully, dissect Mllers muscle from the
conjunctiva and excise the muscle.
Complications the lid frequently rises to its Close the wound in the tarsal plate with a
original position once the traction suture is continuous 6/0 or 7/0 absorbable suture
removed. taking care to bury the knots at either end of
the wound to avoid abrasion of the cornea.
(a) (b)
Figure 7.6 (a) Gold weight placed between the tarsal plate and orbicularis muscle, (b) orbicularis muscle
sutured to tarsal plate over the gold weight.
Incise the ellipse of skin to the level of the conveniently classified as: orbicularis muscle
frontalis muscle on the deep surface of the functioning normally but normal lid closure
subcutaneous fat. Excise the ellipse of prevented; orbicularis muscle not functioning
tissue. Special care is needed in the region normally; or eyelid defects.
of the supraorbital nerve and vessels.
Close the deep layers with 4/0 Orbicularis muscle functioning normally
nonabsorbable or long-acting absorbable
sutures which include a deep bite through Tight skin, tight upper or lower lid
the periostium at the level of the superior retractors or tight conjunctiva prevent normal
wound edge. Omit the deep bite in the upper or lower lid movement and closure.
region of the supraorbital nerve and Common causes are scarring and proptosis.
vessels. An extra row of more superficial
subcutaneous sutures may be needed. Tight skin is due to scarring (or
Close the skin with a 4/0 monofilament occasionally skin loss). Diffuse scarring is
subcuticular suture. Remove this at one treated with a skin graft; linear scarring is
week. treated with a z-plasty.
Complications altered sensation in the Tight upper or lower lid retractors may be
forehead may occur due to damage to the due to overcorrected ptosis or scarring. The
supraorbital nerve.This may recover gradually retractors are recessed with either excision of
over several months but it may be permanent. Mllers muscle (simple recession is usually
The position of the brow commonly droops ineffective), or recession of the retractors
again slightly in the weeks following surgery. themselves (levator aponeurosis or lower lid
retractors). This is done through the anterior
(skin) or the posterior (conjunctiva) approach.
Corneal exposure A spacer (e.g. sclera) is optional in the upper lid
The risk factors for corneal exposure are but is essential in the lower lid. Alternately, in
well known: lid lag (inadequate eyelid the upper lid adjustable sutures may be used.
closure), poor Bells phenomenon, insensitive
cornea and dry eye. Apart from release of a Tight conjunctiva must be released and a
tight inferior rectus muscle to improve Bells graft of oral mucosa or hard palate inserted.
phenomenon and reduce upper lid retraction
indirectly, the only surgical option in corneal Proptosis if severe (lid surgery alone is
exposure is to improve eyelid closure with or not effective) is treated with decompression of
without overall reduction in the palpebral the medial wall and floor, and the lateral wall
aperture. The latter may be achieved in either if necessary. A lateral tarsorrhaphy may be
a vertical direction by lowering the upper lid necessary in severe cases.
and stabilising the lower lid or in a horizontal
direction by approximating the lids at the Orbicularis muscle not functioning
inner or outer canthi. normally
The commonest cause is facial palsy but
Causes of inadequate eyelid closure
patients who blink less than normal may have
Select the surgical technique to improve an added risk factor e.g. mental deficiency;
corneal protection after analysing the causes comatose patients, especially those on
of the inadequate eyelid closure. These can be ventilators; premature babies; etc.
73
PLASTIC and ORBITAL SURGERY
Levator aponeurosis
Donor
sclera
Central and medial
Hang-back sutures
Tarsal plate
(a) (b)
Figure 7.8 (a) Spacer of donor sclera placed between tarsal plate and levator aponeurosis, (b) upper lid
retractors recessed and fixed with central and medical hang-back sutures.
74
SEVENTH NERVE PALSY and CORNEAL EXPOSURE
and Mllers muscle) superiorly and to the posteriorly and the levator aponeurosis
superior tarsal plate border inferiorly. anteriorly. Downward traction on Mllers
If no spacer is to be used (Figure 7.8b), muscle will expose a white line (Figure
estimate how much recession of the upper 7.9a) which is the edge of the levator
lid retractors is required and insert three 6/0 aponeurosis folded on itself. Incise and
long-acting absorbable or nonabsorbable turn down the levator aponeurosis for the
hang-back sutures.The lateral suture can be full width of the tarsal incision to expose,
omitted if there was difficulty achieving but taking care not to damage the
satisfactory correction laterally. underlying orbicularis muscle (Figure
Close the lid with deep bites to create a 7.9b). Turn the lid back into its correct
skin crease. Insert a traction suture into the anatomical position and assess the
upper lid and tape it to the cheek until the correction of the retraction. An over-
first dressing. correction of 23mm is usually required. If
it is inadequate, dissect superiorly between
The technique for the posterior approach the levator aponeurosis and the orbicularis
is as follows (Figure 7.9a and b). muscle for a few millimetres and reassess
the lid position. Repeat this until adequate
Place a 4/0 stay suture into the centre of the correction is achieved.
tarsal plate close to the lid margin. Evert the Excise the narrow strip of superior tarsal
lid over a Desmarres retractor. Make a plate which is attached to the Mllers
short incision through the tarsal plate close muscle. The retractors may be left free.
to the superior border. An obvious surgical Alternatively, suture them to the orbicularis
space the post-aponeurotic space is muscle to fix their position.
entered. Extend the incision medially and The conjunctiva does not need to be closed.
laterally, staying close to the superior Place a traction suture in the upper lid and
border of the tarsal plate. The levator tape it to the cheek until the first dressing.
aponeurosis is the structure in the depths of
the wound (see Figure 7.4). Complications the lid level, or the curve of
Pull down the lower wound edge which the lid margin, may be incorrect. If there is no
includes a strip of the superior tarsal plate obvious cause, such as swelling, adjust the
and dissect between Mllers muscle level early, within a week or so. If there
Everted tarsal
Cut edge of
plate Cut edge of
everted tarsal plate
tarsal plate
Orbicularis
White line
Septum
Levator
Muller's muscle aponeurosis
overlying conjunctiva Muller's muscle
overlying conjunctiva
(a) (b)
Figure 7.9 (a) Everted upper lid showing the white line of the folded aponeurosis, (b) aponeurosis and septum
exposed.
75
PLASTIC and ORBITAL SURGERY
appears to be a probable cause, for example If donor sclera is to be used as the spacer
haematoma or swelling, and you think the lid suture the lower border of the sclera to the
may settle, wait then readjust the level, if recessed lower lid retractor layer with
necessary, at six months. 6/0 absorbable sutures (Figure 7.10b).
An inevitable side effect of an upper lid Draw up the conjunctiva to cover the sclera
retractor recession by the posterior approach is and suture the superior border of the sclera,
that the skin crease is raised. Further surgery together with the edge of the conjunctiva,
may be needed to restore symmetry of the upper
lid skin creases and lid folds either lowering the
skin crease in the operated upper lid or raising
the skin crease in the opposite upper lid. Palpebral conjunctiva
reflected up
Lower lid retractor recession Lower lid retractors
(Figure 7.10)
The principle here is that the lower lid
retractors are separated from the lower border Orbicularis muscle Lower border
of the tarsal plate and recessed. Their position of tarsal plate
76
SEVENTH NERVE PALSY and CORNEAL EXPOSURE
77
8 Cosmetic surgery
Richard N Downes
Patient discussion
Figure 8.2 Post operative appearance of the same The clinical findings and treatment options
patient after face and brow lift, blepharoplasty and are explained in detail with the patient.
periocular laser resurfacing. Remember to be honest and realistic with
regard to surgical outcomes as well as
symmetry, excess lid tissue, i.e. is the problem treatment limitations and complications.
one of dermatochalasis or blepharochalasis, Ensure as much as you are able that the patient
and fat prolapse. Specifically examine for fully understands what treatment entails, that
lower lid eyelid laxity. If this is present to any his/her expectations are realistic and that he/
significant degree and lower lid blepharoplasty she is psychologically fit for any procedure.
is contemplated then a lower lid tightening Always document what has been discussed.
procedure may well be necessary. The lower
lid skin is assessed for excess tissue, skin
Anaesthetic considerations
wrinkles and altered skin texture. If the latter
is the case then periocular laser resurfacing The anaesthetic options available for
may provide a better result with less risk of cosmetic surgery are local anaesthesia with
complications than skin excision. Is the or without sedation or general anaesthesia.
patient suffering from festoons of excess lower Remember that surgery is elective and has
lid skin? If so a variation in the surgical been requested by the patient; it is incumbent
approach from conventional blepharoplasty upon the surgeon to ensure that any surgical
may be needed. treatment is as comfortable as possible.
Examine the rest of the face with particular Most procedures can be undertaken
attention to any scars, wrinkles and skin folds with local anaesthesia but supplementary
and generalised skin texture changes. It is intravenous anaesthesia provided by a trained
important to document the patients skin anaesthetist should be considered in all cases,
colouring and type which is best assessed especially if the procedure is likely to be
using Fitzpatricks classification. (Fitzpatrick prolonged or the patient is apprehensive or
described six skin types with types 1 and nervous. Allow adequate time for the
2 representing a fair skin complexion, anaesthetic to take effect and ensure skin
susceptible to sunburn, types 3 and 4 dark marking is undertaken before local infiltration.
Mediterranean/Asian type of complexion, General anaesthesia should be considered if a
79
PLASTIC and ORBITAL SURGERYPLASTIC and ORBITAL SURGERY
number of areas of the face are operated on at amount and extent of the brow lift required.
the same time, the surgery is likely to be The sutures are positioned 1cm apart and
prolonged or at the patients specific request. passed transcutaneously through the lower
Supplementary local infiltrative anaesthesia is brow on to periosteum and horizontally
useful for haemostatic purposes as well as post through periosteum 115cm above the orbital
operative analgesia even when general rim. The suture is then passed back, again
anaesthesia is the anaesthesia of choice. horizontally, through the brow muscle at the
level of the transcutaneous suture avoiding
superficial placement; the transcutaneous end
Brow surgery of the suture is pulled through the brow tissue
(but not the periosteum) and tied (Figure 8.3).
Brow ptosis generally results from ageing This manoeuvre is a straightforward way of
changes of the skin and soft tissues but may be accurately positioning the suture with regard
secondary to other causes such as trauma or to both the periosteal and brow tissues.
seventh nerve palsy. It is essential to examine Additional sutures are used as required; if
for these and treat, as appropriate. Eyebrow more than one suture is necessary then tying of
ptosis which is characterised by inferior the suture is best delayed until all sutures have
displacement of the brow, often below the been positioned. The height and curvature
orbital rim, is usually greatest laterally. If of the brow are assessed and adjusted as
unilateral, the position is measured in relation necessary. The skin incision is closed in
to the opposite brow. If bilateral then the the conventional way as for upper lid
extent of ptosis is measured by comparing the blepharoplasty.
difference in positions of marked fixed points
on the brow medially, centrally and laterally
when the brow is manually elevated to the Transcutaneous
suture Reflected flap
desired position.
There are a number of approaches to
surgical correction of brow ptosis.
Periosteum
Internal brow fixation (browpexy)
This is useful for the treatment of mild Orbital rim
unilateral or bilateral, predominantly lateral, Medial lid
Lateral lid
brow ptosis. It is often undertaken in
conjunction with blepharoplasty.
The amount of brow lift is determined as Figure 8.3 This demonstrates the horizontal
outlined above. After a standard blepharoplasty periosteal suture, and return suture pass, before the
upper lid skin crease incision, dissection is transcutaneous suture is drawn through flap tissues
only and tied.
continued superiorly and laterally in the
submuscular fascia plane over the orbital rim.
Deep to the plane of dissection the brow fat Complications including skin dimpling,
pad is identified overlying the lateral orbital skin erosion and cheese-wiring of the sutures
rim.This is excised on to periosteum. Between can occur with superficial placement. Contour
one and three 4/0 Prolene sutures are then and brow height abnormalities are seen with
used to fixate or plicate the brow to the inappropriate suture placement. Recurrent
periosteum in the desired position. The brow ptosis may occur particularly if
number of sutures used depends upon the absorbable sutures have been used. Reduced
80
COSMETIC SURGERY
eyelid elevation on upgaze is described which The forehead creases lying above the lateral
is an unavoidable limitation of the technique. brow are chosen as incision sites. Ideally the
creases are at different levels over either brow.
Direct brow lift (browplasty) Following skin marking, skin, subcutaneous
tissues and hypertrophic muscle are all excised
This procedure is particularly suitable for
as appropriate with layered wound closure as
male patients with thick bushy eyebrows and
described in a direct brow lift.
receding hairlines (thereby masking brow
scarring and avoiding coronal scarring), The complications mainly relate to scarring
patients requiring a less extensive procedure and are minimised by careful surgical technique.
and those with unilateral brow ptosis
secondary to facial nerve palsy. Temporal brow lift
The extent of tissue excision is marked with This procedure is useful in patients with
the patient sitting upright aiming to position the predominantly lateral brow ptosis. The
scar within the upper row of brow hairs. The incision site needs to be within the hairline
lower skin incision is made with the scalpel and is therefore more appropriate for the
blade bevelled such that the incision is parallel female patient.
to the hair shafts. This obviates transverse
A 1012cm vertical incision above the ear is
sectioning of the hair follicles thus minimising
made in the hair bearing scalp down to
brow hair loss. Skin and subcutaneous tissue,
temporalis fascia. Blunt dissection towards the
with underlying orbicularis muscle as necessary,
eyebrow initially at the plane of temporalis
are excised taking care to identify and therefore
fascia then becoming more superficial over
avoid damage to the supraorbital neurovascular
the scalp hairline (to minimise damage to
bundle. If surgery is undertaken for seventh
superficial seventh branches) is undertaken.
nerve palsy then tissue excision down to the
The flap is undermined onto the brow with
periosteum with deep fixation of brow tissue
excision of redundant scalp tissue followed by
to periosteum using interrupted 4/0 Prolene
layered skin closure.
sutures is necessary. The deeper tissues are
closed with 4/0 or 5/0 Vicryl taking care to evert
Complications include unacceptable elevation
the skin edges prior to skin closure using a
of the temporal hairline and local seventh
subcuticular 5/0 Prolene suture which is
nerve weakness if the facial nerve branches are
removed after five to seven days. This layered
damaged.
skin closure approach facilitates a thin flat scar.
Coronal brow lift
Complications including loss of brow hair
and/or an unsightly scar may result from poor This procedure is ideally suited to patients
surgical technique. An unacceptable brow with a combination of brow ptosis, excessive
position or contour is usually due to forehead skin and soft tissue and a low non-
inappropriate marking. Permanent forehead receding hairline.
parasthesia may occur with supraorbital nerve
damage. A bevelled high coronal incision is made
within the hairline following the shape of
the latter far enough posterior to position
Mid forehead brow lift
the subsequent scar 34cm posterior to the
This procedure is suitable for males with anterior hairline. The incision is angled to run
deep forehead furrows and excess forehead skin. parallel with the axis of the hair follicles down
81
PLASTIC and ORBITAL SURGERY
to periosteum. A forehead scalp flap is elevated facilitating further dissection using endoscopic
using predominantly blunt dissection in the control. This proceeds inferolaterally along the
loose sub-galeal plane above the periosteum to temporal line with subsequent fascial incision,
within 2cm of the supraorbital rim centrally. facilitating adequate release of the lateral brow.
Careful lateral dissection is undertaken Dissection with release of the periosteum, galea
avoiding seventh nerve branch damage.This is and depressor muscles is then undertaken.
continued along the supraorbital rim with The brows are now free for fixation which
selective weakening surgery to the corrugator may be effected in a number of ways. The
procerus and frontalis muscles avoiding most common method is screw fixation
damage to the supraorbital neurovascular whereby a screw is placed in each lateral
bundles. A supraorbital periosteal incision may frontal incision site at a predetermined
further enhance the procedure. Meticulous distance from the anterior margin of the
haemostasis throughout is essential before incision. A skin hook then pulls the
excision of excess flap tissue within the periosteum margin posteriorly; the incision
hairline.The wound is carefully closed in layers site is closed with staples or suture so that the
using deep 3/0 Vicryl and surgical staples or screw is now at the anterior part of the wound
4/0 Prolene, after placement of a supraorbital and the forehead lifted and fixated by the
drain.The staples or sutures are removed seven predetermined amount. Additional fascial
to ten days post operatively. fixation may then be undertaken prior to skin
Post operative haematoma leading to flap closure using 4/0 Prolene or staples.
necrosis, localised sensory and motor nerve Complications are as for those described
damage, hair loss and unacceptable scarring with bi-coronal brow lift technique, although
are all recognised complications, the majority with the exception of nerve damage, they
of which can be avoided with careful surgical occur less commonly.
technique.
The skin and excess underlying tissues to be Fat excision may be inadequate or
excised are outlined taking care to position the excessive. Significant excess fat excision will
excision symmetrically and, if possible, in a result in a hollowed out appearance
co-existent lid crease in the area overlying the particularly apparent in the lower lid. Surgery
inferior orbital rim. The skin and deeper in the form of suborbicularis oculi fat
tissues are incised followed by excision of transposition may be necessary to rectify this
all excess tissue using scissors. Haemostasis asymmetry. If fat excision has been limited
is secured. Layered closure with careful then further fat removal may be necessary.
skin margin approximation using a 6/0 Lid asymmetry as a consequence of
subcuticular Prolene suture is undertaken improperly positioned incisions is described.
which is removed five to seven days post The most noticeable asymmetry relates to
operatively. asymmetric skin crease positions which if
unacceptable will require revisionary surgery.
Blepharoplasty complications
Blindness is described as occurring in
Lasers in oculoplastic surgery
between 1 : 10 000 and 1 : 40 000 cases. It only The use of lasers in oculoplastic surgery has
occurs when the orbital compartment is become increasingly widespread of late. Two
entered with fat excision and is thought to be lasers are at present pre-eminent in the field;
related to traction on the posterior orbital the carbon dioxide and more recently erbium
vessels with subsequent orbital haemorrhage. YAG lasers. The basic principle for all these
Diplopia is an uncommon complication of lasers is that of delivering high laser energy in
blepharoplasty usually related to damage to short pulses or bursts, thus maximising tissue
the inferior oblique muscle. ablation whilst minimising adjacent thermal
Ptosis may occur transiently or damage and hence scarring.The current lasers
permanently. It is caused by either direct produce these short burst effects either by the
damage or significant stretching of the levator provision of a super or ultra pulse pattern such
muscle. as the Coherent CO2 laser or Erbium YAG or
Inadequate or excessive skin excision may a continuous wave laser which is interrupted
result in a number of complications. If excess by a rapidly moving mechanical system such
upper lid skin is excised lagophthalmos as the Sharplan laser.
results which may or may not be a A number of carbon dioxide laser systems
permanent feature. More marked excess are currently available for oculoplastic
upper lid skin excision may result in frank lid surgery. Carbon dioxide lasers have both
margin rotation and ectropion. Excess skin tissue ablative and haemostatic properties
removal from the lower lid can result in which make them ideally suited for both
rounding of the lateral canthal region with incisional and resurfacing surgery.
enhancement of scleral show and frank lid The Erbium YAG laser delivers increased
margin ectropion or lid retraction. Excess tissue ablation with co-incidental reduction of
skin removal is the commonest significant adjacent thermal damage when compared to
complication following blepharoplasty. The the carbon dioxide laser. This results in
abnormal lid position may respond to reduced tissue damage, erythema and post
vigorous regular lid massage but often operative inflammation. The major
recourse to revisionary lid surgery is disadvantages of the erbium YAG are lack of
necessary. Inadequate skin removal requires coagulation, so that it is not suitable for
further skin excision. incisional surgery, and lack of contractile
85
PLASTIC and ORBITAL SURGERY
effect when used for resurfacing which may be or regional nerve blocks, with or without
important in the maintenance of medium to intravenous sedation is used. Full face
long term effects. resurfacing is best undertaken using local
anaesthesia and sedation or general
Skin resurfacing anaesthesia.
Laser safety precautions must always be
Laser skin resurfacing is used to smooth facial observed which include protection of areas
skin and reduce wrinkles or rhytides. Dynamic not being treated with wet swabs and/or
rhytides resulting from underlying muscle protective eye shields. Anaesthetic equipment
activity, i.e. glabellar folds do not respond as if used, must be protected using silver foil
well as static rhytides, i.e. periocular folds around the exposed endotracheal tube and
caused by ageing and ultraviolet exposure. The connection and all theatre staff, including the
technique of laser skin resurfacing results in surgeon, must wear protective goggles.
vaporisation of the epidermis and upper dermal Techniques for resurfacing vary greatly
layers with subsequent repair resulting in an from one surgeon to the next but all adhere to
improved cosmetic appearance. This relatively certain basic tenets. The skin thickness varies
precise skin ablation with reduced thermal considerably over different parts of the face
damage results in a more reproducible and with the periocular skin being the thinnest and
superior result than alternative techniques such skin over the cheek and chin the thickest. In
as dermabrasion or chemical peels. order to achieve a similar improvement in
Patients for laser resurfacing should be each area more laser treatment or resculpting
carefully selected and understand the aims and is necessary with the thickest tissues.
limitations of laser treatment.A thorough history The skin is thoroughly cleansed with saline
with particular emphasis upon the use of topical and dried. The area of treatment is outlined
skin preparations, allergies and sensitivities and and any deep wrinkles individually marked.
previous herpetic infections is taken. Fair The laser pattern and power are set, the laser
skinned patients (Fitzpatrick grades 1 and 2) are tested and treatment commenced. The initial
ideal for resurfacing whereas darker skinned treatment centres on the individual wrinkles or
individuals (Fitzpatrick grades 3 and 4) run a scars outlined, with treatment to the shoulders
risk of post laser hyperpigmentation and should or elevated areas adjacent to the deeper
be approached cautiously. Laser resurfacing is wrinkle or scar. The ablated debris is removed
contra-indicated in patients with deeply with saline soaked gauze swabs. Confluent
pigmented skin (Fitzpatrick grades 5 and 6). laser passes are then made over the entire
Pre-operative photographs with detailed region or regions to be treated, taking care to
diagrams and sketches are mandatory. avoid significant overlap of the laser pattern.
The number of passes with the laser is
dependent on the region of skin treated and
Technique of carbon dioxide laser
the laser characteristics. Usually 12 passes are
resurfacing
all that is required when treating periocular
Pre-operative skin preparation may be skin whilst 24 passes may be necessary in
necessary in certain patients. Prophylactic areas of thicker skin such as the forehead,
anti-virals, i.e. Zovirax and oral antibiotics cheeks or chin. All desiccated tissue must be
are frequently used and started 24 hours carefully wiped away with saline swabs after
pre-operatively. If limited areas are being each pass (Figure 8.6). Assessment of the
resurfaced, i.e. periocular or perioral regions depth of treatment is facilitated by recognised
only, then local anaesthesia, either infiltrative colour changes occurring in the tissues.
86
COSMETIC SURGERY
88
9 Socket surgery
Carole A Jones
(a) (a)
(b) (b)
(c) (c)
placement of the orbital implant in this site An elliptical incision is made through the
posterior to Tenons capsule allows a larger skin and deep tissues to the bone of the orbital
volume to be implanted and reduces the rim. The periosteum is separated from the
incidence of implant migration or extrusion. bony orbit; the trochlea, medial and lateral
The orbital implant may be of inert material, for canthal tendons are detached. The apical
example silicone ball or one that allows structures, including the optic nerve, are cut
fibrovascular ingrowth, for example Medpor and the orbital contents are removed within
and Hydroxyapatite. Implants are wrapped in a the periosteum. The orbit may be allowed to
synthetic mesh or donor sclera.The four rectus heal by granulation or a split skin graft used to
muscles are attached to the implant. The line the bony cavity.
superior rectus should not be placed too If the eyelid skin is to be preserved the
anteriorly to minimise the incidence of upper lid periorbital skin is undermined, the lid margins
retraction or ptosis.When using Hydoxyapatite, are sacrificed and the resultant skin edges
holes should be made in the wrap to allow the sutured together. The dead space behind the
attachment of the extra ocular muscles and skin is gradually obliterated as the skin
to facilitate fibro-vascular ingrowth. Muscle adheres to the bony orbit. Any attempt to
sutures are then placed through the conjunctival replace the volume within the orbit using a
fornices to improve prosthesis mobility.Tenons thick skin flap or temporalis muscle may make
capsule and conjunctiva are closed carefully in the detection of local recurrences more
two layers. A conformer, with a large central difficult.
drainage hole should be inserted post
operatively and left in place until a prosthesis is
fitted at approximately six weeks. Orbital implants
Enucleation is not appropriate in the When the globe is removed its volume
presence of endophthalmitis nor where a cannot be replaced solely with an ocular
malignant tumour may have spread to extra- prosthesis. By replacing orbital volume in the
ocular structures. In this case an exenteration form of a orbital implant a light artificial eye
should be performed. An orbital implant is can be fitted.
normally inserted at the time of primary
enucleation but may be avoided in the
presence of intraocular malignancy or in a Box 9.1 Calculation of implant
very inflamed orbit where the incidence of volume
post operative extrusion is high.
Globe volume 8ml
Implant volume globe volume
Exenteration
prosthesis volume
This involves the total excision of the orbital 8ml 2ml
contents, with or without the removal of the
eyelids. Indications for this surgery are Ideal implant volume 6ml
advanced malignancy, either of the eyelid, the
globe or surrounding adnexal structures. The
extent of the procedure depends upon the size Many shapes have been suggested but a
and extent of the tumour. If the tumour of the sphere is routinely used as it has the
globe does not involve the eyelid skin the lids maximum volume for a given surface area. An
may be retained but they must be sacrificed in 18mm sphere has a volume of 3ml and when
the presence of an extensive skin tumour. wrapped this increases to 4ml. Studies have
91
PLASTIC and ORBITAL SURGERY
shown that patients may require larger implants have led to a high extrusion rate.
volume. More recently a conoid shape with a Hydroxyapatite, as it becomes fully integrated
flat front surface has been suggested. with fibro-vascular ingrowth, allows direct
In 1885 Mules first suggested the insertion coupling of the orbital implant and prosthesis.
of a glass ball into the scleral cup. Following implantation and integration of the
Subsequently inert materials such as silicone Hydroxyapatite a drill hole is placed, into
and methyl methacrylate have been which a peg can be inserted.This can be made
developed. More recently, a natural to fit a depression in the artificial eye which
component of coral reefs known as porous can further improve prosthesis mobility
hydroxyapatite has proved to be an ideal although it is not always necessary.
implant material. This allows fibro-vascular
ingrowth, the implant becoming fully Complications of orbital implants
integrated rather than forming a sequestrated
Extrusion of implant
foreign body, as was the case with inert ball
implants. Synthetic and cheaper forms of Early (in the first six weeks)
hydroxyapatite and other integrateable Inadequate suturing of Tenons
materials such as Medpor (porous capsule and conjunctiva
polyethylene) are also now available. Infection
Orbital implants are generally wrapped to Too large an orbital implant
allow ease of placement and to allow Late
attachment of the extra-ocular muscles. Inert Chronic infection
implants are best inserted posterior to Tenons Pressure necrosis
capsule whilst hydroxyapatite should be Poorly fitted prosthesis
inserted within Tenons capsule. Inappropriate orbital implant.
The aim of orbital implantation is to
increase orbital volume and promote Early extrusion may be controlled with
prosthesis mobility. It is essential that the resuturing of Tenons capsule and conjunctiva.
orbital implant is stable and does not extrude. Chronic extrusion requires patching the
Until recently attempts to improve mobility in extruded area with sclera or fascia lata. In the
the form of partially exposed peg-type presence of infection removal of the orbital
implant may be necessary.
do not fare well in extensively traumatised be left in for up to 3 weeks and removed in
sockets nor in severely contracted sockets with stages.
poor vascularity. Wound infection this is minimised by the
De-epithelialised dermofat is harvested routine use of post operative systemic
from a donor site, generally the upper outer antibiotics.
quadrant of the buttocks. Here, even in thin
individuals, a moderate degree of fat exists
By harvesting dermofat from the upper
and the donor site is easily hidden.
outer buttocks post operative discomfort and
A horizontal ellipse is marked of
unsightly scarring are minimised.
appropriate size allowing a circle of 25cm
diameter of dermis with attached fat of 34cm
in depth to be harvested. The size of the graft Socket
should be tailored to the amount of orbital
replacement required, allowing for an Early
expected shrinkage of at least 25%. One per Graft failure, partial.
cent lignocaine with adrenaline is injected Here, central necrosis and ulceration
superficially into the dermis to allow a split occurs as vascularisation of the centre
skin graft to be taken. Once the epithelium has of the graft is delayed. This area
been removed in this way the ellipse of dermis, frequently heals with time or if
with attached fat to a depth up to twice the necessary the central avascular ulcer
diameter of the dermis, is removed. 30 catgut can be excised and the edges sutured
is used to close the fat and 40 black silk or directly.
nylon to close the skin. A pressure dressing Graft failure, total.
should be applied and the patient should be Here, shrinkage and pallor of the graft
advised not to soak the wound in a bath until occurs within the first few weeks
it is fully healed. following the operation. If
The socket is prepared as for the insertion appropriate, repeated surgery may be
of other orbital implants. All measures to necessary.
encourage vascularity of the graft are taken. Infection minimised by routine post
These include opening Tenons capsule to operative systemic antibiotics.
encourage ingrowth of blood vessels,
attachment of four rectus muscles to the graft Late
and suturing the conjunctiva and Tenons Residual epithelium if skin and
capsule to the surface of the graft. If muscles conjunctiva co-exist this can be
cannot be identified the subconjunctival associated with a creamy discharge
fibrous tissue should be opened and sutured from the socket which may
to the graft as this will contain the muscle require removal of the residual skin
insertions. Particular care should be paid to epithelium.
haemostasis and minimal handling of the graft Hair growth hair may appear on the
to maximise graft survival. surface of the graft. This often
disappears within a period of months, if
Complications not the hair can be removed by
electrolysis.
Donor site
Granuloma formation post operative
Wound dehiscence avoid physical activity granulomas may need to be removed
and soaking of the skin edges. Sutures can surgically.
93
PLASTIC and ORBITAL SURGERY
The volume deficient socket Lower lid laxity the degree of lower lid
(post-enucleation socket laxity and the strength of the medial
canthal tendon should be assessed. The
syndrome) inferior fornix depth should be reviewed as
Main features lid laxity may be associated with a shallow
inferior fornix.
Enophthalmus
Ptosis To correct the features of the volume
Deep upper lid sulcus deficient socket its components must be
Lax lower lid. managed in an appropriate order. Volume
replacement is the primary requirement
With the loss of the globe and post followed by the surgical correction of the lax
operative fat atrophy enophthalmos of the lower lid and shallowing of the inferior fornix.
prosthesis occurs. Attempts to improve this by Finally, once all other features have been
fitting a larger artificial eye lead to lower lid resolved, any residual ptosis can be addressed
laxity and downward displacement of the following the principles described in ptosis
lower lid with the loss of the inferior fornix surgery elsewhere.
and associated deepening of the upper lid By supplementing orbital volume and
sulcus. The prosthesis no longer provides an correcting enophthalmos, a lighter well-
adequate fulcrum for the levator muscle so positioned prosthesis will provide a better
ptosis results. In some cases retraction of the fulcrum for levator. The prosthesis becomes
upper lid rather than ptosis is seen as a feature more stable and cosmetically acceptable.
of a volume deficient socket. This is due to
retraction of the levator complex with Replacement of orbital volume with an orbital
posterior rotation of the orbital contents. This implant. Where an inadequate orbital
further deepens the superior sulcus and there implant exists this should be replaced with
is associated forward redistribution of the a larger implant. The details of this
orbital fat and upward displacement of the procedure are covered in the section on
inferior rectus, all resulting in a backwards tilt enucleation (page 93). In the presence of a
of the prosthesis. previously extruded orbital implant,
autogenous material such as dermofat
should be employed, as described earlier.
Management of post-enucleation Replacement of orbital volume with sub-
socket syndrome periosteal implant. Using a subciliary
Each of the features of the post enucleation blepharoplasty approach a skin and muscle
syndrome should be assessed: flap is raised to expose the inferior orbital
rim.The periosteum is incised and elevated
Enophthalmos evident clinically but may to reveal the orbital floor. A flat topped,
be quantified using exophthalmometry wedge shaped block of silicone or Medpor
measurements. is inserted deep into the periosteum this
Ptosis assessment of the degree of ptosis acts to elevate the orbital contents,
and amount of levator function is necessary. displacing them superiorly and anteriorly.
The margin reflex distance and skin crease The periosteum is closed with 4/0 Vicryl
should be recorded. The tarsoconjunctival and the skin and muscle flap sutured using
surface should also be examined. 6/0 black silk.
Deep upper lid sulcus evident as hollowing Horizontal lid laxity. A full thickness lid
above the upper lid. resection or lateral tarsal strip should
94
SOCKET SURGERY
Conjunctival inclusion cysts produced by closure over the prosthesis. In mild cases of
implantation of conjunctiva or epithelial socket contracture entropion correction is
downgrowth at the site of implant often sufficient but if the socket is grossly
extrusion contracted, a mucous membrane graft may be
Granuloma formation. necessary. Lid surgery, which repositions the
puncta improving epiphora, may be necessary
Lids but if nasolacrimal or canalicular blockage
Poor closure. Shortage of skin and/or exists lacrimal drainage surgery may be
conjunctiva; implant too large required.
Infected focus. Blepharitis or meibomianitis.
Further reading
Socket lining Collin JRO. Socket surgery. A manual of systemic eye lid surgery.
London: Churchill Livingstone, 1989.
Dutton JJ. Coralline Hydroxyapatite as an ocular implant.
Attempts at surgical correction using a Ophthalmology 1991; 98:3707.
mixture of skin and mucous membrane can Jones CA, Collin JROC. A classification and review of the
lead to chronically discharging socket. causes of discharging sockets. Trans Ophthal Soc UK 1983;
103:3513.
Jordan DR, Allen L, Ells A et al. The use of Vicryl mesh to
Lacrimal system implant hydroxyapatite implants. Ophthal Plast Reconstr
Surg 1995; 11:959.
Defective tear production. Resulting in dry Jordan DR, Gilberg SM, Mawn L, Grahovac SZ. The
synthetic Hydroxyapatite implant: a report on 65 patients.
socket with crusting of secretions on the Ophthal Plast Reconstr Surgery 1998; 14:2505.
surface of the prosthesis Kaltreider SA, Jacobs LJ, Hughes MO. Predicting the ideal
implant size before enucleation. Ophthal Plast Reconstr
Defective tear drainage. Because of poorly Surg 1999; 15:3743.
positioned puncta or nasolacrimal Karesch JW, Dresner SC. High density porous polyethylene
(Medpor) as a successful anophthalmic socket implant.
blockage Ophthalmology 1994; 101:168896.
Infected focus. Such as dacryocystitis Levine MR, Pou CR, Lash RH. Evisceration: Is sympathetic
producing retrograde spread of infection. ophthalmla a concern in the new millennium. Ophthal
Plast Reconstr Surg 1999; 15:48.
McNab AA. Orbital Exenteration.Manual of orbital & lachrymal
All patients wearing prostheses should be surgery (2nd Ed.). Oxford: Butterworth Heinemann, 1998.
Nunery WR, Chen WP. Enucleation and evisceration. In:
advised to handle them as little as possible Bosniak S, ed. Principles and practice of ophthalmic plastic
In acute infection antibiotic drops should be and reconstructive surgery. London: WB Saunders, 1995.
Perry AC. Advances in enucleation. Ophthal Plast Reconstr
prescribed. In the case of chronic discharge Surg 1991; 7:17382.
both steroid and antibiotic drops may be Shaefer DP. Evaluation and management of the
anophthalmic socket and socket reconstruction. Smiths
effective after the socket has been swabbed Ophthalmic Plastic and Reconstructive Surgery (2nd
and the scraping sent for microbiology and Ed.). London: Mosby, 1997.
cytology. Regular polishing of the prosthesis Smit TJ, Koornneef L, Zonneveld FW, Groet E, Oho AJ.
Primary and secondary implants in the anophthalmic
and a viscus lubricant, usually polyvinyl orbit: pre-operative and postoperative computer
alcohol, may help to clear the prosthesis of tomographic appearance. Ophthalmology 1991; 98:10610.
Smith B, Petrelli R. Dermis fat graft as a movable implant
dried secretions. If the prosthesis is heavily within the muscle cone. Am J Ophthalmol 1978; 85:626.
caked patients should be advised to wash Soll DB. The anophthalmic socket. Ophthalmology 1982; 89:
40723.
the prosthesis in a mild household detergent. Thaller VT. Enucleated volume measurement. Ophthalmic
If the implant is extruding this should be Plast Reconstr Surg 1997; 13:1820.
Tyers AG, Collin JRO. Orbital implants and post-
addressed and conjunctival inclusion cysts or enucleation socket syndrome. Trans Ophthalmol Soc UK
granulomata excised. Lid and socket surgery 1982: 102:902.
should be performed to provide adequate
97
10 Investigation of lacrimal and orbital
disease
Timothy J Sullivan
10.1b). Enophthalmos may be seen with post- carotico-cavernous fistulae, or rarely with
traumatic enlargement of the orbital cavity, tumours having a significant arterial supply.
orbital venous anomalies, scirrhous tumours CSF pulsation occurs with the sphenoid wing
(typically breast or bronchial carcinoma) or hypoplasia of neurofibromatosis or after
with hemifacial atrophy (Figure 10.1c). surgical removal of the orbital roof.
Visual loss
Sudden loss of vision is often due to a
vascular cause and associated nausea and
vomiting suggests orbital haemorrhage.
Although periorbital or subconjunctival
ecchymosis may be evident at presentation,
(a)
often it does not track forward from the orbit
(and become visible) for several days. Vaso-
obliterative conditions, such as orbital
mucormycosis or Wegeners granulomatosis,
may also be associated with multiple cranial
nerve deficits.
Optic nerve compression generally causes a
progressive loss of function, which the patient
(b) will notice as failing colour perception and a
drab, washed-out and grey quality to
their vision. Slow-growing retrobulbar masses
may compress the globe and affect vision by
inducing hypermetropia (or premature
presbyopia) or by causing choroidal folds.
Gaze evoked amaurosis with visual failure
on certain ductions may occur with large
and slowly growing retrobulbar masses that
(c)
stretch the optic nerve.
(a)
(a)
(b)
(c)
incomplete closure are also very common and Figure 10.4 Signs typical of dysthyroid orbitopathy:
hallmarks of thyroid orbitopathy (Figure 10.4). (a) bilateral proptosis and upper lid retraction; (b) lid
An S-shaped contour of the upper lid may be lag, best demonstrated by asking the patient to follow
a slowly descending target; (c) lagophthalmos on
associated with a number of conditions: gentle eyelid closure; (d) festoons due to marked
plexiform neurofibroma of the upper eyelid, periorbital oedema.
101
PLASTIC and ORBITAL SURGERY
if present, confirms the diagnosis of peripheral pressure in the retinal venous circulation leads
neurofibromatosis; dacryoadenitis, either acute to loss of the spontaneous pulsation of the
or chronic, may be associated with inflammatory central retinal vein, and the presence or
signs; tumours or infiltration of the lacrimal absence of pulsation should be noted in both
gland.Anterior venous anomalies give a blue hue fundi.
to eyelid skin and xanthomatous lesions may Periocular sensory loss should be assessed,
present as a yellow plaque. as it provides a good guide to location of the
Corkscrew episcleral vessels suggest a low- orbital disease, and loss of corneal sensation
flow dural shunt (Figure 10.5a) or, in the must be noted.
presence of more extreme vessels and Examination of the nose and mouth is
chemosis, a small carotico-cavernous fistula important: palatal varices may indicate orbital
and these are often associated with a raised varices as a cause of spontaneous orbital
and widely-swinging intraocular pressure. haemorrhage, or the presence of a nasal mass
Markedly dilated, tortuous vessels with a or palatal necrosis may indicate a sino-orbital
palpable thrill or audible bruit suggest a high- tumour or infection (such as mucormycosis).
flow carotico-cavernous fistula or arterio-
venous malformation (Figure 10.5b). Raised
Signs of intraocular or systemic disease
Slit lamp bio-microscope examination of the
ocular surface and the anterior and posterior
segments should be performed: conjunctival
chemosis may be seen in inflammatory
conditions, including thyroid related
ophthalmopathy, and superior limbic kerato-
conjunctivitis is typically related to thyroid
orbitopathy. The pathognomonic Lisch nodules
of neurofibromatosis are readily apparent in
the postpubertal patient (Figure 10.6).
Anterior or posterior segment inflammation
may accompany the orbital inflammatory
(a)
syndromes as a secondary phenomenon.
(b)
With compression of the globe due to tight measurement of the field of binocular single
inferior recti in thyroid orbitopathy, the vision (BSV) and Hess chart is a useful and
measured intra-ocular pressure is often permanent record of binocular motility and
elevated during fixation in primary gaze; a balance in various orbital conditions, such as
true measure of the underlying pressure is thyroid ophthalmopathy, orbital fractures and
given by placing the chin forward, in front of orbital myositis.
the rest, and having the patient look in slight The clinical and imaging features of most
down-gaze. A widely-swinging pulsation of the orbital conditions will guide the clinician
mires during applanation tonometry suggests toward the correct diagnosis and for some
an arterio-venous communication affecting there may be appropriate systemic blood tests
the orbital circulation, or transmitted dural (Table 10.1). Diagnosis of specific forms of
pulsation as with dysplasia of the sphenoid inflammatory orbital disease remains elusive.
in neurofibromatosis.
Choroidal striae result from globe
indentation by an orbital mass, from optic
nerve meningiomas or can be idiopathic; the Table 10.1 Systemic investigations in orbital disease.
folds occur almost exclusively at the macula Orbital disease Tests for causative systemic diseases
and are not related to the position of the
Thyroid Ultra-sensitive TSH
orbital mass. Atrophy or swelling of the optic orbitopathy Free T3, Free T4
disc may be due to many causes and optico- TSH receptor antibodies
Anti-peroxidase antibodies
ciliary shunt vessels develop with longstanding Anti-thyroglobulin antibodies
optic nerve compression as, for example, with Orbital cellulitis Full blood count
optic nerve meningioma. Blood cultures
The regional lymph nodes should be (Cultures of abscess contents)
Orbital ultrasonography
With orbital diseases, ultrasonography is
principally of value in examination of the
intraocular structure (where ultrasonographic
resolution is greater than CT or MRI) and for
the examination of vascular size and flow-rates,
using colour-coded Doppler ultrasonography. It
is, therefore, particularly useful for the detection
of small intraocular tumours, intraocular
tumours in the presence of opaque media,
(a)
scleritis and inflammation in the posterior
Tenons space, arterio-venous malformations
and low- or high-flow vascular shunts.
With orbital vascular anomalies, there may be
not only enlargement of the superior ophthalmic
vein (compared with the normal side), but also
an arterial wave-form to the flow, together with
reversal of direction of flow within the vein.
Computed tomography
As the orbit and surrounding sinuses have (b)
tissues with naturally high radiographic
Figure 10.7 A patient with dysthyroid orbitopathy,
contrast, thin-slice computed tomography is showing gross proptosis and enlargement of extraocular
the most effective and economical tool for the muscles, as imaged by (a) axial and (b) coronal soft
initial imaging of the orbit (Figure 10.7). tissue CT scans through the mid-orbits.
For a suspected orbital mass, a single run of
axial scans with intravenous contrast (unless
contraindicated), together with coronal
reformats images, is generally sufficient to give
a probable diagnosis and allow planning of
surgery or medical therapy; if needed, direct
coronal imaging may give greater detail of the
relationship of the mass to the optic nerve or
rectus muscles. For planning the repair of
blowout fractures, or the diagnosis and
treatment of thyroid orbitopathy, a single run
of direct coronal scans (without contrast) is Figure 10.8 Parasagittal reformatted CT, imaged
along the line of the vertical recti, showing the inferior
often sufficient. Parasagittal reformats along rectus muscle to be free from the site of a repaired
the plane of the vertical recti and optic nerve orbital floor fracture.
may also be of help in orbital floor trauma and
in evaluating the relationship of lesions to the both soft tissue and bone window settings.
optic nerve (Figure 10.8). Spiral CT allows greatly reduced imaging
For orbital pathology arising in bone, or time and three-dimensional studies may be
where secondary bone invasion is suspected, of help in planning major cranio-facial
then it is important to obtain images with reconstruction (Figure 10.9).
104
INVESTIGATION of LACRIMAL and ORBITAL DISEASE
(a)
Figure 10.9 Three-dimensional CT reformat for a
patient with severe clefting of the facial soft tissues
and bone.
(b)
Ancillary tests for lacrimal
assessment
Dacryocystography
Dacryocystography provides very good
anatomical detail of the outflow system
revealing occlusion, stenosis or dilatation of
the outflow tract and also, in some cases,
diverticulae, stones, or tumour (Figure 10.17)
but does not give a true measure of the
(c)
physiological function. However, where the
system is patent during injection of contrast,
Figure 10.15 Analysis of lacrimal probing and the failure of spontaneous clearance of oil-
syringing: (a) hard stop with a patent canalicular based contrast media after the patient resumes
system; (b) medial soft stop with obstruction of
common canaliculus; (c) lateral soft stop due to
lower canalicular obstruction.
(a) (b)
(c) (d)
Figure 10.17 Dacryocystography showing: (a) an anatomically normal left system but a dilated right lacrimal
sac with filling defect due to a stone; (b) an anatomically normal right system (although contrast reflux suggests
distal stenosis within the outflow tract) and a tiny, non-functional left surgical anastomosis after endonasal
dacryocystorhinostomy, (c) a small right and large left mucocoele; (d) a functional right dacryocystorhinostomy
with direct drainage of contrast to the nasal space.
Computed tomography
Computed tomography is indicated when a
lacrimal sac tumour is suspected and may be
helpful in planning surgery for trauma cases,
Figure 10.19 Lacrimal scintigraphy showing a
particularly when plating systems have been
normal right drainage pattern but a marked delay in used. Craniofacial disorders and sclerosing
the exit of tracer from the left lacrimal sac. bony dysplasias may have unusual bone
anatomy shown on CT, and these changes
examination or dacryocystography (Figure may influence the approach to surgery and the
10.19). In this situation, scintigraphy will prognosis.
111
11 Dysthyroid eye disease
Carol Lane
Dysthyroid eye disease is the commonest cause rarely with primary hypothyroidism. The high
of proptosis in adults and the disease typically correlation between Graves disease and
presents as Graves disease in the third and orbital disease suggests a shared antigen,
fourth decade, with a four- to seven-fold such as TSH receptor, thyroglobulin or
predominance in females. Bilateral orbital thyroid peroxidase. Circulating activated T
inflammation is often accompanied by eyelid lymphocytes infiltrate the orbital tissues,
retraction and restriction of ocular movements. where they release cytokines which, in turn,
Asymmetrical involvement and extensive stimulate proliferation of fibroblasts and
fibrosis are less frequent presentations and the deposition of glycosaminoglycans (GAGs).
diagnosis of dysthyroid eye disease should Intense lymphocytic infiltration, fibroblast
always be suspected in the presence of any proliferation and perimysial oedema result in
inflamed orbit or with proptosis. expansion of orbital contents and proptosis.
Sight is threatened by corneal exposure due Subsequent fibrosis of involved perimysial
to incomplete eyelid closure over a proptotic connective tissue results in varying degrees of
globe, uncontrolled ocular hypertension or muscular contracture.
optic nerve compression. One-fifth of patients Hales and Rundle described the natural
with untreated compressive optic neuropathy history of dysthyroid eye disease, with the
develop irreversible visual impairment (to disease typically peaking after six months
6/36 or less). and active inflammation resolving within 18
Treatment of dysthyroid eye disease aims to months. Of 67 patients followed for an average
conserve or restore normal visual function, of 15 years, those with gross eye disease
relieve ocular pain and achieve an acceptable persisting for more than six months after control
appearance. of thyroid status had a worse outcome. The
disease tends to be more severe in males and in
smokers, and the elongated myopic globe is at
Pathogenesis greater risk of exposure keratopathy, whereas a
In Graves hyperthyroidism it is likely that tight orbit without proptosis is at greater risk of
thyroid damage leads to activation of compressive optic neuropathy (Figure 11.1).
autoimmune thyroid disease by activation of
anti-receptor antibodies to the thyrotrophin Features of dysthyroid eye
receptor (TSH receptor). Eye disease is
disease
clinically evident in 40% of patients with
Graves disease but, in contrast, in only 3% of Although Werners early NOSPECS
patients with Hashimotos thyroiditis and very classification of dysthyroid eye disease
112
DYSTHYROID EYE DISEASE
may be needed when the eye disease has been radiotherapy is more effective than treatment
shown to be stable and inactive for some of orbitopathy with steroids alone. As there
months. may be an increase in orbital inflammation
Management of more severe and significant and oedema whilst undergoing orbital
thyroid eye disease should be first directed radiotherapy, it is prudent to continue a
towards suppression of orbital inflammation moderate steroid dosage (for example,
and later the restoration of orbital function. prednisolone 20mg daily) during this
treatment.
Suppression of orbital
inflammation in dysthyroid eye Surgical rehabilitation of the
disease patient with dysthyroid eye disease
Patients with significant signs or symptoms Severe conjunctival chemosis is self-
of active orbital inflammation, or with optic perpetuating due to the throttling effect of
neuropathy or significant exposure keratopathy, the lower eyelid on the prolapsed conjunctiva
should receive systemic therapy to reduce the and will, in some patients, prevent eyelid
degree of orbital inflammatory congestion. closure (Figure 11.3a). After subconjunctival
Those with an activity score of 3 or more are injection of local anaesthetic with adrenaline,
likely to benefit, as are those with a muscle drainage of subconjunctival fluid and
oedema shown on STIR-sequence MRI. placement of Frost sutures in the upper and
Systemic steroids at high dosage (either lower eyelids will typically allow closure of the
intravenous methyl prednisolone or oral eyelids under an occlusive dressing, with
prednisolone) should be administered and the topical application of a steroidal ointment
patient checked for improvement after a few (Figure 11.3b). This typically produces a
days. The patient should be monitored for dramatic improvement within 12 hours
hyperglycaemia and hypertension during (Figure 11.3c), allows the cornea to rehydrate
treatment and the prescription of a gastric and gives time for systemic antiinflammatory
proton-pump inhibitor or Histamine-2 therapy to act.
receptor antagonist considered; patients on Orbital decompression is necessary if visual
long-term steroids, especially the elderly, function deteriorates despite the use of high-
should be given calcium supplementation to dose systemic steroids (Figure 11.1b). As
counteract steroid-induced osteoporosis. If compression of the optic nerve occurs mainly
systemic steroids produce an improvement in at the orbital apex, decompression for visual
the inflammatory orbitopathy, the dosage failure must include removal of the posterior
should be slowly reduced towards about 20mg part of the medial wall (Figure 11.4); in a few
daily if possible and the patient referred for patients the most posterior part of the medial
low-dose, (20002400 cGy) lens-sparing wall being the lateral wall of the sphenoid
radiotherapy to the posterior tissues of the sinus. Pre-operative CT is required to confirm
orbit; some authors consider radiotherapy the diagnosis (especially with unilateral
contraindicated in diabetics, as it may hasten disease), to exclude underlying sinus disease
the development of retinopathy. and to detect any cranio-facial anomalies,
Steroids probably suppress dysthyroid such as a midline encephalocoele.
orbitopathy by inhibition of the production of Although Olivari has described reduction of
cytokines by activated T cells and macrophages proptosis by meticulous excision of orbital fat
and fibroblasts within the orbit. It has been from the intraconal and extraconal spaces,
reported that treatment with steroids and most orbital decompressions involve removal
115
PLASTIC and ORBITAL SURGERY
(a)
(a)
(b)
Figure 11.4 Patient referred with persistent
compressive optic neuropathy on the left side, due to
the failure to remove the posterior half of the left
medial orbital wall.The right side had successful relief
of optic neuropathy after a complete ethmoidectomy
(b) reaching the orbital apex.
(c)
(d)
(a)
(b) (e)
(c)
The lamina papyracea is infractured lid swinging flap), provides excellent access
medially and the ethmoidectomy completed, to the orbital floor, although decompression
keeping posterior to the posterior lacrimal of the medial wall requires greater dexterity
crest and below the level of the anterior than with the Lynch approach as access is
ethmoidal artery; bone excision is continued more restricted. A 12 cm extension of the
inferiorly until the medial part of the orbital canthotomy into the lateral part of the upper
floor is removed. The periosteum is incised eyelid skin crease (Figure 11.8a) eases access
widely, to allow free prolapse of orbital fat into to, and decompression of, the lateral wall.
the areas of bone removal, and the anterior A horizontal canthotomy of 1.5 cm is made
periosteal incision and superficial tissues and the orbicularis oculi cauterised and
closed in layers. divided infero-laterally to the orbital rim;
division of this muscle must be continued
until there is a clear release of the lateral
Extended lateral canthotomy approach
tethering of the lower eyelid. The conjunctiva
The lateral canthotomy approach is divided at a point 1 mm below the lower
(Figure 11.7), with extension of the incision border of the lower tarsus and the conjunctival
along the lower conjunctival fornix (the lower edge attached to the upper eyelid with a
118
DYSTHYROID EYE DISEASE
(d)
(a)
(e)
scalp incision closed with surgical staples. A second image is distracting or dangerous.
firm scalp dressing is applied and the vacuum Where there is no risk with diplopia as, for
drains maintained until dry. example, with watching television the
patient should be encouraged to try and fuse
the two images.
Post operative management and Other complications, such as persistent
complications infraorbital neuropraxia, nasolacrimal duct
The patient should be nursed half-seated on obstruction with epiphora, or secondary lower
bed-rest, to minimise post operative swelling, lid entropion, are uncommon. Likewise,
and (where accessible) the pupils checked for a major intraoperative or post operative
few hours after surgery. If the patient complains (Figure 11.9b) haemorrhage, or loss of
of severe or increasing pain, the affected side cerebro-spinal fluid is relatively rare.
should be examined for signs of rising
intraorbital pressure due to haemorrhage and
appropriate measures taken if it is impairing
optic nerve function.
Post operative antibiotics and anti-
inflammatory drugs (such as prednisolone
80mg daily, tailing over about ten days)
should be administered and the patient
instructed to avoid nose-blowing and
strenuous exercise over this period. Forced
ocular ductions are to be encouraged, as this
(a)
probably encourages clearance of post
operative oedema and recovery of normal
ocular balance and movements.
With administration of post operative
systemic antibiotics, early infection is rare but
sinusitis, particularly maxillary, can be a
recurrent late complication of decompression
and may require middle meatal antrostomy or
other corrective procedure. Under- or over-
correction of the proptosis may occur
(Figure 11.9a) and, very rarely, the latter
(enophthalmos) may be accompanied by
hypoglobus. (b)
Loss of vision is extremely rare, but the Figure 11.9 Complications of orbital decompression:
(a) late enophthalmos due to maxillary atelectasis; (b)
patient must be made aware of this remote limited orbital haemorrhage after third-time revisional
possibility prior to surgery. orbital decompression.
Diplopia is almost universal after surgery,
will settle within a few weeks in most cases, Further reading
but presents the greatest practical problems
Bartalena L, Marcocci C, Bogazzi F et al. Relation between
with the activities of daily living. If diplopia is therapy for hyperthyroidism and the course of Graves
troublesome, it is worthwhile occluding one ophthalmopathy. New Engl J Med 1998; 338:738.
Burch HB, Wartofsky L. Graves ophthalmopathy: current
eye in the early post operative period for those concepts regarding pathogenesis and management.
activities (such as descending stairs) where a Endocrinology Rev 1993; 14:74793.
121
PLASTIC and ORBITAL SURGERY
Char DH. Thyroid eye disease (3rd ed.) Boston: Butterworth- Mourits MP, Koornneef L, Wiersinga WM, Prummel MF,
Heinemann, 1997. Berghout A, van der Gaag R. Orbital decompression for
Claridge KG, Ghabrial R, Davis G et al. Combined Graves ophthalmopathy by inferomedial, by inferomedial
radiotherapy and medical immunosuppression in the plus lateral, and by coronal approach. Ophthalmology
management of thyroid eye disease. Eye 1997; 11:71722. 1990; 97:63641.
Consensus of an ad hoc committee. Classification of eye Naniaris N, Hurwitz JJ, Chen JC, Wortzman G. Correlation
changes of Graves disease. Thyroid 1992; 2:2356. between computed tomography and magnetic resonance
Fatourechi V, Garrity JA, Bartley GB, Bergstralh EJ, imaging in Graves orbitopathy. Can J Ophthalmol 1994;
DeSanto LW, Gorman CA. Graves ophthalmopathy. 29:919.
Results of transantral orbital decompression performed Olivari, N. Transpalpebral decompression of endocrine
primarily for cosmetic indications. Ophthalmology 1994; ophthalmopathy (Graves disease) by removal of
101:93842. intraorbital fat: experience with 147 operations over 5
Garrity JA, Fatourechi V, Bergstralh EJ et al. Results of years. Plast Reconstr Surg 1979; 87:62741.
transantral orbital decompression in 428 patients with Perros P, Crombie AL, Kendall-Taylor P. Natural history of
severe Graves ophthalmopathy. Am J Ophthalmol 1993; thyroid associated ophthalmopathy. Clin Endocrinol Oxf
116:53347. 1995; 42:4554.
Hales JB, Rundle FF. Ocular changes in Graves disease: a Prummel MF, Wiersinga WM. Medical management of
long term follow-up study. QJM 1960; 29:1139. Graves ophthalmopathy. Thyroid 1995; 5:2314.
Kalmann R, Mourits MP, van der Pol JP, Koornneef L. Prummel MF, Wiersinga WM, Mourits MP et al. Effect of
Coronal approach for rehabilitative orbital decompression abnormal thyroid function on severity of Graves
in Graves ophthalmopathy. Br J Ophthalmol 1997; ophthalmopathy. Arch Intern Med 1990; 150:1098101.
81:415. Shine B, Fells P, Edwards OM, Weetman OP. Association
Lyons CJ, Rootman J. Orbital decompression for disfiguring between Graves ophthalmopathy and smoking. Lancet
exophthalmos in thyroid orbitopathy. Ophthalmology 1994; 1990; 335:12613.
101:22330. Tagami T, Tanaka K, Sugawa H, et al. High-dose intravenous
McCord CD Jr. Orbital decompression for Graves disease; steroid pulse therapy in thyroid-associated opthalmopathy.
exposure through lateral canthal and inferior fornix Endocr J 1996; 43:68999.
incision. Ophthalmology 1981; 88:53341. Trokel S, Kazim M, Moore S. Orbital fat removal.
Metson R, Dallow RL, Shore JW. Endoscopic orbital Decompression for Graves orbitopathy. Ophthalmology
decompression. Laryngoscope 1994; 104:9507. 1993; 100:67482.
Mourits MP, Koornneef L, Wiersinga WM, Prummel MF, Werner SC. Classification of changes in Graves disease.
Berghout A, van der Gaag R. Clinical criteria for the J Clin Endocrinol Metab 1969; 29:9829.
assessment of disease activity in Graves ophthalmopathy; Wulc A, Popp JC, Bartlett SP. Lateral wall advancement in
a novel approach. Br J Ophthalmol 1989; 73:63944. orbital decompression. Ophthalmology 1990; 97:135869.
122
12 Benign orbital disease
Christopher J McLean
Benign orbital diseases, for many of which the fashion. A dermoid cyst contains dermal
clinical history and examination findings are structures (hairs, sebaceous glands), whereas
diagnostic, cover a wide spectrum. The more rarely there is only an epithelial
incidence varies with age but, although (epidermoid cyst) or a conjunctival lining
obviously dependent upon referral patterns, in (conjunctival dermoid).
childhood the most common benign lesions Implantation cysts may arise and develop in
are dermoid and epidermoid cysts (637%), a similar fashion to congenital dermoids, but
capillary haemangiomas (813%) and trauma do not respect the characteristic anatomic
(7%), whereas adult series are typically sites of the latter and will generally present in
dominated by thyroid orbitopathy (Chapter patients with a past history of periocular
11), orbital trauma (Chapter 14) and orbital trauma.
infections. The commonest dermoid cysts are firm and
smooth, mobile preseptal masses overlying the
supero-temporal quadrant of the orbit and,
Benign cystic anomalies of the less commonly, the supero-nasal quadrant.
orbit Many cysts have a variable periosteal
attachment near the underlying fronto-
Orbital cysts generally arise from
zygomatic or fronto-ethmoidal sutures, but
epithelium sequestered within the orbit during
occasionally the dermoid will pass into or
embryological development, by implantation
through defects in the neighbouring bone. In
after trauma or due to expansion of epithelial-
some cases the dermoid is incompletely
lined sinus lesions into the orbit.
separated from the skin surface and presents
as a chronically inflamed and discharging
Dermoid and epidermoid cysts
sinus (Figure 12.1).
These lesions arise from surface epithelium A clinically characteristic lesion presenting
implanted at sites of embryological folding in childhood does not require radiological
and, if situated anteriorly within the orbit, are investigation if anteriorly situated and mobile.
commonly noted soon after birth. Due to the Likewise, fixed anterior masses do not
accumulation of epithelial debris and necessitate imaging, provided the orbital
sebaceous oil in the lumen of the cyst, the surgeon is adequately experienced to follow
cysts slowly enlarge and leakage of the the lesion to its limits if necessary within
contents into the surrounding tissues may the orbital depths. Deep orbital dermoids,
cause marked inflammation with deeper often presenting as orbital inflammation or
dermoid cysts tending to present in this proptosis, require thin-slice CT with bone
123
PLASTIC and ORBITAL SURGERY
ductules. To avoid adherence between the therapy and drainage of the orbital abscess if
lateral rectus and the orbital rim, only fat threatening vision. Once the infection has
anterior to the rim should be removed and been shown to be under control, the
this abnormal cutaneous fat has a subtle plane mucocoele and other sinus disease should
of dissection free from the normal orbital fat. receive definitive treatment under the care of
Incautious excision of dermolipomas is a an otorhinolaryngologist. In general,
source of medico-legal cases, as there is a treatment involves removal of the mucocoele
significant risk of damage to the lacrimal gland lining and re-establishment of a new drainage
ductules, restriction of eye movements and pathway for the affected sinus.
ptosis if the lesions are not managed properly. Orbital cellulitis secondary to infected
mucocoeles may lead to an orbital abscess or
Paranasal sinus mucocoeles the formation of a transcutaneous fistula,
typically in the medial aspect of the upper
Mucocoeles, most commonly in the
eyelid. Late presentation of mucocoeles within
anterior ethmoid and frontal sinuses, are
the sphenoid or posterior ethmoid sinuses can
slowly-enlarging, mucus-filled, cystic lesions
lead to compressive optic neuropathy and
that arise from paranasal sinus mucosa and
irreversible visual loss.
gradually encroach into the orbit; occasionally
the contents of a mucocoele become infected,
which may lead to orbital cellulitis. Most Cranial and orbital anomalies
mucocoeles will present with a gradual
displacement of the globe and proptosis Microphthalmos with cyst
(Figure 12.3), although those of the maxillary
sinus may lead to collapse of the orbital floor Microphthalmos with cyst arises from
and secondary enophthalmos. incomplete closure of the fissure in the optic
The CT appearance of a mucocoele is a vesicle, with formation of a cyst below a
cystic cavity smoothly expanding the bone of microphthalmic globe. The cysts can vary
a paranasal sinus and necessary with patchy greatly in size and may slowly enlarge.
thinning or loss of bone. T1- and T2-weighted Small cysts can be left and may be in
MR images can show a wide variation in communication with the vitreous cavity. Large
signal intensities due to continuing changes in cysts are cosmetically unacceptable, cause
the contents of the mucocoele. excessive orbital bony expansion, and
Severe acute sinusitis or orbital cellulitis generally need to be removed together with
requires admission for intravenous antibiotic the microphthalmic globe; a ball implant can
be placed at the same operation and, in all
cases, a suitable fornix conformer must be
placed (Chapter 9).
Excision of small or moderately sized orbital
cysts may retard orbital growth and lead to
problems with prosthetics fitting later in life.
Ball implantation can, on occasion, be difficult
due to abnormal extraocular musculature.
Cephalocoeles
Figure 12.3 Outward displacement of the left globe Congenital clefts of the skull, with
due to ethmoidal mucocoele. herniation of intracranial contents, leads to
125
PLASTIC and ORBITAL SURGERY
When the haemangioma has regressed, it and these tend to present early due to optic
may be necessary to remove redundant neuropathy. On MRI scanning, cavernous
atrophic eyelid skin or correct ptosis resulting haemangiomas are hypointense to fat on T1-
from disinsertion of the levator muscle weighted images and isointense to vitreous
aponeurosis. and hyperintense to fat and vitreous on T2-
The complications of intralesional steroid weighted images.
injections are necrosis of the skin overlying the Patients with asymptomatic tumours,
capillary haemangioma, and atrophy of discovered by chance on imaging for other
subcutaneous fat or dermis. Rarely growth reasons, can be monitored for orbital signs
retardation and blindness have been reported and many presumed haemangiomas show
with this therapy. minimal change over many years. Indications
for removal include optic neuropathy,
proptosis and diplopia.
Cavernous haemangiomas Lateral orbitotomy with intact excision of
Cavernous haemangioma is the most the tumour is usually required, as many
common benign orbital tumour of adults and haemangiomas are large and intraconal. The
may be a developmental hamartoma that tumour typically is like a purple plum and
presents late in life, typically in the fourth or contains large blood-filled cystic spaces.
fifth decades, with gradually increasing
Method for lateral orbitotomy
painless proptosis. It is usually solitary and lies
in the retrobulbar space, thereby causing axial An upper eyelid skin-crease incision is
proptosis, induced presbyopia, choroidal folds extended laterally to about 1cm below the
and optic disc congestion. There is often a lateral canthus (Figure 12.6a) and the tissues
global reduction in the extremes of eye opened to the supero-lateral orbital rim. The
movement. periosteum is incised 6mm outside the rim,
CT scanning reveals a well defined, round from the lateral one-third of the upper rim to
intraconal lesion that commonly displaces the the level of the zygomatic arch, the origin of the
optic nerve medially and, due to a very slow temporalis muscle separated from the bone over
blood flow, shows a very slow and patchy its antero-superior 2cm, and the periosteal
contrast enhancement (Figure 12.5). Some incision extended backwards over the zygomatic
haemangiomas are wedged in the orbital apex arch (Figure 12.6b).The periosteum is elevated
over the rim of the orbit and separated from the
inner aspect of the lateral wall, with particular
care being taken to cauterise and divide any
bridging vessels.Two parallel saw cuts are made,
in the coronal plane, at the upper and lower
ends of the lateral osteotomy, drill holes placed
either side of the cuts and the inner aspect of the
lateral wall fragment weakened 1cm behind the
rim, using a burr; the fragment is then broken
away and trimmed, to be swung outwards on
the temporalis muscle (Figure 12.6c), and the
periosteum opened to provide access for the
intraorbital procedure.
Figure 12.5 CT scan appearance of well-defined
intraconal cavernous haemangioma; the differential After achieving intraorbital haemostasis, a
diagnosis being the rarer orbital neurilemmoma. vacuum drain is placed within the intraconal
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PLASTIC and ORBITAL SURGERY
(a) (c)
(b) (d)
Figure 12.6 Lateral orbitotomy: (a) the largely hidden skin incision; (b) the periosteum being raised over the
lateral rim; (c) the lateral wall hinged outwards on temporalis muscle; (d) the bone fixed in position with a 4/0
absorbable suture.
space and passed out through the skin overlying accumulation of orbital haemorrhage and this
the temporalis fossa. The bone is swung may lead to irreversible visual loss. If this
medially into the correct position and fixed into emergency appears to be developing, the drain
place with a 4/0 absorbable suture passed should be moved slightly to see if drainage of
through the drill holes (Figure 12.6d). The fluid from the orbit occurs; if this does not
deep subcutaneous tissues over the outer succeed, the operative site should be reopened
canthus and further laterally are closed with a at the bedside, without delay, and any
4/0 or 5/0 absorbable suture and the skin accumulation of blood allowed to drain.
incision closed with a running 6/0 nylon suture. The vacuum drain is removed when active
The patient should be nursed upright after fluid drainage has ceased (usually 1218 hours
surgery and it is important that any severe or after surgery) and post operative systemic
increasing pain is reported. Where pain is anti-inflammatory medications at high dosage
severe or increasing, the vision in the affected are useful, particularly where there has been
eye and the state of the orbit should be manipulation in the region of the superior
checked; a very tense orbit with markedly orbital fissure or optic nerve. The patient
decreased vision, a relative afferent pupillary should refrain from vigorous exercise for 10
defect and loss of eye movements, suggests days after surgery, normal ocular ductions
128
BENIGN ORBITAL DISEASE
encouraged and the skin suture removed at Whilst an ophthalmologist should supervise
one week. the day-to-day management of visual
development of children with these
Complications malformations, the surgical management is an
ophthalmic specialist field, being both difficult
Excision of cavernous haemangiomas is
and liable to complication.
curative, although the induced hyperopia and
choroidal folds do not resolve in all cases. Lymphangiomas
Complications with removal of cavernous
haemangiomas are more related to the lateral These typically present between the ages of
orbitotomy and the need to displace tissues to 6 and 10 years, as haemorrhage within cystic
reach the tumour. It is common to get a spaces deep in the orbit (so-called chocolate
transient weakness of ocular ductions, cysts) or as superficial lesions with multi-
particularly abduction, and this typically loculated cysts of the conjunctiva or lid
improves over several weeks. Motor margin; proptosis and displacement of the
neuropraxias, which may recover over many globe occur as deep components enlarge.
months, are also fairly common with surgery An increase in the size of lymphangiomas
near the orbital apex and superior orbital during respiratory infections, possibly due to
fissure; post operative mydriasis, probably due lymphoid hypertrophy or vascular congestion,
to denervation at the ciliary ganglion, is is frequently noted with these malformations.
relatively common and may be permanent. Orbital CT scan will demonstrate irregular,
Blindness due to optic nerve compression or multi-loculated cystic opacities within the
ischaemia is a distinct risk with any surgery normal (but displaced) structures of an
involving the posterior half of the orbit. expanded orbit. Ultrasonography often shows
acoustically empty cystic spaces.
An attempt should be made to optimise
Orbital varices and
visual development in the eye affected by the
lymphangiomas
orbital malformation, with treatment of
Orbital varices and lymphangiomas are a anisometropia or astigmatism, and occlusion
spectrum of congenital low-pressure vascular of the unaffected eye where necessary.
malformations with venous-type channels that Complete surgical excision of orbital
typically are unilateral and may involve lymphangiomas is, effectively, impossible and
ipsilateral parts of the face and brain, as well would be liable to damage the interspersed
as the orbit. normal orbital structures. Surgery is,
In the absence of lymphatics from the therefore, reserved for debulking the lesion
human orbit, the term lymphangioma anterior to the equator of the globe to improve
appears to be a misnomer. It serves, however, cosmesis for example, where there is
to emphasise an important clinical distinction prolapse of abnormal tissues through the
between the two groups of low-pressure palpebral aperture. Otherwise deep
vascular anomalies that occur in various components may be drained or resected
admixtures within different patients. Varices where there is gross displacement of the globe
are largely blood-filled and generally in free or compressive optic neuropathy.
communication with the normal low-pressure Despite all efforts to maintain visual
vascular system of the orbit, whereas development, large lymphangiomas almost
lymphangiomas are largely isolated from inevitably result in some degree of amblyopia.
the venous system and have a much greater Compressive optic neuropathy may result
component of inflammatory infiltration. from large intraorbital haemorrhages and
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PLASTIC and ORBITAL SURGERY
Dural shunts
Dural shunts commonly present with a
chronic red eye (Figure 12.8) and are due to
a spontaneous fistula between a minor dural
vessel and the cavernous venous sinus. CT
Figure 12.7 CT scan of orbital varices in an scan shows orbital changes similar to those of
enlarged orbit. an intraorbital arterio-venous communication
130
BENIGN ORBITAL DISEASE
but, in addition, there may be engorgement of effective in 90% of cases and has a low
the ipsilateral cavernous sinus and possibly morbidity.
also some subtle changes in the contralateral
cavernous sinus and orbit. Doppler
ultrasonography is, again, valuable in the Benign lacrimal gland disease
diagnosis of these lesions.
Most low-flow dural arterio-venous shunts The lacrimal gland is liable to inflammation,
will resolve spontaneously over many months cysts and benign tumours, but these
and treatment (with arteriography and possible conditions can present in a similar fashion to
embolisation) is required only where a malignancy and this complicates the clinical
high-flow fistula is causing visual failure, management of these patients. Inappropriate
unacceptable proptosis, or persistent severe management of benign conditions can lead to
proptosis. serious consequences as with, for example,
malignant recurrence after biopsy of a benign
Carotico-cavernous fistula pleomorphic adenoma.
Very rarely the affected ductule will become clinical history and radiological signs, with
infected with Actinomyces, this causing a avoidance of biopsy. Because of the long-term
slightly inflamed and chronically discharging risk of spontaneous malignant transformation,
eye. tumours of the orbital lobe should be excised
intact through a lateral orbitotomy and breach
Pleomorphic adenoma of the pseudocapsule of compressed tissues
avoided; to this end, the tumour is handled at
Pleomorphic adenomas account for about
all times with a malleable retractor and not
5% of all orbital tumours, 25% of lacrimal
with any form of forceps.
fossa masses and 50% of all epithelial tumours
Palpebral lobe pleomorphic adenomas,
of the lacrimal gland. Most affect the orbital
sometimes mistaken for large chalazia and
lobe and become evident in the fourth and
curetted, are excised intact through an upper
fifth decade as a slow onset of painless
eyelid skin-crease incision.
proptosis and infero-medial displacement of
Breach of the pseudocapsule of these
the globe; the much rarer palpebral lobe
tumours risks a pervasive recurrence of tumour
lesions present in young people with a shorter
(sometimes malignant) throughout the orbit,
history of a hard, mobile mass above the
this necessitating orbital exenteration.
lateral part of the upper tarsus.
Although there are advocates of fine-needle
Orbital lobe tumours show a smooth
aspiration biopsy of these tumours, there is no
expansion of the lacrimal gland fossa by an
logical reason for undertaking this in the
oval lesion in which calcification is rare, the
presence of clinically and radiologically
mass causing displacement of orbital
characteristic disease.
structures and often flattening of the globe
Keratitis sicca can be troublesome in a few
(Figure 12.10); it is unusual for these
cases, although the incidence of this condition
tumours, even when large, to extend anterior
is lower with preservation of the palpebral lobe
to the orbital rim. In contrast, the rare
during excision of these tumours. It is treated
palpebral lobe tumours show a normal gland
with topical lubricants and, where necessary,
with an enlarged, rounded anterior surface
occlusion of the lacrimal drainage canaliculi.
extending outside the orbital rim on CT scan.
The key to treatment of pleomorphic
adenomas is recognition, on the basis of Dacryoadenitis
The lacrimal gland may be affected by an
acute polymorphic inflammation, which may
be due to bacterial infection, or a chronic,
predominantly lymphocytic, dacryoadenitis
which may be due to underlying systemic
diseases such as sarcoid or Wegeners
granulomatosis.
Acute dacryoadenitis presents with painful,
red swelling of the upper eyelid with an S-
shaped ptosis (Figure 12.11) and tenderness
of the underlying lacrimal gland; systemic
malaise is unusual.
Figure 12.10 CT scan of a typical pleomorphic Painless swelling of one or both lacrimal
adenoma, showing displacement and flattening of the
globe by a round lesion that may cause scalloping of glands is the usual manifestation of chronic
the bone in the lacrimal fossa. dacryoadenitis and the gland often shows
132
BENIGN ORBITAL DISEASE
antibiotics; these should be given on clinical Severe complications of visual loss, cavernous
suspicion alone and their administration sinus thrombosis and intracranial spread of
should not, under any circumstances, be infection may be secondary to late presentation,
delayed whilst arranging imaging or other or progression due to inappropriate antibiotic
investigations. Appropriate antibiotics should selection at inadequate dosage; the latter
be at suitable dosage and active against the situation should be preventable in most cases by
common organisms: a typical adult might close clinical monitoring.
receive Cefuroxime 15g every 8 hours (the Late abscess formation may require drainage
child receiving a reduced dosage), along with to hasten resolution.
Metronidazole 500mg every 8 hours in patients
over the age of about 15. Orbital myositis
When intravenous antibiotics have been
Typically presenting with a relatively
given, thin slice CT of the orbits and sinuses
sudden onset of orbital ache (worse on eye
will be required to demonstrate the likely
movement), ocular redness and diplopia, this
source of infection and whether there is a
condition is commonest in young women.
localised collection of pus in the orbit or
The characteristic history and clinical signs
subperiosteal spaces. Once the orbital infection
with pain worse when looking away from the
is controlled, with stabilisation or improvement
field of action of the affected eye muscle is
in orbital status, then the patient should be
sufficient to justify treatment with a
referred for urgent treatment of the underlying
non-steroidal anti-inflammatory drug, this
sinus disease by an otorhinolaryngologist.
typically relieving pain within a day. CT scan
Where there is failing vision due to rising
will demonstrate diffuse enlargement of one,
orbital pressure, the loss of vision can
or rarely more, eye muscles and, if severe,
progress rapidly and lead to permanent
some spillover inflammatory changes in the
blindness; in these cases, urgent drainage of
surrounding orbital tissues.
the orbit is required and should be
Biopsy should be undertaken if the
undertaken as an emergency. The site for
condition does not settle, with a view to
primary exploration is indicated by the
treatment with systemic steroids or low-dose,
direction of globe displacement and drainage
lens-sparing irradiation of the retrobulbar
of pus and oedema (using, if urgency
tissues.
dictates, just local skin-infiltration
Patients may get recurrent episodes of
anaesthesia) should be undertaken in the
myositis in various muscles and, in some
same fashion as drainage of an acute, sight-
cases, severe fibrosis of the affected
threatening haematoma (Chapter 14). When
muscles can result in a gross ocular deviation
the focus of infection has been identified and
(Figure 12.14).
drained, a corrugated drain should be left in
place until there has been a clear
improvement in orbital function.
Idiopathic orbital inflammation
If infective orbital cellulitis persists (or Idiopathic orbital inflammation occurs
worsens after initial improvement) then the most commonly in the fourth and fifth
possibility of abscess formation, the presence decades, with no sex predilection, and is
of foreign material, reinfection with other characterised by a polymorphous lymphoid
bacteria, unusual organisms (fungi or infiltrate with a variable degree of fibrosis. It
tuberculosis) or a non-infective inflammatory may present as an acute form with marked
cause (such as tumour necrosis) should be inflammation, or as a chronic form with a
considered. tendency to pain and fibrosis.
135
PLASTIC and ORBITAL SURGERY
(a) (b)
(c) (d)
Figure 12.15 A non-inflamed eye with almost complete (but reversible) loss of eye movements and periorbital
sensory impairment, due to orbital inflammation at the superior orbital fissure: (a) right gaze, (b) left gaze,
(c) upgaze, (d) downgaze.
136
BENIGN ORBITAL DISEASE
formed specimens are much more readily optic nerve (Figure 12.16); MRI is
interpreted than those taken by aspiration particularly useful for demonstrating changes
needle biopsy; needle biopsy should, in the intracanalicular and intracranial
therefore, probably be used only for sampling portions of the nerve. Gliomas require
lesions in patients with known carcinomatosis, neurosurgical resection, if progressing to
in whom confirmation of a likely orbital threaten the optic chiasm, or orbital resection
metastasis is required prior to radiotherapy. if causing gross proptosis. Optic nerve
Treatment after biopsy is aimed at meningiomas do not cause significant
suppressing the inflammatory response with proptosis, but profound visual failure due to
systemic corticosteroids or radiotherapy. In impairment of optic nerve perfusion. CT scan
most instances, there is a good response to typically shows a diffuse expansion of the
prednisolone 60100mg per day (or optic nerve and, in some cases, calcification
1mg/kg/day) and the dosage should be reduced within the optic nerve sheath (Figure 12.17)
towards 20mg daily within 34 weeks and and MRI may demonstrate a normal or small
more slowly thereafter. Radiotherapy nerve passing through an enlarged sheath.
to the retrobulbar tissues (generally Neurosurgical resection of optic nerve
20002400cGy, in fractionated doses of meningiomas may be considered in younger
200cGy) may be valuable where there is a poor people, in whom the tumour appears to have
response to steroids, or where it is not possible a more active course and risks intracranial
to reduce the dosage to an acceptable level. involvement.
Cytotoxic agents, such as cyclophosphamide, There are many rare diseases that affect the
cyclosporin or methotrexate, have been used in orbital bones, but the commonest is sphenoid
recurrent and steroid-resistant orbital wing meningioma. This tends to present in
inflammation. middle age with chronic variable lid swelling,
chemosis and mild proptosis. The CT scan
shows hyperostosis of the greater wing of the
sphenoid with en-plaque soft tissue on the
Benign neural and osseous
lateral wall of the orbit, the temporalis fossa or
lesions the middle cranial fossa (Figure 12.18).
Neurilemmomas (Schwannomas) typically Although a metastasis may very rarely present
present like cavernous haemangioma and have with a similar radiological appearance, the
a similar scan appearance, and neurofibromas
usually form a mass in the supraorbital nerve,
with slowly progressive proptosis and
hypoglobus; resection of these tumours, when
causing loss of orbital function, is curative. In
contrast, plexiform neurofibromas diffusely
affect the anterior orbital tissues, especially in
the upper eyelid and lacrimal gland, and
resection is difficult and does not eliminate
the disease.
Primary optic nerve tumours, either
meningioma or glioma, are usually benign and
present in childhood or young adults. Gliomas
cause proptosis and mild visual loss and CT Figure 12.16 Optic nerve glioma causing fusiform
scan shows a fusiform enlargement of the enlargement of the nerve.
137
PLASTIC and ORBITAL SURGERY
(a) (a)
(b) (b)
Figure 12.17 Elongated enlargement of the optic Figure 12.18 Hyperostosis and soft tissue mass of
nerve, with linear calcification, due to primary optic sphenoidal wing meningioma: (a) axial soft tissue, (b)
nerve meningioma: (a) axial view, (b) coronal view. bone CT scan windows.
clinical behaviour is different with sphenoid Lacey B, Chang W, Rootman J. Nonthyroid causes of
wing meningioma progressing very slowly and extraocular muscle disease. Surv Ophthalmol 1999;
44:187213.
usually not requiring any active treatment; Lacey B, Rootman J, Marotta TR. Distensible venous
biopsy is indicated if a rapid progression is malformations of the orbit: clinical and hemodynamic
features and a new technique for management.
suggestive of metastatic disease. Ophthalmology 1999; 106:1197209.
McNab AA, Wright JE. Cavernous haemangiomas of the
Further reading orbit. Aust NZ J Ophthalmol 1989; 17:33745.
McNab AA, Wright JE. Lateral orbitotomy a review. Aust
Ferguson MP, McNab AA. Current treatment and outcome NZ J Ophthalmol 1990; 18:2816.
in orbital cellulitis. Aust NZ J Ophthalmol 1999; 27:3759. McNab AA,Wright JE. Orbitofrontal cholesterol granuloma.
Harris GJ. Subperiosteal abscess of the orbit: computed Ophthalmology 1990; 97:2832.
tomography and the clinical course. Ophthal Plast Reconstr McNab AA, Wright JE, Casswell AG. Clinical features and
Surg 1996; 12:18. surgical management of dermolipomas. Aust NZ J
Harris GJ, Logani SC. Eyelid crease incision for lateral Ophthalmol 1990; 18:15962.
orbitotomy. Ophthal Plast Reconstr Surg 1999; 15:916. Miszkiel KA, Sohaib SAA, Rose GE, Cree IA, Moseley IF.
Harris GJ, Sokol PJ, Bonavolonta G, De Conciliis C. An Radiological and clinicopathological features of orbital
analysis of thirty cases of orbital lymphangiomas. xanthogranuloma. Br J Ophthalmol 2000; 84:2518.
Pathophysiologic considerations and management Nugent RA, Lapointe JS, Rootman J, Robertson WD, Graeb
recommendations. Ophthalmology 1990; 97:158392. DA. Orbital dermoids: features on CT. Radiology 1987;
Katz BJ, Nerad JA. Ophthalmic manifestations of fibrous 165:4758.
dysplasia: a disease of children and adults. Ophthalmology Rootman J. Why orbital pseudotumour is no longer a
1998; 105:220715. useful concept. Br J Ophthalmol 1998; 82:33940.
138
BENIGN ORBITAL DISEASE
Rootman J, Hay E, Graeb D. Orbital adnexal Shields JA, Kaden IH, Eagle RC Jr, Shields CL.
lymphangiomas: a spectrum of hemodynamically isolated Orbital dermoid cysts: clinicopathologic correlations,
vascular hamartomas. Ophthalmology 1986; 93:155870. classification, and management. The 1997 Josephine E.
Rootman J, Kao SC, Graeb DA. Multidisciplinary Scheler Lecture. Ophthal Plast Reconstr Surg 1997;
approaches to complicated vascular lesions of the orbit. 13:26576.
Ophthalmology 1992; 99:14406. Shields JA, Bakewell B, Augsberger JJ et al. Classification and
Rootman J, McCarthy M, White V, Harris G, Kennerdell J. incidence of space occupying lesions of the orbit: A survey
Idiopathic sclerosing inflammation of the orbit. A distinct of 645 biopsies. Arch Ophthalmol 1984; 102:160611.
clinicopathologic entity. Ophthalmology 1994; 101:57084. Sullivan TJ, Wright JE, Wulc AE, Garner A, Moseley IF,
Rose GE. Suspicion, speed, sufficiency and surgery: keys to Sathananthan N. Haemangiopericytoma of the orbit. Aust
the management of orbital infection. Orbit 1998; 17:2236. NZ J Ophthalmol 1992; 20:32532.
Rose GE, Hoh B, Harrad RA, Hungerford JL. Intraocular Wright JE, McNab AA, McDonald WI. Primary optic nerve
malignant melanomas presenting with orbital inflammation. sheath meningioma. Br J Ophthalmol 1989; 73:9606.
Eye 1993; 7:53941. Wright JE, McNab AA, McDonald WI. Optic nerve glioma
Rose GE, Wright JE. Isolated peripheral nerve sheath and the management of optic nerve tumours of the young.
tumours of the orbit. Eye 1991; 5:66873. Br J Ophthalmol 1989; 73:96774.
Rose GE, Wright JE. Pleomorphic adenomas of the lacrimal Wright JE, Sullivan TJ, Garner A, Wulc AE, Moseley IF.
gland. Br J Ophthalmol 1992; 76:395400. Orbital venous anomalies. Ophthalmology 1997;
Sathananthan N, Moseley IF, Rose GE, Wright JE. The 104:90513.
frequency and significance of bone involvement in outer
canthus dermoid cysts. Br J Ophthalmol 1993; 77:78994.
139
13 Malignant orbital disease
Michael J Wearne
Malignant orbital disease, either primary or rapidly growing tumour mass is a deep orbital
secondary, is rare but can affect all ages from capillary haemangioma, although children
infancy to old age.The possibility of malignant with haemangiomas will often have other
disease should, therefore, be entertained cutaneous vascular lesions.
wherever there is a rapidly or relentlessly The tumour mass may be located anywhere
progressive disease, an inflammatory picture or in the orbital soft tissues, most commonly in
where assumed non-malignant orbital disease the supero-medial quadrant, and typically does
does not display characteristic behaviour. not arise in the extraocular muscles. Orbital
imaging will usually demonstrate a fairly well
defined, round mass arising within the orbital
Malignant orbital disease in fat and flattening the globe (Figure 13.1b),
children
Although very rare, the very aggressive
malignancies of rhabdomyosarcoma or
neuroblastoma tend to present under the
age of 10 years, the acute haematological
malignancies within the first two decades and
primary lacrimal gland malignancy has a peak
(a)
incidence in the fourth decade.
Rhabdomyosarcoma
Rhabdomyosarcoma, with a peak incidence
at age 7, is the commonest primary orbital
malignancy of childhood and arises from
pleuripotent mesenchyme that normally
differentiates into striated muscle cells.
Although rhabdomyosarcoma classically
presents with signs of acute orbital cellulitis
(b)
(Figure 13.1a), in some cases it is more
insidious and mimics a benign process; a high Figure 13.1 Childhood rhabdomyosarcoma may
index of suspicion is required for any present as a rapidly growing orbital mass (a) or with
inflammatory signs; (b) the rapidly progressive
unilateral orbital disease in childhood. At this tumour may compress the globe and typically is not
age the main differential diagnosis for a associated with muscle.
140
MALIGNANT ORBITAL DISEASE
Other malignancies
(b)
Neuroblastoma may present as rapidly
progressive metastasis within the orbital Figure 13.3 (a) Acute myeloid leukaemia presenting
with persistent orbital cellulitis; (b) the tumour may
soft tissues or bone (Figure 13.2), the be termed chloroma because the tissue turns green in
clinical presentation being very similar to air.
141
PLASTIC and ORBITAL SURGERY
are three main variants) is a proliferative pain may suggest acute dacryoadenitis, but
disease of Langerhans cells that may be failure of any inflammatory lesion of the
malignant, although the variant found most lacrimal gland to clearly improve within a few
commonly in children eosinophilic weeks should prompt further investigation for
granuloma verges on a benign proliferation malignancy.
and is readily treated. CT scan shows expansion of the lacrimal
All of these childhood tumours require gland by a mass that typically moulds to the
urgent biopsy, systemic investigation and globe and extends posteriorly alongside the
chemotherapy with, in some cases, lateral orbital wall, displacing the lateral rectus
radiotherapy. Although prognosis for vision medially (Figure 13.4b). In more advanced
with most of the haematological malignancies cases there may be erosive changes in the bone
is generally good there is a significant of the lacrimal gland fossa, best shown with
mortality, depending on pre-chemotherapy bone-window settings. Calcification, usually a
disease staging. few flecks, may be present in up to one-third
of malignant lacrimal gland tumours.
The tumour should be biopsied through the
Malignant orbital diseases in upper lid skin crease (Chapter 12). Adenoid
cystic carcinoma is composed of solid cords of
adults
malignant epithelial cells, often with cystic
As with all cancers, orbital malignancy is spaces giving a Swiss cheese pattern. The
more common in middle age and in the tumour infiltrates well beyond the
elderly and may be either primary disease macroscopic boundaries evident at surgery
arising in the orbit, secondary to spread from and on radiological imaging, and adenoid
the sinuses, or metastatic from remote sites. cystic carcinoma has a propensity for
perineural spread into the cavernous sinus
and pterygo-palatine fossa.
Lacrimal gland carcinoma The best method of treatment remains
Adenoid cystic carcinoma, with a peak controversial, because recurrences of adenoid
incidence in the fourth decade, is the cystic carcinoma may be very slowly
commonest malignancy of the lacrimal gland progressive and can become manifest at more
and accounts for 30% of all epithelial than 10 years after primary treatment; it
tumours. Other, much rarer, carcinomas is likely, therefore, that a cure can only
include primary adenocarcinoma, muco- be countenanced after 20 years without
epidermoid carcinoma, squamous carcinoma recurrence. These patients probably do best
and malignant mixed tumours; malignant with removal of the tumor bulk (which can
mixed tumours arising either within a often be almost complete) through an anterior
longstanding pleomorphic adenoma, or orbitotomy and subsequently they should
within recurrent pleomorphic adenoma after receive 5560cGy of radiotherapy to both the
previously incomplete resection. orbit and the cavernous sinus (Figure 13.4c).
The diagnosis of lacrimal carcinoma is Unless frankly invaded by tumour, the cortical
suggested by an unrelenting, relatively rapid bone of the lateral orbital wall should be left
progression of ocular displacement and upper undisturbed as any breach is likely to
eyelid swelling caused by a non-tender encourage seeding of tumour cells into the
lacrimal gland mass; such patients will often cranial diploe, with a slow and relentless fatal
present with a history of less than 6 months recurrence of local disease (Figure 13.4d).
(Figure 13.4a). The rapid progression and Implantation brachytherapy has been
142
MALIGNANT ORBITAL DISEASE
(a) (c)
(d)
(b)
Figure 13.4 (a) A patient with left lacrimal gland carcinoma, (b) such tumours typically producing enlarged
lacrimal gland moulding to the globe and extending posteriorly alongside the lateral orbital wall, (c) treatment
with debulking and fractionated high-dose radiotherapy to the orbit and cavernous sinus produces good disease
control with a satisfactory cosmesis, (d) craniofacial resection may encourage seeding of the tumour into the
cranial diploe, with subsequent slow and relentless fatal local recurrence.
advocated as delivering a high radiation the lacrimal drainage puncta, are often
dosage to the tumour bed whilst relatively required. Radiation-induced cataract is
sparing the globe, but it does not, however, common at about two years after treatment.
treat the cavernous sinus or pterygo-palatine Tumour recurrence occurs relatively late
fossa to which these tumours often extend with adenoid cystic carcinoma and the
by perineural invasion. relatively young person may have many years
There is no reliable evidence to suggest that of useful, symptom free life before regrowth of
either exenteration or super-exenteration tumour is evident. Unfortunately most
(with removal of the neighbouring orbital patients will eventually suffer a painful and
bones) leads to a reduction of recurrence rate relentlessly progressive local recurrence of the
or a prolongation of life; such procedures disease (Figure 13.4d), with a high mortality
are associated with a marked disfigurement from intracranial recurrence or metastasis.
in relatively young people. Intra-carotid
chemotherapy may have a role as an adjunct
Other mesenchymal tumours
to radiotherapy in advanced disease.
Dry eye is inevitable with removal of the Sarcomas of the orbit are extremely rare.The
lacrimal gland and radiotherapy; frequent highly malignant osteosarcoma is generally
topical lubricants, together with occlusion of secondary to childhood orbital radiotherapy
143
PLASTIC and ORBITAL SURGERY
(a)
(a)
(b)
disease and usually require multiple cycles Once the orbital contents have been
of chemotherapy. If there is significant mobilised within the periosteum, the posterior
impairment of orbital function (with, tissues are transected about 710mm from the
for example, optic neuropathy) then local apex (Figure 13.9b); this is most readily
radiotherapy provides a useful means to achieved from the lateral side, using a
accelerate resolution of the orbital disease. monopolar diathermy in a blended cutting
When the disease is confined to the orbit and coagulation mode. The ophthalmic artery
the visual prognosis is excellent and should also be cauterised with bipolar
complications are unusual, but the overall diathermy and any persistent bleeding from
mortality is variable. Review for at least 10 the bones should be plugged with bone wax.
years is required, as systemic lymphoma can With skin-sparing exenteration, the upper
become evident for many years after the ands lower eyelid flaps are sutured together
presentation of solely orbital disease. using buried 5/0 absorbable sutures in the
orbicularis muscle layer and the skin closed
with continuous 6/0 nylon; the aim is to create
Method for orbital exenteration an air-tight closure to encourage retraction of
Exenteration, for certain pervasive the socket surface during healing (Figure
malignant or benign orbital diseases, involves 13.9c). If a complete exenteration of the
complete removal of the eyeball, retrobulbar eyelids and orbit has been performed, the
soft tissues and most, or all, of the eyelids. socket can either be left to granulate or lined
Skin-sparing exenteration provides a very with split-thickness skin grafts (Figure 13.9d).
rapid rehabilitation and is particularly useful Complications of exenteration include
for benign disease, post-septal intraorbital operative leakage of cerebro-spinal fluid, post
malignancy and for the palliation of fungating operative infection, necrosis of flaps and grafts,
terminal orbital malignancy (Figure 13.9a). or delayed socket granulation. Breakdown of the
The skin incision should be placed well clear lamina papyracea may lead to communication
of the malignancy, either near the orbital rim if between the ethmoid sinuses and the
dealing with extensive eyelid malignancy exenteration cavity (a sino-orbital fistula) and
invading the orbit, or alongside the lash-line if failure of closure of the nasolacrimal duct may
a skin-sparing exenteration; if skin-sparing, the lead to a blow-hole fistula.
skin and orbicularis oculi muscle should be
undermined to the orbital rim.The periosteum
Secondary orbital tumours
is incised just outside the rim, raised intact
over the rim and posteriorly into the orbit; The orbit may be infiltrated by malignant
resistance to raising the periosteum may be tumours arising in the globe or in any of the
encountered at the arcus marginalis, the surrounding structures, such as the eyelids
trochlear fossa, the interosseous suture lines and paranasal sinuses. If there is extensive
and the lacrimal crest. It is necessary to orbital involvement, it may be necessary for
cauterise and divide the anterior and posterior orbital exenteration as part of the surgical
ethmoidal vessels in the supero-nasal rehabilitation.
quadrant, the nasolacrimal duct, and any
vessels crossing between the orbit and the
Eyelid tumours
lateral orbital wall and floor. Care is required
to avoid damage to the lamina papyracea, as Tumours originating in the lids, particularly
entry into the ethmoid sinuses may lead to a meibomian gland carcinoma and neglected
chronic sino-orbital fistula. basal cell or squamous carcinomas, can spread
146
MALIGNANT ORBITAL DISEASE
(a)
(b)
(c) (d)
Figure 13.9 (a) Fungating melanoma in young patient with terminal disease, (b) the periosteum is incised
outside the orbital rim, separated from the orbital walls, the orbital contents are removed leaving a 710mm
stump at the orbital apex, to prevent CSF leakage, (c) with skin-sparing exenteration there is a rapid healing and
retraction of the skin over a few weeks after surgery; (d) where the eyelid skin has been excised, the socket can
either be left to heal by granulation, or else grafted with split-thickness skin.
well-circumscribed, benign disease to Goldberg RA, Rootman J, Cline RA. Tumours metastatic to
the orbit: a changing clinical picture. Surv Ophthalmol
infiltrative malignancy. Treatment of the 1990; 35:124.
benign lesions is intact excision, which is Mamalis N, Grey AM, Good JS, McLeish WM, Anderson
RL. Embryonal rhabdomyosarcoma of the orbit in a 35-
curative, whereas the malignant variants year-old man. Ophthalmic Surgery 1994; 25:3325.
require wide clearance, usually by orbital Meekins B, Dutton JJ, Proia AD. Primary orbital
exenteration. Local and remote recurrence leiomyosarcoma: a case report and review of the literature.
Arch Ophthalmol 1988; 106:826.
are fairly common with malignant Rose GE, Wright JE. Exenteration for benign orbital disease.
haemangiopericytoma. Br J Ophthalmol 1994; 78:1418.
Rose GE, Wright JE. Pleomorphic adenomas of the lacrimal
gland. Br J Ophthalmol 1992; 76:395400.
Further reading Schworm HD, Boergen KP, Stefain FH. The initial clinical
manifestations of rhabdomyosarcoma. Ophthalmology
Affeldt JC, Minchler DS, Azen SP, Yeh L. Prognosis in uveal 1995; 92:3625.
melanoma with uveal extension. Arch Ophthalmol 1980; Shields CL, Sheilds JA, Peggs M. Metastatic tumours of the
98:19759. orbit. Ophthal Plast Reconstr Surg 1988; 4:7380.
Bartley GB, Garrity JA, Waller RR et al. Orbital exenteration Sohaib SA, Moseley I,Wright JE. Orbital rhabdomyosarcoma
at the Mayo clinic. 1967-1986. Ophthalmology 1989; the radiological characteristics. Clin Radiol 1998;
96:46873. 53:35762.
Ferry AP, Font RL. Carcinoma metastatic to the eye and Weber AL, Jakobiec FA, Sabates NR. Lymphoproliferative
orbit. A clinicopathologic study of 227 cases. Arch disease of the orbit. Neuroimaging Clin N Am 1996;
Ophthalmol 1974; 92:27686. 1:93111.
Fratkin JD, Shammas HF, Miller SD. Disseminated Wright JE, Rose GE, Garner A. Primary malignant
Hodgkins disease with orbital involvement. Arch neoplasms of the lacrimal gland. Br J Ophthalmol 1992;
Ophthalmol 1978; 96:1024. 76:4017.
149
14 Orbital trauma
Brett ODonnell
150
ORBITAL TRAUMA
Assessment
Orbital roof injury should be suspected where
head trauma is accompanied by a large upper
eyelid haematoma, hypoglobus, restricted up
gaze and sensory loss over the forehead
(Figure 14.7). Late manifestations include
deformity of the orbital rim underlying the Figure 14.7 Child presenting with a delayed onset
brow and failure of descent of the upper eyelid of severe compressive optic neuropathy due to a large
during down gaze due to adhesions between subperiosteal haematoma along the orbital roof; the
child had sustained a blunt orbital injury a week
the fracture site and the levator muscle. before, with fracture of the orbital roof.
Tripod fracture of the zygoma, with
disarticulation from the neighbouring frontal
Management
bone and maxilla, tends to occur with a major
blow to the cheek and is manifest by a Small fractures of the orbital roof are
flattening of the prominence of the cheek managed conservatively if they cause no
(although this may be masked by overlying functional deficit and only minimal
haematoma), by palpable discontinuity of the irregularity of the orbital rim and brow. Small
orbital rim, by tenderness with upward bone fragments that interfere with the
pressure below the zygomatic arch, and by an function of the levator or superior rectus
ipsilateral buccal haematoma. muscles should be repositioned or removed,
Le Fort fractures involve the maxilla and either through the open wound at the time of
extend posteriorly through the pterygoid primary repair, or through an incision in the
plates. The orbit is involved in types II and III upper eyelid skin crease. Larger bone
Le Fort fractures, both extending across the fragments require reduction and microplate
medial part of the orbit at the level of fixation, although most such surgery is beyond
the cribriform plate, but the type II fracture the realm of the ophthalmic surgeon and
(the commonest) passes infero-laterally to the involves a multi-disciplinary approach.
level of the inferior orbital fissure, whereas the Adherence of the levator muscle or upper
type III fracture extends laterally higher in the eyelid scars to fractures of the orbital rim or
155
PLASTIC and ORBITAL SURGERY
Complications
Both the injury itself and the surgery for the
repair of these complex fractures may be
associated with supraorbital nerve injury, loss
(a)
of other ocular motor innervation due to
damage near the superior orbital fissure,
orbital emphysema and pneumocephalus, a
subperiosteal haematoma with a secondary
compressive optic neuropathy (Figure 14.7)
and associated intracranial injuries. Late
complications include persistent ptosis, due
either to mechanical damage or denervation,
lagophthalmos due to scarring and retraction
of the upper eyelid or levator muscle and
chronic or recurrent sinusitis, particularly that
of the frontal sinus.
(b)
(a)
(a)
(b)
thought. It is believed that the energy of impact Surgery may be considered for removal of
and shearing forces due to deceleration are bone fragments, where these are thought to be
transmitted to the area of the optic canal, causing a compressive optic neuropathy, and
resulting in axonal damage and tearing of the for drainage of intraorbital haematomas.
pial vessels supplying the intracanalicular optic Although visual improvement has been
nerve; oedema of the injured tissues and post- reported after drainage of haematomas from
traumatic vasospasm will both exacerbate neural within the optic nerve sheath, there is no
ischaemic damage and this forms a rational evidence that this procedure actually alters the
basis for the use of high-dose corticosteroids natural course of the condition.
after such injuries. The role of optic canal Decompression of the optic canal, by removal
decompression, however, remains in doubt. of the lateral wall of the sphenoid sinus where it
Treatment of indirect optic neuropathy may overlies the optic canal, has not been shown to
be empirically based on the results for spinal improve visual recovery after injury to the
cord injury: a loading dosage of 30mg/kg intracanalicular optic nerve; it may, however,
Methyl-prednisolone within 8 hours of injury have a role where vision deteriorates in the face
is followed by an infusion of about 5mg/kg/hr of adequate medical therapy. Decompression
for 24 hours after injury. A tailing dosage of may be achieved through a trans-cranial or a
prednisolone or dexamethasone may then be trans-ethmoidectomy approach and may be
continued for a few days. usefully incorporated as part of an open repair
158
ORBITAL TRAUMA
Subperiosteal haematoma
A subperiosteal haematoma of the orbit Figure 14.13 Blindness and gross right exotropia
may follow blunt trauma, is usually superiorly after avulsion of the right medial rectus, inferior
within the orbit and the presentation with a oblique and optic nerve during endoscopic sinus
surgery.
slowly progressive displacement of the globe
may lead to delayed diagnosis (Figure 14.7).
traction damage to small deep orbital vessels.
The haematoma should be drained through a
A venous bleed is of slower onset and will
transcutaneous approach and a vacuum drain
usually self tamponade with vision frequently
left in place until the bleeding settles;
recovering. Firm orbital pressure may assist
compressive optic neuropathy, whilst rare,
tamponade and a lateral cantholysis after 510
dictates urgent intervention.
minutes may assist reduction in intraorbital
pressure after tamponade has occurred.
A rapid development of proptosis is likely to
Surgical trauma to the orbit be arterial bleeding and should be dealt with
The orbital contents may occasionally be by very firm orbital pressure applied for about
damaged due to inadvertent entry into the 810 minutes, but being released for about 15
orbit during endoscopic sinus surgery and seconds every 2 minutes to allow ocular
may result in devastating complications, such perfusion. If the orbital pressure rises to a very
as severe motility restriction or blindness high level, with loss of eye movements and
(Figure 14.13). Direct damage to the orbital vision not attributable to local anaesthesia,
fat, muscles and, more rarely, optic nerve, may then the orbit should be drained through a skin
occur, especially during power-assisted incision in the affected quadrant; once the skin
debridement of diseased sinus tissues. The is opened, a closed pair of blunt-ended scissors
most important point in the management of should be gently advanced about 3cm into the
inadvertent orbital entry is recognition and orbital fat of the affected quadrant and the
immediate cessation of further surgery; in blades gently opened to spread the tissues and
particular the orbit should be observed for encourage drainage of blood and tissue fluid.
signs of traction on the orbital tissues and for This manoeuvre is generally sufficient to
small movements of the globe. release the orbital tamponade, with restoration
Injury to the ethmoidal arteries may result of vision, and a drain should be placed until
in orbital haemorrhage with compressive optic the bleeding has stopped.
neuropathy and this may require anterior
orbitotomy, drainage of the haematoma and Further reading
diathermy of damaged vessels. Anderson RL, Panje WR, Gross CE. Optic nerve blindness
Orbital haemorrhage more commonly following blunt forehead trauma. Ophthalmology 1982;
89:44555.
follows orbital surgery or after retrobulbar or Baker RS, Epstein AD. Ocular motor abnormalities from
peribulbar injections for intraocular and head trauma. Surv Ophthalmol 1991; 35:24567.
Biesman BS, Hornblass A, Lisman R, Kazlas M. Diplopia
periocular surgery; it may also occur with after surgical repair of orbital floor fractures. Ophthal Plast
blepharoplasty, when it is thought to arise from Reconstr Surg 1996; 1:916.
159
PLASTIC and ORBITAL SURGERY
Bracken MB, Shepard MJ, Collins WF et al. A randomised, Guy J, Sherwood M, Day AL. Surgical treatment of
controlled trial of methyl prednisolone or naloxone in the progressive visual loss in traumatic optic neuropathy.
treatment of acute spinal cord injury. Results of the Report of two cases. J Neurosurg 1989; 70;799801.
Second National Acute Spinal Cord Injury Study. N Eng Harris GJ, Garcia GH, Logani SC, Murphy ML. Correlation
J Med 1990; 322:140511. of preoperative computed tomography and post operative
Crompton MR. Visual lesions in closed head injury. Brain ocular motility in orbital blowout fractures. Ophthal Plast
1970; 93:78592. Reconstr Surg 2000; 16:17987.
Dutton JJ. Management of blowout fractures of the orbital Rose GE, Collin JRO. Dermofat grafts to the extraconal
floor. Editorial. Surv Ophthalmol 1990; 35:27980. orbital space. Br J Ophthalmol 1992; 76:40811.
Goldberg RA, Marmor MF, Shorr N, Christenbury JD. Smith B, ReganWF Jr. Blowout fracture of the orbit:
Blindness following blepharoplasty: two case reports, and mechanism and correction of internal orbital fractures.
a discussion of management. Ophthalmic Surg 1990; 21:859. Am J Ophthalmol 1957; 44:7339.
Goldberg RA, Steinsapir KD. Extracranial optic canal Steinsapir KD, Goldberg RA. Traumatic optic neuropathy.
decompression: indications and technique. Ophthal Plast Surv Ophthalmol 1994; 38:487518.
Reconstr Surg 1996; 12:16370. Streitman MJ, Otto RA, Sakal CS. Anatomic considerations
Gross CE, DeKock JR, Panje WR, et al. Evidence for orbital in complications of endoscopic and intranasal sinus
deformation that may contribute to monocular blindness surgery. Ann Otol Rhinol Laryngol 1994; 103:1059.
following minor frontal head trauma. J Neurosurg 1998;
55:9636.
160
15 Basic external lacrimal surgery
Cornelius Ren
and below the trochlea. Additional anaesthesia general and local anaesthetic cases. The
and vasoconstriction at the site of incision is continuous use of a sucker in the non-
achieved by skin infiltration with 23ml of dominant hand is a mainstay to aiding
the same local anaesthetic preparation. To viewing, and to displacing tissues and
achieve maximal vasoconstriction, the local protecting them from other instruments. The
anaesthetic should be administered at least 10 appropriate use of bipolar diathermy, careful
minutes before surgery commences and may handling and retraction of the tissues, respect
usefully be given just prior to scrubbing, skin for the surgical planes, and widespread
preparation and sterile draping; topical ocular suturing of mucosal flaps, also help to control
anaesthesia, such as 0.5% amethocaine haemorrhage during open lacrimal surgery.
eyedrops, is also required at the time of The judicious use of bone wax may, rarely, be
surgery. necessary to stop persistent haemorrhage
from bone.
164
BASIC EXTERNAL LACRIMAL SURGERY
No. 11 blade to create a larger anterior flap lacrimal probe in the sac helps to identify and
(about two-thirds of the antero-posterior protect the internal opening while the
extent) and a smaller posterior flap and, after mucosal flaps are being united, and this can
cauterisation wherever possible, relieving later be replaced by intubation where there is
incisions are made at the superior and inferior common canalicular disease or a markedly
bone edges to mobilise both flaps. Incising the inflamed lacrimal sac. The absorbable suture
nasal mucosa often results in some bleeding retracting the anterior nasal flap is then used
which, under general anaesthesia, can be to unite the anterior mucosal flaps and three
controlled by passing the sucker up the nose or four sutures are usually necessary to secure
and positioning it just behind the posterior a good anastomosis (Figure 15.7). The cut
flap thus acting similarly to the second, medial canthal tendon is sutured to the medial
intranasal sump drain placed during surgery periosteum using the same suture, and closure
under local anaesthesia. A 6/0 absorbable of the orbicularis is not usually necessary if the
suture on an 8mm diameter half-circle needle fibres were bluntly separated in the plane
is passed through the middle of the free edge between the palpebral and orbital parts. Skin
of the anterior nasal flap and the ends secured closure is achieved with 6/0 nylon interrupted
with a bulldog clip, with the needle left or continuous mattress sutures, antibiotic
attached. This is slung across the nasal bridge ointment instilled into the conjunctival sac,
to retract the anterior flap medially whilst and a pressure dressing applied to the
suturing the posterior flaps (Figure 15.6). incision. Post operative haemorrhage is
The posterior mucosal flaps are infrequent with primary anastomosis of the
approximated and sutured using a similar 6/0 mucosal edges, and packing of the nasal space
absorbable suture, the needle being reverse- is not required routinely, but an adrenaline-
mounted in an angled, non-locking needle moistened pack may be placed if there is
holder in such a way that its entire length is persistent brisk haemorrhage after surgery is
used this facilitating maximum suture completed; such a pack should be left
rotation at quite a distance below the small undisturbed for five days.
incision. Either a locked continuous suture, or
three or four interrupted sutures, is placed Post operative management
from the sac to the nasal mucosa. Keeping the
In the immediate post operative period the
patient is nursed semi-erect on bed rest to
Lacrimal probe
through common
canaliculus
Traction
suture
Complications
traction on the orbital fat should be avoided in
Serious complications due to external such cases, but a small fat prolapse does not
lacrimal surgery are extremely rare, but there require any specific treatment.
are several minor complications (Box 15.1). Whilst early post operative nasal oozing is
In cases of severe continued haemorrhage, common and requires no treatment except
nasal packing may be required either with ribbon upright positioning of the patient and
gauze moistened with a mixture of 1:1000 avoidance of hot beverages, continued brisk
adrenaline and antibiotics, with an absorbable primary haemorrhage is very rare. If simple
haemostatic sponge, or with a commercially measures, such as pinching of the nasal bridge
available expanding nasal tampon. or icepacks applied to the nasal bridge, do not
Minor leak of cerebrospinal fluid may, control brisk primary haemorrhage, then the
extremely rarely, result from an inadvertent nose should be packed with 125mm ribbon
fracture of the cribriform plate. Once identified, gauze moistened in 1:1000 adrenaline, the pack
the site of leakage may be plugged with a slip of being left undisturbed for five to seven days and
orbicularis oculi muscle obtained from the a systemic antibiotic given for that period.
surgical field, and post operative systemic Prophylactic systemic antibiotics reduce the
antibiotics administered. Although most cases risk of post operative infection (Figure 15.8)
resolve without further complication, close and probably reduce the risk of surgical
post operative monitoring is required for failure. A single dose of a systemic antibiotic is
continued CSF rhinorrhoea or meningitis and as effective as a post operative course, but
neurosurgical advice is recommended. antibiotics should be continued after surgery
Orbital fat prolapse may occur if the lateral where there has been significant preoperative
wall of the lacrimal sac or the orbital infection, placement of a nasal tamponade, or
periosteum is breached while incising the significant primary or secondary epistaxis.
lacrimal sac or performing a membranectomy. Use of nasal packs also increases the risk of
To avoid the risk of orbital haemorrhage, post operative infection.
166
BASIC EXTERNAL LACRIMAL SURGERY
Further reading
Dresner SC, Klussman KG, Meyer DR, Linberg JV.
Figure 15.9 Post operative skin necrosis at the Outpatient dacryocystorhinostomy. Ophthalmic Surg 1991;
dacryocystorhinostomy incision in a patient with 22:2224.
previous radiotherapy. Ezra EJ, Restori M, Mannor GE, Rose GE. Ultrasonic
assessment of rhinostomy size following external
dacryocystorhinostomy. Br J Ophthalmology 1998;
Although the incision line after almost all 82:7869.
Hanna IT, Powrie S, Rose GE. Open lacrimal surgery: a
external DCR is imperceptible by six months, comparison of admission outcome and complications after
the incision may rarely heal with excessive scar planned daycase or inpatient management. Br J
Ophthalmol 1998; 82:3926.
contracture, especially with posteriorly sited Hartikainen J, Grenman R, Pukka P, Seppa H. Prospective
incisions (Figure 15.2). Subcutaneous sutures randomized comparison of external dacryocystorhinostomy
and endonasal laser dacryocystorhinostomy. Ophthalmology
may also increase the tendency to 1998; 105:110613.
hypertrophic scar formation. Prominent scars Jordan DR. Avoiding blood loss in outpatient
dacryocystorhinostomy. Ophthal Plast Reconstr Surg 1991;
may become less noticeable as they mature, 7:2616.
especially if massaged or if pressure is applied Jordan DR, Miller D, Anderson RL. Wound necrosis
by, for example, the wearing of glasses on the following dacryocystorhinostomy in patients with
Wegeners granulomatosis. Ophthalmic Surg 1987;
scar. Very rarely revision of an operative scar 18:8003.
is required for unacceptably tight scars, Linberg JV. Lacrimal surgery; contemporary issues in
ophthalmology volume 5. New York: Churchill Livingstone,
and generally involves a double Z-plasty 1988.
technique. Wound necrosis is occasionally McNab AA. Diagnosis and investigation of lacrimal disease.
In McNab AA. Manual of orbital and lacrimal surgery (2nd
seen at the incision margins after prior ed.) Oxford: Butterworth Heinemann, 1988.
radiotherapy or in patients with Wegeners Neuhaus RW, Baylis HI. Cerebrospinal fluid leakage after
dacryocystorhinostomy. Ophthalmology 1983; 90:10915.
granulomatosis (Figure 15.9). Tarbet KJ, Custer PL. External dacryocystorhinostomy.
Surgical success, patient satisfaction, and economic cost.
Summary Ophthalmology 1995; 102:106570.
Walland MJ, Rose GE. Soft tissue infections after open
lacrimal surgery. Ophthalmology 1994; 101:60811.
External DCR surgery is a safe and effective
procedure for managing troublesome epiphora.
167
16 Laser-assisted and endonasal
lacrimal surgery
Jane M Olver
Table 16.2 Reported results for endonasal laser-assisted dacryocystorhinostomy, more extensive
dacryocystorhinostomy.
common canalicular block or obstruction of
Author Bone Number Success the individual canaliculi is better treated by an
instruments of cases
external technique (Chapter 17).
Gonnering CO2 (5) or 5 + 15 indeterminate Endonasal surgery does not allow a full
KTP (15) laser
inspection of the lacrimal sac mucosa and
Woog Holmium:YAG 40 82% external surgery should, therefore, be used if
laser with or
without surgical there is suspicion of a tumour, or other
instruments problem, within the lacrimal sac. Other
(25 cases where
only laser used ) (72%) relative contraindications to endonasal DCR
Boush Argon and surgical 46 70%
include a very narrowed nasal space, a small
instruments sac and failed previous DCR with extensive
Sadiq Laser 28 79% fibrosis at the rhinostomy.
(22 cases where
no tubes used) (59%)
Hartikainen CO2 or Nd:YAG 32 63% Endonasal endoscopic
Szubin Argon or Holmium: 31 97% dacryocystorhinostomy
YAG with surgical
instruments Local anaesthesia is achieved as previously
Camera Holmium:YAG 48 896% described (Chapter 15), but with particular
laser only
Laser with 123 992% attention paid to establishing vasoconstriction
Mitomycin C of the nasal mucosa (Figure 16.2); it is often
necessary to directly infiltrate the submucosal
space, anterior to the middle turbinate, using
readily performed with relatively little lidocaine 2% with 1:80,000 adrenaline.
perioperative bleeding. The procedure is, During the procedure localised haemorrhage
therefore, particularly useful in elderly or frail may be treated with 1:1000 adrenaline
patients, and in patients who do not wish to solution applied to the bleeding points with
accept the low risk of a visible cutaneous scar neurosurgical patties.
after external DCR, albeit accepting the
higher failure rate for endonasal surgery.
Most cases of primary acquired stenosis,
functional block or complete obstruction
of the nasolacrimal duct are suitable for
endonasal DCR, although patients with Middle
secondary obstruction may be treated if nasal meatus
access is adequate and there is no major nasal
disruption. Major mid-facial fractures, being Septum
associated with gross disruption of anatomy,
are not suitable for this approach and patients
with inflammatory nasal diseases associated Nasal
with scarring (such as sarcoidosis or Wegeners floor
granulomatosis) should probably not undergo
endonasal surgery, as the technique is
dependent on secondary intention healing.
Figure 16.2 Right nasal space; topical anaesthesia and
Whilst membranous block of the common vasoconstrictive medications (both spray and packing)
canaliculus may be treated during endonasal should be applied to these areas before surgery.
169
PLASTIC and ORBITAL SURGERY
Endonasal dacryocystorhinostomy may be the nose, and the ends of the intubation either
performed solely with surgical instrument- knotted or clipped together within the nasal
ation, or with laser-assistance. space (Figure 16.7a and 16.7b).
Light
LR
MT
S
16.3a 16.3b
16.4a 16.4b
Lacrimal
bone
Maxilla
bone
Mucosal
edge
B
16.5a 16.5b
Sac
mucosa
16.6a 16.6b
171
PLASTIC and ORBITAL SURGERY
MT
ST
B
16.7a 16.7b
172
LASER-ASSISTED and ENDONASAL LACRIMAL SURGERY
Caldwell GW. Two new operations for obstruction of the Sadiq SA, Hugkulstone CE, Jones NSS, Downes RN.
nasal duct with preservation of the canaliculi, and an Endoscopic holmium:YAG laser dacryocystorhinostomy.
incidental description of a new lacrymal probe. Am J Eye 1996; 10:436.
Ophthalmol 1993; 10:18995. Sprekelsen MB, Barberan MT. Endoscopic dacryo-
Camera JG, Bennzon AU, Henson RD. The safety and cystorhinostomy: surgical technique and results.
efficacy of mitomycin C in endonasal endoscopic laser- Laryngoscope 1996; 106:1879.
assisted dacryocystorhinostomy. Ophthal Plast Reconstr Steadman MG. Transnasal dacryocystorhinostomy.
Surg 2000; 16:11418. Otolaryngol Clin North Am 1985; 18:10711.
Gonnering RS, Lyon DB, Fisher JC. Endoscopic laser-assisted Szubin L, Papageorge A, Sacks E. Endonasal laser assisted
lacrimal surgery. Am J Ophthalmol 1991; 111:1527. dacryocystorhinostomy. Am J Rhinol 1999; 13:3714.
Hartikainen J, Grenman R, Puukka P, Seppa H. Prospective Weidenbecher M, Hoseman W, Buhr W. Endoscopic
randomised comparison of external dacryocystorhinostomy endonasal dacryocystorhinostomy: results in 56 patients.
and endonasal laser dacryocystorhinostomy. Ophthalmology Ann Otol Rhino Laryngol 1994; 103:3637.
1998; 105:110613. West JM. A window resection of the nasal duct in cases of
Jokinen K, Karja J. Endonasal dacryocystorhinostomy. Arch stenosis. Trans Am Ophthalmol Soc 1909-11; 12:6548.
Otolaryngol 1974; 100:414. West JM.The intranasal lacrimal sac operation. Its advantages
Massaro BM, Gonnering RS, Harris GJ. Endonasal laser and its results. Arch Ophthalmol 1926; 56:3516.
dacryocystorhinostomy. A new approach to nasolacrimal Whittet HB, Shun-Shin GA, Awdry P. Functional
duct obstruction. Arch Ophthalmol 1990; 108:11726. endoscopic transnasal dacryocystorhinostomy. Eye 1993;
McDonough M, Meiring JH. Endoscopic transnasal 7:5459.
dacryocystorhinostomy. J Laryngol Otol 1989; 103:5857. Woog JJ, Metson R, Puliafito CA. Holmium:YAG endonasal
Metson R. The endoscopic approach for revision laser dacryocystorhinostomy. Am J Ophthalmol 1993;
dacryocystorhinostomy. Laryngoscope 1990; 100:13447. 116:110.
Orcutt JC, Hillel A, Weymuller EA. Endoscopic repair of Yung MW, Hardman-Lea S. Endoscopic inferior
failed dacryocystorhinostomy. Ophthal Plast Recontr Surg dacryocystorhinostomy. Clin Otolaryngol 1998, 23:1527.
1990; 6:197202. Zilelioglu G, Ugurbas SH, Anadolu Y, Akiner M, Akturk T.
Rouviere P, Vaille G, Garcia C, Teppa H, Freche C, Lerault Adjunctive use of Mitomycin C on endoscopic lacrimal
P. La dacryocysto-rhinostomie par voie endo-nasale. Ann surgery. Br J Ophthalmol 1998; 82:636.
Otolaryngol Chir Cervicofac 1981; 98:4953.
173
17 Specialist lacrimal surgery and
trauma
Alan A McNab
primary canalicular surgery. DCR not only canaliculus have been obliterated by scar
increases canalicular conductance by having tissue. The principle of the procedure is to
bypassed the physiological resistance of the excise the block of scar tissue and unite the
nasolacrimal duct, but adequate primary medial end of one or both canaliculi to the
rhinostomy allows the relatively straight- nose, using the lacrimal sac mucosa as a
forward closed placement of a canalicular bridging flap; the operation, although
bypass tube should the primary canalicular technically feasible, carries a much lower
surgery fail to control symptoms. success rate than the standard external DCR
Where there is blockage of each individual or surgery for a more medial common
canaliculus, the length of patent canaliculus can canalicular obstruction (Chapter 15) and
be estimated clinically and dacryocystography is closed placement of a Lester Jones canalicular
not possible. With common canalicular bypass tube may be required later if the
obstruction, where syringing leads to reflux of operation fails.
dye-free fluid from the opposite punctum A standard DCR incision is made but,
(Chapter 10), a dacryocystogram is helpful in before mobilising the lacrimal sac and
establishing the extent of common canalicular periosteum, probes are placed in the blocked
disease. Lateral obstruction, with complete canaliculi, and the overlying medial canthal
obliteration of the common canaliculus, tendon divided and dissected laterally using
requires canaliculo-DCR whereas medial blunt or sharp dissection (Figure 17.1a). This
obstruction, due to adherence and fibrosis of dissection is continued laterally until the tips
the mucosal valve over the common canalicular of the canalicular probes are revealed in the
opening, may be dealt with by excision of the underlying tissues, the ends of the canaliculi
membrane at the time of DCR and intubation. are transected at their most medial point and
There is no need for CT of the facial fine silicone tubing inserted and pulled
skeleton when considering lacrimal surgery laterally, to aid in retraction. If only one
after previous mid-facial trauma, provided canaliculus is patent, either a monocanalicular
that the presence of a nasal space alongside stent can be used, or the other end of a
the site of future rhinostomy is established by bicanalicular intubation can be returned to
clinical inspection or nasal endoscopy. Where the nasal space through a blind passage (via
there has been major facial trauma, however, the punctal annulus, if present), ensuring
CT of this region may be useful in case other entry into the nasal space well away from the
procedures such as septoplasty, sinus one remaining functional canaliculus.
surgery or intercanthal wiring are to be A large rhinostomy is created and nasal
combined with the lacrimal reconstruction. mucosal flaps fashioned (Figure 17.1b); with
canaliculo-DCR, however, a very large
anterior nasal flap is required and relatively
Surgical options small posterior flap. The lacrimal sac is
opened, not in the mid-part of its medial
Canaliculo-dacryocystorhinostomy
wall as with ordinary DCR (Chapter 15)
(CDCR)
but much more anteriorly at the junction of
Canaliculo-dacryocystorhinostomy is the medial wall and anterior border; this
indicated where there is bicanalicular block allows the lacrimal sac to be unfurled
with canalicular obstruction situated a posteriorly to create a large bridging flap
minimum of 8mm from at least one of the between the back wall of the canaliculi and the
puncta and for lateral common canalicular small posterior nasal flap. The canalicular
block, in which several millimetres of common mucosa is united to the small anterior edge of
175
PLASTIC and ORBITAL SURGERY
Complications
(b) Although canaliculo-DCR has the same
spectrum of complications as simple DCR
(Chapter 15), the commonest specific
complication is failure of tear drainage due to re-
obstruction of the fine surgical anastomosis.
Trephination and silicone intubation may be
tried where the obstruction is a small membrane,
but in most cases the closed placement of a
Lester Jones bypass tube will required.
Lateral migration of the tube occurs inserted in a closed fashion. For optimum
most often and the tube will sometimes positioning of the distal end of the bypass tube,
be completely dislodged, when closed nasal examination is required and is best
replacement should be undertaken. Repeated achieved with endoscopy, although a good
episodes of tube extrusion generally occur due headlight and nasal speculum are often
to residual bone in the area of the rhinostomy adequate. A 3mm diameter rigid sucker is
and, in such cases, open revision of the required to clean the nasal space during
rhinostomy should be undertaken. More rarely surgery. The procedure is best performed
the tube will sink medially into the tissues and under general anaesthesia as vasoconstriction
may require a cut-down to retrieve it. from the endonasal local anaesthesia
Malposition of the ocular end of the tube encourages, due to an artificially shrunken
may result in failure of tear drainage where the middle turbinate and septal mucosa, a
tube is too anterior or, more usually, the tube misjudgement of the position of the nasal end
is too posterior and becomes embedded in of the tube.
conjunctiva or against the globe, causing First-time placement of a closed Jones
episcleritis. In more extreme cases, the tube is similar to the open canalicular bypass
irritation will cause formation of a pyogenic tube, using and positioning the guide wire
granuloma this being particularly and trephine in the same way; the intranasal
troublesome where the tube has become filthy position of the introducer should be checked
through neglect. In such cases of malposition endoscopically and, if necessary, the anterior
with secondary inflammation, the tube should part of the middle turbinate removed to make
be removed and replaced in a better position room for the tube. If there has recently been
at a later date when the inflammatory changes a satisfactorily functioning tube, the double-
have settled. ended (bullhorn) dilator that accompanies
Build-up of tear-film debris on the surface the commercial sets of tubes may be used to
of a bypass tube tends to lead to obstruction dilate the previous track and the tube forced
and repeated ocular infections. If the into place along an 0 gauge probe
obstruction cannot be cleared with the tube in introduced into the dilated track. After
place, the device should be removed and placement of any bypass tube, the position of
cleaned, or else replaced. both the ocular and the nasal ends of the
unsupported tube should be checked and it is
Closed placement of a canalicular particularly important to verify that the nasal
bypass tube end lies free within the nasal cavity and not
up against the septum, lateral wall or
Indications turbinate. A newly-placed tube needs to be
Closed secondary placement of a glass secured in the same way as a primary tube, but
canalicular bypass tube is indicated when a a replacement tube does not need fixation.
previously inserted bypass tube has become
dislodged, after failed canaliculo-DCR or
Medial canthoplasty during
retrograde canaliculostomy, or where, in the
lacrimal surgery
absence of reflex lacrimation, a functioning
DCR fails to control watering. Where injury to the lacrimal drainage
The procedure is similar to a primary (open) system has been accompanied by significant
bypass tube, except that the DCR has already midfacial trauma, there may be traumatic
been performed and the rhinostomy does not telecanthus or canthal dystopia and
have to be opened; in other words, the tube is repositioning of the canthus may be required
179
PLASTIC and ORBITAL SURGERY
(a) (a)
A
(b) (b)
Figure 17.4 Medial canthoplasty performed at the Figure 17.5 Redistribution of the soft tissues as part
time of open lacrimal surgery: (a) pre- and (b) post of a medial canthoplasty for inferior displacement of
surgery. Although there is an improvement in the the medial canthus. The apex A of the flap of skin
canthal position and elevation after postero-superior and muscle is transposed from the upper eyelid (a)
fixation of the lower eyelid, this is limited by scarring into the lower (b) after fixing the canthal structures
at the site of the previous injury. deeply to bone or periosteum.
180
SPECIALIST LACRIMAL SURGERY and TRAUMA
181
Index
Page numbers in bold refer to figures; those in italic refer to tables or boxed material
182
INDEX
183
INDEX
184
INDEX
185
INDEX
186
INDEX
187
INDEX
188
INDEX
189
INDEX
peau dorange effect in dermisfat grafting 14 for dysthyroid eye disease 115
pentagon excision for central ectropion 1617, 17 for idiopathic orbital inflammation 137
periorbital oedema in thyroid orbitopathy 101 for orbital lymphoma 145
periorbital signs in orbital disease 1012 for orbital metastases 148
periosteal flap for lower eyelid reconstruction 60 for sebaceous gland carcinoma 52
PET see positron emission tomography RamsayHunt syndrome 67
phenylephrine test in ptosis 35 rectus muscle attachment to orbital implant 91
pigmentary benign lesions 45 red eye
pilomatrixoma 45 from dural shunts 130
pleiomyorphic adenoma 132, 132 management 68
plication for ectropion 18, 19, 19 painful 67
pneumatocoele following orbital floor repair 154, 154 refraction measurement in ptosis 34
positron emission tomography in orbital disease 106 retention cyst 131
post-caruncular transconjunctival orbital retinoblastoma, extraocular extension 148
decompression 117 retractors see eyelid retractors
post-enucleation syndrome 945 retrobulbar masses 99
posterior lamella 1 rhabdomyosarcoma 1401, 140
advance following lid split 29, 30 differential diagnosis 126
lengthening 2930 rhinostomy 164, 164
repair 11
pre-aponeurotic fat pad 2 saline irrigation 8
presbyopia, premature 99 salmon patch lesion 100, 101, 144, 145
proptosis 73, 131, 150 sarcoma, orbital 1434
in dysthyroid eye disease 113, 11517 scalp-flap, bicoronal, for orbital decompression 117,
following surgical trauma to orbit 159 118, 119, 11921
and lagophthalmos 100 scarring
in orbital disease 989 following dacyrocystorhinostomy 162, 163, 167
in thyroid orbitopathy 101 management 1214
under/over correction in dysthyroid eye disease minimising formation 5
121 Schwannomas 137
prosthesis causing discharge 967 scintigraphy, lacrimal drainage 11011, 111
see also orbital implant scissors 9
pseudocapsule breach 132 scleral defect 158
pseudoepitheliomatous hyperplasia 54 scleral spacer donation 76
pseudoptosis 38 scleritis 134
ptosis 3243 sebaceous gland
aponeurotic 33, 37 benign tumours 45
assessment 325 carcinoma 489, 48
brow 79, 80 management principles 512
classification 358 seborrhoeic keratosis 45
following blepharoplasty 85 secretory system of eye 3
following enucleation 94, 95 semicircular flap
mechanical 38 for lower eyelid reconstruction 57, 58
myogenic 257 for upper lid reconstruction 623, 63
neurogenic 378 sensory disturbance in orbital disease 100
props 43 seventh nerve
repair 11 aberrant regeneration 38
S-shaped 1323, 133 palsy 15, 16, 21, 6773
surgical correction 3943 assessment 678
pulsation 99 management 68
punctal ectropion 1819, 108 prognosis 67
pupil size measurement in ptosis 33 surgery 6873
silk sutures 8
Quickerts procedure 28 single photon emission CT in orbital disease 106
sino-orbital cavity following exenteration 146
radiography for weapon demonstration 9 sino-orbital tumour 102
radio-iodine adverse effects 113 sinus
radiotherapy 534 mucocoeles imaging 106
complications 53, 54 paranasal, mucocoeles 125, 125
190
INDEX
sinusitis following surgery for dysthyroid eye disease surgical rehabilitation in dysthyroid eye disease
121 11517
skin surgical spaces of orbit 45
analysis for cosmetic surgery 79 sutures
crease measurement in ptosis 33, 33 adjustable, in ptosis surgery 40, 40
eyelid, anatomy 12 everting 25, 278, 28, 29
graft to eyelids 1, 11, 13 for browpexy 80
for entropion 27 for browplasty 81
full-thickness composite 645 for canalicular repair 12
see also eyelid reconstruction for dacyrocystorhinostomy 163, 163, 165, 167
necrosis following dacyrocystorhinostomy 167, and Jones canalicular bypass tube 178
167 for eyelid laceration repair 10
resurfacing, laser 868, 87 inverting 201, 21
tag 45 for lower eyelid reconstruction 5661
tight, causes 73 for orbital exenteration 146
see also dermis removal 8
skull, congenital clefts 1256 types 89
Smiths Lazy-T procedure 19 for upper eyelid reconstruction 625
socket for wound closure 8
complications following dermofat graft 93 see also specific types
congenital small 956 sweat gland benign tumours 45
contracted 956 Swiss cheese pattern biopsy 143
acquired 96 symblepharon following enucleation 95
causes 96 synkinesis 68
discharging 967 syringoma 45
lining problems causing 97 systemic disease 1023, 103
preparation for dermofat graft 93
surgery 8997 T cell lymphoma 144
volume-deficient, following enucleation T lymphocytes in Graves disease 112
945 tarsal dissection with or without mucous membrane
soft tissue grafting 29
diagnosis in orbital disease 106 tarsal eversion, total 201
injury, orbital 1579 tarsal margin split 29
loss in eyelid repair 11 tarsal plates 3
preservation 8 tarso-conjunctival diamond excision 18, 19
redistribution in medial canthoplasty 180, 180 tarso-conjunctival free graft 60
repair, principles 78 tarso-conjunctival flap
spacer for eyelid retractor recession 74, 767 pedicle 5860, 589
SPCET see single photon emission CT sliding 63
sphenoid wing meningioma 1378, 138 tarsorrhaphy, lateral 689, 69
spiradenoma, eccrine 45 in dysthyroid eye disease 117
squamous carcinoma 478, 48, 146, 147 tarsotomy 71, 72
management principles 512 tarsus 15
stab wounds 910 tattoo of tissues, prevention 7
Steristrips 8 tear film
steroid therapy assessment in ptosis 34
adverse effects 113 staining 108
in dysthyroid eye disease 115 tears
following optic nerve injury 158 overflow in ectropion 17, 18
for idiopathic orbital inflammation 137 production/drainage, defective 97, 10611
strawberry naevus 126, 126 telecanthus, traumatic 180
subciliary blepharoplasty in dysthyroid eye disease temporalis transfer surgery 68
119 Tensilon test in myasthenia gravis 36
subconjunctival lesion, salmon patch 100, 101 Tenzel flap 57, 58
subperiosteal haematoma 159 Tenzels lateral canthal sling modification 1718
subperiosteal implant following enucleation 94 third nerve palsy and ptosis 37
subperiosteal space 4, 5 thyroid orbitopathy 99, 100, 101, 101, 103
superior limbus 1 imaging 104, 104, 106
superior transverse ligament 3 see also dysthyroid eye disease
191
INDEX
192