Oculoplastics

 

Anatomy

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Abnormal Facial Movements

 

 

Facial Nerve Anatomy

Facial Muscles

 

Overactive facial conditions

 

Obicularis myokymia

 

Facial tics

 

Hemifacial spasm

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Essential blepharospasm

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Botulinum Toxin

 

Facial Nerve Palsy

Facial Nerve Palsy- Signs and Symptoms

Facial Nerve Palsy- Treatment

Facial Nerve Palsy- Abberant Renervation

 

Other Conditions causing Facial Weakness

Enucleation, Evisceration & Exenteration

Eyelid Reconstruction

 

 

Eyelid & Brow malpositions

 

Entropion

 

Ptosis- Evaluation and Treatment

 

Ptosis- Anatomy

• Upper eyelid retractors are: 1) Levator muscle. 2) Müller's muscle 3) Frontalis muscle
• Whitnall's ligament is an important landmark: extends from the fascia of the lacrimal gland to the trochlea
• Levator aponeurosis fans out to form "horns"
• peripheral arcade: lies on the surface of Müller's muscle

 

Ptosis- Classification- key is levator function

• Simple Congenital ptosis
• Involutional ptosis
• Other causes

 

Simple Congenital Ptosis

• A dystrophy of the levator muscle
• Present from birth
• Muscle is infiltrated with fat: dystrophic
• Levator function is reduced proportionally to the degree of ptosis
• Weak or absent skin crease
• Lid lag in downgaze
• Bilateral but can be quite asymmetric
• Treatment:

Degree of Levator Function Procedure
> 4mm Levator aponeurosis advancement
3-4 mm Levator advancement- to muscle
< 3 mm Frontalis sling

  

Involutional Ptosis

Other Causes of Ptosis

 

 

Misdirected Eyelashes

Marginal Entropion- most common cause

Traumatic Misdirection

 

Epiblepharon

 

Distichiasis

 

Benign & Malignant Eyelid Lesions

 

Epidermal Lesions

 

Benign Epidermal Lesions

 

Acrochordon

 

Seborrheic Keratosis

 

Cutaneous Horn

 

Epidermal Cyst

 

Milia

 

Sun-Damage Skin Changes

 

Actinic Keratosis

 

Malignant Epidermal lesions

 

Characteristics of Malignancy

 

Basal Cell Carcinoma (BCC)

 

Squamous Cell Carcinoma (SCC)

 

Keratoacanthoma

 

Adnexal tumors

Normal Adnexal Structures

Benign Adnexal Tumors

 

Hordeolum & Chalazion

 

Sebaceous hyperplasia

 

Sebaceous Adenoma

 

Syringoma

 

Eccrine hidrocystoma- eccrine glands participate in thermoregulation.

 

Apocrine hidrocystoma- apocrine glands are specialized scent glands (glands of Moll on eyelids)

 

Sebacious Cell Carcinoma

 

Eyelid lesions arising from Pigment Cells

Characteristics of Benign pigmented lesions

Characteristics of Malignant pigmented lesions

Melanocytic Nevus- Has a devleopmental "Life cycle"

Congenital Nevus

 

Lentignes

 

Ephelides- freckles

 

Melanoma - pigmented lesion with malignant characteristics

 

Lid Lesion Biopsy Techniques

Incisional biopsy

Shave biopsy

Punch biopsy

Excisional biopsy

 

Moh's Micrographic Tumor Excision

Cyst excision & Marsupialization

Proptosis

Hertel measurments

            Race          Average Measurement
            Asian                   18 mm
            White                   20 mm
            Black                   22 mm

 

Orbital Surgical Spaces

"P's" of the history and exam- introduced by Krohel, Stewart and Chavis

Differential Diagnosis of Proptosis

Differential Diagnosis based on Imaging-  primary scan is CT, MRI to see orbital apex, brain, intraorbital organic foreign bodies. Imaging to help identify the pathology and devleop a plan for a surgical approach.

 

Proptosis in Adults- Common Causes

Thyroid Orbitopathy- ill defined onset of progressive painless orbital inflammation. Most common cause of unilateral or bilateral proptosis

Surgical procedures on these patients are more difficult due to fibrosis and bleeding, outcomes are less predictable.

 

 Idiopathic Orbital Inflammatory Disease (Orbital Pseudotumor)

Orbital Cellulitis in Adults

Cavernous Hemangioma

Lymphoid lesions

Metastatic tumors

 

Optic nerve tumors

 

Lacrimal gland tumors

 

Secondary Orbital tumors

Proptosis in Children

Dermoid Cyst

Capillary Hemangioma

 

Orbital Cellulitis in Children

Optic Nerve Glioma

Lymphangioma

Rhabdomyosarcoma

 

Orbital Surgical Approaches

 

Tearing

 

Trauma

Soft Tissue Trauma
Canalicular Trauma
Blowout Fractures
Complex Facial Fractures

Blowout Fractures

Blowout fracture- Characteristics

Blowout fractures- Diagnosis

Blowout fractures- Indications for repair

Blowout fractures- Treatment

Index of Surgical Procedures

Post-op Orders

 

 

Blepharoplasty, Lower Lid- Transcutaneous- to remove skin and fat

  1. Mark skin: subcilary incision 2-3 mm below lower lashes extending from punctum to lateral canthus and 5mm lateral to lateral canthus in wrinkle line
  2. Anesthetic: subcutaneous along mark
  3. Prep entire face.
  4. Skin incision: Colorado needle, 15 blade or CO2 laser
  5. Dissect skin and muscle flap to orbital rim.
  6. Open orbital septum and dissect orbital fat: using Wescott scissors cut the septum and identify the nasal, central and lateral fat pads. Open  the thin fibrous capsule of each pad and dissect posteriorly to the lower lid retractors: a white band of tissue a thicker horizontal band of tissue is Lockwood's ligament. The inferior oblique lies within the retractors. Inject additional local anesthetic into the fat. Use bipolar cautery at the base of the fat. Excise the fat just anterior to the inferior orbital rim, be conservative. Leave symmetric amounts of fat in each orbit. Consider repositioning fat over orbital rim to mask the droop of the malar fat.
  7. Consider lateral canthoplasty: make a canthotomy incision with Wescott scissors through marked wrinkle line. Then preform a cantholysis with the scissors.  Make a strip of bare tarsus by dissecting the anterior lamella from the tarsus and scraping the epithelium off the posterior aspect of the tarsus.  Then suture the strip onto the inner aspect of the lateral orbital rim using two 4-0 Vicryl (P2 1/2 circle needle) or 4-0 Mersilene.  Tie it moderately tight with superior placement of the tendon.
  8. Excise skin and muscle: drape the excess skin and muscle over the lid margin to estimate amount to remove. Mark the excess skin to remove (2-3 mm usually).   Try not to remove more skin laterally and cause a tempral lid droop.
  9. Close the skin: deep fixation 4-0 Vicryl suture at the 1cm below lateral canthus pulling tissue up and tying to lateral orbital rim without dimpling skin. Reform canthal angle with interrupted 7-0 Vicryl suture. Then run 7-0 Vicryl from the puncta to the lateral wrinkle line.
  10. Post-op care: Topical antibiotic to wound and conjunctiva cul de sac. Cold compress for 24-48 hours.

 

Blepharoplasty, upper eyelids

  1. Mark the Skin: most important step. The goal is to leave a symmetric amount of skin after excision between eyebrow and the skin crease. Mark the skin crease from the punctum to the lateral canthus. Use caliper to measure down from brow.   Leaving 15mm of skin is safe in most patients. Men 15-20, women 10-15.  Leave 10mm for more cosmetic result. Leave more if browpexy will be preformed. While sitting up extend lateral excision in one of crow's feet wrinkle lines. Watch for symmetry while sitting up.
  2. Anesthesia: 1/10th cc of local with epi. in two or three spots within area of planned excision. After 30 seconds inject additional 1-1.5 cc of anesthetic. Hold gentle pressure. Consider light IV sedation.
  3. Prep entire face.
  4. Incise skin: 4-0 Silk retraction suture through meibomian gland orifices of upper lid. Make sharp incision through skin only using 15 blade, CO2 laser, or Colorado needle. Extend skin incision through obicularis muscle to the septum.
  5. Excise skin & muscle: in one layer dissect inveriorly from superior incision toward the skin crease, pull with non-dominant hand using forceps.  Try not to open the orbital septum.
  6. Remove fat: if necessary. Open septum the width of your wound at the superior edge of the eliptical incision. Westcott scissors might be better tolerated than the Colorado needle. Dissect the septum off the fat inferiorly first then superiorly towards the orbital rim. Preaponeurotic fat should be visible.   Dissect the preaponeurotic fat off the levator towards the superior orbital rim (central fat pad). Dissect medially to find the white nasal fat pad.  Inject more local anesthetic into fat. If palpebral artery is cut use bipolar cautery.  Trim fat anterior to the superior orbital rim.  Remove more fat in women than men. Leave symmetric amounts of fat behind. Bipolar cautery can be used to shrink fat to make sides symmetric.
  7. Close the Skin: use one or two interrupted 7-0 Vicryl sutures to reform the skin crease. Pass the needle from skin edge at the peak of the lid through the levator at the top of the tarsus. A second suture to reform the crease would be passed at the level of the lateral canthus.    Place patient in sitting positon to make final check of symmetry. Close the skin with running 7-0 Vicryl suture. (Other choices 6-0 fast absorbing gut or 7-0 nylon)
  8. Post-op care: Topical antibiotic to wound. Cold compress for 24-48 hours.

 

Browplasty, direct- for temporal browplasty use this technique for only the lateral 1/2 to 1/3 of the brow

  1. Mark the skin to be removed. Hold the brow in the desired positon and measure the amount the eyelid drops. Multiply this factor by 1 to 1.5 times to arrive at the final height of excision. Draw an elipse from the eyebrow hairs to the barks placed above the brow. The shape of the elipse should correspond to the anticipated change in brow contour. Usually 8-15mm of tissue is excised. Do not extend the temporal excision more than 1cm lateral to the tail of the brow to avoid damage to the frontal nerve.
  2. Inject local anesthesia into skin down to periosteum. Avoid injection into the supraorbital vein.
  3. Excise skin and muscle in one layer: Use a No. 15 blade, CO2 laser or Colorado needle to incise the skin to the subcutaneous fat. Keep the incision superficial at the head of the brow to avoid damage to the supraorbital nerve. Use Stevens scissors, CO2 laser or Colorado needle to dissect the flap in the loose areolar layer anterior to the periosteum. Stay superficial to the fontalis near the tail of the brow. Cauterize the bigger vessels and cover with a wet sponge while doing the fellow brow.
  4. Close the wound: Use  interrupted 4-0 Vicryl to close the deep tissues. Use a running 5-0 Prolene suture to close the skin.
  5. Place topical antibiotic
  6. Remove skin sutures in 7-10 days.

 

Dacryocystorhinostomy, external

  1. Preop Nasal preparation: Nasal decongestion using Afrin (oxymetazoline HCL 0.05%) 2 puffs q5min x 3, 20 minutes before surgery.  Mark skin incision: half way between nasal bridge and medial canthus. Draw inferiolaterally toward the lateral alae of the nose for 12mm. Palpate lacrimal crest and place mark closer to crest if necessary. Inject local anesthetic (2% lidocaine with 1:100,000 epinepherine with 0.5% bupivicaine) into tissue under skin marking, lacrimal sac, skin around canuliculi, mucosa of lateral nasal wall adjacent to anterior tip of middle turbinate and mucosa of middle turbinate. Pack the nose with Afrin soaked cottonoids. (Cocaine 5% if not elderly or under general anesthesia because of sesitization to arrhythmias). reverse Trendelenburg position 10-15 degrees. Prep entire face if local anesthesia or if general anesthesia prep ipsilateral eye and nostril.
  2. Expose lacrimal sac: Make skin incision with 15 blade or Colorado needle. Stevens scissors to spread obicularis muscle down to periosteum. Pass 4-0 Silk traction sutures though the muscle in the four corners for exposure. Elevate the periosteum with a Freer elevator in the dominant hand and a Baron suction tube in the nondominant hand for retraction. Clean muscle off periosteum. Incise periosteum with elevator parallel to skin incision and reflect it toward the anterior lacrimal crest. Use bone wax as necessary to stop bleeding. Lift contents of lacrimal sac fossa off the bone.
  3. Create the osteotomy: Use suction tube to retract lacrimal sac tissue to expose lacrimal sac fossa. Break through the suture between the lacrimal bone and maxilla with the Freer elevator without disturbing underlying muscosa. Use the Hardy sella punch (90 degree) to start the ostium, rotate the punch in the hole like turning a key.  Enlarge the ostomy with the larger Kerrison rongeurs. When the entire lacrimal sac is adjacent to nasal mucosa, ostium is complete (usually 15mm by 15mm).  Remove spine of bone on neck of sac with Belz lacrimal sac rongeur.
  4. Form the flaps, intubate and close flaps: Use No. 1 Bowman probe through canaliculus into sac and tent up sac. Use No. 66 Beaver blade or Crescent blade to incise sac along long axis. Turn blade 90 degrees and incise anterior flaps at both ends. Incise the nasal mucosa with same blade and again turing blade form anterior mucosal flap. Use Wescott scissors to cut the posterior sac and nasal mucosal flaps. Nasal packing can be removed. Suture posterior flaps with two interrupted 4-0 chromic gut (G-2 micropoint cutting needle, 1/2 circle needle) sutures. Pass the Crawford stents through the canaliculi & ostium and pull out through nose. Cut off a 3 inch piece of the 4-0 silk traction suture and tie it around stents in ostium using a needle holder. Tie the ends of the stent in the nose after grasping the stents with a empty needle holder and cut the ends.   Close the anterior flap using two interrupted backhanded passes with the same needle and suture (4-0 chromic gut)
  5. Close the incision: Remove traction sutures. Use two or three 5-0 Vicryl sutures to close the muscle, bury knots. 7-0 Vicryl suture or other absorbable stuture to close the skin.
  6. Post-op care: topical antibiotic on wound and conjunctival fornix. Cephalexin 500 mg po QID for 7 days. See one week post-op.  Remove stent after at least 6 months- cut in canthus and pull out from nose.

DCR with Jones Tube Placement-Used when the canalicular system is occluded and there is no hope of reconstruction

  1. Preform a DCR: either an External DCR or endoscopic DCR can be used. The tube is placed after the posterior flaps have been sutured.
  2. Determine tube position and length: The tube should enter the conjunctiva between the plica and the caruncle, just inferior to the lower lid margin. It sould be angled slightly inferiorly into the nose, emerging through the ostium anterior to the tip of the middle turbinate. Place a 20-gauge needle attached to a 5ml syringe through the conjunctiva of the nose. Check the intranasal position of the tube to ensure it is open without obstruction. Retract the needle as necessary to position it. The anterior portion of the middle turbinate can be excised using a rongeur after it is injected with lidocaine with epinepherine. Airflow distrubance in the nose and post-op bleeding can be troublesome. Clamp a hemostat on the needle at the medial canthus and draw it out. The needle length is a guide for choosing the correct tube length. A 4mm flange and 17-mm length is average.
  3. Place the Tube: (Described by John Dutton) Direct a 14-gauge IV catheter needle and sleeve along the same path as the above 20-gauge needle. Check the intranasal postion. Withdraw the needle but leave the sleeve. Tie a double-armed 6-0 Vicryl suture to itself around the tube on the flange end and leave the needles on the suture. Push the Jones tube into the conjunctival end of the catheter sleeve. A Stevens scissors can be used to dilate the proximal end of the catheter sleeve. Pull the sleeve out of the nose with a hemostat while pushing the Jones tube into position. The tube should protrude 3mm into the nose with a slight inferior tilt and it should not be obstructed by the septum or turbinate.
  4. Suture the tube in position: Pass the Vicryl suture ends into the conjunctival tissue pulling the tissue snugly around the tube. Conjunctiva might need to be trimmed before tying the suture if there is too much tissue around the tube.
  5. Post-op care: Topical antibiotic. Oral antibiotic if DCR has been preformed (Cephalexin 500 mg po QID for 7 days) See one week post-op. If a tube becomes clogged it may be exchanged using the plastic tube in the Jones tube set. This is rarely necessary.

Enucleation- with scleral wrapped Medpor implant

  1. Ensure correct eye is identified for removal. Dilate the eye to be removed if necessary. Visit the patient preoperatively. Look into the dilated eye to confirm the pathology
  2. Anesthesia: general anesthesia is usually used. Inject local anesthetic with epinepherine under the conjunctiva for hemostasis
  3. Detach extraocular muscles: 360 degree peritomy with Wescott scissors. Dissect Tenon's capsule away from the eye using Stevens scissors. Hook the muscles with a von Graefe hook followed by a Green hook. Pass a double armed 5-0 Vicryl suture on a spatula needle (S-14 needle) through the muscle insertion using the von Pirquet suture style (locking the suture at each border). Cut the muscle off the eye leaving a few millimeters of the insertion on the eye. Detach all four rectus muscles in the same way. Tape the sutures to the drape. Hook the oblique muscles and cut them from the eye. Cauterize the inferior oblique before cutting it. Place 4-0 silk traction sutures through the medial and lateral rectus muscle insertions.
  4. Cut the optic nerve: Pull up on the traction sutures, prolapsing globe out of the conjunctiva. Use Sewall retractors to retract the posterior tenon's capsule away from the globe. Use a long hemostat to clamp the optic nerve 1 cm posterior to the globe. Tap the optic nerve from below and above then open the clamp and tap each side of the nerve to ensure the nerve is between the blades. Use enucleation scissors to cut the nerve in the same way by taping below and above first. Cut any soft tissue connections. Visualize the cut end of the nerve. Use bayonet bipolar cautery and cauterize the end of the optic nerve. Slowly release the clamp under direct visualization. Place a 4x4 damp gauze into the the wound.
  5. Prepare the implant: most will use a 20mm spherical Medpor implant. Place the implant into the sclera by making relaxing incisions. Trim the posterior sclera with a No. 15 blade so that the posterior half the implant is exposed. Use 5-0 Vicryl or Dacron to tighten the wrap around the implant. Cut four 5mm-2mm.windows in the scleral wrap with the No. 15 blade and pointed tiped scissors
  6. Attach the muscles to the implant: Place two pieces of 1 inch X 6 inch plastic drape into the wound. Place the implant onto the plastic and push into the socket. Slide the drapes and suture each rectus muscle to the anterior edge of each window.
  7. Close Tenon's and conjunctiva: Use the 5-0 Vicryl to close the Tenon's capsule with interrupted bites. Close the conjuntiva with a running locking 7-0 Vicryl suture.
  8. Inject local anesthetic with bupivacaine into the retrobulbar space for post-op pain relief.
  9. Place topical antibiotic and a conformer into the conjunctival fornix.
  10. Tape a pressure patch over the eye for 2-7 days.
  11. Recovery inpatient care for 24 hours for IV pain control is appropriate.
  12. See in 1 week, fog the lens of the glasses with tape.
  13. A custom fit prothesis can be made in 6 weeks.

 

Gold Weight Implantation

  1. Topical anesthetic
  2. Mark upper eyelid skin crease 1-2 mm higher than normal
  3. Inject local anesthetic with epinephrine
  4. Dissect a pretarsal pocket: use a 4-0 silk traction suture in the upper eyelid margin. Make the skin incision with No. 15 blade or Colorado needle. Dissect the skin and muscle off the tarsus inferiorly stop 2-3 mm above the eyelashes.
  5. Suture the weights onto the tarsus: Use 5-0 Dacron sutures.  Ensure no stress on the overlying skin.  The upper edge of the gold weight should rest at the upper edge of the tarsal plate.
  6. Close the wound: Close the obicularis with interrupted 5-0 vicryl suture. Close the skin with 7-0 Vicryl or 5-0 fast absorbing gut.
  7. Apply topical antibiotic.

Levator Aponeurosis Advancement

  1. Prepare the patient: Instill topical drops. Mark an upper lid crease incision from lateral canthus to punctum. Inject local under skin.
  2. Make a skin incision: 4-0 silk traction suture through meibomian glands. Colorado needle or No. 15 blade to make skin incision.
  3. Identify levator aponeurosis: Incise orbicularis muscle off the wound.   Dissect orbicularis off the orbital septum for 5mm. Look through the septum to see the preaponeurotic fat.  Open the septum with Wescott scissors and Paufique forceps.  Lift septum towards ceiling and cut through it. Slide the scissors into the incision and cut to left and right. You can have the patient look up to cause the levator to contract to help get oriented. Dissect the septum off the preaponeurotic fat. Dissect the preaponeurotic fat off the aponeurosis.
  4. Dissect the levator aponeurosis off Müller's muscle: dissinsert the levator aponeurosis from the anterior surface of the tarsus using either the Colorado needle or Wescott scissors. This will "bare" the superior margin of the tarsus. Dissect the obicularis muscle off the superior one third of the tarsus. Dissect the aponeurosis free from Müller's muscle. By pulling the edge of the aponeurosis superiorly dissect a plane superior to Müller's muscle with thin adhesions, avoid bleeding by avoiding the peripherial arcade in the muscle. Continue the dissection superiorly for 10-12 mm.
  5. Advance the levator aponeurosis onto the tarsus: pass a double armed 5-0 nylon suture (s-24 spatula needle) into the tarsus in a lamellar fashion 3 mm inferior to the superior tarsal edge the pass should extend for 6-7 mm. Pass the arms of the suture through the aponeurosis about 10mm superiorly. Tie a temporary knot. Have patient open both eyes and examine the height and contor.
  6. Adjust height and contor: If lid is too high or low,  untie the knot and back one arm out of the aponeurosis, reposition the suture lower or higher in the aponeurosis, using the first suture to guage where the second should go. If the lid peak is incorrect (usually lid peaks nasal to the pupil), reposition the tarsal bite or pass a second nylon suture to correct temporal droop. Have the patient sit up to make a final inspection. Cut the suture bow and tie it down permanently. Trim off extra aponeurosis.
  7. Close the skin: consider a suture to reform the skin crease; 7-0 Vicryl from one skin edge, through the superior margin of the tarsus to the opposite skin edge. Run 7-0 Vicryl or 6-0 fast absorbing gut to close skin.
  8. Post-Op care: topical antibiotic to lid and eye TID for a week.

 

Medial Spindle

  1. Anesthesia: Topical anesthetic, Inject local into the inferior fornix of medial conjunctiva, and under the skin at the orbital rim inferior to the punctum.  If doing a lateral tarsal strip in conjuction, inject in the lateral canthus as well.
  2. Excise a diamond of conjunctiva: Place a No. 1 Boman probe into the inferior canuliculus and rotate inferiorly. Excise a diamond shaped piece of conjuctiva and lower lid retractors inferor to the punctum and tarsal plate (3x3mm). Grasp the conjuctiva with Paufique forceps and using Wescot scissors excise a V of conjuctiva inferiorly, cut a similar V superiorly.
  3. Close the conjunctiva: Use a double armed 5-0 chromic suture (G-3 needle). First pass the needle through the lower lid retractors in the center of the diamond. Pass the two ends of the suture backhanded through the apex of the diamond adjacent to the punctum. Pass each suture end through the inferior apex of the diamond and continue full thickness through the lid exiting at the juction of the eyelid and cheek skin.
  4. Do a lateral tarsal strip now, tie the suture ends after the strip is tied down.
  5. Tie the sutures: Cut the needles off and tie the suture down so there is a slight overcorrection. The chromic suture will fall out in 7-10 days leaving the lid in its normal postion.

Frontalis Sling

  1. Mark the skin:  Mark an upper eyelid skin crease incision and three 4-mm incisions on the forhead, one above the brow hairs just medial to the lateral canthus, a second just lateral to the medial canthus and the last 1-2 cm above the brow in line with the pupil.
  2. Inject local anesthetic with epinepherine then prep and drape the patient
  3. Make skin incisions: 4-0 Silk traction suture through the upper lid margin. No. 15 blade to make the 4 mm incisions in the brow- cut down to periosteum avoiding the supraorbital neurovascular bundle. Spread the wound with a hemostat. Bleeding usually stops with pressure. Incise the skin crease with the blade or a Colorado needle. Identify the levator muscle just as in the levator advancement
  4. Suture the facia to the tarsus: Bare the superior half the tarsus by dissecting the obicularis off the tarsus. Suture two strips of fascia to the tarsus using 5-0 polyester with a spatula needle. Suture the middle of the length of the first strip to the upper third of the tarsus at the peak of the lid then suture the same piece to the tarsus at the medial limbus. Then sew the second strip of facia at the peak of the lid and the lateral limbus.
  5. Pass the fascia: Using a Mayo trocar, pass the fascia ends under the orbital septum and out the brow wounds hold the trocar with a Webster needle holder. Place a Yeager lid plate in the superior conjunctival fornix to protect the eye. Don't pass the needle into the periosteum. Pass the medial fascia ends out the medial incision and the lateral ends out the lateral brow incision. Inspect the lid contor by pulling the fascia superiorly through the brow incisons adjust the tarsal sutures to give a natural lid contour.
  6. Close the skin: Use interrupted 7-0 Vicryl to reform the skin crease by passing the suture from one skin edge, through the superior edge of the tarsus and out the opposite skin edge. Finish the closure with a running suture.
  7. Adjust the lid height and contor: Tie the fascia so that the lid margin is at the limbus. Tie a piece of 5-0 Vicryl suture over a square knot of fascia to keep it from slipping. Cut one piece of the fascia 1 cm past the knot. Pass the long end of each piece of fascia out the central incision using the Mayo trocar. Tie the fascia ends in the same way. Use forceps to slip the ends of the fascia under the frontalis muscle.
  8. Close the forhead incisions with 7-0 vicryl
  9. Place a 4-0 silk suture through the lower lid margin and tape it to the forhead (Frost suture) to avoid post-op exposure. Remove the Frost suture the first post-op day.
  10. Use frequent lubricating ointment for the first week. Use topical and oral antibiotics for the first week.

Dynarod Frontalis Sling- use for patients at high risk for corneal exposure e.g. myogenic ptosis, the rod can be adjusted post-op

  1. Technique similar to the Frontalis sling with fascia
  2. Modifications include passing the rod in a pentagon pattern using one piece of silicone rod tied to the apex of the pentagon. Use 5-0 polyester suture to attach the rod to the tarsus
  3. 3 mm segments of Watzke #270 sleeve are theaded over the ends of the rod.
  4. 5-0 polyester suture is tied around each sleeve to prevent slipping.

Tarsal Fracture- treat marginal entropion

Horizontal incision across the posterior surface of the tarsus.

  1. Prep patient: topical and local anesthetic under skin and conjunctiva of lid
  2. Stabilize lower lid: 4-0 silk through lower lid margin. Evert the lid over a Jaeger lid speculum (shoehorn).
  3. Horizontal tarsal incision: No. 15 blade or Colorado needle full thickness horizontal incision through the tarsus 2-3 mm laterally beyond area of entropion, make at least halfway down tarsal plate. Cautery as necessary
  4. Pass double-armed 6-0 Vicryl sutures (S-14 needle): full thickness through lid with backhanded pass entering inferior to edge of wound and exiting just inferior to lashes anteriorly.  Usually 3 sutures used.
  5. Tie sutures to evert lid margin. Aim for slight overcorrection
  6. Post-op care: topical antibiotic ointment

Pentagonal Wedge Resection- removes localized segment of lashes, scar or lid lesion

  1. Local anesthesia
  2. Excise the abnormal lid segment: Mark a pentagonal wedge excision, include 2-3mm of normal lid on either side. Extend the vertical marking to superior edge of tarsus. No. 15 blade to make skin incision. Use scissors with straight blades to complete the excision.
  3. Align lid margin: use 7-0 Vicryl suture through the meibomian gland orifices to align lid margin in a vertical mattress fashion.   Evert wound slightly.  Keep ends long until tarsus sutures passed.
  4. Suture tarsal plate: two or three interrupted 5-0 Vicryl sutures in a lamellar fashion to align the tarsal plate.
  5. Suture lid margin: place a second 7-0 Vicryl suture at teh base of the eyelashes in a vertical matress fashon causing slight eversion of the eyelid margin. If the eyelid margin is not aligned, replaced the marginal suture placed in step #3 above. An additional marginal suture can be placed to help align the eyelid margin. Cut the suture ends close to the knot.
  6. Close the Skin: Use absorbable sutures. If wound is under tension, close the obicularis muscle with 5-0 Vicryl before closing skin. 
  7. Post-op care: topical antibiotic ointment

 

Cryoepilation- destroy larger areas of misdirected lashes

  1. Double freeze- thaw is most successfull
  2. Instill topical anesthetic
  3. Inject anesthetic with epinepherine under skin and conjunctiva and wait 10 minutes
  4. Prep patient without drape
  5. Protect lid with plastic plate.
  6. Place cryoprobe onto skin inferior to misdirected lashes
  7. Leave probe on for 30 seconds on upper lid and 25 seconds on lower lid to give an iceball that surrounds the probe for 2 or 3 mm.
  8. Let the probe warm slowly until it releases spontaneously
  9. Repeat the treatment a second time
  10. Move to adjacent tissue and overlap slightly
  11. Epilate the lashes- should slide out easily
  12. Apply Antibiotic ointment, narcotic treatment and warn patient of significant swelling.

    13.  

Laser Epilation- for a few misdirected lashes

  1. Aim argon beam parallel to hair shaft by everting eyelid
  2. Start with: 300 mW, 0.5 second duration, 50 micron spot
  3. Increase power as necessary
  4. Burn hole 1-2 mm deep to destroy hair follicle'

 

Lateral Tarsal Strip

  1. Topical anesthetic drops
  2. Local anesthetic with epinephrine into the lateral canthal skin, inner aspect of the orbital rim against teh bone and lateral third of lower eyelid skin and conjunctiva.
  3. Lateral canthotomy: Using Wescott scissors or the Colorado needle make a lateral canthotomy entending the incision to the periosteum so it is visible. Use a Freer elevator if necessary to bluntly dissect tissue to visualize the periosteum
  4. Cantholysis: Cut the lower limb of the lateral canthal tendon. Hold the eyelid toward the ceiling and strum the tendon to identify the fibers to cut. The lid should release from the orbital rim. Try to complete this in one or two cuts.
  5. Form the strip: Split the anterior and posterior lamellae for appoximately 5mm by sliding Wescott scissors between the tarsal plate and obicularis muscle. Cauterize along the inferior margin of the tarsus then cut where you cauterized. This frees the tarsus from the conjunctiva and lid retractors.  Remove the skin from the strip with Wescott scissors. Denude the conjunctiva from strip with a No. 15 blade.
  6. Shorten the strip: pull the strip to the periosteum and remove excess strip, be conservative.
  7. Reattach the strip: reattach the inner aspect of the strip to the lateral orbital rim with a double armed 4-0 Vicryl or Mersline. Back the needle into the wound and rotate the needle. Grasp the needle with forceps. Tie the suture temporarily to check the tension of the lid. Do not over tighten
  8. Trim redundant anterior lamella.
  9. Close the canthotomy with two interrupted 7-0 Vicryl sutures.

Electrolysis of lashes- for small number of lashes, failure rate ~50%

  1. Hyfrecator (or battery operated electrolysis wire)
  2. Slide wire down follicle shaft.
  3. Start with lowest power setting, advance power until small amount of tissue around follicle coagulates

 

Epiblepharon Repair

  1. General anesthesia for children
  2. Mark redundant lower lid skin. Pinching skin will help determine amount to remove. Make superior excision close to the eyelashes. Blend line of excision into any medial epicanthal fold that is present. Upper epiblepharon excision will form a upper eyelid crease.
  3. Inject local anesthetic with epinepherine.
  4. 4-0 Silk traction suture in lid margin.
  5. Incise skin with No. 15 blade or Colorado needle
  6. Excise skin and muscle with Wescott scissors or Colorado needle. Marginal arcade will be near superior incision.
  7. Close skin edges with 7-0 Vicryl or 5-0 fast absorbing gut.
  8. Post-op antibiotic ointment

 

Chalazion: Incision and Drainage

  1. Topical anesthesia then Inject 2% lidocaine with 1:100,000 epinepherine subconjunctivally proximal to the tarsal plate and under the pretarsal skin
  2. Clamp the area with a chalazion clamp and incise the lesion with a No. 11 blade. Make a cross shape excision.
  3. Use a chalazion curette to remove contents of the cyst
  4. Excise the corners of the cross-shaped incision with Wescott scissors.
  5. Thermal cautery for hemostasis
  6. Antibiotic ointment
  7. If there is persistant oozing, patch the eye for 6-12 hours.

 

Orbital Floor Fracture repair- transconjunctival approach (use a subciliary approach

  1. General Anesthesia
  2. Inject local anesthetic with epinephrine in the conjunctival fornix and under the skin adjacent to the inferior orbital rim.
  3. Keep both eyes exposed for comparison and repeat forced ductions
  4. Dissect the preseptal plane to inferior orbital rim: pass a 4-0 Silk traction suture though the lower lid and the conjunctiva under the insertion of the inferior rectus. Do a Canthotomy and inferior cantholysis. Evert the eyelid with a Jaeger lid plate and make a transconjunctival incision from the medial puncum to the lateral canthal insertion just inferior to the margin of the tarsus. Use another 4-0 Silk traction suture to retract the conjunctiva and lower lid retractors. Pull the septum and obicularis apart with two Paufique forceps and continue the preseptal dissection to the inferior orbital rim. Turn the disection 90 degrees towards the orbital rim. Palpate the rim and dissect the cheek fat away from the rim with a Freer elevator.
  5. Elevate the periosteum off the orbital floor: Place a Jaffe lid speculum. A Desmarres vein retrator gives additional retraction. Wear a headlight for this portion and dim the operating room lights. Use a No. 15 blade or Colorado needle to cut the periosteum along the inferior orbital rim. Elevate the periosteum off the inferior orbital rim with a Freer elevator and a Frazier suction tube. Continue elevating periosteum until reaching the anterior edge of the fracture.
  6. Free entraped tissue: Tease the periorbita off the anterior edge of the fracture and extend the dissection posteriorly around the perimeter of the fracture. Retract orbital contents with a Sewall or malleable retractor. When the entire perimeter of the fracture has been exposed try to elevate the entrapped orbital tissue from the fracture. The entire perimeter of the fracture should be visible. There is no need to elevate broken bone fragments. Repeat forced ductions which should be normal.
  7. Position the implant: Use Supramid or MEDPOR implant. Use the MEDPOR channel implant with plates if there is no posterior edge for support. Cut the implant to size, usually the shape is similar to a guitar pick. Elevate the tissue and position the implant to entirely cover the defect. Make sure there is no tissue prolapsing around the implant. Screw the implant into position with two 3 mm microscrews at the inferior orbital rim. Repeat forced duction tests to ensure the implant did not entrap tissue.
  8. Close the wound: Close the periosteum with 4-0 Vicryl suture (P-2 needle). Close the conjunctiva with interruped 7-0 Vicryl sutures (or 6-0 plain gut). Reattach the lateral canthal tendon with the same 4-0 Vicryl suture. Close the canthotomy with 7-0 Vicryl suture.
  9. Apply topical antibiotic ointment in the fornix and skin.
  10. Observe in the hospital overnight to check visual acuity. Oral steroids can be given to reduce post-op swelling. Use parenteral antibiotics concurrently with steroids. Keep head of bed elevated and ice in place for 48 hours. Resume activity over 48 hours.

Retractor Reinsertion- for lower lid involutional entropion, usually combined with a lateral tarsal strip

  1. Mark a subciliary incision
  2. Local anesthetic with epinephrine under the lower eyelid skin and in the lower lid fornix
  3. Make a subciliary incision: Place a 4-0 silk traction suture to stabilize the lower lid. Cut along the mark with a No. 15 blade or Colorado needle. Use Wescott scissors or Colorado needle to cut the pretarsal obicularis muscle then dissect anterior to the septum inferiorly toward the inferior orbital rim.
  4. Indentify the lower lid retractors: Landmark is the preaponeurotic fat. Open the orbital septum and find the preaponeurotic fat. Often the fat is difficult to see in older patients. Identify the lower lid retractors as a white layer.  Having the patient look up and down can often cause some movement of the retractors.
  5. Dissect the retractors off the conjunctiva: Remove the fat from the anterior surface of the retractors with Wescott scissors. Staring below the inferior edge of the tarsus, cut through the retractors and dissect a plane between them and the conjunctiva. Don't worry about a button hole in the conjunctiva. Free up 5-10mm.
  6. Advance the retractors onto the tarsus: Suture the edge of the retractors with three interrupted 5-0 Vicryl sutures on a spatula needle. Release the traction stuture and inspect the lower lid position.  Do a lateral tarsal strip now if necessary to prevent overcorrection.
  7. Close the skin: Use fast absorbing gut or 7-0 Vicryl running sutures. Combine the canthotomy with the subciliary skin closure to reform the lateral canthal angle.
  8. Topical antibiotic ointment.

Permanent Lateral Tarsorrhaphy

  1. Topical anesthetic plus local subconjunctival and subcutaneous anesthetic with epinephrine.
  2. Split the lateral 1/3 of the upper and lower lids: Use a No. 15 or No. 75 blade to incise the lid margins along the grey line keeping the plane parallel to the posterior surface of the tarsus. Separate the lamellae with Wescott scissors for approximately 4mm.
  3. Remove the epithelium of the posterior lamella with the scissors or the blade.
  4. Suture the upper and lower posterior lamella together with 5-0 Vicryl sutures.
  5. Suture the upper and lower anterior lamella together with 7-0 Vicryl sutures and evert the eyelashes with the closure.
  6. Apply topical antibiotic

 

Permanent Medial Tarsorrhaphy

  1. Topical anesthetic
  2. Mark a V-shaped incison just peripheral to the canuliculi to the upper and lower lid.
  3. Inject local anesthetic with epinephrine
  4. Make small myocutaneous flaps at the canthus: Place a Bowman probe into the canuliculus. Use a No.15 blade, Wescott scissors or Colorado needle to cut through the skin and muscle adjacent to the canuliculus on both upper and lower lids. Connect the incisions to form a "V". Dissect a small skin and muscle flap away from the canuliculi.
  5. Suture the medial lids together: Use three interrupted 5-0 Vicryl sutures in the muscle to close the tarsorrhaphy. This will invert the canaliculi.   Close the skin with 7-0 Vicryl or 5-0 fast absorbing gut.
  6. Apply topical antibiotic

 

Post-Op Orders