Beruflich Dokumente
Kultur Dokumente
OCULOPLASTIC AND
ORBITAL SURGERY
JONATHAN J. DUTTON, M.D., Ph.D.
University of North Carolina
Chapel Hill, North Carolina, USA
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Preface
his atlas is an updated version of a book originally published in 1992 as part of a four-volume set on ophthalmic
surgery. That version has been out of print for several years.
In the present version we have updated many procedures,
eliminated some that are no longer in general use, and added
12 new procedures that have gained popularity during the
past decade. As in the original version, this book presents a
visual guide to ophthalmic plastic and reconstructive surgery.
We present basic oculoplastic eyelid, lacrimal, and orbital
procedures in a manner that will provide a quick and readily comprehensible reference. There is no attempt at exhaustive compilation of procedures, many hundreds of which have
been described. Instead, for each group of disease processes
or anatomical conditions we have selected those operations
that have withstood the tests of time and numbers and that
most oculoplastic surgeons have found particularly useful.
We do not intend this book primarily for the trained
oculoplastic specialist who is familiar with a variety of surgical procedures. Rather, we direct it at the less experienced
surgeon in oculoplastic procedures, in particular residents
in training, as well as those who may perform these operations infrequently, such as the general ophthalmologist,
otolaryngologist, dermatologist, and some general plastic
surgeons.
The atlas is organized into three major sections: eyelid surgery, lacrimal system surgery, and orbital surgery.
Most of the eyelid procedures are grouped according to
the disease processes they correct, such as blepharoptosis
or ectropion. Lacrimal drainage operations are grouped
according to the anatomic location of the blockage; for
example punctal, canalicular, and nasolacrimal duct. Deep
orbital operations are arranged mainly by the route of
access into the most important surgical spaces, not by specific pathologic processes.
Each major section or part begins with a discussion of
relevant surgical anatomy, illustrated with sequentially layered figures through the relevant structures. It is difficult to
perform any surgery optimally without a solid understanding of local anatomic and physiologic relationships. These
anatomical chapters provide foundations for understanding the surgical descriptions that follow.
For each group of related procedures, there is a discussion of etiologic pathology and techniques of preoperative
evaluation that are indispensable for planning any surgical approach. The proper selection of a specific operation
for any given disease or malposition often means the difference between success and failure. Therefore, the text
includes key points that will help the reader plan the most
appropriate operation and minimize unnecessary complications. We conclude each section with a short list of
selected references for those interested in further readings.
Following the general discussion of the disease or condition, we detail our approach to the operative techniques in
stepwise fashion, with captioned text on the left-hand page
and matching illustrations on the right-hand page. In the
original version of this book, we introduced the concept
of inverting the figures. Again, here, we depart from the
standard approach of illustrating oculoplastic procedures
facing the patient in the upright position. Rather, we draw
illustrations from the view as seen by the operating surgeon, which in most cases is standing at the patients head.
The image is thereby seen upside-down, but best approximates the view seen by the surgeon. For some operations,
such as dacryocystorhinostomy or lateral orbitotomy, the
view is from the side, again approximating the surgeons
perspective. We believe that this eases the transition from
the printed page to the operating table.
In a few cases, certain eponyms are so intrinsic to the
literature that deleting them would be confusing. For the
most part, however, eponyms are nondescriptive and convey little useful information. Therefore, we have elected to
replace most of them with more anatomically meaningful
descriptive terms. For each operation, we also include a
brief list of the most appropriate indications and, in some
cases, contraindications. Following a description of the
technique, we indicate appropriate postoperative care. In
addition, we list the most common potential complications, along with a brief discussion of how to avoid and
correct them.
The number of individuals who have contributed innovative approaches to the field of oculoplastic and reconstructive surgery is legion, and useful modifications of
older procedures frequently appear in the literature. Few
operations described in this book are new, and in most
cases, we have merely compiled the cumulative experiences of our colleagues. We are indebted to their vision
and dedication.
Jonathan J. Dutton, M.D., Ph.D., and
Thomas G. Waldrop, M.S.M.I.
iv
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Contents
About the Author/About the Illustrator
Preface
iv
PART I
Eyelid Surgery
A. Anesthesia
iii
H. Ectropion
25
30
E. Cosmetic Blepharoplasty
8.
9.
10.
11.
12.
13.
14.
F. Brow Ptosis
70
G. Blepharoptosis
80
I. Entropion
38
74
104
112
118
123
148
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vi
Contents
48. Lower Eyelid Retractor Disinsertion with Scleral
Graft
154
49. SMAS Midface Elevation and Fixation
156
172
186
PART II
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PART III
Orbital Surgery
247
B. Orbitotomy Procedures
250
252
270
281
D. Enucleation, Evisceration,
andExenteration 302
93. Enucleation with Primary Acrylic or Silicone
Implant
306
94. Enucleation with Biointegrated Porous Ocular
Implant
310
95. Dermis-fat Orbital Implant Graft
312
96. Repair of the Exposed Ocular Implant
314
97. Evisceration
316
98. Orbital Exenteration
318
Index
321
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I
Eyelid
Surgery
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function of ocular protection. They provide a mechanical barrier against sunlight and foreign material. The eyelids also contribute to the physiologic maintenance of the corneal surface and precorneal tear lm. Adequate function of the
eyelids requires the integrity of numerous structural components, proper alignment
with the globe, and the coordination of several different neuromuscular groups.
Many congenital and acquired deformities can affect the eyelids. Some result from
normal aging phenomena such as canthal ligament laxity, involutional ptosis, prolapse
of orbital fat, or redundancy of eyelid skin. Others may follow traumatic injury or be
associated with periocular manifestations of systemic diseases, such as thyroid orbitopathy. When mild, as with minimal ptosis, or dermatochalasis, these deformities may
be of cosmetic concern only. When severe, however, they may signicantly interfere
with vision. In some cases, eyelid malpositions or deformities may cause corneal injury
and permanent loss of vision. It is important to remember that some eyelid abnormalities result from deeper orbital pathologic processes. Thus, subtle proptosis can mimic
eyelid retraction, and enophthalmos may initially be confused with ptosis.
Complete evaluation of the eyelid and the orbit is essential before consideration of
any oculoplastic operation. As with all ophthalmic procedures, a best-corrected visual
acuity must be recorded before proceeding further with any examination. A complete
medical and ophthalmic history is taken, and a current list of medications is noted.
There is some disagreement in the literature regarding the need to stop anticoagulation
therapy prior to oculoplastic surgery. These days as many as 60% of individuals may be
on such medications, most of them for nonmedical reasons. Most often, this may be
a low-dose aspirin for prophylactic purposes. In such cases, it is reasonable to ask the
patient to discontinue aspirin use 7 to 10 days prior to surgery. However, if the patient
is on anticoagulation for medical reasons, such as recently placed arterial stents, pulmonary embolism, recent stroke, or deep venous thrombosis, then the risks of bleeding
must be weighed against the risk of a thromboembolic event. For procedures with a
low risk of bleeding and negligible consequences such as ptosis or blepharoplasty, and
a higher risk of thromboembolism, it is usually best not to discontinue anticoagulation.
This approach has been documented extensively in the surgical literature. On the other
hand, for cases at higher risk of bleeding or those with a greater consequence from
bleeding, such as deep orbital surgery or procedures on vascular tumors, if the risk of
thromboembolism is low to moderate, it may be possible to stop anticoagulation with
or without bridge therapy, with the consultation of the patients cardiologist or primary
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care physician. In cases at high risk for both bleeding and a thromboembolic event, it
may be better to postpone the surgery until the patient can more safely be taken off
these medications.
The eyelids are examined in the primary position and in all other positions of gaze.
The height, contour, tone, and orientation of the eyelid margins are noted. Levator
muscle function, associated dystonic movements, and synkinetic contractions with
ocular motility or facial movements are carefully documented. Unsuspected anterior
orbital pathologic processes may be revealed by palpation and eversion of the eyelids. A slit lamp examination is essential to determine either ocular surface or anterior
segment disease that may result in secondary eyelid dysfunction, or to establish the
extent of corneal injury from eyelid malpositions. A Schirmers test for baseline tear
production is important in estimating the potential effect of eyelid repair, especially in
elderly patients. Specialized tests must be employed for certain disease states, such as
the Jones tests in lacrimal drainage disorders and orbital radiology or echography for
suspected orbital extension of eyelid lesions.
For most cases where oculoplastic surgery may be indicated, preoperative photographs should be taken for documentation and are usually required for third-party
reimbursement. In cases of eyelid and brow ptosis, visual eld testing is important for
documentation and is usually done with the brows in normal position and elevated.
In cases of traumatic loss or surgical injury from excision of tumors, the size and
location of the defect are recorded, as is any involvement of associated structures, such
as the levator aponeurosis, canthal ligaments, or the lacrimal drainage system. The
visual status of the opposite eye and the condition of adjacent tissues, including laxity
or the presence of any pathologic process, must be noted because these may affect the
choice of operative technique.
In all cases of eyelid reconstruction, choosing the appropriate surgical procedure is
critical to successful treatment. Numerous etiologies may be responsible for any anatomic disorder, and each may require a different approach to therapy. In some cases,
medical management may be more appropriate than surgical intervention. Therefore,
in the sections below, we discuss the specic causes of each condition and attempt to
provide some rationale for determining the most suitable operation. Where appropriate for each disorder, there is further discussion of preoperative evaluation and specic
diagnostic tests.
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SECTION
Anesthesia
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1
T
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SECTION
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2
S
Eyelid Anatomy
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FIG. 2.1
2
3
8
4
9
5
10
6
FIG. 2.2
FIG. 2.3
1
2
3
4
1
2
7
8
5
6
9
10
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12
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FIG. 2.4
7
2
3
4
9
10
11
12
FIG. 2.5
5
1
3
8
4
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14
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FIG. 2.6
9
1
10
2
11
3
12
4
5
6
7
13
14
15
16
17
FIG. 2.7
1
2
4
5
6
7
3
8
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16
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FIG. 2.8
4
5
3
7
FIG. 2.9
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18
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FIG. 2.10
FIG. 2.11
2
3
4
5
6
7
10
11
12
13
14
15
16
17
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20
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FIG. 2.12
10
1
11
2
3
12
13
4
5
14
15
6
16
7
17
18
19
20
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FIG. 2.13
5
1
6
7
2
8
9
3
10
4
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FIG. 2.14
2
3
4
5
6
7
8
9
FIG. 2.15
1
2
3
4
7
8
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24
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Kleinjes WG. Forehead anatomy: arterial variations and venous link of the
midline forehead flap. J Plast Reconstr Aesthet Surg. 2007;60:593606.
Most SP, Mobley SR, Larrabee WF Jr. Anatomy of the eyelids. Facial Plast
Surg Clin North Am. 2005;13:487492.
Oh SR, Priel A, Korn BS, Kikkawa DO. Applied anatomy for the aesthetic
surgeon. Curr Opin Ophthalmol. 2010;21:404410.
Ridgway JM, Larrabee WF. Anatomy for blepharoplasty and brow lift.
Facial Plast Surg. 2010;26:177185.
Seiff SR, Seiff BD. Anatomy of the Asian eyelid. Facial Plast Surg Clin
North Am. 2007;15:309314.
Stewart JM, Carter SR. Anatomy and examination of the eyelids. Int Ophthalmol Clin. 2002;42:113.
Zide BM, Jelks GW. Surgical Anatomy of the Orbit. New York, NY: Raven
press; 1985:2132.
7/16/2012 9:19:51 AM
SECTION
Hordeolum and
Chalazion
A
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INDICATIONS: Chronic chalazion granuloma with the major portion pointing anterior to the tarsus and acute internal
hordeola pointing toward the skin and not responding to medical therapy.
FIG. 3.3. With chronic chalazia, excise the entire granulomatous capsule with scissors. Avoid excessive excision within
2 mm of lid margin to prevent lid notching and injury to the
cilia.
FIG. 3.4. Gently hyfrecate the base of the cavity with
bipolar cautery to achieve hemostasis. Remove the chalazion
clamp and close the skin wound with 6-0 fast-absorbing plain
gut sutures. If the lesion was very large, a small amount of
redundant skin may be excised before closure.
lash bulbs, which lie about 2 mm from the mucocutaneous eyelid border.
Eyelid notchingOccasionally, the full-thickness tarsus is
necrotic. If the excision bed is large and is carried closer
than 2 mm from the eyelid margin, a buckling or notching may result. If cosmetically objectionable, this is
corrected with a secondary eyelid wedge resection and
primary repair.
Recurrence of chalazion or hordeolumRecurrence
may follow incomplete excision of the abscess cavity lining or failure to curette all loculated chambers.
26
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FIG. 3.1
FIG. 3.3
FIG. 3.2
FIG. 3.4
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INDICATIONS: Acute internal hordeolum or chronic chalazion pointing on the conjunctival surface.
FIG. 4.4. Remove the cyst contents completely with a chalazion curette. Explore for loculated pockets toward the eyelid
margin, being careful not to injure eyelash follicles. Excise the
residual brous cyst capsule with scissors. Lightly hyfrecate
the cavity walls, if necessary, to promote hemostasis. Remove
the clamp and leave the wound open for continued drainage.
FIG. 4.3. Grasp one edge of the wound and cut a small,
triangular ap of the tarsus and conjunctiva from one side
of the posterior cyst wall to allow for drainage.
28
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FIG. 4.1
FIG. 4.3
FIG. 4.2
FIG. 4.4
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SECTION
richiasis is a disorder in which eyelid cilia are misdirected toward the globe, thus resulting in corneal and
conjunctival abrasion and chronic ocular surface pain.
Trichiasis may be primary or secondary. In primary trichiasis, the lash follicles are distorted and misaligned in an
otherwise normally positioned eyelid margin. It may result
from chronic inflammatory disorders such as severe blepharitis or recurrent chalazia. Primary trichiasis may also follow as a result of mechanical or chemical eyelid trauma or
previous eyelid surgery. In secondary trichiasis, the lash
follicles are normally aligned in the lid, but the eyelid margin is rotated inward and the lashes touch the cornea. This
condition may be caused by any severe entropion associated with horizontal eyelid laxity, retractor disinsertion,
or posterior lamellar contraction. Posterior lamellar contraction may be seen with conjunctival cicatricial inflammatory diseases, such as cicatricial ocular pemphigoid or
Stevens-Johnson syndrome, in trachoma, or with chemical
burns. In congenital or acquired epiblepharon, the anterior
skinmuscle lamella rides up over the lower eyelid tarsus
and mechanically rotates the lashes inward against the
globe, especially in downward gaze.
Distichiasis is a congenital or acquired development of
one or more extra rows of cilia located within the tarsus
and situated behind the normal row of lashes. Even though
growth is usually undistorted, because of their abnormal
position, these cilia frequently result in corneal touch. In
both primary trichiasis and distichiasis, the aberrant cilia
must be removed for comfort and to prevent further corneal damage.
Medical management of trichiasis consists of liberal
ocular lubrication and frequent mechanical epilation of
the offending cilia. The results are usually unsatisfactory
and surgical intervention eventually will be necessary in
most cases. However, many surgical approaches yield less
than ideal results, usually because of recurrence and less
commonly because of undesirable functional or cosmetic
sequelae.
When associated with eyelid malpositions such as
entropion or eyelid margin deformity, the management
of secondary trichiasis must be directed toward marginal
reconstruction. This is discussed later under the appropriate sections. The treatment of trichitic or distichitic cilia in
an otherwise normal eyelid can be achieved by a number of
procedures with varying success rates.
The technique of cryodestruction is useful in the management of large areas of trichiasis and when carefully performed is associated with minimal risk to normal eyelid
tissues. Its success depends upon adequate degree of freezing at the site of the lash follicle and requires the use of a
thermocouple probe. A rapid rate of freeze induces intracellular crystallization, which is necessary for cell destruction. Slow thaw is associated with recrystallization, which
further enhances intracellular membrane disruption. The
use of epinephrine in the local anesthetic reduces heat
transfer through adjacent tissues and improves the effectiveness of treatment. In addition, the rate of thermal conductivity is significantly enhanced with repeat freezing,
and a double freezethaw cycle yields greater destructive
results. Caution should be used in applying cryotherapy to
dark-skinned individuals since this can result is significant
depigmentation.
Electrohyfrecation and radiosurgery are more suited to
eradication of one or a few cilia. However, because of the
very small area of destruction and the uncertainty of localizing the needle tip at individual follicles, results are less
predictable and recurrences more frequent than with cryosurgery. In this procedure, injury to normal tissues is also
more common, especially when large numbers of lashes
are treated simultaneously.
When the entire eyelid margin is involved, surgical
excision may be more appropriate, especially if cryodestruction has failed. Excision may be accomplished by an
internal resection of the lash follicles beneath a small myocutaneous flap. Eyelid splitting procedures, either with or
without mucous membrane grafting, are more difficult,
may require harvesting of oral mucosa, and usually lead to
poorer functional and cosmetic results.
SUGGESTED FURTHER READING
Alemayehu W, Kello AB. Trichiasis surgery: a patient-based approach.
Community Eye Health. 2010;23:5859.
Bartley GB, Lowry JC. Argon laser treatment of trichiasis. Am J Ophthalmol. 1992;113:7174.
Baar E, Ozdemir H, Ozkan S, et al. Treatment of trichiasis with argon
laser. Eur J Ophthalmol. 2000;10:273275.
Chi MJ, Park MS, Nam DH, et al. Eyelid splitting with follicular extirpation using a monopolar cautery for the treatment of trichiasis and
distichiasis. Graefes Arch Clin Exp Ophthalmol. 2007;245:637640.
Choo PN. Distichiasis, trichiasis, and entropion: advances in management. Int Ophthalmol Clin. 2002;42:7587.
Dutton JJ, Tawfik HA, DeBacker CM, Lipham WJ. Direct internal eyelash bulb extirpation for trichiasis. Ophthal Plast Reconstr Surg.
2000;16:142145.
Gower EW, Merbs SL, Munoz BE, et al. Rates and risk factors for unfavorable outcomes 6 weeks after trichiasis surgery. Invest Ophthalmol Vis
Sci. 2011;52:27042711.
Kersten RC, Leiner FP, Kulwin DR. Tarsotomy for the treatment of cicatricial entropion with trichiasis. Arch Ophthalmol. 1992;110:714717.
30
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FIG. 5.1. Position a scleral shell over the globe for protection. Inject local anesthetic with 1:100,000 epinephrine 3 to
4 mm from the lid margin and subconjunctivally along
the proximal tarsal border. Take care to avoid injury to the
marginal vascular arcade. Allow 10 minutes for maximum
vasoconstriction.
FIG. 5.3. Place the cryoprobe tip on the conjunctival surface 2 to 3 mm from the eyelid margin and adjacent to the
aberrant cilia near the thermocouple needle. Apply a freeze
cycle to 20C. A white area of frost should form on the lid.
Allow the lid to thaw slowly and completely, followed by a
second freeze cycle to 20C.
POTENTIAL COMPLICATIONS:
Eyelid edemaThis may be significant for 12 to 72 hours
after treatment and is proportional to the size of the
area treated. It typically resolves without sequelae.
Eyelid necrosisThe risk of necrosis is greater with temperatures below 30C. Epidermal necrosis is more
common with cryoprobe application to the skin surface.
32
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FIG. 5.1
FIG. 5.3
FIG. 5.2
FIG. 5.4
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POTENTIAL COMPLICATIONS:
Lid margin distortionThis may result from excessive
tissue destruction and thermal contraction of the tarsus.
Apply only the minimal RF power necessary to cause
very mild bubbling. Avoid simultaneous treatment over
large areas of the eyelid.
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FIG. 6.2
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INDICATIONS: Trichiasis with more than one-quarter lid margin involvement; failure of other treatment modalities.
used to destroy the lash bulbs. Take care not to cut through the
skin. If distichitic cilia are noted arising from within the tarsus,
follow their shafts with small, vertical cuts into the tarsus until the
bulb is found. These are then excised or destroyed with cautery.
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours while awake. Place antibiotic ointment on the suture line three to four times daily for 5 to 7
days or until the sutures are dissolved.
POTENTIAL COMPLICATIONS:
Treatment failureThis is caused by inadequate excision of all offending lash bulbs in the affected area. If
36
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FIG. 7.1
FIG. 7.4
FIG. 7.2
FIG. 7.5
FIG. 7.3
FIG. 7.6
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SECTION
Cosmetic Blepharoplasty
B
38
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39
Smith BC, Bosniak SI. Reconstructing the supratarsal crease. In: Bosniak
SL, Smith BC, eds. Advances in Ophthalmic Plastic and Reconstructive
Surgery. Vol I. New York: Pergamon Press Ltd; 1982.
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FIG. 8.5. Temporal hooding of eyelid skin may hang over the
lateral palpebral ssure and canthal angle. It requires more
extensive lateral skin resection over the orbital rim.
FIG. 8.6. Medial pouching results from bulging of the
medial fat pocket, with or without associated redundant
skin. When extensive, an M-plasty modication of the medial
excision bed may be required.
FIG. 8.7. Prolapse of the lacrimal gland results in lateral
fullness of the upper eyelid, which supercially resembles
bulging fat. On palpation, the gland is rm with rounded
contour and can easily be displaced upward beneath the
orbital rim.
FIG. 8.8. Lower eyelid laxity is frequently associated with
dermatochalasis and results from stretching of the lateral
canthal ligament or the tarsus. It may cause inferior scleral
show, ectropion, and epiphora.
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FIG. 8.5
FIG. 8.2
FIG. 8.6
FIG. 8.3
FIG. 8.7
FIG. 8.4
FIG. 8.8
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INDICATIONS: Redundant upper eyelid skin with herniation of orbital fat pockets.
FIG. 9.5. Place the lid on tension horizontally and cut the
skin with a rounded scalpel blade along the upper and
lower marked lines.
FIG. 9.6. With scissors, cut through the orbicularis muscle
laterally to enter the areolar space between muscle and
underlying periosteum. Pull the eyelid margin downward to
atten the orbital septum. Dissect in the plane between the
muscle and the septum in a medial direction by dividing the
ne fascial attachments. Cauterize bleeding along the muscle
edge with bipolar cautery. If a skin-only blepharoplasty is to be
performed, proceed to Fig. 9.13 below. In some cases, where
the orbital septum is lax but there is no signicant fat herniation, the septum can be tightened with gentle bipolar cautery
over its surface until it contracts sufficiently.
FIG. 9.7. Apply gentle pressure on the globe through the
closed eyelid. The excess medial and central fat pockets will
be seen bulging forward from behind the overlying orbital septum. Tent up the septum with forceps to pull it away from the
underlying fat, and open it with scissors along the entire eyelid.
Cut the thin fat capsules and any imsy fascial attachments to
the underlying levator aponeurosis. Medially, the fat capsules
may be thicker and the interlobular septa more extensive.
FIG. 9.8. Hold the herniated medial fat lobules with forceps
and clamp a small, curved hemostat across its base near the
orbital rim. Do not exert excessive traction on the fat.
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FIG. 9.1
FIG. 9.5
FIG. 9.2
FIG. 9.6
FIG. 9.3
FIG. 9.7
FIG. 9.4
FIG. 9.8
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44
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment on the
suture line three to four times daily for 7 days or until the
sutures are dissolved.
POTENTIAL COMPLICATIONS:
HematomaThis may result from inadequate hemostasis
of the orbicularis muscle or the transected fat pedicle. If
severe, open the wound to drain clots and cauterize any
residual bleeding points.
Visual lossThis rare event is usually caused by deep
orbital bleeding from traction on the fat pedicle during excision. It can result in central retinal artery occlusion and requires immediate opening of the wound
for decompression. If necessary, a lateral canthotomy
should be performed, and medical treatment for arterial
occlusion should be instituted.
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FIG. 9.9
FIG. 9.13
FIG. 9.10
FIG. 9.14
FIG. 9.11
FIG. 9.15
FIG. 9.12
FIG. 9.16
45
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10
INDICATIONS: Redundant upper eyelid skin obscuring superior visual field, or creation of a secondary upper eyelid fold
in a patient with Asian eyelid crease anatomy.
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment on the
suture line three to four times daily for 7 days or until the
sutures are dissolved.
POTENTIAL COMPLICATIONS:
LagophthalmosThis is caused by excessive removal of
skin and usually resolves with time. Improvement may
be hastened with vigorous massage. Topical lubricants
are used until resolution occurs. If severe and persistent,
the condition may require skin grafting for correction.
46
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FIG. 10.5
FIG. 10.2
FIG. 10.6
FIG. 10.3
FIG. 10.7
FIG. 10.4
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47
FIG. 10.8
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11
INDICATIONS: Downward displacement of the lacrimal gland with lateral upper eyelid fullness.
48
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FIG. 11.5
FIG. 11.2
FIG. 11.6
FIG. 11.3
FIG. 11.7
FIG. 11.4
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49
FIG. 11.8
7/12/2012 10:10:31 AM
12
INDICATIONS: Asymmetric, or absent upper eyelid crease, either primary or as a complication of eyelid surgery.
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment on the
suture line three to four times daily for 5 to 7 days.
POTENTIAL COMPLICATIONS:
Irregular creaseCare must be taken to maintain a uniform line of closure and attachment of muscle to the
50
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FIG. 12.1
FIG. 12.4
FIG. 12.2
FIG. 12.5
FIG. 12.3
FIG. 12.6
51
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13
INDICATIONS: Redundant lower eyelid skin with herniation of extraconal orbital fat pockets.
FIG. 13.1. Mark the incision line 2 to 3 mm below the lid margin, beginning 1 mm temporal to the inferior punctum and
extending to 2 mm beyond the lateral canthal angle. Continue
the line laterally and downward in a preexisting laugh crease for a
distance of 10 to 15 mm, depending upon the amount of skin to be
excised. Inltrate 0.5 to 1.0 mL of local anesthetic subcutaneously.
FIG. 13.2. Pull the lid taut to prevent horizontal buckling and
cut the skin along the marked line with a rounded scalpel blade.
fascial connections between them. With scissors, sharply dissect the ap from the underlying tarsal plate and orbital septum.
FIG. 13.5. Tent up the orbital septum with forceps to pull
it away from the underlying fat pockets. Make a small cut
through it centrally with scissors. Open the septum to either
side along the width of the eyelid.
FIG. 13.6. Identify the lateral, central, and medial fat
pockets. Cut the delicate, brous fat capsules overlying the
individual pockets and gently apply pressure on the globe to
further prolapse the fat lobules.
FIG. 13.3. Pull up the skin at the lateral end of the wound
with forceps and cut through the orbicularis muscle to enter
the fascial plane between muscle and periosteum of the
orbital rim. Cut through the muscle along the incision line and
continue dissecting medially in the postorbicular fascial plane.
Cauterize bleeding points with a bipolar electrode forceps.
FIG. 13.4. Gently pull the eyelid margin upward and the
skinmuscle ap downward with forceps to visualize the
FIG. 13.8. Cut the fat along the upper edge of the hemostat and
cauterize the pedicle stump with bipolar electrode forceps.
52
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FIG. 13.5
FIG. 13.2
FIG. 13.6
FIG. 13.3
FIG. 13.7
FIG. 13.4
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53
FIG. 13.8
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54
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FIG. 13.9
FIG. 13.13
FIG. 13.10
FIG. 13.14
FIG. 13.11
FIG. 13.15
FIG. 13.12
FIG. 13.16
55
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14
INDICATIONS: Redundant lower eyelid skin with or without herniation of orbital fat pockets, associated with deepening
of the tear trough and descent of the malar fat pad.
FIG. 14.4. Gently pull the eyelid margin upward and the
skinmuscle ap downward with forceps to visualize the
56
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FIG. 14.1
FIG. 14.4
FIG. 14.2
FIG. 14.5
FIG. 14.3
FIG. 14.6
57
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58
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POTENTIAL COMPLICATIONS:
Potential complications are similar to those for Lower Eyelid Blepharoplasty with fat excision, page 58. Prevention
and management are as discussed previously.
7/12/2012 10:17:41 AM
FIG. 14.10
FIG. 14.8
FIG. 14.11
59
FIG. 14.9
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15
INDICATIONS: Redundant lower eyelid skin, with or without herniation of orbital fat pockets, combined with horizontal
eyelid laxity.
FIG. 15.1. Mark the lower eyelid incision line, cut the skin,
and elevate a skinmuscle ap as described in Figs. 13.113.4
(page 55).
FIG. 15.2. Open the orbital septum and excise the lateral,
central, and medial fat pockets as described in Figs. 13.5
13.10 (pages 5556).
FIG. 15.3. With two toothed forceps, grasp the eyelid and
pull it away from the globe. With a pointed scalpel blade,
pierce through the eyelid from the conjunctival side just below
the tarsal plate at the lateral third of the lid. Pull the blade
upward toward the lid margin to complete the vertical cut.
FIG. 15.4. Cut through the capsulopalpebral fascia and
conjunctiva with scissors, beginning at the lower edge
of the vertical incision and extending diagonally in an
inferomedial direction. The greater the horizontal width of lid
to be resected, the more this diagonal cut is angled medially.
60
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FIG. 15.1
FIG. 15.5
FIG. 15.2
FIG. 15.6
FIG. 15.3
FIG. 15.7
FIG. 15.4
FIG. 15.8
61
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62
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment on the
suture line three to four times daily for 7 to 10 days. Leave
the eyelid margin sutures in place for 10 to 14 days.
POTENTIAL COMPLICATIONS:
Complications are the same as for Lower Eyelid Blepharoplasty with Fat Excision (page 58). In addition:
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Dutton_Chap15.indd 63
FIG. 15.9
FIG. 15.13
FIG. 15.10
FIG. 15.14
FIG. 15.11
FIG. 15.15
FIG. 15.12
FIG. 15.16
63
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16
INDICATIONS: Redundant lower eyelid skin, with or without herniation of orbital fat pockets, combined with eyelid
laxity due to lateral canthal ligament redundancy.
FIG. 16.1. Mark the lower eyelid incision line, cut the skin,
and elevate a skinmuscle ap as described in
Figs.13.113.4 (page 55).
FIG. 16.2. Open the orbital septum and excise or redrape
the fat pockets as described in the previous procedures on
lower eyelid blepharoplasty (pages 5563).
FIG. 16.3. Pull the eyelid medially to straighten the lateral canthal ligament. Make a horizontal cut through the
lateral canthal angle to perform a lateral canthotomy to the
orbital rim. Transect the inferior crus of the ligament. Grasp
the edge of the lower eyelid and pull gently to conrm that all
attachments are free.
FIG. 16.4. Split the eyelid along the gray line laterally
with ne scissors to separate the anterior skinmuscle
lamella from the posterior tarsusconjunctiva lamella for a
distance of 5 to 10 mm, depending upon the amount of lid
shortening required. Continue this separation down to the
inferior border of the tarsus.
FIG. 16.5. With a scissors, cut the lower eyelid retractor
from the inferior border of the tarsus beneath the split
portion of the lid.
FIG. 16.6. Remove a thin strip of marginal epithelium from
the split portion of the lid using a scissors.
64
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FIG. 16.1
FIG. 16.4
FIG. 16.2
FIG. 16.5
FIG. 16.3
FIG. 16.6
65
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66
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment on the
suture line three to four times daily for 7 days or until the
sutures are dissolved.
POTENTIAL COMPLICATIONS:
Potential complications are the same as for Lower Eyelid
Blepharoplasty (page 58).
Dutton_Chap16.indd 66
In addition:
Rounded lateral canthal angleThis results from failure
to reform the canthus by suturing the lateral upper and
lower eyelids together at the lateral canthal angle.
Canthal angle dystopiaThe lateral lower lid margin can
stand away from the globe if the periosteal anchoring
suture is not placed inside the lateral rim. This is corrected
by repositioning the suture or later by repeating a lateral
tarsal strip procedure.
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FIG. 16.7
FIG. 16.9
FIG. 16.8
FIG. 16.10
67
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17
INDICATIONS: Lower eyelid herniated orbital fat without dermatochalasis; fat herniation in thyroid orbitopathy;
patients with known history of keloid formation.
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment on the inferior
palpebral conjunctiva three to four times daily for 7 days.
POTENTIAL COMPLICATIONS:
Sunken, hollow appearanceThis is usually the result of
excessive resection of orbital fat so that a concave contour is present above the orbital rim. Do not apply more
than gentle pressure on the globe during resection, and
do not put excessive traction on the fat pedicles. In some
cases redrapping of the fat beneath the tear trough will
provide a more aesthetically pleasing lid-cheek contour.
capsulopalpebral fascia. In this case, open the septum with scissors to reveal the orbital fat.
FIG. 17.6. Reverse the Desmarres retractor by placing the
blade inside the wound to expose the fat pockets. Cut open
the ne interlobular fascial capsules and apply gentle pressure
to the globe to further prolapse the fat. Hold the lateral fat
pocket with forceps and apply a curved hemostat across its
base.
FIG. 17.7. With scissors cut the fat along the upper edge of
the clamp and cauterize the pedicle with bipolar electrode
forceps. Hold the pedicle below the hemostat, release the clamp,
and inspect the cut surface for residual bleeding. Alternatively,
the fat can be cauterized and cut without a hemostat. Excise the
central and medial fat pockets in similar fashion. Alternatively,
some of the fat may be redrapped to ll in a deep tear trough as
in Figs. 14.614.7, pages 6162).
FIG. 17.8. Reverse the Desmarres retractor to evert the lid
margin and expose the wound. Reattach the cut edges of the
capsulopalpebral fascia and Mllers muscle with a running
stitch of 6-0 plain gut. The lid may be splinted with strips of
tape below the tarsus and extended to the temple and nasal
bridge.
AsymmetryThis is caused by unequal resection of fat
on the two sides. Save the fat from each side and carefully compare the volume taken from each fat pocket
before closure. The exception is in cases where initial
asymmetry of fat herniation is noted and marked preoperatively.
Lower eyelid retraction and scleral showThis is seen
rarely but may result from inadvertent shortening of the
orbital septum during closure. Care should be taken to
cut open and to close only the capsulopalpebral fascia.
If the septum was opened to reach the fat pockets, it
should be left without closure.
68
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FIG. 17.1
FIG. 17.5
FIG. 17.2
FIG. 17.6
FIG. 17.3
FIG. 17.7
FIG. 17.4
FIG. 17.8
69
7/12/2012 10:25:03 AM
SECTION
Brow Ptosis
B
70
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71
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18
FIG. 18.1 With the patient upright, elevate the brow to the
desired position, and then allow the brow to relax. Measure
the distance (x) between the central upper brow margin in the
ptotic position and elevated position. Repeat the measurement
medially and laterally. This represents the width of skin to be
removed from above the brow.
FIG. 18.2. Mark a fusiform incision pattern with the inferior
line just at the uppermost row of brow hairs, and the superior line an appropriate distance above the brow as determined in Figure 18.1 The medial and lateral extent of the
incision should not continue beyond the eyebrow. The exact
shape of the area to be excised and its location, for example,
lateral part of the brow only, are determined by the pattern of
the ptosis. For reference, mark a small line where the supraorbital neurovascular bundle exits from the supraorbital notch.
Inject local anesthetic subcutaneously along the incision lines.
POTENTIAL COMPLICATIONS:
Visible scarFailure to cut the incision line parallel to the hair
shafts may result in truncation of the lash follicles and loss of
several rows of cilia adjacent to the incision line. The resulting scar will then lie several millimeters from the new superior brow margin, thus making camouflage more difficult. A
wide scar is the result of excessive tension on the skin caused
by inadequately placed dermal and subdermal sutures. Failure to evert the skin edges may result in a depressed scar.
AsymmetryBrow ptosis is frequently asymmetric and
must be corrected for when planning the incisions.
Careful preoperative measurements taken while the
patient is in the upright position with a relaxed brow
will minimize this complication.
72
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FIG. 18.1
FIG. 18.5
FIG. 18.2
FIG. 18.6
FIG. 18.3
FIG. 18.7
FIG. 18.4
FIG. 18.8
73
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19
INDICATIONS: Mild to moderate brow ptosis, especially lateral brow droop, exaggerated by gravity.
74
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FIG. 19.1
FIG. 19.5
FIG. 19.2
FIG. 19.6
FIG. 19.3
FIG. 19.7
FIG. 19.4
FIG. 19.8
75
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20
INDICATIONS: Brow and forehead ptosis, especially with medial brow droop associated with horizontal glabellar folds
and forehead creases.
CONTRAINDICATIONS: Balding males or patients with a receding hairline.
76
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Dutton_Chap20.indd 77
FIG. 20.1
FIG. 20.5
FIG. 20.2
FIG. 20.6
FIG. 20.3
FIG. 20.7
FIG. 20.4
FIG. 20.8
77
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78
POSTOPERATIVE CARE: Apply antibiotic ointment liberally along the staple lines and place a firm head dressing
for 48 hours. Place topical antibiotic ointment on the incisions three to four times daily for 7 to 10 days. The staples
are removed after 10 days.
POTENTIAL COMPLICATIONS:
HematomaThis results mainly from the cut muscles.
Meticulous hemostasis is mandatory before closure.
Small hematomas will resolve without treatment. Larger
ones can be aspirated once they liquefy. Rarely, open
drainage will be required.
Scalp anesthesiaNumbness occurs with injury to the
supraorbital nerve during dissection along the superior
orbital rim. Sensation is usually reestablished within 6
to 8 months.
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FIG. 20.13
FIG. 20.10
FIG. 20.14
FIG. 20.11
FIG. 20.15
79
FIG. 20.12
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SECTION
Blepharoptosis
P
G
Mllers sympathetic muscle are not known. By far, the
most common cause is a congenital developmental dystrophy, accounting for half of all cases of ptosis. Rarely a
similar dystrophic development of the levator muscle is
associated with a genetic dysmorphic syndrome such as
blepharophimosis syndrome. Some cases of adult ptosis appear to be the result of an acquired myopathy that
combines poor levator muscle function, fatty infiltration,
and fibrous replacement of muscle fibers. A similar, lateacquired myopathy occurs as a hereditary disorder. Congenital fibrosis of extraocular muscles is usually associated
with myogenic ptosis. Other rare causes include chronic
progressive external ophthalmoplegia (CPEO), myotonic
dystrophy, and oculopharyngeal muscular dystrophy.
Myasthenia gravis may properly be included among
both the neurogenic and myogenic classifications, although
it is most frequently associated with the latter. Toxic myogenic ptosis is reportedly a result of prolonged use of corticosteroids and mascara. Traumatic injury to the levator
muscle may produce a myopathic dysfunction that generally resolves spontaneously.
Determination of a myogenic cause for ptosis may alert
the surgeon to potentially life-threatening conditions,
such as CPEO. Conditions such as myasthenia gravis also
demand very different consideration, and surgery is generally delayed until stable medical therapy is certain.
Surgical correction of myogenic ptosis is indicated when
the condition is stable. The choice of procedure depends
upon the degree of residual levator muscle function and
the nature of associated dysfunctions. Surgical intervention
in some patients, for example, where Bells phenomenon
may be severely defective, requires a far more conservative
approach or modification of technique.
Aponeurotic Ptosis. Defects in the mechanical linkage between the levator muscle and tarsal plate are grouped
as the aponeurotic ptoses. Involutional redundancy of the
aponeurosis is the most common cause of adult-acquired
ptosis and frequently accompanies senile degeneration of
other periorbital tissues. Thinning and dehiscence of the
aponeurosis are also seen as aging phenomena, as is frank
disinsertion, although the last is much less common. Separation of the aponeurosis from the tarsus is seen frequently
with trauma, both congenital and adult, and following
repeated bouts of eyelid edema.
In aponeurotic ptosis, the levator muscle is usually
completely normal, and function is excellent. Correction
is directed at shortening the aponeurosis or reattaching it
to the tarsal plate. Similar surgery can also yield gratifying
80
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SECTION G Blepharoptosis
results in some cases of neurogenic and myogenic ptosis
where function is good, in spite of the fact that the pathologic process does not reside with the aponeurosis itself.
Mechanical Ptosis. In mechanical ptosis, there is
a physical obstruction impeding eyelid elevation in the
presence of an otherwise normal levator muscle and oculomotor nerve. Eyelid mass lesions, such as abscesses and
tumors, and skin or conjunctival scarring can restrict lid
movement. Dermatochalasis and brow droop may put
excessive weight on the lid, resulting in a secondary ptosis. Orbital lesions frequently present with ptosis when the
levator and superior rectus muscles are involved. The correction of mechanical ptosis is directed first at the cause.
Any residual ptosis may then be corrected with other surgical techniques designed to elevate the lid.
Pseudoptosis. This is a poorly defined group of unrelated disorders resulting in ptosis and caused by defects
in posterior eyelid support, changes in ocular position, or
counter effects of the protractor muscles. Loss of orbital
volume seen with microphthalmos, phthisis bulbi, enucleation, and traumatic fat atrophy result in sagging of support
to the levator muscle and Whitnalls ligament, with associated ptosis. Correction may require orbital soft tissue volume augmentation or repositioning rather than standard
ptosis repair. Hypotropia and ptosis are frequently related
because of both anatomic and physiologic mechanisms.
Correction of the strabismus frequently also corrects the
ptosis. Blepharospasm, either primary or secondary to ocular surface irritation or iritis, can increase protractor force
against the levator muscle, resulting in a pseudoptosis.
Eyelid retraction from thyroid orbitopathy or sympathomimetic drugs can cause a pseudoptosis of the contralateral
eyelid because of reduced central output and Herings law of
equal innervation. In all these conditions, treatment clearly
is not directed at the levator muscle or its aponeurosis without first attending to the primary pathologic process.
PATIENT EVALUATION
Evaluation of the ptotic patient should include an attempt
to determine the precise etiology. Once other treatable diseases have been ruled out, attention is directed at repair of
the ptosis. The most important criterion in selecting a successful surgical procedure is levator muscle function. This
must be measured with extreme care because in the poor
function range, even a difference of 1 or 2 mm may result
in the choice of an inappropriate operation.
Levator muscle function is measured as maximum eyelid
margin excursion from extreme downward gaze to extreme
upward gaze positions. The frontalis muscle must be immobilized with the examiners finger at the brow to eliminate
its contribution to lid elevation. This is especially important
in children. By convention, more than 12 mm of function is
considered excellent, 8 to 11 mm is good, 5 to 7 mm is fair, 3
to 4 mm is poor, and 0 to 2 mm is considered absent.
Minimal degrees of ptosis up to 3 mm with good levator muscle function may be corrected with any number of
Dutton_Chap21.indd 81
81
Ptosis
12 mm
3 mm
3 mm
4+ mm
4+ mm
Levator Muscle
Function
good (8+ mm)
good (8+ mm)
fair (57 mm)
fair (57 mm)
poor (34 mm)
Levator Muscle
Resection
1013 mm
1417 mm
1822 mm
2326 mm
27+ mm
7/12/2012 10:42:52 AM
82
SECTION G Blepharoptosis
Dutton_Chap21.indd 82
Older JJ. Levator aponeurosis surgery for the correction of acquired ptosis. Analysis of 113 procedures. Ophthalmology. 1983;90:10561059.
Waqar S, McMurray C, Madge SN. Transcutaneous blepharoptosis surgeryadvancement of levator aponeurosis. Open Ophthalmol J.
2010;14:7680.
Frontalis Suspension
Chow K, Deva N, Ng SG. Prolene frontalis suspension in paediatric ptosis.
Eye. 2011;25:735739.
Osborn SF, Sloan B. Modified eyelid crease approach frontalis suspension
without brow incision. Ophthal Plast Reconstr Surg. 2011;27:e11e13.
7/12/2012 10:42:52 AM
SECTION G Blepharoptosis
Sokol JA, Thornton IL, Lee HB, Nunery WR. Modified frontalis suspension techniques with review of large series. Ophthal Plast Reconstr
Surg. 2011;27:211215.
Takahashi Y, Leibovitch I, Kakizaki H. Frontalis suspension surgery in
upper eyelid blepharoptosis. Open Ophthalmol J. 2010;14:9197.
Dutton_Chap21.indd 83
83
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21
FIG. 21.8. Cut out the three temporary silk sutures and the
marginal traction suture. Return the lid to its normal position. Take small bites through the skin with each end of
the chromic suture and tie the ends to themselves.
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment on the
globe four times daily for 7 days or until the chromic
sutures dissolve.
POTENTIAL COMPLICATIONS:
UndercorrectionThis is more common when patients
are not carefully evaluated and more than 2.5 mm of
ptosis is present. The procedure should be limited to
cases of minimal, good-function ptosis.
OvercorrectionThis may occur if more than 3 to 4 mm
of tarsus is resected. If minimal, overcorrection requires
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FIG. 21.1
FIG. 21.5
FIG. 21.2
FIG. 21.6
FIG. 21.3
FIG. 21.7
FIG. 21.4
FIG. 21.8
85
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22
INDICATIONS: Mild to moderate ptosis of up to 3 mm with good to excellent levator muscle function, especially Horners
neurogenic ptosis, and where the phenylephrine test shows correction with Mllers muscle stimulation.
CONTRAINDICATIONS: Ptosis >3 mm with fair to poor function, or where the phenylephrine test fails to correct the lid
position.
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment beneath
the upper lid four times daily for 7 days.
POTENTIAL COMPLICATIONS:
UndercorrectionThis results from failure to resect
enough tissue or from poor patient selection. If 10%
FIG. 22.5. Pull the clamp and enclosed tissues upward and
the overlying skin downward to conrm that the skin and
levator aponeurosis are not included in the bite. The skin
should pull away easily. If there is resistance, remove the clamp
and replace it.
FIG. 22.6. Hold the clamp straight out and pass a
double-armed 6-0 plain gut suture through the clamped
tissues nasally, 1.5 mm behind the clamp blades. Run
one end of this suture to the temporal side of the clamp as a
mattress stitch, taking 2-mm bites.
FIG. 22.7. With a scalpel, cut the conjunctiva and Mller's
muscle between the clamp and the running mattress
suture. Remove the previously placed 6-0 silk conjunctival
marking suture.
FIG. 22.8. Replace the Desmarres retractor and run the
nasal end of the 6-0 plain suture in continuous fashion
across the wound, apposing the edges of Mller's muscle
and conjunctiva to the superior tarsal border. Bring the two
arms of the suture through the lid temporally and into a 4-mm
horizontal skin incision at the temporal edge of the supratarsal
eyelid crease. Tie the ends to bury the knot below the skin.
Remove the traction suture.
phenylephrine fails to elevate the lid to within 1 mm
of the desired level, an alternative procedure should be
selected.
Punctate corneal stainingThis may be caused by the
tarsal sutures. It is treated with liberal topical lubrication and typically resolves within 1 week after the
sutures dissolve.
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FIG. 22.1
FIG. 22.5
FIG. 22.2
FIG. 22.6
FIG. 22.3
FIG. 22.7
FIG. 22.4
FIG. 22.8
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23
INDICATIONS: Mild to severe aponeurotic ptosis with good to excellent levator function. Also, mild to moderate neurogenic and myogenic ptosis with good function.
CONTRAINDICATIONS: Ptosis from any cause in which levator function is poor or absent.
FIG. 23.1. Mark the incision line within the existing eyelid
crease or at a level symmetric with the opposite eyelid.
In bilateral surgery, place the incision lines 8 to 10 mm above
the lid margin.
FIG. 23.3. Hold the lid taut to prevent buckling and cut
the skin with a rounded scalpel blade. The circumferential
bers of the orbicularis muscle should be visible within
the wound.
FIG. 23.7. Open the septum all the way across the wound.
Carefully separate all attachments between the septum and
aponeurosis at the extreme medial and lateral sides of the incision to prevent postoperative lagophthalmos.
FIG. 23.4. Tent up the skin edges with forceps and cut
through the orbicularis muscle with scissors to enter the
postorbicular fascial plane. Open the muscle nasally and
temporally to expose the underlying orbital septum and
aponeurosis.
88
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FIG. 23.1
FIG. 23.5
FIG. 23.2
FIG. 23.6
FIG. 23.3
FIG. 23.7
FIG. 23.4
FIG. 23.8
89
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90
SECTION G Blepharoptosis
FIG. 23.9. Note the status of the aponeurosis. It may be attached to the tarsus but
redundant, or it may be dehisced or disinserted. In the latter case, Mller's muscle
will be visible inferior to the edge of the aponeurosis, and the ne peripheral vascular
arcade will be seen running horizontally just above the tarsal border.
FIG. 23.10. Excise a strip of orbicularis muscle from the inferior skin edge to
reveal the tarsal surface.
FIG. 23.11. Pass a 6-0 prolene suture through partial thickness of the tarsus
3mm from its upper border and above the central pupil and then through the
lower edge of the aponeurosis.
FIG. 23.12. Tie the suture in a temporary knot and ask the patient to look forward with eyes open. If necessary, replace the suture upward or downward in the
aponeurosis until the eyelid margin lies 1.5 to 2.0 mm above the desired level. Some
fall in eyelid height usually will be seen within 5 to 10 minutes of suture placement.
FIG. 23.13. Place additional sutures through the tarsus and aponeurosis medially and laterally to produce a normal marginal contour. Adjust the sutures as
needed.
FIG. 23.14. If necessary, resect a strip of the skin and orbicularis muscle from
along the superior wound edge to prevent excessive overhang. Close the skin with
a running suture of 6-0 fast-absorbing plain gut or interrupted stitches of 7-0 chromic.
If the skin-muscle lamella is not xed to the tarsus and folds down over the lashes
easily, reform the eyelid crease. Except when an Asian lid is to be maintained, pass the
suture through the aponeurosis with every second or third loop to reform the eyelid crease. Alternatively, reform the crease by placing 4 to 5 interrupted 6-0 chromic
sutures to x the orbicularis muscle to the aponeurosis prior to closing the skin.
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment on the
suture line four times daily for 7 days.
POTENTIAL COMPLICATIONS:
UndercorrectionThis results from inadequate advancement of the aponeurosis or from failure to allow for the
expected 1- to-2 mm postoperative fall in the eyelid
height. Within the first week, it may be corrected in the
office by pulling the wound open and placing the sutures
higher on the aponeurosis.
OvercorrectionThis is uncommon but is seen with
excessive advancement of the aponeurosis. If mild, it
may be corrected with vigorous downward massage
after 2 weeks. If overcorrection is more than 2 mm, it
can be repaired at 1 week in the office by pulling open
the wound and replacing the tarsal sutures lower on the
aponeurosis.
Asymmetry of the eyelid creaseThis is caused by failure
to adequately reform the eyelid crease or by misplace-
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FIG. 23.9
FIG. 23.12
FIG. 23.10
FIG. 23.13
FIG. 23.11
FIG. 23.14
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24
INDICATIONS: Myogenic or neurogenic ptosis with fair to poor levator muscle function of 4 to 6 mm.
CONTRAINDICATIONS: Ptosis with good to excellent levator muscle function or very poor to absent function.
FIG. 24.1. Mark the incision line within the existing eyelid
crease or symmetric with the opposite lid. For bilateral
ptosis, place the line 8 to 10 mm above the lid margin. Inject
local anesthetic with epinephrine along the marked line for
hemostasis.
FIG. 24.2. Cut the skin with a rounded scalpel blade while
holding the lid taut to prevent buckling.
FIG. 24.3. Tent up the skin edges to pull the orbicularis
away from the levator. With scissors, cut the muscle centrally
to enter the postorbicular fascial plane.
FIG. 24.4. Open the orbicularis muscle across the entire
wound. Cauterize the muscle edges with bipolar electrodes.
FIG. 24.5. Identify the orbital septum, which inserts onto
the aponeurosis 3 to 5 mm above the tarsus, and the
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FIG. 24.1
FIG. 24.5
FIG. 24.2
FIG. 24.6
FIG. 24.3
FIG. 24.7
FIG. 24.4
FIG. 24.8
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94
SECTION G Blepharoptosis
FIG. 24.9. Slide one jaw of a Berke ptosis clamp beneath the levator muscle just
above the level of Whitnalls ligament. Tighten the clamp.
FIG. 24.10. With scissors, cut the levator muscle between the clamp and
Whitnalls ligament.
FIG. 24.11. Evert the levator muscle by pulling the clamp upward. Divide the
fascial connections between the levator and the underlying superior rectus muscle
and conjunctiva superiorly for 10 to 15 mm, depending upon the amount of planned
resection.
FIG. 24.12. Pass three double-armed 6-0 prolene sutures through partial thickness of the tarsus, near its superior border.
FIG. 24.13. Advance the levator muscle over Whitnalls ligament and over the
intact aponeurosis and Mllers muscle to the tarsus. Pass the central prolene
suture through the levator muscle Z mm above the cut edge as determined in
Fig. 24.7.
FIG. 24.14. Remove the Berke ptosis clamp. Note the position of the upper eyelid.
The lid margin should rest at or within 1 mm of the superior corneal limbus. If it does
not, reposition the prolene suture.
FIG. 24.15. Pass the nasal and temporal prolene sutures through the levator
muscle and adjust their positions to achieve an adequate eyelid contour. Excise
any excess levator muscle distal to the sutures with Westcott scissors.
FIG. 24.16. Use scissors to remove a strip of skin and orbicularis muscle from
along the upper edge of the wound if necessary to prevent overhang. This is
frequently needed with larger resections for congenital ptosis. Close the skin with a
running suture of 6-0 fast-absorbing plain gut. Reform the eyelid crease if necessary by
incorporating the bite through the levator muscle on every second or third loop.
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place ophthalmic ointment on the
globe at the end of the operation and every 2 hours for 24
hours. Thereafter, apply ointment four times daily and at
bedtime for 1 week. Substitute artificial tears during the
day, but continue applying ointment at bedtime for at least
4 weeks. Adults may have to continue bedtime application
indefinitely.
POTENTIAL COMPLICATIONS:
UndercorrectionThis is a common occurrence, especially in poor function cases. After several months,
additional resection can be performed, using the
same criteria as used initially. A tarsectomy procedure
performed transcutaneously works well for smaller
amounts of undercorrection.
OvercorrectionThis is seen rarely in primary repair of
congenital ptosis but is more commonly seen in repeat
operations and adults. Massage and time may resolve
small overcorrections of 1 to 2 mm. For larger or persis-
Dutton_Chap24.indd 94
tent overcorrections, levator muscle recession or a horizontal tarsotomy with gaping of the wound may be useful.
Prolapse of conjunctivaThis results from loss of forniceal fascial suspension during dissection. If it is recognized intraoperatively, refix the fornix with several
double-armed 4-0 chromic sutures passed from the
conjunctiva through the levator muscle. Postoperatively,
prolapse is corrected with full-thickness eyelid sutures
passed from conjunctiva to skin. With chronic edema
and hypertrophy, a portion of the thickened conjunctiva
may have to be excised.
Poor eyelid creaseThis is caused by failure to reform
the crease during closure or from an overhang of excess
skin. It is repaired with a secondary crease reformation
procedure, or blepharoplasty.
Poor eyelid contourThis follows inadequate adjustment
of sutures intraoperatively. This is best repaired within 1
week after surgery with further advancement or recession of the levator muscle. Later, segmental tarsotomy
or tarsectomy will correct small defects.
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Dutton_Chap24.indd 95
FIG. 24.9
FIG. 24.13
FIG. 24.10
FIG. 24.14
FIG. 24.11
FIG. 24.15
FIG. 24.12
FIG. 24.16
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25
FIG. 25.1. Straighten the leg with the toes turned medially.
Mark the approximate direction of bers in the iliotibial tract
with a line sited between the lateral femoral condyle and a
point 1 to 2 cm behind the anterior superior iliac crest. With
two short cross-marks, dene a 2-cm segment of this line 6 cm
above the lateral condyle of the femur. Inject 0.5 mL of local
anesthetic with 1:100,000 epinephrine subcutaneously beneath
this short segment.
FIG. 25.2. Cut through the skin with a scalpel blade along
the 2-cm segment previously marked and dissect through
subcutaneous fat to the level of the fascia lata. There may be
a thin membrane beneath the fat, which obscures the fascia.
FIG. 25.3. Bluntly dissect upward between the fascia lata
and the overlying fat with a long-handled Metzenbaum
scissors. Extend the dissection for a distance of 15 cm along the
externally marked leg line by pushing the closed scissors into the
wound, opening the scissors, and withdrawing it without closing
again. This separates the fascia and prevents later bleeding.
POTENTIAL COMPLICATIONS:
InfectionThis is uncommon; however, because of its
location, the wound is more difficult to keep clean. Systemic antibiotics may be used postoperatively, although
they are not routinely necessary.
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FIG. 25.1
FIG. 25.5
FIG. 25.2
FIG. 25.6
FIG. 25.3
FIG. 25.7
FIG. 25.4
FIG. 25.8
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26
INDICATIONS: Severe ptosis with very poor to absent levator muscle function of 3 mm or less.
CONTRAINDICATIONS: Ptosis with 6 mm of function. Caution is required in patients with impaired Bells phenomenon.
FIG. 26.6. Reinsert the Wright needle into the lateral brow
incision and pass it toward the central eyelid incision.
Thread the fascia into the eyelet.
FIG. 26.3. Place a lid plate beneath the eyelid to the orbital
rim, and pass a Wright fascia needle from the lateral brow
stab incision toward the lateral lid incision. As the needle
passes over the brow ridge, direct it slightly backward to
remain deep to the orbicularis muscle. Continue advancing the
needle at a level just anterior to the levator aponeurosis and
the tarsus.
FIG. 26.5. Pass the Wright needle from the central to the
lateral eyelid incision. Thread the free end of the fascia
into the needle eyelet, and pull the strip into the central lid
incision.
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FIG. 26.1
FIG. 26.5
FIG. 26.2
FIG. 26.6
FIG. 26.3
FIG. 26.7
FIG. 26.4
FIG. 26.8
99
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POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place ophthalmic ointment on the
globe immediately, four times daily, and at bedtime for 7
days. Continue the bedtime ointment application for several weeks with children and several months with adults.
POTENTIAL COMPLICATIONS:
UndercorrectionThis is caused by failure to position the
lid at the superior limbus when the knot is tied. Pushing
the knot into the wound results in lowering of the lid
by 1 to 1.5 mm. If recognized within the first week, the
fascia can be retrieved at the brow wounds and relied.
After fibrosis, a new sling will be needed.
OvercorrectionThis is exceptionally rare in children but
is more common in adults. The sling may loosen with
vigorous massage. After fibrosis has developed along
the sling, cutting the fascial strip will allow some recession of the lid. Fibrosis along the strip prevents complete
return of ptosis.
LagophthalmosThis is a very common sequel to frontalis suspension. The condition is temporized with
Dutton_Chap26.indd 100
artificial tears and ophthalmic ointments until the cornea adapts to chronic exposure. If keratitis is severe
and persistent, especially in adults, the sling may have
to be lowered.
EctropionThis results from placing the sling too close to
the lid margin, especially when the eyes are deep set or
the brow ridges are prominent. If mild, it may resolve
with time. Small amounts of ectropion can be corrected
with minimal lid shortening at the lateral canthus. If
ectropion is more severe, the sling must be reversed.
EntropionThis is caused by failure to excise overhang
of excess skin or from placing the sling too close to the
upper tarsal border. If necessary, an eyelid crease formation procedure can be performed with excision of a strip
of skin and orbicularis muscle from the upper skin edge
prior to closure. Occasionally, the sling may have to be
replaced.
Poor lift contourThis results from inadequate adjustment at the time of surgery. If noted intraoperatively,
slide the lid margin over the sling, using forceps to
adjust the contour.
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FIG. 26.9
FIG. 26.12
FIG. 26.10
FIG. 26.13
FIG. 26.11
FIG. 26.14
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27
INDICATIONS: Severe ptosis with very poor to absent levator muscle function of 3 mm or less.
CONTRAINDICATIONS: Ptosis with 6 mm of function. Caution is required in patients with impaired Bells phenomenon
or those at risk for corneal exposure.
POSTOPERATIVE CARE: Apply iced compresses continuously for 2 hours and intermittently for 24 hours. Place
ophthalmic ointment on the globe immediately, four times
daily, and at bedtime for 7 days. Continue the bedtime
ointment application for several weeks with children and
several months with adults. For young children, the bedtime application should be continued indefinitely.
POTENTIAL COMPLICATIONS:
UndercorrectionThis is caused by failure to position the lid
at the superior limbus when the silicone band is synched.
Pushing the knot into the wound results in lowering of the
lid by 1 to 1.5 mm. With silicone, the sling can be adjusted
at any time postoperatively, even many years later.
OvercorrectionThis is rare in children but is more common in adults. If there is corneal compromise, the central brow incision can be opened and the sling loosened.
the needle eyelet and pull them through to the brow incisions.
Then pass the Wright needle from the central brow incision
to each of the medial and lateral incisions and pull the rod
through so that both emerge from the central incision.
FIG. 27.5. Pass the silicone rod ends through a silicone band
in opposite directions. A Watsky sleeve spreader will facilitate
this operation.
FIG. 27.6. Before tightening the rod, close the upper eyelid incision with a running suture of 6-0 fast-absorbing gut. Tighten
the silicone sling by pulling the ends through the sleeve until the
eyelid margin is at or just below the superior corneal limbus. Synch
the band with an interrupted suture of 6-0 prolene.
FIG. 27.7. Close the medial and lateral brow incisions with
one or two interrupted sutures. Cut the free ends of the
silicone rod to a length of about 1 cm. With a narrow smooth
dressing forceps, grasp each end of the rod and push it into the
wound beneath the frontalis muscle. Make sure it lies at and
is not bucked to prevent extrusion.
FIG. 27.8. Close the central brow incision with one or two
interrupted sutures of 6-0 fast-absorbing plain gut.
LagophthalmosThis is a very common sequel to frontalis
suspension. The condition is temporized with artificial
tears and ophthalmic ointments until the cornea adapts
to chronic exposure. If keratitis is significant and persistent, especially in adults, the sling may have to be lowered.
EctropionThis results from suturing the sling too close
to the lid margin, especially when the eyes are deep set
or the brow ridges are prominent. If mild, it may resolve
with time. If ectropion is more severe, the sling must be
revised.
EntropionThis is caused by failure to excise overhang
of excess skin or from placing the sling too close to the
upper tarsal border. If necessary, an eyelid crease formation procedure can be performed with excision of a strip
of skin and orbicularis muscle from the upper skin edge
prior to closure. Occasionally, the sling may have to be
repositioned on the tarsus.
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FIG. 27.1
FIG. 27.5
FIG. 27.2
FIG. 27.6
FIG. 27.3
FIG. 27.7
FIG. 27.4
FIG. 27.8
7/12/2012 11:20:14 AM
SECTION
Ectropion
I
H
orbicularis tightening. These may be used on the upper as
well as the lower eyelid. Lid shortening alone may not always
correct punctal eversion, in which case, it can be combined
with a medial spindle tarsoconjunctival resection. When
long-standing ectropion has resulted in secondary deformities, such as punctal occlusion or cicatricial eyelid retraction,
other procedures may have to be added. These include punctoplasty or canaliculoplasty, recession of the eyelid retractors, or release of the cicatrized subcutaneous tissues.
In paralytic ectropion resulting from seventh nerve
dysfunction, the canthal ligaments are frequently normal.
However, loss of orbicularis muscle tone results in outward
displacement of the lower lid under the influence of gravity and the downward traction of a droopy cheek. Paralytic
ectropion is often associated with brow ptosis and secondary dermatochalasis, pseudoptosis of the upper eyelid, and
drooping of the lateral canthal angle. With long-standing
downward tension on the atonic eyelid, progressive stretching occurs so that laxity becomes an additional component.
The goals in the management of paralytic ectropion are
protection of the cornea, ocular comfort, and improved
cosmesis. When ectropion is mild, a simple tarsorrhaphy
shortens the horizontal interpalpebral fissure, provides
minimal vertical support for the lateral lower lid, and reapposes the lid margins to the globe. With greater degrees of
ectropion, especially when significant facial droop is also
present, a tarsorrhaphy alone does not usually withstand
the continued downward tension, and results are temporary at best. Lid shortening achieves good functional and
cosmetic results but must be combined with subcutaneous
cheek suspension to relieve downward traction. When tensional forces are marked, more substantial lid support is
required. This is achieved with a fascial sling or temporalis
muscle transfer procedure.
In cicatricial ectropion, the anterior skin or skinmuscle lamella is shortened, resulting in outward forces on the
lid margin. It is seen in both the upper and lower eyelid
and may be associated with dermatologic disorders, such
as rosacea and ichthyosis, traumatic scarring, burns, infection, radiation, or sequelae to eyelid surgery. Secondary
complications that involve the puncta, conjunctiva, and
cornea may be seen as with other forms of ectropion.
Correction is directed at replacing the deficient tissue with
local flaps or free skin grafts.
Mechanical ectropion results from mass lesions that
interpose between the eyelid and the globe. The lesions
may be conjunctival or subconjunctival infiltrates, lid or
epibulbar tumors, or abscesses. Treatment involves medical or surgical elimination of the causative lesion.
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Ectropion
Lateral Tarsorrhaphy
Cole G. Lateral canthoplasty in ophthalmic plastic surgery. In: Hughes
WL, ed. Manual on Oculoplastic Surgery. San Francisco, CA: The
American Academy of Ophthalmology; 1961.
de Silva DJ, Ramkissoon YD, Ismail AR, Beaconsfield M. Surgical technique: modified lateral tarsorrhaphy. Ophthal Plast Reconstr Surg.
2011;27:216218.
Garber PF. Lateral canthoplasty. In: Smith B, Bosniak S, eds. Advances in
Ophthalmic Plastic and Reconstructive Surgery. Vol 2. Elmsford, NY:
Pergamon Press; 1983.
Soll DB. Entropion and ectropion. In: Soll DB, ed. Management of Complications in Ophthalmic Plastic Surgery. Birmingham, UK: Aesculapius; 1976.
Dutton_Chap28.indd 105
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28
Lateral Tarsorrhaphy
FIG. 28.1. Grasp the lower eyelid margin with forceps and
cut along the gray line with a scalpel blade from the lateral
canthal angle medially for a distance of about 10 mm. The
exact distance depends on the amount of intermarginal adhesion needed.
FIG. 28.2. With micro-Westcott scissors, sharply dissect in
the postorbicular fascial plane to a depth of 3 to 4 mm to
separate the anterior skinmuscle lamella from the anterior tarsus.
FIG. 28.3. Cut a strip of epithelium from the marginal border of the tarsus along the area of the split eyelid. Leave the
lashes along the skinmuscle ap intact so the tarsorrhaphy
can be taken down later without distortion of the lid margin.
FIG. 28.4. Grasp the upper eyelid margin and split the
lid along the gray line for a distance equal to that in the
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FIG. 28.1
FIG. 28.5
FIG. 28.2
FIG. 28.6
FIG. 28.3
FIG. 28.7
FIG. 28.4
FIG. 28.8
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29
INDICATIONS: Mild to moderate horizontal laxity of the lower or upper eyelid, especially when resulting from stretching of the lateral canthal ligament.
CONTRAINDICATIONS: Eyelid laxity resulting from medial canthal ligament redundancy; all but the mildest forms of
cicatricial ectropion.
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FIG. 29.1
FIG. 29.5
FIG. 29.2
FIG. 29.6
FIG. 29.3
FIG. 29.7
FIG. 29.4
FIG. 29.8
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30
INDICATIONS: Ectropion of the medial one-third to one-half of the eyelid with punctal eversion.
POTENTIAL COMPLICATIONS:
Canalicular injuryThis results from placement of the
spindle excision too high on the lid or passing the
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FIG. 30.1
FIG. 30.4
FIG. 30.2
FIG. 30.5
FIG. 30.3
FIG. 30.6
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31
INDICATIONS: Ectropion from diffuse horizontal eyelid laxity; floppy eyelid syndrome.
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment on the
suture line and in the fornix four times daily for 7 days.
Remove the silk marginal suture after 7 days.
POTENTIAL COMPLICATIONS:
Corneal abrasionThis may result from placing the lid
excision centrally and the tarsal sutures through the
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FIG. 31.1
FIG. 31.5
FIG. 31.2
FIG. 31.6
FIG. 31.3
FIG. 31.7
FIG. 31.4
FIG. 31.8
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32
FIG. 32.1. Hold the lid margin with two forceps, and with
scissors make a full-thickness vertical cut through the lid
4mm lateral to the inferior punctum. Cauterize the marginal
artery.
FIG. 32.2. With forceps, grasp the two free tarsal edges and
overlap them with moderate tension. On the lateral side of
the wound, mark the amount of excess lid to be resected.
FIG. 32.3. Cut along the mark with scissors to excise a
V-shaped segment of full-thickness eyelid.
FIG. 32.4. Evert the medial portion of the eyelid with
forceps. Place a no. 00 or 0 Bowman probe into the canaliculus
to mark its location. Cut a horizontal V-shaped segment of
conjunctiva and capsulopalpebral fascia 4 mm below the
canaliculus. The excised wedge should measure about 5 mm
vertically by 8 mm horizontally and should have its broad base
laterally, at the previously cut vertical eyelid defect.
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FIG. 32.5
FIG. 32.2
FIG. 32.6
FIG. 32.3
FIG. 32.7
FIG. 32.4
FIG. 32.8
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33
INDICATIONS: Laxity of the medial canthal ligament with medial ectropion or punctal eversion. This may be combined
with any other procedure for ectropion repair.
POTENTIAL COMPLICATIONS:
Canalicular occlusionPlacement of the plication suture
around or through the canaliculus will occlude its lumen
and result in possible epiphora.
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FIG. 33.1
FIG. 33.4
FIG. 33.2
FIG. 33.5
FIG. 32.3
FIG. 33.6
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34
INDICATIONS: Paralytic ectropion or recurrent lower eyelid laxity where vertical support is needed.
portion of the strip over the anterior edge of the orbital rim
with a Freer elevator. Rotate the fascial strip medially into the
lower eyelid defect.
FIG. 34.6. Make an incision 5 to 6 mm long, inferior and
medial to the medial canthal ligament. Expose the ligament
and surrounding periosteum with blunt dissection. Pass a
Wright needle from the medial canthal incision beneath the
orbicularis muscle and laterally to the lower lid incision. Thread
the fascial strip into the needle eyelet and pull it through to the
medial canthal ligament.
FIG. 34.7. Put enough tension on the fascia to pull the lid
margin against the globe and to position it 2 mm above the
inferior corneal limbus. Mark the point where the fascial strip
contacts the insertion of the medial canthal ligament. Trim off
the excess. Pass a double-armed 5-0 prolene suture through the
insertion of the medial canthal ligament and then through the
fascial strip.
FIG. 34.8. Fix the fascia to the tarsus just below the lid
margin with 4 to 5 interrupted 6-0 prolene sutures. Close
the medial canthal incision with interrupted 6-0 fast-absorbing
plain gut. Drape the skinmuscle ap over the lid and close
the orbicularis muscle laterally with several buried 6-0 chromic
or Vicryl sutures. Close the skin with a running suture of 6-0
fast-absorbing plain gut.
118
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Dutton_Chap34.indd 119
FIG. 34.1
FIG. 34.5
FIG. 34.2
FIG. 34.6
FIG. 34.3
FIG. 34.7
FIG. 34.4
FIG. 34.8
7/12/2012 11:39:34 AM
35
FIG. 35.7. Suture the graft into the recipient bed using
interrupted 7-0 Vicryl stitches. Fibrin tissue glue can be used
to help x the graft in position. If the graft is larger than 2cm in
diameter, cut one or more stab incisions in its central portion
for drainage. Place a 4-0 silk Frost suture through the eyelid
margin and tape it to the brow to keep the eyelid closed and
the graft at.
FIG. 35.4. Cut the donor skin along the marked line with a
scalpel blade. Undermine the graft with scissors and dissect
it from the orbicularis muscle. It may be necessary to excise
part of the muscle to allow closure of the wound. Closethe
donor site with a running suture of 6-0 fast-absorbing
plaingut.
POTENTIAL COMPLICATIONS:
Persistent or recurrent ectropionThis usually results
from failure to completely undermine the skin beyond
the area of cicatricial shortening or from not allowing for
graft shrinkage. The graft should be 1.5 times the width
of the shortest vertical dimension of the recipient defect.
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FIG. 35.1
FIG. 35.5
FIG. 35.2
FIG. 35.6
FIG. 35.3
FIG. 35.7
FIG. 35.4
FIG. 35.8
7/16/2012 9:16:59 AM
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SECTION
Entropion
E
123
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Dutton_Chap36.indd 124
Marginal Rotation
Bleyen I, Dolman PJ. The Wies procedure for management of trichiasis or
cicatricial entropion of either upper or lower eyelids. Br J Ophthalmol.
2009;93:16121615.
7/12/2012 12:19:14 PM
Dutton_Chap36.indd 125
Quickert-Rathbun Sutures
Miyamoto T, Eguchi H, Katome T, et al. Efficacy of the Quickert procedure for involutional entropion. The first case series in Asia. J Med
Invest. 2012;59:136142.
Pereira MG, Rodrigues MA, Rodrigues SA. Eyelid entropion. Semin
Ophthalmol. 2010;25:5258.
Quist LH. Tarsal strip combined with modified Quickert-Rathbun sutures
for involutional entropion. Can J Ophthalmol. 2002;37:238244.
Retractor Reinsertion
Caldato R, Lauande-Pimentel R, Sabrosa NA, et al. Role of reinsertion of
the lower eyelid retractor on involutional entropion. Br J Ophthalmol.
2000;84:606608.
Erb MH, Uzcategui N, Dresner SC. Efficacy and complications of the
transconjunctival entropion repair for lower eyelid involutional entropion. Ophthalmology. 2006;113:23512356.
Then SY, Salam A, Kakizaki H, Malhotra R. A lateral approach to
lower eyelid entropion repair. Ophthalmic Surg Lasers Imaging.
2011;42:519522.
7/12/2012 12:19:14 PM
36
INDICATIONS: Mild to moderate involutional entropion; acute spastic entropion following ocular surgery; mild
cicatricial entropion when more definitive procedures cannot be performed.
FIG. 36.3. Pull the skin downward slightly and move the
needle point upward beneath the skin to a position 3 mm
below the eyelid margin. Push the needle through the skin.
FIG. 36.4. Pass the second arm of the mattress suture in
a similar fashion 3 to 4 mm from the rst arm. Place two
additional mattress sutures 8 mm medial and lateral to the
rst. Tie all three sutures rmly without bolsters, and adjust the
tension to produce a slight ectropion. Place ve to six throws in
the knot to prevent loosening.
laxity. The situation is usually temporary, and correction
may be hastened with massage to soften the scar bands.
RecurrenceThis is common and results from the inability of the operation to reattach the retractors to the tarsus. The procedure fixes the retractors to the orbicularis
muscle and serves mainly to prevent preseptal muscle
override.
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FIG. 36.3
FIG. 36.2
FIG. 36.4
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37
128
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Dutton_Chap37.indd 129
FIG. 37.1
FIG. 37.3
FIG. 37.2
FIG. 37.4
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38
INDICATIONS: Congenital and acquired epiblepharon with corneal irritation, especially in older children and adults.
130
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Dutton_Chap38.indd 131
FIG. 38.1
FIG. 38.4
FIG. 38.2
FIG. 38.5
FIG. 38.3
FIG. 38.6
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39
INDICATIONS: Involutional entropion with vertical redundancy or disinsertion of the lower eyelid retractors.
FIG. 39.3. Tent up the skin edges with forceps and cut
through the orbicularis muscle temporally with scissors.
Open the muscle along the entire length of the skin incision.
FIG. 39.6. Drape the skin and muscle ap upward and with
gentle tension pull the ap laterally. Mark the excess skin
along the lid margin and at the lateral wound edge. Cut the
excess skin and muscle along the mark. Rarely is it necessary to
remove more than 2 to 4 mm of vertical skin.
FIG. 39.4. With scissors dissect downward in the postorbicular fascial plane to the inferior orbital rim to expose
the orbital septum. Open the septum across the length of
theeyelid. If the retractors are disinserted, the edge of the
capsulopalpebral fascia may be seen some distance below
the inferior tarsal border, thus revealing Mllers muscle and
conjunctiva.
FIG. 39.5. Place a 6-0 prolene suture through the edge of the
capsulopalpebral fascia if disinserted or 4 to 6 mm below
132
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Dutton_Chap39.indd 133
FIG. 39.1
FIG. 39.5
FIG. 39.2
FIG. 39.6
FIG. 39.3
FIG. 39.7
FIG. 39.4
FIG. 39.8
7/12/2012 12:25:38 PM
40
INDICATIONS: Involutional entropion from retractor disinsertion combined with horizontal eyelid laxity.
and slightly medially so that the resulting wedge resection is 2 to 3 mm wider at the tarsal base than at the eyelid
margin. Complete the pentagonal resection by extending this
cut to the inferior fornix. Repair the marginal eyelid defect
as described for Direct Layered Closure of Marginal Defects,
Fig.56.2 through 56.5 (pp. 214 to 215).
FIG. 40.4. Drape the skin and muscle ap upward and
with gentle tension pull it laterally over the wound edges.
Mark the excess ap and excise it with scissors. Rarely is it
necessary to remove more than 2 to 4 mm vertically. Place
four to ve interrupted 7-0 chromic sutures through the
preseptal orbicularis muscle 5 to 6 mm below the skin edge
and through the capsulopalpebral fascia. Close the skin edges
with a running stitch of 6-0 fast-absorbing plain gut along the
lid margin and with interrupted sutures laterally.
operatively, remove and replace the marginal sutures.
Postoperatively, a soft contact lens may be applied until
sutures are removed. Occasionally, the posterior marginal sutures may have to be removed early.
Wound dehiscenceThis may be caused by resection of
too much eyelid with repair under excessive tension. It
is corrected by freshening the wound margins if necessary and resuturing the defect.
134
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FIG. 40.1
FIG. 40.3
FIG. 40.2
FIG. 40.4
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41
136
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Dutton_Chap41.indd 137
FIG. 41.1
FIG. 41.3
FIG. 41.2
FIG. 41.4
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42
FIG. 42.1. Mark the line of incision along the upper eyelid
4to 5 mm from the margin centrally and 3 to 4 mm from
the margin laterally and medially.
FIG. 42.2. Pull the eyelid laterally to prevent buckling, and
with a scalpel blade cut the skin along the marked incision
line.
FIG. 42.3. Tent up the skin edges with forceps and cut
through the orbicularis muscle with scissors to enter the
postorbicular fascial plane. Extend the incision along the
entire eyelid skin wound.
POTENTIAL COMPLICATIONS:
Undercorrection of entropionThis results from insufficient shortening of the anterior lamella or failure to
suture the orbicularis muscle to the tarsus. It also results
from using this procedure in the presence of significant
tarsal deformity. Following closure, the eyelid should be
slightly ectropic.
138
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Dutton_Chap42.indd 139
FIG. 42.1
FIG. 42.5
FIG. 42.2
FIG. 42.6
FIG. 42.3
FIG. 42.7
FIG. 42.4
FIG. 42.8
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43
140
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Dutton_Chap43.indd 141
FIG. 43.1
FIG. 43.4
FIG. 43.2
FIG. 43.5
FIG. 43.3
FIG. 43.6
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44
INDICATIONS: Moderate to severe upper or lower eyelid cicatricial entropion from the tarsal deformity.
FIG. 44.3. With scissors extend the cut laterally and medially
across the full width of the tarsal plate. Do not extend
beyond the tarsus to avoid injury to the palpebral arteries.
POTENTIAL COMPLICATIONS:
OvercorrectionSeen in the immediate postoperative
period, this condition is usually temporary. If persistent,
it may be corrected with massage or Ziegler-type light
cautery to contract the conjunctival surface.
142
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CHAPTER 44 Horizontal Blepharotomy with Marginal Eyelid Rotation (Wies Procedure) 143
Dutton_Chap44.indd 143
FIG. 44.1
FIG. 44.4
FIG. 44.2
FIG. 44.5
FIG. 44.3
FIG. 44.6
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45
INDICATIONS: Severe cicatricial entropion with conjunctival contraction and tarsal deformity.
POTENTIAL COMPLICATIONS:
Corneal abrasionThis results from exposure of the Vicryl sutures on the conjunctival surface. Care should be
taken to bury these within the tarsus only.
144
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CHAPTER 45 Posterior Lamellar Eyelid Lengthening with Free Tarsoconjunctival, Scleral, or Cartilage Graft 145
Dutton_Chap45.indd 145
FIG. 45.1
FIG. 45.5
FIG. 45.2
FIG. 45.6
FIG. 45.3
FIG. 45.7
FIG. 45.4
FIG. 45.8
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46
INDICATIONS: Moderate cicatricial entropion with conjunctival scarring and epidermalization, without tarsal deformity.
FIG. 46.1. Grasp the eyelid margin with two forceps and
split the lid at the gray line along its entire length with a
scalpel blade.
FIG. 46.2. With micro-Westcott scissors, separate the
anterior skinmuscle lamella from the posterior tarsus
conjunctiva lamella. Continue the dissection for a distance of
5 to 6 mm.
FIG. 46.3. Fix the skinmuscle ap to the anterior tarsal
surface with three double-armed 6-0 Vicryl sutures so it is
recessed 2 mm behind the lid margin.
FIG. 46.4. Pass a 4-0 silk traction suture through the
marginal tarsus and evert the eyelid over a Desmarres
retractor. Remove the scarred and epidermalized conjunctiva
from the entire tarsal surface with a diamond dermabrasion
tip on a rotary drill. Alternatively, conjunctiva may be dissected
with micro-Westcott scissors.
FIG. 46.5. Evert the lower lip with two towel clips. Using a
long 27-gauge needle, inject 4 to 6 mL of solution containing
POTENTIAL COMPLICATIONS:
Corneal abrasionThis results from the graft fixating suture being placed low on the tarsus. This can be
146
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Dutton_Chap46.indd 147
FIG. 46.1
FIG. 46.5
FIG. 46.2
FIG. 46.6
FIG. 46.3
FIG. 46.7
FIG. 46.4
FIG. 46.8
7/12/2012 1:11:57 PM
SECTION
Correction of Eyelid
Retraction
I
n eyelid retraction, the vertical palpebral fissure is generally wider than normal because of an elevation of the upper
lid or a depression of the lower lid. However, a normal palpebral fissure does not always correlate with normal eyelid
positions; for example, in Graves disease, retraction of the
lower lid may be associated with ptosis of the upper lid,
which results in a normal interpalpebral width. In evaluation of eyelid retraction, it is best to measure marginal eyelid
position with respect to the central pupillary reflex or the
corneal limbus.
The causes of this condition are numerous. Primary
retraction may be the first sign of an orbital tumor, with
or without proptosis or extraocular muscle involvement.
Trauma or orbital surgery may result in fibrosis of the levator muscle or orbital septum with consequent retraction.
A pseudoretraction may be seen with marked proptosis or
associated with ptosis of the contralateral eyelid attributable to Herings phenomenon. Certainly, the most common etiology of eyelid retraction is Graves orbitopathy.
The ophthalmic manifestations of Graves disease
include chronic inflammation with ocular surface irritation, eyelid retraction, orbital congestion and proptosis,
extraocular muscle restriction, corneal exposure, and
occasionally compressive optic neuropathy. These consequences of the disease are not strictly correlated with
abnormal thyroid function, and many patients experience
progressive ocular complications long after restoration of
the euthyroid state. Early anatomic changes are related
to osmotic edema caused by deposition of abnormal
amounts of hyaluronic acid, inflammatory cellular infiltration, and adipogenesis. This results in increased orbital
fat volume and thickened extraocular muscles. This
inflammatory component is largely reversible with resolution of the disease. When chronic and long-standing,
however, inflammation and congestion lead to ischemic
fibrosis and permanent anatomic deformity. These complications will remain after abatement of the inflammatory
manifestations.
The management and rehabilitation of Graves orbitopathy must be individualized according to the patients specific symptomatology and to the evolutionary stage of the
disease. During the inflammatory phase, which may last for
1 to a few years, symptomatic therapy is indicated for the
eyelid retraction. This includes ocular lubrication, nocturnal patching, or a temporary lateral tarsorrhaphy for comfort. It is essential that any surgical intervention be delayed
until the disease burns itself out and the anatomic alterations have stabilized for at least 6 to 12 months. Although
148
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Dutton_Chap47.indd 149
Kahana A, Lucarelli MJ. Adjunctive transcanthotomy lateral suborbicularis fat lift and orbitomalar ligament resuspension in lower eyelid
ectropion repair. Ophthal Plast Reconstr Surg. 2009;25:16.
Marshak H, Morrow DM, Dresner SC. Small incision preperiosteal midface lift for correction of lower eyelid retraction. Ophthal Plast Reconstr Surg. 2010;26:176181.
Turk JB, Goldman A. SOOF lift and lateral retinacular canthoplasty.
Facial Plast Surg. 2001;17:3748.
7/12/2012 1:16:10 PM
47
INDICATIONS: Eyelid retraction attributable to Graves orbitopathy. For other causes, extirpation of Mllers muscle
may be omitted.
150
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Dutton_Chap47.indd 151
FIG. 47.1
FIG. 47.5
FIG. 47.2
FIG. 47.6
FIG. 47.3
FIG. 47.7
FIG. 47.4
FIG. 47.8
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Dutton_Chap47.indd 153
FIG. 47.9
FIG. 47.12
FIG. 47.10
FIG. 47.13
FIG. 47.11
FIG. 47.14
7/12/2012 1:16:16 PM
48
FIG. 48.1. Place a 4-0 silk traction suture through the tarsus
at the lower eyelid margin. Evert the lid over a Desmarres
retractor to expose the palpebral conjunctiva.
POTENTIAL COMPLICATIONS:
UndercorrectionThis results from incomplete detachment
of the eyelid retractors from the lateral or medial ends of
the tarsus or from failure to separate the retractors from
the orbicularis muscle. Following dissection, the eyelid
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FIG. 48.5
FIG. 48.2
FIG. 48.6
FIG. 48.3
FIG. 48.7
FIG. 48.4
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49
INDICATIONS: Lower eyelid retraction with or without ectropion and mild vertical shortage of skin.
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment on the
suture line three to four times daily for 7 days.
POTENTIAL COMPLICATIONS:
Lateral canthal angle dystopiaThis may result from
placing the periosteal sutures too high on the lateral
orbital rim, thus distorting the lateral canthal angle
upward. It is avoided by carefully checking the canthal
position before closing the wound.
156
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FIG. 49.4
FIG. 49.2
FIG. 49.5
FIG. 49.3
FIG. 49.6
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SECTION
Repair of Superficial
Non-marginalEyelid Defects
E
158
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Advancement Flaps
Anderson RL, Edwards JJ. Reconstruction by myocutaneous flaps. Arch
Ophthalmol. 1979;97:23582362.
Limberg AA. Designs of local flaps. In: Gibson T, ed. Modern Trends in
Plastic Surgery. 2nd ed. London, UK: Butterworth; 1966.
Motomura H, Taniguchi LL, Karada NM, et al. A combined flap reconstruction for full-thickness defects of the medial canthal region. J Plast
Reconstr Aesthet Surg. 2006;59:747751.
Rotational Flaps
Bertelmann E, Rieck P, Guthoff R. Medial canthal reconstruction by a
modified glabellar flap. Ophthalmologica. 2006;220:368371.
Emsen IM, Benlier E. The use of the super thinned inferior pedicled glabellar flap in reconstruction of small to large medial canthal defect.
JCraniofac Surg. 2008;19:500504.
Lister GD, Gibson T. Closure of rhomboid skin defects: the flaps of
Limberg and Dufourmental. R J Plast Surg. 1972;25:300314.
Maloof AJ, Leatherbarrow B. The glabellar flap dissected. Eye. 2000;
14:597605.
Ng SG, Inkster CF, Leatherbarrow B. The rhomboid flap in medial canthal
reconstruction. Br J Ophthalmol. 2001;85:556559.
Perry JD, Taban M. Superiorly based bilobed flap for inferior medial canthal and nasojugal fold defect reconstruction. Ophthal Plast Reconstr
Surg. 2009;25:276279.
Dutton_Chap50.indd 159
Transposition Flaps
Campbell LB, Ramsey ML. Transposition island pedicle flaps in the
reconstruction of nasal and perinasal defects. J Am Acad Dermatol.
2008;58:434436.
Custer PL. Trans-nasal flap for medial canthal reconstruction. Ophthalmic Surg. 1994;25:601603.
Jelks GW, Zide RT. Medial canthal reconstruction using a medially
based upper eyelid myocutaneous flap. Plast Reconstr Surg. 2002;110:
16361643.
Seo YJ, Hwang C, Choi S, Oh SH. Midface reconstruction with various flaps based on the angular artery. J Oral Maxillofac Surg.
2009;67:12261233.
Zinkernagel MS, Catalano E, Ammann-Rauch D. Free tarsal graft combined with skin transposition flap for full-thickness lower eyelid
reconstruction. Ophthal Plast Reconstr Surg. 2007;23:228231.
7/12/2012 1:20:43 PM
50
INDICATIONS: Primary repair of small, nonmarginal skin or skin and muscle eyelid defects for which the edges can be
closed without excessive tension.
FIG. 50.2. With a scalpel blade, cut through the skin and
orbicularis muscle, remaining perpendicular to the skin
surface. Dissect beneath the ap in the subcutaneous plane,
160
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Dutton_Chap50.indd 161
FIG. 50.1
FIG. 50.3
FIG. 50.2
FIG. 50.4
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51
INDICATIONS: Primary repair of eyelid defects that cannot be closed directly and for which adjacent tissue can be
advanced into the defect with little or no tension.
FIG. 51.2. Cut through the skin and orbicularis muscle with
a scalpel blade. Dissect the ap free from its underlying bed.
Cut the Burows triangles with scissors, making certain the
corners are sharp and free of subcutaneous tissue.
FIG. 51.4. Close the muscle layer with interrupted 6-0 Vicryl
stitches. Place several vertical mattress sutures across the
Burows triangles and close the skin with interrupted 6-0 Vicryl
or prolene sutures.
162
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FIG. 51.1
FIG. 51.3
FIG. 51.2
FIG. 51.4
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52
INDICATIONS: Primary repair of eyelid defects for which adjacent tissue can be rotated sideways directly into the defect
or for which it is necessary to transfer the tension of direct closure away from the eyelid margin.
FIG. 52.2. Cut along the marked line with a scalpel blade.
Gently dissect beneath the orbicularis muscle to elevate a
skinmuscle ap, taking care to preserve the vascular supply.
Undermine the ap from its bed and continue the dissection
beneath the edges of the donor site.
164
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Dutton_Chap52.indd 165
FIG. 52.1
FIG. 52.3
FIG. 52.2
FIG. 52.4
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53
INDICATIONS: Primary repair of eyelid defects where tissue is not available immediately adjacent to the eyelid but must
be transposed from a somewhat more distant site over an otherwise normal area.
166
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FIG. 53.1
FIG. 53.3
FIG. 53.2
FIG. 53.4
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54
Rhombic Flap
INDICATIONS: Primary repair of quadrangular eyelid defects with adjacent tissue when tension must be avoided at the
flap edges.
168
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FIG. 54.1
FIG. 54.3
FIG. 54.2
FIG. 54.4
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55
INDICATIONS: Repair of eyelid defects for which lengthening of the resection bed is indicated, reduction of tension is
needed, and redirection of stress lines is desired. Also can be used to reposition structures, such as the canthal angle.
FIG. 55.1. Mark the central arm of the Z along the scar
or line of contraction and outline the elliptical area to be
excised. Complete the Z by marking the cross arms at 45 to
60degrees to the central arm. A larger angle allows greater
lengthening of the bed but is more difficult to close.
FIG. 55.2. Excise the scar along the central elliptical line
(or simply cut along the line) with a scalpel blade, and cut
along the cross arms. With scissors dissect beneath the two
triangular skinmuscle aps. Hold the aps with skin hooks to
avoid injury to the triangular tips.
170
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Dutton_Chap55.indd 171
FIG. 55.1
FIG. 55.3
FIG. 55.2
FIG. 55.4
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SECTION
172
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56
INDICATIONS: Reconstruction of small to medium eyelid defects involving the full-thickness lid margin where the
wound can be approximated without excessive tension.
Eyelid notchingThe primary cause is nonpentagonal, pie-shaped sides to the defect to be closed. Eyelid
174
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FIG. 56.5
FIG. 56.2
FIG. 56.6
FIG. 56.3
FIG. 56.7
FIG. 56.4
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57
INDICATIONS: Reconstruction of 30% to 50% upper eyelid defects that cannot be closed directly.
PtosisSome degree of ptosis is expected with this procedure but usually resolves within several weeks or
months. Added care should be taken to mobilize enough
flap to close the defect without excessive tension on the
upper eyelid.
Wound dehiscenceThis results from too much tension
on the marginal wound. Deep 5-0 Vicryl sutures are
used to anchor the orbicularis muscle of the temporal
flap to the periosteum of the lateral orbital rim to relieve
tension on the wound.
Rounded lateral eyelid contourThis may be caused by
failure to refix the lid to the lateral ligament.
POTENTIAL COMPLICATIONS:
Poor eyelid margin contourThe lateral canthal incision
line should follow the downward curve of the opened
eyelid margin. Angulation of the margin results from
extending the lateral cut horizontally instead of in a
downward curve.
176
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Dutton_Chap57.indd 177
FIG. 57.1
FIG. 57.5
FIG. 57.2
FIG. 57.6
FIG. 57.3
FIG. 57.7
FIG. 57.4
FIG. 57.8
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58
Horizontal Tarsoconjunctival
Transposition Flap
INDICATIONS: Reconstruction of 40% to 50% of upper eyelid defects when there is insufficient laxity of adjacent tissue to
mobilize myocutaneous flaps.
178
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FIG. 58.1
FIG. 58.5
FIG. 58.2
FIG. 58.6
FIG. 58.3
FIG. 58.7
FIG. 58.4
FIG. 58.8
7/12/2012 1:37:30 PM
59
INDICATIONS: Reconstruction of the upper or lower eyelid where the defect is of shallow to moderate depth, where
replacement of up to two-thirds of the posterior tarsoconjunctival lamella is required, and where the ipsilateral or contralateral upper eyelid is available for donor tissue.
POTENTIAL COMPLICATIONS:
Corneal abrasionThis results from placing the tarsal
graft sutures through the conjunctival surface. Take care
to place these through partial-thickness tarsus only.
180
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FIG. 59.1
FIG. 59.5
FIG. 59.2
FIG. 59.6
FIG. 59.3
FIG. 59.7
FIG. 59.4
FIG. 59.8
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60
182
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Dutton_Chap60.indd 183
FIG. 60.1
FIG. 60.5
FIG. 60.2
FIG. 60.6
FIG. 60.3
FIG. 60.7
FIG. 60.4
FIG. 60.8
7/12/2012 1:33:25 PM
61
INDICATIONS: Reconstruction of an upper eyelid defect or contracted scarring when the marginal eyelid and lash line
can be preserved.
FIG. 61.6. Excise the epithelium and scar tissue from the
inferior border of the lower lid bridge and the superior
border of the upper lid bridge to expose all layers. If
necessary, excise a small portion of the stretched lower and
upper lid aps. Repair both the lower and upper eyelids by
reapproximating the conjunctiva with a running 6-0 plain gut
suture. Close the muscle with 6-0 Vicryl sutures and the skin
with 6-0 fast-absorbing plain gut.
Lower eyelid retractionThis is caused by separating the
flap too low during the second stage of reconstruction.
It is best not to trim too much of the flaps and, if necessary, perform secondary reduction of eyelid length.
Persistent edemaIt is usual for the reconstructed eyelids to have edema for several months following separation. This usually resolves with time.
184
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FIG. 61.1
FIG. 61.4
FIG. 61.2
FIG. 61.5
FIG. 61.3
FIG. 61.6
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SECTION
187
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62
INDICATIONS: Reconstruction of 30% to 50% horizontal lower eyelid defects, especially those located in the lateral or
central thirds of the lid.
188
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Dutton_Chap62.indd 189
FIG. 62.1
FIG. 62.5
FIG. 62.2
FIG. 62.6
FIG. 62.3
FIG. 62.7
FIG. 62.4
FIG. 62.8
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63
INDICATIONS: Reconstruction of 40% to 60% horizontal lower eyelid defects with replacement of the posterior lamella.
190
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Dutton_Chap63.indd 191
FIG. 63.1
FIG. 63.5
FIG. 63.2
FIG. 63.6
FIG. 63.3
FIG. 63.7
FIG. 63.4
FIG. 63.8
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64
FIG. 64.6. Dissect a temporally based muscle ap by separating the preseptal and orbital portions of the orbicularis
from below the defect. Rotate the muscle ap upward to
cover the tarsal graft and suture it into position with 6-0 Vicryl
stitches. It is not necessary to cover the tarsal graft with muscle; therefore, this step may be omitted.
FIG. 64.3. Make a vertical cut from each end of the previous
horizontal incision and extend it to the upper border of the
tarsus. Separate the tarsus from the levator aponeurosis with
ne scissors. At the superior tarsal border, disinsert Mllers
muscle and continue the dissection between the conjunctiva
and the underlying muscle up to the superior fornix. Extend
the vertical incisions through the conjunctiva to the fornix.
192
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FIG. 64.5
FIG. 64.2
FIG. 64.6
FIG. 64.3
FIG. 64.4
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FIG. 64.7
FIG. 64.8
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FIG. 64.11
FIG. 64.10
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SECTION
Canthoplasty
Alfano C, Chiummariello S, De Gado F, et al. Lateral canthoplasty
10-year experience. Acta Chir Plast. 2006;48:8588.
Carmine A, Stefano C, Cristiano M, et al. Lateral canthoplasty by the
Micro-Mitek Anchor System: 10-year review of 96 patients. J Oral
Maxillofac Surg. 2011;69:17451749.
Dailey RA, Chavez MR. Lateral canthoplasty with acellular cadaveric dermal matrix graft (AlloDerm) reinforcement. Ophthal Plast Reconstr
Surg. 2012;28:e29e31.
Glat PM, Jelks GW, Jelks EB, et al. Evolution of the lateral canthoplasty: techniques and indications. Plast Reconstr Surg. 1997;100:
13961405.
Shin YH, Hwang K. Cosmetic lateral canthoplasty. Aesthetic Plast Surg.
2004;28:317320.
Shorr N, Goldberg RA, Eshaghian B, Cook T. Lateral canthoplasty. Ophthal Plast Reconstr Surg. 2003;19:345352.
Taban M, Nakra T, Hwang C, et al. Aesthetic lateral canthoplasty. Ophthal
Plast Reconstr Surg. 2010;26:190194.
Turk JB, Goldman A. SOOF lift and lateral retinacular canthoplasty.
Facial Plast Surg. 2001;17:3748.
Yi SK, Paik HW, Lee PK, et al. Simple epicanthoplasty with minimal scar.
Aesthet Plast Surg. 2007;31:350353.
196
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Bennett SP, Richard BM, Graham KE. Median forehead flaps for eyelid
reconstruction. Br J Plast Surg. 2001;54:733734.
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65
1
198
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Dutton_Chap65.indd 199
FIG. 65.1
FIG. 65.3
FIG. 65.2
FIG. 65.4
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66
POTENTIAL COMPLICATIONS:
Hypertrophic scar formationThis may be especially
prominent in young children, 4 to 6 weeks after surgery.
Warm compresses and massage with steroid cream will
help reduce scar formation.
200
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FIG. 66.1
FIG. 66.3
FIG. 66.2
FIG. 66.4
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67
INDICATIONS: Lengthening of the horizontal eyelid fissure for correction of ankyloblepharon and severe
blepharophimosis.
FIG. 67.1. Gently pull the eyelids medially to put the lateral canthal ligament on stretch. With scissors, cut a lateral
canthotomy the desired distance necessary to widen the
interpalpebral ssure.
FIG. 67.2. Separate the conjunctiva from along the cut lid
margins to raise mucosal aps 1 to 2 mm in width.
202
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Dutton_Chap67.indd 203
FIG. 67.1
FIG. 67.3
FIG. 67.2
FIG. 67.4
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68
INDICATIONS: Shortening of the horizontal interpalpebral fissure in euryblepharon and mild congenital ectropion
syndrome, or in thyroid eye disease patients with globe prolapse.
FIG. 68.1. Beginning at the canthal angle, split the lower lid
along the gray line to a depth of 2 mm and for a horizontal
distance of about 5 mm. Adjust the latter distance as needed
to correct the deformity. Continue the dissection around the
angle and onto the upper lid for a similar distance.
FIG. 68.2. Trim the marginal conjunctival epithelium from
the posterior lamella around the canthal angle and from
the tarsus along the area of the split lids to expose bare
edges of the canthal ligament and tarsus. Remove any
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment on the
sutures three to four times daily for 5 to 7 days.
204
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Dutton_Chap68.indd 205
FIG. 68.1
FIG. 68.3
FIG. 68.2
FIG. 68.4
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69
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment on the
suture line three to four times daily for 7 days.
206
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FIG. 69.1
FIG. 69.3
FIG. 69.2
FIG. 69.4
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70
208
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FIG. 70.1
FIG. 70.3
FIG. 70.2
FIG. 70.4
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71
POTENTIAL COMPLICATIONS:
Flap necrosisDevelopment of a flap that is too long for
its width or injury to the angular vascular pedicle during
210
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Dutton_Chap71.indd 211
FIG. 71.1
FIG. 71.4
FIG. 71.2
FIG. 71.5
FIG. 71.3
FIG. 71.6
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II
Lacrimal
Drainage
System
Surgery
Dutton_Chap72.indd 213
the secretion, transcorneal ow, and drainage of tears. Proper function of the
system depends on normal tear production and chemical composition, adequate eyelid position and pump mechanism physiology, and an anatomically patent
drainage conduit. Defects in any portion of the system may result in signicant symptomatology. The nature of the symptoms depends upon the balance between tear production and tear drainage. Hypersecretion, even with normal drainage, could result in
epiphora. Thus, appropriate therapy is aimed at elimination of the ocular irritation or
other sources of secondary overproduction. When tear secretion is normal or reduced,
the patient may be asymptomatic or may experience epiphora or dry eyes, depending on the status of the drainage system. Even in the presence of signicant drainage
obstruction, a patient may experience bothersome dry eye symptoms.
Appropriate management of lacrimal system dysfunction demands careful evaluation for the precise etiology. Attention is directed toward the ocular surface and anterior
segment, possible eyelid malpositions, the physiologic pump function, and anatomic
blockages anywhere along the drainage system. Marginal blepharitis, conjunctivitis,
keratitis, and iritis all may cause secondary hypersecretion syndrome. Therapy in these
cases is usually medical. Lower eyelid entropion with associated corneal abrasion from
inturned lashes also produces excessive reex tearing. The same is true for ectropion
with corneal exposure. In these cases of hypersecretion, surgical management of the
anatomic eyelid malposition is required.
Defects affecting the physiologic pump mechanism may result from eyelid laxity, in
which signicant orbicularis muscle tone is lost, or from seventh nerve palsies. Scarring
or mass lesions of the eyelids that impair horizontal movement also reduce pumping
action. Malpositions of the eyelids, even when not associated with corneal irritation,
can interfere with tear drainage because of punctal eversion or drooping lateral eyelid
contour. In all such cases, initial therapy is directed toward the anatomic defect, utilizing any of the eyelid reconstructive procedures discussed earlier in this volume.
Physical obstruction of tear drainage may occur anywhere along the lacrimal outow system, from the puncta to the nasolacrimal ostium. A delayed dye disappearance
test, palpation of a dilated sac, reux of mucopurulent material on sac compression,
and echographic imaging of a dilated sac and duct conrm nasolacrimal duct (NLD)
obstruction. More specic clinical tests, such as the Jones dye tests, and occasionally
canalicular probing will identify the site of obstruction in most cases.
The dye disappearance test provides an accurate assessment of tear outow. Several
drops of 2% uorescein are placed into the inferior conjunctival cul-de-sac over several
minutes, and the amount of dye remaining after 5 minutes is graded on a 0 to 4+ scale,
with 0 equal to no dye remaining and 4+ equal to all the dye remaining. In the presence of normal outow, little or no dye should remain after 5 minutes. In the Jones
I test, the dye is placed in the eye, and after 5 to 10 minutes, an attempt is made to
8/3/2012 6:48:01 PM
recover it in the inferior meatus of the nose. In up to 20% of normal individuals, however, no dye will be recovered after 20 minutes. A negative (no dye recovered) test, with
a delayed dye disappearance test, and symptomatic epiphora are strongly suggestive
of a nasolacrimal duct obstruction. The Jones II test is a nonphysiologic evaluation of
absolute nasolacrimal duct patency. After performing the dye disappearance or Jones
I test, saline solution is irrigated through the lacrimal drainage system. It is important
for complete evaluation of this test to collect any irrigant that enters the nose or pharynx. If the irrigant does enter the nose, only an incomplete obstruction is present that
can be overcome with increased hydrostatic pressure. The presence of uorescein dye
in the irrigant demonstrates a low lacrimal sac or duct obstruction because the dye
had to have entered during the previous dye disappearance test. This suggests that the
puncta and canaliculi, as well as the pump mechanism, are functioning normally. In
the absence of dye in the irrigant, it is more likely that canalicular or punctal stenosis
is present, or there is a defect in the lacrimal pump mechanism, because dye was prevented from entering the sac during the previous dye disappearance test. If no irrigant
enters the nose, then a high-grade or absolute obstruction is present that cannot be
overcome with increased hydrostatic pressure.
SUGGESTED FURTHER READING
Becker BB. Tricompartment model of the lacrimal pump mechanism. Ophthalmology. 1992;99:1139
1145.
Benger R. Surgical management of the lacrimal drainage system. Aust N Z J Ophthalmol.
1988;16:281290.
Camara JG, Santiago MD, Rodriguez RE, et al. The Micro-Reflux Test: a new test to evaluate nasolacrimal duct obstruction. Ophthalmology. 1999;106:23192321.
Doane M. Blinking and the mechanics of the lacrimal drainage system. Ophthalmology. 1981;88:844
851.
Dutton JJ. Diagnostic tests and imaging techniques. In: Linberg JV, ed. Lacrimal Surgery. New York:
Churchill Livingstone; 1988:1948.
Dutton JJ. Standardized echography in the diagnosis of lacrimal drainage dysfunction. Arch
Ophthalmol. 1989;107:10101012.
Haefliger IO, Keskinaslan I, Piffaretti JM, Pimentel AR. Improvement of chronic epiphora symptoms
after surgery in patients with different preoperative Schirmer-test values. Klin Monatsbl Augenheilkd. 2011;228:318321.
Lee MJ, Kyung HS, Han MH, et al. Evaluation of lacrimal tear drainage mechanism using dynamic
fluoroscopic dacryocystography. Ophthal Plast Reconstr Surg. 2011;27:164167.
Mandeville JT, Woog JJ. Obstruction of the lacrimal drainage system. Curr Opin Ophthalmol.
2002;13:303309.
Maurice DM. The dynamics and drainage of tears. Int Ophthalmol Clin. 1973;13:103116.
Meyer DR. Lacrimal disease and surgery. Curr Opin Ophthalmol. 1993;4:8694.
Rose GE. Lacrimal drainage surgery in a patient with dry eyes. Dev Ophthalmol. 2008;41:127137.
Weil D, Aldecoa JP, Heidenreich AM. Diseases of the lacrimal drainage system. Curr Opin
Ophthalmol. 2001;12:352356.
Yeatts RP. Current concepts in lacrimal drainage surgery. Curr Opin Ophthalmol. 1996;7:4347.
214
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SECTION
215
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72
T
216
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Dutton_Chap72.indd 218
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11
12
1
13
2
3
4
14
5
15
6
16
7
8
17
9
10
18
Dutton_Chap72.indd 219
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SECTION
Excision of medial canthal tumors frequently must sacrifice the punctum or portions of the canaliculus. As with
laceration injuries, attempts at primary reconstruction are
justified and preferable to the later placement of a Jones
tube. As with eyelid reconstruction, the possibility of tumor
recurrence dictates the choice of operative procedure.
Lacrimal drainage surgery may be performed under
local or general anesthesia, except in children, in which
case general or inhalation anesthesia is necessary. Packing of the nose with neurosurgical cottonoid sponges
soaked in 4% cocaine and 0.5% phenylephrine is helpful
to shrink the nasal mucosa for visualization and hemostasis. It also provides adequate nasal anesthesia for local
cases. Cocaine in children should be used with caution, if
at all, because of systemic toxicity. The medial canthus is
infiltrated with 1 mL of local anesthetic with epinephrine
down to the level of the periosteum for local anesthesia
and hemostasis.
Nasal mucosal bleeding can be a problem in lacrimal
surgery. It is important to instruct the patient to avoid the
use of platelet-inhibiting medications, such as aspirin and
other anticoagulation agents. In some cases, this may not
be possible because of complicating medical conditions.
SUGGESTED FURTHER READING
Punctoplasty
Caesar RH, McNab AA. A brief history of punctoplasty: the 3-snip revisited. Eye. 2005;19:1618.
Chak M, Irvine F. Rectangular 3-snip punctoplasty outcomes: preservation of the lacrimal pump in punctoplasty surgery. Ophthal Plast
Reconstr Surg. 2009;25:134135.
Guercio B, Keyhani K, Weinberg DA. Snip punctoplasty offers little additive benefit to lower eyelid tightening in the treatment of pure lacrimal
pump failure. Orbit. 2007;26:1518.
Hughes WI, Maris CSG. A clip procedure for stenosis and eversion of
the lacrimal punctum. Trans Am Acad Ophthalmol Otolaryngol.
1967;71:653655. Jones LT. Epiphora: its causes and new surgical procedures for its cure. Am Ophthalmol. 1954;38:824831.
Jones LT. Epiphora. II. Its relation to the anatomic structures and surgery
of the medial canthal region. Am J Ophthalmol. 1957;43:203212.
Kashkouli MB. 3-Snip punctoplasty. Eye. 2006;20:517.
Shahid H, Sandhu A, Keenan T, Pearson A. Factors affecting outcome
of punctoplasty surgery: a review of 205 cases. Br J Ophthalmol.
2008;92:16891692.
220
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Dutton_Chap73.indd 221
Canalicular Reconstruction
Hurwitz J. The slit canaliculus. Ophthal Surg. 1982;13:572575.
McCord CD Jr. Canalicular resection and repair by canaliculostomy. Ophthal Surg. 1980;11:440445.
Pratt DV, Patrinely JR. Reversal of iatrogenic punctal and canalicular
occlusion. Ophthalmology. 1996;103:14931497.
Zoumalan CI, Maher EA, Lelli GJ Jr, Lisman RD. Balloon canaliculoplasty for acquired canalicular stenosis. Ophthal Plast Reconstr Surg.
2010;26:459461.
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73
Two-snip Punctoplasty
POSTOPERATIVE CARE: Apply an antibiotic and steroid combination solution to the eye three times daily for
7days.
222
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FIG. 73.3
FIG. 73.2
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74
224
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Dutton_Chap74.indd 225
FIG. 74.1
FIG. 74.5
FIG. 74.2
FIG. 74.6
FIG. 74.3
FIG. 74.7
FIG. 74.4
FIG. 74.8
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FIG. 74.12
FIG. 74.10
FIG. 74.13
FIG. 74.11
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75
Canalicular Reconstruction
INDICATIONS: Loss of one or more canaliculi from trauma or surgical excision of tumor.
228
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Dutton_Chap75.indd 229
FIG. 75.1
FIG. 75.5
FIG. 75.2
FIG. 75.6
FIG. 75.3
FIG. 75.7
FIG. 75.4
FIG. 75.8
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SECTION
230
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Balloon Dacryoplasty
Couch SM, White WL. Endoscopically assisted balloon dacryoplasty
treatment of incomplete nasolacrimal duct obstruction. Ophthalmology. 2004;111:585589.
Goldstein SM, Goldstein JB, Katowitz JA. Comparison of monocanalicular stenting and balloon dacryoplasty in secondary treatment of
congenital nasolacrimal duct obstruction after failed primary probing.
Ophthal Plast Reconstr Surg. 2004;20:352357.
Maheshwari R. Balloon catheter dilation for complex congenital nasolacrimal duct obstruction in older children. J Pediatr Ophthalmol Strabismus. 2009;46:215217.
Perry JD. Balloon dacryoplasty. Ophthalmology. 2004;111:17961797.
Zoumalan CI, Maher EA, Lelli GJ Jr, Lisman RD. Balloon canaliculoplasty for acquired canalicular stenosis. Ophthal Plast Reconstr Surg.
2010;26:459461.
Dacryocystorhinostomy
Anijeet D, Dolan L, Macewen CJ. Endonasal versus external dacryocystorhinostomy for nasolacrimal duct obstruction. Cochrane Database
Syst Rev. 2011;(1):CD007097.
Demorest BH. Dacryocystorhinostomy. In: Stewart WB, ed. Ophthalmic Plastic and Reconstructive Surgery. San Francisco, CA: American
Academy of Ophthalmology; 1984.
Hurwitz JJ, Rutherford S. Computerized survey of lacrimal surgery
patients. Ophthalmology. 1986;93:1419.
Jordan DR, Anderson RL. Prevention of prolapsed silicone stents in dacryocystorhinostomy surgery. Arch Ophthalmol. 1987;105:455.
Kaynak-Hekimhan P, Yilmaz OF. Transconjunctival dacryocystorhinostomy: scarless surgery without endoscope and laser assistance.
Ophthal Plast Reconstr Surg. 2011;27:206210.
Leong SC, Macewen CJ, White PS. A systematic review of outcomes after
dacryocystorhinostomy in adults. Am J Rhinol Allergy. 2010;24:8190.
Dutton_Chap76.indd 231
Canaliculodacryocystorhinostomy
Doucet TW, Hurwitz JJ. Canaliculodacryocystorhinostomy in the treatment of canalicular obstruction. Arch Ophthalmol. 1982;100:306309.
Doucet TW, Hurwitz JJ. Canaliculodacryocystorhinostomy in the
management of unsuccessful lacrimal surgery. Arch Ophthalmol.
1982;100:619621.
Hurwitz JJ, Archer KF. Canaliculodacryocystorhinostomy. In: Linberg JV,
ed. Lacrimal Surgery. New York: Churchill Livingstone; 1988.
Tenzel RR. Canaliculo-dacryocystorhinostomy. Arch Ophthalmol.
1970;84:765.
Conjunctivodacryocystorhinostomy
Afshar MF, Parkin BT. A new instrument for Lester Jones tube placement
in conjunctivodacryocystorhinostomy. Orbit. 2009;28:337338.
Athanasiov PA, Madge S, Kakizaki H, Selva D. A review of bypass
tubes for proximal lacrimal drainage obstruction. Surv Ophthalmol
2011;56:252266.
Devoto MH, Bernardini FP, de Conciliis C. Minimally invasive conjunctivodacryocystorhinostomy with Jones tube. Ophthal Plast Reconstr
Surg. 2006;22:253255.
Gladstone GJ, Putterman AM. A modified glass tube for conjunctivodacryocystorhinostomy. Arch Ophthalmol. 1985;103:12291230.
Jones LT. Conjunctivodacryocystorhinostomy. Am J Ophthalmol.
1965;59:773783.
Kartchner MD, Mather TR, Dryden RM. Intraoperative monitoring of
Jones tube function. Ophthal Plast Reconstr Surg. 1989;3:192193.
Lampling K, Levine MR. Jones tubes; how good are they? Arch Ophthalmol. 1983;101:260261.
Maluf RN, Bashshur ZF, Noureddin BN. Modified technique for tube fixation in conjunctivodacryocystorhinostomy. Ophthal Plast Reconstr
Surg. 2004;20:240241.
Pearson A. The use of Medpor-coated tear drainage tube in conjunctivodacryocystorhinostomy. Eye. 2009;23:21202121.
Putterman AM. Fixation of Pyrex tubes in conjunctivodacryocystorhinostomy. Am J Ophthalmol. 1974;8:10261027.
Putterman AM. Consecutive conjunctivodacryocystorhinostomy instrumentation. Ophthal Plast Reconstr Surg. 2011;27:396397.
Schwarcz RM, Lee S, Goldberg RA, Simon GJ. Modified conjunctivodacryocystorhinostomy for upper lacrimal system obstruction. Arch
Facial Plast Surg. 2007;9:96100.
Steele EA, Dailey RA. Conjunctivodacryocystorhinostomy with the
frosted Jones Pyrex tube. Ophthal Plast Reconstr Surg. 2009;25:
4243.
Welham RA, Guthoff R. The Lester-Jones tube: a 15 year follow-up. Graefes Arch Clin Exp Ophthalmol. 1985;223:106108.
Zileliolu G, Gndz K. Conjunctivodacryocystorhinostomy with Jones
tube. A 10-year study. Doc Ophthalmol. 19961997;92:97105.
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76
INDICATIONS: Congenital nasolacrimal duct obstruction unresponsive to medical therapy; secondary procedure after
failed primary probing; some cases of congenital amniocele.
232
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Dutton_Chap76.indd 233
FIG. 76.1
FIG. 76.3
FIG. 76.2
FIG. 76.4
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77
INDICATIONS: One or more failed simple probings for congenital nasolacrimal duct obstruction; acquired canalicular
stenosis.
canthus. This may be corrected by pulling the knot downward in the nose and suturing it to the nasal wall with a
4-0 Mersilene stitch.
Dislocation of the tubing into the palpebral fissure
The use of a silastic button will prevent such dislocation. When a button is not used, a 4-0 silk or Mersilene
suture can be used to secure the tubing to the lateral
nasal wall. If the suture comes loose, the tubing may be
dislocated toward the cornea, especially in children. If
visible in the nose, it can be pulled downward with a
bayonet forceps. If the knot is pulled up into the duct, it
can sometimes be pushed into the inferior meatus with
a Bowman probe passed into the system from above. If
not, it can be removed by pulling the stent out through
the superior canaliculus.
POTENTIAL COMPLICATIONS:
Punctal erosion and canalicular slittingThis results
from tying the silicone tubing too tightly. Care must be
taken to secure the knot without tension in the nose. A
small amount of slitting up to 2 to 3 mm will be tolerated without functional compromise. If more than this
is noted, the stent may have to be removed early.
Corneal abrasion or discomfortIf the tubing is tied too
loosely, a large loop of tubing may be present at the medial
FIG. 77.3. Dilate the upper punctum and pass the opposite
wire introducer of the silicone stent through the superior canaliculus and down to the nose in similar fashion.
Retrieve the introducer with the grooved director or Crawford
hook and pull it out through the nostril.
234
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Dutton_Chap77.indd 235
FIG. 77.1
FIG. 77.3
FIG. 77.2
FIG. 77.4
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78
INDICATIONS: Partial nasolacrimal duct obstruction with fibrotic narrowing of the lacrimal sac/duct.
canthus. This is corrected by pulling the knot downward in the nose and suturing it to the nasal wall with a
4-0 Mersilene stitch.
Dislocation of the tubing into the palpebral fissure
The use of a silicone button will prevent such dislocation. When a button is not used, a 4-0 silk or Mersilene
suture can be used to secure the tubing to the lateral
nasal wall. If the suture comes loose, the tubing may be
dislocated toward the cornea, especially in children. If
visible in the nose, it can be pulled downward with a
bayonet forceps. If the knot is withdrawn into the duct,
it can sometimes be pushed into the inferior meatus
with a Bowman probe passed into the system from
above. If not, it can be removed through the superior
canaliculus.
236
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FIG. 78.1
FIG. 78.2
FIG. 78.4
FIG. 78.5
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79
Dacryocystorhinostomy
INDICATIONS: Acquired nasolacrimal duct (NLD) obstruction, where the canaliculi are patent; congenital NLD
obstruction after two or more failed probings with intubation.
238
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Dutton_Chap79.indd 239
FIG. 79.1
FIG. 79.5
FIG. 79.2
FIG. 79.6
FIG. 79.3
FIG. 79.7
FIG. 79.4
FIG. 79.8
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Dutton_Chap79.indd 241
FIG. 79.9
FIG. 79.13
FIG. 79.10
FIG. 79.14
FIG. 79.11
FIG. 79.15
FIG. 79.12
FIG. 79.16
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80
Canaliculodacryocystorhinostomy
INDICATIONS: Focal common canalicular obstruction located at least 8 mm proximal to the punctum, combined with
nasolacrimal duct obstruction.
FIG. 80.1. Proceed as for a standard dacryocystorhinostomy, Fig. 79.1 through 79.5 (pp. 290 to 291), to expose the
lacrimal sac fossa, except carry the incision 5 to 6 mm above
the medial canthal ligament. Transect the anterior crus of the
canthal ligament near its periosteal attachment andreect it
laterally.
FIG. 80.2. Pass the introducer of a silicone intubation
stent into the superior and inferior canaliculi up to the
obstructed segment of the common canaliculus. Using the
sharp end of a Freer elevator and the operating microscope
or loupes, dissect the canthal ligament from the common
canaliculus immediately beneath it.
FIG. 80.3. Cut through the canaliculus at the tip of the
introducers and excise the obstructed portion to the
lacrimal sac.
FIG. 80.4. Pass the stents through the canaliculus and out
the cut end of the common canaliculus.
FIG. 80.5. Complete the DCR osteum, opening the sac and
nasal mucosa, and anastomose the posterior mucosal
POSTOPERATIVE CARE AND POTENTIAL COMPLICATIONS: See care and complications as for Dacryocystorhinostomy (p. 294).
242
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Dutton_Chap80.indd 243
FIG. 80.1
FIG. 80.5
FIG. 80.2
FIG. 80.6
FIG. 80.3
FIG. 80.7
FIG. 80.4
FIG. 80.8
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81
Conjunctivodacryocystorhinostomy
INDICATIONS: Complete obstruction of the individual and common canaliculi with or without nasolacrimal duct
obstruction.
FIG. 81.1. Proceed as for a standard dacryocystorhinostomy, Fig. 79.1 through 79.11 (pp. 290 to 293), to closing of
the posterior mucosal aps.
FIG. 81.2. If the anterior tip of the middle turbinate lies
at the level of the surgical osteum, resect it. Inject local
anesthetic with epinephrine into the anterior portion of the
turbinate. Apply a straight hemostat across its base and crush
the tissue. Apply a curved hemostat vertically at the anterior
third of the turbinate. Cut at the crush marks with nasal
scissors. Cauterize the cut surfaces.
FIG. 81.3. Resect the anterior half of the caruncle with
Westcott scissors.
FIG. 81.7. Anchor the Pyrex tube by passing a 6-0 silk suture
around the collar several times, and then through the
caruncle and out the skin of the adjacent eyelid. Tie the
suture over a bolster.
POTENTIAL COMPLICATIONS:
Failure of the tube to drainThis may result from placement of a tube that is too long and in contact with the
nasal septum. If significant septal deviation is present,
it should be corrected before lacrimal drainage surgery.
The middle turbinate occasionally extends forward, and
if not resected, there may be insufficient space for the
tube.
Lateral migration of the tubeThis may be seen with a
tube that is in contact with the septum or one that is
244
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Dutton_Chap81.indd 245
FIG. 81.1
FIG. 81.5
FIG. 81.2
FIG. 81.6
FIG. 81.3
FIG. 81.7
FIG. 81.4
FIG. 81.8
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III
Orbital
Surgery
Dutton_Chap82.indd 247
S WITH ANY SURGERY, THE INITIAL STEP IN PREPARATION FOR ORBITAL SURGERY
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can distinguish tissues based on subtle biochemical differences not separable on CT.
Finally, the plain orbital x-ray series is an inexpensive, easily obtained study that can
sometimes provide useful information at a low cost.
If it is determined that surgical intervention is necessary, such preliminary studies
will indicate the most appropriate approaches and prepare the surgeon for potential
difficulties. These imaging studies allow advanced planning for necessary consultations
and the assembly of an interdisciplinary surgical team when required.
Orbital surgery is indicated for the evaluation or treatment of orbital disease, for restoration of anatomic relationships following trauma, or for cosmetic improvement of
congenital or acquired deformity. Biopsy of mass lesions is an important technique that
may yield inadequate results unless extreme care is observed. Although some authors
advocate ne needle aspiration biopsy of orbital mass lesions under CT or echographic
guidance, cytologic evaluation on such specimens requires experience and may be
inaccurate. In addition, the procedure carries the risk of orbital hemorrhage, which may
compromise vision and might require immediate surgical intervention. In some cases,
as with lymphoproliferative diseases, larger specimens may be necessary for complete
histologic and immunologic evaluation. For most orbital lesions, an open biopsy is preferred if the lesion is accessible. Frozen section conrmation that the lesion has been
adequately sampled is recommended because some diffuse masses may not be distinguished readily from surrounding normal orbital tissues or associated inammation on
visual examination alone during surgery.
Removal of orbital masses may be indicated when they are well dened and result
in either functional compromise or cosmetic deformity. Benign tumors, such as hemangiomas, schwannomas, dermoid cysts, and mixed lacrimal gland tumors, and some
malignant lesions, can usually be dissected from adjacent structures. More inltrative
lesions, such as lymphangiomas or plexiform neurobromas, are usually impossible to
extirpate completely. When not amenable to medical therapy and when necessary to
restore function, these lesions may be carefully debulked. Some residual tumor may
have to be left behind to avoid injury to important orbital structures; therefore, recurrences are to be expected.
Orbital abscesses, either following trauma or surgery or associated with sinusitis,
require direct drainage and antibiotic therapy. When loculated within the orbit, direct
drainage to the surface is appropriate. In the presence of sinus infection, orbital and
sinus drainage through a combined orbital and transnasal approach in conjunction
with an otolaryngologist may be indicated. Because the ethmoid sinus is most frequently involved, an anterior medial orbitotomy usually gives adequate visualization.
Traumatic injury to the orbit frequently involves bony fracture or hemorrhage.
Orbital rim fractures are easily accessible through anterior approaches and may be
repaired with miniplate xation of the displaced fragments. Orbital wall fractures,
which may be associated with soft tissue injury or incarceration, must be carefully
explored and realigned or replaced when necessary to restore function or orbital volume. The exact surgical approach depends on the nature and location of the fractures.
When more complex craniofacial fractures are involved, cooperation of an otolaryngologist, plastic surgeon, or neurosurgeon may be necessary.
Diffuse orbital hemorrhage following trauma may produce massive proptosis
and occasionally increased intraocular pressure or optic nerve compression. Orbital
decompression with a lateral canthotomy is usually sufficient to manage the potential
visual loss. If this fails, drainage of loculated pockets or bony decompression may be
248
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necessary. Progressive loss of vision associated with proptosis and downward displacement of the globe suggest a subperiosteal hematoma. The diagnosis is conrmed with
orbital echography or CT, and immediate drainage via an anteromedial orbitotomy
usually reverses the visual loss.
Massive proptosis associated with Graves orbitopathy may require orbital decompression for treatment of threatened visual function or for cosmetic disgurement. It is
achieved by removal of the inferior, medial, and/or lateral orbital walls. In some Graves
patients, the extraocular muscles are only minimally enlarged, but fat volume is markedly increased. Here, a fat only decompression may be sufficient. Bony decompression
may also be indicated for other expanding lesions of the orbit that cannot be surgically
extirpated.
Removal of the globe and part or all of normal orbital contents may be necessary
for management of neoplastic processes or for control of pain in a blind or phthisical
eye. It is also useful for cosmetic improvement of congenital or traumatic ocular or
orbital deformities. If only the globe is involved, enucleation or evisceration is indicated.
Neoplasms that extend into the orbit from the globe or eyelids may require more radical exenteration of orbital soft tissues for cure.
SUGGESTED FURTHER READING
Byrne SF, Green RL. Ultrasound of the Eye and Orbit. St. Louis, MO: Mosby; 2002,505p.
Doxanas MT, Anderson RL. Clinical Orbital Anatomy. Baltimore, MD: Williams & Wilkins; 1984, 232p.
Conneely MF, Hacein-Bey L, Jay WM. Magnetic resonance imaging of the orbit. Semin Ophthalmol.
2008;23:179189.
DiBernardo CW, Greenberg EF. Ophthalmic Ultrasound. A Diagnostic Atlas. 2nd ed. New York:
Thieme; 2006,154p.
Dutton JJ, Proia AD, Byrne SF. Diagnostic Atlas of Orbital Diseases. London, UK: WB Saunders;
2000,179p.
Dutton JJ. Radiographic evaluation of the orbit. In: Doxanas MT, Anderson RL, eds. Clinical Orbital
Anatomy. Baltimore, MD: Williams & Wilkins; 1984, pp. 35-56.
Dutton JJ. Radiology of the Orbit and Visual Pathways. London, UK: Saunders Elsevier; 2010, 408p.
Goh PS, Gi MT, Charlton A, et al. Review of orbital imaging. Eur J Radiol. 2008;66:387395.
Kennerdell JS, Dekker A, Johnson BL, Dubois PJ. Fine-needle aspiration biopsy: its use in orbital
tumors. Arch Ophthalmol. 1979;97:13151317.
Krohel GB, Tobin DR, Chavis R. Inaccuracy of fine needle aspiration biopsy. Ophthalmology.
1985;92:666670.
Lemke AJ, Kazi I, Felix R. Magnetic resonance imaging of orbital tumors. Eur Radiol. 2006;16:2207
2219.
Nerad JA. Techniques in Ophthalmic Plastic Surgery. A Personal Tutorial. London: Elsevier, Saunders;
2010:301486.
Rootman J. Diseases of the Orbit. A Multidisciplinary Approach. Philadelphia, PA: JB Lippincott;
1988:628.
Rootman J, Stewart B, Goldberg RA. Orbital Surgery. A Conceptual Approach. Philadelphia, PA:
Lippincott-Raven; 1995:378.
Shields JA, Shields CL. Eyelid, Conjunctival, and Orbital Tumors. Philadelphia, PA: Lippincott, Williams & Williams; 2008:782805.
Spoor TC, Kennerdell JS, Dekker A, et al. Orbital fine needle aspiration biopsy with B-scan guidance.
Am J Ophthalmol. 1980;89:274277.
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SECTION
Surgical Anatomy of
the Orbit
251
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82
T
252
Dutton_Chap82.indd 252
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Dutton_Chap82.indd 255
Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. 2nd ed. London, UK: Elsevier; 2011,262p.
Hayreh SS. The ophthalmic artery, III: branches. Br J Ophthalmol. 1962;
46:212247.
Hayreh SS, Dass R. The ophthalmic artery, II: intraorbital course. Br J
Ophthalmol. 1962;46:165185.
Kakizaki H, Takahashi Y, Asamoto K, et al. Anatomy of the superior
border of the lateral orbital wall: surgical implications in deep lateral orbital wall decompression surgery. Ophthal Plast Reconstr Surg.
2011;27:6063.
Koornneef L. Details of the orbital connective tissue system in the adult.
Acta Morphol Neerl Scand. 1977;15:134.
Koornneef L. The architecture of the musculofibrous apparatus in the
human orbit. Acta Morphol Neerl Scand 1977;15:3564.
Koornneef L. Orbital septa, anatomy and function. Ophthalmology.
1979;86:876880.
Rootman J, Stewart B, Goldberg RA. Orbital Surgery. A Conceptual
Approach. Philadelphia, PA: Lippincott-Raven; 1995:79146.
Sacks JG. Peripheral innervation of the extraocular muscles. Am J
Ophthalmol. 1983;95:520527.
Sevel D. The origins and insertions of the extraocular muscles: development, histologic features, and clinical significance. Trans Am Ophthalmol Soc. 1986;84:488526.
Takahashi Y, Kakizaki H, Nakano T. Accessory ethmoidal foramina: an
anatomical study. Ophthal Plast Reconstr Surg. 2011;27:125127.
Whitnall SE. Anatomy of the Human Orbit and Accessory Organs of
Vision. 2nd ed. London, UK: Oxford Medical Publishers; 1932,467p.
Zide BM, Jelks GW. Surgical Anatomy of the Orbit. New York: Raven;
1985,75p.
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10
11
12
3
4
13
14
15
16
7
8
17
FIG. 82.2
4
6
7
FIG. 82.3
1
2
10
11
12
13
14
15
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Dutton_Chap82.indd 258
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3
9
10
11
6
FIG. 82.5
1
7
2
8
3
9
4
10
11
5
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12
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Dutton_Chap82.indd 260
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2
3
4
10
5
11
12
FIG. 82.7
1
8
9
4
10
5
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Dutton_Chap82.indd 262
8/3/2012 6:49:13 PM
10
11
12
5
13
6
14
7
15
FIG. 82.9
1
2
8
9
3
10
4
5
11
12
13
14
15
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Dutton_Chap82.indd 264
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8
9
10
11
12
5
13
FIG. 82.11
1
7
2
8
9
10
11
3
4
5
12
6
13
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Dutton_Chap82.indd 266
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1
2
3
7
8
4
5
9
10
6
11
FIG. 82.13
8
2
9
3
4
10
11
12
7
13
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Dutton_Chap82.indd 268
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7
1
2
3
4
9
10
5
11
12
FIG. 82.15
1
2
3
4
8
5
9
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SECTION
Orbitotomy Procedures
T
he orbitotomy procedures include a number of operations for access into the various orbital soft tissue compartments. The specific approach selected depends on the
type and location of the pathologic process, involvement of
adjacent bone or paraorbital areas, the need for wide surgical
margins, and the requirements for adequate exposure.
There are three surgical spaces of interest to the orbital
surgeon and each requires specific consideration for appropriate visualization. The subperiosteal compartment is a
potential space between the orbital bony walls and periorbita. Access to this space is necessary for repair of orbital
wall fractures or for decompression of expanding orbital
volume, as in Graves orbitopathy. This compartment is
the location for accumulation of subperiosteal hematomas
following blunt trauma and for subperiosteal abscesses
associated with ethmoid or frontal sinusitis. Expanding
mucoceles and some intracranial lesions, such as sphenoid
wing meningiomas, may involve only this compartment.
Bone lesions, such as epidermoid and aneurysmal bone
cysts, cholesterol granulomas, and eosinophilic granulomas are also frequently largely confined to the subperiosteal space. Access is through a transperiosteal anterior
or lateral orbitotomy, or via a transcaruncular medial
approach.
The extraconal or peripheral orbital space lies between
the periorbita and the fascial septa that interconnect the
extraocular muscles. This septal system is far more complex than once believed, and it is unusual for lesions to be
precisely confined to the extraconal space alone. Access
to the extraconal orbital space may be through a transcutaneous transseptal orbitotomy if in the anterior orbit or
through a lateral orbitotomy if deeper.
The intraconal, or central orbital, space is delimited by the
extraocular muscle cone from the annulus of Zinn to posterior Tenons capsule. It is not a clearly defined compartment, however, because the intermuscular septum is largely
incomplete posteriorly and poorly defined anteriorly. Lesions
frequently extend between the extraconal and intraconal
compartments without regard to these artificial boundaries. Optic nerve gliomas and sheath meningiomas are typically located within the muscular cone. Any surgery on the
optic nerve, for example, biopsy or sheath decompression,
requires access to this compartment. The surgical approach
is via a lateral orbitotomy for deep lesions or an anterior orbitotomy for lesions immediately behind the globe. A superior
transcranial orbitotomy is necessary for lesions that involve
the orbital apex or for those extending intracranially into the
cavernous sinus or middle cranial fossa.
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Medial Orbitotomy
Cheng JW, Wei RL, Cai JP, Li Y. Transconjunctival orbitotomy for orbital
cavernous hemangiomas. Can J Ophthalmol. 2008;43:234238.
Krohel GB. Orbital surgery. In: Smith BC, Delia Rocca RC, Nesi FA, Lisman RD, eds. Ophthalmic Plastic and Reconstructive Surgery. St.
Louis, MO: Mosby-Year Book; 1987.
McCord CD. Oculoplastic Surgery. New York: Raven Press; 1981.
Edgin WA, Morgan-Marshall A, Fitzsimmons TD. Transcaruncular
approach to medial orbital wall fractures. J Oral Maxillofac Surg
2007;65:23452349.
Dutton_Chap83.indd 271
Lateral Orbitotomy
Berke RN. A modified Kronlein operation. Arch Ophthalmol. 1954;51:
609632.
Halli RC, Mishra S, Kini YK, et al. Modified lateral orbitotomy approach:
a novel technique in the management of lacrimal gland tumors.
JCraniofac Surg. 2011;22:10351038.
Harris GJ, Logani SC. Eyelid crease incision for lateral orbitotomy.
Ophthal Plast Reconstr Surg. 1999;15:916.
Jones BR. Surgical approaches to the orbit. Trans Ophthalmol Soc UK.
1970;90:269281.
Kennerdell JS, Maroon JC. Microsurgical approaches to intraorbital
tumors: technique and instrumentation. Arch Ophthalmol. 1976;94:
13331336.
Kim JW, Yates BS, Goldberg RA. Total lateral orbitotomy. Orbit.
2009;28:320327.
Leone CR. Surgical approaches to the orbit. Ophthalmology. 1979;86:
930941.
Mariniello G, Maiuri F, de Divitiis E, et al. Lateral orbitotomy for removal
of sphenoid wing meningiomas invading the orbit. Neurosurgery.
2010;66:287292.
McCord CD. A combined lateral and medial orbitotomy for exposure of
the optic nerve and orbital apex. Ophthal Surg. 1978;9:5866.
McNab AA, Wright JE. Lateral orbitotomya review. Aust N Z J Ophthalmol. 1990;18:281286.
Nemet A, Martin P. The lateral triangle flapnew approach for lateral
orbitotomy. Orbit. 2007;26:8995.
Rootman J, Stewart B, Goldberg RA. Orbital Surgery. A Conceptual
Approach. Philadelphia, PA: Lippincott-Raven; 1995:151392.
Wright JE. Orbital surgery. In: Silver B, ed. Ophthalmic Plastic Surgery.
3rd ed. San Francisco, CA: American Academy of Ophthalmology;
1977.
Wright JE. Surgical exploration of the orbit. Trans Ophthalmol Soc UK.
1979;99:238240.
Yuen HK, Chong YH, Chan SK, et al. Modified lateral orbitotomy for
intact removal of orbital dumbbell dermoid cyst. Ophthal Plast Reconstr Surg. 2004;20:327329.
7/12/2012 3:27:04 PM
83
INDICATIONS: Access to the anterior extraconal orbital space for biopsy or excision of small lesions.
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Dutton_Chap83.indd 273
FIG. 83.1
FIG. 83.5
FIG. 83.2
FIG. 83.6
FIG. 83.3
FIG. 83.7
FIG. 83.4
FIG. 83.8
7/12/2012 3:27:05 PM
84
INDICATIONS: Access to the extraperiosteal orbital space for biopsy or excision of lesions adjacent to the periosteum
and orbital bones, for drainage of subperiosteal hematomas or subperiosteal abscesses, or for repair of orbital wall
fractures.
FIG. 84.2. With a scalpel blade, cut the skin along the
marked line. Tent up the skin edges with forceps and
cut through orbicularis muscle with scissors to enter the
postorbicular fascial plane.
FIG. 84.6. Retract orbital fat and the levator muscle with
narrow malleable retractors for visualization. Following
biopsy or excision of the lesion, use gentle bipolar cautery to
attain complete hemostasis.
FIG. 84.7. Close the periorbita over the orbital rim with
interrupted 4-0 Vicryl sutures.
FIG. 84.8. Close the orbicularis muscle with several
interrupted 6-0 chromic sutures and the skin with a
running stitch of 6-0 fast-absorbing plain gut.
FIG. 84.4. Dissect the periosteum over the orbital rim with
a Freer periosteal elevator. Continue elevating the periosteum
from the orbital bones until the site of pathologic process is
visible. In the medial superior orbit take care to avoid injuring
the trochlea while separating it and periorbita from the frontal
bone.
POSTOPERATIVE CARE: Apply a moderately firm dressing to the eye and orbit for 24 hours and intermittent iced
compresses for another 24 hours. Avoid excessive pressure. Place antibiotic ointment on the suture line three
to four times daily for 1 week. If a paranasal sinus was
entered during surgery, appropriate systemic antibiotics
are administered for 7days.
POTENTIAL COMPLICATIONS:
Postoperative orbital hemorrhageThis rare complication can be avoided by meticulous attention to hemostasis during surgery. An expanding hematoma is
heralded by progressive proptosis, deep orbital pain,
and decreasing vision. A CT scan and an echogram
help localize the blood pocket. Treatment may require
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Dutton_Chap84.indd 275
FIG. 84.1
FIG. 84.5
FIG. 84.2
FIG. 84.6
FIG. 84.3
FIG. 84.7
FIG. 84.4
FIG. 84.8
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85
Lateral Orbitotomy
INDICATIONS: Access to the deeper intraconal orbital space, lacrimal gland, and optic nerve.
FIG. 85.5. Place six half-length 4-0 silk sutures around the
wound edges and clamp the sutures to the drapes for better
exposure. Separate periosteum over the lateral orbital rim and
into the temporalis fossa. With a Freer elevator, push a gauze
sponge between periosteum and the bone of the temporalis
fossa to facilitate clean dissection of the muscle. Allow several
minutes for hemostasis.
FIG. 85.6. At the level of the frontozygomatic suture line,
place wide malleable retractors on either side of the bony
orbital rim to protect the soft tissues. Cut through the bone
with an oscillating saw, angling the cut slightly inferiorly and
parallel to the orbital roof. Make the cut 1 cm deep and extend
it to the thin bone along the sphenozygomatic suture.
FIG. 85.7. Move the malleable retractors inferiorly to the
upper surface of the zygomatic arch. Make a cut 1.5 cm deep
through the orbital rim just above the arch. Angle the cut
slightly upward.
FIG. 85.8. Drill a hole 1 mm in diameter near the rim on
either side of each cut. Use a malleable retractor to protect
periorbita.
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Dutton_Chap85.indd 277
FIG. 85.1
FIG. 85.5
FIG. 85.2
FIG. 85.6
FIG. 85.3
FIG. 85.7
FIG. 85.4
FIG. 85.8
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Dutton_Chap85.indd 279
FIG. 85.9
FIG. 85.13
FIG. 85.10
FIG. 85.14
FIG. 85.11
FIG. 85.15
FIG. 85.12
FIG. 85.16
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SECTION
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Dutton_Chap86.indd 282
Orbital Fractures
Bratton EM, Durairaj VD. Orbital implants for fracture repair. Curr Opin
Ophthalmol. 2011;22:400406.
Cheong EC, Chen CT, Chen YR. Endoscopic management of orbital floor
fractures. Facial Plast Surg. 2009;25:816.
Chi MJ, Ku M, Shin KH, Baek S. An analysis of 733 surgically treated
blowout fractures. Ophthalmologica. 2010;224:167175.
Dutton JJ, Manson PN, lliff N, Putterman AM. Management of blow-out
fractures of the orbital floor. Surv Ophthalmol. 1991;35:279280.
Gagnon MR, Yeatts RP, Williams Z, Matthews B. Delayed enophthalmos
following a minimally displaced orbital floor fracture. Ophthal Plast
Reconstr Surg. 2004;20:241243.
Garibaldi DC, Merbs SL, Grant MP. Repair of orbital fractures. Ophthalmology. 2009;116:2265.
Gerbino G, Roccia F, Bianchi FA, Zavattero E. Surgical management of
orbital trapdoor fracture in a pediatric population. J Oral Maxillofac
Surg. 2010;68:13101316.
Gilliland GD, Gilliland G, Fincher T, et al. Timing of return to normal activities after orbital floor fracture repair. Plast Reconstr Surg.
2007;120:245251.
Gosse EM, Ferguson AW, Lymburn EG, et al. Blow-out fractures: patterns
of ocular motility and effect of surgical repair. Br J Oral Maxillofac
Surg. 2010;48:4043.
Harris GJ. Orbital blow-out fractures: surgical timing and technique. Eye.
2006;20:12071212.
Hartstein ME, Roper-Hall G. Update on orbital floor fractures: indications and timing for repair. Facial Plast Surg. 2000;16:95106.
Hwang K. Medial orbital wall reconstruction through subciliary approach:
revisited. J Craniofac Surg. 2009;20:12801282.
Kellman RM, Bersani T. Delayed and secondary repair of posttraumatic
enophthalmos and orbital deformities. Facial Plast Surg Clin North
Am. 2002;10:311323.
Kim S, Helen Lew M, Chung SH, et al. Repair of medial orbital wall fracture: transcaruncular approach. Orbit. 2005;24:19.
Koornneef L. Current concepts on the management of orbital blowout
fractures. Ann Plast Surg. 1982;9:185200.
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86
INDICATIONS: Expansion of the bony orbital contour, primarily in thyroid orbitopathy for cosmetic reduction of
proptosis or optic nerve compression, when extraocular muscles are enlarged.
FIG. 86.1. Pack the inferior and middle nasal meatus with
cottonoid strips soaked in 4% cocaine or substitute and
0.25% phenylephrine for vascular constriction.
FIG. 86.2. Mark a subciliary incision 2 mm below the
lower eyelid lash line from just inferior to the punctum
to the lateral canthus. Incise the skin with a scalpel blade.
Alternatively, a transconjunctival incision may be used, placed
just below the tarsus (see Orbital Decompression, Inferior Wall,
Transconjunctival, Fig. 88.1, pp. 350-351).
FIG. 86.3. Tent up the skin edges with forceps and
transect the orbicularis muscle with scissors to enter the
postorbicular fascial plane.
FIG. 86.4. Dissect inferiorly in the postorbicular fascial
plane, anterior to the orbital septum, to the inferior orbital
rim.
FIG. 86.5. Incise periosteum 2 mm outside the orbital rim
with a scalpel and dissect it over the bony rim with a Freer
elevator. Continue elevating periorbita off the orbital oor for
284
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Dutton_Chap86.indd 285
FIG. 86.1
FIG. 86.5
FIG. 86.2
FIG. 86.6
FIG. 86.3
FIG. 86.7
FIG. 86.4
FIG. 86.8
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Dutton_Chap86.indd 287
FIG. 86.9
FIG. 86.13
FIG. 86.10
FIG. 86.14
FIG. 86.11
FIG. 86.15
FIG. 86.12
FIG. 86.16
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87
INDICATIONS: Expansion of the bony orbital contour, primarily in thyroid orbitopathy for cosmetic reduction of
proptosis or optic nerve compression, when extraocular muscles are enlarged.
POSTOPERATIVE CARE AND POTENTIAL COMPLICATIONS: See care and complications as for Orbital
Decompression, Inferior and Medial Walls, p. 346.
290
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FIG. 87.1
FIG. 87.5
FIG. 87.2
FIG. 87.6
FIG. 87.3
FIG. 87.7
FIG. 87.4
FIG. 87.8
7/12/2012 3:35:19 PM
88
INDICATIONS: Expansion of the bony orbital contour, primarily in thyroid orbitopathy for cosmetic reduction of
proptosis or optic nerve compression, when extraocular muscles are enlarged.
FIG. 88.1. Place a 4-0 silk suture through the lower eyelid
margin and evert the lid over a Desmarres retractor. Make a
horizontal incision through the conjunctiva and capsulopalpebral
fascia with a scalpel blade 1 to 2 mm below the inferior tarsus.
FIG. 88.2. Using Westcott scissors, carry the dissection inferiorly between the orbital septum and the orbicularis muscle.
FIG. 88.3. Expose the inferior orbital rim from medial to
lateral to visualize the arcus marginalis. If extraconal fat is to
be removed, it can be dissected from the orbital oor and the
intermuscular septum and removed en bloc with cautery and
cutting.
FIG. 88.4. Using a scalpel blade, incise periosteum along
the orbital rim just outside the arcus. With a Freer dissector,
elevate periorbita from the orbital oor back for a distance
of about 3 to 4 cm. A small anastomotic vessel will often be
encountered extending from the inferior periorbita to the
infraorbital bundle. Cauterize this and cut it.
FIG. 88.5. Break a small hole through the maxillary bone
with a small hemostat or elevator medial to the infraorbital
POSTOPERATIVE CARE AND POTENTIAL COMPLICATIONS: See care and complications as for Orbital
Decompression, Inferior and Medial Walls, p. 346.
292
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FIG. 88.1
FIG. 88.5
FIG. 88.2
FIG. 88.6
FIG. 88.3
FIG. 88.7
FIG. 88.4
FIG. 88.8
7/12/2012 3:34:49 PM
89
INDICATIONS: Expansion of the bony orbital contour, primarily in thyroid orbitopathy for cosmetic reduction of
proptosis or optic nerve compression, when extraocular muscles are enlarged.
POSTOPERATIVE CARE AND POTENTIAL COMPLICATIONS: See care and complications as for Orbital
Decompression, Inferior and Medial Walls, p. 346.
294
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FIG. 89.1
FIG. 89.5
FIG. 89.2
FIG. 89.6
FIG. 89.3
FIG. 89.7
FIG. 89.4
FIG. 89.8
7/12/2012 3:45:20 PM
90
INDICATIONS: Repair of any size blow-out fractures of the orbital floor associated with inferior rectus muscle entrapment
or significant enophthalmos; large floor fractures without entrapment or enophthalmos.
POSTOPERATIVE CARE: Place a light pressure dressing for 24 hours and apply iced compresses to the eyelids
intermittently for 24 hours after the dressing is removed.
Antibiotic ointment is applied to the suture line three to
four times daily for 7 days. Systemic antibiotics are prescribed for 1 week.
POTENTIAL COMPLICATIONS:
Visual lossThis is exceedingly rare unless the floor
exploration is carried too far to the orbital apex. Care
must be used in upward retraction of the globe and
pressure must be released intermittently. The implant
should not exceed 3.5 cm in anteroposterior depth
because longer implants may compress the optic nerve
posteriorly.
296
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FIG. 90.1
FIG. 90.4
FIG. 90.2
FIG. 90.5
FIG. 90.3
FIG. 90.6
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91
INDICATIONS: Realignment of displaced orbital rim or other bony fragments following fracture.
298
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Dutton_Chap91.indd 299
FIG. 91.1
FIG. 91.5
FIG. 91.2
FIG. 91.6
FIG. 91.3
FIG. 91.7
FIG. 91.4
FIG. 91.8
7/12/2012 3:47:50 PM
92
INDICATIONS: Correction of enophthalmos in the anophthalmic socket. With modification, the procedure may be used
in the presence of a seeing eye, but with extreme caution.
However, protrusion into the lower eyelid will necessitate repositioning and refixation.
Muscle imbalanceWhen volume augmentation is performed on a socket with a seeing eye, displacement of
the inferior oblique and rectus muscles may result in
postoperative diplopia and hyperophthalmia. This usually resolves after several months. If it does not, the
implant may have to be removed or strabismus surgery
performed.
300
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Dutton_Chap92.indd 301
FIG. 92.1
FIG. 92.4
FIG. 92.2
FIG. 92.5
FIG. 92.3
FIG. 92.6
7/12/2012 3:49:16 PM
SECTION
Enucleation, Evisceration,
andExenteration
R
302
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Dutton_Chap93.indd 303
Dermis-Fat Graft
Aguilar GL, Shannon GM, Flanagan JC. Experience with dermis-fat grafting: an analysis of early postoperative complications and methods of
prevention. Ophthal Surg. 1982;13:204209.
Bengoa-Gonzlez A, Dolores Lago-Llins M, et al. The use of autologous dermis grafts for the reconstruction of the anophthalmic socket.
Orbit. 2010;29:183189.
Guberina C, Hornblass A, Meltzer MA, et al. Autogenous dermis-fat
orbital implantation. Arch Ophthalmol. 1983;101:15861590.
Lee MJ, Khwarg SI, Choung HK, et al. Dermis-fat graft for treatment of
exposed porous polyethylene implants in pediatric postenucleation
retinoblastoma patients. Am J Ophthalmol. 2011;152:244250.
Lisman RD, Smith BC. Dermis-fat grafting. In: Smith BC, Delia Rocca RC,
Nesi FA, Lisman RD, eds. Ophthalmic Plastic Reconstructive Surgery.
St. Louis, MO: Mosby-Year Book; 1987.
7/16/2012 9:33:08 AM
Evisceration
Berens C, Breakey AS. Evisceration utilizing an intrascleral implant. Br J
Ophthalmol. 1960;44:665671.
Bernardino CR. Evisceration vs. enucleation. Ophthalmology. 2007;114:
1959.
Brown SM. Evisceration of blind, painful eyes with occult uveal melanoma
not a crime. Arch Ophthalmol. 2009;127:12281229.
Eagle RC Jr, Grossniklaus HE, Syed N, et al. Inadvertent evisceration of eyes
containing uveal melanoma. Arch Ophthalmol. 2009;127:141145.
Georgescu D, Vagefi MR, Yang CC, et al. Evisceration with equatorial sclerotomy for phthisis bulbi and microphthalmos. Ophthal Plast Reconstr Surg. 2010;26:165167.
Goisis M, Guareschi M, Miglior S, Giann AB. Evisceration vs. enucleation. Ophthalmology. 2007;114:1960.
Green WR, Maumenee AE, Sanders TE, Smith ME. Sympathetic uveitis following evisceration. Trans Am Acad Ophthalmol Otolaryngol.
1972;76:625644.
Huang D, Yu Y, Lu R, et al. A modified evisceration technique with scleral
quadrisection and porous polyethylene implantation. Am J Ophthalmol. 2009;147:924928.
Jordan DR, Khouri LM. Evisceration with posterior sclerotomies. Can J
Ophthalmol. 2001;36:404407.
Kostick DA, Linberg JV. Evisceration with hydroxyapatite implant.
Surgical technique and review of 31 case reports. Ophthalmology.
1995;102:15421548.
Massry GG, Holds JB. Evisceration with scleral modification. Ophthal
Plast Reconstr Surg. 2001;17:4247.
Park YG, Paik JS, Yang SW. The results of evisceration with primary
porous implant placement in patients with endophthalmitis. Korean
J Ophthalmol. 2010;24:279283.
Perry JD, Lewis CD, Levine M. Evisceration after complete evaluation; an
acceptable option. Arch Ophthalmol. 2009;127:12271228.
Ruedemann AD Jr. Sympathetic ophthalmia after evisceration. Trans Am
Ophthalmol Soc. 1963;61:274314.
Sales-Sanz M, Sanz-Lopez A. Four-Petal evisceration: an new technique.
Ophthal Plast Reconstr Surg. 2007;23:389392.
Tawfik HA, Budin H. Evisceration with primary implant placement in
patients with endophthalmitis. Ophthalmology. 2007;114:11001103.
Tawfik HA, Dutton JJ. Primary peg placement in evisceration with the
spherical porous polyethylene orbital implant. Ophthalmology.
2004;111:14011406.
Exenteration
Ben Simon GJ, Schwarcz RM, Douglas R, et al. Orbital exenteration: one
size does not fit all. Am J Ophthalmol. 2005;139:1117.
Coston TO, Small RG. Orbital exenteration simplified. Trans Am
Ophthalmol Soc. 1981;79:136152.
Dutton_Chap93.indd 304
Gass JDM. Technique of orbital exenteration utilizing methylmethacrylate implant. Arch Ophthalmol. 1969;82:789791.
Goldberg RA, Kim JW, Shorr N. Orbital exenteration: results of an individualized approach. Ophthal Plast Reconstr Surg. 2003;19:229236.
Levin PS, Dutton JJ. A 20-year series of orbital exenteration. Am J Ophthalmol. 1991;112:496501.
Mohr C, Esser J. Orbital exenteration: surgical and reconstructive strategies. Graefes Arch Clin Exp Ophthalmol. 1997;235:288295.
Nemet AY, Martin P, Benger R, et al. Orbital exenteration: a 15-year study
of 38 cases. Ophthal Plast Reconstr Surg. 2007;23:468472.
Rahman I, Cook AE, Leatherbarrow B. Orbital exenteration: a 13 year
Manchester experience. Br J Ophthalmol. 2005;89:13351340.
Rathbun JE, Beard C, Quickert MH. Evaluation of 48 cases of orbital exenteration. Am J Ophthalmol. 1971;72:197199.
Spaeth EB. Information learned from fifty years of orbital exenteration.
Trans Ophthalmol Soc UK. 1971;91:611634.
Tyers AG. Orbital exenteration for invasive skin tumours. Eye. 2006;20:
11651170.
Yeatts RP. The esthetics of orbital exenteration. Am J Ophthalmol. 2005;139:
152153.
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93
INDICATIONS: Removal of the eye for chronic pain, traumatic disruption, endophthalmitis, intraocular malignancy, or
cosmetic improvement of a blind, disfigured eye.
FIG. 93.8. Pass the two arms of the lateral rectus muscle
suture through anterior Tenons capsule 5 mm from the
lateral canthal angle and tie the ends on the conjunctival
surface. In similar fashion, suture the medial rectus muscle to
Tenons capsule.
306
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Dutton_Chap93.indd 307
FIG. 93.1
FIG. 93.5
FIG. 93.2
FIG. 93.6
FIG. 93.3
FIG. 93.7
FIG. 93.4
FIG. 93.8
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Dutton_Chap93.indd 309
FIG. 93.9
FIG. 93.13
FIG. 93.10
FIG. 93.14
FIG. 93.11
FIG. 93.15
FIG. 93.12
FIG. 93.16
7/16/2012 9:33:15 AM
94
INDICATIONS: As a primary ocular implant following enucleation or evisceration, or as a secondary implant when
improved prosthetic mobility is desired. Also, following multiple extrusions where stabilization of the implant is necessary.
310
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Dutton_Chap94.indd 311
FIG. 94.1
FIG. 94.5
FIG. 94.2
FIG. 94.6
FIG. 94.3
FIG. 94.7
FIG. 94.4
FIG. 94.8
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95
INDICATIONS: As a primary ocular implant following enucleation especially in children, or as a secondary implant after
implant exposure with partial loss of conjunctiva and Tenons capsule.
FIG. 95.5. Cut around the exposed dermis with a scalpel and
extend the cut through the underlying fat to the level of the
muscular fascia.
FIG. 95.6. Transfer the graft to the recipient orbit. Pass both
arms of the preplaced 6-0 Vicryl suture on the medial rectus
muscle through one edge of the dermis plug and tie it down.
Suture the conjunctiva and Tenons adjacent to the muscle to
the dermis graft with interrupted stitches of 6-0 Vicryl.
FIG. 95.7. Continue placing sutures around the graft
perimeter inferiorly and superiorly, gently pushing the fat
into the orbit as you go. As each rectus muscle is approached,
suture it to the dermis plug. If muscle were not retrieved, just
suture the graft to Tenons. Before closing the lateral quadrant,
if the graft volume appears too large, excise some of the fat.
FIG. 95.4. With a scalpel blade, incise the skin along the
marked line. Dissect the epidermis from underlining dermis
with a scalpel blade or scissors.
POTENTIAL COMPLICATIONS:
Graft failureTotal graft failure is uncommon but
may be seen where vascular supply is compromised
such as after irradiation or in cases of severe socket
contracture.
312
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FIG. 95.1
FIG. 95.5
FIG. 95.2
FIG. 95.6
FIG. 95.3
FIG. 95.7
FIG. 95.4
FIG. 95.8
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96
INDICATIONS: Exposure of an ocular implant after enucleation or evisceration without significant loss of Tenons
capsule or conjunctiva.
314
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FIG. 96.1
FIG. 96.5
FIG. 96.2
FIG. 96.6
FIG. 96.3
FIG. 96.7
FIG. 96.4
FIG. 96.8
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97
Evisceration
INDICATIONS: For removal of a blind painful, or cosmetically undesirable eye from trauma, end-stage disease, or
endophthalmitis.
FIG. 97.5. Cauterize the central retinal artery and the vortex
veins. Use a suction catheter for visualization.
FIG. 97.6. Scrub the inside of the scleral shell with
cotton-tipped applicators soaked in 100% alcohol to
remove all traces of uvea. Irrigate the shell copiously several
times with saline solution.
can be resected or the eviscerated shell can be enucleated and a secondary ocular implant placed.
Sympathetic ophthalmiaThe true incidence of this
disease with modern evisceration techniques remains
unknown but is exceedingly rare and may not be much
higher than with enucleation. However, evisceration
should be undertaken only with informed consent after
penetrating injuries with uveal prolapse. Treatment of
sympathetic ophthalmia is medical, with use of systemic
steroids.
POTENTIAL COMPLICATIONS:
Wound dehiscenceAs with enucleation, this results
most commonly from poor wound closure or the
placement of too large an implant. Early dehiscence
is repaired immediately, replacing the implant with a
smaller size if necessary.
Chronic painThis may be seen after evisceration with
retention of the cornea. When intractable, the cornea
316
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Dutton_Chap97.indd 317
FIG. 97.1
FIG. 97.5
FIG. 97.2
FIG. 97.6
FIG. 97.3
FIG. 97.7
FIG. 97.4
FIG. 97.8
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98
Orbital Exenteration
INDICATIONS: Removal of the orbital contents for control of ocular and adnexal malignancies, for eradication of uncontrolled Mucor orbital cellulitis, for severe orbital contracture, for painful infiltrative benign orbital lesions, or for congenital deformities.
FIG. 98.1. Mark an incision line around the orbit just inside
the orbital rim. If necessary because of tumor extension in the
skin, mark the line outside this limit to allow at least 5 mm of
normal tissue beyond the tumor edges. Cut through the skin
and muscle with a scalpel blade or cautery needle.
FIG. 98.2. Dissect beneath the orbicularis muscle to the
orbital rim. Incise periosteum along the rim. At the medial
and lateral rims, disinsert the canthal ligaments from their
attachments to bone.
FIG. 98.3. Separate periorbita from the orbital walls with a
Freer elevator. Firm attachments will be encountered at the
trochlea and along the superior and inferior orbital ssures.
Transect the lacrimal duct as it enters the lacrimal canal just
inside the inferomedial orbital rim. If the tumor involves the
lacrimal sac and duct, remove the anterior wall of the canal
with rongeurs and transect the duct at its entrance into the
nose.
FIG. 98.4. Pass enucleation scissors medially around the
orbital tissues to the apex. Transect the tissues and remove
the specimen. Alternatively, a wire snare allows clean separation of the orbital contents closer to the apex.
FIG. 98.5. Pack the orbit with gauze sponges soaked with
epinephrine and apply pressure for 10 minutes. Remove the
sponges and cauterize any residual bleeding vessels. Perforating
vessels through the orbital bones are controlled with bone wax.
FIG. 98.6. Harvest a split-thickness skin graft from the
upper, outer quadrant of the thigh with a dermatome. Place
the graft in the orbit and trim excess skin from the wound
margins. If the graft was not meshed, excise the dog-ear aps
that develop when the graft is folded into the orbital concavity.
FIG. 98.7. Suture the graft to skin at the orbital rim with
interrupted and running 6-0 Vicryl stiches.
FIG. 98.8. Lay multiple 2-inch strips of Telfa or nonadherent
gauze to cover the graft and overlap the orbital rim. Pack
the orbit rmly with cotton balls soaked to dripping in saline
solution that contains gentamicin. Press the cotton into the
cavity to mould it into the crevices, while removing all excess
saline solution with suction. Cover the wound with a rm
dressing.
318
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Dutton_Chap98.indd 319
FIG. 98.1
FIG. 98.5
FIG. 98.2
FIG. 98.6
FIG. 98.3
FIG. 98.7
FIG. 98.4
FIG. 98.8
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Index
Note: Page numbers in Italics denote figures
A
Abducens nerve, 254, 264267, 265, 267
Abrasion, corneal (see Corneal abrasion)
Abscesses, orbital, 248
Acquired entropion, 123
Advancement
levator aponeurotic for ptosis, 81, 8891, 89, 91
myocutaneous, free tarsoconjunctival graft for
lower eyelid reconstruction, 190, 191
myocutaneous for superficial non-marginal
eyelid defects, 158
single bridged, of lower eyelid, for upper
eyelid reconstruction, 182, 183
tarsoconjunctival, upper to lower eyelid,
192195, 193, 195
Y to V, for reduction of epicanthal folds, 198,199
Advancement flap, 162, 163
double bridged, of lower eyelid, for upper
eyelid reconstruction, 184, 185
Adynamic brow, as complication of direct brow
lift, 72
A-frame Mllers muscle aponeurectomy, 81
Agger nasi cells, 216
Alloplastic ocular implant, in enucleation, 303,
306309, 307, 309
Alopecia, as complication of endoscopic forehead lift, 78
Ampulla, 216, 218219, 218
Anesthesia
for brow elevation, 72, 73
for enucleation, 72, 73, 302
forehead, as complication of transblepharoplasty endotine brow fixation, 74
infraorbital nerve, as complication of orbital
decompression, 288
inhalation, 5
in ophthalmic plastic surgery, 45
retrobulbar, 4
scalp
as complication of endoscopic forehead
lift, 78
as complication of transblepharoplasty
endotine brow fixation, 74
supraorbital as complication of direct brow
lift, 72
Anesthetic agent, choice of, 4
Angle, canthal (see Canthal angle)
Angular artery, 8, 14, 15
Angular vein, 14, 15, 264, 265
Annulus of Zinn, 254, 260, 261
Antibiotics for hordeolum, 25
Aponeurosis, levator, 260, 261
horn of, 12, 13
recession of, with Mllers muscle extirpation, 150153, 151, 153
Aponeurotic advancement/levator, for ptosis,
81, 8891, 89, 91
Aponeurotic ptosis, 80
Arcus marginalis, 7
Arterial arcades, 9
Artery(ies)
angular, 8, 14, 15
carotid, 268, 269
internal, 262, 263
ciliary, 262, 263, 268, 269
ethmoidal, 262, 263, 268, 269
facial, 9, 14, 15
infraorbital, 14, 15, 262, 263
infratrochlear, 262, 263
lacrimal, 14, 15, 254, 262, 263, 266269,
267, 269
maxillary, 262, 263
nasal, 262, 263, 268, 269
nasofrontal, 262, 263, 268, 269
ophthalmic, 8, 254, 262265, 263, 265
palpebral, 14, 15, 217, 262, 263, 268, 269
retinal, central, 254, 262, 263
supraorbital, 262, 263, 266269, 267, 269
supratrochlear, 14, 15
temporal superficial, 9
zygomaticofacial, 14, 15, 260, 261, 268, 269
zygomaticotemporal, 254
Asian upper eyelid blepharoplasty, 46, 47
Aspirin, use before ophthalmic surgery, 1
Asymmetry
as complication of direct brow lift, 72
as complication of transconjunctival excision
of herniated orbital fat,68
eyelid crease
as complication of aponeurotic advancement, 90
as complication of Asian upper eyelid
blepharoplasty, 46
as complication of upper eyelid blepharoplasty with fat excision,44
Augmentation canthoplasty, lateral, 202,203
Augmentation of orbital volume subperiosteal,
300, 301
Autogenous fascia lata
frontalis muscle suspension with, 98101,
99, 101
harvesting, 96, 97
B
Balloon dacryoplasty, nasolacrimal system,
236, 237
Biointegrated porous ocular implant, with
enucleation, 310, 311
Bleeding, nasal
as complication of dacryocystorhinostomy, 240
as complication of nasolacrimal system
probing, 232
as complication of orbital decompression, 288
Blepharoplasty
cosmetic, 3869
etiology and associated deformities, 40, 41
lower eyelid
with canthopexy, 5255, 53, 55
with eyelid shortening, 6063, 61, 63
with fat excision, 5255, 53, 55
with fat redraping, 5659, 57, 59
upper eyelid
Asian upper eyelid, 46, 47
with fat excision, 4245, 43, 45
refixation of prolapsed lacrimal gland, 48, 49
Blepharoptosis, 80103
external levator aponeurosis advancement,
8891, 89, 91
frontalis muscle suspension with autogenous
fascia lata, 98101, 99, 101
frontalis muscle suspension with silicone rod,
102, 103
harvesting autogenous fascia late, 96, 97
posterior Mllers muscle-conjunctival resection, 86, 87
posterior tarsoconjunctival resection, 84, 85
Supra-Whitnalls ligament levator muscle
resection, 9295, 93, 95
Blepharotomy, horizontal, with marginal rotation, 142, 143
Blindness (see Vision, loss of )
Block(s)
nerve, orbital, for ophthalmic surgery, 5
retrotarsal, for ophthalmic surgery, 5
subcutaneous, pretarsal for ophthalmic
surgery, 5
Blow-out fractures of orbit, 306
Bone
ethmoid, 253, 256259, 257, 259
frontal, 218, 219, 253, 256259, 257, 259
lacrimal, 218, 219, 253, 256, 257
maxillary, 218, 219, 252, 253, 256259,
257,259
nasal, 218, 219, 256, 257
palatine, 252
sphenoid, 256, 257
temporal, 256, 257
zygomatic, 252, 256259, 257, 259
Bony orbit, 252
Bridged advancement flap
double bridged, of lower eyelid, for upper
eyelid reconstruction, 184,185
lower eyelid single, for upper eyelid reconstruction, 182, 183
Brow
adynamic, as complication of direct brow
lift, 72
contour defects, as complication of posterior
tarsoconjunctival resection, 84
Brow contour, poor, as complication of direct
brow lift, 72
321
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322 Index
Brow elevation
direct, 70, 72, 73
endoscopic forehead elevation, 7679, 77, 79
transblepharoplasty endotine fixation, 74, 75
Brow fixation, endotine, 74, 75
Brow ptosis, 7079 see also Brow elevation and
Brow fixation
causes of, 70
correction of, 70
Buccal branch of the facial nerve, 16, 17
Bulbar conjunctiva, 22, 23
Bulging of medial fat pocket, 40, 41
C
Canalicular injury
as complication of medial spindle tarsoconjunctival resection, 110
as complication of modified Lazy-T procedure, 114
Canalicular occlusion as complication of medial
canthal ligament plication, 116
Canalicular slitting, as complication of canalicular reconstruction, 228
Canaliculodacryocystorhinostomy, 220, 242,243
Canaliculus
common, 216, 218, 219
lacerations, repair of, 224227, 225, 227
lacrimal puncta and surgery on, 220229
obstruction of, 220
reconstruction of, 228, 229
slitting of
as complication of nasolacrimal system
balloon dacryoplasty, 236
as complication of nasolacrimal system probing with silicone intubation stents, 234
erosion of lacrimal puncta as complication
of canalicular repair, 226
stenosis of, 220
as complication of canalicular reconstruction, 228
at laceration site as complication of
repair,226
superior, 218, 219
Canthal angle
lateral, dystopia of
as complication of lateral tarsal strip
fixation, 108
as complication of SMAS midface
elevation and fixation, 156
as complication of temporal fascia lower
eyelid suspension, 118
lateral, ectropion of
as complication of retractor reinsertion and
lateral tarsal strip eyelid fixation, 136
as complication of temporal fascia lower
eyelid suspension, 118
elevation of, as complication of retractor
reinsertion with lateral tarsal strip
eyelid fixation, 136
rounded, as complication of lower eyelid
blepharoplasty, 54
medial, 10, 11
rounded, as complication of retractor reinsertion with lateral tarsal strip eyelid
fixation, 136
vertical dystopia correction of, 206, 207
Canthal angle dystopia, 66
Canthal ligament
lateral, 202
Dutton_Index.indd 322
medial
crus of, 218, 219
plication, 116, 117
Canthoplasty
augmentation, lateral, 202, 203
reduction, lateral, 204, 205
Canthus
lateral
reconstruction, 196211
trichiasis at, as complication of lateral
tarsal strip fixation, 108
medial, reconstruction, 196211
Capsulopalpebral fascia, 78, 253
Carotid artery, internal, 262, 263, 268, 269
Cartilage graft, posterior lamellar lengthening
with, 144, 145
Caruncle, 10, 11
Cavernous sinus, 260, 261, 264, 265
Cells
agger nasi, 216
ethmoid sinus, 258, 259
Central orbital space, 270
Central retinal artery, 254, 262, 263
Central retinal vein, 264, 265, 268, 269
Cerebrospinal fluid leak, as complication of
orbital decompression, 288
Cerebrum, 258, 259
Cervical nodes, 18, 19
Chalazion, 25
hordeolum and, 2529
incision and drainage of
transconjunctival approach to, 28, 29
transcutaneous approach to, 2627
recurrence of following incision and drainage
procedures, 26
Check ligaments, 253
Chronic pain, as complication of evisceration,
316
Cicatricial ectropion, 104 (see also Ectropion)
as complication of Z-plasty transpositional
flaps, 170
Cilia
loss of, complicating incision and drainage of
chalazion, 26, 28
marginal, superior, 10, 11
Ciliary artery, 262, 263, 268, 269
Ciliary ganglion, 262, 263, 266, 267
Ciliary nerve, 262, 263, 266, 267
Closure
direct of elliptical defect, simple, 160,161
layered, direct, of marginal defects of upper
eyelid, 174, 175
of soft-tissue opening as complication of lost
Jones tube, 244
Cocaine, use of, 220
Common canaliculus, 216, 218, 219
Computerized tomography of orbit, 246
Congenital ectropion syndrome, 204
Congenital nasolacrimal duct obstruction, 230
Conjunctiva, 8
bulbar, 22, 23
lymphatic vessels, 9
palpebral, 22, 23
prolapse of, as complication of supra-Whitnalls levator muscle resection, 94
Conjunctival fornix, 20, 21
Conjunctival hypertrophy of eyelid margin as
complication of tarsoconjunctival
advancement flap, 194
D
Dacryocystorhinostomy, 230, 238241, 239,
241
Dacryoliths, 230
Decompression, orbital
inadequate, as complication of orbital
decompression, 288
inferior and medial walls, 284288, 285,287
Dehiscence, wound
as complication of evisceration, 316
as complication of lateral semicircular rotational flap, 176
as complication of retractor reinsertion with
eyelid shortening, 134
Delayed healing, as complication of orbital
exenteration, 318
Depigmentation as complication of cryosurgery, 32
Dermatochalasis of upper eyelid, 40, 41
Dermis-fat orbital implant graft, 312, 313
7/12/2012 4:02:54 PM
Index 323
Diplopia
as complication of orbital decompression,
288
as complication of anterior orbitotomy, 272
Direct brow lift, 70, 72, 73
Direct closure of elliptical defect, simple,
160, 161
Direct layered closure of marginal defects of
upper eyelid, 174, 175
Disc, optic, 258, 259
Disinsertion of lower eyelid retractor, with
scleral graft, 154, 155
Displacement of implant as complication of
enucleation with primary alloplastic
implant, 308
Distichiasis, 30
electrohyfrecation for, 30
trichiasis and, 3037
Donor eyelid
retraction of, as complication of posterior
lamellar lengthening with free tarsoconjunctival, 144
upper, lagophthalmos of, as complication of
anterior lamellar lengthening with
skin graft, 120
Donor site, granulation over growth as complication of posterior lamellar lengthening with free tarsoconjunctival, 144
Double bridged advancement flap, lower eyelid,
for upper eyelid reconstruction, 184,
185
Drainage, incision and, of chalazion
transconjunctival approach to, 28, 29
transcutaneous approach to, 2627
Duct, lacrimal
membranous, 217, 218, 219
surgery on, 213245
Dye disappearance test, 213
Dystopia, canthal angle
lateral
as complication of lateral tarsal strip fixation, 108
as complication of temporal fascia lower
eyelid suspension, 118
vertical correction of, 206, 207
E
Echography of orbit, 247, 248
Ectropion, 104121
causes of, 104
cicatricial, 104
as complication of Z-plasty transpositional
flaps, 170
as complication of free tarsoconjunctival
graft and myocutaneous advancement
flap, 190
as complication of frontalis muscle suspension
with autogenous fascia lata, 102
with silicone rod, 102
as complication of temporal fascia lower
eyelid suspension, 118
congenital, 204
involutional, 104
lateral canthal angle
as complication of retractor reinsertion with
lateral tarsal strip eyelid fixation, 136
as complication of temporal fascia lower
eyelid suspension, 118
Dutton_Index.indd 323
mechanical, 104
paralytic, 104
persistent or recurrent, as complication of
anterior lamellar lengthening with
skin graft, 120
residual lower eyelid, as complication of
SMAS midface elevation, 156
Edema
eyelid
as complication of cryosugery for trichiasis, 32
as complication of transcutaneous transperiosteal anterior orbitotomy, 274
persistent, as complication of lower eyelid
double bridged advancement flap, 184
single bridged advancement flap, 182
Electrohyfrecation for trichiasis and distichiasis, 30
Elevation of lateral canthal angle as complication of retractor reinsertion with
lateral tarsal strip eyelid fixation, 136
Elliptical defect, simple direct closure of, 160, 161
Endoscopic forehead elevation, 7679, 77, 79
Endotine
brow fixation, 74, 75
palpable
as complication of endoscopic forehead
lift, 78
as complication of transblepharoplasty
endotine brow fixation, 74
Enophthalmos
as complication of enucleation, 308
and subperiosteal orbital volume augmentation, 300, 301
Entropion, 123147
acquired, 123
cicatricial, 124
classification of, 123
congenital, 123
involutional, 123
marginal, as complication of horizontal tarsoconjunctival transposition flap, 178
mechanical, 123
overcorrection of
as complication of anterior lamellar shortening with epitarsal fixation, 138
as complication of full-thickness eyelid
sutures, 126
as complication of horizontal blepharotomy with marginal rotation, 142
recurrence of
as complication of full-thickness eyelid
sutures, 126
as complication of lower eyelid retractor
reinsertion, 132
spastic chronic, 123
undercorrection of
as complication of anterior lamellar shortening with epitarsal fixation, 138
as complication of marginal rotation by
anterior horizontal tarsal groove
resection, 140
Enucleation, 302319
with biointegrated porous ocular implant,
310, 311
with dermis-fat graft, 312, 313
with primary acrylic or silicone implant,
306309, 307, 309
Epiblepharon
acquired, 123
as complication of lower eyelid retractor
reinsertion, 132
correction of, lower eyelid crease reformation
for, 130, 131
induced, 7
lower eyelid, as complication of anterior
orbitotomy, 272
repair of, modified full-thickness eyelid
sutures for, 128, 129
Epicanthal folds, reduction of, 198, 199, 200, 201
Epinephrine
lidocaine with, for ophthalmic surgery, 5
systemic effects of, 5
Epiphora
persistent, as complication of dacryocystorhinostomy, 240
recurrent, as complication of nasolacrimal
system probing, 232
surgery to correct, 220
Epitarsal fixation, anterior lamellar shortening
with epitarsal fixation, 138, 139
Erosion, of lacrimal puncta
and canaliculus slitting as complication of
canalicular repair, 226
as complication of nasolacrimal system
balloon dacryoplasty, punctal, 236
probing with silicone intubation stents, 234
Ethmoid bone, 252, 256, 257, 258, 259
Ethmoid foramina, 252, 256, 257
Ethmoid sinus cells, 258, 259
Ethmoidal artery, 262, 263, 268, 269
Ethmoidal nerve, 262, 263, 266, 267
Ethmoidal vein, 264, 265, 268, 269
Euryblepharon, interpalpebral fissure, 204
Evisceration, 316, 317
enucleation and exenteration, 302319
Excision
of excess eyelid skin, 38
of fat
lower eyelid blepharoplasty, 5255, 53, 55
upper eyelid blepharoplasty, 4245, 43, 45
of lash bulbs, internal, 32
transconjunctival, of herniated lower eyelid
orbital fat, 68, 69
Exenteration
enucleation and evisceration, 302319
orbital, 318, 319
Exposed ocular implant, repair of, 314,315
External tarsoaponeurectomy, 81
Extirpation, Mllers muscle, levator aponeurosis recession with, 150153, 151, 153
Extraconal orbital fat, 258, 259
Extraconal space, 270
Extraocular muscle(s), 253, 254, 270
anatomy, 258265, 259, 261, 263, 265
congenital fibrosis, 80
paresis of, as complication of anterior orbitotomy, 274
Extrusion of ocular implant
as complication of enucleation with primary
acrylic or silicone implant, 308
as complication of subperiosteal orbitalvolume augmentation contents, 300
Eyebrow (see Brow)
Eyelash bulb
internal resection, 36, 37
internal excision of, 32
7/12/2012 4:02:54 PM
324 Index
Eyelid
anatomy, 724, 11, 13, 15, 17, 19, 2123
arterial supply to, 89, 14, 15
contour of, poor
as complication of frontalis muscle suspension with autogenous fascia lata, 100
as complication of lateral semicircular
rotational flap, 176
as complication of levator aponeurosis
recession with Mllers muscle extirpation, 152
as complication of levator aponeurotic
advancement, 90
as complication of supra-Whitnalls, levator muscle resection, 94
defects of, non marginal superficial, repair of,
158171
donor
retraction of, as complication of posterior
lamellar lengthening with graft, 144
edema of
as complication of cryosurgery for trichiasis, 32
as complication of transcutaneous transperiosteal anterior orbitotomy, 274
excess skin of, excision of, 108
fixation of, lateral tarsal strip, retractor reinsertion with, 136, 137
lamellae of, vascular supply, 8
lateral skin redundancy of, as complication of
eyelid shortening by lateral tarsal strip
fixation, 108
laxity
as complication of free tarsoconjunctival
graft, 190
overcorrection of, as complication of
lateral tarsal strip fixation, 108
persistent as complication of lateral tarsal
strip fixation, 108, 109
lower (see Lower eyelid)
lymphatic vessels, 9, 18, 19
margin of
conjunctival hypertrophy, as complication
of upper to lower eyelid tarsoconjunctival advancement flap, 194
distortion of, as complication of electrohyfrecation for trichiasis, 30
notching of, as complication of lower
eyelid blepharoplasty combined with
eyelid shortening, 62
necrosis of, as complication of cryosugery for
trichiasis, 32
normal position of, 7
notching of
as complication of direct layered closure of
marginal defects, 174
as complication of incision and drainage of
chalazion, 26, 28
overcorrection of
as complication of levator aponeurosis
recession with Mllers muscle extirpation, 152
as complication of lower eyelid retractor
disinsertion with scleral graft, 154
periorbital structures, external anatomy, 10, 11
persistent eyelid fullness, as complication of
refixation of lacrimal gland prolapse, 48
ptosis of, as complication of anterior orbitotomy, 274
Dutton_Index.indd 324
retraction of
as complication of free tarsoconjunctival
graft, 180
as complication of horizontal tarsoconjunctival transposition flap, 178
as complication of lower eyelid double
bridged advancement flap, 184
as complication of lower eyelid retractor
reinsertion, 132
as complication of lower eyelid single
bridged advancement flap, 182
correction of, 148157
lower eyelid recession with Mllers
muscle extirpation, 150153, 151,
153
lower eyelid retractor disinsertion with
scleral graft, 154, 155
SMAS midface elevation, 156, 157
shortening of
horizontal full-thickness, retractor reinsertion with, 134, 135
by lateral tarsal strip fixation, 108, 109
lower eyelid blepharoplasty with canthopexy, 6467, 65, 67
lower eyelid blepharoplasty with, 6063,
61, 63
skin of
residual redundant, as complication of
upper eyelid blepharoplasty with fat
excision, 44
undercorrection of
as complication of anterior lamellar shortening with epitarsal fixation, 138
as complication of levator aponeurosis
recession with Muellers muscle extirpation, 152
as complication of lower eyelid retractor
disinsertion with scleral graft, 154
vascular supply to, 89, 14, 15
venous supply to, 9, 14, 15
Eyelid crease, 10, 11
asymmetric
as complication of Asian upper eyelid
blepharoplasty, 46
as complication of upper eyelid blepharoplasty with fat excision, 44
fixation of, after cosmetic blepharoplasty,
38
inferior, 10, 11
irregular
as complication of anterior lamellar shortening with epitarsal fixation, 138
as complication of Asian upper eyelid
blepharoplasty, 44
lower, reformation of, for epiblepharon correction, 130, 131
poor, as complication of supra-Whitnalls,
levator muscle resection, 94
upper, 7
reformation of, 50, 51
Eyelid margin notch
as complication of full-thickness marginal
wedge resection, 112
as complication of modified Lazy-T procedure, 114
Eyelid margin scarring, 36
Eyelid sutures, full-thickness, 126, 127
modified, for epiblepharon repair,
128,129
F
Face, numbness of, as complication of orbital
exenteration, 318
Facial and orbicularis oculi muscles, superficial,
10, 11
Facial artery, 14, 15
Facial nerve, 7
branches of, 16, 17
Facial vein, 14, 15
Fascia, capsulopalpebral, 78, 12, 13, 253
Fascia lata, autogenous
frontalis muscle suspension with, 98103,
99, 101
harvesting, 122124, 123
Fascia lower eyelid suspension, temporal, 96,
97, 119
Fascial plane, postorbicular, 7
Fascial suspension procedure for ectropion,
105, 118, 119
Fat excision
lower eyelid blepharoplasty, 5255, 53,55
upper eyelid blepharoplasty, 4245, 43,45
Fat, orbital
extraconal, 258, 259
lower eyelid, herniated, transconjunctival
excision of, 68, 69
Fat pad
inferior, 12, 13
orbital, precapsulopalpebral, 22, 23
preaponeurotic, 7,
orbital septum and, 12, 13
precapsulopalpebral, 7, 22, 23
superior, 12, 13
Fat pocket, medial, bulging of, 40, 41
Fat redraping, lower eyelid blepharoplasty with,
5255, 53, 55
Fissure(s)
inferior orbital, 252255, 257
interpalpebral, 7, 204
palpebral, dislocation of tubing into, as complication of nasolacrimal system
balloon dacryoplasty, 236
probing with silicone intubation stents, 234
superior orbital, 252255, 257
Fistula, sinus-orbital, as complication of orbital
exenteration, 318
Fixation
epitarsal, anterior lamellar shortening with,
138, 139
eyelid, lateral tarsal strip, retractor reinsertion with, 136, 137
frontalis muscle, with autogenous fascia lata,
98100, 99, 101
lateral tarsal strip, eyelid shortening, 108, 109
orbital rim fracture, miniplate of, 298, 299
periosteal, lateral semicircular rotation flap,
188, 189
Flap
advancement (see Advancement flap)
rhombic, 168, 169
rotational
lateral semicircular, for upper eyelid reconstruction, 176, 177
myocutaneous, 164, 165
skin, for repair of superficial non-marginal
eyelid defects, 158171
transposition
horizontal tarsoconjunctival, for upper
eyelid reconstruction, 178, 179
7/12/2012 4:02:54 PM
Index 325
median forehead, necrosis, 210, 211
myocutaneous, 166, 167
Z-plasty, 170, 171
Fold(s)
epicanthal, reduction of, 198, 199, 201
malar, 10, 11
nasojugal, 10, 11
Foramen(ina)
ethmoidal, 252, 256, 257
infraorbital, 256, 257
pterygopalatine, 256, 257
rotundum, 256, 257
Forehead lift
endoscopic, 7678, 77, 79
temporal, 70
Forehead transposition flap, median, 210, 211
necrosis of, 210
Fornix(ces)
conjunctival, 20, 21, 174, 175
inferior, suspensory ligament of, 7, 22, 23
lacrimal, 216
lacrimal sac, 256, 257
shallow
as complication of enucleation with primary acrylic or silicone implant, 308
as complication of repair of exposed ocular
implant, 314
superior, suspensory ligament of, 8, 2023,
21, 23
Four-flap technique for reduction of epicanthal
folds, 200, 201
Fractures
miniplate fixation for orbital rim, 298,299
orbital, 281
blow-out, 252
repair of, orbital floor, 296, 297
Free tarsoconjunctival graft
and myocutaneous advancement flap for
lower eyelid reconstruction, 190, 191
for posterior lamellar lengthening with, 144,
145
for upper eyelid reconstruction, 180,181
Frontal bone, 218, 219, 252, 256, 257, 258, 259
Frontal nerve, 266, 267
Frontal nerve block for ophthalmic surgery, 5
Frontal vein, 14, 15
Frontalis muscle
suspension of, with autogenous fascia lata,
98101, 99, 101
suspension with, silicone rod, 102, 103
Frontoethmoid suture, 252
Frontozygomatic suture, 252, 256, 257
Full-thickness eyelid shortening with retractor
reinsertion with, 134,135
Full-thickness eyelid sutures
overcorrection of, 126
modified, for epiblepharon repair, 128,129
G
Ganglion
ciliary, 2, 263, 266, 267
semilunar, 260, 261, 264, 265
trigeminal, 260, 261, 264, 265
General anesthesia
for brow elevation, 72, 73
for ophthalmic surgery, 4
Glabellar, rotation flap, 208, 209
Gland
lacrimal (see Lacrimal gland)
Dutton_Index.indd 325
H
Hair growth as complication of dermis-fat
orbital implant graft, 312
Harvesting autogenous fascia lata, 96, 97
Hasner, valve of, 217, 218, 219
Healing, delayed, as complication of orbital
exenteration, 318
Hematoma
as complication of endoscopic forehead lift, 78
as complication of transblepharoplasty endotine brow fixation, 74
as complication of upper eyelid blepharoplasty with fat excision, 44
Hemorrhage, orbital
as complication of anterior orbitotomy, 274
as complication of enucleation with primary
acrylic or silicone implant, 308
as complication of horizontal blepharotomy
with marginal rotation, 142
as complication of lateral orbitotomy, 280
as complication of lower eyelid blepharoplasty with fat excision, 54
as complication of repair of exposed ocular
implant, 314
Herniated lower eyelid orbital fat, transconjunctival excision of, 68, 69
Hooding of eyelid skin, temporal, 40, 41
Hordeolum, 25
and chalazion, 2529
drainage of, 25
external treatment, 25
internal treatment, 25
Horizontal blepharotomy, with marginal rotation, 142, 143
I
Imaging, magnetic resonance, of orbit, 281
Implant, ocular (see Ocular implant)
Incision and drainage of chalazion
transconjunctival approach, 28, 29
transcutaneous approach, 26, 27
Infection
as complication of harvesting autogenous
fascia lata, 96
wound, as complication of dacryocystorhinostomy, 240
Infraorbital artery, 14, 15, 262, 263
Infraorbital canal, 252
Infraorbital foramen, 256, 257
Infraorbital groove, 252, 256, 257
Infraorbital nerve, 9, 260, 261
anesthesia of, as complication of orbital
decompression, 288
Infraorbital neuralgia as complication of orbital
decompression, 288
Infraorbital neurovascular bundle, 258,259
Infraorbital sulcus, 256, 257
Infraorbital vein, 264, 265
Infratrochlear artery, 262, 263
Infratrochlear nerve, 9, 16, 17, 254, 262265,
263, 265
Infratrochlear vein, 266269, 267, 269
Inhalation anesthesia, 5
Injury
canalicular
as complication of medial spindle tarsoconjunctival resection, 110
as complication of modified Lazy-T
procedure, 114
corneal, as complication of marginal rotation
by anterior horizontal tarsal groove
resection, 140
lacrimal gland, as complication of anterior
orbitotomy, 272
to orbit, traumatic, 248
Internal carotid artery, 262, 263
Internal resection of lash bulbs for trichiasis,
36, 37
Interpalpebral fissure, 7
euryblepharon, 204
Intraconal space, 270
Intubation stents, silicone, nasolacrimal system
probing with, 234, 235
Involutional ectropion, 104
Irregular eyelid crease(s)
as complication of anterior lamellar shortening with epitarsal fixation, 138
as complication of Asian upper eyelid blepharoplasty, 44
7/12/2012 4:02:54 PM
326 Index
Irregular eyelid crease(s) (Continued)
as complication of reformation of the upper
eyelid crease, 50
as complication of upper eyelid blepharoplasty with fat excision, 44
Irritation
conjunctival, as complication of dermis-fat
orbital implant graft, 312
corneal, as complication of canalicular reconstruction, 228
Ischemia of Z-plasty transpositional flaps,170
J
Jones I test, 213
Jones II test, 213
Jones pyrex tube
in conjunctivodacryocystorhinostomy, 244,245
L
Lacerations, canalicular, repair of, 224227,
225, 227
Lacrimal artery, 14, 15, 254, 262, 263, 266269,
267, 269
Lacrimal bone, 218, 219, 252, 256, 257
Lacrimal drainage system, 9
anatomy of, 216219, 219
surgery on, 213245
Lacrimal duct
membranous, 217219, 219
surgery on, 213, 220229
Lacrimal fossa, 216
Lacrimal gland, 12, 13, 258269, 259, 261, 263,
265, 267, 269,
injury to, as complication of anterior orbitotomy, 272
prolapse of, 38
refixation, 48, 49
Lacrimal nerve, 9, 16, 17, 260, 261, 266, 267
Lacrimal papillae, 216, 218, 219
Lacrimal puncta, 9, 216, 218, 219
and canaliculi, surgery on, 220229
erosion of
and canalicular slitting as complication of
canalicular repair, 234
as complication of nasolacrimal system
probing with silicone stents, 234
recurrent obstruction of, as complication of
dacryocystorhinostomy, 240
Lacrimal ridge, 216
Lacrimal sac, 9, 10, 11, 216219, 219
surgery on, 213245
Lacrimal sac fossa, 256, 257, 262, 263
Lacrimal vein, 266269, 267, 269
Lagophthalmos
as complication of Asian upper eyelid blepharoplasty, 46
as complication of frontalis muscle suspension
with autogenous fascia lata, 100
with silicone rod, 102
as complication of levator aponeurotic
advancement, 90
as complication of anterior orbitotomy, 272
of donor upper eyelid as complication of
anterior lamellar lengthening with
skin graft, 120
Lamellar lengthening
anterior, with skin graft, 120, 121
posterior
with free tarsoconjunctival, 144, 145
Dutton_Index.indd 326
M
Maier, sinus of, 216
Malar fold(s), 10, 11
Marginal arterial arcades, 9, 14, 15
Marginal cilia, superficial, 10, 11
Marginal defects of upper eyelid, direct layered
closure of, 174, 175
Marginal entropion as complication of horizontal tarsoconjunctival transposition
flap, 178
Marginal rotation
by anterior horizontal tarsal groove resection, 140, 141
horizontal blepharotomy with, 142, 143
Marginal wedge resection, full-thickness,
112,113
Maxillary artery, 262, 263
Maxillary bone, 218, 219, 252, 256259,
257,259
Maxillary division of the trigeminal nerve,9
Maxillary sinus, 256259, 257, 259
Meatus, nasal, inferior, 218, 219
Mechanical ectropion, 104 (see also Ectropion)
Mechanical ptosis, 81
Medial canthal ligament plication, 116, 117
Median forehead transposition flap, 210,211
Meibomian gland, chronic obstruction complicating incision and drainage of
chalazion, 28
Membrane, mucous, graft of, posterior lamellar
lengthening with, 146,147
Membranous lacrimal duct, 217219, 219
Middle turbinate, 218, 219
Midface elevation and fixation of SMAS, 156,157
Midforehead lift, 70
Migration of floor implant as complication of
orbital floor fractures repair, 296
Modified full-thickness eyelid sutures for epiblepharon repair, 128, 129
Modified Lazy-T procedure for ectropion,
114, 115
Motility, ocular, restriction of, as complication
of repair of orbital floor fractures, 296
Motor innervation to the eyelid protractors,
16, 17
Mucous membrane graft, posterior lamellar
lengthening with, 146, 147
Mllers muscle, 8, 2123
aponeurectomy, A-frame, 81
conjunctival resection, 81, 86, 87
extirpation of, levator aponeurosis recession
with, 150153, 151, 153
Muscle(s)
corrugator supercilii, 10, 11
7/12/2012 4:02:54 PM
Index 327
extraocular, 253, 254, 270
paresis of, as complication of anterior
orbitotomy, 274
facial and orbicularis oculi, superficial, 10, 11
frontalis, 10, 11, 16, 17
suspension of, with autogenous fascia lata,
98101, 99, 101
suspension with, silicone rod, 102, 103
Horners, 7, 10, 11
lamella, 205
levator palpebrae superioris, 8, 253255,
258261, 259, 261, 264, 265
resection for ptosis, 8182
Mllers, 8, 2223
Mllers, extirpation of, levator aponeurosis
recession with, 150153, 151, 153
oblique, 253255, 258265, 259, 261, 263,
265
orbicularis, 9, 16, 17, 204, 205
orbicularis oculi, medial canthal insertions
of, 10, 11
procerus, 10, 11
rectus (see Rectus muscle(s)
of Riolan, 9, 10, 11
sympathetic smooth, muscle of Mller, 8, 22,
2223, 150153, 151, 153
Muscle sheath of levator palpebrae superioris
muscle, 8
Myocutaneous advancement flap, 162, 163
and free tarsoconjunctival graft, 190,191
Myocutaneous rotational flap, 164, 165
Myocutaneous transposition flap, 166, 167
Myogenic ptosis, 80
N
Nasal artery, 262, 263, 268, 269
Nasal bleeding
as complication of dacryocystorhinostomy,
240
as complication of nasolacrimal system probing, 232
as complication of orbital decompression,
288
Nasal bone, 218, 219, 256, 257
Nasal meatus, inferior, 218, 219
Nasociliary nerve, 253, 254, 262, 263, 266, 267
Nasofrontal artery, 262, 263, 268, 269
Nasofrontal vein, 14, 15
Nasolacrimal drainage system
anatomy, 216219, 219
balloon dacryoplasty, 236, 237
canalicular reconstruction, 228, 229
canaliculodacryocystorhinostomy, 242, 243
conjunctivodacryocystorhinostomy, 244, 245
dacryocystorhinostomy, 238241, 239, 241
obstruction of, 230
probing of, 232, 233
punctoplasty, 222, 233
Necrosis of Z-plasty transpositional flaps, 170
Nerve(s)
abducens, 254, 264267, 265, 266
ciliary, 262, 263, 266, 267
ethmoidal, 262, 263, 266, 267
facial, 7
frontal, 266, 267
infraorbital, 9, 16, 17, 260, 261
infratrochlear, 9, 254, 262, 263, 266, 267
lacrimal, 9, 16, 17. 260, 261, 266, 267
maxillary division of the trigeminal nerve, 9
Dutton_Index.indd 327
O
Oblique muscle(s), 253255, 258265, 259, 261,
263, 265
Obstruction
canaliculi, 220
of lacrimal puncta, recurrent, as complication of dacryocystorhinostomy, 240
nasolacrimal system, 230
Occlusion, canalicular, as complication of
medial canthal ligament plication, 116
Ocular implant(s)
displacement of, as complication of enucleation 308
enucleation with biointegrated porous, 310,
311
extrusion of
as complication of subperiosteal orbital
volume augmentation, 300
floor, migration of implant in, as complication
of orbital floor fractures repair, 296
primary acrylic or silicone, enucleation with,
306309, 307, 309
repair of exposed, 314, 315
Ocular motility
poor, as complication of porous ocular
implant, 310
restriction of, as complication of orbital floor
fractures repair, 296
Oculomotor nerve, 253254, 260267, 261,
263, 265, 267
Ophthalmia, sympathetic, as complication of
evisceration, 316
7/12/2012 4:02:54 PM
328 Index
Overcorrection
as complication of lateral tarsal strip fixation,
108
as complication of frontalis muscle suspension with silicone rod, 102
of entropion
as complication of anterior lamellar shortening with epitarsal fixation, 138
as complication of full-thickness eyelid
sutures, 126
as complication of horizontal blepharotomy with marginal rotation, 142
of eyelid retraction
as complication of levator aponeurosis
recession with Mllers muscle extirpation, 152
of ptosis
as complication of frontalis muscle suspension, 100
as complication of levator aponeurotic
advancement, 90
as complication of posterior tarsoconjunctival resection, 84
as complication of supra-Whitnalls levator
muscle resection, 94
Overgrowth, granulation, of donor site as
complication of posterior lamellar
lengthening with free tarsoconjunctival graft, 144
P
Pain
chronic, as complication of evisceration, 316
at endotine site, 74
leg, as complication of harvesting autogenous
fascia lata, 96
Palatine bone, 252
Palpable endotine
as complication of endoscopic forehead lift, 78
as complication of transblepharoplasty endotine brow fixation, 74
Palpebral artery(ies), 14, 15, 217, 262, 263, 268,
269
Palpebral fissure, 7
dislocation of silicone tubing into
balloon dacryoplasty, 236
probing with silicone intubation stents, 236
Palpebral portion of orbicularis oculi, 7, 10, 11
Papillae, lacrimal, 266, 218, 219
Paralysis, pupillary, as complication of lateral
orbitotomy, 280
Paresis
extraocular muscle of, as complication of
anterior orbitotomy, 274
lateral rectus muscle, as complication of
lateral orbitotomy, 280
Parotid (preauricular) nodes, 9, 18, 19
Periorbita, 253, 258, 259
Periosteal fixation, with lateral semicircular
rotation flap with, for lower eyelid
reconstruction, 188, 189
Peripheral arterial arcade, 9, 15, 16
Peripheral orbital space, 270
Persistent eyelid fullness, and lacrimal gland
prolapse, 48
Persistent eyelid laxity, as complication lateral
tarsal strip fixation, 108
Pinch test for eyelid redundancy, 104
Plastic surgery, ophthalmic, anesthesia, 45
Dutton_Index.indd 328
R
Radiosurgery for trichiasis, 34, 35
Recession, levator aponeurosis, with Mllers
muscle extirpation, 150153, 151, 153
Reconstruction
lower eyelid, 186195
of medial and lateral canthi, 196211
upper eyelid, 172177
Reconstruction of canthal defect, 202211
Rectus muscle(s), 253255, 258319, 259, 261,
263, 265
imbalance of, as complication of subperiosteal orbital volume augmentation, 300
paresis, as complication of lateral orbitotomy,
280
Reduction canthoplasty, lateral, 204, 205
Reduction of epicanthal folds, 198201, 199, 201
Refixation of lacrimal gland prolapse, 48, 49
Reinsertion
lower eyelid retractor, 132, 133
retractor
with horizontal full-thickness eyelid shortening, 134, 135
with lateral tarsal strip fixation, 136, 137
Repair of exposed ocular implant, 314,315
Resection
eyelash bulb, internal, 36, 37
levator muscle
for ptosis, 8182
Supra-Whitnall, 9295, 93, 95
medial spindle, 110, 111
posterior Mllers muscle-conjunctival, 81,
86, 87
tarsal groove, anterior horizontal, marginal
rotation, 140, 141
tarsoconjunctival graft, 190, 191
transconjunctival for ptosis, Fasanella-Servat,
84, 85
wedge, marginal, full-thickness, 112,113
Residual redundant eyelid skin
as complication of Asian upper eyelid blepharoplasty, 46
as complication of upper eyelid blepharoplasty with fat excision, 44
Retinal artery, central, 254
7/12/2012 4:02:55 PM
Index 329
Retinal vein, central, 264, 265, 268, 269
Retraction
donor eyelid, as complication of free tarsoconjunctival, 144
eyelid (see Eyelid, retraction of )
Retractor(s)
of eyelid, 12, 13
lower eyelid
disinsertion of, with scleral graft, 154, 155
reinsertion of, 132, 133
reinsertion of
with horizontal full-thickness eyelid shortening, 134, 135
with lateral tarsal strip eyelid fixation, 136,137
Retrobulbar anesthesia, 4
Rhombic flap, 168, 169
Riolan muscles of, 9
Rosenmller, valve of, 216
Rotation flap
glabellar, 208, 209
lateral semicircular
with periosteal fixation, for lower eyelid
reconstruction, 188, 189
for upper eyelid reconstruction, 176, 177
myocutaneous, 164, 165
Rotation, marginal
by anterior horizontal tarsal groove resection, 140, 141
horizontal blepharotomy with, 142, 143
Rounded canthal angle as complication of
retractor reinsertion with lateral tarsal
strip eyelid fixation, 136
Rounded lateral canthal angle as complication
of lower eyelid blepharoplasty with fat
excision, 54, 62
Rounded lateral eyelid contour as complication of
lateral semicircular rotational flap, 176
S
Sac, lacrimal (see Lacrimal sac)
Scalp anesthesia
as complication of endoscopic forehead lift, 78
as complication of transblepharoplasty endotine brow fixation, 74
Scar formation
hypertrophic
as complication of incision and drainage of
chalazion, 26
as complication of four-flap technique for
reduction of epicanthal fold, 200
poor, as complication of harvesting autogenous fascia lata, 96
Scarring
eyelid margin, as complication of internal
eyelash bulb resection, 36
visible, as complication of direct brow lift, 72
Sclera, 258, 259
Scleral graft
free posterior lamellar lengthening with, 120,
121
lower eyelid retractor disinsertion with, 154,
155
Scleral show, as complication of transconjunctival excision of lower eyelid herniated
orbital fat, 68
Semicircular rotation flap, lateral
with periosteal fixation, for lower eyelid
reconstruction, 188, 189
for upper eyelid reconstruction, 176, 177
Dutton_Index.indd 329
Sulcus
infraorbital, 256, 257
superior, 10, 11
Sunken hollow appearance as complication of
transconjunctival excision of herniated lower eyelid orbital fat, 68
Superficial facial and orbicularis oculi muscles,
10, 11
Superficial nonmarginal eyelid defects, repair
of, 158170
Superficial parotid nerve, 9
Superficial temporal artery, 9
Superficial temporal vein, 14, 15
Supraorbital anesthesia as complication of
direct brow lift, 72
Supraorbital artery, 262, 263, 266269, 267, 269
Supraorbital nerve, 9, 16, 17
Supraorbital notch, 256, 257
Supraorbital vein, 266269, 267, 269
Supratrochlear artery, 14, 15
Supratrochlear nerve, 9, 16, 17, 266, 267
Supratrochlear nerve block for ophthalmic
surgery, 5
Supratrochlear vein, 266269, 267, 269
Supra-Whitnall levator muscle resection,
9295, 93, 95
Surgery
eyelid, 1211
lacrimal drainage system, 213245
on lacrimal puncta and canaliculi, 220229
on lacrimal sac and duct, 230245
orbital, 247319
on orbital walls, 281301
plastic, ophthalmic, anesthesia, 45
Surgical anatomy
of eyelid, 623
of lacrimal drainage system, 216219, 219
of orbit, 252269
Suspension, temporal fascia lower eyelid, 118, 119
Suspensory ligament
Lockwoods, 8, 12, 13, 253
Whitnalls, 8, 12, 13, 20, 21, 23, 253
Suture(s)
eyelid, full-thickness, 126, 127
modified, for epiblepharon repair, 128, 129
frontoethmoid, 252
frontozygomatic, 252, 256, 257
sphenozygomatic, 256, 257
zygomaticosphenoid, 252
Sympathetic muscle, Mller, 8, 2223, 150153,
151, 153
Sympathetic ophthalmia as complication of
evisceration, 316
Syndrome
congenital ectropion, 204
Horners, 8
T
Transconjunctival inferior wall, orbital decompression, 292, 293
Tarsal groove resection, anterior horizontal,
marginal rotation by, 140, 141
Tarsal plate(s), 8, 11, 12, 1822, 19, 21, 23
Tarsal strip eyelid fixation, lateral
eyelid shortening by, 108, 109
retractor reinsertion with, 136, 137
Tarsectomytarsoaponeurectomy, split-level, 81
Tarsoaponeurectomy, external, 81
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330 Index
Tarsoconjunctival advancement flap, upper to
lower eyelid, 192195, 193, 195
Tarsoconjunctival graft, free
and myocutaneous advancement flap for
lower eyelid reconstruction, 190, 191
posterior lamellar lengthening with, 144, 145
for upper eyelid reconstruction, 180, 181
Tarsoconjunctival resection, 81
medial spindle, 110, 111
posterior, 84, 85
Tarsoconjunctival transposition flap, for upper
eyelid reconstruction, 178, 179
Tarsorrhaphy, lateral, 106, 107
Tear outflow, test of, 213
Tears, drainage, obstruction, 213
Temporal artery superficial, 78, 79, 254
Temporal bone, 256, 257
Temporal branch of facial nerve, 16, 17, 70
Temporal fascia lower eyelid suspension, 118, 119
Temporal forehead lift, 70
Temporal hooding of eyelid skin, 40, 41
Temporal nerve, superficial, 9
Temporal vein, superficial, 14, 15
Temporalis muscle, 118, 119, 188, 189
Tendon, canthal
medial
crus of, 218, 219
plication of, 116, 117
Test
dye disappearance, 213
Jones I, 213
Jones II, 213
pinch, for eyelid redundancy, 104
Thickening of Z-plasty transpositional flaps, 170
Tissue, granulation in central hole as complication of porous ocular implant, 310
Tomography, computerized, of orbit, 281
Transblepharoplasty Endotine brow fixation, 74, 75
Transcaruncular medial wall, orbital decompression, 284, 285
Transconjunctival approach to incision and
drainage of chalazion, 28, 29
Transconjunctival excision of lower eyelid
herniated orbital fat, 68, 69
Transconjunctival resection for ptosis, 84, 85
Transcutaneous approach to incision and drainage of chalazion, 2627, 27
Transcutaneous, transperiosteal anterior orbitotomy, 274, 275
Transcutaneous, transseptal anterior orbitotomy, 272, 273
Transperiosteal anterior orbitotomy, 274,275
Transposition flap
horizontal tarsoconjunctival, for upper eyelid
reconstruction, 178, 179
median forehead, 210, 211
necrosis, 210
myocutaneous, 166, 167
Z-plasty, 170, 171
Transseptal anterior orbitotomy, 272, 273
Transverse facial artery, 9, 14, 15
Transverse facial vein, 14, 15
Transverse ligament of Whitnall, 8, 12, 13, 20,
21, 23, 253
Tarsoconjunctival advancement flap, upper to
lower eyelid, 192195, 193, 195
Triamcinolone acetonide for chalazion, 25
Trichiasis, 30
cryodestruction for, 30
cryosugery for, 32, 33
Dutton_Index.indd 330
U
Undercorrection
as complication of frontalis muscle suspension with silicone rod, 102
of entropion
as complication of anterior lamellar shortening with epitarsal fixation, 138
as complication of marginal rotation by
anterior horizontal tarsal groove
resection, 140
of eyelid retraction
as complication of levator aponeurosis
recession with Mllers muscle extirpation, 152
as complication of lower eyelid retractor
disinsertion with scleral graft, 154
of ptosis
as complication of frontalis muscle suspension with autogenous fascia lata, 100
as complication of levator aponeurotic
advancement, 90
as complication of posterior Mllers
muscleconjunctival resection, 86
as complication of posterior tarsoconjunctival resection, 84
as complication of supra-Whitnalls levator
muscle resection, 94
Upper eyelid
blepharoplasty, with fat excision, 4245, 43, 45
donor, lagophthalmos of, as complication of
anterior lamellar lengthening with
skin graft, 120
major retractors of, 12, 13
margin of, 7
marginal defects of, direct layered closure of,
174, 175
ptosis of
as complication of lateral orbitotomy, 280
as complication of lower eyelid bridged
advancement flap, 182
as complication of anterior orbitotomy, 272
reconstruction of, 172185
Upper eyelid crease, 7
reformation of, 50, 51
Upper lacrimal papilla, 216, 218, 219
Upper to lower eyelid tarsoconjunctival
advancement flap, 192195, 193, 195
V
Valve
of Hasner, 217
of Rosenmller, 216
Vein(s)
angular, 14, 15, 264, 265
central retinal, 264, 265, 268, 269
ethmoidal, 264, 265, 268, 269
facial, 14, 15
frontal, 14, 15
infraorbital, 264, 265
infratrochlear, 266269, 267, 269
lacrimal, 266269, 267, 269
nasofrontal, 14, 15
ophthalmic, 254, 255, 264, 265, 268, 269
superficial temporal, 14, 15
supraorbital, 14, 15, 266269, 267, 269
supratrochlear, 266269, 267, 269
temporal, superficial, 14, 15
vortex, 264, 265, 268, 269
Vertical canthal angle dystopia, correction of,
206, 207
Visible scar as complication of direct brow
lift, 72
Vision, loss of
as complication of lower eyelid blepharoplasty with fat excision, 54
as complication of orbital decompression, 288
as complication of repair of orbital floor
fractures, 296
as complication of upper eyelid
blepharoplasty with fat excision,44
Volume orbital, loss as complication of dermisfat orbital graft, 312
Vortex vein, 264, 265, 268, 269
W
Wedge resection, marginal, full-thickness, 112,
113
Whitnalls ligament, 8, 12, 13, 20, 21, 23, 253
Wies procedure for entropion, 142, 143
Wound dehiscence
as complication of evisceration, 316
as complication of lateral semicircular rotational flap, 176
as complication of retractor reinsertion with
horizontal eyelid shortening, 134
Wound infection as complication of dacryocystorhinostomy, 240
Y
Y to V advancement flap for reduction of epicanthal folds, 198201, 199, 201
Z
Zinn, annulus of, 253, 260, 261
Z-plasty for repair of superficial nonmarginal
eyelid defects, 158
Z-plasty transpositional flaps, 170, 171
Zygomatic arch of temporal bone, 256,257
Zygomatic bone, 252, 256259, 257, 259
Zygomatic branch of facial nerve, 7, 9, 16,17
Zygomatic furrow, 10, 11
Zygomatic nerve, 260, 261
Zygomaticofacial artery, 260, 261, 268, 269
Zygomaticofacial nerve, 9, 16, 17, 260, 261
Zygomaticosphenoid suture, 252
Zygomaticotemporal artery, 254
Zygomaticotemporal nerve, 9, 16, 17
7/12/2012 4:02:55 PM