Lid Repair

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REPAIR OF EYELIDREPAIR OF EYELID

LACERATIONLACERATION

DR. RASHMI JOSHIDR. RASHMI JOSHI

DNB STUDENTDNB STUDENTBCEIRCBCEIRC

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OPHTHALMOLOGICOPHTHALMOLOGIC

EVALUATIONEVALUATION Record visual acuityRecord visual acuity

PupilsPupils-- RAPDRAPD Extraocular muscle movementsExtraocular muscle movements

diplopiadiplopia +/+/--

Assessment of orbital margin Assessment of orbital margin

Documentation of globe projectionDocumentation of globe projection

Eyelid positionEyelid position

CanalicularCanalicular integrityintegrity

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Intraocular injuries treatedIntraocular injuries treated

before eyelid repairbefore eyelid repair

Damage to intraocularDamage to intraocularstructuresstructures

Enhanced exposure of the globeEnhanced exposure of the globe

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REDUCE LID EDEMAREDUCE LID EDEMA

Ice compressesIce compresses

Head elevationHead elevation CorticosteroidsCorticosteroids

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GGoals of Eyelid Reconstructionoals of Eyelid Reconstruction

Development of stable eyelid marginDevelopment of stable eyelid margin

Adequate lid closure Adequate lid closure-- globe protectionglobe protection Smooth,Smooth, epithelialisedepithelialised internal surfaceinternal surface

To achieve acceptable aestheticTo achieve acceptable aestheticresults.results.

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Principles of EyelidPrinciples of Eyelid

ReconstructionReconstruction Reconstruct either anterior or posteriorReconstruct either anterior or posterior

eyelid lamella but eyelid lamella but not bothnot both with graft with graft

Maximize horizontal tension, MinimizeMaximize horizontal tension, Minimizevertical tensionvertical tension

Maintain sufficient and anatomicalMaintain sufficient and anatomical

canthalcanthal fixationfixation

Match like tissue to like tissueMatch like tissue to like tissue

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Principles of EyelidPrinciples of Eyelid

ReconstructionReconstruction contdcontd Narrow the defect as much as possibleNarrow the defect as much as possible

before sizing the graft before sizing the graft

Incisions should follow RSTLIncisions should follow RSTL

Choose the simplest techniqueChoose the simplest technique

Minimize tissue distortionMinimize tissue distortion

Maximize scar camouflage.Maximize scar camouflage.

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EYELID DEFECTS NOTEYELID DEFECTS NOT

INVOLVING LID MARGININVOLVING LID MARGIN Skin sutures onlySkin sutures only

Presence of orbital fat in the wound !!Presence of orbital fat in the wound !!

Orbital septumOrbital septum

LevatorLevator explorationexploration

Do not Do not suture orbital septumsuture orbital septum

TetherTether ptosisptosis

Upper lidUpper lid lagophthalmoslagophthalmos

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EYELID DEFECTSEYELID DEFECTS

INVOLVING LID MARGININVOLVING LID MARGIN SmallSmall -- <33%<33%

ModerateModerate 3333 50%50%

LargeLarge -- > 50%> 50%

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RECONSTRUCTIVE LADDERRECONSTRUCTIVE LADDER

FOR LOWER EYELID DEFECTFOR LOWER EYELID DEFECT <33%<33% Primary closure+/Primary closure+/-- laterallateral

canthotomycanthotomy

3333--50%50% Semicircular advancement orSemicircular advancement orrotation flap ,rotation flap , TarsoconjunctivalTarsoconjunctivalautograftsautografts

>50%>50% FreeFree tarsoconjunctivaltarsoconjunctival and skinand skinflap, Hughes flap,flap, Hughes flap, MustardeMustarde flap.flap.

Other factorsOther factors

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PRIMARY CLOSUREPRIMARY CLOSURE

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PENTAGON EXCISION WITHPENTAGON EXCISION WITH

LATERAL CANTHOLYSISLATERAL CANTHOLYSIS

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PENTAGON EXCISION WITHPENTAGON EXCISION WITH

LATERAL CANTHOLYSISLATERAL CANTHOLYSIS

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TENZEL SEMICIRCULAR FLAPTENZEL SEMICIRCULAR FLAP

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HUGHES PROCEDUREHUGHES PROCEDURE

TarsoconjunctivalTarsoconjunctival Flap for posteriorFlap for posteriorlamellalamella

Defects greater than 50%Defects greater than 50%

Vertical upper lid to lower lid sharing Vertical upper lid to lower lid sharing

Anterior lamella reconstruction Anterior lamella reconstruction

Advancement Advancement musculocutaneousmusculocutaneous flapflap

Free skin graft Free skin graft

Requires 2Requires 2ndnd stage procedurestage procedure

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HUGHES PROCEDUREHUGHES PROCEDURE

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MUSTARDE FLAPMUSTARDE FLAP

Large rotational skinLarge rotational skin--muscle cheek flapmuscle cheek flap

Advantage Advantage single stage proceduresingle stage procedure

Monocular visionMonocular vision

Children withChildren with amblyopiaamblyopia

Active corneal disease Active corneal disease

GlaucomaGlaucoma

DisadvantagesDisadvantages lackslacks orbicularisorbicularis,,saggingsagging

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MUSTARDE FLAPMUSTARDE FLAP

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CANALICULAR TEARCANALICULAR TEAR

REPAIRREPAIR

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METHODS OF REPAIRMETHODS OF REPAIR

Direct Direct anastomosisanastomosis of theof thecanalicularcanalicular mucosa with 8mucosa with 8--00

vicrylvicryl.. ReapproximationReapproximation of of

pericanalicularpericanalicular tissue with atissue with alarger suturelarger suture

Canalicular stents Mono,bicanalicular stents

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MonocanalicularMonocanalicular vs vs

BicanalicularBicanalicular

Monocanalicular intubation:

Avoids manipulation of normal canaliculus

and NLD (eliminating any possibility ofinjury to them)

Stents are easily placed (no intranasalmanipulation)

May be placed using local anesthesia ²OPD procedure

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MonocanalicularMonocanalicular vs vs

BicanalicularBicanalicular

Monocanalicular intubation (cont.):

Easy to remove at the slit lamp

No danger of ´cheesewiringµ or erosionof punctum (occasionally occurs withbicanalicular stents)

No need for any knots or sutures ² stentis anchored at the punctum

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MINI MONOKA STENTMINI MONOKA STENT

For Canalicular Laceration orImperforate Nasolacrimal Duct

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These photos show a canalicular laceration and

its repair with a Monoka monocanalicular stent.

Photos compliments of Mark Brown, MD ± EyePlastics.com

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MONOCANALICULAR SHUNTSMONOCANALICULAR SHUNTS--

DISADVANTAGESDISADVANTAGES

Spontaneously dislodge increasingSpontaneously dislodge increasingchances of postoperativechances of postoperative--

scarring,scarring,

canalicularcanalicular stenosisstenosis, or, or

obstruction.obstruction.

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Ritleng Probe ProcedureRitleng Probe Procedure

The Ritleng Probe is backed out of thelacrimal duct and separated from thepolypropylene thread-guide at its thinner

section (the light blue portion of the thread)

by sliding it out from the open slit that lines

the entire length of the probe.

Figure 1

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The thinner section of the thread-guide is

shown separating from the probe by sliding

out from the open slit.Figure 2

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The Ritleng Probe is shown completely

separated from the thread-guide.Figure 3

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These photos show a canalicular laceration and its repair with a

monocanalicular stent using the Ritleng probe.

Photos compliments of Mark Brown, MD ± EyePlastics.com

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RECONSTRUCTIVE LADDERRECONSTRUCTIVE LADDER

FOR UPPER EYELID DEFECTFOR UPPER EYELID DEFECT <33%<33% Primary closure +/Primary closure +/-- laterallateral

canthotomycanthotomy

3333--50%50% Semicircular flap, TarsalSemicircular flap, Tarsalsharing proceduressharing procedures

>50%>50% Cutler Beard ProcedureCutler Beard Procedure

Other factorsOther factors

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SEMICIRCULAR ROTATIONSEMICIRCULAR ROTATION

FLAPFLAP

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SLIDING TARSOCONJUNCTIVAL FLAPSLIDING TARSOCONJUNCTIVAL FLAP

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PEDICLE FLAP FROMPEDICLE FLAP FROM

LOWER LIDLOWER LID

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CUTLER BEARDCUTLER BEARD-- STAGE 1STAGE 1

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LATERAL CANTHAL RECONSTRUCTIONLATERAL CANTHAL RECONSTRUCTION

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LATERAL CANTHAL RECONSTRUCTIONLATERAL CANTHAL RECONSTRUCTION

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MEDIAL CANTHAL RECONSTRUCTIONMEDIAL CANTHAL RECONSTRUCTION

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THANK YOU

Lid Repair

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