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8/8/2019 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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TENZEL SEMICIRCULAR FLAPTENZEL SEMICIRCULAR FLAP
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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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MINI MONOKA STENTMINI MONOKA STENT
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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MINI MONOKA STENTMINI MONOKA STENT
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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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Ritleng Probe ProcedureRitleng Probe Procedure
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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Ritleng Probe ProcedureRitleng Probe Procedure
The Ritleng Probe is shown completely
separated from the thread-guide.Figure 3
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Ritleng Probe ProcedureRitleng Probe Procedure
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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CUTLER BEARDCUTLER BEARD-- STAGE 2STAGE 2
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CUTLER BEARDCUTLER BEARD-- STAGE 2STAGE 2
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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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MEDIAL CANTHAL RECONSTRUCTIONMEDIAL CANTHAL RECONSTRUCTION
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MEDIAL CANTHAL RECONSTRUCTIONMEDIAL CANTHAL RECONSTRUCTION
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THANK YOU