Tips Οφθαλμοπλαστικης για τον Γενικο Οφθαλμιατρο

ΕΥΑΓΓΕΛΟΣ ( Π. & Ν.) ΛΙΝΑΡΔΟΣ

Oculoplastics ρεπερτόριο γενικού οφθαλμιατρουLid cysts

Lateral cantholysis - canthotomy

Full thickness lid defect reconstruction + Lateral cantholysis - canthotomy

entropion : Everting sutures, Wies τεχνική, Quickert τεχνική

Full thickness skin graft

Lateral tarsorhaphy

Enucleation, evisceration, primary orbital implant

1, 2 or 3- snip punctoplasty

ΓΕΝΙΚΑ tipsSort out blood pressure

Stop aspirin prior to any lid operation

Consider visual status in each eye especially in upper lid cases and in patient with high refractive errors

Who is at home ?

• Who will escort the patient ?

• Warn about stitches and bruising

• Patients often shocked at post appearance

Allow plenty of time 45 min for

any lid procedure

Loupes very helpful 2,5 times focus 33 cm ideal do not get any higher

magnification

Always do full face prep use turban

drape and leave face uncovered

Patient record - file

SYSTEMIC -OPHTHALMIC HISTORY

Thyroid

Post - operative bleeding episode

Bleeding disorders

Trauma –previous surgery

Eye surgery –

Hx amblyopia-patch

Medications -Allergies

Needs -expectationsof patient

Preoperative photos – old photographs

Lacrimalfunction -basic tear secretion

test Schirmer

Cornealstatus

CONSENT FORM

anesthesia

• 2% xylocaine (lidocaine) with 1: 100.000 epinephrine and

0.5% bupivacaine (Marcain)

• JUST BENEATH THE LID SKIN 1- 1,5 ml

• Topical anesthetic solutions (no vasoconstriction)• EMLA cream ( topical lidocaine 2,5% and

prilocaine 2,5%) – 1 hour before• Betacaine gel (topical lidocaine 5%) - 30

minutes before

instrumentsSkin hooks and Αdson’s toothed forceps essential kit for lid surgery

Incision - tipsMarking before anesthesia

Begin cutting at the lowest part of the incision

Keep blood from obscuring the incision line

Perpendicular to skin surface

Keep skin taut

Avoid beveling incision

Poor wound closure

Through the epidermis and dermis

in a continous motion the entire length of the incision

Start and stop creates jagged, irregular wound

Minimize tissue trauma

Skin hooks - fine toothed forceps, on wound edges

Non toothed forceps ONLY FOR TYING SUTURES

• crush tissue

retard wound healing

make histologic examination difficult

hemostasis

• aspirin products 2 weeks prior to surgery ( inhibit platelet activity)

• Warfarin and NSAID 5 days before surgery

• 3G (Garlic, Ginko, Ginseng)

• Large amounts of vitamin C and E ( post op bleeding)

• Retard healing

• Increase scarring

• Microorganism growth

• Lidocaine hydrochloride 0.5 –2% withepinephrine 1:100.000 – 1:200.000

• Inform anesthetist

• Digital pressure

• Pressure applied with forceps or hemostat

• Cautery disposable thermal cautery unit for capillary bleeding

• Bleeding from larger vessels: monopolar – bipolar electrocoagulation

•- tissue identification

•- tissue dissection

•- optimum wound healing•- accurate wound closure

Meticulous types

Patients asked not

to use

Blood clots trapped in

wound

Wound closure• W9566 Vicryl Double Ended ½ Circle Spatulated needle: the best for tarsal stitching • W500 5.0 Silk makes a good traction suture

dressing

• Steristrip after meticulous hemostasis and wound closure

• Protective plastic shield to bed to avoid injury during sleep

• Cold packs until bedtime the day of surgery

• vasoconstrictive effect in minimizing postoperative edema

• Warm packs for 10 min every 3 hours the morning after surgery

• promote vasodilation and absorption of the edema

• Keep the area clean gentlewipping twice daily with clean moist cloth or cotton ball

• Steroid - antibiotic ointment

AVOID

•PatchMask signs and symptoms

•Injury to delicate eyelid tissue

•Blindness

•Prolonged soaking of the wound

disrupts the healing process

•Excessive straining venous congestion increased swelling bleeding

ptosis

• NEVER do Fasanella Servat• Pseudoptosis

• Hypotropia in involved, non-fixating side• Eyelid retraction in contralateral fixating eye• Inadequate lid support by globe and orbital structures

(reduced orbital volume)• Phthisis bulbi• Microphthalmos• Enophthalmos• Anophthalmos

• Overhang of skin over the eyelid margin• Heavy eyebrow, or fat pads

cysts

Verrucavulgaris

cutaneoushorn

Milia

Molluscum contagiosum

Xanthelasmas

nevus

chalazion

tumours

• BCC

• biopsy

• Slitlamp useful for very small tumours

• 2-3 mm cleareance for nodular BCC usually sufficient

• Do not attempt upper lids

• Cantholysis ‘ buys ‘ extra 3 mm

• Full thickness skin graft INAVALUABLE - learn how to do it

Lateral cantholysis - canthotomy• Indications

• Orbital compartment syndrome• decreased visual acuity• intraocular pressure higher than 35-40mmHg• a relative afferent pupillary defect • decreased arterial circulation of the optic

nerve visualized by the absence of flow or pulsing of retinal arteries with minimal or no digital pressure on the globe

• Eyelid procedures (lateral tarsal strip)

• instruments• Αntiseptic betadine • Totopical anesthesia (Lidocaine +/- epi)• Straight mosquito hemostat• Iris scissors• Forceps

Eyelid trauma

Gardinal rules for the management of eyelid trauma

•history

•best acuity for each eye

•thorough evaluation of the globe and orbit

•radiologic studies

•eyelid and orbital anatomy knowledge •ensure the best possible primary repair Penetrating

eyelid injuries

• detailed knowledge of eyelid anatomy helps

• the surgeon in repairing a penetrating eyelid injury

• reduces the need for secondary repairs

• the treatment of eyelid lacerations depends on the depth and location of the injury

Blunt trauma

• Echymosis–edema the most common

• evaluate for intraocular injury • thorough biomicroscopic evaluation

• dilated fundus examination

• Computed tomography ( axial - direct coronal), detect orbital fracture

Lacerations involving the eyelid marginRepair of eyelid margin lacerations requires

• precise suture placement and critical suture tension, to minimize notching of the eyelid margin

• Precise anatomical alignment of the margin and secure tarsal closure in a meticulous, direct manner

• Surgeons differ as to whether they place the tarsal or the eyelid margin sutures first

Eyelid margin closure may be accomplished by placing

• 2 or 3 sutures ( 6-0 silk or Vicryl ) for alignment through the lash line, the meibomian gland plane, and optionally the gray line

• The eyelid margin closure should result in a moderate eversion of the well-approximated wound edges

To avoid corneal epithelial disruption, the tarsal sutures

• (5-0 Vicryl), should not extend through the conjunctival surface

OOM suture 5- 0 Vicryl

Skin closure with 6-0 silk

Lacerations not involving the eyelid margin

TIPS

Superficial eyelid lacerations involving just the skin and orbicularis

muscle usually require only skin sutures

foreign bodies

superficial or deep should be searched for meticulously before these deeper eyelid lacerations are repaired

• Copious irrigation washes away contaminated material in the wound

presence of orbital fat in the wound means that the orbital septum has been violated

• Orbital fat prolapse in an upper eyelid wound is an indication for levatorexploration

• A lacerated levator muscle or aponeurosis must be carefully repaired to enable the levator to function as normally as possible

• Upper eyelid lagophthalmos and tethering to the superior orbital rim are common if the orbital septum is inadvertently incorporated into the laceration repair

• Orbital septum lacerations should not be sutured

• Meticulous closure of overlying eyelid skin and orbicularis muscle is adequate in all cases and avoids possible vertical shortening of the sutured orbital septum

Unnecessary scarring can be avoided by following the basic principles of plastic repair

• conservative debridement of the wound

• use of small-caliber sutures

• eversion of the wound edges

• early suture removal

Eyelid Defects Not Involving the Eyelid Margin

repairIf undermining does

not allow direct closure,

advancement or transposition of

flaps of skin may be used

If the defect is too large to be closed primarily, several advancement or transposition techniques

of local skin flaps may be used

flaps most commonly used are rectangular advancement, rotation, and transposition

provide the best tissue match and aesthetic result but require planning in order to minimize

secondary deformities

skin-grafting procedureseasier to perform

the final texture, contour, and cosmesis are typically better with flaps

Anterior lamella upper eyelid defects are best repaired with full-thickness skin grafts from the contralateral upper eyelid

Preauricular or postauricular skin grafts, but their greater thickness may limit upper eyelid mobility.

Lower eyelid defects are best healed with preauricular or postauricular skin grafts

If skin is not available from the upper eyelids or auricular areas, full-thickness grafts may be obtained from the supraclavicular fossa or the inner upper arm

It is important to avoid placement of hair-bearing skin grafts near the eyes

direct closure NO distortion of the eyelid

margin

Tension of closure should be directed horizontally, so that secondary deformity can be

avoided

vertical tension may cause eyelid retraction or ectropion

Avoidance of vertical tension

requires placement of

vertically oriented incision lines

tarsorrhaphy

Permanent

permanently protect the cornea from a long-term risk of damage

only closes the lateral (outer) eyelids, so that the patient can still

see through the central opening and the eye can still be examined

Temporary to help the cornea heal

or to protect the cornea during a short period of exposure or

disease

INDICATIONS

To protect the cornea in the case

of

inadequate eyelid closure, due to

- facial nerve palsy or

- cicatricial (scarring) damage to the eyelids caused by a chemical or burns injury

an anaesthetic(neuropathic) cornea

that is at risk of damage and infection

marked protrusion of the eye (proptosis) causing a risk of corneal exposure

poor or infrequent blinking,

in patients in intensive care or with severe

brain injuries

promote healing of the cornea

Non healing epithelial abrasions

an infected corneal ulcer, which is taking a

long time to healretain a conformer or other device

prevent conjunctival swelling

3 snip punctoplasty

ENTROPION

congenital

cicatricialMarginal

Pull lid inwards

Involutionalspastic

Turn lid inwards

Symptoms

• Pain - irritation• Redness• Tearing

• Secondary blepharospasm, worsens picture

• 💡Latent entropion 💡

obvious after 5 minutes anesthetic drop instalation ? Mechanism?

• LID MARGIN POSITION

• SCAR

• laxed lateral laxed medial canthal canthal tendons

• Orbital fat PROLAPSE

in inferior fornix ( BEIGI’S sign)•

• Horizontal lid laxity

• Lower lid retractors

Everting sutures

Transverse separation of lower lid + sutures

• NO horizontal laxity of lower lid

• Postsurgical effect lasts longer

Transverse separation of lower lid + lower lid horizontal shortening + sutures

horizontal laxity of lower lid

Eyelash misdirection

Trichiasis

• Lashes arise from normal site of origin

• Directed abnormally

• Common

• Acquired

• Normal lash caliber

Distichiasis

• Growth of extra row of lashes arising from an abnormal position in the posterior aspect of the lid margin ( frequently from meibomian gland orifices)

• Rare

• Congenital

• Fine lash

Metaplastic

• Abnormal position

• Metaplasia

• Late stage cicatrizing conjuctivitis

• Meibomianglands dedifferentiation to hair follicles

•

TRICHIASIS TREATMENT

Lid margin position NORMAL

Single aberrant lash or few lashes ELECTROLYSIS

Localised areaFULL THICKNESS LID EXCISION

More extensive areas

CRYOTHERAPY

Distichiasis

Upper lid:LID SPLIT- CRYOTHERAPY

Lower lid: CRYOTHERAPY

Lid margin position ABNORMAL

CORRECT IT

Tarsal fracture

Or

Epiblepharon repair

ECTROPION

mechanical

cicatricial

congenital

paralytic -atonic

involutional

Clinical examination

FACE: parkinsonism, collagen diseases, floppy eyelid

LID

Ectropic area

Medial canthus laxity

Excess skin Horizontal laxity

Lateral canthus laxity

Shrinkage of ant. lamella– scar (trauma, surgery)

Tumour - mass Facial nerve palsy

sockets• Never do secondary orbital implant

• Enucleation / evisceration MUST

for general ophthalmologist

• Sclera must be opened posteriorly

• Go for 20 mm implant

• Use test sphere and be sure

tenon’s closes without tension

• Consider Fascia Lata or scleral wrap

• Conjuctival much more likely to heal

• Cover orbital implants with antibiotic, anti-inflammatory, analgesia+++ and pressure dressing

• Conformers only if conjuctiva prolapses after dressing pressure removed

7 P’s • Pain

• Progression

• Past medical history

•Proptosis

•Periorbital changes

• Palpation

• Pulsation

Pain – Progression of disease

• rapid (hours- days)hemorhage

• intermediate(weeks -months)

• inflammation – infection

• slow (months - years) inflammatory process

• inflammation

• infection

• hemorhage

• nerve or bone involvement from tumour growth

History of initiation

photo

painCharacteristics of progression

detailed history

Gender

age

Previous history

Neoplasia elsewhere

surgery

Facial trauma

Genetic abnormalities

Systemic diseases

drugs

allergiesprofession

Smoke alcohol

Family history

Proptosis

Differential diagnosis in proptosis

or bulbar displacement

CAUSES

TREATMENT

history

physical examination

CT scan Biopsy

>18mm ( asian)>20mm ( caucasian)

>22mm ( black)

Αsymmetria of both sides difference >2mmChanges in time

displacement

Non axial proptosis

enophthalmosBulbar ptosis

Axial proptosis

small eye ball• congenital (microphthalmos, nanophthalmos)• acquired ( bulbar phthisis)

abnormal architecture of orbital wall (congenital – post-traumatic )

Orbital atrophy• Congenital

• trauma

• radiotherapy

• scleroderma cicatricial orbital changes- metastatic cicatricial carcinoma- chronic sclerotic orbital inflammation

enophthalmos

Non axial displacement

(right eye)

maxillary sinus carcinoma

Orbital fat

Lymphoid tumor

Benign mixed tumor

lacrimal gland

Lacrimal gland

benign mixed tumour lymphoid tumor

Frontal sinus

mucocele

trauma

encephalocele

Orbital roof

sphenoidal meningioma

Ethmoidal sinus

carcinomamucocele

enlargement of extraocular

muscles

• thyroid orbitopathy

intraconal mass

• Cavernous hemangioma

optic nerve tumor

• Optic nerve meningioma

• glioma

axial dispacement

anterior segmentorbit

• periorbital edema

lid

• Lid edema

• Eyelid tumour

conj

• Conjuctival edema

• Conjuctival ‘salmon patch’

cornea

• Dry keratoconjuctivitis

• Limbal keratoconjuctivitis (S.L.K)

• Dry eyes

eyelids

lid position retraction

(retraction / scleral show)

edema - echymosis

Lid lag

temporal flare

ptosis

• height, marginal reflex distance

• Intrapalpebral distance

• Skin crease

• Levator function

• Bell’s phenomenon, jaw winking

• pseudoptosis

S- shaped dysmorphy

Extraocular muscles

ophthalmoplegia

limitation -neurological

diplopia

Hess Chart

Cover -uncover

Test

Ocular movements

Forced duction test

Intraocular pressure

difference(6mmHg)

Away from action field of involved muscle

Optic nerve

Visual acuity

Marcus Gunn pupil

appearance

( Colour, Contour,

Cup)

fundoscopy

C o l o u r v i s i o nred colour

desaturation

Thyroid orbitopathy

• Soft tissues

• Lid retraction

• proptosis • Optic neuropathy

• ophthalmoplegia

Cosmetic surgeryBlepharoplasty• Upper lid• Respect lid crease minimum of 9mm from

lid margin and do not overdo skin excision

• do pinch test

• General rule leave minimum 18 mm skin between lid margin and brow

• Taking fat straight forward done with care –• bleeders will retract into the orbit • patients can rarely be blinded by fat excision

and this has to be discussed with the patients pre op

• Lower lid• Leave it to experts

ΣΑΣ ΕΥΧΑΡΙΣΤΩ ΘΕΡΜΑ