Ophthalmic Surgery Sandeep Saxena
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12

Lid Surgery1.

Milind N Naik,
Santosh G Honavar
 
PTOSIS SURGERY
The decision regarding the management of congenital ptosis depends mainly on the age of the patient and the magnitude of functional and cosmetic deficit.
Cosmetic correction is ideally performed after about 4 years of age when accurate ptosis measurements can be obtained and child is cooperative for postoperative management. In cases where there is high risk of amblyopia or abnormal head posture, early surgery may be considered.4
Bilateral mild congenital ptosis may be left untreated unless the patient is cosmetically conscious about the problem. It is usually associated with good levator action and hence bilateral simultaneous Fasanella-Servat procedure may be optimal. Other options are levator plication or a small levator resection.
Bilateral moderate congenital ptosis is associated with good-to-fair levator action and is of cosmetic and functional consequence. It is best treated with bilateral simultaneous levator resection.
Bilateral severe congenital ptosis usually has associated poor levator action. Most patients have a head posture and may need to be treated early in childhood. A tarso-frontal sling is a good option in such cases.5
 
Fasanella-Servat Procedure
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Modified Fasanella-Servat Procedure: The Fasanella-Servat procedure classically involves tarso-conjunctivo-mullerectomy. Best results are achieved in up to 2 mm congenital ptosis with minimum 10 mm levator action. In such cases, 2 mm of tarsectomy is performed for every 1 mm of ptosis.6
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A set of three forniceal stay sutures are placed, starting from conjunctival fornix, and exiting at the eyelid margin through the full thickness of the eyelid. The upper tarsus is stretched over an eyelid spatula.7
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The tarsus is marked along the line of excision with a monopolar cautery. Full-thickness excision is performed along the entire extent.8
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A skin suture is placed with 6-0 catgut at the medial end of tarsal excision, and the needle is brought out on the conjunctival side to close the tarsal wound. Suture is exteriorized onto the eyelid skin at the lateral end for the final knot.9
 
Skin Approach Levator Resection
Levator resection has several variations. The approach could be transconjunctival or transcutaneous. Skin approach levator resection is more popularly practiced.
Guidelines for intraoperative placement of eyelid position based on levator action, during congenital ptosis surgery via skin approach under general anesthesia (Described by Berke) are as following:
Levator action
Eyelid position
2-3 mm
At upper limbus
4-5 mm
1-2 mm below the limbus
6-7 mm
2-3 mm below the limbus
8-9 mm
3-4 mm below the limbus
10-11 mm
6 mm below the limbus
10
 
Skin Approach Levator Resection
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Skin incision is placed.11
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Orbicularis is separated to expose the orbital septum. Subsequently, superior tarsal surface is exposed.12
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The orbital septum is incised to expose the pre-aponeurotic fat pad (asterix) and levator aponeurosis (arrow).13
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The conjunctiva is lifted away from the levator aponeurosis by subconjunctival injection of xylocaine. 4-0 silk traction sutures are placed through the levator aponeurosis at its insertion.14
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The levator is then disinserted, and separated from the underlying Muller's-conjunctiva by blunt dissection. Medial and lateral horns are cut if necessary.15
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Three cardinal sutures are passed from the tarsus through the levator muscle at the desired height.16
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Orbicularis muscle is closed with interrupted 6-0 vicryl sutures. Skin is closed with 6-0 prolene continuous suture.17
 
Tarso-frontal Sling
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Tarso-frontal sling can be performed with non-absorbable synthetic materials including 3-0 ethibond suture, 3-0 prolene suture, Silicone or Goretex. Autogenous fascia lata is however, considered the best sling material. Although the synthetic slings have a recurrence rate of 20-30 percent, they have the advantage of reversibility, minimal lagophthalmos, and absence of donor site morbidity.18
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Silicone rod sling with pre-swedged needle at either end, and a silicone sleeve is shown.19
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Stab incisions are placed over the eyelid and brow markings, and the needle is passed in the suborbicularis plane from central brow incision to lateral brow incision.20
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The needle is then passed towards the lateral eyelid stab incision, while the eyeball is protected by a lid guard.21
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Needle is passed through the suborbicularis plane towards medial eyelid incision. The silicone rods are held under tension to look for eyelid lift and contour. Similar procedure is repeated for the right eye.22
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The needle is passed through the suborbicularis plane towards medial brow incision.23
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The needle is passed finally out through the central brow incision.24
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The silicone rods are held under tension to look for eyelid lift and contour. Similar procedure is repeated for the right eye. Silicone sleeve is passed over the two ends of silicone rod that are brought out through the central brow incision.25
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The eyelid height is adjusted to the desired level by applying traction over each end of the silicone rod.
The silicone sleeve can be transfixed to subcutaneous tissues with 6-0 prolene suture. Cut ends of silicone rods are tucked into superior subcutaneous pocket, and the wound is closed with interrupted 6-0 prolene sutures. Frost suture is applied.26
 
Complications of Ptosis Surgery
  • Undercorrection is the most frequent complication. Persisting undercorrection may be treated with repeat surgery after 4 to 6 months.
  • Overcorrection is rare but could easily occur following surgery for acquired ptosis. Methods to treat overcorrection include downward traction over lashes against forced upgaze, downward traction over the eyelid with forceps, and surgical correction.
  • Localized lid contour abnormalities are treated by loosening the cardinal suture for localized peaking, and further small levator resection for localized flattening.
  • Lid crease abnormalities include absence of a crease, improper position and overhanging skin. Lid crease abnormalities may require reformation of the eyelid crease at the desired level.
    27
 
EYELID RECONSTRUCTION
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Large full thickness defects of the eyelid require lid-sharing procedures. Cutler Beard is the most commonly performed two stage eyelid sharing procedure.
Cutler Beard Stage I: Area of excision marked is in a rectangular fashion.
Full-thickness marginal cuts, and skin incision is performed along the marking.28
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Full-thickness excision is completed with straight scissors. Upper eyelid coloboma is created after excision of tumor.29
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Lower eyelid flap is marked, starting 4 to 5 mm below lower eyelid lash line.30
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Full-thickness lower eyelid flap is created, and brought up under the lower eyelid margin.31
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The anterior and posterior lamella of the flap is separated. Posterior lamella is sutured to the levator and conjunctiva of upper eyelid coloboma.32
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Skin is sutured with interrupted 6-0 silk sutures.33
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Cutler Beard Stage II: The bridge flap is exposed. Skin is incised with Bard-Parker blade, and soft tissue is incised differentially to obtain a longer length conjunctiva.34
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The conjunctival edge is rolled outwards, and sutured to skin edge with continuous 6-0 vicryl sutures.35
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Appearance of the upper eyelid margin after the two epithelial edges are sutured.36
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Upper border of the lower eyelid wound is marked and freshened with Bard-Parker blade.37
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The posterior lamella of the lower eyelid is sutured to lower border of the tarsus with 6-0 vicryl sutures.
 
Complications of Eyelid Reconstruction
Common complications include localized eyelid defect, notching or malposition. Upper eyelid entropion is common and requires electrolysis of offending skin hair. Lymphedema following reconstruction with periocular flaps usually settles with time.38
 
LOWER LID ECTROPION
 
Kuhnt-Szymanowski Procedure
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This procedure is preferred in patients with excessively lax anterior lamella, without lateral canthal tendon laxity. Skin incision is placed 2 mm below lash line from inferior punctum to lateral canthus and beyond.39
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Skin flap is raised without orbicularis, and pentagon is marked for excision assessing the eyelid laxity. Full-thickness pentagon is excised, and closed in a standard manner.40
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Excess anterior lamella is excised.41
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Subciliary incision is closed with interrupted 6-0 prolene sutures.42
 
UPPER LID ENTROPION
 
Tarsal Wedge Resection
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This is the procedure of choice in cases of upper lid entropion who have an intact or thickened tarsus. Eyelid traction sutures are placed, and upper eyelid crease incision is made.43
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Orbicularis is separated to expose the anterior tarsal surface. Marking is made along the entire extent of tarsus 4 mm away from the lash line with radiofrequency monopolar cautery.44
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Partial-thickness tarsal wedge is resected along the marking with triangular tip Ellman monopolar cautery. This step can also be performed using No. 15 Bard-Parker blade.45
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Double armed 6-0 vicryl sutures are passed across the wedge, and can be brought out through the skin 2 mm above the lash line. These sutures are tightened to evert the distal tarsus. Skin muscle strip is excised from upper edge of skin incision.46
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Orbicularis and skin are closed in layers with 6-0 interrupted sutures.47
 
BOTULINUM TOXIN IN CHEMODENERVATION
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Botulinum toxin is an exotoxin produced by Clostridium botulinum. Botox ® (Allergan, Irvine, CA) can be used by diluting 100 unit vial with 4 ml or 2 ml of non-preserved normal saline to obtain a dilution of 2.5 units/0.1ml or 5 units/0.1ml respectively. Common sites for injection for managing Benign Essential Blepharospasm are shown. Similar sites can be injected unilaterally for hemifacial spasm.48