Eyelid Surgery: A Fresh Perspective on Correcting Common Conditions [1st ed. 2023] 303131526X, 9783031315268

Citation preview

Eyelid Surgery A Fresh Perspective on Correcting Common Conditions Vladimir Thaller

123

Eyelid Surgery

Vladimir Thaller FRCOphth, FRCS

Vladimir Thaller

Eyelid Surgery A Fresh Perspective on Correcting Common Conditions

Vladimir Thaller Royal Eye Infirmary Plymouth, UK

ISBN 978-3-031-31526-8 ISBN 978-3-031-31527-5 (eBook) https://doi.org/10.1007/978-3-031-31527-5 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To my teacher, mentor, and friend, Richard Collin, in gratitude for showing me the way.

Foreword: Keeping Eyelid Surgery Simple—A Surgical Manual

Many medical texts attempt to cover all issues and repeat concepts prevalent at the time of writing—including those ideas that are ill-conceived or, in some cases, clearly wrong. As thoughts change slowly with time, this leads to most textbooks becoming out-of-date fairly soon and requiring frequent revision if to remain of value. It therefore is particularly refreshing to have a manual of eyelid surgery using a frank and logical teaching of principles and practice, this arising through the author’s evolution as a surgeon and based on decades of practical experience. A lesson is usually best remembered where teaching is presented with a touch of humour, and in a well-explained fashion: To do the latter requires an enquiring and objective mind (as mathematician Alfred North Whitehead said, “It requires a very unusual mind to undertake the analysis of the obvious”), and to provide the former requires a slight sense of mischief and humour. For the 40 years we have been acquainted, Ok Thaller has certainly shown both the analytical and a humorous mindset! The author is not afraid to discuss experience learnt through both good and bad results, and many of his ideas were ahead of their time, challenging the common attitude of “that is the way it has always been done”? Einstein said, “the only source of knowledge is experience”, and this condensation of the author’s life experience provides an invaluable—and enjoyable—resource for both trainee and more experienced surgeons. We must congratulate and thank Ok Thaller for condensing the broad spectrum of eyelid surgery into a practical and highly readable manual, and remember that “a person who never made a mistake never tried anything new” (Einstein). It is very clear that the author has tried many new things, very wisely learnt from any such misjudgements, and has had the courage to pass on this knowledge to the next generation. We “all build on the shoulders of giants”, and this book is not only a delight to read, but also a particularly thoughtful foundation on which we can continue to build a better future for those trusting in our care. January 2023

Geoffrey E. Rose, D.Sc., FRCOphth

vii

Preface

Why? Experience is simply the name we give our mistakes. —Oscar Wilde

I admit to not being an avid reader of textbooks, probably because I still read in the way I was taught to as a child. In mitigation, it may be that most textbooks were not written to be read, merely consulted. Either way, what follows is a basic surgical manual, not a textbook! Similarly, I have yet to outgrow the annoying childhood habit of always asking “Why?”. Often, I am surprised by the lack of clear answers. Now, at the end of a career’s worth of surgical “experience”, I feel honour bound to attempt at least to pass on my few, hard gained, answers. Although we are each destined make our own mistakes, all must start from somewhere. I consider this manual to be as good a starting point as any. May it set you on the right path. Plymouth, UK

Vladimir Thaller, FRCS, FRCOphth [email protected]

Acknowledgements I thank my many teachers for all they have taught me and for their kind forbearance at my endless questions. I include patients among my teachers. I have learnt much from them. The National Health service, for all its imperfections, is a wonderful altruistic organisation whose dedicated staff have supported me throughout my career and made me look forward to each working day. And last but not least I thank my dear wife Linda for her unwavering support and understanding.

ix

Contents

1

2

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 Congratulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3 The Target (Fig. 1.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.4 “Common Things are Common…Save Common Sense” . . . . . . 1.5 Less is More . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6 The Truth, NOT the Whole Truth, and Nothing But the Truth! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.7 A Matter of Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8 Heresy, Not Hearsay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9 Concept or Cookbook? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.10 10,000 hour Expert? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.11 Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.12 The Good Outcomes Secret . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.13 Style and Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.14 Exceptions Prove the Rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.15 Warning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 1 1 1 2 2

The Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2 Do Least Harm! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3 Surgery is Directed Scarring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4 The Healing Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4.1 Primary Intention Healing . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4.2 Secondary Intention Healing . . . . . . . . . . . . . . . . . . . . . . . 2.5 Stages of Wound Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.6 Thermal Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.7 Tension, Expansion, Migration, and Contraction . . . . . . . . . . . . . . 2.7.1 Tissue Expansion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.7.2 Suture Migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.7.3 Contraction (Hydrocortisone Ointment and Massage) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.8 The Dog Ear Dilemma (Waste Not, Want Not!) (Fig. 2.3) . . . . 2.9 Active v Passive Surgical Mechanisms (Fig. 2.5) . . . . . . . . . . . . .

7 7 7 8 8 8 8 8 9 9 9 9

2 3 3 3 4 4 4 4 5 5

10 12 14 xi

xii

Contents

2.10 2.11 2.12

The Kit (Instruments) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Haemostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.12.1 Vasoconstriction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.12.2 Positioning (Fig. 2.6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.12.3 Diathermy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.12.4 Cut Uphill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Plication v Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Post-operative Antibiotics and Padding . . . . . . . . . . . . . . . . . . . . . . . 2.14.1 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fail-Safe Redundancy (Fig. 2.7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15 15 16 16 16 17 17 17 17 18 18 19

3

Sutures and Suturing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2 Suture Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.1 Absorbable v Non-absorbable . . . . . . . . . . . . . . . . . . . . . . 3.2.2 Suture Tension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.3 Suture Gauge (Table 3.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.4 Knotting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.5 Monofilament v Braided . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.6 Suture Needles (Fig. 3.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.7 Needle Shape (Fig. 3.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3 Suturing Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.1 Interrupted v Continuous (Fig. 3.3) . . . . . . . . . . . . . . . . . 3.3.2 Suture Bite Spacing (Fig. 3.4) . . . . . . . . . . . . . . . . . . . . . . 3.3.3 Suture Spaghetti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.4 Simple v Mattress (Fig. 3.5) . . . . . . . . . . . . . . . . . . . . . . . . 3.3.5 Horizontal v Vertical Mattress (Fig. 3.7) . . . . . . . . . . . . 3.3.6 The Humble Horizontal Mattress (Fig. 3.8) . . . . . . . . . 3.3.7 The ‘Magic Suture’ (Fig. 3.9) . . . . . . . . . . . . . . . . . . . . . . 3.4 The Cotton Bud: An Aid to Suturing . . . . . . . . . . . . . . . . . . . . . . . . . 3.4.1 Steps (Fig. 3.11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21 21 22 22 22 22 23 23 23 24 25 25 26 26 27 28 30 30 33 33 34 34

4

Pertinent Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 The Lid Skeleton (Fig. 4.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2.1 Canthal Tendons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2.2 Orbital Septum (7 Veils) . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3 Lid Layers (or Lamellae) (Fig. 4.2) . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.1 Anterior Lamella (Fig. 4.2a) . . . . . . . . . . . . . . . . . . . . . . . . 4.3.2 Posterior Lamella (Fig. 4.2b) . . . . . . . . . . . . . . . . . . . . . . . 4.3.3 In-Between . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35 35 35 35 36 36 36 37 37

2.13 2.14 2.15 2.16

Contents

4.4

xiii

Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4.1 Skin Tension Lines (Langer’s Lines) (Fig. 4.3) . . . . . . Don’t Get Lost (Surgical Landmarks) (Fig. 4.4) . . . . . . . . . . . . . . Tarsal Plate (Fig. 4.6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Meibomian Orifice Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Grey Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pre-aponeurotic Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lacrimal Ductules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Blood Supply (Fig. 4.7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Rest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38 38 39 40 40 40 41 41 41 43 45 45

5

Fundamental Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 Overview (Fig. 5.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 Lid Margin Repair (Fig. 5.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.1 Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.2 Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.4 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3 Lateral Canthal Repair (Fig. 5.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3.1 Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3.2 Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4 The Magic Suture (Fig. 5.4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4.1 Principle and Considerations . . . . . . . . . . . . . . . . . . . . . . . 5.4.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4.4 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5 Tarsal Traction Suture (Fig. 5.6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5.1 Principle and Considerations . . . . . . . . . . . . . . . . . . . . . . . 5.5.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5.4 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6 Emergency Cantholysis (Fig. 5.7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6.1 Principle and Considerations . . . . . . . . . . . . . . . . . . . . . . . 5.6.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6.4 Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.7 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

47 47 48 49 50 50 51 53 53 53 53 55 56 56 56 58 58 59 59 59 60 60 61 61 61 61 61

6

Eyelid Malposition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1 Overview (Fig. 6.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2 Lid Stability (Fig. 6.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2.1 Tarsal Plate Width . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2.2 Orbicularis Tone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

63 63 64 64 64

4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.12 4.13 4.14

xiv

Contents

6.2.3 Lid/Globe Apposition and Volume Deflation . . . . . . . . 6.2.4 Gravity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2.5 Retractor Tethering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.3 The Palpebral Aperture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.4 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.5 Significance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.6 Causation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.7 Don’t Strip! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.8 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

64 65 65 65 66 66 66 67 68 68

7

Ingrowing Eyelashes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2 Treatment Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2.1 Epilation (Fig. 7.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2.2 Electrolysis to the Lash Root . . . . . . . . . . . . . . . . . . . . . . . 7.2.3 Localized Full Thickness Lid Margin Resection . . . . . 7.2.4 Localized ‘en bloc’ Lash Resection . . . . . . . . . . . . . . . . . 7.2.5 Lash Cryotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2.6 Anterior Lamellar Repositioning . . . . . . . . . . . . . . . . . . . . 7.3 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

69 69 70 70 70 70 71 71 71 71

8

Entropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2 Types of Entropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2.1 Congenital Entropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2.2 Involutional (Age Related) Entropion . . . . . . . . . . . . . . . 8.2.3 Cicatricial Entropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.3 Entropion Assessment/Examination . . . . . . . . . . . . . . . . . . . . . . . . . . 8.3.1 Lid Tone and Laxity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.3.2 Medial Canthal Tendon and Lateral Canthal Tendon Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.3.3 Conjunctival Scarring/Symblepharon . . . . . . . . . . . . . . . 8.3.4 Orbicularis Over-Riding . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.4 Temporary Lower Lid Involutional Entropion Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.4.1 Taping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.4.2 Botulinum Toxin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.4.3 Everting (Quickert) Sutures . . . . . . . . . . . . . . . . . . . . . . . . 8.5 ‘Permanent’ Surgical Correction of Involutional Entropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.5.1 Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.5.2 The Lid Shortening Rule . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.6 Lateral Lid Margin Resection and Modified Bick Repair (Fig. 8.7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.6.1 Principle and Considerations . . . . . . . . . . . . . . . . . . . . . . .

73 73 73 73 74 75 76 76 76 76 76 77 77 77 78 79 79 79 79 79

Contents

8.6.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.6.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.6.4 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.7 Lower Lid Retractor Plication (Fig. 8.8) . . . . . . . . . . . . . . . . . . . . . . 8.7.1 Principle and Considerations . . . . . . . . . . . . . . . . . . . . . . . 8.7.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.7.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.8 Posterior Medial Canthal Thermoplasty . . . . . . . . . . . . . . . . . . . . . . 8.8.1 Principle and Considerations . . . . . . . . . . . . . . . . . . . . . . . 8.8.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.8.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.8.4 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.9 ‘Permanent’ Surgical Correction of Moderate Cicatricial Entropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.9.1 Anterior Lamellar Repositioning . . . . . . . . . . . . . . . . . . . . 8.9.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.9.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.10 Mucosal Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.11 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Ectropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.3 Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.3.1 Congenital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.3.2 Involutional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.3.3 Eye Rubbing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.3.4 Cicatricial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.3.5 Paralytic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.4 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.4.1 Relative Lid/Globe Laxity (Invariably Present) . . . . . . 9.4.2 Medial Canthal Tendon and Lateral Canthal Tendon Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.4.3 Anterior Lamellar Insufficiency . . . . . . . . . . . . . . . . . . . . . 9.4.4 Orbicularis Tone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.5 Temporary Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.6 Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.7 Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.7.1 Lid Margin Wedge Resection and Bick Repair . . . . . . 9.7.2 Medial Lower Lid Retractor Plication (Fig. 9.6) . . . . . 9.7.3 Central Lower Lid Retractor Posterior Plication (Fig. 9.7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.7.4 Free Skin Graft (Fig. 9.8) . . . . . . . . . . . . . . . . . . . . . . . . . . 9.7.5 Upper to Lower Lid Skin Pedicle Flap (Fig. 9.9) . . . .

xv

79 80 84 84 84 86 86 87 87 87 87 89 89 89 90 90 92 92 93 95 95 95 96 96 96 96 97 97 97 97 98 98 98 98 99 100 100 104 106 108 111

xvi

Contents

9.7.6

9.8

Permanent (Overlap) Lateral Tarsorrhaphy (Fig. 9.10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 9.7.7 Medial Canthoplasty (Fig. 9.11) . . . . . . . . . . . . . . . . . . . . 115 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

10 Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.1 Overview (Fig. 10.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.2 Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.2.1 Vertical Palpebral Aperture (PA) . . . . . . . . . . . . . . . . . . . . 10.2.2 Levator Function (LF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.2.3 Skin Crease (SC) and Skin Fold (SF) (Fig. 10.5) . . . . 10.2.4 ‘Hang-Up’ in Downgaze (Fig. 10.6) . . . . . . . . . . . . . . . . 10.3 Types of Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.3.1 Congenital Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.3.2 Acquired Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.4 Choice of Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.5 Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.5.1 White Line Advancement (Anterior Approach) Fig. 10.8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.5.2 Conversion to an Anterior Levator Aponeurosis Reinsertion/Resection Fig. 10.9 . . . . . . . . . . . . . . . . . . . . . 10.5.3 Levator Resection Fig. 10.10 . . . . . . . . . . . . . . . . . . . . . . . 10.5.4 Addition of a Skin and Muscle Blepharoplasty Fig. 10.11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.5.5 Müller’s Muscle Resection Fig. 10.12 . . . . . . . . . . . . . . 10.5.6 Frontalis Suspension (Fox’s Pentagon) Fig. 10.13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.6 General Observations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.6.1 Lower Lid Traction Suture Fig. 10.14 (See Chap. 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.6.2 ‘On Table’ Lid Height . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.6.3 Post-operative Adjustment—Early Suture Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.6.4 Hering’s See-Saw (Fig. 10.15) . . . . . . . . . . . . . . . . . . . . . . 10.7 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

119 119 120 120 121 122 124 124 124 124 125 127

144 144 145 145

11 Dermatochalasis and Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.2 Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.3 Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.4 Upper Lid Skin and Muscle Blepharoplasty (Fig. 11.1) . . . . . . . 11.4.1 Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.4.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

147 147 147 147 148 148 148

127 131 133 134 137 138 142 142 143

Contents

11.5 11.6 11.7

xvii

Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

12 Lid Lumps and Bumps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.2 Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.2.1 Meibomian Cyst Incision and Curettage (I & C) . . . . 12.3 Tumour Excision (Fig. 12.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.3.1 First is Best . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.3.2 Clear Cutaneous Margins . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.3.3 Stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.3.4 Deep Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.3.5 Waste Not, Want Not . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.3.6 Beware the Canthi (Fig. 12.3) . . . . . . . . . . . . . . . . . . . . . . 12.3.7 Biopsy: Excision V Incision . . . . . . . . . . . . . . . . . . . . . . . . 12.3.8 Histology First! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.3.9 One Stop Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.4 Full Thickness Lid Margin Tumour Resection (Fig. 12.4) . . . . . 12.4.1 Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.4.2 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.5 Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

153 153 153 154 155 156 157 157 157 157 158 158 158 159 159 160 160 160

13 Eye Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.1 Overview (Fig. 13.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.2 Occlusive Dressing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.3 Manual Blink (Fig. 13.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.4 ‘Cling Film’ Occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.5 Closing the Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.5.1 Not the ‘Grey Line’! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.5.2 Avoid Toxin Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.5.3 The ‘Tarsal Traction Suture’ (see Chap. 5) . . . . . . . . . . 13.5.4 Non-tarsal Traction (Fig. 13.5) . . . . . . . . . . . . . . . . . . . . . 13.5.5 Temporary Central Suture Tarsorrhaphy (Fig. 13.6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.5.6 Temporary Lateral Suture Tarsorrhaphy (Fig. 13.6e) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.5.7 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.6 Permanent Surgical Tarsorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.6.1 Permanent (Overlap) Lateral Tarsorrhaphy (Fig. 13.7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.6.2 Permanent Medial Canthoplasty (Fig. 13.8) . . . . . . . . . 13.6.3 Lower Lid Lifting (Fig. 13.9) . . . . . . . . . . . . . . . . . . . . . . . 13.7 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

161 161 162 162 163 163 163 164 164 166 167 167 169 169 169 172 173 174

xviii

Contents

14 Lid Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.2 The Reconstruction Ladder (Fig. 14.2) . . . . . . . . . . . . . . . . . . . . . . . 14.3 Upper Lid Essential, Lower Lid Optional! . . . . . . . . . . . . . . . . . . . . 14.4 Proof of Cure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.5 Eyelid Tension: Normal and Necessary . . . . . . . . . . . . . . . . . . . . . . . 14.6 Don’t Undermine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.7 Direct Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.7.1 Tissue Expansion (Fig. 14.6) . . . . . . . . . . . . . . . . . . . . . . . 14.7.2 No Cantholysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.7.3 Closure Scar Lengthening . . . . . . . . . . . . . . . . . . . . . . . . . . 14.8 Direct Closure of Lid Margin Defect (Fig. 14.8) . . . . . . . . . . . . . . 14.8.1 Principles and Considerations . . . . . . . . . . . . . . . . . . . . . . 14.8.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.8.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.9 The Trans Incisional Tarsal Traction Suture (Fig. 14.9) . . . . . . . 14.9.1 Principle and Considerations . . . . . . . . . . . . . . . . . . . . . . . 14.9.2 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.10 Direct Closure of a Skin Defect (Fig. 14.10) . . . . . . . . . . . . . . . . . 14.10.1 Principle and Considerations . . . . . . . . . . . . . . . . . . . . . . . 14.10.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.10.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.11 Directed Laissez-Faire (Incomplete Direct Closure) . . . . . . . . . . . 14.11.1 Principle and Considerations . . . . . . . . . . . . . . . . . . . . . . . 14.11.2 Directed Laissez-Faire of a Lid Margin Defect (Fig. 14.11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.11.3 Directed Laissez-Faire of Skin Defect (Fig. 14.12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.12 Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.12.1 Paper Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.12.2 Upper to Lower Lid Skin Flap (Fig. 14.16) . . . . . . . . . 14.12.3 Cheek Pedicle Flap (Fig. 14.17) . . . . . . . . . . . . . . . . . . . . 14.12.4 Mustardé Lower Lid Switch Flap . . . . . . . . . . . . . . . . . . . 14.13 Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.13.1 Skin Graft Donor Sites (Fig. 14.20) . . . . . . . . . . . . . . . . . 14.13.2 Alternative Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.13.3 Skin Graft Harvesting (Fig. 14.21) . . . . . . . . . . . . . . . . . . 14.13.4 Split Skin Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.13.5 Mucous Membrane Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . 14.14 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.15 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

175 175 176 177 178 178 178 179 180 182 182 183 183 183 183 187 187 188 188 188 188 189 190 190 190 192 194 195 196 198 199 204 204 205 205 207 207 207 207 207

Contents

xix

15 Revision Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.2 Avoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.3 Healing Shrinks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.3.1 Pout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.3.2 Planes Contract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.4 Faces Are Mobile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.5 Delay (Fig. 15.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.6 Analyse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.7 Lengthen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.8 Transverse Release-Plasty (Fig. 15.5) . . . . . . . . . . . . . . . . . . . . . . . . 15.8.1 Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.8.2 Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.8.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.8.4 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.9 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

209 209 209 209 210 211 211 211 212 212 213 213 214 214 215 215

16 Watering Eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.2 Causes (Fig. 16.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.3 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.3.1 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.3.2 Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.3.3 Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.3.4 Lacrimal Syringing (Fig. 16.2) . . . . . . . . . . . . . . . . . . . . . 16.3.5 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.4 Treatment Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.4.1 Lacrimal Mucocoele Expression (Fig. 16.3) . . . . . . . . . 16.4.2 Lacrimal Probing (± Silicone Intubation) . . . . . . . . . . . 16.4.3 Punctal Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.4.4 Punctal Inversion Surgery (Fig. 16.8) . . . . . . . . . . . . . . . 16.4.5 Lid Margin Tightening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.4.6 Lacrimal Drainage Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 16.5 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

217 217 217 218 218 219 220 220 222 222 222 223 225 228 230 230 232 232

17 Eye Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.2 Specific Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.3 Evisceration V Enucleation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.4 Evisceration (Fig. 17.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.4.1 Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.4.2 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.5 Enucleation (Fig. 17.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.5.1 Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.5.2 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

233 233 233 234 234 234 234 236 236 236

xx

Contents

17.6

17.5.3 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

18 Socket Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.2 Socket Lining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.3 Orbital Implantation (Fig. 18.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.3.1 Implant Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.3.2 Implant Material and Shape . . . . . . . . . . . . . . . . . . . . . . . . 18.3.3 Implantation Following Evisceration (Fig. 18.4) . . . . . 18.3.4 Implantation Following Enucleation (Fig. 18.5) . . . . . 18.4 Orbital Implant Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.4.1 Conjunctival Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.4.2 Early or Late Wound Dehiscence . . . . . . . . . . . . . . . . . . . 18.4.3 Implant Migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.4.4 Late Implant Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.4.5 Post Enucleation Socket Syndrome (Fig. 18.7) . . . . . . 18.4.6 Lower Lid Laxity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.4.7 Upper Lid Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.5 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

241 241 241 242 242 244 244 246 247 247 249 249 250 251 252 252 252 252

19 Thyroid Eye Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.1 Overview (Fig. 19.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.2 Wet or Dry? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.3 Immunosuppression of Active TED . . . . . . . . . . . . . . . . . . . . . . . . . . 19.3.1 Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.4 Orbital Triamcinolone Injection [2] . . . . . . . . . . . . . . . . . . . . . . . . . . 19.4.1 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.4.2 Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.4.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.4.4 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.5 Surgical Management of Inactive (Dry) Thyroid Eye Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.5.1 Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.5.2 Inferior Rectus Recession with Lid Retractor Recession (Fig. 19.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.5.3 Eyelid Recession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.6 Upper Lid Blepharotomy [3] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.6.1 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.6.2 Steps (Fig. 19.7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.6.3 Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.7 No Spacers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.8 Lower Lid Retractor Recession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.8.1 Considerations and Principle . . . . . . . . . . . . . . . . . . . . . . . 19.8.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

253 253 254 255 255 256 256 256 256 257 257 258 258 264 265 265 266 267 267 267 267 268

Contents

19.8.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.8.4 Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.9 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xxi

268 270 270 270

20 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271

1

Introduction

1.1

Overview

• Is this book for you? • This book’s philosophy and style.

1.2

Congratulations

Congratulations on choosing the eyelids as your surgical field! Being functional as well as aesthetic units, you should find them an absorbing challenge. In terms of healing, there is no better or more forgiving part of the body, unlike for example an elderly shin. Consequently, your repairs and grafts should invariably heal well. However, the outcomes of your endeavours will be very visible (‘in your face’ as they say), so you’d better get them right the first time! I hope that the tips contained in the following pages help you in this respect.

1.3

The Target (Fig. 1.1)

This book is a practical manual for anyone performing eyelid surgery. It is particularly aimed at those in training, including non-oculoplastic surgeons who venture into this field. Experienced colleagues may find some of the content unconventional (to put it kindly). Please indulge me by not dismissing my novel ideas and assertions out of hand. Instead, give them your critical consideration, perhaps even try them out? You might be pleasantly surprised. Dear reader, if you have an interest in eyelid surgery and an open mind, please read on!

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_1

1

2

1

Introduction

Fig. 1.1 Target audience

1.4

“Common Things are Common…Save Common Sense”

Lid surgery, like many other things, follows the 80–20 rule (known as the Pareto principle). Eighty percent of your surgery is for the mere 20% of conditions that are common. This book aims to help you get that 80% of common operations right the first time by promoting simple, safe, and above all, effective techniques. It is not comprehensive making no attempt to cover less usual conditions or critique the myriad of alternative operations. Established texts already do this admirably. However, in my humble opinion some popular operations fail the commonsense test, so here I only describe techniques which make sense to me.

1.5

Less is More

You will discover that I favour a minimalist approach to surgery to do “the least harm”. As an enthusiastic novice I had a naïve faith in the benefits of surgery. Experience tempered that enthusiasm with the realization that surgery is always a trade-off, and the risk of complications is ever present.

1.6

The Truth, NOT the Whole Truth, and Nothing But the Truth!

This book builds on sound foundations handed down by generations of innovative surgeons. Everything I have included is based on my personal experience and I currently believe it to be true. But learning continues and beliefs change. So, ‘my current truth’ cannot be the whole truth and will, in time, be superseded by new knowledge. I challenge you to add to that knowledge base, as I have tried to do.

1.9 Concept or Cookbook

1.7

3

A Matter of Principle

Look for the principles behind each operation. Your chosen procedure should address all the factors you believe to be causing a particular problem. Analyse your current and future surgical repertoire on this basis, to help you discern the best of several options. Doing so may even stimulate you to develop your own improvements.

1.8

Heresy, Not Hearsay

Some of what I describe is unorthodox and does not appear in or even contradicts existing textbooks. I challenge some popular practices e.g., use of the lateral tarsal strip procedure, or employing complex reconstructions when direct closure would suffice. Some regard this as heresy. The following heresies are currently unique to this manual: • Meibomian orifice line superiority over the grey line • Suture tarsorrhaphy as a replacement for temporary surgical tarsorrhaphy • Maximizing the use of direct closure, directed laissez-faire, and tissue expansion in eyelid reconstruction • The magic suture subcutaneous closure • Medial canthal thermoplasty • Control of active thyroid eye disease with depot orbital steroid injections • Full orbital volume replacement of after eye removal • Modified Bick lid margin resection in preference to the lateral tarsal strip for lid tightening • Transverse release-plasty of radial traction bands.

1.9

Concept or Cookbook?

Individual learning styles vary. Some of us will always practise ‘painting by numbers’ surgery. The step-by-step instructions in this manual should cater to your taste. Like a recipe, these ‘cook-book’ instructions generally give good outcomes. They are the best way for a novice to learn. Those of an artistic or inquisitive nature will gain more from understanding the principles outlined and adapt the procedures described to suit specific situations.

4

1.10

1

Introduction

10,000 hour Expert?

No book can take the place of ‘hands on’, supervised, surgical experience. However, the saying “practice makes perfect” only holds true if you practise the right things. This manual guides you in that ‘right direction’.

1.11

Challenge

In this book I sometimes question accepted treatments. I challenge you to do the same and analyse alternative operations critically, particularly when you try new techniques. You can only do this by auditing your own outcomes.

1.12

The Good Outcomes Secret

Good outcomes are more likely when you operate on patients who by the nature of their condition should do well. For example, a ptosis patient with normal levator function should do better than one with poor levator function. Case selection may be a luxury for a veteran but is essential for the less experienced surgeon who needs positive outcomes in order to acquire the confidence needed to progress. This book aims to build that confidence by promoting simple and safe procedures for appropriately selected patients.

1.13

Style and Structure

I have chosen a didactic, first-person style for this manual. Most chapters loosely follow the structure below: • • • • • •

Overview Introduction Principle and considerations Case selection (indications) Steps (technique, method) Notes (variations / discussion / surgical pitfalls / what can go wrong / complications) • Take home message You will notice much repetition for which I make no apologies. Firstly, should you delve in mid-way I would not want you to miss important points mentioned previously. Secondly, the repetition helps to reinforce the message. I have included few references because references are not the authority behind this volume. My personal experience is. The selected references which are included are there to support some of my more contentious assertions.

1.15 Warning

1.14

5

Exceptions Prove the Rule

Occasionally I have broken my own rule by including uncommon procedures because they are so important, e.g., Emergency lateral canthotomy and upper lid reconstruction using the Mustardé lid switch flap.

1.15

Warning

As a single author work this book is necessarily biased. It is neither comprehensive, nor a typical surgical textbook. Beware, you may find some of the unorthodox concepts and techniques which I promote useful and possibly infectious. My not so hidden agenda is to help you to improve your surgical outcomes.

2

The Basics

2.1 • • • • • • • •

Overview

Surgery = directed scarring Primary v secondary intention healing Tension, expansion, migration and contraction Active v passive operations Surgical instruments Anaesthesia Haemostasis Plication v resection

2.2

Do Least Harm!

The famous exhortation to physicians to “First do no harm”, sounds laudable but is impossible for a surgeon. Fundamentally, all surgery involves judicious wounding, albeit with altruistic intent. So, while we cannot avoid harm, we should strive to limit our wounding to the minimum required to achieve our goal, for example by not undermining unnecessarily the naturally mobile skin around the eye. Similarly, do not use a flap or graft to repair a lid defect that you can close directly. Virgin tissue is always better than an additional avoidable scar.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_2

7

8

2.3

2 The Basics

Surgery is Directed Scarring

Having first wounded the patient, the benefits of surgery derive from ensuring that the tissues heal in the desired way. To achieve this, we direct the healing with sutures. In lid surgery the direction of the suture induced tension is all important.

2.4

The Healing Response

Millennia of evolution have equipped us with amazing powers of healing. All wounds heal in one of two ways, referred to as primary intention and secondary intention healing.

2.4.1 Primary Intention Healing Primary intention healing occurs when a wound’s edges are brought together and held, usually with sutures, long enough for healing to take place. On the face such wounds heal very quickly and are usually secure within 5 to 7 days. However, it may take 6–8 weeks for them to attain maximum strength. Align wound edges ‘anatomically’ (layer by layer) to restore the best function and appearance.

2.4.2 Secondary Intention Healing Evolution has ensured that gaping wounds still heal even when their edges are not brought together. Such healing takes longer, the length of time depending on the degree of wound edge separation. The process by which this occurs is known as healing by secondary intention. It results in larger scars, and therefore we use it less. But, in many cases, the ultimate result is acceptable. It is a viable alternative to a graft or flap repair which are both more complex and create additional donor site scars. Note that secondary intention scars contract radially in all directions creating forces that a free lid margin is unable to resist. This results in lid margin retraction.

2.5

Stages of Wound Healing

The stages of wound healing are similar for both types of healing. They are: 1. Haemostasis. Fibrin clot formation occurs within seconds to minutes of wounding and, apart from assisting haemostasis, provides the scaffold for stage 3. As surgeons we are often impatient and assist haemostasis by coagulating vessels that continue to bleed with heat in the form of diathermy or cautery. Keep this to a minimum as burns cause further tissue damage and incite fibrosis. Simply applying local pressure and waiting a few minutes can be as effective.

2.7 Tension, Expansion, Migration, and Contraction

9

2. Inflammatory. Starting immediately, this phase continues for several days. It involves leakage of intravascular fluid into the tissues causing swelling, pain, and redness. The relevance of this phase for the reconstructive surgeon is that the suture holding strength of inflamed tissues is significantly reduced and they are more prone to bleed at operation. This makes early delayed wound repair more difficult. Therefore, if wound repair must be delayed it is better to delay it by several days until the acute inflammatory phase has subsided. 3. Proliferative. This phase starts at about three days and continues for several weeks. Myofibroblast invade the clot and contract to pull the edges together and make the wound smaller. Type III collagen is laid down. Surface epithelialisation occurs during this phase. 4. Maturation/remodelling. Scar remodelling begins at 3–4 weeks and continues for 1–2 years. The type III collagen is converted to type I and the scars soften and thin. When possible, delay any revision surgery you plan until this phase is well under way. The surgery will be easier to perform and its outcome more predictable.

2.6

Thermal Burns

Thermal burns sometimes incite an ongoing scarring (cicatricial) process which can be difficult to manage. Use diathermy and cautery sparingly and avoid them on the skin to minimize visible scarring.

2.7

Tension, Expansion, Migration, and Contraction

2.7.1 Tissue Expansion Tissues subjected to sustained tension relieve that tension by elongating. You see an example of this in cicatricial ectropion. In this condition the sustained pull of a tight skin scar causes the lid margin to lengthen and sag so that it no longer sits against the eye. The expanded lid margin does not return to its original position after the traction has been surgically released. The phenomenon of tissue expansion is underused in lid reconstruction.

2.7.2 Suture Migration We use sutures to pull and hold tissues together during healing. If you tighten a suture too much it will either exceed its own tensile strength and break or tear through the tissue. What few people realise is that all sutures migrate. This is a process that allows a suture to move through tissues until all its tension is lost (Fig. 2.1). Individual cells in front of a tight suture temporarily divide and then

10

2 The Basics

a

b

Fig. 2.1 Suture migration. Sutures dissipate tension by migrating through tissues

reunite behind it. This allows the suture to pass through tissues without visible inflammation or scarring. The fact of suture migration calls into question the rationale behind using so called ‘permanent’ non-absorbable sutures. They may last permanently but their tension is most definitely transient, lasting only a matter of weeks. Consequently, the only two reasons for choosing non-absorbable sutures are their relative inertness (e.g., polypropelene v polygalactin) and their higher tensile strength. For eyelid surgery these differences are rarely relevant.

2.7.3 Contraction (Hydrocortisone Ointment and Massage) Linear scars shorten, wounds and grafts shrink concentrically. Because the lid margin is unattached it is unable to resist the pull of scar contraction and becomes distorted (Fig. 2.2a and b). These are facts of life. Can anything be done to reduce this? Yes, massage! Tissues under strain grow by ‘tissue expansion’ and ‘biological creep’. Therefore, repeatedly stressing tissues in a desired direction will lengthen them in that direction. Firmly massaging a scar can, to some extent, mitigate the inevitable contraction that is an integral part of the healing process. This contraction takes place within the first 6–8 weeks of healing. Massage is most helpful during this critical period. Thereafter tissue remodelling softens the scar naturally.

2.7 Tension, Expansion, Migration, and Contraction

11

a

b

Fig. 2.2 Scar contraction. a Linear lid margin scars contract along their length to cause a lid margin notch. b Tissue defects and scar planes contract radially, distorting the free lid margin

The same phenomenon takes place in scar planes which contract in two dimensions. The interface between a graft or skin flap and its recipient bed is such a scar plane. Scarring is the reason that the linear dimensions of full thickness skin grafts and flaps contract by about one third of their linear dimensions. Regular firm massage reduces this shrinkage. Start massage a week or so after surgery, to allow time for revascularization to occur. Use oils or ointments to protect the skin during massage. Whether the type of lubricant plays a role in the process is unclear. I recommend the sparing application of 1% hydrocortisone ointment as the lubricant for scar massage. The additional benefit of using a steroid ointment remains to be proven. However, this weak steroid does not carry significant risk during prolonged topical use. Hydrocortisone does help to reduce healing associated inflammation and can work wonders on the eczematous component of an ectropion prior to surgery. Very occasionally, massage with hydrocortisone alone can cure the ectropion, avoiding surgery altogether.

12

2.8

2 The Basics

The Dog Ear Dilemma (Waste Not, Want Not!) (Fig. 2.3)

You create tension across a wound whenever you close it. This tension is maximal at the widest point of the original wound, progressively decreasing towards its end(s) (Fig. 2.4a). As you pull the wound edges together the tension at the ends becomes negative compared to that at the centre. This pushes the slack tissue forward to form so called ‘dog ears’ (Fig. 2.4b). It is customary to extend defects into ellipses by removing additional skin at the ends, to smooth the tension transition and minimize dog ears (Fig. 2.4c and d). However, this extends the scar length and discards healthy skin. This is counterintuitive in periocular reconstruction where lid skin is in short supply. Fortunately, tissue tension acts to remodel scars and periocular dog ears usually disappear within a matter of months. So, I recommend ignoring dog ears and reassuring the patient that they are likely to vanish.

Fig. 2.3 Dog-ears

2.8

The Dog Ear Dilemma (Waste Not, Want Not!) (Fig. 2.3)

13

b a

c

d

Fig. 2.4 Dog-ears. Direct wound closure a results in closure scar tension b that is maximal centrally and reverses at each end to create dog ears of loose tissue. Converting a circular excision into an ellipse by excising extra tissue c lengthens the scar but smooths the tension transition d reducing dog ear formation

14

2.9

2 The Basics

Active v Passive Surgical Mechanisms (Fig. 2.5)

The mechanism by which any given operation achieves its purpose is active, passive, or a combination of both. By active we mean a procedure which reattaches a muscle or its tendon/aponeurosis or one that modifies the direction (vector) of a muscle’s action. Every time the muscle contracts it actively exerts its effect e.g., the levator muscle in ptosis correction. Such operations continue to work indefinitely. Passive operations on the other hand work by transferring or tightening non muscle connected tissues and do not involve altering muscle function e.g., lid margin resection and skin blepharoplasty (although both may involve functionally insignificant orbicularis muscle resection). Such passive operations fail in time as the tissues involved stretch under load (exceptions being bone, ligaments, and tendons). It is instructive to analyse the mechanism by which an operation achieves its effect.

Fig. 2.5 Active v passive mechanisms active operations rely on muscle action to achieve their effects

15

2.10

The Kit (Instruments)

Few surgical instruments are required in a basic lid set. The following list includes the essentials: 1. Large-toothed tissue holding forceps e.g., Toothed Adsons 2. Fine toothed tissue holding forceps e.g., Jayles forceps (long handled) and St Martins forceps (short handled) 3. Moorfields (non-toothed) tissue forceps. Used for holding conjunctiva, tenons fascia and silicone tubes 4. Fine Needle holders e.g., Castroviejo, locking 5. Scissors: a. Spring scissors e.g., Curved Westcott tenotomy, –for dissection b. Straight tenotomy, –for cutting tougher tissues c. Straight pointed, –for suture cutting and blunt dissection 6. Retractors e.g., 3 Desmarres (small, medium, and large) 7. Squint hooks e.g., 2 Squint hooks & 1 Chavasse hook. Can double as retractors 8. Eye protecting plate e.g., Berke-Jaeger lid plate 9. Straight bipolar diathermy forceps 10. Cotton buds (used as a surgical instrument for blunt dissection and counter pressure during suturing) 11. Artery clips (haemostats). Curved and straight 12. Bulldog (aneurysm) clips for holding pairs of suture ends together prior to tying. Additional specialist instruments are required for specific tasks e.g., Wright’s fascia needle for ptosis sling insertion or Thaller tarsal forceps (A6360 Altomed) for easy lid margin traction suture placement (see Chap. 13).

2.11

Anaesthesia

Most eyelid surgery can be performed under direct infiltration local anaesthesia. Lacrimal surgery is easier under general anaesthesia for both the patient and the surgeon. For lid surgery use local anaesthetic combined with adrenaline. The adrenaline induced vasoconstriction prolongs the duration of anaesthesia by slowing anaesthetic absorption. This doubles the total safe dose that may be administered, although toxicity is rarely a concern with the small volumes used for lid surgery. The true reason we use adrenaline is the vasoconstriction it causes which reduces bleeding and improves surgical field visibility. Unfortunately, adrenaline containing local anaesthetics sting more on injection as they are acidic.

16

2.12

2 The Basics

Haemostasis

Surgery relies on accurate anatomical orientation and dissection. Visualization is facilitated by good haemostasis.

2.12.1 Vasoconstriction Full vasoconstriction, following local adrenaline injection, takes longer to manifest than one might expect (about 15 min).

2.12.2 Positioning (Fig. 2.6) Position your patient with their upper body slightly raised on the operating table to reduce venous congestion and reduce bleeding. The head should be at least as high as the highest point on the patient’s chest or abdomen. This posture both aids venous return and reduces abdominal content pressure on the diaphragm, so improving breathing. This is important as hypercapnia causes vasodilation and bleeding.

Fig. 2.6 Patient posturing. Ensure the patient’s head is higher than the chest and abdomen to reduce bleeding

2.14 Post-operative Antibiotics and Padding

17

2.12.3 Diathermy Use bipolar diathermy for the eyelid (in preference to monopolar) and set it to the minimum power that works. To control coagulation further adjust the spacing between the bipolar forceps tips. The closer they are together, the stronger the current. Remember that once the tips meet, they short-circuit and cease to work.

2.12.4 Cut Uphill Cutting causes bleeding. Cutting in an ‘uphill’ direction causes the blood to flow away from the skin markings that you are trying to cut along. This makes life easier for you and less stressful for your assistant.

2.13

Plication v Resection

‘Plication’ means to tuck or pleat a tissue. The dissection and suturing involved produce relatively mild wounding and therefore little stimulus for the scarring (healing) needed to permanently hold the tissues in their new configuration. Resection means cutting and removing tissue (excision). This creates raw edges which are more likely to heal together strongly and permanently.

2.14

Post-operative Antibiotics and Padding

The applications of postoperative antibiotic ointment (usually Chloramphenicol) and a pressure dressing are deeply ingrained in oculoplastic practice. As neither has a strong evidence base, it is only right that we should now question their use. Despite this I strongly recommend postoperative pressure dressing following periocular surgery. The laxity of periocular tissues gives them a great propensity to swell. I believe that applying pressure to the surgical site reduces haematoma formation, bruising, and inflammatory phase exudation, leading to less strain on suture lines and faster rehabilitation. Furthermore, the dressing hides the surgical site from the patient’s view, reducing their immediate postoperative anxiety, and providing protection from interfering fingers. I find it harder to argue in favour of antibiotic ointment over an aseptic lubricant even though the traditional use of chloramphenicol ointment at the end of surgery has stood me in good stead over many years. More evidence is needed.

18

2 The Basics

2.14.1 Steps 1. Wash and dry the surgical site to remove any residual antiseptic skin-prep and blood. 2. Apply a thin coating of tincture of benzoin solution (Friar’s Balsam) to the surrounding skin and allow it to dry. This improves surgical tape to skin adherence. 3. Place a non-stick paraffin gauze or non-adherent film such at Tegapore® (3 M Health Care Ltd) over the surgical site. Fold the latter if it is too large as cutting it to size impairs its non-stick properties. 4. Apply Chloramphenicol ointment freely over the film. 5. Place one folded eye-pad over the orbital area followed by two more unfolded pads. 6. Tape this dressing in place with several overlapping strips of 1 (2.5 cm) elastic adhesive surgical tape to apply pressure. Press on the tape for a few seconds until it adheres fully. If your patient has a history of allergy to elastic surgical tape use a hypoallergenic stretchy alternative tape such as Blenderm® (3 M Health Care Ltd).

2.15

Fail-Safe Redundancy (Fig. 2.7)

Many of the operations described in this manual use more sutures than are strictly necessary to achieve the desired result, thus adding to the cost and duration of the procedure. While this goes against my ‘minimalist’ philosophy, the extra sutures are deliberately redundant to provide a degree of safety. Two sutures in a lateral canthal repair mitigate against a critical suture failure. Three levator aponeurosis sutures in ptosis correction are not only a fail-safe but also add a degree of control over the lid curve. Additional skin suturing after the wound is effectively closed by the retractor sutures allows for selective early retractor suture removal to resolve an overcorrection without fear of the wound opening. After all, would you go skydiving without a reserve parachute?

2.16 Take Home Message

Fig. 2.7 Fail-safe redundancy. Back-ups can avert disaster

2.16

Take Home Message

• Surgery is judicious wounding followed by suture directed healing. • Even permanent sutures have only a temporary effect.

19

3

Sutures and Suturing

3.1 • • • •

Overview

Suture characteristics Suturing techniques Mattress sutures The magic suture.

Although a plethora of surgical sutures exist, you can carry out most eyelid surgery using only four types of suture: • 6/0 Polygalactin 910 (Vicryl®) on an 8 mm ½ circle, spatulate cutting needle, (Ethicon W9756) • 7/0 Polygalactin 910 (Vicryl®) on an 8 mm 3/8 circle, spatulate cutting needle, (Ethicon W9561) • 4/0 Polygalactin 910 (Vicryl®) on a 20 mm ½ circle, spatulate cutting needle, (Ethicon W9113) • 4/0 Polypropelene (Prolene®) on a 17 mm ½ circle round-bodied taper-point needle (Ethicon W8557). Choose your suture according to the properties you require for the particular task.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_3

21

22

3.2

3

Sutures and Suturing

Suture Characteristics

3.2.1 Absorbable v Non-absorbable Much is made of the differences between non-absorbable (permanent) and absorbable sutures. Modern absorbable sutures usually take about two months to absorb fully. This is more than enough to allow satisfactory wound healing. Suture longevity is consequently an irrelevant characteristic except for the fact that non-absorbable sutures may require removal. The only significant difference between absorbable and non-absorbable sutures is the degree of inflammation that they incite. Absorbable sutures stimulate more inflammation due to enzymatic hydrolysis. In practice, for eyelid surgery, this difference is rarely important and polygalactin sutures may safely be used in the skin.

3.2.2 Suture Tension Sutures must be tied under sufficient tension to hold the tissues together. This tension dissipates within a matter of weeks as the suture migrates through the tissues. So, although non-absorbable sutures persist as foreign bodies and retain their strength, after a few weeks they no longer fulfil any useful function. Consequently, they are no more effective than absorbable sutures.

3.2.3 Suture Gauge (Table 3.1) Suture gauge refers to the cross-sectional area of the suture which correlates positively with the suture’s tensile strength. When you need more strength use a thicker suture. The suture diameter also correlates positively with its tissue holding ability. A thin suture cheese-wires through tissues more easily. Table 3.1 Commonly used suture gauges in relation to their metric diameters

USPa

Ø mm

7–0

0.05

6–0

0.07

4–0

0.15

a USP

= United States Pharmacopeia

3.2 Suture Characteristics

23

3.2.4 Knotting Silk is a naturally occurring polymer and braided silk sutures hold knots extremely well. A silk surgical knot will hold securely with only two successive single throws. Most other sutures are synthetic and prone to knot slippage and unravelling. Tie synthetic suture knots with a minimum of three single throws. I often add an ‘hysterical 4th’ throw to help me sleep better. Cut the knot suture ends no shorter than 2 mm to avoid spontaneous unravelling.

3.2.5 Monofilament v Braided Braided multifilament sutures are more compliant (bendy) and have less memory (springiness). The cut ends of monofilament sutures are sharp and can cause pricking under the skin. On the other hand, monofilament sutures are less likely to wick in bacteria and secretions that can cause a suture abscess.

3.2.6 Suture Needles (Fig. 3.1) Most surgical sutures are now supplied swaged to ‘atraumatic’ needles. In this context an ‘atraumatic needle’ is defined as an eyeless surgical needle with the suture attached to a hollow end. The needles however are far from ‘atraumatic’ to the tissues that they penetrate. They are in effect tiny knives with a point and

Fig. 3.1 Suture needle tip profiles. a Triangular cutting, b Spatulate cutting, c Taper point noncutting

24

3

Sutures and Suturing

two or three cutting edges. Hence, they are referred to as cutting needles. They cut tissue to ease their entry and passage. Cutting needles have either a triangular or a spatulate (flat) cutting profile. The former, as its name suggests, has three cutting surfaces, one always cutting inwards or outwards. The spatulate needle only has only two, cutting to either side. Spatulate needles are the more useful in oculoplastic surgery as the needle is less likely to inadvertently cut into or out of the delicate lid tissues. The one non-cutting needle is the ‘round bodied’ or ‘taper point’ needle which has only a sharp point and lacks a cutting edge. Its sharp point enables tissue penetration, and the tapered body stretches the opening to allow the needle and suture to pass. Its passage causes minimal tissue damage. It is the least likely to cut out of delicate tissues. The downside is that taper point needles require more force to penetrate tissues. This is not an issue in lid surgery.

3.2.7 Needle Shape (Fig. 3.2) Curved needles are the more useful for lid surgery. They allow shorter tissue bites to be taken. They come in different radii of curvature and arc of curve (1/4, 3/8 or ½ circle). The 8 mm, tightly curved ½ circle needles are especially suited to tarsal plate suturing.

1/2

3/8

1/4

a

b

c

Fig. 3.2 Curved suture needle arc. a Half circle needles are best for eyelid suturing. c Quarter circle needles are suited to suturing extraocular muscle to sclera

3.3 Suturing Techniques

3.3

25

Suturing Techniques

3.3.1 Interrupted v Continuous (Fig. 3.3) Interrupted sutures are knotted individually and are independent of each other (Fig. 3.3a and b). They take slightly longer to place but if one fails this does not affect the remaining sutures. Individual sutures can be removed selectively as necessary e.g., for a suture abscess, without weakening the remainder of the wound. Continuous sutures only have a knot at either end. Fewer knots make them faster to insert. However, when one bite cuts out the suture loosens along the whole length of the suture line. Figure 3.3c, d and e illustrate how to bury the knots of a continuous suture (only useful for absorbable sutures).

a

b

c

d

e

Fig. 3.3 Interrupted versus continuous suturing. a Place the first interrupted suture centrally to align the closure. b Add sufficient additional sutures to close the defect. c Start a continuous absorbable suture with a buried knot. d To finish, externalize a deep loop to tie a self-burying knot. e Only bury absorbable suture knots

26

3

Sutures and Suturing

3.3.2 Suture Bite Spacing (Fig. 3.4) As a rule of thumb, sutures (or suture bites for a continuous suture) should be spaced the same distance apart as span of the suture (Fig. 3.4a). The longer the suture span the fewer sutures are needed to close the wound (Fig. 3.4b). This is because their closing force is spread over a wider segment of the wound edge. In thin skin use a short suture span by placing the bites close to the wound edges to prevent the edges from rolling (in or out) and space the bites closely to reduce gaping between them (Fig. 3.4c).

3.3.3 Suture Spaghetti In a restricted space, such as the eyelid, pre-place all adjacent sutures before tying any. Doing so allows you see the wound edges clearly before they are obscured by the first stitch tied. You can evert the edges for clear visualization without fear of loosening or of pulling out a previously tied suture. Clip each pair of suture ends together with an aneurysm clip before placing the next one. This simplifies the subsequent tying of the correct pairs of ends together and avoids a suture spaghetti. Fig. 3.4 Suture bite spacing. a Inter suture spacing should equal the suture span X. b In thick skin place the sutures further from the edge and spaced further apart than in thin skin. The longer the bite, the more widely the suture’s force is spread along the wound (shaded sector). c Too long a span encourages in rolling of thin skin edges

a

x

x X/2

b

c

3.3 Suturing Techniques

27

3.3.4 Simple v Mattress (Fig. 3.5) Mattress suturing is designed to evert epithelial surfaces to improve wound adhesion (as epithelial surfaces do not heal together when apposed). It also discourages inclusion cyst formation (caused when surface epithelium gets buried). An additional benefit is to cause the wound edges to pout, making allowance for inward scar contraction during healing (Fig. 3.6a). This discourages unsightly, depressed scars from forming (Fig. 3.6b).

a

b

Fig. 3.5 Simple versus mattress suture. a A simple suture causes flat edge approximation. b A horizontal mattress suture causes wound edge eversion (pouting)

28

3

Sutures and Suturing

a

b

c

d

Fig. 3.6 Scar depression. Because of healing scar contraction, a vertical mattress pouting closure (a) results in a flat scar (b). Simple suture flat closure (c) results in a depressed scar (d)

3.3.5 Horizontal v Vertical Mattress (Fig. 3.7) In terms of suture line eversion there is little to choose between horizontal (Fig. 3.7a) and vertical mattress (Fig. 3.7b) configurations. Use horizontal mattress sutures in thin skin and vertical in thick skin (such as in the forehead). Do not insert the suture bites too far from the skin edges or the edges will separate as you tighten the suture (Fig. 3.7c).

3.3 Suturing Techniques

29

a

b

c

Fig. 3.7 Mattress sutures. a Horizontal mattress suture. b Vertical mattress sutures. c Horizontal mattress suture induced wound edge separation as the bites are too far from the edge

30

3

Sutures and Suturing

3.3.6 The Humble Horizontal Mattress (Fig. 3.8) The horizontal mattress has three additional advantages over a simple suture: 1. The long surface loop pulls down against the skin, rather than towards the wound edge. This makes a mattress suture less prone to cut out than a simple suture (Fig. 3.8a). 2. The two bites act as a double pully during suture tightening, halving the suture tension required to bring the wound edges together (Fig. 3.8b). 3. The downward pull of the first throw against the skin during knot tightening significantly enhances friction. This prevents the first throw from slipping while you tie the second knot throw (Fig. 3.8c). These properties make the horizontal mattress suture particularly useful for directly closing wounds under tension, as recommended in Chap. 14. A buried horizontal mattress suture is very useful for suturing tarsal plate to canthal tendon.

3.3.7 The ‘Magic Suture’ (Fig. 3.9) The exotically named magic suture is nothing more than a strategically placed, buried, subcutaneous, absorbable suture (Fig. 3.10). It should run subcutaneously for 10 mm on either side of a facial wound. Within thin eyelid orbicularis a 5 mm long bite is sufficient. Insert the suture from within the wound so that the knot becomes deeply buried. The magic in these sutures is twofold. Placing a single suture in this fashion magically transforms a defect’s geometry. The first stitch simulates the final effect that the specific wound closure direction will have on the lid position. If you judge the effect to be sub-optimal, remove and replace the suture in a more favourable orientation. Secondly, because the muscle layer carries the overlying skin, the suture almost closes the skin defect. This makes skin suturing easier by reducing skin closure suture tension which, in turn, makes the resulting scar less likely to stretch. For magic suture placement steps see Chap. 5.

3.3 Suturing Techniques

31

a

b

c

Fig. 3.8 Horizontal mattress suture advantages. a Mattress closure force is spread along the length of the suture bite (low skin pressure) making it less likely to cut out than a simple suture whose force is concentrated on a small area of skin the width of the suture gauge (high pressure). b The horizontal mattress double pulley action makes pulling the wound edges together easy. c The knot first double throw locks against the skin and doesn’t slip

32

3

Sutures and Suturing

Fig. 3.9 Suture magic

a

b

c

d

Fig. 3.10 The magic suture. a Take a long muscle bite (5−10 mm) starting deep in the wound. b Take a similar bite on the far side starting close to the skin. c Lift and tighten the knot’s first double throw until the wound closes. d Complete the knot ensuring it retracts deep into the wound

3.4 The Cotton Bud: An Aid to Suturing

3.4

33

The Cotton Bud: An Aid to Suturing

Cotton buds (cotton tip applicators) are commonly used in eyelid surgery to swab blood and to help localize bleeding points. When doing this, roll the cotton bud over the surface to be cleaned rather than wiping as wiping may restart bleeding by rubbing off clots that have already formed. Forwards and backward rolling across a bleeding point helps to visualize the leaking vessel for accurate diathermy. The friction between cotton bud and tissue is useful for tissue retraction, either by gently pressing and pulling or by rolling the cotton bud between one’s fingers. The friction is also useful for blunt dissection of tissue planes. A novel use of the cotton bud is as an aid to suturing in which role it has five functions: 1. To unroll thin skin to reveal the true wound edge before suture placement. 2. To aid needle penetration of lax skin by applying counter pressure under the needle tip. 3. To pull the needle and suture through the tissues once the needle tip is embedded in the bud. 4. To hold the needle for re-grasping with a needle holder in preparation for the next suture bite. 5. As a needle tip protector to reduce the likelihood of tip damage or needle stick injury. The technique of using a cotton bud for suturing is easy to learn but requires a little practice. Tightly wound cotton buds are better for use in suturing. Remember that buds have a hard central core which you need to avoid with your needle tip by entering the bud at a glancing angle.

3.4.1 Steps (Fig. 3.11) 1. Hold the bud against the surface or underneath the skin and slowly rotate it to retract and unroll any in-turned skin revealing the true wound edges. 2. Use the bud to apply tissue counter pressure under the needle tip (Fig. 3.11a). 3. During needle penetration adjust the angle between the needle tip and the bud so that the needle penetrates the soft cotton covering without hitting the hard central core (Fig. 3.11b). 4. When the needle tip is embedded, rotate the bud to pull the remainder of the curved needle through the tissues (Fig. 3.11c). Avoid doing this too vigorously so as not to disengage the needle from the bud. 5. As soon as the whole needle is clear of the tissue apply slight counter rotation to the bud and lift it up to pull the suture through (Fig. 3.11d). The counter rotation prevents the suture drag from pulling the needle out of the bud prematurely. 6. Re-grasp the needle with the needle holder ready for the next suture bite and disengage it from the bud.

34

3

Sutures and Suturing

Fig. 3.11 Cotton bud as an aid to suturing. a Apply skin counterpressure over the suture needle tip until it penetrates. b Engage the needle tip in the cotton bud. c Pull the needle completely through by rotating the bud. d Apply 180° counterrotation to the bud and pull the suture through by lifting the bud

Note: Although the technique has been broken down into individual steps, in practice they blend into one smooth movement [1].

3.5

Take Home Message

• The horizontal mattress and the magic suture techniques are powerful and underused. • A cotton bud can be used as a surgical instrument when suturing thin skin.

Reference 1. Cotton Bud: An Aid to Suturing. YouTube video: https://youtu.be/K2-_QzJhW5U

4

Pertinent Anatomy

4.1

Overview

• Lid Layers • Surgical landmarks. An understanding of functional lid anatomy is essential if you are to avoid getting lost and have successful surgical outcomes. The upper and lower lids are analogous in structure save for a few important differences which I shall highlight.

4.2

The Lid Skeleton (Fig. 4.1)

The eyelids are attached to orbital rim by the medial and lateral canthal tendons (known by some as canthal ligaments) and by the orbital septum. The tarsal plates and canthal tendons together make up the eyelid skeleton. Repair any disruption to their integrity as a priority.

4.2.1 Canthal Tendons The canthal tendons are inelastic. The tarsal plate, on the other hand, stretches slowly under sustained load. The medial lid margin is pulled posteriorly towards the posterior lacrimal crest by Horner’s muscle (formerly thought to be a posterior limb of the medial canthal tendon). The medial canthal tendon arises from the periosteum of the anterior lacrimal crest, and the lateral canthal tendon from the lateral orbital tubercule situated just inside the orbital rim.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_4

35

36

4

Pertinent Anatomy

Orbital Septum Upper Tarsal Plate

Lateral Canthal Tendon

Horner’s Muscle Medial Canthal Tendon

Arcus Marginalis Lower Tarsal Plate Orbital Septum

Fig. 4.1 Eyelid skeleton. The tarsal plates and canthal tendons together make up the eyelid skeleton

4.2.2 Orbital Septum (7 Veils) The orbital septum arises from the arcus marginalis of the orbital rim and separates the orbital from the pre-orbital compartments. Though spoken of as a single layer and contrary to common belief, the orbital septum is made up of seven layers. This can be a cause of confusion during surgery for the uninitiated when, after having divided one or more septal layers further ones are found. The septum is relatively inelastic. This is the reason orbital pressure can rise dangerously high with a retrobulbar haemorrhage. The septum also restricts medial and lateral movement of the lid margin and may need to be divided if you are trying to move a section of lid margin to a new position. Scarring and contraction of the septum cause lid margin retraction.

4.3

Lid Layers (or Lamellae) (Fig. 4.2)

Think of the lid as a two-layer sandwich. We call the layers ‘lamellae’.

4.3.1 Anterior Lamella (Fig. 4.2a) The outer lid layer (anterior lamella) is made up of skin and orbicularis muscle. These are closely bound together by the orbicularis fascia, though this attachment weakens with age. So, dissection is easier in the sub-orbicularis plane than in the

4.3 Lid Layers (or Lamellae) (Fig. 4.2)

a

Orbicularis Skin

37

b Conjunctiva

Tarsal Plate

Fig. 4.2 Eyelid layers. a Anterior lamella = Skin and Orbicularis. b Posterior lamella = Tarsal plate and Conjunctiva

subcutaneous plane. This is of practical significance when performing blepharoplasty. Removing excess skin together with its attached orbicularis is quicker and easier than separating the two. External to the orbital rim always dissect in the subcutaneous plane to avoid damaging facial nerve branches which run on the muscular layer. Remember this when raising periocular flaps. Confusingly some surgeons have recently begun to refer to the orbicularis as a separate ‘middle lamella’ because it can be used as a vascular flap to support both an anterior and a posterior free graft.

4.3.2 Posterior Lamella (Fig. 4.2b) The inner lid layer (posterior lamella) is made up of tarsal plate and conjunctiva. The conjunctiva is inseparably bound to tarsal plate. Proximal to the tarsal plate border the conjunctiva is bound progressively less tightly to the overlying Muller’s muscle. Lower lid Muller’s muscle is not surgically visible and can only be discerned microscopically.

4.3.3 In-Between The sandwich filling, between the anterior and posterior lamellae, contains the orbital septum, the insertions of the retractor muscles via their aponeuroses, and the

38

4

Pertinent Anatomy

palpebral arteries and veins. The pre-aponeurotic fat pads lie between the orbital septum anteriorly and the retractor aponeurosis posteriorly. There is no distinct levator muscle in the lower lid. Instead, inferior rectus movement is transmitted to the lower lid by a fibrous aponeurosis known as the capsulo-palpaebral head. As in the upper lid, this lies immediately posterior to the preaponeurotic fat pad.

4.4

Skin

Eyelid skin is very thin, mobile, and elastic. It has no underlying fat (unlike other skin). With aging the skin usually thins (except in patients with severe sun damage), stretches and loses elasticity.

4.4.1 Skin Tension Lines (Langer’s Lines) (Fig. 4.3) Karl Langer, a Viennese anatomist, plotted the direction in which skin punctures made in fresh cadavers elongated due to inherent skin tension. By joining the puncture axes, he drew lines that are named after him. More recently skin tension has been measured in living subjects resulting in slightly different line orientations. Siting surgical incisions along such tension lines minimizes the tension across the healing scars, making them stretch less and consequently less visible. However, when there is significant skin loss do not align the closure scar with the tension lines or you will cause ectropion and/or interfere with eyelid movement. Instead, close the wound to align the closure tension tangentially to the lid margin. The resulting scar orientation is usually perpendicular or oblique to the skin tension lines.

Fig. 4.3 Skin tension lines. These indicate the direction of maximal tension within the skin

4.5 Don’t Get Lost (Surgical Landmarks) (Fig. 4.4)

4.5

39

Don’t Get Lost (Surgical Landmarks) (Fig. 4.4)

It is easy to get lost in the lid layers, especially during re-operations. Apart from the skin anteriorly, and the conjunctiva posteriorly, only two landmarks are constant within the eyelid. They are the tarsal plate and the pre-aponeurotic fat pad (Fig. 4.5). Use them to orientate yourself during surgery. When re-operating on a scarred lid start dissecting in a previously uninvolved area where the tissue planes are still clear and develop your surgical plane from there.

Fig. 4.4 Don’t get lost

Pre-aponeurotic fat fad

Tarsal Plate

Fig. 4.5 Surgical landmarks. The two constant landmarks are tarsal plate and preaponeurotic fat

40

4

Pertinent Anatomy

Fig. 4.6 Tarsal plate and meibomian glands. Alignment of the meibomian glands that make up 70% of the tarsal plate and open onto the lid margin

4.6

Tarsal Plate (Fig. 4.6)

Tarsal plate is a distinctive, firm, pale tissue that extends away from the eyelid margins. Meibomian glands (approx. 30 per lid) make up 70% of it. They are aligned side by side and held together by collagen and elastin (Fig. 4.6). Tarsal plate is the strongest layer of the eyelid margin and must be repaired following lid margin lacerations or incisions. Note that unlike tendon, tarsal plate stretches progressively under tension. This makes a tarsal strip a poor substitute for a lateral canthal tendon. Respect tarsal plate as there are no good substitutes to replace it with (cartilage being much stiffer).

4.7

The Meibomian Orifice Line

The meibomian orifice line marks the mid tarsal plate plane at the lid margin. You can make it more visible by squeezing the lid margin and looking for the egress of Meibomian secretions. Sutures placed in the Meibomian orifice line will engage tarsal plate and thus gain firm lid margin purchase (which can be used for lid traction).

4.8

The Grey Line

The grey line marks the junction of the anterior and posterior lamellas. Though frequently referred to in textbooks it is a poor anatomical landmark as it becomes increasingly difficult to discern with age. Its only surgical significance is when splitting the lid margin into its two lamellae. The grey line derives its colour from the underlying muscle of Riolan (modified terminal orbicularis) as seen through the extremely thin lid margin skin. Because

4.11 Blood Supply (Fig. 4.7)

41

of this, and contrary to common practice, sutures placed in the grey line have almost no holding strength and serve no useful function.

4.9

Pre-aponeurotic Fat

Pre-aponeurotic fat, unlike other fat, is extremely fine without visible globules. Deep yellow in colour, it flows at body temperature. You can encourage preaponeurotic fat to prolapse through a septal incision by pressing on the eye or on the opposing lid. Anteriorly the fat pad is contained by the orbital septum. The structure immediately posterior (deep) to the pre-aponeurotic fat is, by definition, the levator aponeurosis in the upper lid and the retractor aponeurosis in the lower lid.

4.10

Lacrimal Ductules

The lacrimal gland, which sits superotemporally between the upper lid lamellae, secretes tears into the upper conjunctival fornix via one or several lacrimal ductules. Take care to avoid damaging them during surgery. As they are not easily visible you should identify and mark the ductules before you operate. Do this by first doubly everting the upper lid over a large Desmarres retractor, and then instilling a drop of Fluoresceine 2% onto the conjunctiva laterally. Wait and watch until you see tears from the ductule opening dilute the orange fluoresceine to make it fluoresce green. This reveals the ductule openings which you should mark with ink for easy identification when you operate.

4.11

Blood Supply (Fig. 4.7)

Eyelids possess an excellent anastomosed blood supply. This enables them to heal quickly and protects wounds from infection. It also makes lids bleed a lot during surgery. There are two main bleeding points in the eyelid margin – the marginal and the peripheral vascular arcades (Fig. 4.7). The marginal arcade lies on the anterior surface of the tarsal plate, deep to orbicularis, just proximal to the lash roots. The peripheral arcade lies on Muller’s muscle in the upper lid, close to the proximal border of the tarsal plate. [Note: Most textbooks only show a single arcade in the lower lid, but surgical experience tells a different story]. Knowing the vessel location makes accurate diathermy easier. To perform diathermy, first squeeze the full thickness of the cut lid sandwich with forceps and clean away any blood with a cotton bud (Fig. 4.8a). Then identify the bleeding points as you slowly release the pressure and bleeding restarts (Fig. 4.8b). Diathermy the cut vessels (Fig. 4.8c). The two arcades unite into a single palpebral artery and vein at either end of the lid.

42

4

Pertinent Anatomy

Peripheral Vascular Arcade Marginal Vascular Arcade

Palpaebral Arteries

Fig. 4.7 Eyelid vascular arcades. The marginal arcade is on the anterior tarsal plate surface close to the margin. The peripheral arcade lies on Müller’s muscle, just proximal to the tarsal plate. They join at either end to form the palpaebral arteries

a

b

Marginal Vascular Arcade Peripheral Vascular Arcade

c

Fig. 4.8 Eyelid bleeding points. a Grasp and squeeze the lid margin and remove the blood. b Gently ease the forceps pressure until bleeding restarts to reveal the cut vessels. c Apply diathermy to the bleeding vessels

4.12 Muscles

4.12

43

Muscles

The eyelid closing muscle (protractor) is the orbicularis oculi. This is a thin sheet of concentrically arranged muscle fibres extending from the lid margin to well outside the orbital rim. It is customary to consider it in three functional parts: the pretarsal, the pre-septal and the orbital, even though they are a continuum (Fig. 4.9). The pretarsal orbicularis is responsible for blinking, whereas the orbital part performs strong lid squeezing. The pre-septal orbicularis takes part in both but also serves a lid stabilizing function that is lost if it is allow migrate to a pretarsal position through weakening of the orbicular fascia. Loss of orbicularis function may result in incomplete eye closure. Bell’s reflex (involuntary upward rolling of the eyes on attempted eye closure) mitigates the consequent corneal exposure. Loss of orbicularis function may also give rise to lower lid paralytic ectropion. Occasional involuntary contraction of the orbicularis is called a tick, when persistent and unilateral, hemi facial spasm, and when persistently bilateral, the idiopathic blepharospasm syndrome. The eye-opening muscle (retractor) of the upper lid is the levator palpebrae superioris (Fig. 4.10a & b). It shares the same innervation as the superior rectus muscle (upper division of the oculomotor nerve). It inserts into the orbicular fascia at the level of the skin crease and into the anterior surface of the mid and lower tarsal plate. Its function is modulated by Muller’s muscle by up to 2 mm. Muller’s muscle is a thin sheet of sympathetically innervated muscle that originates from the under surface of the levator and inserts into the upper border of the tarsal plate. At its insertion it is closely bound to the conjunctiva but becomes easier to separate surgically higher up. Paralysis of the sympathetic nerve supply, as in Horner’s syndrome, causes no more than 2 mm of ptosis. Unlike the upper lid, the lower lid does not have a separate retractor. This function is performed by the capsulo-palpebral head of the inferior rectus. Likewise, the lower lid does not have a surgically visible Muller’s equivalent.

Orbital Pre-septal Pre-tarsal

Fig. 4.9 The orbicularis oculi. Artificial subdivision of the continuous orbicularis sheet into functional parts: pretarsal for blinking, pre-septal for stabilization, and the orbital for squeezing

44

4

a

Pertinent Anatomy

Levator aponeurosis

Müller’s muscle

Capsulo-palpaebral aponeurosis

b

Levator aponeurosis Levator Palpaebri Superioris Müller’s muscle

Inferior Rectus

Capsulo-palpaebral aponeurosis Fig. 4.10 Lid retractors. a Anterior view of the retractor aponeuroses. b Lateral view showing the relationships of Müller’s muscle to levator, and the capsulo-palpaebral aponeurosis to the inferior rectus

The shared oculomotor innervation of the eyelid and eye is important for lifting the upper lid in up-gaze and retracting the lower lid in downgaze.

4.14 Take Home Message

4.13

45

The Rest

This simplified account of the anatomy misses out a lot. The lacrimal gland and drainage apparatus are mentioned in Chap. 16. Whitnall’s ligament is of note. It is a strong fibrous band that runs from the trochlea, where it is narrow, over the surface of the levator aponeurosis, widening as it inserts into the peri-lacrimal fascia. The novice is only likely to encounter it when converting a white line advancement ptosis correction to a levator resection (see Chap. 10).

4.14

Take Home Message

• The tarsal plate and the pre-aponeurotic fat pads are constant anatomical landmarks. • The orbital septum is a multi-layered structure.

5

Fundamental Procedures

Fig. 5.1 Fundamentals

5.1 • • • • •

Overview (Fig. 5.1)

Lid margin repair Lateral canthal repair The magic suture The tarsal traction suture Emergency canthotomy

Most lid operations are made up of a combination of basic surgical blocks. The first four techniques listed are integral to many procedures; hence I consider them to be fundamental. The last, emergency canthotomy, though rarely needed can be sight saving.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_5

47

48

5.2

5

Fundamental Procedures

Lid Margin Repair (Fig. 5.2)

Lid margin repair forms part of entropion and ectropion correction, tumour resection and laceration repair. This technique uses absorbable sutures which only require removal should they loosen and irritate. It works equally well for surgical resections as for traumatic lid lacerations. The same technique, with minor modification, works at the lateral canthus.

a

b

c

d

e

f

Fig. 5.2 Eyelid margin repair. a Turn the wound edge out. b View the cut surface end on to place the suture. c Push the skin and orbicularis back with the flat of the needle to enters the anterior tarsal plate surface. d Advance the needle to emerge on the cut surface of the tarsal plate. e Place 3 tarsal sutures. f Clip the paired suture ends together. g Enter the wound edge through the orbicularis with a 7/0 suture and rotate the needle to emerge from the lash line. h Re-enter the lid margin through the meibomian orifice line on the same side to exit the cut tarsal plate surface close to the margin. i With the same needle re-enter the far side similarly. j Put a loose single throw on this suture and clip the untied suture ends together. k Tie and cut the preplaced tarsal sutures in reverse order of placement. l Tighten and tie the pre-placed lid margin mattress suture. m Confirm that it causes the lid margin join to pout. n Repair the remainder of the skin wound

5.2 Lid Margin Repair (Fig. 5.2)

49

g

h

i

j

k

l

m

n

Fig. 5.2 (continued)

5.2.1 Considerations As the tarsal plate forms the skeleton of the lid it is the most important lid margin structure needing repair. Ensure that the lid margin union pouts by the end of the repair or a notch will later form through scar contraction.

50

5

Fundamental Procedures

5.2.2 Principle • • • •

Accurately align the two sides. Pre-place all the tarsal plate and lid margin sutures before tying any. Place them so that they are unable to irritate the cornea once tied and cut. Always tie the tarsal suture furthest from the margin first to take the tension. This makes it easier to subsequently tie the more important marginal sutures tightly without slippage. • Use a buried lid margin mattress suture to make the lid margin pout.

5.2.3 Steps 1. Insert a 6/0 absorbable suture, mounted on an 8 mm spatula, ½ circle needle, through the tarsal plate on either side to span the wound. Place it as close to the lid margin as possible. Take particular care to align the suture bites on each side to avoid creating a step in the margin. a. Grasp the full thickness of the lid ‘sandwich’ perpendicularly to the margin, about 2–3 mm from the cut edge, with toothed forceps. Turn this edge outwards to improve visibility and access (Fig. 5.2a and b). b. Use the flat surface of the suture needle to push the skin and orbicularis to the side, so that the needle tip enters the anterior tarsal plate surface perpendicularly, about 1–1½ mm from the tarsal plate edge (Fig. 5.2c). c. As soon as the needle tip engages the tarsal plate rotate and advance the needle so that it emerges close to the conjunctival surface on the cut surface of the tarsal plate, i.e., after engaging almost the full tarsal plate thickness. Do not penetrate the conjunctiva. This is particularly important for upper lid repairs. d. Retrieve and remount the needle from this first bite and grasp the far side of the lid margin with tissue forceps, as in step 1a. e. Insert the needle into the cut surface of the tarsal plate close to its conjunctival surface. Take special care to place this bite at the same distance from the lid margin as the first bite (Fig. 5.2d). f. As soon as the needle tip engages tarsal plate rotate and advance the needle so that it emerges on the anterior surface of the tarsal plate 1–1½ mm from the wound edge. Avoid engaging the orbicularis and skin. If you do, lift them off your needle tip. g. Clip the two untied suture ends together with a bulldog clip and retract them. 2. In the lower lid, place 2 further sutures below the first one in a similar fashion, spacing them about 1 mm apart (Fig. 5.2e). In the upper lid, which has a wider tarsal plate, 3 or 4 additional sutures may be required. Again, clip each pair of untied suture ends together to aid later identification when tying (Fig. 5.2f).

51

3. Preplace a lid margin horizontal mattress 7/0 absorbable suture so that its knot will become buried in the lash line. This configuration will cause the lid margin repair to pout as intended when you eventually tie this suture. a. With the needle enter the wound edge through the orbicularis, just anterior to the tarsal plate surface. Rotate the needle so that it emerges from the skin within the lash line, 1½ mm from the wound edge, having engaged the orbicularis and skin (Fig. 5.2g). b. With the same needle re-enter the lid margin perpendicularly through the meibomian orifice line on the same side (Fig. 5.2h). Rotate and advance the needle to exit the cut tarsal plate surface close to the margin. Take special care not to engage accidentally the first preplaced tarsal plate suture from step 1, as this would prevent it from being tightened when tying. c. With the same needle enter the far tarsal cut edge perpendicularly and bring the needle tip out through the meibomian orifice line. Take special care not to engage accidentally the first preplaced tarsal plate suture from step 1. d. With the same needle re-enter the lid margin perpendicularly through the lash line and bring it out through the cut edge of orbicularis (Fig. 5.2i). e. Put a loose single throw on this suture and clip the untied suture ends together out of the way (Fig. 5.2j). 4. Now tie firmly and cut the preplaced tarsal sutures in reverse order of placement, i.e., starting with the one furthest from the lid margin (Fig. 5.2k). Once tied, this first suture takes up most of the wound tension. This makes tying the remaining tarsal plate sutures easy and their first throws unlikely to slip. By the end of this step the lid margin wound should be accurately and securely closed. 5. Tighten and tie the pre-placed lid margin mattress suture (Fig. 5.2l). Confirm that it causes the lid margin join to pout (Fig. 5.2m). Cut its ends short enough for them to retract into the wound anterior to the tarsal plate (away from the cornea). 6. Repair the remainder of the skin wound with interrupted 6/0 or 7/0 absorbable sutures which incorporate the underlying orbicularis into each bite, (Fig. 5.2n) or suture the orbicularis first, as a separate layer with a ‘magic suture’ (see below).

5.2.4 Notes An accurately repaired lid margin will not leave a noticeable scar, notch, or lash line gap.

52

5

a

b

c

d

e

f

g

h

Fundamental Procedures

Fig. 5.3 Lateral canthal repair. a Grasp the lateral canthal tendon with toothed forceps performing the ‘tug test’. b Place a 6/0 absorbable suture, through the tendon. c Place a second, double armed suture in a similar fashion slightly below the first. d Insert the first pair of needles into the tarsal plate. e Place the second pair of sutures similarly, 1 mm below the first pair. f Preplace a lid margin horizontal mattress 7/0 absorbable suture so that its knot will become buried in the lash line at the lateral canthus. g With the same needle enter the canthal tendon/tarsal junction of the opposing lid. h Put a loose single throw on this suture. i Tie and cut the two preplaced tarsal mattress sutures in reverse order of placement. j Tighten and tie the pre-placed lateral canthal margin mattress suture. k Repair the remainder of the skin wound with interrupted 6/0 or 7/0 absorbable sutures

5.3 Lateral Canthal Repair (Fig. 5.3)

i

53

j

k

Fig. 5.3 (continued)

5.3

Lateral Canthal Repair (Fig. 5.3)

5.3.1 Considerations The lateral canthal angle is formed by the pull of the lateral canthal tendon (LCT). If the LCT is damaged, repair it. Should that not be possible use an alternative lateral fixation point such as the orbital rim periosteum or insert a self-tapping bone screw from which to anchor your suture. Eyelid incisions at the lateral canthus heal aesthetically without a visible notch.

5.3.2 Principle This is a modification of the lid margin repair described above. As there is no lateral tarsal plate, strong fixation relies on suturing to the canthal tendon. A single horizontal mattress suture is sufficient, but I recommend using two, as a failsafe.

5.3.3 Steps 1. Grasp the presumed lateral canthal tendon with toothed forceps in the lateral wound edge (Fig. 5.3a). The tendon can be difficult to see, especially if the lateral palpaebral artery is bleeding. Ask an assistant to pull the lateral canthal tissues apart to improve visualization. Positively identify that what you are holding is tendon by performing the ‘tug test’. Tug firmly on the tissue you

54

5

Fundamental Procedures

are holding. A tendon resists such tugs without any ‘give’, what we might call ‘a hard stop’. If the resistance to your tug is ‘softer’ you are not holding the tendon. Re-grip presumed canthal tendon and repeat the tug test until you are certain that you are holding the tendon. 2. Without releasing your grip, place a double armed 6/0 absorbable suture, mounted on an 8 mm spatula, ½ circle needle, through the tendon. Follow this with a second, locking, pass, and clip the suture ends together (Fig. 5.3b). 3. Place a second, double armed suture in a similar fashion slightly below the first (Fig. 5.3c). 4. Insert the first pair of needles into the tarsal plate (Fig. 5.3d), either transconjunctivally or through its cut edge, the former being easier. Note: Normally we avoid breaching the conjunctiva with an abrasive suture, but at the lateral canthus the chance of the suture irritating the cornea is remote and it quickly migrates subconjunctivally. Place the first bite close to the lid margin so that it emerges on the anterior surface of the tarsal plate 1½ mm from the wound edge. Avoid engaging the orbicularis and skin. Place the second needle similarly but 1 mm below the first. Clip the two untied suture ends together with a bulldog clip and retract them. 5. Place the second pair of sutures similarly, 1 mm below the first pair (Fig. 5.3e). Clip the untied suture ends together. 6. Preplace a lid margin horizontal mattress 7/0 absorbable suture so that its knot will become buried in the lash line at the lateral canthus. This configuration will cause the lateral canthal margin to pout when this suture is eventually tied. a. With the needle enter the wound edge through the orbicularis, just anterior to the tarsal plate surface and rotate the needle so that it emerges from the skin within the lash line, 1½ mm from the wound edge after engaging the orbicularis and skin. b. With the same needle re-enter the lid margin perpendicularly through the meibomian orifice line on the same side (Fig. 5.3f). emerging on the cut tarsal plate surface close to the margin. Note: Take special care not to accidentally engage the first preplaced tarsal plate suture from step 4, as this would prevent it from being tightened. c. With the same needle enter the canthal tendon/tarsal junction of the opposing lid (Fig. 5.3g). Bring the needle tip out through the meibomian orifice line. d. With the same needle re-enter the lid margin perpendicularly through the lash line and bring it out through the cut edge of the orbicularis at the lateral canthus. e. Put a loose single throw on this suture and clip the untied suture ends together out of the way (Fig. 5.3h).

5.4 The Magic Suture (Fig. 5.4)

55

7. Now, tighten, tie firmly and cut the two preplaced tarsal mattress sutures in reverse order of placement, i.e., starting with the one furthest from the lid margin. Lift and pull each pair of suture ends laterally, to close the wound using the pulley effect, before snugging down the first throw. Once tied, the first suture takes up most of the wound tension. This makes it easy to tie the second suture tightly (Fig. 5.3i). By the end of this step the lid margin wound should be accurately and securely closed. 8. Tighten and tie the pre-placed lateral canthal margin mattress suture (Fig. 5.3j). Cut its ends short enough for them to retract into the wound. The canthus is now reformed. 9. Repair the remainder of the skin wound with interrupted 6/0 or 7/0 absorbable sutures which incorporate the underlying orbicularis into each bite (Fig. 5.3k), or suture the orbicularis first, as a separate layer with a magic suture.

5.4

The Magic Suture (Fig. 5.4)

A long reach, subcutaneous, suture, placed across the centre of a tissue defect can transform a gaping wound into a narrow slit “as if by magic”, hence its name. It is an extremely useful technique for two reasons: • Temporarily tying this first stitch simulates the ultimate effect that your chosen closure direction will have on the eyelid margin position. Should it cause ectropion or retraction, the suture is quick and easy to replace in a better orientation. • Secondly, by aligning and approximating the skin edges this suture speeds up the remainder of the wound closure.

a

b

Fig. 5.4 Magic suture direction. a In the right lower lid, the suture is placed at an oblique wound axis. In the left brow along the long wound axis. b When tightened the suture tension is parallel to the respective lid margin tangent and transforms the wound’s geometry

56

5

Fundamental Procedures

5.4.1 Principle and Considerations Bringing the subcutaneous tissue layer together carries the overlying skin with it. The salient properties of any suture bite are its direction, length and depth, and the tissue it engages. With the magic suture all three properties differ from those of conventional subcutaneous sutures. The most critical factor is the suture direction. In conventional wound closure the sutures are placed across the short axis of a defect. For a magic suture, by contrast, the direction of the closure tension must be parallel to the tangent at the nearest point on the lid margin, irrespective of the short axis of the actual defect (Fig. 5.4a). This ensures that the repair does not pull on the lid margin to cause retraction. Consequently, the resulting closure scar tends to lie more perpendicularly to the lid margin though not necessarily at right angles. Place the Magic suture very roughly centrally on each side of the wound, as this is the point at which maximum closure tension develops. However, Fig. 5.4 illustrates that with oblique and irregular wounds this is not necessarily the case. Therefore, align the suture parallel to the lid margin, irrespective of the wound’s orientation. Do not worry if you don’t get it right the first time. The suture is quick to replace. The suture bites should start and end in the depth of the wound to bury the suture knot when tied. The suture material used for this technique is not critical. However, as suture tension invariably dissipates by suture migration, I recommend an absorbable suture on a half-circle needle. You gain no advantage by using non-absorbable sutures. 6/0-gauge sutures work well within the eyelid area. Stronger 4/0-sutures are preferable more peripherally.

5.4.2 Case Selection Widely applicable to most wounds.

5.4.3 Steps 1. From the depth of the wound engage the subcutaneous tissue roughly at the midpoint with a suture on a ½ circle needle (Fig. 5.5a). Within the periocular area the subcutaneous tissue is mostly orbicularis muscle. Note: Do not to engage immobile structures, such as the orbital septum inadvertently, as this would limit wound edge movement. Occasionally one may deliberately choose to engage a canthal tendon in the knowledge that this side of the repair will remain fixed, and all the mobility must come from the opposite bite. 2. The bite length on each side of the wound should be no less than 5 mm within the pre-tarsal area and no less than 10 mm in the surrounding tissue. Make this bite deep enough to strongly engage the subcutaneous layer (usually the orbicularis).

5.4 The Magic Suture (Fig. 5.4)

a

57

b Skin

Skin

Orbicularis

Periocular Eyelid

c

Orbicularis Periocular Eyelid

10 mm 5 mm

10 mm 5 mm

d

Fig. 5.5 The magic suture. a From the depth of the wound engage the subcutaneous orbicularis muscle. b Bring the needle tip up until it is just visible through the skin, rotate by 90° and advance subcutaneously to the wound edge. Traverse the wound and take a similar bite on the far side. c Place the first double throw of the knot and tighten. d Complete the knot with three additional single throws

3. At the required distance, bring the suture needle tip up until it is just visible through the skin. At this point rotate the needle by 90° towards the wound edge. 4. Advance the needle within the subcutaneous plane close to the skin until it exits at the wound edge. 5. Traverse the wound and enter the subcutaneous plane on its far side. 6. Advance the needle within this plane for 5 or 10 mm, as for the first bite, and then rotate the tip down to penetrate the muscle layer. 7. Rotate the needle out through the deep wound edge (Fig. 5.5b). 8. Place the first double throw of the knot (Fig. 5.5c). Note: When tying the suture, it is helpful to have an assistant push the two sides of the wound towards each other, temporarily reducing the wound tension. Lift this first double suture throw clear of the tissues by lifting and pulling on both the suture ends. Rock the knot side to side during this step to encourage the suture to slide through the tissues as you pull them together. 9. While maintaining the suture tension, snug the knot down. Repeat this sequence of lifting, rocking, and tightening several times until the wound edges stop coming closer. The phenomenon of ‘tissue creep’ is gradually occurring as you do this so do not rush this step. 10. Complete the knot with three additional single throws (Fig. 5.4d). Ask an assistant to hold the first throw with the very tips of Moorfields forceps to stop it slipping while you lock it with the second throw.

58

5

Fundamental Procedures

5.4.4 Notes • Occasionally more than one magic suture is required. If you need even stronger tissue holding use a buried horizontal mattress suture configuration instead. However, the placement steps essentially remain the same. • A ‘magic suture’ enables the direct closure of larger defects than at first appears possible. Use it as a first step to minimize any defect, even if you are planning a flap or graft repair. Once it is in place reconsider your options. You may find that direct closure has now magically become possible.

5.5

Tarsal Traction Suture (Fig. 5.6)

You will often need to pull on a lid with a suture either during an operation or during the early healing phase. Traditionally you would do this by placing your traction suture into the grey line and out through the skin, tarsorrhaphy tubing or over a bolster to spread the load over a larger area, and back into the skin to exit the grey line. The following method is a surer, longer lasting and more comfortable alternative.

a

b

Grey Line Meibomian Orifice Line

900

Meibomian Gland

c

d

Fig. 5.6 The tarsal traction suture. a Lid margin landmarks. b Perpendicular needle entry into the Meibomian Orifice Line. c Needle advanced within the tarsal plate. d Taping the lid margin suture on traction

5.5 Tarsal Traction Suture (Fig. 5.6)

59

5.5.1 Principle and Considerations The tarsal plate is the strongest part of the eyelid despite 70% of it being meibomian gland tissue. Consequently, it is the best structure into which to anchor a traction suture. Although the tarsal plate is only 1–2 mm thick the meibomian gland orifices provide a convenient surface landmark for the mid-tarsal plane (Fig. 5.6a). Tarsal plate has few nerve endings so a suture pulling on it causes no pain. Eyelid skin, by contrast, is sensitive to suture pressure, even if you pass your traction suture over a bolster or through tubing. A tapered, non-cutting needle causes minimal tarsal damage because it separates, rather than cuts as it passes. Do not use a cutting needle for fear of shredding the relatively thin tarsal plate, weakening it with each pass. A 4/0 monofilament polypropylene suture on a 17 mm half circle, non-cutting taper-point needle (Ethicon Prolene W8557) makes an excellent traction suture. It is both strong and inert. This way of applying lid traction is applicable to either lid, anywhere along its margin. It is the basis of the ‘bolster-less suture tarsorrhaphy’ (see Chap. 13).

5.5.2 Case Selection Any lid requiring sustained traction per operatively or postoperatively up to several weeks e.g., to immobilize a graft bed or protect an eye.

5.5.3 Steps (1) Grasp the full thickness of the lid as parallel to the margin as possible with large forceps (e.g., Toothed Adson’s or the specifically designed Thaller Tarsal forceps [Altomed A6360]) and evert the margin. As you squeeze the lid the egress of meibomian secretions identifies the meibomian orifice line. (2) Enter the meibomian orifice line with the round bodied needle tip held perpendicularly to the lid margin (Fig. 5.6b). (3) Slowly advance the needle within the plane of the tarsal plate, allowing it to follow its own curve to exit once more through the meibomian orifice line some 10 to 12 mm from its point of entry (Fig. 5.6c). If the needle exits prematurely, too anteriorly through the lash line or too posteriorly through the conjunctival surface of the tarsal plate, partially withdraw the needle, alter the angle at which you are holding the lid margin and re-advance the needle until the tip exits the meibomian orifice line as intended. Even if you have to repeat this a few times the non-cutting needle does minimal damage. (4) Finally inspect the lid to ensure that the suture has not breached the conjunctiva or skin during its long passage. (5) Apply traction as required (Fig. 5.6d).

60

5

Fundamental Procedures

5.5.4 Notes • Premature failure results through cutting out if you engage an insufficient length of tarsal plate or inadvertently miss it. This is caused by not entering the meibomian gland orifice line perpendicularly. • Eventual failure by suture migration out of the lid is inevitable but takes several weeks. It occurs gradually and is only an issue with long-term suture tarsorrhaphy. If this occurs, simply replace the suture. • A correctly placed tarsal traction suture causes no pain or inflammation while in place, nor scarring after removal.

5.6

Emergency Cantholysis (Fig. 5.7)

Emergency lateral cantholysis is rarely required but I include it here because it is a sight saving procedure when raised intra-orbital pressure threatens vision. It heals spontaneously and seldom needs to be repaired. It can be performed in any setting.

a

b

c

Fig. 5.7 Emergency cantholysis. a At the lateral canthus crush the lid downward and laterally at 45°. b Cut downward and laterally at 45° through the crush mark dividing the full thickness of the lid. c Extend the incision until the lower lid is completely detached

5.7 Take Home Message

61

5.6.1 Principle and Considerations Release the lid from its attachment to the lateral orbital rim by making a diagonal full thickness cut at the lateral canthus. Cutting at an oblique angle, rather than horizontally, avoids damaging the lateral canthal tendon.

5.6.2 Case Selection Emergency decompression of a tense orbit following trauma, haemorrhage or infection.

5.6.3 Steps (1) Grasp and hold the lower lid close to the lateral canthus with strong toothed forceps (Adson’s). (2) Insert one blade of a pair of straight artery forceps under the lower lid margin at the lateral canthus and crush the lid downward and laterally at 45° (Fig. 5.7a). (3) Remove the artery forceps and insert one blade of a pair of strong scissors (e.g., Steven’s tenotomy scissors) under the lower lid margin at the lateral canthus and cut downward and laterally at 45° through the crush mark dividing the full thickness of the lid (Fig. 5.7b). (4) If the lower lid is not completely detached from the canthus, extend the incision further until it is (Fig. 5.7c).

5.6.4 Note • Cantholysis may be performed on either the upper or the lower lid, or even on both.

5.7

Take Home Message

• Accurately align a lid margin repair. • A single, correctly aligned, subcutaneous suture can positively transform a lid defect. • Place sutures in the meibomian orifice line, not the grey line. • Emergency cantholysis saves sight.

6

Eyelid Malposition

Fig. 6.1 Lid malposition

6.1

Overview (Fig. 6.1)

• Factors affecting eyelid position and stability. The palpebral aperture, being the gap between the upper and lower lid margins, is affected by both vertical and rotational lid margin malposition. Vertical eyelid malpositions comprise blepharoptosis (usually abbreviated ‘ptosis’) and eyelid retraction. The rotational malpositions are entropion (inward turning of the margin) and ectropion (outward turning of the margin).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_6

63

64

6.2

6

Eyelid Malposition

Lid Stability (Fig. 6.2)

6.2.1 Tarsal Plate Width The lower lid is prone to rotational malposition as its tarsal plate is narrow (4 mm wide) making it inherently less stable about its long axis than the upper lid (tarsal plate width 8–10 mm).

6.2.2 Orbicularis Tone The lids gain stability by being held flat against the globe. The active force doing this is the orbicularis muscle tone. Usually this is spread evenly thanks to the orbicular attachments to skin. With aging these attachments weaken allowing the pre-septal orbicularis to move to a pre-tarsal position during contraction. This creates net inward pressure on the lid margin which can cause entropion.

6.2.3 Lid/Globe Apposition and Volume Deflation Passive stability stems from the geometry of the bony attachments of the lids (via the canthal tendons) relative to the pupillary plane. For the lid to gain support it must be bowed forwards by the eye. Aging leads to facial and orbital volume loss (deflation). The resulting enophthalmos gives less lid support and the lid becomes lax relative to the eyeball (‘eyelid/globe disparity’). In severe enophthalmos a space can develop between the lower lid margin and the sunken eye. Fig. 6.2 Lower lid stability Factors contributing to lower lid margin instability

Centre of rotation 8-10 mm Enophthalmos 4 mm Narrow Tarsus Retractor Laxity Gravity

6.3 The Palpebral Aperture

65

6.2.4 Gravity Gravity presses the upper lid down against the eye improving stability. By contrast, in the upright posture gravity pulls the lower lid downwards, away from the eye, reducing stability.

6.2.5 Retractor Tethering The above factors allow the lower eyelid to rotate more easily about its long axis (length) and flip inwards under the pressure of orbicularis contraction during blinking and eye squeezing, or outwards if the orbicularis is atonic, as in facial palsy. The lower lid retractors help to resist such rotation by tethering the inferior edge of the tarsal plate. This stabilizing effect is lost if the retractors dehisce or become relatively lax through volume deflation. Visible lower fornix fat prolapse is a sign of retractor dehiscence. Pull the lower lid down to the orbital rim and look for a fat bulge between the eye and the tarsal plate [1].

6.3

The Palpebral Aperture

The horizontal palpebral aperture length depends on the integrity of the medial and lateral canthal tendons. The vertical aperture (degree of lid opening) is determined by: (1) The dynamic balance between the opening muscles (retractors), the levator and Müller’s muscle, and the closing muscle (protractor), the orbicularis oculi. The tone in the levator is controlled by the upper division of the oculomotor (III) nerve, that of Müller’s muscle by the sympathetic nervous system, and the orbicularis by the facial (VII) nerve. (2) Static factors acting on the lid: a. Normally, gravity and posture have relatively little effect on eyelid position. b. Lid mass and volume does affect the palpebral aperture. Increase in volume, such as by oedema, retention cysts or tumour infiltration can push the lid margin towards closing. In the upper lid the increased weight causes posture dependent ptosis, an effect that is occasionally exploited by implanting gold or platinum lid weights in facial palsy. c. Tissue elasticity is reduced by aging, frequent eye rubbing, recurrent inflammation, and scarring, d. Anterior lamellar tissue loss or relative shortage due to scarring or mid face descent causes retraction and/or ectropion. Posterior lamellar (conjunctival) scarring leads to lid margin retraction and cicatricial entropion.

66

6.4

6

Eyelid Malposition

Assessment

Note the following: 1. The lid margin appearance, contour, lash and meibomian orifice orientation, and the symmetry between the two eyes. 2. The eyelid movement in various gaze positions. 3. The strength of forced eyelid closure. 4. The presence of masses or tethering. 5. Internal or external scarring.

6.5

Significance

Eyelid malpositions affect function and appearance. With upper lid ptosis the lid margin can occlude the visual axis and impair vision. With lesser degrees of ptosis, the affected eye appears smaller, attracting unwelcome attention. Conversely, eyelid retraction increases corneal exposure, giving rise to discomfort and a staring look. Always ask yourself whether you are observing true ptosis or contralateral lid retraction. The latter can cause a pseudo ptosis thanks to Hering’s law of equal innervation. Entropion allows lash and skin keratin contact with the cornea causing irritation and potentially corneal ulceration and scarring. Ectropion, on the other hand, causes little discomfort or risk to vision. Instead, increased watering, and redness and crusting of the exposed conjunctival lid surface are the commonest complaints.

6.6

Causation

Aging is by far the commonest cause of eyelid malposition in temperate climates. It leads to weakening of connective tissues and deflation of the mid face and orbit resulting in relative eyelid laxity against the now enophthalmic eye as already mentioned. The exact mechanism of individual malpositions is still debated. Why for example are the signs of involutional ptosis, contact lens wear related ptosis, and Horner’s ptosis identical (normal levator function, raised skin crease and no ‘hang-up in downgaze)? Might Müller’s muscle failure be a common denominator? Apparent medial canthal tendon laxity could be a consequence of deflation, dehiscence, or weakening of the posterior pull of Horner’s muscle.

6.7 Don’t Strip!

6.7

67

Don’t Strip!

Eyelid tightening is an integral part of most entropion and ectropion correction. If the canthal tendons are intact, it involves resection of part of the lid margin. This may be carried out anywhere along the lid margin. Performing the resection at the lateral canthus gives the best functional and aesthetic outcomes. There are two ways of performing this: the lateral tarsal strip (LTS) (Fig. 6.3b) and the Bick resection (BR) (Fig. 6.3c). They both achieve a similar initial outcome (Fig. 6.3d), but the more complex LTS risks damaging the lateral canthal tendon and has a higher complication rate [2], so avoid it. Lateral canthopexy involves using a suture to suspend the lid from the lateral orbital rim periosteum. It is used by some to temporarily tighten a lid e.g., after a lower lid blepharoplasty. However, as minimal permanent scarring is induced, this procedure soon fails through suture migration. Note: Originally, the ‘lateral canthal sling’ operation was developed to correct lateral canthal tendon weakness. Since being rebranded as the LTS it has become the most popular lateral lid shortening procedure. This is unfortunate because the LTS relies on burying a strip of the tarsal plate. The tarsal plate stretches, losing effectiveness, and burying the meibomian glands it contains may cause granulomas.

a

b

c

d

Fig. 6.3 Lateral lid shortening options. a Full thickness, oblique, lateral canthal incision. b Lateral tarsal strip (fashioned from the excess lid margin). c Lateral lid margin resection. d Result of both looks similar. However, the LTS stretches with time

68

6.8

6

Eyelid Malposition

Take Home Message

• Eyelid position is determined by the sum of all the active and passive forces acting on it.

References 1. Beigi B, Kashkouli MB, Shaw A, Murthy R (2008) Fornix fat prolapse as a sign for involutional entropion. Ophthalmology 115(9):1608–1612 2. Vahdani K, Rebecca F, Garrott H, Thaller V (2018) Lateral tarsal strip versus Bick’s procedure in correction of eyelid malposition. Eye 32. https://doi.org/10.1038/s41433-018-0048-9

7

Ingrowing Eyelashes

Fig. 7.1 Epilation

Inwardly growing eyelashes are not only uncomfortable but can cause corneal ulcers. The commonest cause is lid margin or conjunctival scarring which misdirects lash growth. We call this trichiasis (normal lashes growing in an abnormal direction). Rarely, individuals are born with an extra row of lashes growing from an abnormal position such as from the meibomian glands. This is termed distichiasis. Metaplastic lashes are abnormal lashes growing from an abnormal position as a result of chronic inflammation.

7.1

Assessment

1. Is there a recognised reason for the lash line distortion, such as previous trauma? 2. Establish whether the lid margin is correctly orientated by noting the position of the meibomian orifice line. An entropion of the lid margin causes symptoms similar to trichiasis but is treated differently.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_7

69

70

7

Ingrowing Eyelashes

3. Look for conjunctival scarring as the cause (cicatricial lash entropion). Unexplained symblepharon (abnormal connection between the palpaebral and bulbar conjunctiva) is a red flag for cicatricial pemphigoid. It is best seen by pulling the lid away from the eye and looking for conjunctival tethering. 4. Look for rounding of the posterior lid margin (seen in chronic staphylococcal lid margin disease). 5. Check whether the lashes are being pushed inwards by an overhanging skin fold. This might require a blepharoplasty. 6. Note the position and number of lashes involved.

7.2

Treatment Options

7.2.1 Epilation (Fig. 7.1) Pulling the lashes out is worth trying on the first occasion if only a few lashes are involved. Review the patient after 8 weeks to check whether the lashes have regrown. Do not use epilation as a long-term treatment. Note: If you fail to epilate the eyelash bulb the broken lash will regrow as sharp stubble which is more dangerous for the cornea than a long bendy lash.

7.2.2 Electrolysis to the Lash Root Passing a small electric current through the root can permanently destroy individual lashes if administered correctly. Because the lash roots are not visible it can be difficult to be certain that you have positioned the electrolysis needle tip correctly alongside the root. Overtreatment risks causing lid margin scarring and distortion which can lead to further trichiasis of adjacent lashes. Therefore, use the lowest current that causes bubbling for the shortest time that allows you to lift the lash out without pulling. There is approximately a 50% treatment failure per lash treated so warn the patient that the treatment may have to be repeated. For this reason, reserve electrolysis for the treatment of isolated lashes.

7.2.3 Localized Full Thickness Lid Margin Resection This is the most effective way of treating a clump of in turning lashes. It does not leave a visible gap in the lash line but carries the risk of causing a lid margin notch if not performed well.

7.3 Take Home Message

71

7.2.4 Localized ‘en bloc’ Lash Resection Resecting only the lash bearing anterior lamella is an effective and less invasive alternative to full thickness resection but leaves a denuded lash free section on the lid margin which patients may find less acceptable.

7.2.5 Lash Cryotherapy This is very effective and avoids surgery. Use only a proprietary, calibrated, trichiasis cryoprobe, applying a double freeze/thaw cycle. The freeze timing is cryoprobe dependent e.g., for the Cryo II Collins Trichiasis Pencil (Keeler) use two freeze cycles each lasting for 25 s in the upper lid and for 20 s in the lower lid. Protect the eye with an insulating shield as you do so. Cryotherapy destroys all the lash roots treated. However, it also causes skin depigmentation, lid margin atrophy, and occasionally full thickness lid margin necrosis (especially if the lid vascularity has been compromised by previous surgery).

7.2.6 Anterior Lamellar Repositioning This is the most effective and aesthetically acceptable treatment for trichiasis involving 1/3 or more of the lid margin. (See Chap. 8).

7.3

Take Home Message

• Repeated epilation is not a good long-term trichiasis treatment strategy.

8

Entropion

8.1

Overview

• Types of entropion • Entropion assessment • Lower lid involutional entropion: temporary management and permanent correction. The lower lid is inherently less stable about its long axis than the upper lid, as explained in Chap. 6. It flips inwards on minimal provocation giving rise to entropion. By contrast, upper lid margin entropion requires a sustained strong force, such as that caused by conjunctival scarring, to cause margin entropion.

8.2

Types of Entropion

8.2.1 Congenital Entropion Entropion present at birth is uncommon. Lower lid entropion often resolves spontaneously as the mid-face develops. Therefore, monitor a child who is happy and does not have a red eye or photophobia. By contrast, prompt surgical entropion correction is necessary for an unhappy, photophobic child with a red eye watery eye. Excise a narrow horizontal strip of skin and orbicularis from below the lash line, avoiding the lash roots. Form a skin crease by including a bite of the inferior tarsal plate edge in the skin closing sutures (Hotz repair Fig. 8.1). Rarely, congenital entropion may be part of the ocular fibrosis syndrome (associated with strabismus due to extraocular muscle fibrosis). The tarsal kink syndrome is a rare form of upper lid entropion occurring when the lid becomes folded in on itself in utero. Unnecessarily complex procedures have © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_8

73

74

8

a

b

c

d

Entropion

Fig. 8.1 Hotz repair for congenital lower lid entropion. a Lower lid congenital entropion. b Evert the lower lid margin by pulling down and mark a narrow skin ellipse that avoids the lash roots (3– 4 mm below the lashes). Excise the marked ellipse of skin with the underlying orbicularis. c Place 3 or 4 absorbable 6/0 sutures across the defect ensuring that each includes a bite of the lower tarsal plate edge. d Tie the sutures to close the wound and create a skin crease to prevent future orbicularis overriding

a

b

Fig. 8.2 Tarsal kink everting sutures. a Congenital tarsal kink is a rare condition in which the upper tarsal plate is folded on itself at birth. b Place three absorbable everting sutures to permanently cure the problem

been described to treat it. Simply inserting temporary absorbable transcutaneous lid everting sutures between the superior and inferior edges of the tarsal plate effects a permanent cure (Fig. 8.2).

8.2.2 Involutional (Age Related) Entropion Age is the commonest cause of lower lid entropion in temperate climates, consequently the focus of this chapter. A similar type of entropion can occur in younger patients as the result of persistent eye rubbing.

8.2 Types of Entropion

75

The factors requiring surgical correction are: 1. the relative laxity of the eyelid against the eye (lid-globe disparity), 2. lower lid retractor laxity or imbalance, and 3. the overriding of the pre-septal orbicularis to a pre-tarsal position. Spastic entropion is a subset of involutional entropion. Corneal irritation provokes reflex orbicularis contraction, which leads to in-turning of an unstable lid margin. The irritation caused by the entropion perpetuates the squeezing and hence also the entropion.

8.2.3 Cicatricial Entropion The term ‘cicatricial’ implies scarring related. Any condition that causes conjunctival or sub-conjunctival shrinkage will pull the lid margin inwards. Either one or both lids may be affected. The following are the most common causes.

8.2.3.1 Trachoma Trachoma is a chronic infectious conjunctivitis caused by chlamydia trachomatis. It causes progressive conjunctival scarring which leads to cicatricial entropion. The entropion, in turn, leads to secondary corneal scarring and eventually to blindness. It is endemic in parts of Africa, South America, Asia, and Australia, and is the commonest cause of preventable blindness worldwide. 8.2.3.2 Chronic Staphylococcal Lid Margin Disease This is the most common cause of cicatricial entropion in temperate climates. It causes initial rounding of the normally angled posterior lid margin followed by in turning of the meibomian orifice openings and then progressive lash/corneal contact (Trichiasis). 8.2.3.3 Ocular Cicatricial Pemphigoid Ocular cicatricial pemphigoid is a rare auto-immune condition giving rise to recurrent conjunctival inflammation which results in scarring and shrinkage. It is ultimately a blinding condition if not managed by effective immunosuppression. The onset is insidious, and sadly it is often diagnosed too late. Unless you specifically look for it you will miss the diagnosis. Regard unexplained symblepharon (abnormal attachment between the bulbar and tarsal conjunctiva) as cicatricial pemphigoid until proved otherwise. Diagnostic conjunctival biopsy is advocated, but it only has a 50% sensitivity. Conjunctiva breaching surgery accelerates the condition, and any surgery, including biopsy, should be delayed until the patient is effectively immunosuppressed. In my opinion the diagnosis remains a clinical one.

76

8.3

8

Entropion

Entropion Assessment/Examination

8.3.1 Lid Tone and Laxity Grasp the lower lid skin, close to the lashes, between your thumb and forefinger and pull it away from the eye. Note how far away from the cornea the margin moves. Then let go and note how quickly and completely it returns to a normal position (the ‘snap back’ test). Alternatively perform the ‘snap back’ test by pulling the lower lid down to the orbital rim with your thumb or finger and observe the speed of its return when released. Apparent lid laxity may result from age associated enophthalmos. The backward displacement of the globe through loss of orbital fat means that the eye is no longer pressing as firmly against the lid from behind. Actual lid lengthening occurs through a combination of aging and chronic eye rubbing. Finally, the canthal tendons, which anchor the lid to the orbital rim, may have weakened or dehisced (see below).

8.3.2 Medial Canthal Tendon and Lateral Canthal Tendon Integrity Grasp the lower lid close to the lashes, between your thumb and forefinger and pull it laterally, away from the medial canthus while observing the movement of the lower lid punctum relative to the corneo-scleral limbus. Any movement past the medial limbus (in straight ahead gaze) suggests significant medial canthal tendon laxity. Repeat this manoeuvre again but this time pulling the lid medially while observing the movement of the lateral canthus. A significant drift of the lateral canthus medially towards the lateral limbus suggests lateral canthal tendon dehiscence.

8.3.3 Conjunctival Scarring/Symblepharon Evert the lids to examine the conjunctival surface with a slit lamp. Note any subconjunctival scarring. This is best seen using green illumination. Scarring may be a sign of previous surgery, trauma, trachoma, or of an on-going process such as cicatricial pemphigoid. Check particularly for any conjunctival fornix shrinkage or localized bands (symblepharon) between the lid and the globe. Do this by pulling the lid away from the eye and asking the patient to look in the opposite direction.

8.3.4 Orbicularis Over-Riding Correct the lower lid entropion by pulling downward on the skin to restore the lid margin to its correct orientation. Observe whether the entropion returns when the

8.4 Temporary Lower Lid Involutional Entropion Management

77

patient blinks. If it does not, ask the patient to squeeze their eyes tightly shut to see whether this triggers entropion recurrence.

8.4

Temporary Lower Lid Involutional Entropion Management

8.4.1 Taping Teach the patient to apply a strip of adhesive tape to the lower lid skin, just below the lashes, to pull the skin downwards towards the cheek. This additional pull on the lid margin may temporarily control the entropion while the patient awaits surgery.

8.4.2 Botulinum Toxin A single subcutaneous injection of botulinum toxin (10 units of Dysport® or 2.5 units of Botox® ) to the pre-tarsal orbicularis at the junction of the lateral 1/3 and medial 2/3 of the lid temporarily paralyses the lower lid orbicularis and may control a spastic entropion for several weeks (Fig. 8.3). It is not a permanent solution but a useful temporising treatment of the spastic component while surgical correction is being arranged. Paradoxically, it can make it harder to persuade a patient of the need for surgical correction once their symptoms have temporarily abated.

Dysport®10 units or Botox® 2.5 units

1/3

2/3

Fig. 8.3 Botulinum toxin entropion relief. Paralyse the pretarsal orbicularis with a subcutaneous injection of botulinum toxin

78

8

Entropion

8.4.3 Everting (Quickert) Sutures Absorbable 6/0 sutures placed obliquely through the lid, from the conjunctival surface just below the tarsal plate to emerge on the skin just below the lashes (Fig. 8.4), will temporarily stop the orbicularis from overriding and may tighten the lower lid retractors and so prevent the entropion from occurring. In my hands the effectiveness of everting sutures is short lived, lasting only as long as the sutures themselves. I consider them to be a temporizing manoeuvre. However, some authors have reported longer lasting success (78% at 18 months) [1].

a

b

Fig. 8.4 Quickert everting sutures. a. Insert three double armed absorbable sutures transconjunctivally from the lower fornix to exit the skin 3–4 mm below the lash line. b. The tied sutures transfer the lower lid retractor pull to the anterior lamella and create a barrier to orbicularis overriding

8.6 Lateral Lid Margin Resection and Modified Bick Repair (Fig. 8.7)

8.5

79

‘Permanent’ Surgical Correction of Involutional Entropion

8.5.1 Principle Surgical correction of lower lid involutional entropion requires: 1. tightening of a lax lid margin, 2. reinsertion of dehisced lower lid retractors into the anterior lamella, and 3. preventing the pre-septal orbicularis from overriding pre-tarsally. ‘Permanent’ is used loosely in this context as the aging that caused the involutional entropion is not stopped by surgery. In my experience, effective surgery prevents entropion recurrence for a minimum of 5 years and usually much longer. If your corrections fail sooner review your surgical technique. The above three factors are all corrected by the well described Quickert ‘four snip’ entropion correction procedure [2] (Fig. 8.5). The shortening of the lid margin can be performed more elegantly at the lateral canthus using a Bick resection/ repair, and the retractor plication under direct vision can be performed without breaching the conjunctiva as described below (Fig. 8.6). I describe these two components separately although you will perform both together for most entropion corrections.

8.5.2 The Lid Shortening Rule As a rule of thumb, shortening a lid margin by less than 5 mm verges on homeopathy. In contrast, never shorten by more than 15 mm because you will have missed a canthal tendon dehiscence which must be corrected first.

8.6

Lateral Lid Margin Resection and Modified Bick Repair (Fig. 8.7)

8.6.1 Principle and Considerations Relative lid/globe laxity is a usual pre-requisite for involutional entropion to occur. The simplest surgical remedy is to shorten the lid margin. Only undertake shortening once you have confirmed the integrity of the medial and lateral canthal attachments. Address any dehiscence of these before attempting to shorten the lid. Combine lid shortening with a retractor plication.

8.6.2 Case Selection Involutional entropion without canthal tendon laxity.

80

8

a

b

c

d

e

f

Entropion

Fig. 8.5 Quickert entropion correction. a. Pull the lid down to correct the entropion. b. Mark and incise a horizontal incision 4–5 mm below the lash line and a vertical incision from the lid margin to meet it. c. Overlap the resulting lid margin flaps and mark and excise the excess. d Insert 3 double armed sutures transconjunctivally to pick up the lower lid retractors. Then repair the lid margin. e Bring the retractor sutures out through the orbicularis and skin 2 mm below the lash line. f Tie the retractor sutures tightly and close the horizontal skin wound

8.6.3 Steps 1. Load two double ended 6/0 absorbable sutures onto locking needle holders and prepare them for instant use. 2. Grab the full-thickness lid margin laterally with Adson’s forceps and place the lateral canthus on stretch by pulling the lid medially. Detach the lower lid margin from the lateral canthus by cutting infero-laterally at 45° from the lateral canthus for approximately 5–8 mm with Steven’s tenotomy scissors (Fig. 8.7b).

8.6 Lateral Lid Margin Resection and Modified Bick Repair (Fig. 8.7)

a

81

b

5 mm

c

d

e

f

Fig. 8.6 Entropion correction. a Incise the skin and orbicularis. b Find and tag the lower lid retractors with 3 double armed absorbable sutures. c Shorten the lid margin laterally. d Repair the lateral defect to tighten the lid margin. e Bring the retractor sutures out through the skin edges. f Tie the sutures to simultaneously close the skin, plicate the retractors and create a barrier to orbicularis overriding. Consider adding a continuous skin suture between the retractor suture knots

Note: Cut slowly to crush the vessels and reduce bleeding. 3. Without delay (before the bleeding starts) grab the exposed cut lateral canthal tendon with toothed forceps (St Martins) and insert the first of the two premounted double armed 6/0 sutures as close to the canthus as possible. Before letting go, insert the second arm of the suture 1 mm below the first. Confirm a strong purchase by tugging the suture ends firmly. There should be no give. Clip the pair of suture ends together with a bulldog clipboard (Fig. 8.7c).

82

8

a

b

c

d

e

f

g

h

i

j

Entropion

Fig. 8.7 Bick resection. a Pull the lid down to correct entropion and mark incision at the lateral canthus. b Cut the full thickness of the lid infero-laterally to detach it from the canthus. c Preplace two lateral canthal tendon absorbable sutures. d Overlap the cut edges to mark the excess lid margin. e Excise the excess lid margin. f Reattach the tarsal plate with the preplaced sutures. g Insert a margin closing 7/0 absorbable horizontal mattress suture. h Tighten and tie the tarsal plate sutures. i Tighten and tie the lid margin suture to bury the knot. j Close the orbicularis and skin

8.6 Lateral Lid Margin Resection and Modified Bick Repair (Fig. 8.7)

83

Note: An assistant is required to spread the canthal tissues apart to improve visualization. 4. Place the second 6/0 suture 2 mm below the first in a similar fashion and again confirm strong fixation. If there is any ‘give’ replace the suture more deeply. Clip both ends together. 5. Ask an assistant to pull the upper of the two lateral canthal tendon sutures medially to put the lateral canthus on medial stretch. Grasping the cut lateral edge of the lid margin with toothed Adson’s forceps, pull it laterally to overlap the taut lateral canthus until the lid margin is straight and mark the extent of the overlap with a surgical marking pen (Fig. 8.7d). Measure this overlap. It is normally between 7 to 15 mm. In the unlikely event that it is less, there was either no lid margin laxity or the lid was not being pulled firmly enough. If greater than 15 mm, undiagnosed medial canthal laxity is present and needs to be treated before continuing. 6. Excise the excess lid margin as a triangle or pentagon, with tenotomy scissors (Fig. 8.7e). 7. Insert the two pairs of pre-placed LCT 6/0 sutures in sequence through the cut edge of the tarsal plate, starting with the uppermost (Fig. 8.7f). Insert them from behind, trans-conjunctively, through the full thickness of the tarsal plate, exiting through its anterior surface and bring them out of the wound edge. Avoid engaging the orbicularis or skin. Place each subsequent suture about 1 mm below the previous one. Clip the corresponding pairs of sutures together again, temporarily. This results in the shortened lid being reattached by the two horizontal mattress sutures. 8. Before tying the above sutures, place a single ended 7/0 absorbable suture in the lid margin as a horizontal mattress (Fig. 8.7g). This time insert the suture through the orbicularis to exit the skin through the lash line, 1–2 mm from the wound edge. 9. Then, with the same needle, re-enter the lid through the meibomian orifice line and exit through the cut tarsal plate edge just above the top, already placed, 6/0 suture bite (taking care not to inadvertently engage it with your needle). 10. Now enter the lateral canthal wound with the same needle, engage the upper lid tarsal plate, and bring the needle out through the meibomian orifice line 1–2 mm from the lateral canthus. 11. Re-enter the upper lid lash line and exit the wound through orbicularis to complete this lid margin mattress suture. Clip its two ends together. 12. Now that you have placed the sutures under direct vision, pull the ends of the lower of the two 6/0 sutures laterally (Fig. 8.7h). Use their pulley action to pull the lid margin laterally towards the LCT to close the posterior lamella. Tie the suture with no less than three throws and cut the ends no shorter that 2 mm (to prevent spontaneous unravelling). 13. Tighten, tie and cut the upper 6/0 suture similarly.

84

8

Entropion

14. Tie the 7/0 pre-placed margin suture (Fig. 8.7i). This will align the lid margin at the lateral canthus. Cut the ends flush with the skin so that the knot becomes buried and does not irritate. 15. Close the remaining anterior lamellar defect with two or three horizontal mattress 7/0 absorbable sutures through the skin and orbicularis (Fig. 8.7j).

8.6.4 Notes • The tightened lid margin may slip below the globe appearing retracted. This is usually only temporary and resolves within a couple of weeks. • In Bick’s original procedure the lid margin is crushed before cutting to reduce bleeding. This advantage is gained at the expense of clear visualization of the epithelial surfaces and makes an accurate two lamellar repair more difficult. • For entropion repair, the lid margin shortening is usually combined with a retractor plication (Fig. 8.8). Pre-place the retractor sutures before performing the lid margin resection but do not bring them through the skin until the lid shortening is complete to avoid horizontal misalignment.

8.7

Lower Lid Retractor Plication (Fig. 8.8)

8.7.1 Principle and Considerations In humans lower lid retraction in down gaze is achieved by a fibrous connection between the inferior rectus muscle and the eyelid. It is known as the capsulopalpebral head or aponeurosis of the inferior rectus (the lower lid has no distinct retractor muscle analogue to the upper lid levator palpaebri superioris). A secondary effect of the retractor is to stabilize the lower edge of the tarsal plate. Laxity of this retractor, through stretching, dehiscence, or relative laxity from enophthalmos, may render the eyelid margin unstable. Dehiscence of only the anterior lamellar attachment allows the pull of the posterior lamellar attachment to pull the lid margin inwards. Surgically re-attaching the retractor to the anterior lamella works dynamically pulling the lid margin outwards each time the retractors pull. Additionally, anterior approach retractor plication prevents orbicularis overriding by creating a surgical barrier scar that separates the pre-tarsal from the pre-septal orbicularis (a passive mechanism). Always combine plication with a concurrent lid margin tightening unless you have a strong reason not to [3].

8.7 Lower Lid Retractor Plication (Fig. 8.8)

a

85

b

5 mm

d

c

White line Retractor aponeurosis Septum & Pre-apo fat

e

f

g

h

Fig. 8.8 Lower lid retractor plication. a Pull the lid down to unroll any margin entropion. b Keeping the skin on a downward stretch, incise the skin and orbicularis horizontally 5 mm below the lash line. c Bluntly dissect the septum and fat pad infero-posteriorly to reveal the retractor aponeurosis. d Grab the aponeurosis fold (‘white line’) and insert a suture centrally. e Place two more white line sutures. f For each suture bring one end out through the upper and the other through the lower edge orbicularis and skin. g Tie the white line sutures tightly. h Close the skin between the retractor sutures and cut them flush with the lid margin

86

8

Entropion

8.7.2 Case Selection Involutional entropion if combined with a lid tightening.

8.7.3 Steps 1. Place the lower lid skin on a gentle downward stretch (Fig. 8.8a) and make a horizontal incision through the lower lid skin and orbicularis approximately 5 mm below the lash line (Fig. 8.8b). 2. Bluntly separate the deeper tissues downwards, retracting and pushing the orbital septum and underlying fat pad posteriorly with a cotton bud while stretching the lid margin upwards. This reveals a whitish sheet of tissue and often a ‘white line’ where the aponeurosis reflects on itself (Fig. 8.8c). 3. Grab the ‘white line’ with toothed forceps centrally (in the mid-pupillary line) and tag it with a double armed 6/0 absorbable suture (e.g., polygalactin) (Fig. 8.8d). 4. While asking the patient to look up with both eyes open, take up any slack in the suture and hold it under gentle tension between the thumb and forefinger. Then ask the patient to look downward as far as possible. You should feel a tug on the suture, positively confirming that it is anchored in the retractors. If you do not feel a tug, try again, but this time instruct the patient to follow your other hand in a downward arc, to ensure that you elicit full down gaze. If there is still no pull, then the suture is not anchored in the retractors, and you need to replace it following further dissection. 5. Place two similar sutures, one on either side at about 5 mm from the central suture. Keep each pair of suture ends together with a bulldog clip until all three are placed (Fig. 8.8e). 6. At this point perform full thickness lid margin shortening if necessary (see Bick repair above). 7. At the end of the operation (after any lid margin resection) pass one end of each pair of retractor placation sutures through the superior and inferior skin edges respectively (Fig. 8.8f). 8. Tie them across the wound. They both close the wound and create a skin crease which deepens when the patient looks downward. Do not cut the suture ends at this stage but clip them together again (Fig. 8.8g). 9. Finally, close the skin incision further with a continuous absorbable 7/0 suture, placing a bite between each of the retractor sutures and a knot at either end (Fig. 8.8h). Cut the retractor sutures flush with the lid margin. This leaves their ends long enough to grasp easily should a suture need early removal. Note: In the unlikely event that you discover an overcorrection the next day (a lid margin ectropion) remove the retractor suture(s) which appears to be responsible. You may do this safely as the continuous skin suture will prevent the wound from re-opening.

8.8 Posterior Medial Canthal Thermoplasty

8.8

87

Posterior Medial Canthal Thermoplasty

8.8.1 Principle and Considerations Laxity of the medial canthal tendon (MCT) is common. Whether it is due to failure of the tendon itself or merely a dehiscence of its attachment to the tarsal plate is unclear. Several techniques have been described to address the problem, but none are straightforward, and most are not long lasting. Most use non-absorbable sutures. Although the sutures remain permanently, any useful tension they provide is soon lost through suture migration. The technique I describe here is what I call a “cheat operation”. It involves no dissection and works by creating a directed, posterior lamellar, thermal scar. This simple procedure is surprisingly effective in about 3/4 of cases.

8.8.2 Case Selection Significant medial canthal tendon laxity (the punctum can be pulled laterally past the medial corneal limbus).

8.8.3 Steps 1. Check whether there is significant MCT laxity by observing punctal movement as you pull the lid laterally (Fig. 8.9a). If it moves as far as the medial limbus or further the laxity is clinically significant. 2. Before embarking on a thermoplasty check for the presence of a strong medial canthal fixation point. Do this by grabbing the tissue between the medial canthus and the caruncle, through the conjunctiva, with toothed forceps and pulling (Fig. 8.9b). This tissue probably represents the lateral extent of the medial canthal tendon. If there is firm resistance (no give), then a thermoplasty can be used. 3. Insert a 6/0 double armed, absorbable suture transconjunctivally behind your forceps through this firm tissue with a double pass (Fig. 8.9c). Clip the two ends of the suture together. Confirm firm placement by tugging on the suture. There should be no give. 4. Place a second suture similarly to the first just below it as a failsafe (optional). Clip this pair of ends together. If you are unable to obtain strong suture fixation abandon the procedure. 5. Insert a Bowman’s lacrimal probe into the lower canaliculus until it stops against the nose and use this probe as a lever to evert the medial lower lid over a cotton bud held by an assistant (Fig. 8.9d). 6. Mark an inverted triangle of conjunctiva with its base extending from the caruncle medially to the lacrimal punctum laterally and just avoiding the lower canaliculus (made visible by the probe). The apex of the triangle is in the conjunctival fornix, 5 mm proximal to the lid margin (Fig. 8.9e).

88

a

c

8

Entropion

b

d

e

f

g

h

Fig. 8.9 Posterior medial canthal thermoplasty. a Assess medial canthal laxity by observing punctum movement as you pull the lid laterally. b Check for a strong medial canthal fixation point. Grab the tissue between the medial canthus and the caruncle with toothed forceps and pull. You should feel firm resistance (no give). c Pre-place two absorbable sutures into firm tissue. d Evert the medial lid with a lacrimal probe and cotton bud. e Mark a medial triangle, based below the canaliculus and the apex in the fornix. f Apply strong diathermy to burn the marked conjunctiva. g Insert the pre-placed sutures into the tarsal plate transconjunctivally, bringing them out through a skin stab incision. h Tie the sutures firmly and encourage the knots to retract under the skin

8.9 ‘Permanent’ Surgical Correction of Moderate Cicatricial Entropion

89

7. Burn the whole of this triangle with bipolar diathermy forceps, keeping their tips slightly apart, until it is white (Fig. 8.9f). Avoid the canalicular area. 8. Rub off any loose necrotic conjunctiva with a cotton bud. Then withdraw the lacrimal probe. 9. Make a small skin stab incision 4 mm below the lacrimal punctum. 10. Now pass the first of the pre-placed sutures into the tarsal plate, just lateral to the punctum, from the conjunctival surface, as close to the lid margin as possible, and bring the needle out through the skin stab incision. If this bite is too far from the margin a punctal ectropion may result. 11. Pass the second end of the first suture similarly but enter the tarsal plate a millimetre below the first. Bring the needle out through the same skin stab incision. 12. Pass the second pair of preplaced sutures similarly, each a millimetre below the previous one (Fig. 8.9g). 13. Tie each of the two pairs of sutures tightly, allowing their knots to retract into the skin stab incision and bury themselves (Fig. 8.9h).

8.8.4 Notes • This procedure causes temporary distortion and kinking of the canalicular portion of the lid margin medial to the punctum. This will resolve once the sutures absorb. The purpose of the sutures is to direct the conjunctival scar formation and contraction medially rather than inferiorly. • The sutures may occasionally cut through and cause some discharge and irritation. Remove any loose sutures. • The efficacy of this procedure does not distinguish between the possible aetiologies of the original medial laxity. The thermal scar created could equally well address a Horner’s muscle failure as a MCT dehiscence.

8.9

‘Permanent’ Surgical Correction of Moderate Cicatricial Entropion

8.9.1 Anterior Lamellar Repositioning 8.9.1.1 Principle and Considerations Anterior lamellar repositioning corrects mild to moderate lash entropion. It works by first separating the anterior from the posterior lid lamella as far as the lash roots and then suturing the lamellae together again with the anterior lamella pulled away from the margin. This everts the lid margin and lashes and provides a static component to the correction. Suturing the lid retractors to the skin incision during wound closure adds a long-acting dynamic component to the operation. The procedure is equally applicable to the upper or the lower lid.

90

8

Entropion

8.9.2 Case Selection Cicatricial lid margin entropion with sufficient conjunctival fornix not to require a mucous membrane graft.

8.9.3 Steps 1. Make a skin crease incision, through the skin and the orbicularis, the length of the lid. In the upper lid make this at the level of the desired post-operative skin crease (usually about 7–8 mm from the lid margin in Caucasians). In the lower lid 4–5 mm from the margin is usually satisfactory (Fig. 8.10a). 2. Dissect down, perpendicularly to the surface, to reach the tarsal plate. If you cut at an oblique angle, you confuse your orientation. 3. Starting in the middle of the incision, dissect towards the lid margin taking care to remain on the surface of the tarsal plate throughout (Fig. 8.10b). 4. Continue the dissection towards the lid margin until the lash roots become visible from behind (Fig. 8.10c). At this point the scissors usually enter a narrow, channel like, space. Extend the dissection medially and laterally by keeping one blade of the Westcott scissors within this channel and the other outside it on the surface of the tarsal plate. This makes extending the dissection very easy. This dissection separates the anterior lamella from the posterior lamella, but they remain hinged at the margin. 5. Place five 6/0 absorbable interrupted, everting sutures (Fig. 8.10d). Penetrate the anterior lamella just proximal to the lash line. Then take a partial thickness, horizontal, 2 mm long bite of tarsal plate about 2 mm proximal to the skin entry site i.e., higher up the tarsal plate. Finally exit the anterior lamella just proximal to the lash line (but distal to the tarsal bite) to complete the ‘box’ type suture. Do not tie this suture but clip its ends together. Now insert and clip the next suture similarly before tying the first. This delayed tying allows clear access and visualization for the accurate placement of the subsequent suture and avoids stressing the previously placed suture. Repeat this sequence for all the sutures. Note: As each suture is tied the lashes are seen to evert. Very slight lid margin eversion may also be seen. If there is significant eversion of the margin, then the tarsal bite has been placed too proximally. That suture should either be tied less tightly or replaced.

8.9 ‘Permanent’ Surgical Correction of Moderate Cicatricial Entropion

a

b

c

d

e

f

91

g

i

ii

iii

iv

Fig. 8.10 Anterior lamellar repositioning (ALR). a Mark and make a skin crease incision. b Dissect down to the tarsal plate. c Dissect on the tarsal plate surface to expose the lash roots. d Insert 5 box type everting sutures from low down on the anterior lamella to higher on the posterior lamella. e Plicate the levator aponeurosis to the skin incision to reform a skin crease. f Use the plication sutures to close the skin incision. g i & ii Cross-sectional view of simple ALR. iii & iv ALR augmented by grey line split

92

8

Entropion

If more lash eversion is needed, make a 1–1.5 mm deep grey line incision along the length of the lid margin (Fig. 8.10g iii and iv). Take care not to detach the whole anterior lamella from the margin by joining this incision to the deep dissection plane. 6. Bluntly dissect beneath the upper wound edge, proximally upwards (on the surface of Müller’s muscle in the upper lid) to reveal the ‘white line’ of the reflected retractor aponeurosis. In patients with strong connective tissue Westcott spring scissors may need to be used for this dissection. Pull Muller’s muscle downwards to make the white line appear. 7. Suture the white line to the skin with three absorbable 6/0 sutures (Fig. 8.10e). Note: In this way the retractor pulls on the anterior lamella imparting a lasting ‘dynamic’ component to the operation. 8. When applying the dressing ensure that the lashes are padded in an everted direction. Note: Warn the patient that the lashes will initially point unnaturally upwards but that they will gradually return to a more normal position.

8.10

Mucosal Grafting

If conjunctival scarring has caused significant shrinkage of the fornix, additional labial or buccal mucosal grafting will be required to deepen the fornices. Details of this fall outside the scope of this book.

8.11

Take Home Message

• Aging is the commonest cause of entropion. • Cicatricial pemphigoid, though rare, is easily missed if not specifically looked for. • Lasting correction of involutional entropion requires lid margin shortening, retractor reinsertion and orbicularis stabilization.

References

93

References 1. Meadows AE, Reck AC, Gaston H, Tyers AG (1999) Everting sutures in involutional entropion. Orbit 18(3):177–181. https://doi.org/10.1078/orbi.18.3.177.2708.PMID:12045982. 2. Quickert MH. In: Sorsby A (ed) Modern ophthalmology, vol 4, 2nd edn. Butterworth, London, p 940 3. Danks JJ, Rose GE (1998) Involutional lower lid entropion: to shorten or not to shorten? Ophthalmology 105(11):2085–2087. ISSN 0181–8420. https://doi.org/10.1018/S0181-8420(98)911 28-5

9

Ectropion

9.1

Overview

• Types • Assessment • Surgical management: – Lid margin wedge resection & Bick repair – Medial lower lid retractor plication – Central lower lid retractor posterior plication – Free skin graft – Upper to lower lid skin pedicle flap – Permanent (overlap) lateral tarsorrhaphy – Medial canthoplasty. Lid margin ectropion (outward turning) can affect both the upper and the lower lids. The commonest cause of lower lid ectropion is aging (involutional ectropion). Upper lid ectropion is the result of anterior lamellar scarring (cicatricial ectropion). Iatrogenic upper and lower lid cicatricial ectropion sometimes follow periocular or mid face surgery. They can be avoided by following simple rules (see Chap.14).

9.2

Symptoms

Watering is the commonest symptom of ectropion. It occurs with as little as a millimetre of punctal ectropion. An ectropic punctum dries and closes spontaneously. Lower lid margin ectropion allows tears to collect in the trough formed between the everted lid and the eye. They overflow when the patient leans forwards, particularly when reading. Constant wetting from tear overflow causes an eczematous skin reaction which adds a cicatricial component to the ectropion. Manage this by waterproofing the

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_9

95

96

9

Ectropion

skin with a thin smear of hydrocortisone 1% skin ointment. This also settles the inflammation. Instruct the patient to massage the ointment gently towards the lid margin two or three times a day. The second commonest complaint is of redness and crusting of the of the exposed lower lid conjunctiva. Even when the patient is not bothered about these, it bothers those who see them. Ectropion may cause minimal symptoms in the elderly whose tear production is naturally reduced. It is not a threat to vision and is safe to leave untreated if the patient prefers.

9.3

Types

9.3.1 Congenital Congenital ectropion is rare, associated with anterior lamellar shortage and it may be part of a syndrome such as Down’s.

9.3.2 Involutional Aging is the commonest cause of lower lid ectropion. Enophthalmos caused by orbital fat atrophy results in a relative laxity of the lid (lid-globe disparity) making it unstable. ‘Facial deflation’ through fat atrophy, together with stretching of the facial suspensory ligaments by relentless gravity, leads to mid face descent, which in turn pulls downward on the lower lid, stretching it. A lifetime of eye rubbing, and relative loss of orbicularis tone are further causative factors. The posterior attachment of the lower lid retractors to the inferior edge of the tarsal plate stabilizes it. Laxity of the retractors permits an unstable lid to flip outwards by 180o (tarsal ectropion). Gravity prevents upper lid involutional ectropion by holding the lid against the eye.

9.3.3 Eye Rubbing Constant eye rubbing stretches the lid margin and weakens the canthal tendons. Nocturnal stretching of the lids by head movement against the bedclothes is a possible explanation for the floppy eyelid syndrome.

9.4 Assessment

97

b

a

Fig. 9.1 Paralytic ectropion. a Paralytic ectropion tends to recur. b Combine lid shortening (passive) with medial canthoplasty and lateral tarsorrhaphy to transfer active lift from the upper to the lower lid

9.3.4 Cicatricial Any condition that causes skin shrinkage will pull the lid margin outwards. Chronic eczema, and the eczematous reaction caused by constant skin wetting through tearing, cause ectropion. Rare conditions such as Icthyosis have a similar effect. However, the commonest cause is sun damage related skin shrinkage. Iatrogenic skin deficit can occur following periocular tumour surgery, cosmetic blepharoplasty and chemical or laser ‘skin resurfacing’.

9.3.5 Paralytic Loss of orbicularis muscle tone, whether age related or due to denervation, as in facial palsy or botulinum toxin treatment, can give rise to a paralytic lower lid ectropion. This type of ectropion has a strong tendency to recur following simple lid margin tightening unless an additional active ‘lift’ from the upper lid is introduced by performing a small lateral tarsorrhaphy and medial canthoplasty (Fig. 9.1).

9.4

Assessment

9.4.1 Relative Lid/Globe Laxity (Invariably Present) Geometry dictates that for a lid margin to hang away from the eye it must have become lax relative to the eye. It is irrelevant whether this is due to enophthalmos or actual lid margin lengthening through a combination of aging, frequent eye rubbing and/or the chronic pull from tight skin.

98

9

Ectropion

9.4.2 Medial Canthal Tendon and Lateral Canthal Tendon Integrity Grasp the lower lid close to the lashes, between your thumb and forefinger and pull it laterally, away from the medial canthus, while observing the movement of the lower lid punctum relative to the corneo-scleral limbus. Any movement past the medial limbus (in straight ahead gaze) suggests significant medial canthal tendon laxity. Repeat this manoeuvre again but this time pulling the lid medially while observing the movement of the lateral canthus. A significant drift of the lateral canthus medially towards the lateral limbus suggests lateral canthal tendon dehiscence. Correct canthal tendon dehiscence before contemplating lid margin resection. If you do not, you will erroneously excise excessive lid margin to the detriment of lid stability.

9.4.3 Anterior Lamellar Insufficiency Attempt to correct (reduce) the lower lid ectropion by pulling the lid margin laterally and upwards with your finger. Observe whether tightness of the skin prevents return of the lid margin to its normal position. Alternatively, while the patient is looking upwards, gently pull the mid cheek slightly up and down and look for coupled movement of the lid margin. Such movement confirms a significant anterior lamellar deficit. Normally the cheek and lid move independently.

9.4.4 Orbicularis Tone Place your forefingers on gently closed upper lids and your thumbs on the lower lids and ask the patient to squeeze their eyes tightly shut. Try to open the eyes with your fingers. This should only be possible with strong effort. Compare the two sides. A weak orbicularis suggests a paralytic component.

9.5

Temporary Management

The management of ectropion is surgical. While awaiting surgery ask the patient to massage their lower lid upwards, towards the lid margin with a thin smear of Hydrocortisone 1% skin ointment (for three minutes, three times a day). This softens the skin, treats tear overflow eczema, and prevents further skin shrinkage, optimizing conditions for surgery. On rare occasions it can even cure the ectropion. You can temporarily correct a tarsal ectropion by placing inverting sutures, but this is seldom justified (Fig. 9.2).

9.6 Surgical Management

99

b

a

Fig. 9.2 Inverting sutures. a Insert 3 double armed absorbable sutures transconjunctivally at the lower edge of the tarsal plate, bringing them out through the skin 5 mm below the lash line. b Tightening the sutures inverts the lid margin

9.6

Surgical Management

Factors requiring potential surgical correction are: 1. The relative laxity of the eyelid against the eye (invariably present), 2. Any apparent anterior lamellar shortage (caused by mid face descent, skin shrinkage or scarring). 3. Significant lower lid retractor laxity ( for tarsal ectropion). 4. Lack of muscle tone. They are present in various combinations and to various degrees. The decision chart Fig. 9.3 may help you plan the appropriate combination of techniques during surgery. The mainstay of ectropion correction is lid margin tightening. This may require canthal tendon repair and/or lid margin shortening. In the presence of an anterior lamellar deficit first decouple the lid margin from the mid face with a horizontal skin and orbicularis incision about 5 mm below the lash line, extending it medially and laterally past the canthi. Once released, carry out the necessary lid margin tightening to restore the lid to its correct position. This reveals the true amount of anterior lamellar deficit. If the lid is flipped completely inside out (‘tarsal ectropion’) with the proximal tarsal plate edge forming the new margin, plicate the lower lid retractors to the bottom of the tarsal plate to pull it downwards. If an anterior lamellar defect remains after margin tightening, fill it with a skin graft or flap, sized to allow for post-operative contraction. Use a temporary tarsal traction suture to pull the lid margin upwards to expand the graft bed when sizing. Tape this suture on tension to immobilize the graft during healing. Finally, where there is significant orbicularis weakness consider performing a small medial canthoplasty and lateral tarsorrhaphy to transfer active upper lid lift to the lower lid.

100

9

Tight Anterior lamella?

Yes

Ectropion

Subciliary anterior release

No Canthal tendon laxity?

Yes

Canthal tendon repair

No Lid margin lax?

Yes

Shorten lid margin

No Tarsal ectropion?

Yes

Retractor plication

No Anterior lamellar deficit?

Yes

Skin graft/flap

No Orbicularis weakness

Yes

Medial canthoplasty & Lateral tarsorrhaphy

No End of operation Fig. 9.3 Ectropion decision chart. Use this to determine the appropriate combination of procedures for a particular case

9.7

Operations

9.7.1 Lid Margin Wedge Resection and Bick Repair 9.7.1.1 Principle and Considerations ‘Tightening’ the lid margin by partial resection or canthal tendon plication stabilizes a lid until it stretches again. Being a static repair, it fails in time. Full thickness lid margin shortening may be carried out anywhere along the lid margin (Fig. 9.4). Some argue that for a medial ectropion the resection should be carried out medially, the merit being that the hypertrophied and inflamed section of the lid is excised. However, this need not be an important consideration as the hypertrophy quickly settles once you restore the lid margin to its normal orientation.

9.7 Operations

101

Medial resection may be combined with medial lower lid retractor plication, as in the Lazy T repair, or the medial plication can be separate from say a lateral resection. I believe the lateral Bick resection to be the most elegant lid margin shortening and the least likely to lead to margin notching or a noticeable scar.

a

b

c

Fig. 9.4 Shorten anywhere. a Lateral canthal lid margin resection. b Lateral lid margin resection. c Medial lid margin resection

102

9

Ectropion

9.7.1.2 Steps 1. Load two double ended 6/0 absorbable sutures and prepare them for instant use. 2. Grab the full-thickness lid margin laterally with Adson’s forceps and place the lateral canthus on stretch by pulling the lid medially. Detach the lower lid margin from the lateral canthus by cutting infero-laterally at 45° from the lateral canthus for approximately 5–6 mm with Steven’s tenotomy scissors (Fig. 9.5a). Note: Cut slowly to crush the vessels and reduce bleeding. 3. Without delay (before the bleeding starts) grab the cut lateral canthal tendon (LCT) with toothed forceps and insert the first of the two prepared double armed 6/0 sutures as close to the canthus as possible with a double pass (Fig. 9.5b). Confirm correct placement by tugging on the suture firmly. There should be no give. Apply a bulldog clip to the pair of suture ends. Note: Get an assistant to stretch the canthal tissues apart to improve visualization. 4. Place the second 6/0 suture 2 mm below the first in a similar fashion and again confirm strong fixation in the tendon. If there is any ‘give’ replace the suture more deeply. Clip both ends together. 5. Ask your assistant to pull the upper of the two lateral canthal tendon sutures medially to put the lateral canthus on medial stretch. Grasping the cut edge of the lid margin with toothed Adson’s forceps pull it laterally to overlap the lateral canthus until the lid margin is straight. Mark the extent of the overlap with a marking pen (Fig. 9.5c). Measure this overlap. It should be between 7 to 15 mm. In the unlikely event that it is less, there was either no lid margin laxity or the lid was not being pulled firmly enough. If greater than 15 mm, undiagnosed canthal tendon laxity is present and needs to be treated before continuing. 6. Excise the excess lid margin with tenotomy scissors as a wedge or pentagon (Fig. 9.5d). 7. Insert the two pairs of pre-placed LCT 6/0 sutures in sequence through the cut edge of the tarsal plate, starting with the uppermost (Fig. 9.5e). Insert them from behind, trans-conjunctivally, through the full thickness of the tarsal plate, exiting through its anterior surface and bring them out of the wound edge before engaging the orbicularis or skin. Place each suture 1 mm below the previous one. Clip the corresponding pairs of suture ends together again, temporarily. This results in two horizontal mattress sutures reattaching the lid. 8. Before tying the above sutures, place a single ended 7/0 absorbable suture in the lid margin as a horizontal mattress (Fig. 9.5f). This time insert the suture through the orbicularis to exit the skin through the lash line, 1-2 mm from the wound edge.

9.7 Operations

103

a

b

c

d

e

f

g

h

i

Fig. 9.5 Bick resection ectropion. a Divide the lower lid from the lateral canthus. b Pre-place 2 double armed absorbable sutures into the lateral canthal tendon (LCT) stump. c Overlap the wound edges and mark the excess lid margin. d Excise the excess lid margin. e Insert the LCT pre-placed sutures into the cut edge of the tarsal plate. f Insert a lid margin horizontal mattress 7/0 absorbable suture. g Tighten and tie the LCT sutures. h Tighten and tie the lid margin mattress to bury the knot. i Close the orbicularis and skin

104

9

Ectropion

9. Then, with the same needle, re-enter the lid through the meibomian orifice line and exit through the tarsal plate just above the top, already placed, 6/0 suture bite (taking care not to inadvertently engage it with your needle). 10. Now enter the lateral canthal wound with the same needle, engage the upper lid tarsal plate, and bring the needle out through the meibomian orifice line 1–2 mm from the lateral canthus. 11. Re-enter the upper lid lash line and exit the wound through the orbicularis to complete this lid margin mattress suture. Clip its two ends together. 12. Now that you have placed the sutures under direct vision, pull the ends of the lower of the two 6/0 sutures laterally (Fig. 9.5g). Use their pulley action to pull the lid margin laterally towards the LCT to close the posterior lamella. Tie the suture with no less than three throws and cut the ends no shorter that 2 mm (to prevent spontaneous unravelling). 13. Tie and cut the upper 6/0 suture similarly. 14. Tie the 7/0 pre-placed margin suture (Fig. 9.5h). This aligns the lid margin at the lateral canthus. Cut the ends flush with the skin so that the knot becomes buried and does not irritate. 15. Close the anterior lamella with two or three horizontal mattress 7/0 absorbable sutures passed through the skin and orbicularis (Fig. 9.5i).

9.7.1.3 Notes • The tightened lid margin will slip below the globe and appear retracted. This is usually only temporary and resolves within a couple of weeks. • For tarsal ectropion correction combine the lid margin shortening with lower lid retractor plication. It is easier to identify the retractor aponeurosis and preplace the sutures before performing the Bick repair.

9.7.2 Medial Lower Lid Retractor Plication (Fig. 9.6) 9.7.2.1 Principle and Considerations Punctal ectropion is a common occurrence. Even an ectropion of as little as 1 mm can give rise to disproportionally symptomatic watering. Traditionally a ‘tarsoconjunctival diamond’ excision is performed below the lower punctum. Such diamond excision is pointless for two reasons. Firstly, there is next to no tarsal plate to excise in that area, so what is excised is conjunctiva. Secondly, excision of conjunctiva achieves nothing, as conjunctiva stretches. A better alternative is to make a horizontal conjunctival incision through which the lower lid retractors are identified and plicated to the inferior edge of the tarsal plate below the punctum to pull it inwards as an active repair.

9.7 Operations

105

9.7.2.2 Case Selection • Punctal ectropion • Medial ectropion if you combine the plication with a lid margin tightening

9.7.2.3 Steps 1. Evert the lower lid and make a 5 mm long, horizontal, conjunctival incision below the lacrimal punctum and the inferior edge of the tarsal plate (Fig. 9.6a).

a

b

c

d

e

Fig. 9.6 Medial lower lid retractor plication. a Evert the lower lid and make a 5 mm long, horizontal, conjunctival incision below the lacrimal punctum and the inferior edge of the tarsal plate. b Bluntly dissect infero-laterally between the conjunctiva and the lower lid retractors. c Withdraw the retractor aponeurosis from the pocket with toothed Jayles forceps and tag it with a 6/ 0 absorbable suture before letting go. d Bring the suture needle out through the inferior edge of the tarsal plate and upper conjunctival edge, below the punctum and take the needle back into the wound through the inferior conjunctival edge. e Tie the suture tightly and cut the ends to 2 mm. so that the knot becomes fully buried

106

9

Ectropion

2. Hold the inferior conjunctival edge on upward stretch with Moorfields forceps while bluntly dissecting infero-laterally between the conjunctiva and the lower lid retractors with Westcott spring scissors (Fig. 9.6b). 3. Keeping the conjunctiva on stretch insert toothed Jayles forceps into the pocket, aimed infero-laterally, and grab and withdraw the retractor aponeurosis. Tag it with a 6/0 absorbable suture before letting go (Fig. 9.6c). 4. Check the retractor pull by putting the suture on gentle upward traction while the patient is looking up, and then asking the patient to look maximally downwards. You should feel a tug on the suture. If it is not felt, repeat the manoeuvre but this time asking the patient to follow your hand into downgaze. If there is still no pull on the suture, remove and replace it. 5. Bring the suture needle out through the inferior edge of the tarsal plate and conjunctiva, below the punctum. 6. Take the needle back into the wound through the inferior conjunctival edge (Fig. 9.6d). Ensure that both ends are on the same side of the suture loop (to allow the knot to retract once tied). Tie the suture tightly and cut the ends to 2 mm. Encourage them to retract into the wound so that the knot becomes fully buried (Fig. 9.6e). This single suture both plicates the retractors to the tarsal plate and closes the conjunctival incision. Whenever the patient looks down the retractors pull the punctum inwards.

9.7.2.4 Note • Tightening the lid margin laterally (Bick repair) can also resolve a mild punctal ectropion without a retractor plication.

9.7.3 Central Lower Lid Retractor Posterior Plication (Fig. 9.7) 9.7.3.1 Principle and Considerations When the lower lid tarsal plate flips out completely (by 180°) a ‘tarsal ectropion’ is said to exist. Reattaching the lower lid retractors to the inferior tarsal edge anchors it downwards stabilizing the lid. However, it is still advisable to tighten the lid margin as well as addressing any anterior lamellar shortage.

9.7.3.2 Case Selection Lower lid tarsal ectropion.

9.7 Operations

107

9.7.3.3 Steps 1. Evert the lower lid over a Desmarres retractor and make a 10 mm long horizontal conjunctival incision centrally, just below the proximal tarsal plate edge (Fig. 9.7a).

a

b

c

d

e

Fig. 9.7 Central lower lid retractor plication. a Evert the lower lid over a Desmarres retractor and make a 10 mm long horizontal conjunctival incision centrally, just below the tarsal plate edge. b Bluntly dissect on the under surface of the conjunctiva. c Grab and withdraw the retractor fascia using toothed Jayles forceps and tag it with a 6/0 absorbable suture. d Bring the suture needle out through the edge of the tarsal plate and conjunctiva, and then back into the wound through the inferior conjunctival edge. e Tie the suture tightly and cut the ends to 2 mm to retract into the wound. Perform a lid margin shortening

108

9

Ectropion

2. Bluntly dissect proximally on the under surface of the conjunctiva while holding the inferior conjunctival edge on upward stretch (Fig. 9.7b). 3. Insert toothed Jayles forceps into the dissected pocket and grab and withdraw the retractor fascia. Tag it with a 6/0 absorbable suture before letting go (Fig. 9.7c). 4. Check the retractor pull by putting the suture on gentle upward traction while the patient is looking up, and then asking the patient to look maximally downwards. You should feel a tug on the suture. If it is not felt, repeat the manoeuvre but this time asking the patient to follow your hand into downgaze. If there is still no pull on the suture, remove and replace it. 5. Bring the suture needle out through the edge of the tarsal plate and conjunctiva, and then back into the wound through the inferior conjunctival edge (Fig. 9.7d). The tarsal bite should be placed 5 mm medially of centre in anticipation of a subsequent lateral lid margin shortening. 6. Tie the suture tightly and cut the ends to 2 mm. Encourage them to retract into the wound so that the knot becomes fully buried. This single suture both plicates the retractors to the tarsal plate and closes the conjunctival incision. 7. Proceed to perform a lid margin shortening (lateral wedge resection and Bick repair) (Fig. 9.7e).

9.7.3.4 Note • Retractor plication alone is only of marginal benefit if performed without lid shortening. • Alternatively, the retractors may be plicated via an anterior approach (see Fig. 8.8b–d). Use this approach when you need to perform anterior lamellar augmentation.

9.7.4 Free Skin Graft (Fig. 9.8) 9.7.4.1 Principle and Considerations Take a full thickness patch of colour and texture matched donor skin from an available donor site and suture it into the anterior lamellar deficit. Stabilize the graft bed with a lid margin traction suture and the graft with a pressure dressing.

9.7.4.2 Case Selection Anterior lamellar deficit (actual or secondary to mid face drop).

9.7 Operations

109

9.7.4.3 Steps 1. Incise the lower lid skin and orbicularis 5 mm below the lid margin and perform lid margin tightening if one is required (Fig. 9.8a). It usually is! 2. Put the recipient bed on stretch and dry it. Blot the area with a piece of paper to obtain a blood-stained imprint of the defect. Remove the paper and cut

a

b

c

d x

y

x + y ≥ 20 mm

e

Fig. 9.8 Anterior lamellar graft. a Incise the lower lid skin and orbicularis 5 mm below the lid margin and perform lid margin tightening if required. b Blot the recipient bed with a piece of paper to obtain a blood-stained imprint of the defect to create a paper template. c Use the template to mark the area of skin to be harvested. d Transfer the skin graft to the donor bed anchoring it at either end. e Use the anchoring sutures to suture the graft in place with a continuous suture. Suture the donor site

110

3.

4. 5. 6.

7.

8. 9.

10. 11.

12.

9

Ectropion

around the imprint to create a paper template of the defect. Check this against the wound and refine it as necessary (Fig. 9.8b). Place the paper template on the gently stretched donor site and mark the area of skin to be harvested. If you choose the upper lid as the donor site, ensure that you leave sufficient skin behind to allow full eyelid closure. As a rule of thumb, leave at least 20 mm of skin between the lid margin and the lower edge of the eyebrow (Fig. 9.8c). Intumesce the donor site with a sub-dermal injection of local anaesthetic with adrenaline. This assists haemostasis and makes it easier to harvest a thin graft. Incise the full thickness of the skin along the marked line with a scalpel. Grasp one edge of the donor skin with toothed forceps to keep the skin on traction and carry out a sharp dissection in the superficial subcutaneous plane with the tip of the scalpel blade or with scissors. Check frequently that you are not perforating the graft. Wrap the harvested skin graft around your index finger, subcutaneous side out, and trim off any excess subcutaneous tissue remaining on the graft with Westcott scissors. Anchor the skin graft to the donor bed at either end with a 6/0 absorbable suture but do not cut the suture ends (Fig. 9.8d). Use the anchoring sutures to suture the graft in place with a continuous suture. Do this in two stages using one of the anchoring sutures for one half and the other for the second half. Tie each suture to the free end of the other one to complete (Fig. 9.8e). Suture the donor site. Tape the lid margin traction suture securely to the forehead (for the lower lid) or cheek (for the upper lid) to keep it on traction and so immobilize the graft bed. Apply a non-stick film, copious antibiotic ointment, and a firm pressure dressing to the closed eye. Leave this undisturbed for 5–7 days to keep the graft immobile while it revascularizes.

9.7.4.4 Notes • Take care when removing the pressure dressing not to pull on the graft as not all dressings marketed as ‘non-stick’ live up to their name. Remove the lid margin traction suture. • Apply twice daily antibiotic ointment to the graft for a further week to keep it soft and moist. • Thereafter the patient should massage the graft gently towards the lid margin, twice daily, with a thin smear of hydrocortisone 1% skin ointment. This helps to reduce postoperative graft shrinkage.

9.7 Operations

111

9.7.5 Upper to Lower Lid Skin Pedicle Flap (Fig. 9.9) 9.7.5.1 Principle and Considerations Skin may be transferred to the donor site on its own vascular pedicle. This has the theoretical advantage of ensuring flap survival. In practice, there is little additional benefit over a free graft because the periocular region is so well vascularized. When possible ‘set in’ the flap pedicle to avoid the need for a second operation.

a

b x

y

x + y ≥ 20 mm

c

d a b c

a

c b

e

Fig. 9.9 Anterior lamellar pedicle flap. a Create a paper template of the defect. b Use the template to mark the pedicle flap. c Raise the flap and transfer it to the recipient site. d Anchor the tip of the flap in its new position with a 6/0 absorbable suture and anchor the lateral corner of the recipient skin (point c) into the lateral end of the donor incision (point a). e Suture the flap into place with a continuous suture and close the upper lid donor bed

112

9

Ectropion

9.7.5.2 Case Selection Anterior lamellar deficit (actual or secondary to mid face drop) when sufficient upper lid donor skin is present.

9.7.5.3 Steps 1. Put the recipient bed on stretch, using a 4/0 monofilament lid margin traction suture, and dry it. Blot the area with a piece of paper to obtain an imprint of the defect. Remove the paper and cut around the blood stain to create a paper template. Check this against the wound and refine it, as necessary (Fig. 9.9a). 2. Place the paper template on the chosen skin donor site. Ensure that the skin is gently stretched before marking the area to be harvested (Fig. 9.9b). Mark also the pedicle on which this donor skin will be transferred. This should not be narrower than the flap. Take particular care to align the upper and lower ends of the pedicle base (points a and b) vertically, one above the other (Fig. 9.9c). This ensures that when transferred the pedicle beds in aesthetically. 3. Intumesce the donor site with a superficial injection of local anaesthetic with adrenaline. This helps with haemostasis. 4. Incise the full thickness of the skin along the marked line with a scalpel. 5. Grasp the tip of the flap and dissect the flap free of its bed with Westcott scissors. The dissection plane can either be between the skin and the orbicularis, or the orbicularis can be included as part of the flap. The latter results in an easier dissection, better vascularity and slightly more ‘support’ from the pedicle. 6. Anchor the tip of the flap in its new position with a 6/0 absorbable suture (do not cut the ends) (Fig. 9.9d). 7. Anchor the lateral corner of the recipient skin (point c) into the lateral end of the donor incision (point a) with a second suture to complete the alignment. 8. Suture the flap into place with a continuous suturing technique, using the uncut anchoring sutures (Fig. 9.9e). 9. Finally, close the upper lid donor bed with a continuous absorbable suture. 10. Tape the lid margin traction suture securely to the forehead to immobilize the flap bed and keep it on traction. 11. Apply a non-stick film, copious antibiotic ointment, and a firm pressure dressing to the closed eye and leave this undisturbed for 1–7 days. It is not strictly necessary to keep a flap padded for as long as a graft. However, a pad does protect the surgical site from the patient’s wandering hands during the early healing phase.

9.7 Operations

113

9.7.6 Permanent (Overlap) Lateral Tarsorrhaphy (Fig. 9.10) 9.7.6.1 Principle and Considerations Adding a short (4 mm) permanent lateral tarsorrhaphy transfers some of the upper lid levator pull to lift the lower lid laterally. This imparts an active component to an otherwise passive ectropion repair. This is especially important when correcting paralytic ectropion.

9.7.6.2 Case Selection Atonic lower lid ectropion. Usually combined with lid margin shortening and with medial canthoplasty.

9.7.6.3 Steps 1. Make a 4 mm long incision in the lower lid grey line up to the lateral canthus (Fig. 9.10a). 2. Based on the grey line incision, excise a semicircle of anterior lamella below it, including skin, lashes, and orbicularis, to expose the underlying tarsal plate (Fig. 9.10b). Ensure that the exposed tarsal plate surface is free of connective tissue. Gentle diathermy may be applied if required to enhance adhesion. 3. Evert the upper lid margin and mark out a corresponding semicircle on the sub-tarsal conjunctiva ensuring that it also starts at the lateral canthus. Apply gentle diathermy to this area to destroy the conjunctiva without significantly damaging the tarsal plate (Fig. 9.10c). Wipe off any loose necrotic conjunctiva. 4. Insert a 6/0 absorbable suture through the middle of the exposed lower lid tarsal plate margin. 5. With the same suture take a bite of the upper edge of the adjacent diathermied area of the everted upper lid tarsal plate (Fig. 9.10d). 6. Tie this suture and cut its ends short, so that they do not irritate the eye. 7. Insert a 4/0 monofilament suture on a round bodied needle through the upper lid skin, just above the lashes so that it exits the denuded tarsal plate close to the lateral canthus. 8. With the same suture now take a strong, partial thickness, bite to span the exposed lower lid tarsal plate. 9. Complete this suture by taking it through the upper lid tarsal plate at the medial end of the denuded tarsal crescent, so that it exits through the skin just above the lashes (Fig. 9.10e). 10. Cut a piece of silicone tubing the length of the distance between the suture entry and exit points and thread it onto the suture. It will act as a bolster. Clip the untied suture ends together. 11. Place one or two 6/0 absorbable sutures to bring together the upper lid meibomian orifice line and the cut edge of the lower lid orbicularis and skin. Tie the suture(s) (Fig. 9.10f).

114

9

a

b

c

d

e

f

Ectropion

Fig. 9.10 Permanent lateral tarsorrhaphy. a Make a 4 mm long incision in the lower lid grey line up to the lateral canthus. b Excise a semicircle of anterior lamella to expose bare tarsal plate. c Evert the upper lid and diathermy a corresponding area without significantly damaging the tarsal plate. d Insert a 6/0 absorbable suture between the middle of the exposed lower lid tarsal plate margin and the upper edge of the adjacent diathermied area of the everted upper lid tarsal plate and tie it. e Insert a 4/0 monofilament suture on a round bodied needle through the upper lid skin, just above the lashes so that it exits the denuded tarsal plate close to the lateral canthus and take a strong, partial thickness, bite of exposed lower lid tarsal plate. Complete this suture by taking it through the upper lid tarsal plate to exit the skin just above the lashes. Thread it through a piece of silicone tubing. f Place two 6/0 absorbable sutures to bring together the upper lid meibomian orifice line and the cut edge of the lower lid orbicularis and skin together

9.7 Operations

115

12. Tighten and tie the preplaced 4/0 monofilament suture to hold the raw tarsal plate surfaces in firm apposition, so that they unite during healing. 13. Before cutting the 4/0 suture ends, thread one end back through the tubing, using the blunt end of its needle. By pulling on this suture the knot can be pulled to lie inside the tubing for the patient’s comfort. Cut both suture ends close to the tubing. 14. No dressing is required. Remove the non-absorbable suture and bolster at two weeks. The remaining sutures are allowed to dissolve spontaneously.

9.7.6.4 Notes • Such tarsorrhaphies are well camouflaged by the upper lid lashes. • They are permanent and cannot be reversed without causing distortion of the lid margin. • They are often combined with a medial canthoplasty which provides medial lift to the lower lid.

9.7.7 Medial Canthoplasty (Fig. 9.11) 9.7.7.1 Principle and Considerations Medial canthoplasty is a tarsorrhaphy carried out medially to the lacrimal puncta. It transfers upper lid levator pull to a paralytic lower lid adding an active component to a paralytic ectropion correction. Take great care not to damage, or suture closed the lacrimal canaliculi during this procedure as they lie close to the tendon.

9.7.7.2 Case Selection Atonic lower lid ectropion. Usually combined with lid margin shortening and with lateral tarsorrhaphy.

9.7.7.3 Steps 1. Insert ‘0’ gauge Bowman lacrimal probes into the upper and the lower canaliculi and ask an assistant to keep them in the lacrimal sac by pressing them gently against the side of the nose (Fig. 9.11a). 2. Carefully make a ‘U’ shape skin incision around the medial canthus from punctum to punctum and 1–2 mm outside the probes (hence also the canaliculi). 3. Separate the orbicularis under the incision by blunt dissection using pointed scissors. 4. Using a 6/0 absorbable suture on a curved needle take a strong horizontal bite of the firm medial canthal tendon tissue adjacent to the canaliculus (Fig. 9.11b).

116

9

a

b

c

d

Ectropion

Fig. 9.11 Medial canthoplasty. a Insert ‘0’ gauge Bowman lacrimal probes into the upper and the lower canaliculi and make a ‘U’ shape skin incision around the medial canthus from punctum to punctum and 1–2 mm outside the probes. b Using a 6/0 absorbable suture on a curved needle place 2 ‘box’ sutures. c Withdraw the Bowman probes and tie both sutures firmly. Place two 6/0 absorbable horizontal mattress sutures across the wound, engaging both the skin and the orbicularis. d Tie the skin sutures to evert the skin edges

5. 6. 7.

8.

9.

The tendon is identified by its resistance to distraction rather than by its visibility. Start at the medial canthus. If you touch metal with your needle tip it has penetrated the canaliculus and should be withdrawn. Take a similar bite of tendon with the same suture through the opposing lid in the opposite direction to make a ‘box’ suture. Clip the two suture ends together. Place a second suture adjacent to the first so that the bites extend to the lateral ends of the incisions, close to the lacrimal puncta. Withdraw the Bowman probes and tie both sutures firmly. In doing so the lid margins become inverted so that there is no epithelium between the raw surfaces of the upper and lower limbs of the medial canthal tendon. Place two 6/0 absorbable horizontal mattress sutures across the wound, engaging both the skin and the orbicularis. As you tie them, they will evert the skin edges (Fig. 9.11c, d). No dressing is required. Leave the sutures to dissolve spontaneously.

9.7.7.4 Notes A medial canthoplasty hides the caruncle. Usually this is not a major aesthetic issue particularly as in paralytic ectropion the pre-operative medial canthus is excessively widened.

9.8 Take Home Message

117

9.7.7.5 Problems Lid margin tightening and anterior lamellar flaps and grafts rely on static mechanisms of action and are therefore prone to ectropion recurrence. Recurrence is particularly likely if a small anterior lamellar deficit has gone unnoticed and uncorrected.

9.8

Take Home Message

• Surgical correction of involutional ectropion requires substantial lid margin shortening ± anterior lamellar supplementation with a skin graft or flap. • Ectropion recurrence is common because the surgery mostly relies on passive mechanisms.

Ptosis

10

Fig. 10.1 Ptosis. When assessing ptosis note the brow position, head posture and facial expression in addition to the lid movement

10.1 • • • •

Overview (Fig. 10.1)

Clinical evaluation Types of ptosis Levator function-based choice of correction Surgical techniques: – White line advancement, anterior approach, – Müller’s resection, – Anterior approach levator aponeurosis reinsertion, – Silicone frontalis suspension.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_10

119

120

10

Ptosis

The word ptosis comes from Greek, meaning the act of falling. Ophthalmologists use the term as shorthand for ‘Blepharoptosis’, namely a dropping upper lid. There are many different causes of ptosis. Age related ptosis is by far the most common and is therefore the focus of this chapter. As always, the history of onset is helpful in diagnosing the type of ptosis, followed by the examination.

10.2

Examination

The following measurements are helpful in choosing the most appropriate ptosis operation.

10.2.1 Vertical Palpebral Aperture (PA) This is the distance between the central upper and lower lid margins in primary gaze (looking straight ahead). It depends on the position of both lids. For greater accuracy therefore the lid margin to corneal light reflex distances (MRD) are measured for both the upper and the lower lid margins (MRD1 & MRD2 respectively) (Fig. 10.2). Added together they should equal the PA. Pseudo ptosis can arise from an overhanging skin fold (Fig. 10.3a) which masks the true palpaebral aperture. Vertical ocular misalignment will also cause ‘pseudo ptosis’ of the hypotropic eye as the lid follows the eye’s position. The pseudoptosis vanishes when the eye is forced to look straight ahead (Fig. 10.3b). Hypotropia should be addressed by squint correction before ptosis correction is contemplated. Ten percent of congenital ptosis has an associated superior rectus weakness (as the superior rectus and levator muscles develop together and share a common innervation).

PA

MRD1 MRD2

Fig. 10.2 Palpebral aperture (PA) and margin reflex distance (MRD). The PA should equal the sum of the upper and lower lid MRD

10.2 Examination

121

a

b

Fig. 10.3 Pseudoptosis. a An overhanging skin fold masks the true PA. b The pseudoptosis of a hypotropic eye disappears when the eye takes up fixation

10.2.2 Levator Function (LF) This is the distance that the central upper lid margin moves from full downgaze to full up-gaze while you neutralize any frontalis muscle contribution by pressing on the brow (Fig. 10.4). Levator function cannot be improved by surgery. Therefore, the LF dictates the choice of operation most likely to work for that patient. The LF also dictates the degree of post-surgical improvement possible. A patient with normal levator function is likely to get an excellent (near normal) surgical outcome. By contrast a patient with poor LF who is successfully corrected for straight ahead (primary) gaze will still have a degree of ptosis in up-gaze and ‘hang-up’ in downgaze. Levator function is a clinical surrogate measure of muscle strength. Normal levator function is an excursion of between 12 and 17 mm. Poor levator function is 0–4 mm.

122

10

Ptosis

LF

Fig. 10.4 Levator Function (LF). LF is the full excursion of the central upper lid margin expressed in millimetres

10.2.3 Skin Crease (SC) and Skin Fold (SF) (Fig. 10.5) Most occidental eyelids have a skin crease about 5–10 mm from the lid margin. It is thought to be caused by the pull of the anterior insertion of the levator aponeurosis into the orbicular fascia. Absence of a skin crease may imply very poor levator function i.e., no pull on the skin. Oriental lids have a much lower skin crease due to a lower aponeurosis insertion. Lax skin above the crease may hang over as a skin fold and hide the true crease. The skin crease is usually raised in age related, contact lens induced, and postsurgical ptosis, as well as in Horner’s syndrome. Why should this be and what

SC

SF

Fig. 10.5 Skin Crease (SC) and Skin Fold (SF). A SF may overhang and mask the true SC

10.2 Examination

123

a

b

c

Fig. 10.6 Hang-up in downgaze. a Left upper lid ptosis in primary gaze. b In downgaze the left ptosis disappears because the lid is prevented from moving down by the dystrophic levator. c In upgaze the left ptosis worsens because the dystrophic levator cannot lift it as well as the right

124

10

Ptosis

is the common denominator? Perhaps they are all caused by a failure of Müller’s muscle rather than of the levator aponeurosis?

10.2.4 ‘Hang-Up’ in Downgaze (Fig. 10.6) A ptosis may seem to reduce, disappear, or even reverse in downgaze. This is because as well as not contracting normally, an abnormally formed levator muscle does not relax or stretch as well as the normal contralateral muscle. Such downgaze ‘hang-up’ strongly suggests a congenital ptosis (or previous levator resection).

10.3

Types of Ptosis

10.3.1 Congenital Ptosis • Present from birth • Reduced levator function (lid margin excursion from full downgaze to full up gaze). • ‘Hang-up’ in downgaze (the affected lid does not move as far down as the normal lid). • Sometimes part of a syndrome (e.g., Marcus Gunn jaw wink).

10.3.2 Acquired Ptosis 10.3.2.1 Age Related Ptosis (synonyms: Involutional, Senile, Aponeurosis disinsertion, Levator dehiscence). • • • •

The most common. Gradual onset. Normal levator function. Often a raised skin crease.

Note: The term Aponeurotic disinsertion ptosis (above), although frequently used, is not indicative of the underlying pathology. Rather it derives from the type of surgery used to correct it i.e., aponeurosis repair or reinsertion.

10.3.2.2 Traumatic Ptosis (Including Post Eye Surgery, Contact Lens Wear and Birth Trauma) • History of causative trauma. • Levator function normal unless direct muscle trauma or complete dehiscence.

10.4 Choice of Operation

125

10.3.2.3 Myopathic Ptosis (Myaesthenia, Progressive External Ophthalmoplegia) • Gradually deteriorating levator function. • Fatiguability. • Normal skin crease.

10.3.2.4 Neurological Ptosis (Associated Neurological Signs) Horner’s Syndrome

• • • •

2 mm of ptosis or less. Normal levator function. Smaller pupil. Ipsilateral anhidrosis and/or skin hyperaemia

Third Cranial Nerve Palsy (Partial or Complete).

• Poor levator function. • Impaired eye movements.

10.4

Choice of Operation

The levator function (range of upper lid movement) dictates the choice of operation, according to the Table 10.1. But there can be exceptions. An otherwise healthy but severely ‘dehisced’ levator may have reduced levator function without being weak. A few patients with congenital ptosis have an unusual levator-extraocular muscle synkinesis that gives them a good levator function measurement, but which does not reflect levator innervation in primary gaze [1]. If this synkinesis is not spotted the standard surgery will result in an under-correction. The better the levator function, the better the likely outcome of ptosis surgery. Near normal levator function should give near normal outcomes. The best that Table 10.1 Choice of ptosis correction procedure based on levator function Normal

Levator function Degree of (mm) ptosis (mm)

Preferred operation

12–17

=2

Aponeurosis re-insertion

Moderate

5–11

Levator resection

Poor

0–4

Frontalis suspension

126

10

Ptosis

a

b

c

Fig. 10.7 Post successful ptosis correction with poor levator function (LF). a Left ptosis correction successful in primary gaze. b In downgaze hang-up is visible (the left upper lid appears retracted). c In upgaze the ptosis becomes visible

10.5 Operations

127

can be hoped for with poor levator function is an acceptable lid level in primary gaze, but under-correction in up-gaze and over correction (hang-up) in downgaze (Fig. 10.7). The cause of the ptosis must also be considered. A patient with progressive external ophthalmoplegia and a LF of 7 may ultimately do better with a frontalis suspension than a levator resection as the LF will continue to decline. Counsel the patients to have realistic expectations regarding what surgery can and can’t achieve.

10.5

Operations

10.5.1 White Line Advancement (Anterior Approach) Fig. 10.8 Age related ptosis is the commonest ptosis. The easiest and most commonly applicable levator re-insertion operation is the ‘white line advancement’. I strongly recommend it for all involutional, contact lens related and post periocular surgery

a

b

c

d

Fig. 10.8 White line advancement ptosis correction. a Mark and incise the desired postoperative skin crease. b Cut through the orbicularis and posterior levator aponeurosis to expose the upper 1/3 of the tarsal plate. c Extend the incision medially and laterally to the full extent of the skin incision. d Clean the exposed anterior surface of the upper 1/3 of the tarsal plate of any remaining connective tissue, to ensure firm healing. e Bluntly dissect upwards with a cotton bud to expose the anterior surface of Müller’s muscle. f Pull the Müller’s muscle downwards and continue the blunt dissection superiorly until the so called ‘white line’ (folded levator aponeurosis) appears. g Insert a double armed 6/0 absorbable suture through the white line centrally. h Insert two further white line sutures similarly and insert both ends of the sutures into the upper 2–3 mm of the exposed tarsal plate as partial thickness bites. Then pass one of each pair of suture ends out through the upper and the other through the lower skin edge. i Tie sutures on the skin and complete skin closure with a suture

128

10

e

Ptosis

f

g h

i

Fig. 10.8 (continued)

ptosis, provided that levator function is normal (which it should be in those cases). White line advancement has two selling points: 1. The first is that mostly it is easy to perform, requiring minimal dissection. 2. The second is that it seems to set the lid at the correct height, as if by magic, without any per-operative measurement. It can be performed either via an anterior (skin) or a posterior (conjunctival) approach. The skin approach is easier to learn and is described below. If required, it can also be combined with excess skin removal (blepharoplasty) and it causes no ocular irritation. I acknowledge that many prefer the posterior, conjunctival approach which avoids a skin incision and works equally well. Should the white line advancement prove difficult or insufficient it is easy to convert it to a more formal aponeurosis insertion or levator resection. The conversion is also described below.

10.5 Operations

129

10.5.1.1 Principle and Considerations Draw the levator aponeurosis down by pulling on Müller’s muscle to create a fold. The aponeurosis fold appears as a ‘white line’. Suture the white line to the upper edge of the tarsal plate. This effectively shortens the aponeurosis. 10.5.1.2 Case Selection Ptosis with good levator function (LF ≤ 12 mm). This includes age related, contact lens induced and post-surgical ptosis. 10.5.1.3 Steps 1. Mark the new skin crease position on the surgical side while holding the skin on gentle upward stretch (Fig. 10.8a). Match its height with the crease on the contralateral lid. In bilateral ptosis set it at about 7–8 mm (for occidental lids). 2. Incise the skin along the marked line with a no. 15 scalpel while protecting the eye with a guard held under the lid. 3. Deepen the incision centrally with Westcott scissors (Fig. 10.8b). Dissect perpendicularly through the orbicularis and posterior levator aponeurosis until the upper 1/3 of the tarsal plate is reached. Note: Angling the dissection can cause you to dissect too proximally, missing the tarsal plate, or too low, where the aponeurosis inserts into the tarsal plate. 4. Bluntly dissect the pretarsal space medially and laterally with closed Westcott scissors. Then extend the incision to the full extent of the skin incision. Do this with one blade of the scissors inside the tunnel and the other on the orbicularis surface (Fig. 10.8c). 5. Clean the exposed anterior surface of the upper 1/3 of the tarsal plate of any remaining connective tissue, to ensure firm healing (Fig. 10.8d). Note: Not cleaning thoroughly can lead to poor union and late surgical failure when the sutures absorb. 6. Pull the lid downwards with toothed forceps and bluntly dissect upwards with a cotton bud, beyond the upper edge of the tarsal plate to expose the anterior surface of Müller’s muscle (Fig. 10.8e). Note: This is usually an easy manoeuvre, but occasionally firmer connective tissue is encountered and a little sharp dissection with Westcott scissors is required. In a few patients some yellow fat may be encountered in this plane. 7. Now pull the upper extent of Müller’s muscle firmly downwards with toothed forceps (e.g., Jayles) and continue the blunt dissection superiorly with a cotton bud until a white fold of connective tissue appears—the so called ‘white line’ (folded levator aponeurosis) (Fig. 10.8f).

130

10

Ptosis

8. Grasp the white line firmly and gently stretch it downwards. Instruct the patient to look upwards. You should feel a strong tug. This confirms that the structure is indeed the levator aponeurosis. 9. Insert a double armed suture 6/0 absorbable (Vicryl) suture through the white line centrally with a double bite. 10. Insert both ends of this central suture into the upper 2–3 mm of the exposed tarsal plate as partial thickness bites. Before completing each needle bite, evert the lid to check that the needle pass has not penetrated the conjunctival surface. If it has, withdraw the needle, and replace it more superficially to avoid corneal irritation by the suture (Fig. 10.8g). 11. Tighten this suture and tie it as a bow. Check the lid height, curve, and movement by asking the patient to look first straight ahead and then up and down. The lid margin height should be 1–2 mm higher than the contralateral side to compensate for the local anaesthetic induced orbicularis paralysis. 12. Undo the bow and insert two further white line sutures similarly, one on either side and each about 3 mm away from the central one. To do this ask an assistant to pull downwards on the previously placed central suture to keep the white line exposed. 13. Undo the temporary bows and pass one of each pair of suture ends out through the upper and the other through the lower skin edge (Fig. 10.8h). 14. Tie the sutures on the skin. This advances the white line to the tarsal plate, closes the incision, and reforms the skin crease. Do not cut the suture ends at this stage but clip them out of the way. 15. Complete skin closure with a continuous 6/0 or 7/0 absorbable suture taking a bite between each of the knots and tie it at each end (Fig. 10.8i). Note: Although this suture is usually superfluous, it keeps the incision closed if you need to remove an aponeurosis suture early because of an overcorrection. 16. Now pull the white line suture ends down and cut them at the level of the lid margin. This ensures that the ends remain exposed and long enough to identify and grasp easily should you need to remove them. 17. Instruct the patient to keep the eye closed and apply antibiotic ointment and a pressure dressing overnight. 18. Review the lid height the next day. If there is an overcorrection remove one or more of the levator aponeurosis sutures by lifting the knot and cutting one side of the suture below it. Pull the whole suture out.

10.5.1.4 Notes Some surgeons advocate using only a single aponeurosis suture to save time. While this can work it does risk creating an unattractive ‘cathedral arch’ upper lid contour if you insert the suture too low on the tarsal plate. Furthermore, there is no redundancy for the eventuality of suture failure. Using three sutures gives more control over the lid contour and the extra time they take to place is a worthwhile investment for the novice.

10.5 Operations

131

10.5.2 Conversion to an Anterior Levator Aponeurosis Reinsertion/Resection Fig. 10.9 Steps 1–5 are as above. If step 7 is problematic (the white line cannot be found) or the lid height is too low at the end of surgery proceed as follows:

a

b

c

d

e

Fig. 10.9 Conversion to an anterior levator aponeurosis reinsertion. a While retracting the upper skin and orbicularis edge upwards, grasp the anterior layer of the levator aponeurosis (immediately posterior to the orbicularis) and incise it. b Pull the aponeurosis and bluntly dissect upwards to expose the orbital septum and pre-aponeurotic fat pad. c Insert a double armed 6/0 absorbable suture into healthy aponeurosis. d Place 2 more sutures similarly and insert them into the upper tarsal plate, bringing all three pairs out through the skin edges. e Tie the sutures while observing the lid margin position and curve. Insert a continuous skin suture taking a bite between each aponeurosis suture

132

10

Ptosis

7. While pulling the upper lid skin incision edge upwards, grasp the layer immediately posterior to the orbicularis muscle layer. This is the anterior layer of the levator aponeurosis (and not the orbital septum as many mistakenly think). Incise this layer along the whole length of the wound (Fig. 10.9a) 8. Pull down the proximal cut edge of the aponeurosis and bluntly dissect upwards on its anterior surface to expose the actual orbital septum. Pressing on the lower lid causes the pre-aponeurotic fat pad to flow forwards under the septum, positively identifying it. 9. The orbital septum is not a single layer but made up of seven thin layers. Divide the several thin layers of orbital septum to expose the pre-aponeurotic fat (Fig. 10.9b) Note: This fat is very fine and has a characteristic deep yellow colour. It is a constant landmark in the lid and helpful for orientation. 10. Retract the pre-aponeurotic fat to expose the full extent of the levator aponeurosis, up to the transversely running Whitnall’s ligament and the aponeurosis levator muscle junction. 11. Insert a double armed 6/0 absorbable suture into healthy aponeurosis, close to its lower edge (Fig. 10.9c) 12. Insert this same suture into the upper tarsal plate centrally and tie it with a bow. 13. Assess the lid height by asking the patient to follow your finger. The operated lid should be set 1–2 mm higher than the other side to compensate for the anaesthetised orbicularis. If the lid is not at the correct height replace the suture higher or lower in the aponeurosis and recheck the lid height. 14. Place two further sutures similarly, one on either side of the first. 15. Now bring all three pairs of aponeurosis/tarsal plate sutures out through the skin edges, one of each pair on either side of the skin incision (Fig. 10.9d) 16. Tie the sutures while observing the lid margin position and curve. If a suture is lifting the lid too much you can loosen it before placing the locking throw. 17. Before cutting the suture ends run a continuous suture along the length of the wound taking a bite between each aponeurosis suture. This suture keeps the wound closed should the aponeurosis sutures require early removal (Fig. 10.9e) 18. Cut the aponeurosis sutures about 4 mm long so that they are easy to find and grasp, should early removal be required.

10.5 Operations

133

10.5.3 Levator Resection Fig. 10.10 10.5.3.1 Principle and Considerations The approach to levator resection is identical to the anterior levator aponeurosis reinsertion/resection described above. It differs in that the ‘horns’ (the medial and lateral extent) of the levator aponeurosis are cut and the aponeurosis dissected free from the overlying Whitnall’s ligament. Müller’s muscle is also separated from its insertion into the upper border of the tarsal plate and dissected free from the underlying conjunctiva. This enables the levator/Müller’s complex to be pulled down as one to enable sutures to be placed higher up within the levator muscle belly. Check the lid height as previously. The desired ‘on table’ lid height depends on the pre-operative levator function. 10.5.3.2 Case Selection Ptosis with levator function of 5–11 mm. Because levator resection is reserved for patients with poorer LF, the surgical outcome is less predictable. Therefore, it should be performed by more experienced surgeons. A detailed description of the technique is beyond this book’s remit. a

b

c

Fig. 10.10 Levator resection ptosis correction. a After exposing the levator aponeurosis cut its medial and lateral horns. b Pull the levator down and insert a suture into the muscle belly and tarsal plate. Check the lid height and replace if necessary. c Insert 2 more sutures similarly

134

10

Ptosis

10.5.4 Addition of a Skin and Muscle Blepharoplasty Fig. 10.11 10.5.4.1 Principle and Considerations As already mentioned, the anterior approach ptosis corrections described above may easily be combined with skin and muscle blepharoplasty. Perform this conversion after performing the ptosis correction but before bringing the levator sutures out through the skin and tying them. Drape the excess upper edge skin and orbicularis over the lower wound edge with the eye closed to ascertain how much may safely be removed. 10.5.4.2 Case Selection Any ptosis correction in which there appears to be excess upper lid skin at the end of the procedure.

10.5.4.3 Steps 1. With the upper eyelid closed drape the upper wound edge skin and orbicularis over the lower edge to achieve the desired skin appearance (Fig. 10.11b). 2. Make an upward cut centrally through the draped skin and orbicularis as far as the lower wound edge (Fig. 10.11c). 3. Pull down and laterally on the flap you have created and excise the redundant anterior lamellar triangle with Westcott spring scissors to meet the medial end of the wound (Fig. 10.11d). 4. Pull the lateral flap down and medially and repeat the same manoeuvre to the lateral wound end (Fig. 10.11e). 5. The blepharoplasty is now complete. Proceed with wound closure by inserting your preplaced levator sutures across the wound as previously described (Fig. 10.11f, g). Notes: You may extend the ptosis correction wound laterally to remove more lateral skin if required.

10.5 Operations

135

a

b

c

d

e

f

g

Fig. 10.11 Conversion to blepharoplasty. a Insert the aponeurosis sutures into the tarsal plate only. b With the upper eyelid closed drape the upper wound edge skin and orbicularis over the lower edge to achieve the desired skin appearance. c Make an upward cut through the draped skin and the orbicularis as far as the lower wound edge. d Excise the medial redundant anterior lamellar triangle with Westcott spring scissors to meet the medial end of the wound. e Excise the lateral triangle similarly. f With the blepharoplasty complete, proceed with wound closure as previously. g Place a skin suture

136

10

a

Ptosis

b

4mm

8mm

c

d

e

f

g

Fig. 10.12 Müllers muscle resection. a Double evert the upper lid and mark the upper border of the tarsal plate. Using a calliper, place a row of marks 4 mm from the border. b Then place a third row of marks again 4 mm more proximally to the previous ones. c Insert a 5/0 monofilament traction suture through the conjunctiva and Müller’s muscle along the middle row of marks. Pull down a fold of conjunctiva and Müller’s muscle and apply two fine artery forceps across this fold spanning the first and third row of marks. Insert a 5/0 monofilament suture transcutaneously so that it exits the conjunctival surface at the lateral edge of the crushed fold, just above the artery clip. d Pass this suture in and out through the fold above the artery clip. Bring the suture out through the skin crease medially. e Remove the artery clips, one at a time and cut along the centre of the crush line to excise the fold of conjunctiva and Müllers. f Pull the suture ends tight to take up any slack. g Tape them to the brow skin in a relaxed position so that they do not impair eyelid closure

10.5 Operations

137

10.5.5 Müller’s Muscle Resection Fig. 10.12 The simplest and least invasive ptosis operation is a Müller’s resection. It is seductively simple but only effective when restricted to the specific selection criteria already mentioned. The indications for it are therefore limited. Müller’s resection is very unlikely to over-correct a ptosis and requires no dissection. It replaces the formerly popular, but now outdated, Fasanella Servat operation. Both sacrifice conjunctiva and work on the principle of shortening Müller’s muscle. The latter also sacrifices the upper tarsal plate (rarely a good idea).

10.5.5.1 Principle and Considerations Müller’s muscle modulates the effect of the levator on the lid margin. Shortening Müller’s muscle lifts the lid by about 2 mm. 10.5.5.2 Case Selection Patients with no more than 2 mm of ptosis and normal levator function. Some surgeons advocate only operating on patients whose ptosis disappears after instilling a drop of phenylephrine. While these patients invariably do well so do many that fail to respond to the phenylephrine test. This is unsurprising as the procedure excises Müller’s muscle rather than relying on it to lift the lid. 10.5.5.3 Steps 1. Double evert the upper lid over a large Desmarres retractor, using it as a lever to visualize the conjunctiva above the tarsal plate. 2. Dry the conjunctiva and mark the upper border of the tarsal plate using a marking pen. Make three marks, one in the centre of the lid and one 6 mm to either side. 3. Using a calliper, place a further row of three marks 4 mm proximal to the first row (Fig. 10.12a). 4. Then place a third row of marks again 4 mm more proximally to the previous ones (Fig. 10.12b). 5. Insert a 5/0 monofilament traction suture through the conjunctiva and underlying Müller’s muscle along the middle row of marks. Remove the Desmarres retractor. 6. Pull downwards on the traction suture to pull down a fold of conjunctiva and Müller’s muscle. Apply two fine artery clips (or use a Putterman clamp if available) across this fold to span the first and third row of marks (Fig. 10.12c). The clips contain an 8 mm wide (4 mm + 4 mm) ellipse of conjunctiva and Müller’s muscle.

138

10

Ptosis

Note: Ensure that the tips of the artery clips are pointed slightly down (as in the diagram) to avoid creating a central lid peak. 7. Insert a 5/0 monofilament suture transcutaneously at the skin crease (approximately 7 mm from the lid margin) so that it exits the conjunctival surface at the lateral edge of the crushed fold, just above the artery clip (Fig. 10.12c). 8. Pass this same suture through the conjunctiva and Müller’s fold above the artery clip exiting on the other side. Then pass it back. Repeat this approximately four or five times to reach the medial end of the fold (Fig. 10.12d). The more suture passes that are made, the harder it will be ultimately to remove the suture. 9. Bring the suture out through the skin crease medially. 10. Remove the artery clips, one at a time and cut along the centre of the crush line to excise the fold of conjunctiva and Müllers along with the traction suture (Fig. 10.12e, f). Allow the everted lid to flip back to its normal orientation. 11. Pull the suture ends tight to take up any slack and tape them to the brow skin in a relaxed position so that they do not impair eyelid closure (Fig. 10.12g) 12. Apply antibiotic ointment to the eye and secure a protective shield. No pad is required. 13. Review the patient a week later and remove the suture by cutting one end flush with the skin and pulling on the other end. The smooth monofilament suture slips out with minimal discomfort. Note: In a child an absorbable suture with buried knots can be used to avoid the need for suture removal. However, when it loosens it may cause corneal irritation, which is why a smooth removable suture is preferred for adults.

10.5.6 Frontalis Suspension (Fox’s Pentagon) Fig. 10.13 10.5.6.1 Principle and considerations A patient with poor levator function does not benefit from having their levator muscle shortened. The only alternative power source available for opening the lid is the frontalis muscle. Frontalis suspension is not technically difficult to perform but as it is rarely needed it is harder to gain experience with this technique. Furthermore, patients with poor levator function have a less satisfactory outcome from ptosis surgery. The likelihood of under or over correction is much higher as is the risk of symptomatic corneal exposure. The operation works by connecting the eyelid to the brow using a sling. The best and longest lasting sling material is undoubtedly living autogenous fascia Lata, harvested from the patient’s own thigh. Such harvesting falls outside the remit of this book (but is available to view on YouTube [2]). However, for the sake of completeness I describe here the Fox pentagon frontalis suspension using a silicone sling. Non-autogenous materials are more prone to infection, extrusion, and late failure. The silicone sling may be supplied swaged onto two long, extremely sharp, malleable needles. I strongly urge the novice not to use these as they are

10.5 Operations

139

a

b

10-15 mm

2mm

c

d

f

e

g

Fig. 10.13 Fox’s frontalis suspension. a Mark two lid entry points 2 mm above the lashes, two further points at the upper edge of the eyebrow, and a horizontal skin incision approximately 4 mm long 10–15 mm above the centre of the eyebrow. b Make horizontal stab incisions using a no. 11 scalpel in the marked points and make the forehead incision. Slightly undermine the forehead incision bluntly to create a small pocket. c Insert the Wright’s fascia needle into the lateral eyelid incision down to the tarsal plate and advance it to exit the second skin incision. Thread the silicone sling material through the eye of the needle and withdraw the needle pulling the sling through. d Insert the empty Wright’s needle vertically into the lateral brow incision and advance the needle to exit the lateral lid incision. Thread the lateral end of the silicone into the needle and withdraw the needle and tubing from the lateral brow incision. Repeat steps for the medial brow incision. e Enter the medial end of the forehead incision with the empty Wright’s needle, to emerge from the medial brow incision. Thread the silicon into the needle and pull it through to the forehead incision. Repeat on the lateral forehead. f Pass both ends of the silicone sling through a 4–5 mm length of silicone sleeve (Watske sleeve). Adjust the tension in the sling. g Close the forehead incision with two vertical mattress 6/0 sutures

140

10

Ptosis

dangerous. The needles bend easily as you advance them through the lid so you receive no tactile feedback and cannot control where the tip is. Being so sharp inadvertent eye penetration is a real risk. Use instead a Wright’s fascia needle which is non-malleable and semi sharp. The finger loop allows good needle tip control. Join the ends of the sling together using a silicone sleeve which allows easy adjustment.

10.5.6.2 Case Selection Severe ptosis with poor levator function (≤4 mm) interfering with vision (lid margin encroaching on the visual axis). 10.5.6.3 Steps (Fig. 10.13) 1. Mark two skin entry points 2 mm above the lashes and aligned to be vertically above the medial and lateral corneal limbus in primary gaze (i.e., about 11– 12 mm apart). 2. Mark two further points at the upper edge of the eyebrow. The lateral point must be vertically lateral to the lateral canthus and the medial point vertically medial to the medial canthus. 3. Mark a final horizontal skin incision approximately 4 mm long 10–15 mm above the centre of the eyebrow (in a frown line if one is present). Position it roughly above the pupil (Fig. 10.13a). 4. Make horizontal stab incisions using a no. 11 scalpel in the marked eyelid points (protecting the eye with a metal shield) and in the two brow points (down to bone). Do not extend them. 5. Make the forehead incision by stabbing down to bone at one end of the marked line, then holding the scalpel still against the bone, pull the forehead skin onto the blade to complete the 4 mm incision. This is more controlled than trying to move the scalpel freehand. Slightly undermine the forehead incision bluntly by inserting closed scissors or an artery clip and opening it to create a small pocket (Fig. 10.13b). 6. Insert the Wright’s fascia needle into the lateral eyelid incision down to the tarsal plate and advance it on the tarsal surface to just past the medial incision. It is usual to feel considerable resistance to the needle’s passage as it is semisharp by design. 7. Lift the tip to feel its location and then push the needle out through the medial skin incision. 8. Thread the silicone sling material through the eye of the needle and withdraw the needle pulling the sling through (Fig. 10.13c). 9. Insert the empty Wright’s needle vertically into the lateral brow incision down to bone. Rotate it horizontally and advance slightly. Now lift the tip to confirm that it has not engaged the periosteum. 10. Advance the needle to just past the lateral lid incision. Ensure that the eye is protected by a metal shield held firmly by an assistant in the upper fornix and deep to the orbital rim. Monitor the tip’s progress throughout its passage by intermittently lifting it and feeling for it by rolling the skin and orbicularis over it with a fingertip. The needle’s passage should be as deep as possible

10.5 Operations

141

within the lid while not breaching the conjunctival surface. It is usual to feel resistance as noted in 6 above. 11. Lift the needle tip and advance it out through the lid skin incision taking care to avoid damaging the silicone tubing. Note: Silicone tubes are only strong until they are nicked by a sharp instrument such as the needle tip or toothed forceps after which they tear and break easily. 12. Thread the lateral end of the silicone into the needle and withdraw the needle and tubing from the lateral brow incision (Fig. 10.13d). 13. Repeat steps 9–12 for the medial brow incision. 14. Enter the medial end of the forehead incision with the empty Wright’s needle, weaving the tip in and out as you advance to engage the frontalis. Make the tip emerge from the medial brow incision. Again, take care to avoid damaging the silicone sling material with the point of the needle (Fig. 10.13e). 15. Thread the silicone into the needle and pull it through to the forehead incision. 16. Repeat steps 15 and 16 from the lateral end of the forehead incision laterally. 17. Now that both ends of the silicone sling are in the forehead incision, pass them through a 4–5 mm length of silicone sleeve (Watske sleeve). Do this by wetting the sleeve and pushing it onto closed fine artery forceps. 18. Force the forceps open to stretch the sleeve widely enough to allow you to feed one end of the sling through it. 19. Instruct an assistant to pull both ends of the threaded sling downwards while you thread the second end of the silicone sling through the sleeve from the opposite direction. 20. Push the sleeve off the artery clip while keeping it slightly open to avoid pulling on the sling. 21. Adjust the tension in the sling by pulling on both ends until the lid is set at the correct height (Fig. 10.13f) Remember that when you push the sleeve into the forehead incision to bury it the sling will slacken slightly. Note: The correct height depends on the cause of the ptosis. A young child with congenital ptosis and a good Bell’s phenomenon will tolerate a degree of nocturnal lagophthalmos that an elderly patient will not. If progressive external ophthalmoplegia is the diagnosis, the lids should be left closed at the end of surgery to avoid corneal exposure. 22. Pre-place two vertical mattress 6/0 sutures across the forehead incision and trim the silicone sling ends to about 10 mm. Tuck the sling ends into the subcutaneous pocket and keep them buried by tying the preplaced sutures tightly to close the wound. Note: The mattress sutures prevent the sling ends from poking out through the wound and prevent the incision from forming a depressed scar during healing.

142

10

Ptosis

The remaining incisions close spontaneously without sutures. 23. Place a lower lid margin traction suture and close the eye by taping it upwards to the brow. Apply antibiotic ointment and an overnight pressure dressing. 24. Review the patient the following day to check the lid height, eye closure and the cornea for exposure. Remove the traction suture unless there is significant corneal exposure due to an overcorrection. In this case use the suture to protect the eye until the overcorrection can be addressed.

10.5.6.4 Notes • Under or over correction can be addressed by opening the brow incision and tightening or loosening the sling within the sleeve. • Alternative synthetic sling materials can be used but have no advantages. Do not use Polyester mesh (Mersilene® Mesh) as this is prone to exposure and incites marked fibrosis which makes it very difficult to remove should it become infected. • Silicone slings are very easy to remove from within the capsule which forms around them. • Consider giving a per-operative dose of prophylactic antibiotic to reduce the chance of sling infection.

10.6

General Observations

10.6.1 Lower Lid Traction Suture Fig. 10.14 (See Chap. 5) At the end of a ptosis correction consider placing a lower lid margin traction suture to pull the lower lid upwards to help keep the operated eye closed under a pressure dressing. This is better than pulling the upper lid down since the point of ptosis surgery is to lift the upper lid. A traction suture is not required after a Müller’s resection as no pressure dressing is necessary. It is optional after ptosis surgery with normal levator function (white line advancement/aponeurosis reinsertion) and the decision depends on how likely a patient is to comply with the instruction to keep the operated eye closed under the dressing. I strongly recommend a traction suture for ptosis correction in the presence of reduced levator function (levator resection and frontalis suspension) to avoid corneal abrasion by the pressure dressing.

10.6 General Observations

143

Fig. 10.14 Lower lid traction suture. Insert a 4/0 monofilament tarsal traction suture to pull the lower lid closed following ptosis correction to protect the eye under the dressing

10.6.2 ‘On Table’ Lid Height Judging the desired lid height at operation can be difficult. It is influenced by surgical swelling and the local anaesthetic induced paralysis of the orbicularis and Müller’s muscles. The main clue is the pre-operative levator function. As a rule of thumb under local anaesthetic set the lid 2 mm higher than desired to compensate for orbicularis paralysis. Under a general anaesthetic assume that lids with good levator function (12–17 mm) will rise from their ‘on table height’ when the patient is awake, those with moderate function (5–11 mm) will stay put, and lids with poor levator function (0–4 mm) will drop. As mentioned earlier, with white line advancement the ultimate lid height is usually correct (provided the levator function is normal).

144

10

Ptosis

10.6.3 Post-operative Adjustment—Early Suture Removal I recommend that all ptosis surgery patients (except those with Müller’s resection) are reviewed on the first post-operative day for: 1. Pad removal 2. Lower lid traction suture removal (if present) 3. A check for possible overcorrection or eyelid contour deformity (peak). It is a simple matter to remove the responsible suture(s) and correct the problem. Do this by pulling on the knot’s suture ends (they were left long specifically for this eventuality) to lift the knot and cut one side of the suture loop below the lifted knot with pointed scissors. Pull the suture out. If the lid position does not improve immediately stretch the insertion by grasping the upper lid lashes and pulling firmly downwards while asking the patient to try and look up. If the issue is still unresolved consider removing a further suture. Should you notice an early under-correction reassure the patient that this is likely to improve once the postoperative swelling resolves (and keep your fingers crossed). It often does. Wait two months before reassessing the patient for possible ptosis revision surgery.

10.6.4 Hering’s See-Saw (Fig. 10.15) The levator muscles follow Hering’s law of equal innervation. Consequently, the additional innervation attempting to open the ptotic lid causes upper lid retraction of the contralateral eye. Bear in mind that the latter will resolve after successful ptosis correction.

Fig. 10.15 Hering’s see-saw. Lifting a ptotic lid reduces the drive to the contralateral levator which goes down as a consequence

References

10.7

145

Take Home Message

• Involutional ptosis is the commonest acquired ptosis. • ‘White Line’ aponeurotic repair is the simplest and best operation for correcting involutional ptosis.

References 1. Harrad RA, Shuttleworth GN (2000) Superior rectus-levator synkinesis: a previously unrecognized cause of failure of ptosis surgery. Ophthalmology 107(11):975–1981, ISSN 0161-6420, https://doi.org/10.1016/S0161-6420(00)00170-6 2. Harvesting Autogenous Fascia Lata. https://youtu.be/RYDJbBvxK7Q

Dermatochalasis and Blepharoplasty

11.1

11

Overview

• Skin and muscle blepharoplasty. Patients are sometimes erroneously referred for ptosis surgery when in fact their lid margin has not dropped, and an overhanging skin fold has masked the true lid margin. This is known as ‘dermatochalasis’ (baggy lids). Some people erroneously call it ‘blepharochalasis’ which is a syndrome affecting younger adults and characterised by recurrent, idiopathic, periocular swelling which eventually gives rise to eyelid atrophy (cigarette paper thin skin, medial orbital fat pad atrophy, canthal tendon and levator aponeurosis dehiscence). Dermatochalasis, on the other hand is usually caused by aging but may also be familial.

11.2

Examination

Observe the position of the upper lid skin fold in relation to the lashes and lid margin. If the skin fold is resting on the upper lid lashes it may cause trichiasis (in turning of the lashes). If it overhangs the lid margin it causes a reduction in the visual field. In both these situations clinically, significant dermatochalasis is present and justifies surgical correction by excision of the superfluous skin fold.

11.3

Considerations

Blepharoplasty means the removal of superfluous tissue from the eyelid. In this chapter only upper lid skin fold reduction is discussed. The secret of successful skin and muscle blepharoplasty is accurate pre-operative marking to ensure that

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_11

147

148

11

Dermatochalasis and Blepharoplasty

sufficient skin remains for full eyelid closure during blinking and sleep, and that the scar is hidden in the skin crease. Prominent or prolapsed fat pads result from weakness of the orbital septum. They can cause significant aesthetic concerns. Unfortunately, removing them only adds to age related orbital volume deflation and as such is not an ideal solution. An alternative is to shrink and tighten the overlying orbital septum using bipolar diathermy. Perform this with the bipolar forceps tips apart. Place both tips on the septum. Turn on the power and gradually bring the tips closer together until the septum shrinks and tightens. This is simple to do and safe, but unfortunately its benefits are short lived. Prolapsed orbital fat can be removed by making perforations in the orbital septum and encouraging the fat to prolapse through these to be clamped, diathermied, and excised. This can, on very rare occasions, cause blindness so should not be undertaken lightly. As aesthetic surgery is not the subject of this book, fat removal will not be discussed further.

11.4

Upper Lid Skin and Muscle Blepharoplasty (Fig. 11.1)

11.4.1 Principle Pinch and mark the excess skin fold with the eye closed. Then excise it.

11.4.2 Case Selection Symptomatic overhanging skin folds causing a reduction in visual field or trichiasis.

11.5

Steps

1. Pull the upper lid skin upwards to lift the overhanging skin fold. Instruct the patient to keep both eyes gently closed while you mark the desired postoperative lid skin crease position (Fig. 11.1b). Do this before injecting local anaesthetic using a fine tipped marker pen. In Caucasians the crease is usually 7–8 mm above the upper lid margin. 2. Gently pull and lift the skin fold away from the eye, with a pair of Moorfields forceps, to take up all the slack. Ensure that the eyelids remain closed. Position a second pair of forceps across the lifted fold with the lower tip on the premarked skin crease. Mark the position of the upper tip on the skin. This marks the maximum extent of the redundant fold (Fig. 11.1c).

11.5 Steps

a

c

149

b

d

X

y

X + y ≥ 20 mm

e

f

g

h

Fig. 11.1 Blepharoplasty. a Lateral overhanging skin fold. b Mark the desired postoperative lid skin crease position. c Mark the maximum extent of the skin fold with the eyes closed. d Complete the skin marking by drawing an ellipse within the upper skin markings and based on the skin crease marking. Leave at least 20 mm of skin. e Incise the skin and orbicularis. f Excise the entire skin and orbicularis ellipse. g Insert an orbicularis suture at the lateral angle to align the wound. h Close the skin, taking bites of the underlying aponeurosis to reform the skin crease

150

11

Dermatochalasis and Blepharoplasty

3. Repeat step 2 medially and laterally at several points along the lid as the amount of loose skin varies (there is usually more laterally). These marks represent the maximum amount of skin that may be safely removed without impairing eyelid closure. 4. Complete the skin marking by drawing an ellipse that falls within the upper skin markings and is based on the skin crease marking from step 1 (Fig. 11.1d). Note: The ellipse must extend laterally, past the lateral canthus as there is usually more excess skin laterally than medially. Try to stay within the orbital region as outside the orbital area scars become more visible. 5. To cross check, measure the distance between the lower edge of the eyebrow and the upper skin ellipse line centrally. Add this value to the planned skin crease height. The sum of these two measurements should exceed 20 mm to ensure that sufficient skin remains for normal blinking. 6. Inject local anaesthetic with adrenaline into the sub-orbicularis plane ballooning the skin along the whole length of the ellipse. 7. Place a metal eye protecting plate in the upper fornix to avoid accidental eye damage and ensure that an assistant holds it in place up against the superior orbital rim. 8. Incise the skin and orbicularis along the markings with a no. 15 scalpel blade (Fig. 11.1e). Remember to cut ‘uphill’ to prevent blood from running down and obscuring your skin markings. Note: Keep the skin stretched tightly between the thumb and fingers of your other hand while performing this incision. This makes it easier to follow the skin marking. Lax skin is difficult to cut accurately. 9. Lift the outer corner of the skin ellipse with St. Martin’s toothed forceps and use Westcott spring scissors to finish cutting through the orbicularis to start raising a flap in the sub orbicular plane (Fig. 11.1f). 10. Extend in this plane to remove the entire skin and orbicularis ellipse. Keep the skin stretched throughout to make the dissection easier. Note: An alternative to scissor dissection is to use a high temperature disposable cautery. This reduces bleeding but takes a little practice. It is essential to pull and lift the skin flap away from the eye to avoid accidental damage. The cautery tip must glow to cut tissue. Because it is immediately cooled by tissue contact develop the technique of making frequent small dabs with the tip to maintain cutting. I strongly advise the inexperienced surgeon against using radio frequency cutting diathermy as this provides no tactile feedback and makes inadvertent globe penetration frighteningly easy. 11. Place a single interrupted absorbable orbicularis suture just above and lateral to the outer canthus to start closing the incision (Fig. 11.1g). This approximates the wound edges and creates an angle. Check the alignment of the skin edges before proceeding. 12. Complete the skin closure using a 6/0 or 7/0 absorbable continuous suture (Fig. 11.1h).

11.7 Take Home Message

151

Note: Geometrically the upper skin wound edge is longer than the lower one. Therefore ‘gather’ the excess along the whole length of the closure. In the central lid portion of the closure alternate bites should engage the levator aponeurosis to ensure that a strong skin crease develops. This adds an ‘active’ component to the operation which reduces the likelihood of an early recurrence. 13. Apply antibiotic eye ointment and a pressure dressing overnight to reduce the almost inevitable lid swelling and bruising. Note: Having both eyes padded is disorientating and unpleasant even if only for one night. Some surgeons do not pad and prefer instead to recommend that the patient applies ice packs to reduce the postoperative swelling. This is neither easy for the patient nor comfortable.

11.6

Notes

• It is possible to remove only skin and to leave the orbicularis intact. However, the subcutaneous plane is harder to dissect than the sub-orbicularis plane as the skin and orbicularis are bound together by the orbicular fascia. • If only skin is removed the skin crease will reform without the need of levator aponeurosis suture bites. • Removing skin but leaving the orbicularis risks creating a ‘stuffed sausage’ appearance with too much orbicularis filling for the remaining skin.

11.7

Take Home Message

• Plan your skin excision carefully to leave enough behind for full eyelid closure.

Lid Lumps and Bumps

12.1 • • • • •

12

Overview

Cyst excision. Meibomian cyst incision and curettage. Marking tumour surface extent and gauging its depth. Choosing the type of biopsy, and the size of clear margin. Full thickness lid margin tumour resection technique.

Eyelid bumps are either caused by cysts or by tumours. Both may distort the lid and interfere with function through their mass effect.

12.2

Cysts

Cysts are closed epithelium lined sacs which tend to enlarge as they fill up with shed cells or secretions. They may be developmental, as in the case of dermoid and epidermoid cysts, or occur as inclusion cysts from epithelium accidentally buried during surgery. If they leak, their contents incite a marked local inflammatory reaction. When symptomatic, such cysts should be excised intact, by careful dissection, to ensure all their epithelial lining is removed or they can reform. Blocked eyelid sweat glands form clear fluid filled cysts of Moll which transilluminate. Blocked grease glands form white cysts of Zeiss. Both occur superficially under the skin and can easily be lanced. If they reform, they should either be de-roofed and left to granulate or excised intact. But by far the commonest lid bump results from a blocked meibomian gland and is known as a meibomian cyst or Chalazion.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_12

153

154

12

Lid Lumps and Bumps

12.2.1 Meibomian Cyst Incision and Curettage (I & C) 12.2.1.1 Case Selection The majority of meibomian cysts settle on conservative treatment with hot compresses. Large, persistent, or recurrent meibomian cysts require surgical drainage.

12.2.1.2 Principle Because meibomian glands are part of the tarsal plate they cannot easily be excised. Incise them instead and remove the gland’s epithelial lining by thoroughly curetting the cavity.

12.2.1.3 Steps 1. Evert and carefully inspect the meibomian orifice line and sub-tarsal surface of the affected lid under magnification to identify the affected gland or glands. Often the offending gland looks darker or redder than its neighbouring glands (Fig. 12.1a). If you are unable to identify blocked gland incise at the point of maximum swelling and hope for the best. 2. Anaesthetise the eye with proxymetacaine drops and the affected lid with adrenaline containing local anaesthetic injections. 3. Apply a large, oval meibomian clamp to the lid to encompass the affected part and tighten it to prevent bleeding (Fig. 12.1b). Note: If you use a small clamp there is a high chance of missing the true position of the cyst or part of it. 4. Evert the lid using the clamp. 5. Incise the length of the suspected gland (or area of maximum intumescence), taking care to avoid damaging the lid margin (Fig. 12.1c). Note: At this point you will hopefully see the gelatinous lipo-granulation contents of the cyst emerge (Fig 12.1d). If you do not obtain the typical contents, you may have missed the cyst. Consider performing a second incision to one side and parallel to the first. When present, the contents are pathognomonic of a meibomian cyst. However, they are not always found, particularly in chronic cases where fibrosis has supervened the granulation stage. 6. Vigorously curette the cyst cavity to remove the lining to remove it and any remaining contents (Fig. 12.1e). 7. Remove the clamp and apply firm pressure until the bleeding stops. 8. Clean the eye, removing any blood and clots, and instill antibiotic ointment. There is no need to apply a dressing providing you have waited for the bleeding to stop.

12.2.1.4 Warning Beware of atypical meibomian cysts or ones that recur after incision. They might be meibomian carcinomas! Take a biopsy of one edge when repeating the I & C.

12.3 Tumour Excision (Fig. 12. 2)

155

a

b

c

d

e

Fig. 12.1 Meibomian cyst incision & curettage. a Identify the responsible gland. b Apply and tighten a large meibomian clamp. c Incise the tarsal plate from the conjunctival surface. d Look for release of the pathognomonic lipo-granulomatous cyst contents. e Curette the cyst cavity

12.3

Tumour Excision (Fig. 12.2)

The obvious priorities of tumour surgery are to cure the patient while minimizing collateral damage. The former requires knowledge of the tumour type and its true extent. The latter involves excising the minimum tissue necessary to effect the cure. The likely tumour type is inferred from its appearance and rate of growth (learnt pattern recognition), combined with probability (95% of malignant lid tumours are basal cell carcinomas). The tumour’s true extent may be obvious, as in a well demarcated nodular basal cell carcinoma. However, infiltrative tumour margins are difficult to discern. Therefore, use all the available clues: appearance, palpation, and mobility (is it fixed to underlying tissues). To determine a tumour’s surface extent, stretch the surrounding skin in all directions. This makes it easier to see the tumour boundary by making surface

156

12

Lid Lumps and Bumps

Fig. 12.2 Butcher. Tumour surgery is destructive

texture, colour, and contour changes easier to spot. Use magnification (a slit lamp or illuminated loops) to see details more clearly. Look specifically for: • Skin hair or lash loss (indicates tumour infiltration of the follicles). • Skin texture alteration viewed by surface reflection of oblique illumination (loss of the normal fine skin wrinkles and semi-matt surface; tumours tend to be smooth and shiny). • Surface contour change. • The capillary network. In tumours it is different from that of normal skin. Time spent carefully marking the tumour margins saves wasting time later with avoidable re-excisions.

12.3.1 First is Best It is said that the first excision attempt has the highest cure rate. This is of course a self-fulfilling prophecy as failure at the first attempt is likely to be due to uncertain margins which will be no clearer the second time around. But there is also some truth in the saying: previous attempts at excision leave scars and distort tumour margins and tissue planes, making re-excision less certain.

12.3 Tumour Excision (Fig. 12. 2)

157

12.3.2 Clear Cutaneous Margins Because of the difficulty in determining a tumour’s boundary with certainty it is standard practice to excise a ‘clear safety margin’ around the tumour. For presumed benign lesions 1–2 mm surface margins suffice. For presumed malignant lesions 4 mm margins are a reasonable compromise between incomplete excision and an unnecessarily large tissue defect (views on this vary considerably (3–5 mm)).

12.3.3 Stretch Eyelid skin is both mobile and elastic. This makes skin marking difficult as the marker pen drags and distorts the skin. Clear margin measurement must be standardized to have any meaning. Get around both problems by having an assistant keep the skin stretched during measuring, marking, and incising.

12.3.4 Deep Excision The depth of a tumour’s extension is gauged differently from its surface markings. Grasp the tumour and pull it to and fro noting its mobility over the underlying tissues. If mobility is restricted, then there is likely to be deep extension. Fortunately, most tumours are reluctant to cross tissue planes unless encouraged to do so, for example by incisional biopsy. Consequently, most cutaneous lid growths do not penetrate the orbicularis plane. So, for complete excision excise the surface marked tumour and include an intact layer of underlying orbicularis in the specimen as the deep safety margin. If the tumour appears fixed, the specimen should include the underlying tarsal plate or periosteum (depending on its location).

12.3.5 Waste Not, Want Not It is customary to excise lesions as elliptical specimens to avoid lax ‘dog ear’ folds at either end of the closure scar (see Chap. 2). This practice results in excess healthy tissue being sacrificed on the altar of cosmesis. I recommend removing only the actual tissue necessary to achieve a cure for two reasons. Firstly, the so called ‘dog ears’ tend to remodel and vanish within a year of surgery and seldom require subsequent treatment. Secondly, the tissue spared may come in useful for the present or for future reconstructions. The same dictum is true when choosing reconstruction procedures. I am suspicious of reconstructions which require you to discard a significant quantity of skin.

158

12

Lid Lumps and Bumps

Fig. 12.3 Beware canthal tumours. Tumours at the canthi can spread into the orbit silently along the canthal tendons

BEWARE!

12.3.6 Beware the Canthi (Fig. 12.3) At the eyelid margin a tumour readily invades the tarsal plate but cannot penetrate deeper than the conjunctival surface. However, at the medial and lateral canthi the canthal tendons provide a direct highway for tumour spread to the orbital rim periosteum, from where it can quietly invade the orbit unnoticed.

12.3.7 Biopsy: Excision V Incision Single stage or ‘one stop’ surgery is preferred by patients and is an efficient use of resources. Therefore, excision biopsy with direct defect closure should be your default management. However, if serious doubt exists about the nature of a large lesion, perform an incisional biopsy first to establish the diagnosis. This biopsy should include part of the tumour margin rather than being taken from the centre. The former shows the tumour invading normal tissue. This is helpful to the histologist. Histological confirmation that a lesion is benign avoids excessive clear margin excision.

12.3.8 Histology First! Delay reconstruction of presumed malignant tumour defects until you have histological proof of tumour clearance. The only exceptions to this rule are direct defect closure or directed laissez-faire. With these all the tumour margins are included in the single scar. Should the subsequent histology report recommend a re-excision, simply excise the scar with the appropriate additional safety margin.

12.4 Full Thickness Lid Margin Tumour Resection (Fig. 12. 4)

159

12.3.9 One Stop Management There are only three options for safe ‘one stop’ management: 1. Excision and direct closure 2. Excision and ‘laissez-faire’ 3. Excision with ‘on table’ frozen section histology followed by reconstruction. This last option is time and resource intensive making it costly. Furthermore, frozen section histology is less reliable than paraffin sections. Mohs’ surgery is a form of sequential frozen section biopsy that may be useful in tumours without any clear margins, but it is by no means infallible. Furthermore, it is difficult to carry out periocularly because of the mobility of the thin tissue planes relative to each other which makes the excision of an intact 2 mm thick Mohs layer neigh impossible.

12.4

Full Thickness Lid Margin Tumour Resection (Fig. 12.4)

See Fig. 12.4. a

b

4 mm

c

d

e

Fig. 12.4 Lid margin tumour resection. a Mark the visible tumour margins. b Mark a clear safety margin. c Incise along the marking with a no. 15 scalpel. d Excise the specimen with scissors. e Flatten the specimen on card and mark the edges with dyes for orientation

160

12

Lid Lumps and Bumps

12.4.1 Considerations Meaningful margins can only be measured with the tissues on stretch. Careful specimen marking and orientation during fixation avoid confusion when the histological margins are reported.

12.4.2 Steps 1. Carefully mark the visible tumour edges with the lid held on stretch (Fig. 12.4a). 2. Mark the planned clear margin (usually 4 mm) using a calliper (Fig. 12.4b). 3. Protect the eye with a metal plate under the lid and incise the skin along the markings with a no.15 scalpel (Fig. 12.4c). Note: Remember to cut ‘uphill’! 4. Complete the orbicularis ± tarsal plate incision with tenotomy scissors (Fig. 12.4d). 5. Get an assistant to apply firm pressure to the area for haemostasis, while you attend to the specimen. 6. Without releasing your hold, rinse and dry the specimen to remove blood. Inspect all the edges and the deep surface to make sure no tumour is visible. If it is, excise an additional specimen from that margin. 7. Place the specimen on a piece of card and spread it, unrolling the skin edges if required. 8. Mark the specimen edges with histology marking inks for orientation (Fig. 12.4e) and record the colours of the respective edges in the notes and on the histology request form. Allow the inks to dry and the specimen to stick to the cardboard for 5 min. 9. Slip the cardboard mounted specimen slowly into a formalin pot so that the specimen remains flat during fixation. This makes the pathologist’s task easier.

12.5 • • • •

Take Home Messages

Biopsy atypical or recurrent meibomian cysts. Careful tumour margin marking pays dividends. Await proof of clearance before undertaking complex reconstructions. Beware of canthal tumours!

Eye Protection

13

Fig. 13.1 Moist chamber eye protection

13.1 • • • • • • •

Overview (Fig. 13.1)

Occlusive dressings Manual blink Tarsal Traction Suture Non-tarsal traction Temporary Suture tarsorrhaphy Permanent lateral tarsorrhaphy Permanent medial canthoplasty.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_13

161

162

13

Eye Protection

The purpose of the eyelids is to both protect the eye and to regularly replenish the optical surface of the pre-corneal tear film through blinking. If eyelid function is impaired, whether by paralysis or by a tissue defect, alternative eye protection becomes a priority.

13.2

Occlusive Dressing

The simplest protective measure is the application of an antibiotic or lubricant ointment under an occlusive, non-stick dressing. This is the treatment of choice for acute lid defects, such as result from lid tumour excision, while awaiting a histology report. Similarly, use it after trauma if you are unable to repair the lid immediately. Occlusive dressings can safely be left undisturbed for a week if necessary.

13.3

Manual Blink (Fig. 13.2)

When eyelid closure is impaired, by paralysis or lid retraction, and there is no significant corneal epithelial defect, teach the patient to perform a ‘manual blink’. This reduces eye drying and discomfort during waking hours. The patient performs this by momentarily pushing the lower lid up across the cornea to spread the marginal tear strip across the eye to replenish the pre-corneal tear film. It needs to be repeated frequently (as often as possible) and requires strong patient motivation and commitment.

a

b

Fig. 13.2 Manual blink. a Place a finger on the lower lid. b Push the lower lid up momentarily to spread the pre-corneal tear film

13.5 Closing the Eye

163

13.4 ‘Cling Film’ Occlusion When a patient is asleep, they cannot perform a ‘manual blink’. Therefore, manage symptomatic lagophthalmos (incomplete eyelid closure) with an occlusive dressing overnight. This can be made from a square of transparent plastic food wrap film hermetically fixed around the eye with adhesive tape to create a moist chamber. This is more effective than using lubricant eye ointment alone. Proprietary transparent occlusive dressings are available as an alternative.

13.5

Closing the Eye

13.5.1 Not the ‘Grey Line’! When the above conservative measures are insufficient or inappropriate, surgical protection may be required. The simplest way of reliably and reversibly closing a lid is to insert a lid margin traction suture and tape this to the skin to pull the lid closed. Traditionally, and in my view wrongly, such sutures are inserted into the grey line of the lid margin. Anatomically the grey line marks the junction between the anterior lamella of the lid (skin and orbicularis muscle) and the posterior lamella (tarsal plate and conjunctiva). The grey colour is imparted by the muscle of Riolan (modified orbicularis of the lid margin) as viewed through extremely thin, translucent skin (Fig. 13.3).

Meibomian orifice line

Grey line Muscle of Riolan

Fig. 13.3 Grey line and meibomian orifice line. The meibomian orifices mark the mid tarsal plate thickness. The grey line marks the anterior and posterior lamellar junction

164

13

Eye Protection

The grey line is a poor landmark as with age it becomes increasingly difficult to discern. Far better landmarks exist on either side of the grey line: the meibomian orifice line posteriorly, marking the mid tarsal plate thickness, and the lash line anteriorly. As a site for traction suture placement the grey line is woefully inadequate as neither thin skin nor muscle have any suture holding strength. Sutures placed in the grey line alone will cut out in a matter of hours when put on traction. For this reason, it is customary to externalize a grey line suture through the skin, pass it over a bolster or through tarsorrhaphy tubing and then re-enter the skin and exit through the grey line. In this way the traction force is spread over an area of skin making the suture less likely to cut through. Unfortunately, the pressure of the tubing on the skin can be uncomfortable or frankly painful. It can even cause lid margin pressure necrosis by impairing perfusion. This results in traction failure, lid margin distortion with possible trichiasis and sometimes lash line necrosis and permanent lash loss. Fortunately, there exists a simple, safe, and effective alternative: the tarsal traction suture.

13.5.2 Avoid Toxin Ptosis Botulinum toxin injection of the upper lid levator muscle has been advocated as a means of inducing temporary upper lid closure. Unfortunately, this is invariably associated with superior rectus paresis knocking out the protective Bell’s reflex. Furthermore, and perhaps surprisingly, on rare occasions permanent vertical diplopia results. There are better ways to protect an eye.

13.5.3 The ‘Tarsal Traction Suture’ (see Chap. 5) 13.5.3.1 Principle and Considerations It is generally accepted that the tarsal plate is the strongest structure in the eyelid and thus best suited for anchoring a traction suture. Furthermore, the edge of the tarsal plate is easily identifiable on the lid margin by the meibomian orifice line which marks the mid tarsal plane. Gently squeezing the lid margin with forceps causes meibomian secretion egress making the orifice line easy to see. A suture inserted perpendicularly into this ‘meibomian orifice line’ will provide strong purchase for many weeks or months. Once in place it is completely painless and does not distort or damage the lid margin. Eventually, like all sutures placed in living tissue, the suture will migrate out through the lid margin. Slow migration is quite different from rapid ‘cheese-wiring’ or ‘cutting out’ in so far as it leaves no scarring or anatomical alteration. The cells simply part in front and re-unite behind the migrating suture until all tension is dissipated.

13.5 Closing the Eye

165

13.5.3.2 Case Selection Any eye requiring temporary lid closure for protection. 13.5.3.3 Steps (Fig. 13.4) 1. Grasp the full thickness of the lid margin with large forceps (such as Adson’s or Thaller Tarsal Forceps (Altomed UK A6360)) and evert it to view the lid margin edge on. 2. Insert a 4/0 monofilament non-absorbable suture on an atraumatic round bodied, taper point half circle needle (e.g., 4/0 Prolene W8557 Prolene™ Ethicon, or 4/ 0 Premilene® B Braun) into the meibomian orifice line perpendicularly to the margin (Fig. 13.4a). 3. Advance the suture needle within the tarsal plate, allowing it to follow its own curve, to exit the lid margin form the meibomian orifice line about 10–12 mm from its insertion point (Fig. 13.4b). 4. If the needle tip exits posteriorly (trans-conjunctively) or anteriorly (transcutaneously), simply withdraw it slightly, adjust the tilt of the lid margin with the grasping forceps and re-advance the needle tip. A non-cutting taper-point needle causes minimal damage during such repeated passage. Had a cutting needle been used, each pass would cut the tarsal plate eventually shredding and weakening it.

a

b

900

c

Fig. 13.4 Tarsal Traction Suture Placement. a Enter the meibomian orifice line perpendicularly with a non-cutting needle. b Advance the needle within the tarsal plate to exit in the meibomian line. c Tape the traction suture to the forehead securely

166

13

Eye Protection

5. Pull the suture tight and stick it to the forehead or cheek with three layers of adhesive tape, bending the suture 180° between layers to prevent it from slipping through the tape (Fig. 13.4c).

13.5.4 Non-tarsal Traction (Fig. 13.5) 13.5.4.1 Principle and Considerations Sometimes it is still possible to protect an eye with traction sutures when the tarsal plate is missing. In this situation the traction suture force must be spread to stop it cutting through the skin. A silicone band can provide the necessary purchase on the remaining tissues. This temporizing technique buys time while awaiting a histology report or planning a definitive repair. During the wait, the stretched tissues will expand.

a

b

c

Fig. 13.5 Non-tarsal traction. a Insert a 4/0 monofilament suture through the conjunctival wound edge and retractor and bring out through the skin and into a silicone band. Re-enter the band 5 mm to one side in the reverse direction picking up the tissue layers. b Place additional sutures in the same manner as the need dictates (usually 3–4). c Tape the sutures to the skin on the opposite side of the wound under strong traction

13.5 Closing the Eye

167

13.5.4.2 Case Selection Temporary eye protection following any full thickness eyelid defect pending reconstruction. 13.5.4.3 Steps 1. Insert a 4/0 monofilament suture through the conjunctival wound edge. 2. With the same suture pick up any retractor tissue and bring this suture out through the skin. 3. Now push it through the centre of a silicone band (240 retinal detachment encircling explant) and re-enter the band 5 mm to one side in the reverse direction. 4. Pass the needle through all the tissue layers picked up with the first bite in the reverse direction (Fig. 13.5a) and clip both ends of this suture together. 5. Place additional sutures in the same manner as the need dictates (usually 3–4 (Fig. 13.5b). 6. Tape the sutures to the skin on the opposite side of the wound under strong traction. Prepare the skin with a coating of tincture of benzoin and apply three layers of tape for each pair of suture ends. Remember to alternate the suture direction between layers to prevent the suture slipping through the tape (Fig. 13.5c). 7. Apply antibiotic ointment to the wound and an occlusive pressure dressing. Note: Avoid getting ointment on the adhesive tape or it will lose its adhesion. 8. Leave the dressing undisturbed until formal reconstruction.

13.5.5 Temporary Central Suture Tarsorrhaphy (Fig. 13.6) The tarsal traction suture technique described above can be extended by passing the same suture through the opposing eyelid margin in the same way (Fig. 13.6c). The suture ends are then tied firmly together creating a simple, yet very effective, temporary tarsorrhaphy (Fig. 13.6d). This can work over many weeks before suture migration eventually causes it to fail. The suture knot should be tied medially or laterally as far from the cornea as possible to minimise the risk of corneal irritation. Furthermore, the suture ends should be left long (2–3 cm) to make it impossible for the sharp cut ends to enter the palpebral aperture and irritate the eye. Because monofilament sutures are smooth, the knot seldom irritates the cornea even when contact occurs.

13.5.6 Temporary Lateral Suture Tarsorrhaphy (Fig. 13.6e) The principle above may be used to create a lateral tarsorrhaphy (Fig. 13.6e). For this I recommend you place two tarsal sutures. The more central suture takes most

168

13

a

Eye Protection

b

900

c

d

e

Fig. 13.6 Temporary suture tarsorrhaphy. a Enter the meibomian orifice line perpendicular with a taper point needle. b Bring the suture out through the meibomian line about 10 mm away. c Take a strong bite of the upper lid margin in the same way. d Tie the suture ends together laterally, away from the cornea. e Use two such sutures to create a temporary lateral tarsorrhaphy

of the strain and will loosen first through migration. Remove it when it is no longer effective, leaving the lateral suture in place until that also fails. In my view there is no longer a place for using tubing or bolsters when performing a suture tarsorrhaphy (provided the meibomian orifice line is used for suture placement).

13.6 Permanent Surgical Tarsorrhaphy

169

13.5.7 Notes • Occasionally, following the removal of a tarsorrhaphy suture a mucosal bridge will be found between the lids. This can be left to break on its own or simply be cut without anaesthetic. • No Temporary Surgical Tarsorrhaphy. Because meibomian line suture tarsorrhaphy is so simple to perform, effective and easy to repeat, I contend that there is no-longer any reason for carrying out a temporary surgical tarsorrhaphy. The latter takes longer to perform and risks leaving an irregular lid margin and trichiasis after it is re-opened.

13.6

Permanent Surgical Tarsorrhaphy

If a patient requires long-lasting eyelid union, as for example when managing nonrecovering seventh nerve palsy, then you must encourage the lids to heal together firmly and permanently. The simplest way is to make the opposing lid margin surfaces raw before suturing them together in close contact until they heal together. This can work well but often the union is too weak to last and the lids either separate spontaneously or else the join stretches into an unsightly and ineffective web. The larger the area of tarsal plate contact that you create the stronger your tarsorrhaphy.

13.6.1 Permanent (Overlap) Lateral Tarsorrhaphy (Fig. 13.7) 13.6.1.1 Principle Create a bare area between the overlapping upper and lower tarsal plates and hold them together with sutures until a strong permanent scar has formed. The greater the bare area of contact the stronger the union obtained. Overlapping the tarsal plates creates a larger area of contact than an edge-to-edge tarsorrhaphy. It is often combined with a medial canthoplasty.

13.6.1.2 Case Selection • Incomplete eye closure e.g., non-recovering facial palsy • Atonic lower lid ectropion • Lower lid retraction e.g., Thyroid eye disease (only when combined with retractor recession).

170

13

a

b

c

d

e

f

Eye Protection

Fig. 13.7 Permanent (overlap) lateral tarsorrhaphy. a Make a 4–5 mm long incision in the lower lid grey line up to the lateral canthus. b Excise a semicircle of anterior lamella below it, including skin, orbicularis, and lash follicles, to expose the underlying tarsal plate. c Evert the upper lid margin and diathermy a corresponding semicircle on the sub-tarsal conjunctiva to destroy the conjunctiva. d Insert a 6/0 absorbable suture through the middle of the exposed lower lid tarsal plate margin and then a bite of the upper edge of the adjacent diathermied area and tie this suture, cutting its ends short. e Insert a 4/0 monofilament suture on a round bodied needle through the upper lid skin, so that it exits the denuded tarsal plate close to the lateral canthus. Then take a strong, partial thickness bite of the exposed lower lid tarsal plate. Complete this suture by taking it through the upper lid tarsal plate, skin and through a silicone sleeve. f Place one or two 6/0 absorbable sutures into the upper lid meibomian orifice line, bringing them down to engage the cut edge of the lower lid orbicularis and skin. Then tie the preplaced 4/0 monofilament suture to hold the raw tarsal plate surfaces in firm apposition, so that they unite

13.6 Permanent Surgical Tarsorrhaphy

171

13.6.1.3 Steps 1. Make a 4–5 mm long incision in the lower lid grey line up to the lateral canthus (Fig. 13.7a). 2. Based on the grey line incision, excise a semicircle of anterior lamella below it, including skin, orbicularis, and lash follicles, to expose the underlying tarsal plate (Fig. 13.7b). Ensure that the exposed tarsal plate surface is free of connective tissue. Apply gentle diathermy if required. 3. Evert the upper lid margin and mark out a corresponding semicircle on the sub-tarsal conjunctiva ensuring that it also starts at the lateral canthus. Apply gentle diathermy to this area to destroy the conjunctiva without significantly damaging the tarsal plate (Fig. 13.7c). Wipe off any loose necrotic conjunctiva. 4. Insert a 6/0 absorbable suture through the middle of the exposed lower lid tarsal plate margin. 5. With the same suture take a bite of the upper edge of the adjacent diathermied area of the everted upper lid tarsal plate (Fig. 13.7d). 6. Tie this suture and cut its ends short, so that they do not irritate the eye. 7. Insert a 4/0 monofilament suture on a round bodied needle through the upper lid skin, just above the lashes so that it exits the denuded tarsal plate close to the lateral canthus. 8. With the same suture now take a strong, partial thickness, bite to span the exposed lower lid tarsal plate. 9. Complete this suture by taking it through the upper lid tarsal plate at the medial end of the denuded tarsal crescent, so that it exits through the skin just above the lashes (Fig. 13.7e). 10. Cut a piece of silicone tubing the length of the distance between the suture entry and exit points and thread it onto the suture. It will act as a bolster. Clip the untied suture ends together. 11. Place one or two 6/0 absorbable sutures into the upper lid meibomian orifice line, bringing them down to engage the cut edge of the lower lid orbicularis and skin. Tie the suture(s) (Fig. 13.7f). 12. Tighten and tie the preplaced 4/0 monofilament suture to hold the raw tarsal plate surfaces in firm apposition, so that they unite during healing. 13. Before cutting the 4/0 suture ends reverse thread (using the blunt end of its needle) one end through the tubing. By pulling on this suture, you can pull the knot to lie inside the tubing for the patient’s comfort. Then cut both suture ends close to the tubing. 14. No dressing is required. Remove the non-absorbable suture and bolster at two weeks. Allow the remaining sutures to dissolve spontaneously. Note: Such tarsorrhaphies cannot be reversed without causing distortion of the lid margin and so should only be used when permanence is intended. They are well camouflaged by the upper lid lashes.

172

13

Eye Protection

13.6.2 Permanent Medial Canthoplasty (Fig. 13.8) 13.6.2.1 Principle and Considerations Medial canthoplasty is effectively a tarsorrhaphy carried out medially to the lacrimal puncta where there is no tarsal plate to suture together. Instead, aim to unite permanently the upper and lower limbs of the medial canthal tendons. Take great care not to damage, or suture closed the lacrimal canaliculi during such surgery as they lie adjacent to the tendon. It is often combined with a lateral tarsorrhaphy.

13.6.2.2 Case Selection • Non-recovering facial palsy • Atonic lower lid ectropion • Lower lid retraction e.g., Thyroid eye disease (only when combined with retractor recession).

a

b

c

d

Fig. 13.8 Permanent medial canthoplasty. a Insert Bowman probes into the upper and the lower canaliculi and make a ‘U’ shape skin incision around the medial canthus from punctum to punctum. b Suture firm medial canthal tendon tissue adjacent to the canaliculus together with two ‘box’ sutures. c Place two horizontal mattress sutures across the skin wound. d The posterior lamella is inverted, and the anterior lamella everted to maximise the contact area

13.6 Permanent Surgical Tarsorrhaphy

173

13.6.2.3 Steps 1. Insert ‘0’ gauge Bowman lacrimal probes into the upper and the lower canaliculi and ask an assistant to keep them in the lacrimal sac by pressing them gently against the side of the nose. 2. Carefully make a ‘U’ shape skin incision around the medial canthus from punctum to punctum and just outside the probes (hence also the canaliculi) (Fig. 13.8a). 3. Separate the orbicularis by blunt dissection using pointed scissors. 4. Using a 6/0 absorbable suture on a curved needle take a strong bite of the firm medial canthal tendon tissue adjacent to the canaliculus (Fig. 13.8b). Note: Identify the tendon by its resistance to distraction rather than by its visibility. Start at the medial canthus. If you feel the needle tip touch metal, then it is intracanalicular and should be removed and replaced. 5. Take a similar bite with the same suture through the opposing lid in the opposite direction to make a ‘box’ suture. Clip the two suture ends together. 6. Place a second suture adjacent to the first so that the bites extend to the ends of the incision, close to the lacrimal puncta. 7. Withdraw the Bowman probes and tie both sutures firmly. In doing so the lid margins become inverted so that there is no epithelium between the raw surfaces of the upper and lower limbs of the medial canthal tendon. 8. Place two 6/0 absorbable horizontal mattress sutures across the wound, engaging both the skin and the orbicularis. As you tie them, they will evert the skin edges (Fig. 13.8c, d). 9. No dressing is required. Leave the sutures to dissolve spontaneously.

13.6.3 Lower Lid Lifting (Fig. 13.9) The lifting of an atonic lower lid is best achieved by combining a medial canthoplasty with a small lateral tarsorrhaphy. Doing so transfers dynamic upper lid lift (levator pull) to the lower lid. The effect can be enhanced by dividing the lower lid retractors first (transconjunctivally) and placing the lower lid on upward traction overnight with a central tarsal traction suture.

174

13

Eye Protection

Fig. 13.9 Permanent medial canthoplasty and lateral tarsorrhaphy. Impart dynamic lift to a lower lid with a small lateral tarsorrhaphy and medial canthoplasty

13.7

Take Home Message

• Use the meibomian orifice line, not the grey line, for bolster-less lid margin traction suture placement. • Use a meibomian orifice line suture tarsorrhaphy instead of a temporary surgical tarsorrhaphy.

Lid Reconstruction Post Tumour Excision Repair

14

The art of surgery (Fig 14.1).

Fig. 14.1 Artist with a scalpel

14.1 • • • • • • • •

Overview

Relative importance of the upper lid Lid tension vectors and tissue expansion Direct closure of lid margin defects Direct closure of skin defects Directed Laissez-faire Upper to lower lid skin flap Cheek pedicle flap Mustardé lower lid switch flap

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_14

175

176

14

Lid Reconstruction

When faced with an eyelid reconstruction, ask first “Is reconstruction is really necessary?” Our natural healing response has evolved over millennia to do just that and is generally very effective. Remember the maxim “First do no harm”, as all surgery involves further wounding, albeit with the best of intentions. So, always attempt direct defect closure, and if that fails consider the option of doing nothing, referred to as “Laissez-faire”. It can produce acceptable results in selected cases and may be preferred by some patients as an alternative to further surgery. A functioning lid requires both an anterior and a posterior lamella. Restore both.

14.2

The Reconstruction Ladder (Fig. 14.2)

Reconstruction techniques are ranked in a hierarchy, sometimes referred to as Gillies’ ladder (after Sir Harold Delf Gillies CBE FRCS 1882–1960). Rank the best technique first and the most complex last: • • • • • •

Direct closure (best tissue match) Directed laissez-faire (incomplete attempted direct closure) Laissez-faire (involves no surgery) Flaps (recruitment of adjacent tissue) Grafts (free transfer of distant tissue) Microvascular flaps (free grafts with a vascular re-anastomosis).

Fig. 14.2 The reconstruction ladder. A hierarchy of reconstruction options with the best at the bottom and the most complex at the top. With experience 80% of reconstructions can be satisfactorily managed using the bottom two rungs

Reconstruction ladder Microvascular Graft Free Graft Local Flap Laissez-faire Directed Laissez-faire Direct Closure

80%

14.3 Upper Lid Essential, Lower Lid Optional!

177

Without doubt, direct closure gives the best outcomes. However, it is not always possible. Consider leaving a wound partially closed when you cannot quite close it completely (termed ‘directed laissez-faire’). Ultimately the size and nature of the defect will dictate the most appropriate management choice. Consider patient preference, although that is in large part dictated by the way you present the options. Never oversell. ‘Under promise and over deliver’ to avoid disappointment. Be aware of the subconscious bias to promote unnecessarily complex repairs because we as surgeons enjoy operating (or possibly derive additional financial benefit?). I challenge you to incrementally increase your direct closure/directed laissezfaire rate to 80% from the probable 30% at which I guess it currently stands.

14.3

Upper Lid Essential, Lower Lid Optional!

The relative functional importance of the upper lid compared with the lower lid is often overlooked. Many papers and chapters are devoted to lower lid reconstruction using harvested upper lid tissue. This is not without risk to upper lid function which is essential for clear vision. Without it the comfort and integrity of the eye itself are in jeopardy. The upper lid is a ‘wash-wiper’, spreading a fresh optical tear film across the upper 2/3 of the cornea with each blink (Fig. 14.3). Bell’s phenomenon (the upward rolling of the eye during blinking) ensures that the lower 1/3 of the cornea is also kept moist by the upper lid. This means that the lower lid is mostly redundant, a fact born out following complete lower lid margin excision without reconstruction (laissez-faire healing). Never compromise upper lid function when you use it as a donor site.

Fig. 14.3 Wash-wiper. The upper lid spreads the tears on blinking to clean and replenish the precorneal tear film, a function essential for clear vision and for corneal survival

178

14.4

14

Lid Reconstruction

Proof of Cure

I contend that histological proof of malignant tumour clearance is mandatory before you undermine or alter the defect margins in case a further wider excision is needed. Therefore, avoid performing flap or graft repairs at the time of excision biopsy, unless on table frozen section histology is available and negative. Consequently, the only safe primary management options are direct closure without undermining, partial direct closure (directed laissez-faire), or simply dressing the defect (laissez-faire).

14.5

Eyelid Tension: Normal and Necessary

Eyelids require tension to hold them against the eye and keep them stable. When a youthful eyelid margin is cut the tension is released and the wound edges spring apart by about a centimetre. Loss of tension is an important factor in the development of entropion and ectropion. Therefore, when reconstructing a lid, restore lid margin tension ensuring that you direct it parallel with the margin. A reconstruction that gives rise to perpendicular tension will cause lid margin stretching and ectropion.

14.6

Don’t Undermine

The undermining of wound edges is common surgical practice. A skin flap must be dissected free from the underlying tissues (undermined) to allow it to be raised. However, our faces are naturally very mobile, anchored by facial ligaments in only a few places. So, undermining wound edges for the direct closure of defects is both unnecessary and creates avoidable scar planes. Contraction of these scar planes during healing may cause undesirable tension vectors. Detaching the mid face from the zygomatico-cutaneous ligament, as when lifting a cheek rotation flap, leads to late progressive mid face descent which spoils an initially satisfactory reconstruction. There is currently a vogue for dividing the confusingly named tear trough ligament from the inferomedial orbital rim in order to “re-drape” the lower lid fat pads for aesthetic reasons instead of removing them. It will be interesting to see what the long-term unintended effects of this will turn out to be.

14.7 Direct Closure

14.7

179

Direct Closure

The benefits of direct wound closure are obvious: 1. Primary repair at the time of tumour resection. 2. Edge to edge suturing gives the best skin colour and texture match. 3. Absence of a donor site and related morbidity. Its limitations are: 1. Limited local tissue availability. 2. Temporary impairment of eyelid function due to raised lid margin tension. 3. Lid margin malposition (retraction, cicatricial ectropion) if the induced tension vectors are wrongly aligned. The direction of the closure tension is more critical than the orientation of the resulting scar. Figure 14.4 illustrates the correct tension vectors’ orientation (black arrows) for closing lid margin and periocular defects. The resulting closure scars (yellow lines) end up at right angles or oblique to the lid margin, and cross skin tension lines. The trio of vectors outside the canthi relate to the bony attachments of the canthal tendons to which you should anchor the soft tissues. But how is it possible to bring together the edges of a significant tissue defect? 1. Most tissues have an inherent degree of elasticity, skin and muscle more so than tarsal plate and canthal tendon. 2. The naturally curved eyelid straightens when pulled. This change in geometry from curve to the shorter straight line relies on the lid displacing the eye backwards and upwards within the orbit (Fig. 14.5), irrespective of whether it is the upper or the lower lid that has been tightened. 3. The phenomenon of ‘tissue creep’ lengthens the lid per operatively. It comprises the squeezing of fluid from the tissues and micro-tears of the collagen. The more slowly you pull the tissues together, the more creep takes place. These three mechanisms together give rise to significant lid length gain.

180

14

Lid Reconstruction

Fig. 14.4 Direction of wound closure vectors. a The arrows indicate the desired closure tension vectors for lid margin defects, the lines the direction of the resulting scars. b The arrows indicate the desired closure tension vectors for defects peripheral to the lid margins, the lines the direction of the resulting scars

14.7.1 Tissue Expansion (Fig. 14.6) Living tissues under abnormal tension expand or grow to reduce that tension. After all, no-one pops from getting fat or pregnant. Ophthalmologists are familiar with lengthened eyelids in cicatricial ectropion and even more so in the floppy eyelid syndrome (surgery to correct these conditions requires significant lid margin

14.7 Direct Closure

181

a

b

B

A

c

d

e

Fig. 14.5 Globe displacement by direct closure. a When a lid (A) is shortened to become a straight line (B) the eye is pushed backwards. Direct closure of a lower lid defect b straightens the lid margin upwards (small arrow) (c) and displaces the eye upwards (large arrow). Direct closure of an upper lid defect d straightens the lid margin downwards (small arrow) e but still displaces the eye upwards (large arrow)

shortening). Plastic surgeons have long used implanted subcutaneous balloons to expand skin so that it can be used to reconstruct a defect. It is therefore surprising that few oculoplastic surgeons exploit the phenomenon of tissue expansion for eyelid reconstruction. Closing a large lid margin defect directly by pulling the wound edges together creates tension that may prevent normal eyelid movement and displace the eye posteriorly and upwards within the orbit as already mentioned (Fig. 14.5). However, these changes are short-lived. The displaced eye acts as an inbuilt tissue expansion balloon, applying sustained pressure to the reconstructed lid thus stimulating it to stretch and grow. Often excessive lid tension after a significant direct closure

182

14

Lid Reconstruction

Fig. 14.6 Tissue expansion. No-one bursts from getting fat or pregnant!

prevents the eye from opening immediately. However, it is usually able to do so again often by the second postoperative day and certainly within a week or two. Within two months the vertical and horizontal palpebral aperture dimensions will have returned to within 1 mm of those on the un-operated side [1, 2]. Consequently, ‘excessive tension’ is not a valid argument against direct wound closure provided the lid tension vector rules in Fig. 14.4 are observed.

14.7.2 No Cantholysis As explained above, raised lid margin tension is necessary for expansion to occur. Relieving that tension by performing an elective cantholysis to enable direct closure is therefore counterproductive. Don’t do it! You end up with an unsightly web of tissue at the cantholysis site devoid of the normal lid margin structures. Note: Some surgeons recommend a cantholysis to allow remaining intact lateral lid margin to move to a pre-corneal position to enhance the stability of the lid reconstruction. This is a valid reason, but in my experience such a manoeuvre is seldom required.

14.7.3 Closure Scar Lengthening Direct closure wounds lengthen, a fact which is not widely recognised (Fig. 14.7). Closing a circular defect results in a closure length approximately 1½ times the defect’s original diameter. This is fortuitous as it counterbalances the naturally occurring scar contraction during healing, which might otherwise pull on the lid margin.

14.8 Direct Closure of Lid Margin Defect (Fig. 14.8)

183

C

D

Circle circumference C = diameter. Closure length L = ½ C =

L

Π , where D is the circle D.Π

≈ 1.5 x D

Fig. 14.7 O to I closure. Directly closing a circular wound lengthens the closure scar by roughly one and a half times the original defect diameter

14.8

Direct Closure of Lid Margin Defect (Fig. 14.8)

14.8.1 Principles and Considerations This technique is the same as that for lid margin repair (described in Chap. 5) but relies on postoperative tissue expansion to restore the lid margin length. The resulting margin is complete with eyelashes, albeit more spaced out, something no other repair achieves. It uses absorbable sutures which, generally, do not require removal. The tarsal plate is the most important structure to suture as it forms the skeleton of the lid margin.

14.8.2 Case Selection Attempt direct closure on most defects, irrespective of size. With experience you will start closing defects much larger than the 1/4 to 1/3 of the lid’s length that textbooks quote.

14.8.3 Steps 1. Insert a 6/0 absorbable suture, mounted on a 1/2 circle needle, through the tarsal plate on either side to span the wound. Place it as close to the lid margin as

184

14

Lid Reconstruction

Fig. 14.8 Lid margin reconstruction by direct closure. a Grasp the full thickness of the lid ‘sandwich’ perpendicularly to the margin with toothed forceps and evert the edge. b Enter the anterior tarsal plate surface perpendicularly with your suture needle. c After engaging almost the full tarsal plate thickness, take a similar bite on the far wound edge. d In the lower lid, place 2 further sutures below the first one in a similar fashion, in the upper lid, 3 or 4. e to h). Place a 7/0 absorbable horizontal mattress suture in the margin, burying its knot. f Tie and cut the preplaced tarsal sutures. g Tighten and tie the lid margin mattress suture. h Ensure the margin pouts. i Repair the remainder of the skin wound. j With lateral defects use the cut lateral canthal tendon as the lateral suture fixation point. k Close the skin and orbicularis

14.8 Direct Closure of Lid Margin Defect (Fig. 14.8)

185

Fig. 14.8 (continued)

possible. Take care to align the suture bites on each side to be equidistant from the lid margin to avoid a margin step. (a) Grasp the full thickness of the lid ‘sandwich’ perpendicularly to the margin with toothed forceps, about 2–3 mm from the cut edge (Fig. 14.8a). Evert the edge slightly to improve visibility and access. (b) Use the flat surface of the suture needle to push the skin and orbicularis away, so that the needle tip enters the anterior tarsal plate surface perpendicularly (Fig. 14.8b). (c) As soon as the needle tip engages the tarsal plate, rotate and advance the needle so that it emerges close to the conjunctival surface on the cut edge of the tarsal plate, i.e., after engaging almost the full tarsal plate thickness. (d) Retrieve and remount the needle from this first bite and grasp the far side of the lid margin with tissue forceps, as in step 1a. (e) Insert the needle into the cut surface of the tarsal plate close to and parallel with its conjunctival surface. Take special care to place this bite at the same distance from the lid margin as the first bite on the other side of the defect (Fig. 14.8c).

186

2.

3.

4.

5.

6.

14

Lid Reconstruction

(f) As soon as the needle tip engages the tarsal plate, rotate, and advance the needle so that it emerges on the anterior surface of the tarsal plate 1½ mm from the wound edge. Avoid engaging the orbicularis and skin (you may have to lift them off the needle tip). (g) Clip the two untied suture ends together with a bulldog clip and retract them. In the lower lid, place 2 further sutures below the first one in a similar fashion, spaced about 1 mm apart (Fig. 14.8d). In the upper lid, 3 or 4 additional sutures may be required as the tarsal plate is wider. Again, clip each pair of untied suture ends together to aid later identification when tying. Preplace a lid margin horizontal mattress 7/0 absorbable suture so that its knot will become buried in the lash line. This configuration will cause the lid margin repair to pout as intended when this suture is eventually tied. (a) With the needle enter the wound edge through the orbicularis, just anterior to the tarsal plate surface in line with the lashes (Fig. 14.8e). (b) Rotate the needle so that it emerges from the skin within the lash line 1½ mm from the wound edge, having engaged the orbicularis and skin. (c) With the same needle re-enter the lid margin perpendicularly through the meibomian orifice line on the same side (Fig. 14.8f). Rotate and advance the needle to exit the cut tarsal plate surface close to the margin. Take special care not to accidentally engage the first preplaced tarsal plate suture from step 1, as this would cause problems when tying the latter. (d) Now insert the same suture through the far wound edge in reverse order i.e., entering the cut tarsal plate first, exiting the meibomian line, re-entering through the lash line and finally exiting the orbicularis just anteriorly to the tarsal plate (Fig. 14.8g). (e) Clip the untied suture ends together (Fig. 14.8h). Now tie firmly and cut the preplaced tarsal sutures in reverse order of placement i.e., starting with the one furthest from the lid margin (Fig. 14.8i). Once tied, the first suture takes up most of the wound tension. This makes tying the remaining tarsal plate sutures easy and their first throws very unlikely to slip during tying. By the end of this step the lid margin wound should be accurately and securely closed. Tighten and tie the lid margin mattress suture (Fig. 14.8j). Confirm that it causes the lid margin join to pout (Fig. 14.8k). Cut its ends short enough for them to retract into the wound. Either repair the remainder of the skin wound with interrupted 6/0 or 7/0 absorbable sutures which incorporate the underlying orbicularis into each bite or suture the orbicularis as a separate layer with a magic suture (see below) (Fig. 14.8l).

14.9 The Trans Incisional Tarsal Traction Suture (Fig. 14.9)

187

14.8.3.1 Notes • An accurately repaired lid margin will not leave a noticeable scar or notch. However, for larger defects the scar may stretch. • Direct margin closure works equally well when a canthus is involved. Use remaining canthal tendon, periosteum, or a bone screw to anchor the sutures at the lateral wound edge (Fig. 14.8m, n).

14.9

The Trans Incisional Tarsal Traction Suture (Fig. 14.9)

14.9.1 Principle and Considerations The direct closure of larger defects can be made easier by placing a modified tarsal traction suture (see Chap. 5) across the defect to reduce the tension across the wound. Its ends may be used to apply lid traction or converted into a suture tarsorrhaphy (see Fig. 13.6).

a

b

900

c

d

Fig. 14.9 Trans incisional traction suture. a Enter the meibomian orifice line with d 4/0 monofilament polypropylene suture. b Advanced the needle within the tarsal plate to exit in the wound. c Re-insert the needle into the far wound edge to engage the tarsal plate and come out through the meibomian orifice line. d Now continue with the direct closure of the lid

188

14

Lid Reconstruction

14.9.2 Steps 1. Grasp the full thickness of the lid as parallel to the margin as possible with large forceps (e.g., Toothed Adson’s) and evert the margin. As you squeeze the lid the egress of meibomian secretions identifies the meibomian orifice line. 2. Enter the meibomian orifice line with a 4/0 monofilament polypropylene suture on a 17 mm half circle, non-cutting needle with its tip held perpendicular to the lid margin (Fig. 14.9a). 3. Slowly advanced the needle within the plane of the tarsal plate, allowing it to follow its own curve to exit in the wound at the base of the tarsal plate (Fig. 14.9b). 4. Re-insert the needle into the far wound edge to engage the tarsal plate and come out through the meibomian orifice line (Fig. 14.9c). 5. Now continue with the direct closure of the lid defect as outlined in the previous section (Fig. 14.9d). 6. Apply traction to the suture ends using an artery clip to approximate the wound edges when you tighten and tie the repair sutures.

14.10 Direct Closure of a Skin Defect (Fig. 14.10) 14.10.1 Principle and Considerations The principles of non-marginal lid wound closure are the same as for any surgical wound: accurate alignment of the edges and closure in layers. The main difference periocularly is the paramount importance of the tension vector (direction) which has already been discussed. This is because the free lid margin edge is unable to withstand any sustained radial traction. The technique below incorporates the magic suture, described in Chap. 5.

14.10.2 Case Selection Potentially applicable to any periocular wound. At best, full closure is achieved. At worst, the defect has been minimized prior to an additional graft, flap or directed laissez-faire.

14.10 Direct Closure of a Skin Defect (Fig. 14.10)

189

14.10.3 Steps 1. Ensure adequate haemostasis. 2. Place a single, strongly anchored, buried, 4/0 or 6/0 absorbable suture in the subcutaneous tissue layer (usually the orbicularis muscle) to span the maximum wound diameter, orientated as in Fig. 14.4b (See also ‘The Magic Suture technique’ Chap. 5). Insert the suture so that the knot becomes buried when tied (Fig. 14.10a). 3. Tighten this suture fully by lifting the first throw free of the tissues, rocking it gently side to side to encourage it to slide through the tissue, and then snugging down the throw (Fig. 14.10b). This manoeuvre may need to be repeated until you bring the tissue edges completely together. Do not rush this step to allow time for ‘tissue creep’ to occur. 4. Tie the suture on a bow and observe the effect that tightening has had on the lid margin position. If there is any sign of margin retraction, remove the suture and replace it in a more favourable alignment. Once happy with the orientation tie it with a minimum of two additional throws.

a

b

10 mm

10 mm

c

Fig. 14.10 Direct closure of a periocular skin defect. a Span the defect with a strongly anchored, orbicularis muscle suture, orientated parallel to the lid margin. b Tighten this suture by lifting and rocking the first throw side to as you pull. Once happy with the orientation tie it with a minimum of two additional throws. c The skin edges should have been brought sufficiently close together to suture

190

14

Lid Reconstruction

5. Observe the effect that the first subcutaneous suture has had on the skin margins. The skin edges should have been brought sufficiently close together to allow suturing without undue tension. If not, add additional subcutaneous sutures in a similar fashion. 6. Close the skin with either interrupted or a continuous suture (Fig. 14.10c). 7. Apply a pressure dressing overnight to minimise oedema. Notes: The tissue at either end of the closure will appear lax in comparison to the central area of maximum tension. This can give rise to a ‘dog ear’ appearance. Ignore this as it is very likely to resolve spontaneously by tissue remodelling.

14.11 Directed Laissez-Faire (Incomplete Direct Closure) 14.11.1 Principle and Considerations Although direct eyelid defect closure remains the first choice, sometimes it is impossible to achieve complete closure. In such circumstances, partially closing the defect to reduce its size is still of benefit. Firstly, it aligns the closure tension vector in the desired axis (see Fig. 14.4), rather than permitting the unmodified concentric wound contraction of laissez-faire to occur. Secondly, because you have greatly reduced the wound area left to heal by granulation, more rapid secondary intention healing occurs. The closure sutures span and reduce the residual defect (Fig. 14.10). Remember, they should only create tension that is parallel to the eyelid margin, as already discussed ad nauseam. Apply antibiotic ointment and a non-stick pressure dressing and leave it undisturbed for a week while awaiting histology. All the excision margins are available for re-excision should the histology suggest incomplete tumour removal. Healing by secondary intention often gives excellent results and further surgery may be unnecessary. At two to three months post excision, decide whether the outcome is functionally and aesthetically acceptable or whether to perform a secondary reconstruction. If reconstruction proves necessary, the tissue expansion that has already taken place in the interim will make it less extensive.

14.11.2 Directed Laissez-Faire of a Lid Margin Defect (Fig. 14.11) 14.11.2.1 Steps 1. Preplace interrupted 6/0 absorbable sutures into the cut tarsal plate edge on one side of the defect. Double armed horizontal mattress sutures hold strongly and are easy to tie under tension. Two will suffice in a lower lid, three may be needed in an upper lid. If you use simple sutures three will suffice for a lower

14.11 Directed Laissez-Faire (Incomplete Direct Closure)

a

b

c

d

e

f

191

Fig. 14.11 Directed laissez-faire margin reconstruction. a A large lid margin defect. b Attempt direct closure, bringing the wound edges as close as tension allows. c Repair the orbicularis and skin as much as you can. Leave the remaining defect to granulate. d Manage a large lateral margin defect similarly. e Reduce the horizontal defect size with sutures. f Reduce the orbicularis and skin defect. Wait for granulation to close the remaining defect

lid and 4–5 in the upper lid. If no tarsal plate remains, insert the sutures into the cut edge of the canthal tendon (Fig. 14.11e). Should that also be absent place them through the orbital rim periosteum (arcus marginalis). If no periosteum remains insert a short, self-tapping, bone screw into the orbital rim and tie the suture to that with a clove hitch knot. 2. Span the wound with the sutures and insert them in the cut far side tarsal plate edge (Fig. 14.11b).

192

14

Lid Reconstruction

3. Tie the sutures in turn, starting with the one furthest from the lid margin: (a) When using simple sutures remember to lift the first throw, rock it a little side to side to help it slide through the tissues and then snug it down under tension. Ask an assistant to grasp and hold the tightened first suture throw with the very tips of a pair of Moorfields forceps before releasing the tension on the suture ends. Repeat this manoeuvre several times until the wound edges stop coming any closer. Ignore the induced palpaebral aperture distortion and globe displacement. Lock the knot with a second single throw, asking the assistant to remove the forceps just before they are trapped by the locking throw. Complete the knot with 1–2 further single throws and cut the ends no shorter than 2 mm (to avoid unravelling). (b) When using horizontal mattress sutures lift and pull the first throw, rock it horizontally to and fro and then tighten it down snugly against the tissues. Normally it is unnecessary to grasp the first throw as the suture tension holds it down firmly against the tissues. The friction this causes prevents it from slipping. Lock the first throw, as above, with 2–3 further throws and cut the suture ends no shorter than 2 mm. 4. Repeat step 3 for the remaining suture(s). Do not rush these steps as tissue creep is gradually occurring as you increase the tension. 5. Close the orbicularis and skin with interrupted sutures as far as the tissue tension allows (Fig. 14.11c, f). 6. Apply a non-adherent dressing membrane, antibiotic ointment, and a pressure dressing. Leave the dressing undisturbed for 5–7 days. 7. Continue twice daily antibiotic ointment thereafter until the remaining defect is epithelialized. When a suture loosens, remove it to prevent irritation.

14.11.3 Directed Laissez-Faire of Skin Defect (Fig. 14.12) This is almost identical to the direct closure of a skin defect, differing only in that the defect is not fully closed at the end.

14.11.3.1 Steps 1. Ensure adequate haemostasis. 2. Place a single, strongly anchored, buried, 4/0 or 6/0 absorbable suture in the subcutaneous tissue layer (usually the orbicularis muscle) to span the maximum wound diameter, orientated as in Fig. 14.4b (See the magic suture technique in Chap. 5). Insert the suture so that the knot becomes buried when tied (Fig. 14.12a). 3. Tighten this suture fully by lifting the first throw free of the tissues, rocking it gently side to side to encourage it to slide through the tissue, and then snugging down the throw (Fig. 14.12b). This manoeuvre needs to be repeated several

14.11 Directed Laissez-Faire (Incomplete Direct Closure)

a

193

b

10 mm

10 mm

c

Fig. 14.12 Directed laissez-faire of skin defect. a Place a magic suture across the defect. b Use it to minimize the orbicularis defect. c Close the skin as much as tension allows. Allow granulation to deal with the residual defect

4.

5.

6.

7.

times over a matter of minutes to encourage ‘tissue creep’, until the tissue edges no longer advance. Note: If your suture breaks consider using a stronger one. If it cuts out use a horizontal mattress configuration instead. Tie the suture on a bow and observe the effect that tightening has had on the lid margin position. If there is any sign of margin retraction remove the suture and replace it in a more favourable alignment. Once happy with the orientation ask an assistant to grasp and hold the tightened first suture throw with the very tips of a pair of Moorfields forceps to prevent it from slipping while you complete the knot with a minimum of two additional throws. Begin closing the skin with interrupted horizontal mattress sutures from either end of the wound. Continue adding sutures until the skin edges can no longer be advanced to meet (Fig. 14.12c). Apply a non-stick film, antibiotic ointment, and a pressure dressing, leaving it undisturbed for 5–7 days. The residual skin defect will granulate by secondary intention healing. Once you remove the dressing ask the patient to apply twice daily ointment to the wound until it is fully healed. Reassure the patient that the appearance will improve with time and that you will reassess the outcome at 2 months to decide whether secondary reconstruction is required (it rarely is).

Note: The healing time depends on the size of the defect and on the individual’s powers of healing.

194

14

Lid Reconstruction

14.12 Flaps Pedicle flaps are peninsulas of tissue attached to a blood supply sufficient to ensure their on-going survival. They are used in eyelid reconstruction to bring additional tissue into the area. They also bring in a blood supply and can therefore be used as a bed for a free graft. Flaps are less prone to shrink than free grafts. They can be thicker and include additional tissue layers e.g., the orbicularis muscle. They must be planned so as not to leave a significant donor site deficit i.e., only take from where there is redundant tissue. Where possible flaps should have their pedicle inlaid to avoid the need for secondary pedicle division surgery. Eyelid flaps can be used to add anterior lamellar or posterior lamellar tissue. Numerous flaps have been described. Here I shall describe only three: two anterior lamellar and one transferring the full thickness of the lower lid margin (Fig. 14.13). The first two are straightforward and widely applicable. The third is rarely needed but I include it as it is the only way of reconstructing a normal upper lid margin following total or subtotal loss. Note: I do not find simple advancement flaps useful for two reasons. Firstly, it is usually possible to close such a defect directly. Secondly, as you pull a flap in one direction it narrows perpendicularly, introducing a new, undesirable force vector (Fig. 14.14a, b).

a

b

c

Fig. 14.13 Useful flaps. a Upper to lower lid pedicle flap. b Cheek pedicle flap. c Mustardé Lid Switch Flap

14.12 Flaps

a

195

b

Fig. 14.14 Advancement flap. a Advancement flap. b Stretching in one direction causes narrowing at right angles

14.12.1 Paper Templates It you need to transfer skin into a defect, first make a paper template of the defect size from a piece of spare, sterile instrument wrapping paper.

14.12.1.1 Steps (Fig. 14.15) 1. Get an assistant to gently stretch the wound to its full size. 2. Fold an appropriately sized piece of paper to make is easier to insert in a concave area (Fig. 14.15a). 3. Dry the wound and then briefly press the paper against it, unfolding it as you do (Fig. 14.15b). 4. Remove the paper, turn it over, and cut round the blood-stained wound imprint with scissors (Fig. 14.15c). 5. Refine the template by putting it back in the wound and trimming its edges if necessary (Fig. 14.15d). 6. Use this paper template to mark the gently stretched skin donor site.

196

a

c

14

Lid Reconstruction

b

d

Fig. 14.15 Making a paper template. a Fold a piece of sterile paper. b Press and unfold on the defect. c Cut around the blood stain. d Recheck the template and refine if necessary

14.12.2 Upper to Lower Lid Skin Flap (Fig. 14.16) See Fig. 14.16.

14.12.2.1 Principle and Considerations Transfer redundant upper lid skin into a lower lid defect on its vascular pedicle. 14.12.2.2 Case Selection Lower lid defects where sufficient redundant upper lid skin is present. 14.12.2.3 Steps 1. Make a paper template of the lower lid skin defect (as described above) (Fig. 14.16a). 2. Position the lower edge of the template on the upper lid skin crease and use it to mark the body of the flap on the gently stretched upper lid donor skin (Fig. 14.16b). Check that there will be sufficient skin remaining after the flap has been transposed (minimum 20 mm between the lashes and eyebrow).

14.12 Flaps

197

a

b C

A B

c

A1

d C

A B

A1

A

D

B

A1

D

C1 5 mm

C

C1

f

e A

A1

B

C

Fig. 14.16 Upper to lower lid skin flap. a Make a template of the defect. b Use it to mark a donor flap on the upper lid. c Raise the flap and incise the skin to join the defect to the flap pedicle. d Anchor the flap tip C into the defect C1 . e Anchor corner A1 into the upper pedicle angle A. f Complete the skin and margin closures

3. Join the donor skin to the intended pedicle base with two parallel lines (Fig. 14.16b). The lower line should end about 5 mm lateral to the lateral canthus (or 5 mm medial to the medial canthus) at the level of the canthus. The upper line should finish vertically above the lower one. The pedicle width should be similar to the maximum flap width. 4. Intumesce the donor area with a subcutaneous injection of local anaesthetic with adrenaline. 5. Incise the skin with a no.15 scalpel blade along the flap outline while your assistant ensures the eye is protected with a metal guard (Fig. 14.16c).

198

14

Lid Reconstruction

6. Lift the tip (or edge) of the flap and dissect it free from the underlying tissue, either as a pure skin flap or as a skin and orbicularis flap. 7. Join the lower lid defect to the base of the pedicle flap, B-D with an incision (Fig. 14.16c). This will allow you to inlay the pedicle. 8. Anchor the tip of the flap C into the far edge of the lower lid defect C1 with a 6/0 absorbable suture (Fig. 14.16d). Do not trim the suture ends or cut off the needle. 9. Anchor the corner of the lateral canthal skin A1 into the upper pedicle angle A (Fig. 14.16e). This effectively transposes the pedicle downwards. Do not cut off the needle. 10. Use the already placed anchoring sutures to finish suturing the flap into the recipient site (Fig. 14.16f) and tie the running suture to the short arm of an available knot. 11. Suture the donor site closed with a running absorbable suture. 12. Ensure that the recipient bed remains stretched and immobilized, usually with a lid margin traction suture, and apply a non-adherent film, antibiotic ointment, and a pressure dressing. Leave the dressing undisturbed at least overnight, but preferably for 5–7 days.

14.12.2.4 Notes There may be a tendency for a narrow pedicle to ‘tube’ because of interface fibrous contraction. Initial lid margin traction and subsequent massage help to avoid this complication.

14.12.3 Cheek Pedicle Flap (Fig. 14.17) 14.12.3.1 Principle and Considerations The thicker cheek skin can be used to construct an anterior lamella for a lower lid replacement when there is no tarsal plate remaining. Its thickness imparts a degree of stiffness to the reconstruction. The posterior lamella can be made of advanced fornix conjunctiva or a free mucosal graft. 14.12.3.2 Case Selection Total lower lid loss requiring reconstruction. 14.12.3.3 Steps 1. Estimate the skin flap length needed by pulling the lid margin edges together and measuring the length of the reduced defect (Fig. 14.17a). Alternatively, use an unfolded gauze swab to measure the defect and then, keeping it held firmly at the lateral canthus, swing the tip of the swab down like a compass and mark the skin (Fig. 14.17b).

14.12 Flaps

2.

3.

4. 5. 6.

7.

8. 9. 10.

199

Note: A common error is to make the flap too long which leads to the reconstructed margin sagging. Measure the vertical width of the defect without tension in order that the reconstructed lid develops no radial tension to later cause an ectropion. Draw the flap, based at the lateral canthus. Check that there is sufficient cheek laxity to close the intended donor defect by pinching the skin at the flap base before raising the flap. Decide whether sufficient conjunctiva can be mobilized for the posterior lamella by undermining the inferior conjunctival fornix. If this is not possible consider harvesting a lower lip mucosal graft. Incise the skin and raise the flap in the subcutaneous plane (dissecting deeper risks damaging the facial nerve) (Fig. 14.17c). Preplace a 7/0 absorbable suture at the lateral canthus (for later suturing of the reconstructed margin). Rotate the flap and anchor its tip B to the far end of the lid margin defect B1 with a 6/0 absorbable suture (Fig. 14.17d). Do not cut this suture as it will be used to suture the inferior flap edge to the defect. Close the donor defect by anchoring point A1 to the pedicle angle A with a 6/0 absorbable suture (Fig. 14.17e). Then suture the vertical defect with the same suture (Fig. 14.17f). Suture the lower flap edge to the defect edge with the suture from step 6. Suture the free conjunctival edge to the skin to recreate the margin with the preplaced 7/0 suture (Fig. 14.17g). Tie it to the end of the anchoring suture. Apply antibiotic ointment and pad the eye firmly closed overnight.

14.12.3.4 Notes • The cheek donor scar remains visible. The recreated lid margin is rounded and lacks the stiffness of a normal lid margin. There is a risk of fine skin hairs irritating the cornea.

14.12.4 Mustardé Lower Lid Switch Flap Inclusion of the lid switch flap in this manual is an anomaly as it is neither commonly needed nor is it a simple technique to perform. However, no better technique exists for restoring a normal functioning upper lid margin (including lashes). Despite this it is not widely known and so I make no apology for including it for the rare occasions when you may find it invaluable.

200

14

a

b

c

d

A

Lid Reconstruction

A B

B1 A1

B1

A1

B

e

f

A A1

g

B

B1

h

Fig. 14.17 Cheek pedicle flap. a Measure the length of the reduced defect. b Or use an unfolded swab as a compass to mark the flap. c Raise the flap and swing it into the defect, point B to B1 . d Anchor the flap in place. e Anchor point A to corner A1 to close the donor defect. f Suture the skin. g Suture the mucosal edge to the flap to create a new lid margin. h Put the flap on traction using a bolster

14.12 Flaps

201

14.12.4.1 Principle and Considerations The lower lid is sacrificed to reconstruct a functioning upper lid after total or near total upper lid loss. It is a two-stage procedure. The longer the interval between stages, the more margin expansion will have taken place and the smaller the ultimate lower lid defect. 14.12.4.2 Case Selection Total or subtotal upper lid loss. 14.12.4.3 Steps 1st stage (Fig. 14.18). 1. Mark and cut a full thickness lower lid flap that includes the whole tarsal plate. Base it medially (Fig. 14.18a). It must be at least 5 mm wide to include the peripheral vascular arcade. Note: Although the flap can be based laterally this is less convenient and there is more risk of canalicular damage. 2. Preplace a double armed 6/0 polypropylene suture in the cut lateral canthal tendon (Fig. 14.18b). Note: this modification was not included in Mustardé’s original description. 3. Rotate and anchor the tip of the flap, A, into the upper lid defect by suturing the tarsal plate to the upper lid tarsal plate remnant, A1 , or the medial canthal tendon with a 6/0 absorbable suture (Fig. 14.18c). This causes the flap to fold on itself and the margin to stick out at the bend because of its stiffness. 4. Starting medially, suture conjunctiva to conjunctiva with a continuous 7/0 absorbable suture as far laterally as is possible. 5. Identify the upper lid levator aponeurosis (using the pre-aponeurotic fat pad as a landmark) and attach it to the flap tarsal plate edge with three interrupted 6/0 absorbable sutures. 6. Suture the recipient skin and orbicularis to the flap skin and orbicularis with a 6/0 interrupted or continuous suture (Fig. 14.18d). Start medially and progress laterally as far as is possible. By this stage the eye will be obscured by the folded lid margin flap. There will be a residual infero lateral defect. 7. Anchor the kinked proximal tarsal plate edge to the lateral canthal tendon with the preplaced 6/0 polypropylene suture. Gradually tighten the suture to pull the flap bend laterally as far as it will go (Fig. 14.18e). Note: This modification was not part of Mustardé’s original description. The addition of this suture induces tension which encourages tissue expansion. 8. Suture the lower defect in layers, starting medially and progressing as far laterally as is possible (Fig. 14.18e). 9. Apply antibiotic ointment, a non-stick film, and an occlusive pressure dressing. Leave this in place for 5–7 days. Subsequently apply antibiotic ointment twice daily until the raw surfaces have healed.

202

14

a

Lid Reconstruction

b

A1 A

>5 mm

c

d

A

A1

e

Fig. 14.18 Lid switch flap 1st stage. a Plan a full thickness lower lid flap. b Cut the flap and place a suture into the cut lateral canthal tendon. c Anchor the flap tip, A to the end of the defect, A1 . d Suture the flap into the defect in layers as far laterally as possible. e Anchor the bend in the flap tarsal plate with the lateral preplaced suture

2nd stage (Fig. 14.19). Delay this as long as possible to allow time for revascularization and tissue expansion. 6–12 weeks is ideal. 1. Insert a squint hook into the lid margin flap bend and pull it laterally. Decide where to divide the lid margin pedicle so as to have sufficient lid margin for the new upper lid and mark it. Usually, this point is about 2/3 of the way from the flap tip, i.e., 2/3 of the flap will remain as upper lid.

14.12 Flaps

203

a

b

c

d

Fig. 14.19 Lid switch flap 2nd stage. a Divide the healed flap roughly 2/3 from the tip. b Freshen the edges and insert 2 double armed sutures into the lateral canthal tendon. c Anchor the lateral ends of the divided flap to the lateral canthal tendon. d Suture the flaps in place laterally

2. Cut the flap at the marked spot with tenotomy scissors perpendicularly to the margin (Fig. 14.19a). 3. Freshen up the healed lateral defect edges to separate the skin from the conjunctiva. 4. Pre-place two double armed 6/0 absorbable sutures into the lateral canthal tendon which is marked by the polypropylene suture placed in stage one. The latter should now be removed (Fig. 14.19b). 5. Reattach the divided flap ends at the margin with the pre-placed 6/0 sutures, one for the upper and the other for the lower cut edge. These sutures reform the lateral canthus (Fig. 14.19c). 6. Complete the flap transfer by suturing conjunctiva to conjunctiva and skin to skin with 6/0 or 7/0 absorbable sutures (Fig. 14.19d). 7. Close the lower lid margin donor defect as much as possible and leave the rest to granulate (directed ‘laissez-faire’). 8. Apply antibiotic ointment and an overnight pressure dressing. Note: By allowing several weeks to elapse between the first and second stages it is usually possible to reconstruct both the upper and the lower lids from the single lower lid flap. The priority however is to attain a functioning upper lid which is essential for sight, the lower lid being entirely optional. If the lower lid defect cannot be closed leave it to granulate.

204

14

Lid Reconstruction

14.13 Grafts Free grafts are the simplest way of bringing additional tissue into an area. However, their use is limited in two important respects. Firstly, they can only be applied onto a vascularized bed from which they derive their new blood supply. Secondly, they must survive long enough to establish this new vascular connection. In eyelid surgery this limits them to full thickness (or split) skin, or conjunctival grafts, where the host contact area is large in relation to the graft’s bulk and metabolic requirement. The exception is dermis-fat grafts which are bulky in relation to their contact area. They only survive thanks to the fat’s low metabolic rate, but even then, the degree of fat survival is unpredictable, ranging from full retention to total absorption. For a graft to take it must be immobilised in intimate contact with its host bed until new vascular channels establish. In eyelids this takes 5–7 days. Grafts also shrink! This is hardly surprising as the graft-host interface fibroblasts contract during the proliferative phase of wound healing. Split skin grafts contract by about half their linear dimensions and full thickness skin by about a third. For this reason, full thickness skin grafts are preferred for lid reconstruction. Oversize the graft to compensate for the anticipated shrinkage and keep the host bed on stretch during the haemostatic and inflammatory stages of wound healing. Here I shall only describe skin grafting as this is the most required. The appearance of healed skin grafts ranges from unnoticeable to unsightly and cannot always be predicted. Warn the patient of this beforehand. It depends to a large extent on the donor site chosen.

14.13.1 Skin Graft Donor Sites (Fig. 14.20) The lateral upper lid is the preferred skin donor site for three reasons: 1. Best colour and texture match 2. Excess skin frequently available at this site 3. Easy access. When there is insufficient skin available in the upper lid, I recommend the upper inner arm as the next best site. Advantages: 1. Plenty of hairless skin available. 2. Donor scar reasonably unobtrusive. Disadvantages: 1. Poorer colour and texture match than lid skin. 2. Surgical access awkward.

14.13 Grafts

a

205

b

Fig. 14.20 Skin graft donor sites. a Upper lid. b Upper inner arm

14.13.2 Alternative Sites Postauricular and pre auricular skin are favoured by some but the former is awkward to access and initially interferes with the wearing of glasses and hearing aids. Skin availability with the latter is limited by beard growth. If the supraclavicular fossa is used the donor scar is quite noticeable in younger patients.

14.13.3 Skin Graft Harvesting (Fig. 14.21) 14.13.3.1 Principle Choose an available donor site, excise the required size of full thickness skin, trim off any subcutaneous tissue, and suture the defect. 14.13.3.2 Steps 1. Make a paper template of the skin defect (Fig. 14.21a). 2. Use the template to mark out the graft on the gently stretched donor site skin (Fig. 14.21b). 3. Intumesce the donor area with a subcutaneous injection of local anaesthetic with adrenaline. 4. Incise the skin with a no.15 scalpel blade along the graft outline (Fig. 14.21c). 5. Lift one end of the graft and dissect it free from the underlying tissue (Fig. 14.21d). This may be done by scratching with the scalpel tip or using Westcott scissors (keep the graft and donor bed stretched during this dissection to avoid accidental graft perforation). 6. Wrap the graft over your finger, deep side out, and trim off excess subcutaneous tissue with Westcott scissors (Fig. 14.21e). 7. Suture the graft into its recipient bed with a continuous 6/0 absorbable suture (Fig. 14.21f).

206

14

Lid Reconstruction

Fig. 14.21 Skin grafting. a Make a template of the defect. b Mark the graft size on the donor site. c Incise the graft. d Excise the graft. e Strip off unwanted subcutaneous tissue. f Suture the graft into the recipient bed

8. Use a lid margin traction suture to ensure that the recipient bed remains stretched and immobilized. 9. Apply a non-stick film, antibiotic ointment, and a pressure dressing. Leave the dressing undisturbed for 5–7 days to encourage vascularization.

14.13.3.3 Notes • Many texts recommend perforating the graft in multiple places to prevent sub graft haematoma accumulation. This is unnecessary if you achieve adequate graft bed haemostasis and apply an effective pressure dressing. Similarly, I deem the use of tie-over graft bolsters unnecessary. They merely serve to lift the graft edges, while depressing the centre of the graft which can lead to a crater-like profile.

References

207

14.13.4 Split Skin Grafts Split skin grafts are useful when large areas of skin need to be replaced. This is seldom the case in lid surgery. Furthermore, split skin grafts contract much more than full thickness skin, so I advise you not to use them.

14.13.5 Mucous Membrane Grafts Mucous membrane is occasionally required to reconstruct a posterior lamella. It is harvested from the mouth: from the lower lip, the cheek, or the hard palate. Mucous membrane harvesting is not something a novice should attempt, so I will not discuss it further.

14.14 Notes • There are, of course, many alternative and more complex ways of reconstructing lid defects, each with its own advantages and drawbacks. Some involve discarding significant quantities of skin when compared to the original defect size, to make them fit. Others involve extensive undermining. Both these practices go against my minimalist grain. The above basic selection should allow you to manage most repairs simply and safely.

14.15 Take Home Message • The upper lid is essential, the lower optional. • Direct defect closure under tension gives the best outcome.

References 1. Thaller VT, Then KY, Luhishi E (2001) Spontaneous eyelid expansion after full thickness eyelid resection and direct closure. Br J Ophthalmol 85:1450–1454 2. Thaller VT, Madge SN, Chan W et al (2019) Direct eyelid defect closure: a prospective study of functional and aesthetic outcomes. Eye 33:1393–1401. https://doi.org/10.1038/s41433-0190414-2

15

Revision Surgery

15.1 • • • •

Overview

Avoid Delay Analyse Transverse release-plasty.

15.2

Avoid

‘Getting it right the first time’ is this book’s mission. As a rule, a good primary operation, be it for a lid malposition or a reconstruction, will avoid the need for revision surgery. Yet despite our best efforts, reoperation is sometimes necessary. Warn the patient of this possibility in advance.

15.3

Healing Shrinks

We know that healing tissues contract. Anticipate and allow for this shrinkage.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_15

209

210

15

Revision Surgery

15.3.1 Pout A linear scar will shorten. So, a lid margin which is smooth and flat at the end of a repair (Fig. 15.1a) will most likely develop a notch during healing (Fig. 15.1b). Therefore, in anticipation, create a pouting margin union at the end of surgery (Fig. 15.1c) which smooths spontaneously during healing (Fig. 15.1d). Fortuitously, when we directly close any defect the closure length exceeds the defect diameter, as discussed in Chap. 12. This counteracts scar shortening (Fig. 15.2). Wound closures in thick skin, such as on the forehead and brow, tend to contract perpendicularly to the surface causing a depressed scar. Make them pout with vertical mattress sutures as described in Chap. 3.

a

b

c

d

Fig. 15.1 Margin notch. When you make a margin repair flat at the end of surgery a a lid margin notch develops b due to scar contraction. Making the margin pout by the end of the repair c results in a flat margin on healing d

a

b

d ≈ 1.5

xd

Fig. 15.2 Scar lengthening. Direct closure of a lid defect diameter d a results in a scar length ≈1.5 × d b

15.5 Delay (Fig. 15.3)

211

15.3.2 Planes Contract We create scar planes when we undermine tissues, raise flaps, or apply grafts. These planes contract in area during healing. Graft bed contraction can result in ‘pin cushion’ distortion of what is initially a flat graft. Flap pedicles may “tube” due to such contraction. Avoid this complication by keeping the graft or flap bed expanded with lid margin traction sutures during initial healing. After a week, get the patient to stretch the graft or flap by regular massage.

15.4

Faces Are Mobile

Try this experiment on yourself: place a finger anywhere on your face and observe how far you can push the skin in all directions. With the face being so mobile there is rarely any justification for undermining wound edges during lid surgery.

15.5

Delay (Fig. 15.3)

Avoid re-operating within a week, as early reoperation is usually accompanied by excessive bleeding, and the local inflammation temporarily weakens the tissue strength and suture holding ability (sutures tear out easily during this time). Delay elective revision surgery as long as possible to allow time for scar maturation and tissue remodelling to occur. Consider two months to be a minimum and a six-to-twelve-month delay as ideal (assuming you can persuade your patients to be patient for that long). While awaiting revision encourage patients to massage

Fig. 15.3 Delay revision. Waiting may remove the need for revision surgery

212

15

Revision Surgery

the affected lid firmly in the appropriate direction (usually toward the lid margin) with a thin smear of 1% hydrocortisone ointment. Ask them to do this at least twice a day for five minutes during the first 2 months. Whether steroid is more effective than ointment base or massage alone remains to be demonstrated. At best such massage can obviate the need for further surgery. More commonly, however, it is a useful delaying tactic.

15.6

Analyse

Analyse the factors that have led to the primary failure to ensure that you correct them with your revision surgery. For example, chronic traction stretches the lid margin. At re-operation you must include lid margin shortening in addition to traction release or the lid will simply not return to its intended position. Inadequate lid margin tightening is a cause of persistent cicatricial ectropion following adequate skin grafting. Not recognising an anterior lamellar deficit (caused by mid face drop) is the commonest cause of early involutional ectropion recurrence.

15.7

Lengthen

A lid margin peak (localized retraction) occurs in response to adjacent scar contraction. Lengthen a linear scar by dividing any deep fibrosis and bringing in tissue. And remember to tighten the lid margin at the same time as mentioned above. ‘Z-plasty’ is a well described and popular technique for scar lengthening (Fig. 15.4). It pulls in adjacent skin and transforms the original linear scar into a zigzag. The latter breaks up the scar (visually this is more aesthetic than a long straight scar). It also prevents further contraction along the original scar axis. But Z-plasty creates additional scars and a scar plane under each flap. It can lengthen the original scar by 50–70%. The ‘Transverse release-plasty’ (below) is a radically simpler alternative that lengthens the scar by any desired amount up to 100% at the expense of creating dog-ears. While less aesthetic, it is simple to perform and useful for correcting localized lid margin tethering within the eyelid area where the adjacent skin is exceptionally elastic, mobile, and remodels well. When there is insufficient adjacent laxity use a skin flap or insert a graft.

15.8 Transverse Release-Plasty (Fig. 15.5)

213

a

b C A

B1 C1

B

B1 A1

A A1 B

c C B1

B A

A1

C1

Fig. 15.4 Z-plasty. a Draw a Z with lines of equal length and its stem along the scar requiring lengthening. b Incise the marked Z and raise two flaps. c Transpose the tips of the flaps, A and B to points A1 and B1 and suture

15.8

Transverse Release-Plasty (Fig. 15.5)

15.8.1 Considerations This ‘cheat’ operation can be used to quickly release a very localized lid scar to restore lid closure when lax adjacent tissue is available. It has the advantage of being incredibly simple and quick to perform, requiring no dissection. Its major drawback is that it creates significant dog ears which may ultimately need late revision.

214

15

a

Revision Surgery

b A

A

B B1

B

A1

c

B1

A1

d B

A

B A1

B1

A A1 B1

Fig. 15.5 Transverse release-plasty. a Place a lid margin traction suture at the notch. Mark the transverse incision, A–A1 . b Make the incision making sure to release the underlying scar until the margin can be pulled straight. c Place an orbicularis suture from beyond the ends of the incision, A–A1 . d Tightening the deep suture lengthens the original scar, B–B1 . Suture the skin

15.8.2 Principle Cut across the middle of the scar to release its pull. Close the resulting defect by bringing the ends of your incision together, thereby pulling in adjacent tissue. Useful for localized lid scar tethering causing a margin peak and incomplete eye closure.

15.8.3 Steps 1. Place a lid margin traction suture at the peak that needs correcting. Pull on this to make the scar stand proud (Fig. 15.5a). 2. Cut across the middle of the scar, parallel to the lid margin at that point (Fig. 15.5b, A–A1 ). Deepen and lengthen the incision until you have fully relieved the traction. It is not essential to excise subcutaneous scar provided you fully divide it (Fig. 15.5b). 3. While pulling on your lid margin traction suture, estimate the amount of lengthening required by measuring the separation between the cut edges of the transected scar. Extend the transverse incision to equal this length.

15.9 Take Home Message

215

4. Place a magic suture along the length of the incision you made to bring its opposite ends together (Fig. 15.5c A–A1 ). As you tighten this suture the released scar edges move away from each other (Fig. 15.5c B–B1 ). 5. Complete the skin and orbicularis closure (Fig. 15.5d). 6. Keep the lid margin on suture traction overnight (remove at the first dressing). Pad the eye with a pressure dressing.

15.8.4 Notes A Z-plasty’s advantage is that it breaks up a linear scar into a zigzag one that is less noticeable. Transverse release-plasty by contrast avoids undermining, has fewer additional cuts, but creates more ‘dog ears’. The length of the transverse incision (A–A1 ) determines the degree of lengthening (B–B1 ) in a 1:1 ratio.

15.9

Take Home Message

• Avoid the need for revision surgery. • Delay revision as long as possible.

Watering Eyes

16.1

16

Overview

• Watering eye assessment • Lid related causes • Lacrimal syringing. Watering of the eyes is a very common symptom which has a surprisingly large impact on quality-of-life scores; surprising at any rate to those who have not suffered from it. The mechanisms of normal tear drainage remain incompletely understood. However, eyelid margin malposition (Chaps. 6, 7, and 8) or anything which interferes with normal blinking (such as facial nerve palsy) is likely to cause watering. Lacrimal syringing is commonly performed as a diagnostic test but misleads when not performed correctly. The principles of lacrimal bypass surgery will be outlined, but details are beyond the scope of this book.

16.2

Causes (Fig. 16.1)

Tear overflow occurs for only two reasons: • An excess production of tears or • Inadequate drainage. Watering is a normal physiological response to emotion (crying) or to corneal stimulation such as from a cold wind or when peeling onions. It is also a normal response to pathological corneal irritation, such as from ingrowing eyelashes (trichiasis) or an entropion.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_16

217

218

16 Watering Eyes

Fig. 16.1 Flow balance. When inflow exceeds drainage, overflow occurs

Insufficient tear drainage is due to lid margin or punctal malposition, stenosis or occlusion anywhere within the lacrimal drainage system, or failure of blink associated lacrimal pumping.

16.3

Assessment

16.3.1 History • • • • •

Onset–When did it start? Association–Trauma? Nasal or sinus disease? Irritation (reflex watering)? Do the tears overflow and run down the face (epiphora)? What makes it worse? Does anything make it better? Is a discharge associated (especially on waking)? Suggests a post lacrimal sac obstruction (mucus collecting in the lacrimal sac) unless due to an acute conjunctivitis.

16.3 Assessment

219

16.3.2 Examination 16.3.2.1 Marginal Tear Strip An increase in the lower lid tear meniscus (marginal tear strip) objectively supports a history of watering. 16.3.2.2 Lacrimal Punctal Size and Position Tears enter the drainage system from the marginal tear strip through the lacrimal puncta (small ~0.2 mm openings on the medial upper and lower lid margins). If these are not positioned within the marginal tear strip, tears will not enter the drainage system. Ectropic puncta become dry and shrink, and eventually occlude. Punctal entropion (the punctum is not visible unless the lid is everted) is not written about but is common. It can cause watering but is usually asymptomatic. 16.3.2.3 Lid Margin Position Entropion will cause corneal irritation and reflex watering. Ectropion, however slight, will create a trough between the eye and the lower lid margin in which tears collect and from which they spill out. 16.3.2.4 Lacrimal Canalicular Appearance The canaliculi run very close to the lid margin and medial canthal tendon where they are prone to trauma. They are only visible when inflamed or distended. This happens when a canaliculus is colonized by actinomyces bacteria and functionally obstructed. Confusingly the canaliculus may still be patent to syringing. The expulsion of yellow ‘sulphur granules’ on squeezing a distended canaliculus is pathognomonic of actinomyces canaliculitis. 16.3.2.5 Conjunctival Appearance Conjunctivitis is associated with increased lacrimation. A papillary conjunctivitis, particularly when associated with itching, points to allergy. The appearance of any discharge present helps to distinguishing the likely cause: • A stringy discharge = allergic conjunctivitis. • Watery = viral conjunctivitis. • Purulent = bacterial conjunctivitis.

16.3.2.6 Corneal Appearance Corneal punctate fluorescein staining, an epithelial defect, or a foreign body imply reflex watering. 16.3.2.7 Lacrimal Sac A visible bump between the bridge of the nose and medial canthus suggests a distended lacrimal sac. Most commonly it is filled with mucus and is therefore

220

16 Watering Eyes

called a mucocoele. The presence of a mucocoele indicates nasolacrimal obstruction beyond the level of the sac. If the lacrimal sac swelling is above the medial canthal tendon, perform a CT scan to exclude a tumour.

16.3.3 Tests 16.3.3.1 Fluorescein Dye Tests Fluorescein Meniscus Time [1]

Insert a single drop of 2% fluorescein dye in the lateral conjunctival fornix. It stains the ocular surface a non-fluorescent orange/yellow. Observe the eye with a slit-lamp using cobalt blue illumination. After a little while, fluorescence starts laterally and progresses medially along the lower marginal tear strip as the fluorescein is diluted by tears. With normal tear production the meniscus fluorescence reaches the centre of the lid within four minutes. It takes longer in dry eye patients and is a useful indication of tear production. Dye Clearance/Overflow

The time it takes for the yellow fluorescein colour to disappear from the eye is a combined measure of tear production and drainage. In the absence of tear overflow one can assume that the dye has been drained through the lacrimal drainage system under physiological conditions. This test is simpler, cheaper, and at least as informative as lacrimal scintigraphy. Corneal Staining

Corneal fluorescein staining suggests reflex lacrimation (as already mentioned). Dye Retrieval from the Nose (Jones’Test)

Fluorescein dye retrieved from the nose confirms anatomical and physiological patency of the drainage system. Ask the patient to blow their nose hard into a clean tissue 5 min after ocular dye instillation. Only if blowing fails to show the dye should you swab the nose under the inferior turbinate with a cotton bud to look for dye (Jones 1 test). The latter is less comfortable than simply blowing the nose.

16.3.4 Lacrimal Syringing (Fig. 16.2) 16.3.4.1 Principle and Considerations Fluorescein dye tests assess the functional state of the lacrimal drainage system. If these indicate a lacrimal drainage obstruction, perform syringing with saline to check the anatomical patency of the passages. Because you inject saline into the canaliculi under pressure, syringing is not a physiological test of function. It is also operator and technique dependent. I have frequently had patients brought to

16.3 Assessment

221

a

b

c

d

Fig. 16.2 Syringing. a Put the lower canaliculus on stretch. b Insert the lacrimal cannula into the vertical portion of the canaliculus through the punctum. c Rotate the cannula laterally through 90°. d Gently inject physiological saline

me as obstructed in whom I found a patent lacrimal system when I performed the syringing myself.

16.3.4.2 Case Selection Epiphora patients without a mucocoele and no nasal fluorescein retrieval. 16.3.4.3 Steps 1. Anaesthetise the eye with a drop of Proxymetacaine Hydrochloride 0.5%. 2. Place a small cotton wool pledget on the medial canthus, soak it with proxymetacaine, and push it into the lower fornix behind the lower punctum using the tip of the Minims® container. Wait several minutes for complete anaesthesia before removing the pledget. 3. Fill a 2 ml Luer lock syringe with sterile saline and lock in place a 26G lacrimal cannula. This size of syringe combines optimum tactile pressure and plunger movement feedback. 4. Straighten the lower canaliculus by pulling the lid laterally (Fig. 16.2a) and insert the tip of the canula perpendicularly into the punctum (Fig. 16.2b). 5. If the canula cannot enter the punctum, clinically significant punctal stenosis is present. Use a punctum dilator/seeker to gently stretch the punctum before reattempting lacrimal canula insertion.

222

16 Watering Eyes

6. As soon as the canula tip has engaged the punctum, rotate the syringe and canula laterally through 90° (Fig. 16.2c) and advance the canula approximately 5 mm into the horizontal part of the canaliculus. Maintain the lateral lid traction throughout to keep the canaliculus straight. Do not attempt to force the canula forwards as this can create a false passage. Do not try to enter the lacrimal sac as it has not been anaesthetized. 7. Warn the patient to expect a feeling of pressure and possibly a salty taste in their throat. 8. Apply gentle pressure to the plunger (Fig. 16.2d) and observe: (a) The patient’s response. Swallowing indicates saline in the throat and consequently patent lacrimal passages. (b) The degree of plunger resistance. In a normal lacrimal system this should be minimal. (c) The extent of plunger movement which equates to the volume injected. (d) Possible fluid regurgitation through the opposite punctum, or around the canula. There should be none. The presence of regurgitation indicates abnormal lacrimal system resistance. Look for mucus in the regurgitated fluid. When present it suggests an obstruction beyond the sac (as mucus has been able to reach the sac from the eye).

16.3.5 Imaging Lacrimal imaging seldom adds more information to a good clinical examination, dye tests, and syringing. Image any atypical presentation that raises the possibility of a tumour, specifically a medial canthal swelling that is predominantly above the medial canthal tendon.

16.4

Treatment Options

Treatment should address the presumed cause of the watering.

16.4.1 Lacrimal Mucocoele Expression (Fig. 16.3) A lacrimal sac full of mucus is prone to infection (dacryocystitis). To prevent this, teach patients how to empty their mucocoele by pressing firmly on it. You must first check whether you are able to empty the sac as not all mucoceles can be expressed. The mucus usually refluxes back through the canaliculi onto the eye from where it should be washed off. Occasionally it can be forced down a partially obstructed nasolacrimal duct. Instruct the patient to express the sac at least twice a day. This is particularly important in babies born with congenital nasolacrimal obstruction, 90% of which will improve spontaneously within the first year of

16.4 Treatment Options

a

223

b

Fig. 16.3 Mucocoele expression. a place a finger against the side of the nose medially to the mucocoele. b While maintaining firm pressure against bone, roll the finger slowly onto the swelling towards the medial canthus

life without other intervention. Perform sac expression by placing a finger against the side of the nose just medially to the mucocoele (Fig. 16.3a). While maintaining firm pressure against bone, roll the finger slowly onto the swelling towards the medial canthus (Fig. 16.3b). Successful expression causes the mucocoele to disappear temporarily.

16.4.2 Lacrimal Probing (± Silicone Intubation) 16.4.2.1 Paediatric Probing Lacrimal probing is indicated in symptomatic children whose mucocoele and watering have not resolved on expression alone during the first year or two of life. It requires a general anaesthetic but has a high success rate. Should the first probing fail to cure the child the second attempt should include nasal endoscopic control to confirm that the probe enters into the nose below the inferior turbinate. The second probing may be combined with the insertion of temporary silicone stents which are left in place for about two months (e.g., Nunchaku tubes®, FCI [email protected]). Principle

Pass a smooth, blunt ended, probe through the lacrimal drainage passages to establish the site of any obstruction and possibly overcome it. Steps

This technique is similar to lacrimal syringing up to the point of lacrimal sac entry. 1. Pull the lid laterally to straighten the canaliculus. Dilate the lacrimal punctum with a punctum finder-seeker, twirling it between your fingers as you push (Fig. 16.4a). The lid margin tension provides counter pressure to the punctal dilator.

224

16 Watering Eyes

b

c

d

00

00

a

e 00

Fig. 16.4 Lacrimal Probing. a Pull the lid laterally to straighten the canaliculus. Dilate the lacrimal punctum with a punctum finder-seeker. b Keeping the lid on lateral stretch insert a Bowman 00-gauge lacrimal probe into the punctum perpendicularly. c Keeping the tip of the probe in the canaliculus rotate the probe laterally through 90°. d Advance the probe gently along the canaliculus until you reach a firm stop. e While maintaining gentle forward pressure on the probe, release the lid traction and rotate the probe’s axis 90° nasally to advance it into the nasolacrimal duct. Continue pushing the probe downwards until you reach an obstruction or encounter the floor of the nose (another ‘hard stop’)

2. Keeping the lid on lateral stretch insert a Bowman 00-gauge lacrimal probe into the punctum perpendicularly (Fig. 16.4b). 3. Keeping the tip of the probe in the canaliculus rotate the probe laterally through 90° (Fig. 16.4c). 4. Advance the probe gently along the canaliculus until you reach a firm stop (Fig. 16.4d). A so called ‘hard stop’ confirms that the tip has entered the lacrimal sac and is hitting the medial sac wall which lies on nasal bone. A ‘soft

16.4 Treatment Options

225

stop’ is when the probe springs back slightly when you release it. It means that the probe tip has encountered a fibrous obstruction within the canaliculus and has yet to enter the sac. If you encounter a soft stop abandon further probing. You have localized a pre-sac obstruction, though it may not be the only obstruction in the drainage system. 5. While maintaining gentle forward pressure on the probe to keep it against the medial sac wall, release the lateral lid traction and rotate the probe’s axis 90o nasally to advance it into the nasolacrimal duct (Fig. 16.4e). Do this gently to avoid creating a false passage. 6. Continue pushing the probe downwards until you reach an obstruction or encounter the floor of the nose (another ‘hard stop’). A novice may find it difficult to distinguish between the two. Now apply more force to the probe. A membranous obstruction will give, and you will feel the probe tip advance to the nasal floor. Note: Probing may be combined with nasal endoscopy to confirm nasal entry of the probe. However, nasal endoscopy requires skill and should not be undertaken without training.

16.4.2.2 Adult Probing Lacrimal probing in adults has a low success rate as a treatment. It has been reported to succeed in 50% of cases when combined with silicone intubation, but only where no bony resistance is encountered in the nasolacrimal duct during probing. However, probing is sometimes helpful in confirming the site of an obstruction. Carry it out under general anaesthesia as adequate local anaesthesia of the entire drainage pathway is difficult to achieve.

16.4.3 Punctal Stenosis A stenosed punctum is one that will not admit a 26 G lacrimal canula without dilatation. As dilatation with a punctum dilator/seeker has only a very temporary effect on patency use one of the more effective remedies below.

16.4.3.1 Perforated Punctum Plug (Fig. 16.5) The most elegant solution for enlarging a stenosed punctum is to stent it for two months with a perforated punctum plug (FCI S.A.S.–Chirurgie Instrumentation, 20–22 rue Louis Armand, 75,015 PARIS–France). This is done under topical anaesthesia alone, does not damage the integrity of the punctal fibroelastic ring and allows some passage of tears while in place to discourage post-plug membrane formation.

226

16 Watering Eyes

Fig. 16.5 Perforated punctum plug. Polyvinylpyrrolidone surface modified silicone stent (to improve wettability)

Steps

1. Anaesthetise the eye with a drop of Proxymetacaine Hydrochloride 0.5%. 2. Place a small cotton wool pledget on the medial canthus, soak it with proxymetacaine and push it into the lower fornix behind the lower punctum, using the tip of the Minims® container. Wait several minutes for complete anaesthesia before removing the pledget. 3. Get the plug ready for insertion by opening its sterile packet. 4. Dilate the punctum with a punctum dilator/seeker, entering perpendicularly and then angling the dilator laterally while twisting and pushing it medially. Do this slowly to avoid tearing the fibrous ring. Note: The punctum plug introducer has a punctum dilator at the other end. However, the taper on this is too short to make it useful. 5. Remove the dilator and insert the plug without delay as the fibrous ring will contract again rapidly. 6. After confirming correct insertion of the plug, remove the plug introducer by squeezing it. The plug should sit flush with the lid margin. 7. Remove the plug after 2–3 months under topical anaesthesia by pulling it out with Moorfields forceps. The punctum remains enlarged. Note: The punctal stenosis may return after several years. The stenting treatment can be repeated if this happens.

16.4 Treatment Options

227

Fig. 16.6 Nunchaku Lacrimal intubation. Silicone stenting tubing on introducer stylets

16.4.3.2 Lacrimal Intubation (Fig. 16.6) Lacrimal intubation with a silicone tube is also an effective form of stenting for punctal stenosis but is more invasive and requires a general anaesthetic. Several types of tubes are available. The self-retaining Nunchaku® tubes (FCI) are particularly easy to place and remove and are self-adjusting. The technique for inserting these tubes is the same as for lacrimal probing (above) with one added step. Once the tube on its introducer stylet is correctly positioned, grasp the stylet loosely with Moorfields forceps, just above the silicone tube. Use the forceps to prevent the tube from coming out as you withdraw the stylet. An alternative form of intubation is to insert a self-retaining monocanalicular stent (e.g., LacriJet® FCI S.A.S.–Chirurgie Instrumentation, 20–22 rue Louis Armand, 75,015 PARIS–France). However, such punctum plug retained stents do not allow tear drainage while in place. 16.4.3.3 Punch Punctoplasty (Fig. 16.7) This procedure is simpler and safer to perform than the previously popular, now hopefully obsolete, ‘three snip punctoplasty’ which it replaces. The latter is nolonger recommended as it damages the capillary action of the canaliculus. But even a punch punctoplasty causes damage to the punctal fibroelastic ring. It has not been shown to be superior to stenting alone. Steps

1. Anaesthetise the eye with a drop of Proxymetacaine Hydrochloride 0.5%. 2. Place a small cotton wool pledget over the medial canthus and push it in place just behind the punctum and soak it using the tip of the proxymetacaine Minims® container. Wait a few minutes for complete anaesthesia. 3. Dilate the stenosed punctum and select the punctal wall to be removed. Choose the posterior wall if there is a slight punctal ectropion. If there is punctal entropion remove the anterior wall instead. A normally positioned punctum can be enlarged medially.

228

16 Watering Eyes

a

b

c

Fig. 16.7 Punch punctoplasty. a Open the punctum with a finder/seeker probe. b Use a punctum dilator to enlarge the punctum. c Use a Kelly’s punch to punch out one of the walls of the vertical portion of the canaliculus

4. Withdraw the punctum dilator and immediately insert the tip of a Kelly trabeculectomy punch into the canalicular ampulla before the fibroelastic ring has time to contract again. Punch out the chosen punctal wall.

16.4.4 Punctal Inversion Surgery (Fig. 16.8) Age related punctal ectropion is common. It used to be corrected by retropunctal cautery or ‘tarsoconjunctival diamond excision’. To achieve correction using cautery an effective symblepharon must be created. This is undesirable as it limits independent movement between the eye and lid. Tarsoconjunctival diamond excision is futile for two reasons. Firstly, there is next to no tarsal plate below the punctum worth excising. Secondly, excising conjunctiva achieves nothing as it is too elastic to add inward traction. Lower lid retractor plication to the sub-punctal tarsal plate on the other hand is an effective alternative. It provides an active inward pull and is the mechanism by which retro-punctal cautery and diamond excision work on the occasions that they do.

16.4 Treatment Options

229

16.4.4.1 Steps 1. Make a short horizontal conjunctival incision 3–4 mm below the punctum, just inferior to the medial end of the tarsal plate (Fig. 16.8b). 2. Grasp and pull on the inferior conjunctival incision edge with Moorfields forceps. Insert closed scissors immediately under the conjunctiva and advance them infero-laterally by 10 mm. Open the scissors and withdraw to bluntly dissect a subconjunctival pocket from the incision to the middle of the inferior fornix (Fig. 16.8c).

a

b

c

d

e

f

Fig. 16.8 Punctal inversion surgery. a Punctal ectropion. b Make a horizontal conjunctival incision below the punctum. c Bluntly dissect a subconjunctival pocket. d Engage the retractors with an absorbable suture, bring the needle out through the inferior edge of the tarsal plate below the punctum and re-insert it through the lower conjunctival edge. e Tie the suture tightly in the wound to bury the knot. f The retractors pull the punctum inwards on down-gaze. The suture knot is burried

230

16 Watering Eyes

3. While still holding and gently stretching the conjunctiva, insert a pair of Jayles forceps into the pocket and grasp the lower lid retractors (found just anterior to the conjunctiva). Confirm that you have grasped the retractors by asking the patient to look down as far as possible. You should feel a tug on your forceps. 4. Ask the patient to look up while you pull the retractor aponeurosis out of the wound sufficiently to engage it with a 6/0 absorbable suture (Fig. 16.8d). 5. Bring the retractor suture needle out through the inferior edge of the tarsal plate below the punctum (Fig. 16.8e). Then re-insert the needle through the lower conjunctival edge, so that when tied the knot is buried. 6. Tie the suture tightly in the wound to bury the knot (Fig. 16.8f). This plicates the retractor directly to the posterior lamella below the punctum. From now on every time the patient looks down the retractors pull the punctum inwards.

16.4.5 Lid Margin Tightening Watering from mild punctal ectropion may simply be a result of lower lid laxity. In this case (and after other possible explanations have been excluded) full thickness lid margin shortening (lateral Bick resection—Chap. 8) can cure the watering.

16.4.6 Lacrimal Drainage Surgery Full surgical details of lacrimal drainage surgery are beyond this book’s remit and can be found in other texts. Here I shall only outline the factors that promote success.

16.4.6.1 Dacryocystorhinostomy (Fig. 16.9) The gold standard lacrimal bypass surgery is an external dacryocystorhinostomy [2] (DCR). Its success rate is upwards of 90% if the obstruction is beyond the lacrimal sac (within the nasolacrimal duct). The role of concurrent silicone intubation in DCR remains uncertain. Factors that promote DCR success are:

16.4 Treatment Options

231

a

b

c

d

Fig. 16.9 Dacryocystorhinostomy (DCR). Crosshatched bone is removed a to connect the sac directly to the nose b, making the lacrimal sac part of the nasal wall. This bypasses the blocked nasolacrimal duct. c Additionally, the crosshatched scarred common canaliculus is excised to convert a DCR into a Canaliculo-DCR (CDCR). d When not enough functioning canaliculus is present insert a glass bypass tube between the medial fornix and the nose

• • • •

Adequate haemostasis Creating a large bony ostium that spans the entire lacrimal sac bed Complete opening of the lacrimal sac top to bottom Suturing both the posterior lacrimal and nasal mucosal flaps to each other as well as the anterior flaps.

The aim of the surgery is to lay fully open the lacrimal sac and make it part of the lateral wall of the nose (Fig. 16.9b) so that the sac as such ceases to exist. Surgical failures are usually due to not achieving the above aims. Mucosal scar contraction can result in partial or complete reformation of the lacrimal sac. The other cause of failure is pre-existing or surgically induced lacrimal canalicular scarring resulting in pre-sac obstruction and persistent symptoms. Endonasal DCR techniques are gaining popularity and in some hands the results equal those of the external approach. However, achieving the goals outlined above is more difficult via the limited endonasal access.

232

16 Watering Eyes

16.4.6.2 Canaliculo-Dacryocystorhinostomy (CDCR) Where the site of drainage obstruction is before the sac, and 8 mm of proximal canaliculus is patent, the stenosed portion of the canaliculus can be resected (Fig. 16.9c). Perform a standard DCR but in addition probe the canaliculi and excise the stenosed portion. Then anastomose the cut ends of the canaliculi to the lateral sac wall and intubate the system. 16.4.6.3 Trans-Canalicular Endoscopic Surgery The advent of ever smaller endoscopes has made trans-canalicular endoscopic surgery possible. Its place in routine lacrimal surgery remains to be established. 16.4.6.4 Lester-Jones Lacrimal Bypass Tube When the canaliculi are insufficiently long for a CDCR the only remaining option is to bypass the drainage system completely with a Pyrex glass tube inserted between the medial conjunctival fornix and the nose (Fig. 16.9d). This can give very good symptomatic relief. However, it is an option of last resort as it commits the patient to lifelong follow up and tube maintenance. These tubes are prone to block with mucus and frequently become displaced (inwards or outwards). 16.4.6.5 Dacryocystectomy Surgical removal of an infected lacrimal sac (dacryocystectomy) is an option for patients suffering recurrent dacryocystitis who are unfit for a DCR as it may be performed under local anaesthesia. It prevents further infections but does not address any watering issues. It is also indicated for the removal of lacrimal sac tumours.

16.5

Take Home Message

• Watering of the eyes has multiple possible causes. • It significantly affects quality of life. • Accurate assessment is key to the correct management.

References 1. Kallarackal GU, Ansari EA, Amos N, Martin JC, Lane C, Camilleri JP (2002) A comparative study to assess the clinical use of Fluorescein Meniscus Time (FMT) with Tear Break up Time (TBUT) and Schirmer’s tests (ST) in the diagnosis of dry eyes. Eye (Lond) 16(5):594–600. https://doi.org/10.1038/sj.eye.6700177. PMID: 12194075 2. McNab AA (1994) Manual of Orbital and Lacrimal Surgery Hardcover. Churchill Livingstone ISBN 0–443–04791-x

Eye Removal

17.1

17

Overview

• Eye evisceration, • Eye enucleation. Eye removal is a treatment of last resort for symptom control or local tumour management. Never underestimate its psychological impact. Loss of an eye can trigger a prolonged bereavement reaction. Forewarn patients and their families about this possibility. Eye removal can be performed in one of three ways: 1. Evisceration—Removal of the cornea and all the eye’s contents (uvea) leaving the empty sclera fully attached. 2. Enucleation—Complete removal of the intact eye by cutting all its attachments. 3. Exenteration—Radical en bloc removal of the orbital contents (including the eyelids, conjunctiva, and periosteum), as far back as possible.

17.2

Specific Indications

Exenteration is very mutilating and fortunately only seldom required for the control of tumour confined to the orbit. It will not be discussed further. Enucleation is indicated for the complete removal of an intraocular tumour that cannot be managed by less destructive means. Evisceration is performed for severe, non-responsive endophthalmitis (effectively abscess drainage) to avoid spreading the infection into the orbital tissues. The removal of blind, painful, or unsightly eyes, which cannot be managed by other means (topical G. Atropine 1% and G. Prednisolone 1% are very effective at © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_17

233

234

17

Eye Removal

controlling pain), can be done either by enucleation or by evisceration. Except for the above specific indications, the choice is largely down to personal preference and current fashion.

17.3

Evisceration V Enucleation

Evisceration is technically easier, quicker, and less invasive than enucleation and results in marginally less volume loss. Hence it fits the philosophy of this book. However, as it carries a small risk of inciting Sympathetic Endophthalmitis in the remaining eye, great care must be taken to remove all the uveal contents leaving no pigmented tissue behind to stimulate an immune response. Evisceration is more painful in the immediate postoperative period as the nerve supply to the sclera remains intact. Send the evisceration contents for histology to look for pre-existing sympathetic uveitis or unsuspected intraocular malignancy. However, anatomical histology cannot be obtained from an evisceration specimen. Enucleation involves systematically dividing all the structures holding the eye in place, including the optic nerve. An enucleated eye allows good anatomical histopathology of suspected tumours including their degree of scleral and vortex vein invasion. Theoretically it causes a slightly greater orbital volume loss than evisceration, but this is not clinically significant. The extra dissection involved results in more post-operative swelling, but there is less pain as all the sensory nerves have been divided. Any form of eye removal results in significant orbital volume loss which needs to be addressed by volume replacement as part of the surgical rehabilitation. Volume replacement is dealt with in the next chapter.

17.4

Evisceration (Fig. 17.1)

17.4.1 Principle Remove the cornea and all the ocular contents (uvea).

17.4.2 Steps 1. Cut the conjunctiva and tenons fascia from the corneoscleral limbus through 360° (Fig. 17.1a). 2. Bluntly dissect them back with a cotton bud, no further than the rectus muscle insertions. 3. Incise the sclera immediately behind the limbus to enter the eye. 4. Extend this incision through 360° to remove the cornea (including the limbal epithelial stem cells) (Fig. 17.1b).

17.4 Evisceration (Fig. 17.1)

235

a

b

c

d

Fig. 17.1 Evisceration. a Cut the conjunctiva and tenons fascia from the corneoscleral limbus through 360°. b Incise the sclera at the limbus and extend this to remove the cornea. c Develop a cyclodialysis plane using an evisceration spoon. d Lift the entire eye contents out of the scleral using the evisceration spoon

5. Develop a 360° cyclodialysis plane using an evisceration spoon (Fig. 17.1c). Do this by holding the scleral edge on tension with toothed forceps and peeling the iris root and attached ciliary body from the scleral spur. Gradually work around the whole perimeter. 6. Deepen the cleft in the same manner to detach the choroid from the sclera up to the equator all the way round. 7. Continue separating in this plane until you reach the optic nerve exit point. Transect this final attachment with the evisceration spoon. 8. Lift the entire eye contents out of the scleral shell and into a histology pot using the evisceration spoon (Fig. 17.1d). In young patients the contents come out as a single, jelly-like, lump. In the elderly with liquified vitreous this runs out before you are able to lift out the collapsed uveal tissue. 9. Examine the now empty sclera to ensure that you have not left any pigmented uveal tissue behind. This is to minimize the risk of inciting sympathetic uveitis. Scrape any remaining uvea out with the spoon. 10. You will have decided whether to place an orbital implant as part of the preoperative planning and consenting process. The default position should be to implant, as volume replacement gives the best rehabilitation. Delay implantation when infection is present (endophthalmitis, suppurative keratitis). Do not implant if it is important to minimise the risk of late complications. An

236

11.

12. 13.

14.

17

Eye Removal

implant introduces the additional risks of infection, implant migration, and/ or exposure requiring revision surgery. (Implantation is dealt with in the next chapter). In the absence of an implant or of infection, close the sclera horizontally with five 6/0 absorbable sutures. Close the tenons and conjunctiva with a continuous 6/0 absorbable suture. In the presence of infection do not suture. Leave the sclera open to drain. It will usually heal spontaneously. Insert a correctly sized* conformer shell to maintain the conjunctival fornices and prevent conjunctival prolapse. Consider placing a central suture tarsorrhaphy to stop the conformer from falling out. Apply antibiotic ointment and a pressure dressing. *Note: Use the largest conformer shell that fits in the socket while still allowing the eyelids to just close.

17.5

Enucleation (Fig. 17.2)

17.5.1 Principle Divide all the eye’s connections and remove it.

17.5.2 Steps 1. Cut the conjunctiva and tenons fascia from the corneoscleral limbus through 360° (Fig. 17.2a). 2. Bluntly dissect them back with a cotton bud, to beyond the rectus muscle insertions (Fig. 17.2b). 3. Place a Chevasse squint hook under the inferior rectus muscle close to its insertion and use a cotton bud or the flat end of a dry ‘bread swab’ to tear back the muscle sheath to fully expose the insertion (Fig. 17.2c). Note: It doesn’t matter which rectus you expose first. 4. Insert a double armed ¼ circle 6/0 absorbable suture into each edge of the muscle with a double locking pass (see Chap. 19, Fig. 19.4) and clip the suture ends together with an artery clip (Fig. 17.2d). 5. Lift the squint hook and completely divide the muscle insertion from the globe (Fig. 17.2e). The weight of the artery clip will retract the muscle insertion. 6. Repeat steps 3–5 above for the remaining three rectus muscles (Fig. 17.2f). 7. Insert a squint hook between the eye and the tenons infero-temporally to engage the inferior oblique muscle insertion. Do this by feel. 8. Once you identify the inferior oblique retract it with this hook and place a curved artery clip across the inferior oblique muscle insertion. Again, do this by feel rather than by direct visualization.

17.5 Enucleation (Fig. 17.2)

237

a

b

c

d

e

g

f

h

Fig. 17.2 Enucleation. a Cut the conjunctiva and tenons fascia from the corneoscleral limbus through 360°. b Bluntly dissect to beyond the rectus muscle insertions. c Place a Chevasse squint hook under the inferior rectus muscle and tear back the muscle sheath to fully expose the insertion. d Insert a double armed absorbable suture into the muscle with double locking passes. e Lift the squint hook and completely divide the muscle insertion from the globe. f Repeat for the remaining three rectus muscles. g Tag and detach the inferior oblique and the superior oblique tendon from the globe. h Tighten the snare wire loop until it is only slightly larger than the eye. Attach a pair of straight artery forceps to the far side of the wire loop. Use these to guide the loop posteriorly between the globe and the detached medial rectus. i Once the snare loop is behind the eye slowly tighten it. At the same time use the stem to push it posteriorly between the globe and lateral rectus. j Expect strong resistance to the final snare tightening. Once the optic nerve is transected, you can lift the eye out of the socket. There will be no bleeding

238

17

i

Eye Removal

j

Fig. 17.2 (continued)

9. Cut between the artery clip and the sclera to divide the inferior oblique insertion from the globe. 10. Now that it is free, pull the muscle insertion out with the clip and tag it with a single armed 6/0 absorbable suture using a double pass locking throw. Clip the suture ends together. The single needle distinguishes this from the rectus muscles (which have two needles attached). Note: The inferior oblique looks like an earthworm. 11. Repeat step 9 supero-temporally to isolate the superior oblique tendon from the globe (Fig. 17.2g). Note: The tendon is fibrous and runs anteromedially toward the trochlea. 12. The remining attachments holding the eye include the optic nerve, the ophthalmic and ciliary arteries, and the vortex veins. Crush and divide them using an enucleation snare as follows: (a) Tighten the snare wire loop until it is only slightly larger than the eye. (b) Attach a pair of straight artery forceps to the far side of the wire loop so that they are equidistant from the stem (Fig. 17.2h). Use this clip to guide the loop posteriorly between the globe and the detached medial rectus. Ask an assistant to keep the loop behind the globe by pushing down on the artery clip. (c) Slowly tighten the snare loop by turning the snare ratchet wheel. At the same time use the stem to push it posteriorly between the globe and lateral rectus, until it is behind the eye. (d) Now remove the artery clip from the loop and continue tightening the snare wire. Maintain posterior pressure with the stem of the snare to keep the loop behind the globe. While you do this, your assistant lifts the globe anteriorly using artery clips attached to the cut rectus insertions (Fig. 17.2i). (e) Expect strong resistance to the final snare tightening. This is dependent on the snare wire thickness (a thicker gauge giving greater resistance). You will feel a sudden ‘give’ as the optic nerve is finally transected. You can now lift the eye freely out of the socket. There will be no bleeding (Fig. 17.2j).

17.6 Take Home Message

239

17.5.3 Notes • It is the complete absence of bleeding when the eye is removed that makes the enucleation snare my preferred choice. The alternative of using enucleation scissors offers no advantages, only copious bleeding. • An enucleated eye allows detailed histological examination.

17.6

Take Home Message

Eye removal has huge psychological impact.

Socket Reconstruction

18.1

18

Overview

• Implantation following evisceration • Implantation following enucleation • Orbital implant complications. The disfigurement resulting from eye removal is primarily due to loss of orbital volume leading to the Post Enucleation Socket Syndrome (PESS) (see below) coupled with reduced socket movement. The latter occurs because the extraocular muscles are no longer attached to an eye and are therefore not working at their former mechanical advantage. Artificial eye (prosthesis) movement is reduced further by slippage in the socket. An adequately sized intraconal implant addresses these problems (apart from the slippage). Perform primary orbital implantation by default unless there is a positive contraindication, such as lack of access to follow-up treatment for possible late complications.

18.2

Socket Lining

The largest possible artificial eye that a socket can accommodate is determined by the surface area of its conjunctival lining. Four millilitres is about the maximum volume. A socket with insufficient conjunctival lining to accept an adequate prosthesis must have its fornices augmented with mucous membrane grafts (never skin which desquamates and smells in a moist socket). Therefore, treat conjunctiva with respect, preserve it at eye removal surgery, and prevent it from shrinking post-operatively by inserting a maximally sized conformer shell to maintain the fornices until a custom prosthesis can be fitted.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_18

241

242

18.3

18

Socket Reconstruction

Orbital Implantation (Fig. 18.1)

Carry out orbital implantation at the time of eye removal unless there is a strong contraindication (such as infection). Insert a 22 mm diameter solid ball implant (acrylic or silicone) into the orbital muscle cone using a ‘no touch’ technique. Attach the extraocular muscles to it to keep it in place within the muscle cone and to maximize movement. Following evisceration place the implant within the recipient’s, now empty, scleral shell. After enucleation wrap the implant in stored human donor sclera (or other suitable material) and attach the extraocular muscles to the covering in approximately their anatomical positions.

18.3.1 Implant Considerations Measure enucleated eye volume by the water it displaces in a measuring cylinder (Archimedes’ principle) (Fig. 18.2). The volume of tissue removed during enucleation is about 7–9 ml [1], which is more than many standard texts suggest. The volume loss from evisceration is slightly less. The actual volume loss in a particular individual depends on the size of the eye removed. This lost volume must be completely replaced if the PESS deformity is to be avoided. Share the replacement volume between a buried ‘motility implant’, that allows the extra-ocular muscles to work at their optimal mechanical advantage (frontal plane diameter similar to that of the removed eye), and an eye prosthesis (artificial eye) held in place by the eyelids (Fig. 18.3). The prosthesis should be as light as possible to reduce Fig. 18.1 Ball too small. Inadequate volume replacement causes the post enucleation socket syndrome

18.3 Orbital Implantation (Fig. 18.1)

243

Fig. 18.2 Enucleated eye volume. Measure enucleation orbital volume loss by water displacement

5 - 7 ml

2 ml

22 mm

4 mm Fig. 18.3 Ideal motility implant dimensions. Share the volume replacement between the prosthesis and the implant. A realistic prosthesis requires a volume of 2 ml and a central thickness of 4 mm. The implant vertical diameter should equal that of the removed eye

the mechanical load on the lower lid to avoid it stretching over time. However, the prosthesis does require a minimum central thickness of about 4 mm to give a realistic anterior chamber appearance. The ideal prosthesis volume is 2 – 21 /2 ml. Subtracting this from the total volume loss leaves a volume deficit of 41 /2 to 7 ml that needs to be replaced by the implant. The volume of a spherical implant is determined by the formula. 4/3r 3 where r is the radius of the implant. The largest commercially available orbital implant has a diameter (Ø) of 22 mm (radius 11 mm) and a volume of 5.6 ml. A 20 mm Ø implant has a volume of only 4.2 ml and an 18 mm Ø sphere has a mere

244

18

Socket Reconstruction

3.1 ml! Therefore, there is seldom any excuse for implanting an implant smaller than 22 mm Ø. Some authors recommend the use of ‘sizing spheres’ to determine the ideal implant volume: “to see what fits”. This logic is flawed as orbital tissues flow at body temperature and will therefore accommodate a range of implant volumes. Operative swelling introduces further inaccuracy when using sizing spheres.

18.3.2 Implant Material and Shape Many different implant materials and shapes have been tried over the years. The ideal one is yet to be determined. A solid sphere made of acrylic or silicone is currently the best compromise. The flat face of hemispherical implants is much better at transmitting movement to the artificial eye. Unfortunately, their sharp edges make them very prone to late exposure and extrusion. Therefore, hemispherical implants should no longer be used. Porous or ‘integrated’ implants have enjoyed a vogue due to the theoretical advantages of (a) implant migration being less likely because of stabilizing scar tissue ingrowth into their pores and (b) the option of drilling them subsequently, once they have become fully vascularized, in order to fit a ‘motility peg’ which directly couples socket movement to implant movement. Unfortunately, these theoretical advantages are counterbalanced by drawbacks. The rough, porous implant surface makes these implants much more prone to erode through the overlying tenons and conjunctiva and become exposed. Many techniques for patching these exposures have been described. They mostly fail with time. Porous implant removal for replacement is made difficult by the tissue ingrowth and requires sharp dissection. The drilling of porous implants to fit a motility peg has also largely fallen out of favour due to the high complication rate (40%). Therefore, avoid using porous motility implants as they have minimal proven advantage and significantly more complications. Free dermis fat grafts have the advantage of being autogenous and adding to the conjunctival lining as they epithelialize. Unfortunately, graft volume retention is very unpredictable, ranging from complete retention to total absorption. For this reason, reserve them for secondary socket reconstruction.

18.3.3 Implantation Following Evisceration (Fig. 18.4) 18.3.3.1 Steps 1. Incise the empty scleral shell with Stevens tenotomy scissors from the superotemporal edge to the optic nerve (Fig. 18.4a). 2. Make a similar incision from infero-nasally to the optic nerve. 3. Circumcise the optic nerve to release it from the sclera and to complete the scleral bisection.

18.3 Orbital Implantation (Fig. 18.1)

245

a

b

c

d

e

f

g

Fig. 18.4 Implantation post evisceration. a Incise the empty scleral shell with Stevens tenotomy scissors from the supero-temporal edge to the optic nerve. Make a similar incision from inferonasally to the optic nerve. Circumcise the optic nerve to release it from the sclera and to complete the bisection. b Place the orbital implant within a plastic sheath lubricated with viscoelastic and insert it into an injection device. c Inject the implant into the orbit between the scleral halves. d Suture the two scleral halves together in front of the implant with interrupted 6/0 absorbable sutures. e Suture the tenons fascia over the sclera with interrupted 6/0 absorbable sutures. f Suture the conjunctiva closed with a continuous 6/0 absorbable suture. g Place a conformer shell (the largest that fits while just allowing eyelid closure)

246

4. 5. 6.

7. 8. 9.

10.

11.

18

Socket Reconstruction

Note: You can use a corneal punch to do this, but it can be difficult to align. The separated scleral halves remain attached by their extraocular muscles. Place the chosen orbital implant (usually 22 mm diameter solid sphere) within a plastic sheath lubricated with viscoelastic. Put the implant containing sheath into a Carter sphere introducer or similar injection device. Using the sphere introducer inject the implant into the orbit between the scleral halves (Fig. 18.4b) while an assistant holds the scleral halves apart with malleable retractors. Remove the introducer and carefully withdraw the plastic sheath by squeezing while preventing the implant from popping out with it. Align the scleral halves around the implant (Fig. 18.4c). Suture the two scleral halves together in front of the implant with interrupted 6/0 absorbable sutures (Fig. 18.4d). Suture the tenons fascia over the sclera with interrupted 6/0 absorbable sutures (Fig. 18.4e). Suture the conjunctiva closed with a continuous 6/0 absorbable suture. Tighten it until the suture line begins to shorten to make the wound watertight (Fig. 18.4f). Insert an appropriately sized conformer shell (the largest that fits while just allowing eyelid closure) into the conjunctival fornices to maintain them and to prevent conjunctival prolapse (Fig. 18.4g). To do this push the conformer into the upper fornix first. Then push the conformer posteriorly while momentarily retracting the lower lid until it flips over the shell. Apply antibiotic ointment and a pressure dressing for one day.

18.3.4 Implantation Following Enucleation (Fig. 18.5) 18.3.4.1 Steps 1. Make two cuts 180◦ apart, from the anterior opening to the equator of the prepared, rinsed, and antibiotic soaked donor sclera shell (Fig. 18.5a). 2. Evert the donor sclera over your finger and then wrap it around the chosen orbital implant (usually 22 mm diameter solid sphere). Tack the scleral incisions closed with 6/0 absorbable sutures to stop the implant from slipping out (Fig. 18.5b). 3. Put the sclera covered implant into a plastic sheath lubricated with viscoelastic. Put the sheath into a Carter sphere introducer or similar injection device (Fig. 18.5c). 4. If the oblique muscles are available place the introducer next to the socket and suture the oblique muscles to the upper and lower edges of the covered implant’s scleral opening (which will end up posteriorly) in roughly their anatomical orientations (Fig. 18.5d). 5. Now carefully position the prongs of the sphere introducer into the conjunctival and tenons opening and slowly inject the implant into the rectus muscle

18.4 Orbital Implant Complications

6. 7.

8.

9.

10.

11.

247

cone making sure that the extraocular muscles and their pre-placed tagging sutures are splayed and correctly orientated. Carefully remove the plastic sheath by squeezing it, taking care to prevent the implant from popping out as you do this. Suture the four rectus muscles to the donor sclera anatomically, as in squint surgery, about 8–9 mm from the optic nerve opening on the scleral shell. This opening should end up centred between the attached recti (Fig. 18.5e). Close the tenons capsule in front of the implant with interrupted 6/0 absorbable sutures (Fig. 18.5f) Note: Some authors recommend suturing both the posterior and the anterior tenons openings in front of the implant, reporting fewer implant extrusions as the benefit. Close the conjunctiva in front of the tenons with a continuous 6/0 absorbable suture (Fig. 18.5g). Tighten this suture until the suture line starts to shorten, before tying it. Insert an appropriately sized conformer shell (the largest that fits while just allowing eyelid closure) into the conjunctival fornices to maintain them and to prevent conjunctival prolapse (Fig. 18.5h). Apply antibiotic ointment and a pressure dressing for one day.

18.3.4.2 Notes • Consider adding a temporary suture tarsorrhaphy as the final step of implantation to prevent excessive chemosis from pushing out the conformer shell. • Per operative intravenous antibiotic prophylaxis is current practice at orbital implant insertion. The evidence for this is now being questioned in line with the move to reduce antibiotic overuse.

18.4

Orbital Implant Complications

18.4.1 Conjunctival Cysts Conjunctival cysts form when conjunctival epithelium is inadvertently buried during surgery. As such they are avoidable. If a cyst occurs, it must be meticulously excised to ensure that all the cyst wall epithelial lining is removed or else the cyst will recur. Note: To make visualization easier you can inject the cyst with a dye, such as methylene blue, prior to excision.

248

18

a

b

c

d

e

f

g

h

Socket Reconstruction

Fig. 18.5 Implantation post enucleation. a Make two cuts 180° apart, from the anterior opening to the equator of the donor sclera shell. b Wrap it around the orbital implant. Tack the scleral incisions closed with 6/0 absorbable sutures. c Put the sclera covered implant into a plastic sheath lubricated with viscoelastic. Put the sheath into an introducer. d Suture the oblique muscles to the upper and lower edges of the covered implant’s scleral opening in their anatomical orientations. e Inject the implant into the rectus muscle cone and suture the rectus muscles to the donor sclera. f Close the tenons capsule in front of the implant with interrupted 6/0 absorbable sutures. g Close the conjunctiva in front of the tenons with a continuous 6/0 absorbable suture. h Insert the largest conformer shell that fits while just allowing eyelid closure

18.4 Orbital Implant Complications

249

18.4.2 Early or Late Wound Dehiscence Wound dehiscence is mainly due to poor surgical technique. Operative infection and impaired healing are other possible reasons. If noted early, re-suture the wound urgently. However, once bacterial and/or epithelial ingrowth have occurred around the implant such a repair is doomed to fail again. In this situation remove the implant, wait for the socket to heal, and then perform late secondary implantation.

18.4.3 Implant Migration The firm attachment of the extraocular muscles to the orbital implant (directly or indirectly to its covering material) is what holds an implant in place. The tenons fascia and conjunctiva alone are insufficient to keep the implant within the muscle cone. An implant can migrate axially forwards or rotate, slipping out of the muscle cone between the recti.

18.4.3.1 Rotational Subluxation (Fig. 18.6) Rotational subluxation is easily missed with spherical implants because they still look spherical when tilted (tilting of a hemispherical implant is obvious). Look for it by observing implant movement in different gaze positions. Fig. 18.6 Implant rotational subluxation. a 22 mm diameter intraconal implant. b A smaller implant sinks downwards in the orbit and causes an upward rotation of the overlying prosthesis. c Equatorial rectus muscle fixation to the implant = stable equilibrium. d Anterior rectus muscle fixation to the implant = unstable equilibrium. The posterior pull of the recti causes implant subluxation out of the muscle cone

a

b

22mm

c

d

18mm

250

18

Socket Reconstruction

Rotational subluxation occurs when the implant slips out of the muscle cone between two rectus muscles or rotates within the cone if one of the rectus muscle insertions dehisces. It occurs for one of four reasons: 1. Rectus muscle imbalance: If only the four rectus muscles are attached to the implant, three of them (superior, medial and inferior rectus) have a net inward/medial pull. This may overpower the lone lateral rectus outward/lateral pull causing the implant to rotate medially and sublux, usually infero-laterally between the lateral and the inferior recti. Note: Attaching the oblique muscles, which both have a net outward pull, anatomically to the implant, may help to mitigate such rotation imbalance (this remains to be proved). 2. Isolated rectus muscle dehiscence: If one of the rectus attachments slips during healing the implant will rotate and sublux anteriorly. Remedy this by finding and reattaching the slipped muscle surgically. 3. Undersized orbital implant: An implant whose diameter is smaller than that of the eye that it replaces does not magically remain in the middle of the orbit. It sinks down due to gravity to rest on the orbital floor (Fig. 18.4a, b). In this position it is no longer central within the muscle cone and the net posterior pull of the rectus muscles will rotate the implant by pulling its anterior pole posteriorly, encouraging the implant to sublux infero-laterally. 4. Rectus muscle anterior insertion: Attaching the rectus muscles at the equator of the implant creates a rotationally stable equilibrium (the implant is stable in all gaze directions) (Fig. 18.4c). By contrast, attaching the recti at the anterior pole of the implant or overlapping them across the front of the implant (as is recommended by some) results in an unstable equilibrium (Fig. 18.4d) because the centre of rotation is transferred from the implant centre to the front of the implant. In this configuration the pull of any rectus muscle disturbs the equilibrium, the anterior pole is pulled posteriorly, and the implant rotates out of the muscle cone. I recommend attaching the recti in roughly their anatomical positions as a practical compromise between the two extreme positions above.

18.4.4 Late Implant Exposure The tenons fascia and conjunctiva tolerate rotational stresses well. They do not tolerate crushing force between the implant and a poorly fitting artificial eye prosthesis. Conjunctival pressure necrosis results in implant exposure. Implant exposure causes a symptomatic increase in socket discharge. Unfortunately, by the time a patient presents, epithelial ingrowth and bacterial colonization of the implant capsule have already occurred. Consequently, surgical patching of the exposure fails because it merely transforms the colonized implant capsule into an infected cyst which eventually ruptures again, re-exposing the implant. Biologically integrated porous implants, such as hydroxyapatite or ceramic (but not polypropylene), do not have a capsule and can therefore be shaved down to

18.4 Orbital Implant Complications

251

remove the necrotic surface until bleeding granulation is reached. The exposure may then be patched and covered with conjunctiva. Even then, recurrent erosion often occurs due to the roughness of the porous implant surface.

18.4.5 Post Enucleation Socket Syndrome (Fig. 18.7) The post enucleation socket syndrome (PESS) comprises: 1. 2. 3. 4.

A deep upper lid hollow (superior sulcus). Upper lid drooping (ptosis). A sunken appearance of the artificial eye (enophthalmos). Progressive lower lid stretching from supporting a heavy artificial eye (prosthesis). 5. Upward tilting of the prosthesis (because the undersized implant sinks to the orbital floor) (Fig. 18.7b). 6. Reduced artificial eye movement. All the above stem from a primary orbital volume deficit, the result of inadequate enucleation volume replacement (too small an implant). If you look for it, you will find that a degree of PESS is exceedingly common. The key to prevention and management is adequate volume replacement. If the intraconal implant is smaller than 22 mm in diameter replace it with a larger one. Additional volume supplementation may subsequently be required with an orbital floor implant (maximum additional volume 2 ml) or a superior sulcus dermis-fat graft. After fitting a new lighter artificial eye prosthesis consider lower lid tightening if necessary. Finally consider possible ptosis correction.

Deep upper lid Sulcus Upper lid Ptosis Enophthalmos Lower lid laxity Upward prosthesis tilt Reduced Movement Fig. 18.7 Post enucleation socket syndrome (PESS). All the PESS signs stem from insufficient orbital volume replacement

252

18

Socket Reconstruction

18.4.6 Lower Lid Laxity The weight of the artificial eye prosthesis applies an insidious stretching force to the lower eyelid causing it to lengthen over time. As a result, the prosthesis sinks downward increasing the upper lid hollow (sulcus) and so marring the patient’s appearance. The remedy is to increase the implant volume to allow a smaller, lighter prosthesis to be fitted before tightening the lower lid. (Lid margin resection). Shortening the lid without first fitting a lighter prosthesis will fail through further stretching. Rarely, a fascia lata lower lid sling may be necessary to support a heavy artificial eye that cannot be reduced in weight.

18.4.7 Upper Lid Ptosis Upper lid drooping (ptosis) is common in artificial eye wearers. It may be of the simple ‘involutional’ type that commonly follows eye trauma or surgery. Alternatively, it may be the consequence of a volume deficient socket. A smaller implant diameter forces the levator muscle to work at a mechanical disadvantage and makes the levator seem relatively longer. Upper lid ptosis correction is the last stage in socket rehabilitation. Only consider it once adequate volume replacement, lower lid tightening, and prosthesis adjustment have all been addressed. Carry it out like any other ptosis surgery but with the artificial eye in place.

18.5

Take Home Message

• Always implant. • Think big! Use a 22 mm diameter solid spherical implant.

Reference 1. Thaller VT (1997) Enucleation volume measurement. Ophthalmic Plast Reconstr Surg 13(1):18–20. https://doi.org/10.1097/00002341-199703000-00003. PMID: 9076778

Thyroid Eye Disease

19

(Grave’s Orbitopathy)

Fig. 19.1 What big eyes you have cartoon. Depot orbital steroid can alleviate TED

19.1

Overview (Fig. 19.1)

• Immunosuppression in active (wet) thyroid eye disease. • Orbital Triamcinolone injection • Inferior rectus recession with lid retractor recession

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_19

253

254

19 Thyroid Eye Disease

• Upper lid blepharotomy • Lower lid retractor recession. Thyroid eye disease (TED) is a disfiguring and sight impairing autoimmune condition for which there is currently no cure. It is the commonest cause of gaze evoked double vision and of unilateral or bilateral lid retraction and/or proptosis. It can threaten sight through optic nerve compression or severe corneal exposure. Treatment is dictated by whether the disease is still active.

19.2

Wet or Dry?

Thyroid eye disease begins as an autoimmune inflammation of the eyelids and orbital contents. During this active phase the periocular tissues are red and swollen, earning the alternative name of ‘wet TED’. Monitor activity by noting changes in the classical signs of inflammation [1] (Fig. 19.2). In addition to the visible signs, active TED usually causes a deep ache in the orbit(s), especially in extreme positions of gaze. The inflammatory component, and along with it the ache, subside spontaneously after several months, leaving behind a widely variable degree of lasting disfigurement and functional impairment. These are the result of fibrosis and hypertrophy of the eyelid and orbital connective tissue, muscles, and fat. Diagnose inactive or ‘dry’ phase TED when the clinical signs become stable, and the ache and inflammatory signs have subsided. Immunosuppression can modify the active, wet phase, and if given early enough may even reverse some of the changes. However, because immunosuppression has

TED Activity based on the classical features of inflammation: clinical activity score (CAS) is the sum of all items present. A CAS ≥ 3/7 indicates active moderate to severe TED

Spontaneous retrobulbar pain Pain on attempted up- or down gaze Redness of the eyelids Redness of the conjunctiva Swelling of the eyelids Inflammation of the caruncle and/or plica Conjunctival oedema

Fig. 19.2 Clinical activity score. Scoring of TED severity based on the clinical signs of inflammation

19.3 Immunosuppression of Active TED

255

the potential for serious side effects, reserve it for preventing visual disability progression (when its benefits outweigh its risks). Surgery has no place in the management of active wet TED except in rare cases of sight threatening optic nerve compression unresponsive to systemic immunosuppression. In these patients, urgent surgical decompression of the orbital apex can prevent blindness. Severe exposure keratopathy may also require urgent surgery.

19.3

Immunosuppression of Active TED

Offer immunosuppression to patients with a Clinical Activity Score [1] (CAS) ≥3. The onset of gaze dependent diplopia is a conservative threshold for starting immunosuppression. Currently there are four immunosuppression options: 1. Steroids. These are the usual first line agent. 2. Non-steroidal immunosuppressants. Use these as adjunctive, steroid sparing treatments. 3. Biologics (Monoclonal antibodies). These are still under investigation, expensive, and carry the risk of rare but devastating side effects. Currently they are a ‘last resort’ option, but this is likely to change. 4. Orbital, low dose radiotherapy to limit extraocular muscle fibrosis. Although this has its strong proponents the evidence base for this modality remains weak. Sadly not all patients respond to available immunosuppression.

19.3.1 Steroids The three options for steroids administration are: 1. Weekly high dose Methylprednisolone given intravenously or orally up to a total cumulative dose of 8 grammes. This is the current European Group on Graves’ Orbitopathy (EUGOGO) recommendation. Seventy five percent of patients respond to this regime. 2. Daily oral Prednisolone. Half of patients respond to this, but the systemic steroid side effects are greater than for weekly methylprednisolone. 3. Two monthly orbital floor depot Triamcinolone injections. This off-label treatment places the steroid directly in the orbit where it is needed. It has the least risk of systemic side effects as the total body steroid dose is comparatively low. However, orbital injection carries the added risks of orbital haemorrhage, needle penetration of the eye and inadvertent intraocular or intravascular injection, risks that are associated with any periocular injection. Despite these, I have found it a very effective treatment for moderate TED. It is also a useful test of clinical activity. The orbital ache of active thyroid eye disease usually improves

256

19 Thyroid Eye Disease

within a couple of days of an orbital triamcinolone injection. Further discussion of immunosuppression and its risks is beyond the scope of this book.

19.4

Orbital Triamcinolone Injection [2]

19.4.1 Case Selection Moderate active thyroid eye disease without optic nerve compression.

19.4.2 Protocol 1. Discuss the risk/benefit of this modality with the patient. Emphasise that this is an off-label use and obtain consent. 2. Administer 40 mg Triamcinolone acetate to the orbital floor. 3. Review in 8 weeks to establish whether there has been any symptomatic improvement. If there has not, do not repeat. If there has been an improvement, ask whether the symptoms are now returning? If they are, administer another dose. If not, review again in 8 weeks to make sure that the active phase is over. 4. Repeat steps 2 and 3 until there is no symptom recurrence on two consecutive visits. 5. Once the TED is inactive, discuss rehabilitative surgical options if required.

19.4.3 Steps 1. Lie the patient down comfortably in a slight head up position (to reduce orbital venous congestion). Ask a nurse to hold the patient’s hand for reassurance. 2. Gently shake the bottle of triamcinolone to resuspend the crystals and draw up the complete 40 mg in 1 ml dose into a 2 ml syringe. Attach a 1” (25 mm) long 25 G disposable needle and expel the air from the syringe and needle. 3. Ask the patient to gaze at a spot on the ceiling to keep their eyes still. 4. Pull down the lower lid to expose the inferior fornix and slowly insert the needle, bevel up, at the junction of the lateral 1/3 and medial 2/3. Advance the needle tangentially to the eye by at least 3/4 of its length until you encounter the bone of the orbital floor. Look for any needle related eye movement during needle insertion (the eye should not move). The sharpness of the needle means that you receive minimal tactile feedback or resistance. Release your pull on the lower lid. 5. Holding the syringe and needle still, ask the patient to follow small movements of your other hand to confirm that the eye movements are free and independent of the needle.

19.5 Surgical Management of Inactive (Dry) Thyroid Eye Disease

257

6. Attempt to withdraw the plunger slightly while keeping the syringe still, to ensure that the needle tip is not positioned intravascularly. If you obtain blood, either withdraw the needle slightly and retest or abandon the injection. 7. While holding the syringe steady with one hand slowly inject using the other. Remind the patient to keep their eye still. Warn them to expect a slight ache as the injection proceeds. Ask the patient to tell you if their vision becomes affected during injection (this could be a sign of intraocular injection). 8. Withdraw the needle and immediately apply moderate pressure to the closed eye for 5 min, to raise the orbital pressure and reduce the chance of orbital bleeding. 9. Sit the patient up for a few minutes before allowing them to stand (to avoid postural hypotension). Check whether their vision remains unaffected and warn them that late bruising may appear. Ensure that they are given a contact number to report any untoward reaction.

19.4.4 Notes • If the lower lid is too tight to pull down easily, administer the injection transcutaneously. To do this place your index and middle fingers on the lateral 1/3 of the lower lid and feel for the orbital rim. Spread your fingers slightly to stretch the skin between them to ease needle penetration and push the eye slightly upwards through the lid with your fingertips. Now, with the syringe needle bevel up and pointing slightly inferiorly, insert it between your two fingers to skim the inferior orbital rim tangentially to the globe. Advance it until you feel the orbital floor. • Give the patient a courtesy phone call two days after injection to check if they have noticed any symptom improvement, as they may forget this by the time of their 8-week review.

19.5

Surgical Management of Inactive (Dry) Thyroid Eye Disease

There is a hierarchy in the surgical management of inactive (‘burnt out’ or ‘dry’) TED: (a) Orbital decompression First consider orbital decompression. This, the highest risk procedure, has the best chance of restoring a normal appearance. The bone of one or more orbital walls is removed to allow the orbital contents to prolapse into the extra space so created. When it is justified, decompression should be performed as the first step of surgical

258

19 Thyroid Eye Disease

rehabilitation as it can affect ocular balance and eyelid position. Orbital surgery is beyond the remit of this book. (b) Extraocular muscle recession TED induced double vision is a consequence of extra ocular muscle fibrosis. A fibrosed muscle tethers the eye so limiting movement when its antagonist muscle contracts. At first the diplopia is noticed in the gaze direction opposite to the field of action of the affected muscle. The inferior rectus is the most commonly affected muscle causing up-gaze diplopia and often a compensatory ‘chin up’ head posture. The medial rectus is the second most commonly affected muscle. Any or all of the extraocular muscles may be affected. The golden rule is only to recess the affected muscle. Never resect its antagonist. The surgery is as straightforward to carry out as any squint surgery, but its outcome is less certain.

19.5.1 Tips The following tips make TED recessions more predictable. • Suture the recessed muscle securely to the sclera at the position that it adopts once separated from its original insertion (with the globe in the primary gaze position). • Suture the muscle directly to the sclera. Do not leave it on a ‘hang-back, adjustable suture’, as is popular practice. Indirect fixation reduces the likelihood of a strong union at the new insertion site (because of the abnormally high stresses at a fibrosed muscle’s insertion). A weak reattachment allows late drift of the muscle insertion when its anchoring suture cuts out or absorbs. This drift is so prevalent that most strabismus surgeons deliberately under correct their adjustable sutures in anticipation. By contrast, ‘late drift’ does not occur if you suture the insertion to the sclera directly. • Recessing the inferior rectus increases lower lid retraction because the lower lid retractor’s origin is the inferior rectus. Separating the retractor origin from the muscle belly and placing the lower lid on temporary upward traction overnight prevents this increase in retraction.

19.5.2 Inferior Rectus Recession with Lid Retractor Recession (Fig. 19.3) 19.5.2.1 Principle Identify and separate the lower lid retractor origin from the inferior rectus muscle belly. Pre-place sutures in the existing muscle insertion before detaching it from the sclera. Suture the muscle back firmly to the sclera in the position it takes up

19.5 Surgical Management of Inactive (Dry) Thyroid Eye Disease

a

b

c

d

e

f

g

259

h

Fig. 19.3 Inferior rectus recession with lid retractor recession. a Pull the eye upward and incise the conjunctiva and tenons over the inferior rectus insertion. b Insert a Chavasse squint hook under the insertion. c Bluntly dissect the inferior rectus muscle sheath from the muscle. d Tear the origin of the retractor expansion off the muscle. e Pre-place a double armed, 6/0 absorbable suture into the inferior rectus close to the insertion. f Use double pass, self-locking loops for muscle fixation. g Do this at either side of the muscle with an additional central bite for security. h Divide the inferior rectus insertion with Westcott scissors while taking care not to cut the pre-placed sutures. i Insert both muscle suture needles through partial thickness sclera at the intended recession point and take further suture bites through the original insertion where the sclera is thicker and stronger. j Make a second suture pass through the insertion. k Pull the rectus muscle to its new insertion and tie the suture. l Suture the conjunctiva and tenons closed over the insertion. m Put the lower lid on upward traction overnight

260

19 Thyroid Eye Disease

i

j

k

l

m

Fig. 19.3 (continued)

in primary gaze. Put the lower lid on upward traction overnight so that the lower lid retractor origin re-inserts itself more anteriorly on the muscle.

19.5.2.2 Case Selection Dry phase TED patients with a chin up head posture and/or up-gaze diplopia. 19.5.2.3 Steps 1. Pre-place a limbal traction suture at 6 o’clock and pull the eye upward on traction (Fig. 19.3a). 2. Incise the conjunctiva and tenons horizontally over the inferior rectus insertion (6–7 mm posterior to the limbus), expose the insertion by blunt dissection and insert a Chavasse squint hook under the insertion (Fig. 19.3b).

19.5 Surgical Management of Inactive (Dry) Thyroid Eye Disease

261

3. Bluntly dissect the inferior rectus muscle sheath from the muscle (Fig. 19.3c). Do this by pushing firmly against the muscle with the flat end of a dry triangular swab in a posterior direction. 4. Continue the dissection until the sheath appears to be fixed to the muscle belly itself by interdigitations (roughly at the equator of the globe). These interdigitations are the origin of the lower lid retractors. They look like the attachment of the medial check ligament to the medial rectus. 5. Grip these interdigitations with Jayles toothed forceps and tear them off the muscle in a posterior direction, so separating the origin of the lower lid retractor expansion from the muscle (Fig. 19.3d). 6. Pre-place a double armed, 6/0 polyglycolic acid, suture with spatulate 1/4 circle needles, into the inferior rectus close to the insertion (Fig. 19.3e). Use double pass, self-locking loops [1] for each fixation (Fig. 19.3f). Do this at either side of the muscle with an additional central bite for security (Fig. 19.3g). Place bulldog clips on the suture ends to retract them from the operative field. 7. Divide the inferior rectus insertion with Westcott scissors while taking care not to cut the pre-placed sutures (Fig. 19.3h). Allow the muscle to retract. 8. Temporarily release the limbal traction suture and return the eye to the primary gaze position. Mark the newly adopted position of the released inferior rectus on the sclera. This will be between 4 and 8 mm posterior to the original insertion. Then retighten the limbal traction suture to pull the eye upwards for ease of access during suturing. 9. Insert both muscle suture needles through partial thickness sclera [2] at the marked positions (Fig. 19.3i). Check that the scleral bites are strong by slightly lifting the needle before completing the pass. Note: The sclera is extremely thin at this point and needle penetration of the eye is a real risk. Never point a needle towards the eye unless it is your intention to penetrate the eye! Avoid this risk by placing the needle tip flat (tangential) against the sclera (Fig. 19.5). 10. Take suture bites through the original insertion where the sclera is thicker and stronger [3]. 11. Take a second bite of the insertion more centrally than the first. Note: This two-bite configuration introduces friction which makes it easy to adjust the suture without it slipping. 12. Again, release the limbal traction suture before pulling slowly on the rectus muscle suture ends to advance the muscle to its new insertion (Fig. 19.3k). Tie the suture firmly and cut the ends at least 2 mm long to prevent spontaneous unravelling. 13. Suture the conjunctiva and tenons closed over the insertion to bury the muscle suture (Fig. 19.3l). 14. Place a tarsal traction suture through the lid margin and put the lower lid on upward traction overnight. This allows the lid retractor origin to reattach to the recessed inferior rectus more anteriorly (Fig. 19.3m).

262

19 Thyroid Eye Disease

a

b

c

d

Fig. 19.4 Double locking suture bites. a Take a partial thickness muscle bite over the squint hook. b With the same suture take a full thickness muscle bite on the posterior slope of the squint hook. c Loop the first bite suture under the needle tip. d Pull the needle through the loop to lock the suture

19.5.2.4 Notes 1. Double pass, self-locking suture steps: (a) Take a partial thickness muscle bite over the squint hook. The latter protects the underlying sclera from the needle tip (Fig. 19.4a). (b) With the same suture take a full thickness muscle bite on the posterior slope of the squint hook (Fig. 19.4b). (c) Before releasing the needle use forceps to loop the first bite suture under the needle tip (Fig. 19.4c). Note: Pulling on the loop lifts the needle tip making it easier to regrasp. (d) Pull the needle through the loop. This magically locks the suture. 2. Scleral suture bites: (a) Only use a spatulate 1/4 circle needle for suturing to the sclera. (b) Place the needle tip flat (tangentially) against the sclera (Fig. 19.5a). (c) Press the flat of the needle tip against the sclera to depress it slightly (Fig. 19.5b). (d) Cautiously advance the needle a short distance tangentially through partial thickness sclera (Fig. 19.5c). (e) You can check the needle tip’s progress the within the sclera by rotating the needle slightly to lift the tip (Fig. 19.5d). (f) Repeat steps c and d as necessary to obtain the length of bite you require. (g) Rotate the needle out of the sclera when you have achieved the length of bite that you require (Fig. 19.5e). (h) Before removing the needle from the sclera, lift it slightly to check the strength of the bite (Fig. 19.5f).

19.5 Surgical Management of Inactive (Dry) Thyroid Eye Disease

a

b

c

d

e

f

263

g

Fig. 19.5 Scleral suture bites. a Place the needle tip flat (tangentially) against the sclera. b Depress the sclera slightly with the flat of the needle. c Cautiously advance the needle a short distance tangentially through partial thickness sclera. d Visualize the needle tip within the sclera by rotating the needle slightly to lift the tip. Repeat steps c and d as necessary to obtain the length of bite you require. e Rotate the needle out of the sclera when you have achieved the length of bite that you require. f Before removing the needle from the sclera, lift it slightly to check the strength of the bite. g Complete the suture pass

264

19 Thyroid Eye Disease

a

b

c

d

Fig. 19.6 Muscle insertion suture placement. a Grasp and lift the muscle insertion with toothed forceps to stabilize it. b Place the suture needle tip flatly against the sclera under the insertion. c Entering the insertion angle, advance the needle and exit 1/2 to 1 mm anterior to the insertion. d Lift the needle slightly to check the strength of the bite

(i) Remove the needle from the sclera. 3. Muscle insertion suture placement (Fig. 19.6): The sclera is thinnest just beneath a muscle insertion (about 1/4 mm thick) so this is a bad place to insert a suture bite. The sclera anterior to the insertion is twice as thick. Entering the angle between the muscle insertion and the sclera reproducibly positions the needle at the correct depth within this thicker sclera. (a) Grasp and lift the muscle insertion with toothed forceps to stabilize it (Fig. 19.6a). (b) Place the suture needle tip flatly against the sclera under the insertion (Fig. 19.6b). (c) Entering the insertion angle, advance the needle and exit 1/2 to 1 mm anterior to the insertion (Fig. 19.6c). (d) Lift the needle slightly to check the strength of the bite (Fig. 19.6d).

19.5.3 Eyelid Recession The final step in the surgical treatment hierarchy is the correction of eyelid retraction, an extremely common sign of TED. It is the last option in the sequence because both orbital decompression and squint surgery can significantly affect eyelid position. Only consider lid margin recession after decompression surgery and/ or squint surgery have either been performed or ruled out.

19.6 Upper Lid Blepharotomy [3]

265

Eyelid tissues in TED behave very differently from those of normal lids. Fibrosis is particularly strong in the peri lacrimal area in the upper lid. It is the cause of lateral lid retraction, sometimes called ‘lateral flare’. Lid retractors exert their action on the lid margin in four ways. Three are well recognized: 1. The levator aponeurosis anterior attachment to skin, responsible for the lid crease, 2. The levator aponeurosis posterior insertion to the middle and distal part of the tarsal plate and 3. Muller’s muscle attachment to the proximal edge of the tarsal plate. 4. The fourth, generally overlooked, attachment is that of the levator/superior rectus common tendon sheath which terminates as the superior suspensory ligament of the fornix (it prevents upper fornix prolapse). Normally this attachment has no effect on lid margin position because its only connection to the lid is via elastic conjunctiva. However, the conjunctival fibrosis of TED transfers levator pull directly to the tarsal plate. You see this clearly during TED lid recession surgery. Having divided all three retractor attachments mentioned above, the lid still moves normally until the conjunctiva is also cut. The simplest and most effective lid margin recession operation, blepharotomy divides all four attachments.

19.6

Upper Lid Blepharotomy [3]

Blepharotomy, as its name suggests, is a full thickness eyelid incision, parallel with the lid margin at the level of the skin crease externally and through to above the upper border of the tarsal plate internally. Carry it out under local anaesthesia so that you can adjust the length of the blepharotomy according to its lid lowering effect. Initially cut only the lateral 1/3 of the lid. If this proves insufficient extend the incision medially in stages until you achieve the desired effect. I recommend that you always leave the medial 1/3 intact as cutting it causes a late medial droop contour deformity. Other authors leave an intact central ‘bridge’ instead. No postoperative traction or dressing is required. What you see on the operating table is the lowering you ultimately get from this procedure.

19.6.1 Case Selection Dry phase TED patients with symptomatic upper lid retraction.

266

19 Thyroid Eye Disease

19.6.2 Steps (Fig. 19.7) 1. Mark the upper lid skin crease (usually at about 7–8 mm in Caucasians) (Fig. 19.7a). 2. Place a protecting plate under the upper lid and ask your assistant to hold it pushed up in the upper fornix. 3. Make a full thickness incision of the lateral 1/3 of the eyelid with a no. 15 scalpel blade (Fig. 19.7b). Extend this laterally to the orbital rim to avoid lateral tethering from perilacrimal fibrosis. 4. Check the effect that this has on the lid position by getting the patient to look up and down.

a b

d c 2/3

1/3

e

Fig. 19.7 Blepharotomy. a Mark the upper lid skin crease. b Make a full thickness incision of the lateral 1/3 of the eyelid with a no. 15 scalpel blade. c To lower the lid further, extend the incision medially in stages. d Do not incise more than the lateral 2/3 of the lid. e Suture only the skin and orbicularis incision with a continuous suture

19.8 Lower Lid Retractor Recession

267

5. To lower the lid further, extend the incision medially in stages, always stopping between stages to assess the lid’s height (Fig. 19.7c). 6. Do not incise more than the lateral 2/3 of the lid (Fig. 19.7d). 7. Suture only the skin and orbicularis incision with a continuous 6/0 or 7/0 suture (Fig. 19.7e). 8. No dressing is required.

19.6.3 Note This operation can be performed transconjunctivally by everting the lid over a Desmarres retractor leaving the skin uncut. However, repeated lid eversion is both difficult and uncomfortable for the patient, and the repeated stretching makes the correct endpoint harder to determine.

19.7

No Spacers

Much has been written about interposing ‘spacers’ of various materials between the recessed levator aponeurosis and the upper tarsal plate border. They serve no useful purpose. They do not prevent further post-operative fibrosis. As foreign bodies they only add to it, and they can become infected or extrude. In theory spacers hold the divided retractors a set distance from the tarsal plate, yet in practice the recommendation is to make them two or three times wider than the desired recession (which negates their purpose). As thyroid lids already have increased fibrosis, late drift only occurs if the retractors have been completely cut (hence leave the medial 1/3 intact). Spacer use has been particularly recommended for ‘lifting’ a retracted lower lid. To do so it would need to be stiff (e.g., cartilage or porous polypropylene) and be fixed to the orbital rim. At best this leads to a static lower lid, at worst to an ectropion.

19.8

Lower Lid Retractor Recession

19.8.1 Considerations and Principle Full thickness external lower lid blepharotomy is possible but unnecessary as generally the lower lid can be everted easily and all the layers cut from the conjunctival surface, sparing the skin. However, because the only lifting force on the lower lid is the orbicularis, apply upward lid margin traction with a suture overnight to avoid an under-correction. Tightening the lid margin over a prominent eye will not help to raise a retracted lower lid. Add additional active lower lid lift from the upper lid levator muscle by performing a medial canthoplasty and a short (4–5 mm),

268

19 Thyroid Eye Disease

a

b

Fig. 19.8 Belt or braces. a Tightening a lower lid margin in the presence of a prominent eye pushes the eye upwards and the lid slips downwards relative to the eye. b Performing a medial canthoplasty and lateral tarsorrhaphy transfers upper lid lift to the lower lid

permanent, lateral tarsorrhaphy (Fig. 19.8). The latter is also helpful in masking proptosis but should only be performed after the lid retractors have been recessed.

19.8.2 Case Selection Dry phase TED patients with symptomatic lower lid retraction.

19.8.3 Steps 1. Insert a 4/0 monofilament tarsal traction suture. Use this to evert the lower lid over a large Desmarres lid retractor (Fig. 19.9a, b). 2. Make an incision along the length of the conjunctiva, just proximal to the tarsal plate. Deepen this incision to divide the underlying retractors. Ensure that it extends medially and laterally as far as the canthi (Fig. 19.9b). 3. Remove the Desmarres retractor and pull the lower lid upwards using the traction suture. With the lid stretched upwards feel for any remaining restricting bands through the skin and divide them with scissors (Fig. 19.9c, d). The lower lid should now no longer be retracted. Furthermore, the lid should not move down when the patient looks down. 4. Tape the lower lid traction suture to the forehead on stretch and apply antibiotic ointment and a pressure dressing overnight (Fig. 19.9e).

19.8 Lower Lid Retractor Recession

269

a b

c

d

e

Fig. 19.9 Posterior Lower lid retractor recession. a Insert a tarsal traction suture and use this to evert the lower lid over a large Desmarres lid retractor. b Incise the conjunctiva just proximally to the tarsal plate. Deepen this incision to divide the underlying retractors. c Pull the lower lid upwards, using the traction suture, to feel for any remaining restricting bands. d Divide any bands with scissors. e Tape the lower lid traction suture to the forehead on stretch

5. Remove the traction suture the following day and assess the lower lid position. Should there be an under-correction instruct the patient to push and hold the lower lid upwards for a couple of minutes at least twice a day for the first two months to stretch the internal scar.

270

19 Thyroid Eye Disease

19.8.4 Note This technique has also been used to recess the upper lid and is the basis of the ‘Henderson procedure’. The latter is less predictable than the Koornneef blepharotomy and not recommended.

19.9

Take Home Message

• Periocular triamcinolone injections are an excellent option for managing moderate active thyroid eye disease. • When recessing fibrosed extraocular muscles suture them directly to the sclera to avoid late drift.

References 1. Clinical Activity Score Mourits MP (1997Jul) Prummel MF, Wiersinga WM, Koornneef L. Clin Endocrinol (Oxf) 47(1):9–14 2. Ebner R, Devoto MH, Weil D, Bordaberry M, Mir C, Martinez H, Bonelli L, Niepomniszcze H (2004Nov) Treatment of thyroid associated ophthalmopathy with periocular injections of triamcinolone. Br J Ophthalmol. 88(11):1380–6. https://doi.org/10.1136/bjo.2004.046193.PMID: 15489477;PMCID:PMC1772392 3. Elner VM, Hassan AS, Frueh BR (2003) Graded full-thickness anterior blepharotomy for upper eyelid retraction. Trans Am Ophthalmol Soc 101:67–73

Conclusion

20

Thank you if you’ve made it this far. Believe me it took a lot longer to write than to read (Fig. 20.1). Hopefully you’ve noticed that I’ve reduced my message to a few common themes that have kept cropping up. For example, lid margin repair (Chap. 5) is almost the same whichever part of the lid you perform it on, and it crops up again in entropion and ectropion correction (Chaps. 8 and 9) and lid reconstruction (Chap. 14). Retractor plication is similar whether you perform it for a ptosis correction in the upper lid (Chap. 10) or as part of an anterior lamellar repositioning in either lid, or as a retractor plication for lower lid entropion or ectropion (Chaps. 8 and 9).

Fig. 20.1 A good read

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_20

271

272

20

Conclusion

Keeping eyelid surgery as simple and safe as possible has been my intention throughout this manual. All the techniques I have described have worked reliably well for me. Therefore, I commend them to you. Naturally, many alternative techniques exist, each with its champions. And no doubt in time you will develop your own modifications and favourites. Things do move on and so must we. I hope that you have found at least some the concepts and techniques interesting and that they are useful in your future practice. May they enable you to generate fewer revisions from your routine surgery and give you more time to devote to the more challenging problems that I have steered clear of. There is, of course, much more to being a good surgeon than mere technique. Listen to your patients as they have much to teach you. Follow up your own outcomes personally, not just as a human courtesy but to complete the feedback loop from which your techniques can evolve. Care about your patients and you will inspire their trust and confidence. These are invaluable on the rare occasions when a surgical outcome is suboptimal. And be realistic. Explain what is and is not surgically possible. Under promise and overachieve! But above all, enjoy your work and never stop learning.

10 Lid Commandments 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Thou shalt do least harm. Thou shalt use the meibomian orifice, not the grey line. Thou shalt always attempt to close wounds directly. Remember, nothing lasts, suture tension least of all. Revere the upper lid. Believe in the magic suture and white line. Thou shalt not strip. Thou shalt replace volume lost. Suppress active and recess for inactive thyroid eye disease. Speak no ill of thy less informed colleagues.