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Entropion is an eyelid malposition manifest by an inward rotation of the eyelid margin. The eyelashes on the eyelid margin abrade the cornea, producing pain and ocular irritation. Entropion has classically been divided into subtypes of congenital, spastic, involutional and cicatricial. Involutional entropion is the most common type of entropion. The incidence of involutional entropion increases with increasing age. The inward rotation of the eyelid margin produces ocular pain, irritation and tearing. Initially, patients are able to correct this eyelid malposition by simply distracting the eyelid away from the globe. With time, the involutional entropion becomes more prolonged and troublesome. With increasing ocular pain, patients will seek medical care for the correction of the entropion. There are four underlying ca

n Needle tip for cautery

n 18-gauge angiocath for shielding the needle tip cautery

n Four-prong skin retractor

n 10 cc syringe

n 27-gauge needle

AnesthesIA

n Tetracaine hydrochloride 0.5% (topical anesthesia)

n 2% lidocaine with 1 : 100 000 epinephrine

n Wydase (sodium hyaluronidase)

n Sodium bicarbonate 8.4% (American Regent)

n 9 cc of 2% lidocaine with 1 : 100 000 epinephrine is mixed with 15 units of Wydase and

1 cc of injectable bicarbonate

IndIcAtIons

Entropion is an eyelid malposition manifest by an inward rotation of the eyelid margin The eyelashes on the eyelid margin abrade the cornea, producing pain and ocular irritation Entropion has classically been divided into subtypes of congenital, spastic, involutional and cicatricial

Involutional entropion is the most common type of entropion The incidence of lutional entropion increases with increasing age The inward rotation of the eyelid margin produces ocular pain, irritation and tearing Initially, patients are able to correct this eyelid malposition by simply distracting the eyelid away from the globe With time, the involu-tional entropion becomes more prolonged and troublesome With increasing ocular pain, patients will seek medical care for the correction of the entropion

invo-There are four underlying causes of involutional entropion In most cases, more than one of these etiologies is present and all of the causes must be considered for the surgical repair of entropion

Horizontal eyelid laxity increases with age The length of the medial canthal tendon, the tarsus and the lateral canthal tendon determine the horizontal length of the eyelid The

me-A dehiscence of the lower eyelid retractor is analogous to a disinsertion of the levator aponeurosis in the upper eyelid When the lower eyelid retractor is disinserted, the lower eyelid excursions are reduced A ‘reverse ptosis’ is often noted With patients looking in down-gaze, the lower eyelid will not be as low as on the unaffected side Examination of

b

Box 1.1 etiology of involutional entropion:

n Horizontal eyelid laxity

n Dehiscence of the lower eyelid retractors

n Orbicularis spasm

n Enophthalmos

n Figure 1.1a Lower eyelid anatomy demonstrating the key anatomic structures that will be repaired during an entropion repair The lateral canthal tendon, the lower eyelid retractor and the orbicularis muscle are all repaired during the correction

of an entropion

n Figure 1.1b A ‘squeeze test’ will help

demonstrate an entropion With the patient forcibly closing the eyelids the physician elevates the upper eyelid The overriding orbicularis muscle will push the eyelid margin toward the cornea

the inferior fornix on the affected eyelid may reveal a visible white line demonstrating the dehisced lower eyelid retractor underneath the overlying conjunctiva.

Orbicularis muscle spasm can cause the skin to override the eyelid margin and push the eyelashes toward the cornea This can be demonstrated with the ‘squeeze test’ The test

is performed by forcibly opening a patient’s eyelid while they try to keep the eyelids closed The test may demonstrate an entropion in patients where the condition is sporadically present

Enophthalmos is also an etiology of involutional entropion With increasing age, there

is a loss of orbital volume A posterior shift of the globe will alter the relationship between the lower eyelid and the globe This altered relationship can lead to an unstable eyelid As enophthalmos develops, involutional entropion becomes more prevalent

entropIon repAIr

Step 1 Local anesthesia: 2% lidocaine with 1 : 100 000 epinephrine, Wydase

and bicarbonate is injected through the conjunctiva, which has been prepared with

a topical anesthetic A total of 3–4 cc is injected through the conjunctiva from the

caruncle to the lateral canthal region

Step 2 Incision design: An infraciliary incision is placed beneath eyelashes,

extending from the punctum to the lateral orbital rim The incision is carried past the lateral canthus since horizontal shortening of the eyelid is an essential part of correcting the involutional entropion A 4-0 silk suture is placed through the eyelid margin to provide elevation of the eyelid during the procedure

Step 3 Skin incision: An incision through the skin and into the suborbicularis space

is carried from the medial canthus to the lateral canthus The eyelid should be kept taut

in order to control the depth of the incision A dissection plane is developed beneath the orbicularis muscle exposing the orbital septum

a

Box 1.2 clinical pearl

Clinical pearl: Hundreds of different techniques to correct entropion have been published in

the historical literature Most of these techniques repaired one or two of the underlying causes

of entropion Current entropion repair combines the repair of horizontal eyelid laxity, dehisced

lower eyelid retractor and the overriding orbicularis muscle The combined procedure has led to

a dramatic increase in the long-term success of entropion repair

n Figure 1.2a A marking pen is used to outline

the potential incision below the eyelashes The line

begins below the punctum and extends beyond

the lateral canthus

b

n Figure 1.2b An incision through the skin and

orbicularis muscle is made to gain access to the suborbicularis plane

1.1

4

Step 4 Opening the orbital septum: The orbital septum covers the underlying orbital

fat Gentle ballottement of the globe will make the fat more easily visualized along with the overlying orbital septum The orbital septum is opened along its entire length A strip

of orbital septum is removed to prevent postoperative adhesions and to clearly expose the underlying fat

Step 5 Identification of the lower eyelid retractor: Under the orbital fat, the dehisced

lower eyelid retractor is identified Orbital fat is brushed inferiorly with a cotton-tip plicator stick Often, a white line is seen in the area of the dehiscence The retractor can

ap-be further visualized by asking the patient to look up and down The lower eyelid retractor will follow the eyeball excursions

Step 6 Lateral canthal tendon tightening: Horizontal eyelid laxity is corrected by

shortening the lateral canthal tendon A lateral cantholysis releases the inferior head of the lateral canthal tendon Removing the overlying skin and epithelium at the eyelid margin further isolates the tendon Once an adequate amount of lateral canthal tendon is isolated,

Box 1.3 clinical pearl

Clinical pearl: Placing the skin incision just beneath the eyelashes is a good idea in entropion

repair since this will expose the pretarsal orbicularis muscle The pretarsal orbicularis muscle is responsible for overriding of the eyelid margin The exposed strip of muscle will be removed later

in the procedure

Box 1.4 clinical pearl

Clinical pearl: The orbital septum originates from the inferior orbital rim and inserts at a variable

location, either on the lower eyelid retractor or on the inferior border of tarsus The excision

of the orbital septum should be carried out in an area that is overlying orbital fat Excising the orbital septum near the eyelid margin risks iatrogenic damage of the underlying lower eyelid retractor

n Figure 1.2c The suborbicularis dissection is

developed to the area overlying the orbital septum

A strip of the exposed orbital septum is removed

from the medial canthus to the lateral canthus

exposing the underlying orbital fat pads

n Figure 1.2d The orbital fat is brushed inferiorly

to identify underlying lower eyelid retractor The dehisced lower eyelid retractor is a whitish tendon with a linear broken leading edge Identification can further be aided by asking the patient to look up and down The lower eyelid retractor will follow the excursions of the eyeball

e f

n Figure 1.2e Isolating the lateral canthal

tendon will allow for the correction of horizontal

eyelid laxity Once the tendon is isolated, the excess

tendon is excised

Box 1.5 clinical pearl

Clinical pearl: With the eyelid anesthetized, horizontal eyelid laxity is accentuated and often a

remarkable amount of horizontal eyelid laxity is present Care must be taken not to overly tighten the eyelid horizontally, as it will result in lower eyelid retraction as the lid slides down under the

curvature of the globe

Box 1.6 clinical pearl

Clinical pearl: Over-advancement of the lower eyelid retractors may lead to lower eyelid

retrac-tion This is the primary complication seen in entropion surgery If the eyelid appears to be

retracted with the lower lid retractors attached to the inferior border of tarsus, sutures can be

removed Reattaching the lower eyelid retractors below the inferior tarsal border may be

neces-sary to correct the eyelid retraction

n Figure 1.2f After the horizontal laxity is repaired the dehisced lower eyelid retractor is reattached to the inferior border of the tarsus

shortening of the lateral canthal tendon can be performed to adequately tighten the zontal eyelid

hori-Step 7 Repair of the lower eyelid retractors: Once the eyelid has been tightened

appro-priately the leading edge of the dehisced lower eyelid retractor is reattached to the inferior border of tarsus with three interrupted 5-0 Dexon sutures

Step 8 Marginal orbicularis myectomy: Removing a 4-mm strip of orbicularis muscle

along the inferior border of the skin incision prevents the orbicularis muscle from ing the eyelid margin The muscle is excised from the lateral canthus to the medial can-thus No skin should be excised at the time of the orbicularis muscle removal

overrid-Step 9 Closure: A triangle of excess of skin is often present at the lateral canthus The

excess skin can be excised as necessary The skin is then closed with either an absorbing

or a permanent suture, placing the skin edges into close approximation The lateral canthal angle is closed with a cerclage suture, which places the epithelial-lined upper and lower eyelid margin in approximation The epithelial-lined lateral margins will not adhere but the lateral angle will be appropriately sharp

Entropion repair surgery is quite effective, and has a very high success rate and a very low complication rate Patients can expect ecchymosis and swelling for approximately 1

n Figure 1.2g A strip of orbicularis muscle is

removed from the inferior border of the eyelid

incision Removing the orbicularis muscle will

prevent the muscle from overriding the eyelid

margin

n Figure 1.2h Skin closure may require the

removal of a triangle of skin at the lateral canthus The lateral canthal angle is reformed with a cerclage suture to insure the sharpness of the lateral canthal angle

Further reAdIng

1 Dortzbach RK, McGetrick JJ: Involutional

entropion of the lower eyelid Adv

Ophthalmic Plast Reconstr Surg 1983;

2:257

2 Wesley RE, Collins JW: Combined procedure

for senile entropion Ophth Surg 1983;

14:401

3 Carroll RP, Allen SE: Combined

procedure for repair of involutional

entropion Ophthal Plast Reconstr Surg

1991; 7:123

4 Kersten RC, Hammer BJ, Kulwin DR:

The role of enophthalmos in involutional

entropion Ophthal Plast Reconstr Surg

1997; 13:195

5 Danks JJ, Rose GE: Involutional lower lid entropion: to shorten or not to shorten? Ophthalmology 1998; 105:2065

6 Jordan DR: Ectropion following entropion surgery: an unhappy patient and physician Ophthal Plast Reconstr Surg 1992; 8:41

7 Benger RS, Musch DC: A comparative study of eyelid parameters in involutional entropion Ophthal Plast Reconstr Surg 1989; 5:281

8 Hawes MJ, Dortzbach RK: The microscopic anatomy of the lower eyelid retractors Arch Ophthalmol 1982; 100:1313

9 Wies FA: Spastic entropion Trans Am Acad Ophthalmol Otolaryngol 1955; 59:503

n Needle tip for cautery

n 18-gauge angiocath for shielding the needle tip cautery

n Four-prong skin retractor

n 10 cc syringe

n 27-gauge needle

AnesthesIA

n Tetracaine hydrochloride 0.5% (topical anesthesia)

n 2% lidocaine with 1 : 100,000 epinephrine

n Wydase (sodium hyaluronidase)

Congenital ectropion is a rare condition and is associated with the congenital absence of the lateral canthal tendon

Mechanical ectropion is caused by a mass, physically pulling the eyelid away from the globe

Paralytic ectropion is commonly found in patients with 7th nerve palsy The loss of bicularis tone may cause the eyelid to fall away from the globe A paralytic ectropion caused

or-by Bell’s palsy may spontaneously improve with time If pain caused or-by an ectropion is persistent an ectropion repair is warranted

Cicatricial ectropion is the result of a shortening of the anterior lamella of the eyelid and may be found in burn patients or in patients with dermatologic diseases such as lamellar ichthyosis Cicatricial ectropion is also a common complication of lower eyelid blepharo-plasty, where an over-excision of skin causes a malposition of the eyelid margin A shortage

or shrinkage of the skin pulls the eyelid margin away from the globe The correction of tricial ectropion usually requires a skin graft to lengthen the anterior lamella of the eyelid.Involutional ectropion is the most common type of ectropion The eyelid is stretched horizontally and falls away from the globe Involutional ectropion is seen with increasing

of the eyelid can stretch, leading to the development of ectropion The stretching occurs

in the medial and lateral canthal tendons The tarsus does not elongate with age, but may migrate laterally with a stretched medial canthal tendon

As the lower eyelid elongates, a medial ectropion is usually the first sign of a clinically significant ectropion Epiphora develops when the punctum is no longer in contact with the lacrimal lake With time and increased stretching, the entire eyelid margin loses contact with the globe At this point, symptoms of ocular irritation, redness in addition to tear-ing develop Conjunctivitis and conjunctival hypertrophy and keratinization may be seen

in cases of longstanding uncorrected ectropion resulting from prolonged exposure of the conjunctiva

Box 2.1 ectropion is typically divided into five broad categories:

n Figure 2.1 The etiology of an involutional lower

eyelid ectropion is a stretched lower eyelid When the eyelid elongates, the eyelid falls away from the globe

n Figure 2.2a An ectropion can be

demonstrated by grasping the lower eyelid and

pulling the eyelid away from the globe

a

n Figure 2.2b With increased eyelid laxity, the

eyelid will fail to snap back into its normal anatomic position An ectropion can be demonstrated with the ‘snap test’

b

A snap test determines whether horizontal laxity is present The eyelid is physically distracted from the globe When released, the eyelid should ‘snap’ back into its normal ana-tomic position If the eyelid is stretched horizontally, there will be a noticeable lag before the eyelid returns to its normal position The evaluation of lower eyelid laxity is important

in patients who are being evaluated for cosmetic lower eyelid blepharoplasty Any eyelid laxity may lead to a lower eyelid ectropion following skin removal If horizontal eyelid lax-ity is present, it can be repaired at the time of the blepharoplasty

InvolutIonAl ectropIon repAIr

Step 1 Local anesthesia: The conjunctiva is prepared prior to injection with a

topical anesthetic Local anesthesia is injected into the lateral canthus through the

conjunctiva The needle is directed towards Whitnall’s tubercle Additional

injec-tion is placed through the conjunctiva of the lateral lower eyelid

Step 2 Lateral cantholysis: The lateral canthal tendon is split horizontally

with Westcott scissors The inferior head of the lateral canthal tendon is cut, freeing the lateral eyelid from its attachment to the lateral orbital rim

n Figure 2.3 Local anesthesia is injected though

the conjunctiva The needle is directed towards the

insertion of the lateral canthal tendon at Whitnall’s

tubercle

Box 2.2 clinical pearl

Clinical pearl: A transconjunctival injection is always preferable when preparing for an ectropion

repair The injection site can be partially anesthetized with topical anesthesia before the injection

of local anesthesia

Box 2.3 clinical pearl

Clinical pearl: The inferior head of the lateral canthal tendon is easily palpable and not easily

visualized With the lower eyelid on stretch, the tip of the Westcott scissors can strum the tendon With a full release of the inferior head of the lateral canthal tendon, the lower eyelid can be easily distracted from the lateral orbital rim

n Figure 2.4a A lateral cantholysis is performed

with Westcott scissors The lateral canthus and the lateral canthal tendon are split for several millimeters to allow access to the inferior head of the lateral canthal tendon

a

2.1

10

Step 3 Isolation of the lateral canthal tendon: Removing the epithelium of the eyelid

margin and the overlying skin isolates the lateral canthal tendon An incision directly der the tendon creates a tongue of tendon and tarsus An adequate amount of tendon and tarsus must be isolated prior to shortening the eyelid Pulling the eyelid laterally over the lateral orbital rim will help determine how much tendon and tarsus to isolate

un-Step 4 Shortening the tendon: Pulling the isolated tendon laterally over the lateral

orbital rim will help determine how much tendon to shorten Westcott scissors are used to excise the excess tendon

Step 5 Replacing the tendon: A double-armed 5-0 Dexon suture is used to reattach

the shortened lateral canthal tendon to the periosteum of the lateral orbital rim or to the

n Figure 2.4c Once the lateral canthal tendon

has been isolated, the tendon is pulled laterally to determine the amount of tendon to be excised Excess tendon is removed with Westcott scissors

c

n Figure 2.4b After releasing the inferior head

of the lateral canthal tendon, the tendon is further

isolated by removing the eyelid margin and the

overlying skin

b

Box 2.4 clinical pearl

Clinical pearl: Over-tightening the eyelid in patients with prominent globes may cause the

eyelid to slide down the arc of the globe Increased lateral pulling will lower the eyelid margin and result in inferior scleral show Patients with prominent globes who require ectropion repair may require a spacer to be placed in the eyelid to help elevate the margin

n Figure 2.4d The shortened lateral canthal

tendon is reattached to the lateral orbital rim or to the superior head of the lateral canthal tendon with a double-armed 5-0 Dexon suture

d

intact superior limb of the lateral canthal tendon A horizontal mattress suture is used to complete the anastomosis.

Step 6 Skin excision: After the lateral canthal tendon is reattached, excess skin may

be present at the lateral canthus A triangle of skin can be excised A cerclage of 6-0 mild chromic suture is used to reform the lateral canthal angle The suture places the epithelial-lined eyelid margin of the upper and lower eyelid into close proximity The lateral eyelid margins with the epithelial lining will not adhere, but the orbicularis muscle lateral to the lateral canthal angle will heal in a good position helping to form a sharp canthal angle The remaining skin incision is closed with the 6-0 mild chromic suture

complIcAtIons

Ectropion repair has a high success rate and a very low complication rate Over-tightening the eyelid, especially in patients with prominent globes, may cause the eyelid margin to slip below the arc of the globe resulting in inferior scleral show

Wound dehiscence is another complication that may occur and is treated by re-suturing the wound This procedure is extremely well tolerated and patients typically have a com-plete resolution of their swelling and bruising at one week

n Figure 2.4e The lateral

canthal tendon can be reattached

to either the periosteum of the lateral orbital rim or to the intact superior head of the lateral canthal tendon Care is taken to reform the lateral canthal angle

n Figure 2.4f Shortening the eyelid margin will

often leave a triangle of excess skin at the lateral canthus The skin can be removed with Westcott scissors

e

f

12

Further reAdIng

1 Anderson RL, Gordy DD: The tarsal strip

procedure Arch Ophthalmol 1979; 97:2192

2 Anderson RL: Tarsal strip procedure for

correction of eyelid laxity and canthal

malposition in the anophthalmic socket

Ophthalmology 1981; 88:895

3 Stefanyszyn MA et al.: The histopathology of

involutional ectropion Ophthalmology 1985;

92:120

4 Shore JW: Changes in lower eyelid resting

position movement and tone with age Am

J Ophthalmol 1985; 99:415

5 Dryden RM, Edelstein JP: Lateral palpebral

tendon repair for lower eyelid ectropion

Ophthal Plast Reconstr Surg 1988; 4:115

6 Jordan DR, Anderson RL: The lateral tarsal strip revisited Arch Ophthalmol 1989; 107:604

7 Jordan DR: Ectropion following entropion surgery: an unhappy patient and physician Ophthal Plast Reconstr Surg 1992; 8:41

8 Glat PM, Jelks GW, Jelks EB et al.: Evolution

of the lateral canthoplasty: techniques and indications Plast Reconstr Surg 1997; 100:1396

n Needle tip for cautery

n 18-gauge angiocath for shielding the needle tip cautery

n Four-prong skin retractor

n 10 cc syringe

n 27-gauge syringe

anesthesia

n Tetracaine hydrochloride 0.5% (topical anesthesia)

n 2% lidocaine with 1 : 100 000 epinephrine

n Wydase (sodium hyaluronidase)

Ptosis may have a neurologic etiology In this category are third nerve palsy, myasthenia gravis and Horner’s syndrome If the underlying neurologic cause of ptosis is medically treatable or spontaneous improvement can be expected, then surgery to correct the ptosis

14

is not indicated Often neurologic ptosis requires surgical repair Depending on the levator function, and diagnosis, a ptosis procedure can effectively elevate the eyelid margin and restore lost vision

Ptosis caused by a dehiscence of the levator aponeurosis is the most common cause

of acquired ptosis The levator aponeurosis inserts on the anterior face of tarsus When the aponeurosis becomes disconnected or dehisced, ptosis will become manifest The frequency of levator aponeurotic ptosis increases with age Other causes of aponeurotic ptosis include previous intraocular surgery, trauma, long-term contact lens use and prednisone use

As in all cases of ptosis, patients with a levator aponeurotic dehiscence may notice a loss

of the superior field of vision Patients will elevate their chin, furrow their brows or hold

up the eyelid margin with their fingers in order to regain the vision that is blocked by the ptotic eyelid Diagnostic features of levator aponeurotic ptosis include a high eyelid fold and increased ptosis in down-gaze with a normal levator function

The evaluation of aponeurotic ptosis requires the recognition of unilateral or bilateral ptosis, documentation of visual field loss and photographic documentation Visual field tests to document the loss of the superior visual field can be performed on a Goldman pe-rimeter, an automated visual field machine or by confrontation Documenting the loss of visual field caused by the ptosis and the potential recovery of visual field is demonstrated

by manually elevating the eyelid margin Visual field testing will emphasize the necessity

of ptosis surgery Photographic documentation also is necessary to provide evidence for the need for surgery

Acquired ptosis caused by a dehiscence of the levator aponeurosis is corrected by taching the levator aponeurosis to the superior edge of the tarsus Levator aponeurosis repair can be combined with a blepharoplasty if the ptosis is bilateral and the patient re-quests removal of excess skin and fat In cases of unilateral ptosis no skin, fat or muscle

reat-is removed

Levator aponeurosis repair

Step 1 Local anesthesia: The repair of the levator aponeurosis is performed under

local anesthesia or with minimal sedation Patient cooperation and the ability to open and close the eyelids is an important aspect of this procedure The precise injection of local anesthesia allows for the preservation of levator function and intraoperative evaluation of eyelid height and contour Injecting local anesthesia

at or below the eyelid crease provides adequate anesthesia for the surgery and does not lyze the levator muscle Approximately 2 cc of 2% lidocaine with 1 : 100 000 epinephrine, Wydase and bicarbonate is injected at or below the eyelid crease

para-Step 2 Incision: The eyelid incision is a curvilinear line arcing to 6–7 mm above the

mid aspect of the eyelid ending approximately 3 mm above the punctum and 5 mm above the lateral canthus The eyelid crease incision can be adjusted in regards to the naturally occurring eyelid fold on the opposite eyelid A scalpel is used to incise the skin and orbicu-laris muscle

Box 3.1 clinical pearl

Clinical pearl: For patients with unilateral ptosis, Hering’s law must be taken into consideration

A central midline nucleus in the brain stem controls the height of both eyelids Elevating one eyelid may result in ptosis on the opposite side due to decreased neural output A contralateral eyelid fall can often be demonstrated clinically by manually elevating the most ptotic eyelid and observing the opposite lid

3.1

Step 3 Suborbicularis dissection: After an incision is made through the skin and

or-bicularis muscle, a suboror-bicularis plane is developed The superior edge of the wound is grasped with 0.5 mm forceps and the plane is developed superiorly between the orbicularis muscle and the underlying orbital septum As the flap is elevated, the orbital septum will

be identified lying over the orbital fat The broken edge of the dehisced levator aponeurosis can often be visualized under the orbital septum as a semi-opaque linear structure

n Figure 3.1a A judicious injection of local

anesthesia is performed to maintain levator

function The needle is placed between the eyelid

crease and the eyelid margin A small amount of

lidocaine is used to provide anesthesia

n Figure 3.1b The skin incision is placed at the eyelid crease A scalpel blade is used to incise the skin and orbicularis muscle

Box 3.2 clinical pearl

Clinical pearl: A 4-0 silk suture can be placed at the eyelid margin to help manipulate the eyelid

during surgery

n Figure 3.1c Westcott scissors are used to

develop a plane between the orbicularis muscle

and the underlying orbital septum

Box 3.3 clinical pearl

Clinical pearl: The levator aponeurosis is an opaque white tendon and will obscure the

underlying blood vessels of Muller’s muscle If the vascular Muller’s muscle is visible, then the

levator aponeurosis is dehisced

n Figure 3.1d A strip of orbital septum is

removed from the lateral canthus to the medial canthus exposing the underlying orbital fat

16

Step 4 Opening the septum: A strip of orbital septum is removed across the entire

length of the eyelid incision If identification of the orbital septum and orbital fat is cult, then gentle ballottement of the globe will push fat anteriorly under the septum

diffi-Step 5 Identification of the dehisced levator aponeurosis: A cotton-tipped applicator

stick is used to brush the orbital fat superiorly exposing the underlying levator aponeurosis

At this point, a dehisced levator aponeurosis can usually be readily identified At times, the dehiscence is diaphanous and indistinct In this situation, the patient can be asked to look

up and down The observed movement of the levator aponeurosis can aid in the tion of the dehisced edge of the tendon

identifica-Step 6 Exposing the superior border of tarsus: The superior border of the tarsus must

be identified in order to accurately place the sutures needed to repair the levator sis This is accomplished by removing a strip of the overlying orbicularis muscle along the superior tarsal border

aponeuro-Step 7 Suture placement: Reattaching the dehisced levator aponeurosis to the superior

border of tarsus is the goal of the surgery The placement of the sutures completing this anastomosis will affect the height and contour of the eyelid Three 5-0 Dexon sutures reat-tach tendon to the tarsus At this point, the patient is asked to open and close the eyelids and the eyelid height and contour are assessed A total of three to five sutures are usually necessary to complete the anastomosis and adjust the contour of the eyelid Care must be taken to make sure that the sutures do not penetrate the full thickness of tarsus leading to

a postoperative suture keratosis

n Figure 3.1e The orbital fat is brushed

superiorly exposing the dehisced levator

aponeurosis The levator aponeurosis is an opaque

white tendon and the broken leading edge of

the tendon is identified The identification can be

further aided by having the patient look up and

down The tendon will move with the excursions of

the eyeball

Box 3.4 clinical pearl

Clinical pearl: The orbital septum is attached to the superior orbital rim and to the levator

aponeurosis Inadvertent suturing of the septum to the levator aponeurosis will lead to poor levator function and a postoperative eyelid malposition A complete removal of a strip of the septum will eliminate this possible complication

e

n Figure 3.1f The exposure of the superior

border of tarsus aids in the placement of sutures to repair the dehisced levator aponeurosis A strip of overlying orbicularis muscle is removed exposing the superior border of tarsus

f

Step 8 Skin closure: The skin can be closed with a 6-0 absorbing or non-absorbing

su-ture The eyelid height, contour and symmetry are again assessed prior to the termination

of the case

The recovery from levator aponeurosis ptosis surgery is usually uneventful Patients can expect approximately 1 week of swelling and ecchymosis Applications of ice to the eyelids and restriction of activity often aids with the recovery

compLications

The major complication of levator aponeurosis ptosis surgery is eyelid asymmetry If the postoperative eyelid height and contour do not match, then revision surgery can be planned Inadequate correction of ptosis often is caused by breakage of the sutures placed to reattach the levator to the tarsal border

Overcorrection during levator aponeurosis ptosis surgery is relatively uncommon and judicious removal of sutures will allow the lid height to fall

Postoperative hematoma formation and infections are rare

n Figure 3.1g The leading edge of the dehisced

levator aponeurosis is sutured to the superior

border of tarsus with 5-0 Dexon sutures Having

the patient open and close the eyelids aids in

the assessment of eyelid height and contour

Adjustment in suture placement can be performed

to achieve an appropriate eyelid position

g

Box 3.5 clinical pearl

Clinical pearl: At the time of surgery, the operative eyelid often appears 1 mm or 2 mm higher

than the non-operative side This is caused by anesthesia of the orbicularis muscle Once the

orbicularis muscle has recovered from local anesthesia, the lid height will return to its normal

1 Jones LT, Quickert MH, Wobig JL: The

cure of ptosis by aponeurotic repair Arch

Ophthalmol 1975; 93:629

2 Anderson RL, Beard C: The levator

aponeurosis Arch Ophthalmol 1977;

95:1437

3 Anderson RL: Age of aponeurotic awareness Ophthal Plast Reconstr Surg 1985; 1:77

4 Older JJ: Levator aponeurosis tuck: a treatment for ptosis Ophthalmic Surg 1978; 9:102

18

5 Linberg JV, Vasquez RJ, Chao GM:

Aponeurotic ptosis repair under local

anesthesia Prediction of results from

operative lid height Ophthalmology 1988;

95:1046

6 Berlin AJ, Vestal KP: Levator aponeurosis

surgery Ophthalmology 1989; 96:1033

7 Doxanas MT: Simplified aponeurotic ptosis

surgery Ophthalmic Surg 1992; 23:512

8 Older JJ: Upper lid blepharoplasty and

ptosis repair using a transcutaneous

approach Ophthal Plast Reconstr Surg 1994; 10:146

9 Gausas R: Technique for combined blepharoplasty and ptosis correction Facial Plast Surg 1999; 15:193

10 Jordan DR, Anderson RL: A simple procedure for adjusting eyelid position after aponeurotic ptosis surgery Arch Ophthalmol 1987; 105:1288

n Needle tip for cautery

n 18-gauge angiocath for shielding the needle tip cautery

n 10 cc syringe

n 27-gauge syringe

anesthesia

n Tetracaine hydrochloride 0.5% (topical anesthesia)

n 2% lidocaine with 1 : 100 000 epinephrine

n Wydase (sodium hyaluronidase)

is predictable and demonstratable to both the physician and the patient

Patients with minimal ptosis (1–3 mm) are candidates for a mullerectomy The ative evaluation of these patients involves the installation of a drop of 10% Neo-Synephrine

preoper-into the conjunctival cul-de-sac If the eyelid elevates to an adequate height 5 minutes after the installation of the drop, then these patients are excellent candidates for a mullerectomy

If the eyelid does not elevate, then they are not candidates for a mullerectomy

The 10% Neo-Synephrine test allows for a preoperative glimpse at the postoperative lid height prior to surgery The ability to preselect patients for the mullerectomy procedure ensures an excellent and predictable surgical outcome A mullerectomy will elevate the eyelid to the exact height that the 10% Neo-Synephrine drop elevated the eyelid in 99% of patients The procedure does not alter the function or the contour of the eyelid A muller-ectomy is especially useful in patients who have unilateral ptosis and no desire to have a concurrent blepharoplasty

eye-muLLerectomy

Step 1 Local anesthesia: Prior to the injection of local anesthesia, the

con-junctiva is anesthetized with a topical anesthetic agent Two percent lidocaine

with 1 : 100 000 epinephrine, Wydase and bicarbonate is injected through the

con-junctiva above the superior border of tarsus The needle is directed towards the

superior orbital rim

Step 2 Eyelid eversion: A 4-0 silk suture is placed though the gray line at the mid

as-pect of the upper eyelid margin The suture aids in the eversion of the eyelid on a medium Desmarres retractor

n Figure 3.2a Local anesthesia in injected

through the conjunctiva above the superior

border of tarsus The needle is directed toward

the superior orbital rim

n Figure 3.2b A 4-0 silk suture is placed at the eye lid margin to aid in the eversion of the eyelid and to control the eyelid during the procedure

n Figure 3.2c A marking pen marks a spot 4 mm

above the superior border of tarsus The marks correspond to the medial limbus, the lateral limbus and to the midpoint of the tarsus

a

c

b

3.2

20

Step 3 Measurement: The superior border of tarsus is identified A caliper is used to

measure 4 mm above the superior border of tarsus towards the superior conjunctival de-sac Three spots are placed, 4 mm above the tarsus The central mark is at the middle

cul-of the tarsus and the medial and lateral marks correspond to the medial and lateral limbus

of the eyeball

Step 4 6-0 silk suture placement: A 6-0 silk suture is placed through each of the marked

points The suture incorporates the conjunctiva and Muller’s muscle The conjunctiva and Muller’s are intimately associated, and elevation of the conjunctiva will ensure the suture

is placed through Muller’s muscle

Step 5 Putterman clamp placement: With the conjunctiva and Muller’s muscle

el-evated with the 6-0 silk sutures, a Putterman ptosis clamp is applied to the elel-evated tissue The inferior border of the clamp is placed at the superior tarsal border The tarsus is not incorporated into the clamp The elevated tissue is distributed evenly across the clamp

Step 6 6-0 plain gut suture placement: With the Putterman ptosis clamp secured on

the elevated conjunctiva and Muller’s muscle, the previously placed 6-0 silk sutures are moved Beneath the Putterman ptosis clamp a 6-0 plain gut double-armed suture is woven from the temporal aspects of the eyelid to the medial aspect A total of five or six passes of the suture are needed to reach the medial aspect of the eyelid

re-Step 7 Tissue excision: With the 6-0 plain gut suture pulled inferiorly and the clamp

pulled superiorly, a scalpel is passed beneath the Putterman clamp with the edge of the

n Figure 3.2d A 6-0 silk suture is placed at

each of the marks on the conjunctiva The sutures

incorporates the conjunctiva and Muller’s muscle

d

n Figure 3.2e A Putterman ptosis clamp

envelops the elevated conjunctiva and Muller’s muscle The edge of the clamp is at the superior border of tarsus Tissue to be excised is evenly distributed medially and laterally across the clamp.e

Box 3.6 clinical pearl

Clinical pearl: The final lid height can be adjusted both by increasing the amount of

conjunctiva and Muller’s muscle resected and by incorporating the superior border of the

tarsus in the Putterman ptosis clamp If the 10% Neo-Synephrine test elevates the eyelid

slightly too much, then a smaller conjunctiva and Muller’s resection can be performed If a

little bit extra height is desired, then additional tissue can be incorporated into the clamp

including a small portion of the superior tarsus

blade directed into the bottom of the clamp A smooth excision of the clamped tissue will prevent the inadvertent cutting of the 6-0 plain gut suture.

Step 8 Conjunctival closure: With the tissue incorporated in the clamp excised, the

6-0 plain gut suture is used to close the conjunctiva in a running manner from medial to lateral The suture is tied and the knot is left in the superolateral aspect of the eyelid With this rapidly absorbing suture, corneal foreign body sensations are uncommon

The recovery from a mullerectomy is usually quite rapid, with minimal swelling and pain The final lid height is often not achieved until 2 weeks after the procedure For a day

or two after the procedure, a slight foreign body sensation or painless blood-tinged tears may be encountered A mullerectomy ptosis repair in patients who are carefully chosen is

an excellent operation to correct unilateral ptosis The contour problems encountered with the Fasanella–Servat procedure are eliminated with this procedure since the tarsus is not involved in the surgical resection

n Figure 3.2f After the 6-0 silk sutures have been

removed, a 6-0 plain gut suture is run beneath the

clamp The 6-0 plain gut suture is woven from the

temporal aspect to the medial aspect in a running

manner

n Figure 3.2g The Putterman ptosis clamp

elevates incorporated tissue and a scalpel releases the clamp from the eyelid Care is taken not to cut the 6-0 plain gut suture

n Figure 3.2h Once the conjunctiva and Muller’s

muscle have been excised, the 6-0 plain gut suture is used to close the conjunctiva in a running manner

Box 3.7 clinical pearl

Clinical pearl: If the suture is inadvertently cut at the time of the tissue excision, the opposite

side of the double-armed 6-0 plain gut suture can be used to complete the anastomosis

f

g

h

pe-Further reaDing

1 Putterman AM: A clamp for strengthening

Mueller’s muscle in treatment of ptosis Arch

Ophthalmol 1972; 87:665

2 Putterman AM, Urist MJ: Mueller muscle–

conjunctiva resection Arch Ophthalmol

1975; 93:619

3 Putterman AM, Urist MJ: Mueller’s muscle–

conjunctiva resection ptosis procedure

Ophthalmic Surg 1978; 9:27

4 Weinstein GW, Buerger GF: Modifications

of the Mueller’s muscle–conjunctival

resection operation for blepharoptosis Am

n Needle tip for cautery

n 18-gauge angiocath for shielding the needle tip cautery

n Four-prong skin retractor

n 10 cc syringe

n 27-gauge syringe

anesthesia

n Tetracaine hydrochloride 0.5% (topical anesthesia)

n 2% lidocaine with 1 : 100 000 epinephrine

n Wydase (sodium hyaluronidase)

n Sodium bicarbonate 8.4%

n 9 cc of 2% lidocaine with 1 : 100 000 epinephrine is mixed with 15 units of Wydase and

1 cc of injectable bicarbonate

Congenital ptosis is a common eyelid malposition associated with poor levator function, decreased ptosis in down-gaze, and a poorly developed eyelid fold Approximately 10% of patients with congenital ptosis have an associated Marcus Gunn jaw-winking phenome-non In these patients, an anomalous neural pathway exists between the pterygoid muscles and the levator muscle Contraction of the temporalis muscle will result in eyelid elevation Congenital ptosis can occasionally cause amblyopia in infants, and early intervention is necessary in these cases

Congenital ptosis is caused by either a maldevelopment of the levator muscle or creased innervation of the levator muscle Histologically, a ptotic levator muscle typically has a reduced number of normal-appearing muscle cells The levator muscle may appear to

de-be more of a tendon than a muscle

Levator function is an important criterion in the evaluation of congenital ptosis because the levator function determines the surgical procedure necessary to correct the problem Patients with poor levator function (less than 5 mm) will often require a sling procedure

In patients with moderate to good levator function (greater than 6 mm), a levator resection can be planned

Congenital ptosis repair in children will require general anesthesia Congenital ptosis surgery in adults can be performed under modified local anesthesia with sedation In both general anesthesia and local sedation cases, the ability of the patient to open and close the eyelid on demand will not be present Adequate local anesthesia to perform the surgery will eliminate the levator function in patients undergoing the surgery under sedation Surgeons performing congenital ptosis surgery must be able to perform the surgery without patient cooperation

Based on the preoperative levator function, a plan is made to either resect a certain length of levator muscle or to leave the eyelid height at a predetermined level at the end of the procedure Congenital ptosis surgery is one of the most difficult procedures in oculo-plastic surgery because of the variability of the final eyelid height and contour While resect-ing a specified amount of levator muscle is a useful plan, intraoperative eyelid positioning based on preoperative levator measurements is the best option for excellent results The goal for levator resection surgery is to elevate the eyelid margin in anticipation of a variable postoperative fall

Postoperative fall is a phenomenon in which the eyelid margin relaxes in the days and weeks following levator resection surgery In patients with poor levator function, the post-operative fall is relatively large In patients with good levator function, the postoperative fall

of the eyelid margin is relatively small The eyelid height at the time of surgery must take into account the levator function and the anticipated fall of the eyelid during the postopera-tive recovery phase

Patients with a moderate levator function (6–9 mm) will require more levator muscle resection than patients with good or excellent levator function With large levator resec-tions, the eyelid skin and fat act as a counterbalancing force The skin and fat of the eye-lid push down on the eyelid margin as it is being raised by a levator resection Improved

Box 3.8 relationship between levator function and intraoperative eyelid position

Levator function Intraoperative final eyelid position

24

results in patients with moderate levator function can be gained with a judicious plasty at the time of the levator resection Reducing the bulk of the upper eyelid at the same time as the levator resection allows for a better postoperative eyelid height and contour

blepharo-Levator resection surgery

Step 1 Anesthesia: Children require general anesthesia for levator resection surgery Adult

surgery can be performed under modified local anesthesia with sedation Local anesthesia

is injected at the eyelid crease for intraoperative hemostasis and postoperative pain control Approximately 3 cc of 2% lidocaine with 1 : 100 000 epinephrine and Wydase is used

Step 2 Incision design: The potential eyelid incision is drawn in a curvilinear position

from the medial canthus to the lateral canthus with an approximate 6–7 mm height For unilateral cases of congenital ptosis, care should be taken to match the opposite eyelid fold Patients with moderate levator function (6–9 mm) may benefit from a conservative blepharoplasty at the time of the levator resection A judicious amount of skin and fat can

be removed A 4-0 silk suture is placed at the eyelid margin to aid in intraoperative eyelid manipulation

Step 3 Identifying the orbital septum: After incising the skin and orbicularis muscle

with a scalpel, the plane between the orbicularis muscle and the orbital septum is oped and the orbital is septum is identified If the underlying orbital fat is not visible, then gentle ballottement of the globe will help push the fat anteriorly under the septum

devel-n Figure 3.3a Local anesthesia for levator

resection surgery is helpful when performing

surgery under general anesthesia and necessary

when modified local anesthesia is used With levator

resection surgery, the patient’s ability to open and

close the eyelid during surgery is not necessary

A higher volume of local anesthesia and a deeper

injection can be performed in contrast to levator

aponeurosis surgery

n Figure 3.3b The eyelid crease incision is

designed to match the opposite eyelid if a unilateral ptosis repair is planned

n Figure 3.3c The orbital septum is identified

below the orbicularis muscle and above the orbital fat The septum is avascular and is attached to the underlying levator muscle

c

n Figure 3.3d Illustration

of the orbital septum and its relationship to the orbital fat and levator aponeurosis

Orbital septumoverlyingorbital fatLevator

aponeurosis

overlying

tarsus

d

n Figure 3.3e A strip of orbital septum is removed

in an area with underlying orbital fat Care is taken not to damage the levator aponeurosis The septum

is completely opened from the medial to the lateral aspect of the eyelid incision

e

n Figure 3.3f Illustration of the

relationship between the orbital fat and levator aponeurosis

Tarsal plate

Cut edge oflevatoraponeurosis

Preaponeurotic

fat pad

f

26

n Figure 3.3g The levator aponeurosis is

visualized attached to the anterior face of tarsus

beneath the orbital fat

g

n Figure 3.3h The levator aponeurosis is

disinserted from the anterior face of tarsus with Westcott scissors The medial and lateral horns of the muscle are cut allowing for the development of

a tongue of tendon to be clamped and advanced.h

n Figure 3.3i A Putterman ptosis clamp is placed

on the cut edge of levator aponeurosis The tendon

is separated from the underlying Muller’s muscle and orbital fat is brushed superiorly

i

Step 4 Opening the septum: A strip of orbital septum is removed across the entire

ex-tent of the eyelid exposing the orbital fat Removing a strip of orbital septum will eliminate the possibility of postoperative adhesions between the orbital septum and levator muscle

Step 5 Identifying the levator aponeurosis: In most cases of congenital ptosis, the

leva-tor aponeurosis is attached to the anterior face of the tarsus The levaleva-tor muscle tendon is opaque, and the fine blood vessels of Muller’s muscle are not visible beneath the tendon

Step 6 Disinsertion of the levator aponeurosis: A buttonhole incision is made through

the levator aponeurosis onto the anterior face of tarsus The levator aponeurosis is elevated from the tarsus and cut parallel to the eyelid margin with Westcott scissors The medial and lateral horns are also cut to allow a tongue of levator aponeurosis to be incorporated into a ptosis clamp in preparation for resection

Step 7 Advancement of the levator muscle: The cut distal end of the levator

aponeuro-sis is incorporated into a Putterman ptoaponeuro-sis clamp Cotton-tipped applicator sticks are used

to brush away the orbital fat At this point, Whitnall’s ligament can often be identified in the superior aspect of the orbit

Step 8 5-0 Dexon suture placement: The levator aponeurosis muscle is advanced across

the anterior face of tarsus The advanced muscle is sutured to the anterior superior border

of tarsus with 5-0 Dexon sutures Care is taken not to penetrate the tarsus with sutures, which could lead to postoperative suture keratopathy Placement of the Dexon suture will alter the eyelid height and contour

Step 9 Eyelid position: The final intraoperative eyelid height and contour are

evalu-ated after placing sutures though the advanced levator muscle The desired intraoperative eyelid height is determined by the preoperative levator function With less levator function,

a higher intraoperative eyelid height must be achieved If the desired position of the eyelid is higher or lower, then sutures can be place or replaced until the desired height is achieved Once the desired eyelid height is achieved, the advanced levator aponeurosis is excised.

Step 10 Closure: The skin incision can be closed with an absorbable or non-absorbable

suture Topical antibiotic ointment and lubricants are used after surgery to keep the cornea moisturized Lagophthalmos is expected in the perioperative period No Frost sutures are necessary following levator resection surgery

n Figure 3.3k The advance levator aponeurosis is

attached to the anterior face of the tarsus with 5-0

Dexon sutures At least three sutures are needed to

ensure an adequate eyelid contour

Box 3.9 clinical pearl

Clinical pearl: Whitnall’s ligament is the suspensory ligament of the levator muscle Levator

resection surgery involves removing a variable amount of tissue between Whitnall’s ligament and the tarsus Cutting Whitnall’s ligament and resecting additional muscle usually does not provide

additional eyelid elevation Whitnall’s ligament is the stopping point for levator resection

n Figure 3.3j Illustration of the

Putterman clamp on the cut edge

of the levator aponeurosis

j

Preaponeurotic

fat pad

Levatoraponeurosis

k

n Figure 3.3l Once the eyelid height and contour

have been assessed and optimized, the advanced levator aponeurosis is excised with Westcott scissors

l

28

Bruising, swelling and mild to moderate pain are typically encountered for the first week following levator resection surgery The eyelid will initially appear to be overcorrected, especially in patients with moderate levator function A postoperative fall of the eyelid margin can be expected days to weeks after the operation

compLications

The most common complication in levator resection surgery is undercorrection of the ptosis Even with initial good results, the eyelid may fall in the weeks and months following the operation Undercorrection of congenital ptosis requires additional surgery to further elevate the eyelid Overcorrection of congenital ptosis is uncommon and an initial overcor-rection in the days following surgery may be desirable in patients with less than normal levator function since a postoperative fall of the eyelid margin can be expected If the eyelid margin remains too high after a reasonable waiting period, then further surgery will be needed to improve the eyelid position Conjunctival prolapse is not uncommon in patients with maximal levator resections The conjunctiva of the superior fornix is attached to the levator muscle With a large resection, these attachments may be released leading to conjunctival prolapse If necessary, the prolapsed conjunctiva can be resected

n Figure 3.3m Skin closure can be performed with

either an absorbable or a non-absorbable suture Supertarsal fixation can be incorporated into the eyelid closure if a deep eyelid fold is present on the opposite eyelid

Box 3.11 clinical pearl

Clinical pearl: Excess skin and fat can push down on the eyelid that is being pulled up with a

levator resection For patients with a large levator resection a judicious blepharoplasty, with the removal of a small amount skin and fat can lead to improved postoperative results

m

Further reaDing

1 Anderson RL, Dixon RS: The role of

Whitnall’s ligament in ptosis surgery Arch

Ophthalmol 1979; 97:705

2 Callahan M, Beard C: Ptosis, 4th edition Aesculapius Publishing Company, Birmingham, AL, 1990

Box 3.10 clinical pearl

Clinical pearl: With general anesthesia, the depth of anesthesia must be assessed to make sure

the globes are in a neutral position and looking straight ahead Under deep general anesthesia, the globes are in a neutral position and are not deviated Under light general anesthesia, the eyeball may roll superiorly making it difficult to judge the eyelid position based on the position

of the eyeballs

3 Baldwin HC, Manners RM: Congenital

blepharoptosis: a literature review of the

histology of levator palpebrae superioris

muscle Ophthal Plast Reconstr Surg 2002;

18:301

4 Mauriello J et al.: Treatment of congenital

ptosis by maximal levator resection

Ophthalmology 1986; 93:466

5 Anderson RL, Jordan DR, Dutton JJ:

Whitnall’s sling for poor function

ptosis Arch Ophthalmol 1990;

108:1628

6 Buckman G, Levine MR: Treatment of prolapsed conjunctiva Ophthal Plast Reconstr Surg 1986; 2:33

7 Beard C: Ptosis surgery past, present, future Ophthal Plast Reconstr Surg 1985; 1:69

8 Dutton JJ: A Color Atlas of Ptosis

A Practical Guide to Evaluation and Management Chapter 6, pp 95–104 PG Publishing, Singapore, 1989

n Tetracaine hydrochloride 0.5% (topical anesthesia)

n 2% lidocaine with 1 : 100 000 epinephrine

n Wydase (sodium hyaluronidase)

The Supramid sling mechanically links the eyebrow and the eyelid Contraction of the frontalis muscle elevates the eyebrows and the eyelids in unison The question of whether a patient can tolerate the sling in the first place is another indication for the Supramid sling This procedure is much less complicated than an autogenous fascia lata sling ptosis repair The advantage of the Supramid sling is that it is quick and easy to place and quick and easy

to remove if exposure keratopathy, dry eyes and pain become a problem For adults who require a Supramid sling procedure, the most common complication is the development of

a dry eye and symptoms of exposure keratopathy Children who require a Supramid sling rarely develop exposure symptoms

30

supramiD sLing ptosis repair

Step 1 Anesthesia: A Supramid sling ptosis repair can be performed under

mod-ified local or general anesthesia Patient cooperation is not required Two cent lidocaine with 1 : 100 000 epinephrine, Wydase and bicarbonate is injected through the skin of the upper eyelids and the eyebrows Three cubic centimeters

per-of local anesthesia is used on each side to adequately anesthetize the area

Step 2 Pentagonal suspension: A pentagonal suspension is marked on the eyelid Two

marks are placed 3 mm above the eyelid margin These marks correspond to the medial and lateral limbus of the eyeball Two marks are placed at the superior edge of the eyebrow The marks above the eyebrow are slightly wider than the eyelid marks A final mark is placed at the apex of the pentagon, several millimeters above the mid-aspect of the eyebrow

A stab incision is made with a scalpel at the highest mark on the forehead

Step 3 Protecting the globe: A bone plate and ocular lubricant are used to protect the

globe and prevent inadvertent injury with the passing of the sleigh needle

Step 4 Passing the sleigh needle: The first needle pass is parallel to the eyelid margin

The needle is passed deep to the orbicularis and ideally though the tarsus The needle exits

n Figure 3.4a Local anesthesia is infiltrated into

the eyelid and the eyebrow

n Figure 3.4b A pentagonal suspension is

outlined with a marking pen The eyelid marks are placed on the eyelid corresponding to the medial and lateral limbus of the eyeball

n Figure 3.4c A bone plate is used to protect the

eyeball during the passage of the sleigh needles nparallel to the eyelid margin Care is taken not to Figure 3.4d The sleigh needle is first passed

penetrate the full thickness of the eyelid

3.3

at the previously marked spot on the eyelid Care is taken not to penetrate the full ness of the eyelid Any exposure of the suture will lead to infection and the need to remove the sling.

thick-Step 5 From the eyelid to the eyebrow: The sleigh needle is passed through the original

skin puncture sites in the eyelid margin to the eyebrows The bone plate is removed once the needle has traveled over the superior orbital rim The needles exit from the skin at the mark placed above the eyebrow

Step 6 Joining the suture at the apex on the pentagonal suspension: Once the sleigh

needles have been passed though the eyebrow, they are redirected through the same skin puncture sites and passed to the apex of the pentagon A stab incision has been placed at the apex of the pentagonal suspension to aid in the joining of the suture

Step 7 Adjusting the height and contour: When both sleigh needles have been passed

though the apex of the pentagon, then adjustment of the eyelid height and contour of the eyelid can begin The final position of the eyelid margin should be at the level of the

n Figure 3.4e The sleigh needle is passed

through the puncture site on the eyelid to the mark

on the medial and lateral eyebrow

n Figure 3.4f The sleigh needle is passed back

though the exit wound in the eyebrow to the stab incision at the apex of the pentagonal suspension

n Figure 3.4g Adjustment of the eyelid height and contour is made by pulling on the suture

Box 3.12 clinical pearl

Clinical pearl: The Supramid sutures are placed deeply in the eyelid to prevent the sutures from

being visible through the eyelid skin It is very important that the sutures are not exposed on the skin or conjunctival surfaces

g

32

superior limbus but still in contact with the globe Over-tightening the suture will lift the eyelid off the globe If the eyelid is overcorrected, then the eyelid margin can be grasped with forceps and pulled lower

Step 8 Burying the knot: After the eyelid height and contour has been adjusted, the

sleigh needles are removed from the Supramid suture The two ends of the Supramid ture are tied in multiple knots The knot is trimmed and placed beneath the surface of the skin Care must be taken to make sure that the knot is not exposed at the skin surface Any exposure of the suture will lead to infection requiring the removal of the Supramid sling Usually, one 6-0 mild chromic suture is adequate to close the stab incision overlying the buried knot

su-compLications

The Supramid sling ptosis repair is a good operation to elevate eyelids with poor levator function The procedure is quick and easy Since Supramid is an alloplastic material, any exposure of the material will lead to infection and the Supramid must be removed A Su-pramid sling may not permanently correct the ptosis With time, a slow return of the ptosis may develop Patients who tolerate Supramid slings without the development of exposure symptoms are good candidates for an autogenous fascia lata sling ptosis repair

n Figure 3.4h A single 6-0 mild chromic suture is

used to close the stab incision in the forehead after the Supramid sutures have been tied and placed beneath the skin surface

h

Further reaDing

1 Tillett CW, Tillett GM: Silicone sling in the

correction of ptosis Am J Ophthalmol 1966;

62:521

2 Leone CR, Rylander G: A modified

silicone frontalis sling for the correction of

blepharoptosis Am J Ophthalmol 1978;

85:802

3 Leone CR et al.: Silicone rod frontalis

sling for the correction of blepharoptosis

5 Carter SR, Meecham WJ, Seiff SR:

Silicone frontalis slings for the correction

of blepharoptosis Ophthalmology 1996; 103:623

autogenous Fascia Lata sLing ptosis repair

instruments

n Marking pen

n No 15 scalpel blade

Blade handle

n Castroviejo needle holder

n Needle tip for cautery

n 18-gauge angiocath for shielding the needle tip cautery

n Four-prong skin retractor

n 10 cc syringe

n 27-gauge syringe

anesthesia

n 2% lidocaine with 1 : 100 000 epinephrine

n Wydase (sodium hyaluronidase)

el-autogenous Fascia Lata sLing ptosis repair

Step 1 Anesthesia: Autogenous fascia lata sling ptosis repair requires general

anesthesia Local anesthesia is infiltrated at the surgical sites to provide

intraop-erative hemostasis and prolonged postopintraop-erative pain relief

Step 2 Incision design: Candidates for an autogenous fascia lata sling often

benefit from a conservative blepharoplasty to remove bulky tissue from the

up-per eyelid Elevating the eyelid margin also requires elevating the volume of the upup-per eyelid If excessive skin and fat in the upper eyelid is present, a small amount of skin and fat can be removed A conservative blepharoplasty reduces the bulk of the upper eyelid and allows for a more adequate elevation of the eyelid with a more pleasing postoperative appearance

Step 3 Skin excision: A strip of skin and orbicularis muscle is removed from the eyelid

consistent with a conservative blepharoplasty Three stab incisions are placed above the eyebrow in preparation for a pentagonal suspension

3.4

34

Step 4 Preparing the eyelid: A strip of orbital septum is excised, exposing the

underly-ing orbital fat A portion of orbital fat is removed The orbicularis muscle overlyunderly-ing the anterior tarsus is removed to expose the anterior tarsal plate The anterior tarsal face is the location where the fascia strips will be sutured once they are harvested

Step 5 Fascia lata harvesting: The incision for harvesting fascia lata is placed on the

lateral aspect of the leg, above the knee An imaginary line is drawn between the anterior superior iliac crest and the lateral knee A 15-cm skin incision is placed, along this line approximately two fingerbreadths above the knee A scalpel is used to incise the full thick-ness of the leg skin Subcutaneous fat is brushed away from the underlying fascia lata A U-shaped flap is fashioned from the fascia lata This fascia lata flap is threaded into a fascia stripper The edge of the fascia strip is grasped with a hemostat With firm, gentle, steady pressure, the fascia stripper is advanced under the skin A 10-cm strip of autogenous fascia lata is harvested The harvested fascia is placed on wet gauze and the leg incision closed with interrupted 5-0 nylon sutures

Step 6 Preparing the fascia strips: The harvested fascia lata is defatted and split into

two equal lengths by splitting it lengthwise on a sterile wooden tongue blade The fascia strips should be kept wet at all times

Step 7 Placing the fascia strips: The middle of the fascia strip is fixed to the anterior

superior face of tarsus with three or four interrupted 5-0 Dexon sutures Directly suturing

n Figure 3.5a Autogenous fascia lata sling

ptosis repair requires general anesthesia Local

anesthesia is infiltrated at the surgical sites to

provide intraoperative hemostasis and prolonged

postoperative pain relief

n Figure 3.5b Candidates for an autogenous

fascia lata sling often benefit from a conservative blepharoplasty to remove bulky tissue from the upper eyelid

n Figure 3.5c The fascia lata flap is threaded into a

fascia stripper in preparation for harvesting

c

the fascia strips to the face of tarsus allows precise control of eyelid contour Care must be taken to ensure that the sutures do not penetrate the full thickness of the tarsus.

Step 8 Wright needle: With the eyeball protected with a bone plate, a Wright needle is

passed from the medial and lateral eyebrow stab incision to the eyelid incision The fascia strips are then pulled to the eyebrow stab incision by gently withdrawing the Wright needle The Wright needle is then passed from the apical incision in the pentagonal suspension

n Figure 3.5d Illustration of

the harvesting of autogenous fascia lata

n Figure 3.5e The fascia lata is split into two

equal strips on a wet tongue blade

Box 3.13 clinical pearl

Clinical pearl: Before passing the fascia stripper, the plane between the fascia and the

subcutaneous fat can be developed with Stevens scissors Advancing the scissors on top of

the fascia and spreading the scissors will make the passage of the fascia stripper easier

n Figure 3.5f Suturing the fascia strips to the

36

to the medial and lateral brow stab incisions The fascia strips are brought together at the midline

Step 9 Adjustment of eyelid height and contour: With the autogenous fascia lata strips

meeting at the apex of the pentagonal suspension, the lid height and contour can be

adjust-ed Pulling on the medial or lateral fascia lata strips will elevate the medial or lateral eyelid Removing and replacing the sutures joining the fascia lata strip to the tarsus can further adjust the eyelid contour The final eyelid margin position should be above the visual axis, but still resting on the globe Once an adequate lid height and contour has been achieved, the fascia lata strips are trimmed and joined together with two interrupted 5-0 Dexon su-tures The cut edges of the fascia lata strips are then placed beneath the skin surface at the apex of the pentagon

Step 10 Skin closure: Skin closure is performed with interrupted and running

absorb-able sutures The eyeball must be lubricated in the postoperative period since mos is an inevitable side effect of an autogenous fascia lata sling ptosis repair There is no need to place Frost sutures

lagophthal-Box 3.14 clinical pearl

Clinical pearl: Directly attaching the fascia lata strips to the anterior face of tarsus allows precise

control of the eyelid contour Sutures can be placed and replaced as needed to adjust the eyelid contour

n Figure 3.5g Utilizing the Wright needle to

draw the fascia strips to the forehead incisions

g

n Figure 3.5h Joining the fascia strips at the

apex of the pentagonal suspension

h

n Figure 3.5i Fascia strips at the apical stab

incision

i

Autogenous fascia lata sling ptosis surgery is usually quite satisfactory to both the sician and the patient The patients learn quite rapidly how to control the lid height by utilizing their frontalis muscle.

phy-compLications

Complications encountered with autogenous fascia lata slings include overcorrection of the eyelid margin leading to ocular exposure and an increased risk of corneal ulcers Overcor-rection is treated by further surgery to correct the eyelid margin Undercorrection of the eyelid margin is a common complication, especially if the procedure is only performed unilaterally Patients with amblyopia may neglect the operative side and exert little effort

to elevate the brow and the eyelid Patching the nonamblyopic eye usually is beneficial and motivates the patient to elevate the eyelid In many patients, transient symptoms of dryness and a foreign body sensation are present With added ocular lubrication and time, these symptoms will often disappear

n Figure 3.5j The proper eyelid height, contour

and symmetry after skin closure

j

Further reaDing

1 Crawford JS: Repair of ptosis using frontalis

muscle and fascia lata Trans Am Acad

Ophthalmol Otolaryngol 1956; 60:672

2 Crawford JS: Repair of ptosis using frontalis

muscle and fascia lata: a 20 year review

Ophthalmic Surg 1977; 8:31

3 Broughton WL et al.: Congenital ptosis:

results of treatment using lyophilized

fascia lata for frontalis suspensions

Ophthalmology 1982; 89:1261

4 Wagner RS, Mauriello J et al.: Treatment of

congenital ptosis with frontalis suspension:

a comparison of suspensory materials

7 Tezel E, Numanoglu A: Readjustment of the degree of lift following frontalis sling operation in ptosis: a new and simple method Plast Reconstr Surg 1999; 104:587

4 Canalicular laceration

Instruments

n Nasal speculum

n Bayonet forceps

n Frazier suction cannula

n 0-00 Bowman lacrimal probe

n 1-2 Bowman lacrimal probe

n Castroviejo needle holder

n Needle tip for cautery

n 18-gauge angiocath for shielding the needle tip cautery

n Four-prong skin retractor

n Neo-Synephrine nasal spray

n 2% lidocaine with 1 : 100 000 epinephrine

n Wydase (sodium hyaluronidase)

canal-Medial canthal lacerations are quite common An assessment of the patency of the nalicular system is important prior to skin closure To assess the canalicular system, the punctum of the involved eyelid is dilated A Bowman probe is passed through the canalicu-lar system and the wound is examined If the Bowman probe is visible in the depths of the wound, then a laceration of the canalicular system is present Fluid irrigated through the

ca-involved canalicular system may help detect a canalicular laceration If fluid is seen leaking from the wound, then a canalicular repair can be planned In children, an examination un-der anesthesia may be necessary to determine the patency of the canalicular system Both upper and lower canalicular systems should be evaluated and repaired if lacerated.

cAnAlIculAr lAcerAtIon repAIr

Step 1 Anesthesia: Canalicular lacerations can be repaired both under general

anesthe-sia and modified local anestheanesthe-sia The nose is prepared with Afrin nasal spray in the preoperative holding area A cocaine-soaked cotton pledget is placed in the nose beneath the inferior turbinate After identification of the cut canalicular system 2% lidocaine with

1 : 100 000 epinephrine, Wydase and bicarbonate is injected into the area of the laceration Judicious use of local anesthesia will prevent swelling in the area of injection, which may result in difficulty identifying the cut canalicular system

Step 2 Identifying the cut canalicular system: The upper and lower puncta are both

dilated and a 0-00 Bowman probe is passed though the canalicular system The lacerated canalicular system is confirmed Cotton-tipped applicator sticks are used to gently spread the tissue in the area of the eyelid laceration The cut proximal canaliculus will appear in

n Figure 4.1a A cocaine-soaked cotton pledget

in placed into the nose beneath the inferior turbinate

n Figure 4.1b Gentle exposure of the eyelid

laceration will aid in the identification of the

proximal cut end of the lacerated canalicular

the area corresponding to the cut distal edge of the canaliculus The ostium of the cut proximal end usually has a circular white mucosal lining in contrast to the surrounding erythematous eyelid tissue

Step 3 Passage of the stents: Once the cut canalicular system has been identified, a

stent is passed though the punctum, across the lacerated canalicular system and into the cut proximal canaliculus Once the stent has entered the lacrimal sac, it is further advanced into the nose for retrieval

n Figure 4.1d Illustration of a

stent passing from the punctum into the lacrimal sac, across the cut canaliculus

n Figure 4.1e Intubation of the lacerated

canalicular system begins with the passage of the

Crawford stent across the laceration and into the

lacrimal sac

n Figure 4.1f The Crawford stent is removed from

the nose with a Crawford hook The stent will enter the nose below the inferior turbinate

Box 4.1 clinical pearl

Clinical pearl: An intimate knowledge of eyelid anatomy improves the chance of success for

canalicular system repair Remember the anterior head of the medial canthal tendon is often

visible and is always palpable The canalicular system is always under the anterior head of the

medial canthal tendon

d

Canalicular laceration repair