Intraoperative Surgical Techniques and Pearls—Special Considerations
Alexander Berlin in Mohs and Cutaneous Surgery, 2014
The primary purpose of the eyelid is to protect the globe and to maintain a moist environment for the cornea. The principal goal in repairing defects of the lid and periorbital tissue is to fully restore these functions as well as to achieve a pleasing aesthetic outcome. Knowledge of lid anatomy is paramount to successfully accomplish these goals. It is useful for the surgeon to consider the eyelid as composed of posterior, middle, and anterior lamellae (Figure 3.1). The posterior lamella is the portion of the eyelid closest to the globe. It is composed of the conjunctiva that covers the inner surface of the lid and is continuous with that of the globe. The middle lamella consists of the firm connective tissue of the tarsal plate, as well as lid retractors and the orbital septum. The tarsus is important for providing structure and form to the lids. The anterior lamella comprises the pretarsal portion of the palpebral orbicularis oculi muscle and a thin layer of skin covering the anterior surface of the lid. The division between the anterior and posterior lamellae is demarcated along the lid margin by the gray line. This structure lies posterior to the lash line and anterior to the orifices of the Meibomian glands. It is important for the surgeon to visualize the gray line to ensure proper alignment during lid reconstruction (Figure 3.2).
Prenatal Cocaine Exposure and the Eye
Richard J. Konkol, George D. Olsen in Prenatal Cocaine Exposure, 2020
An unfortunate consequence of persistent eyelid edema may be bilateral visual deprivation. In one of our patients, eyelid edema was so massive that eye closure persisted for more than two months. The edema was not amenable to surgery or medical management. Ultimately we resorted to the use of eyelid speculums to keep the eyelids open for an hour or two per day. The edema resolved, and although the baby did not exhibit sensory deprivation nystagmus, the ultimate visual outcome still remains uncertain. In another case, a child presented with nystagmus in the setting of a clear history of prolonged eyelid edema after in utero cocaine exposure. In this particular child, cocaine exposure and eyelid edema could have played a pivotal role in leading to failure of a good visual fixation reflex.
Botulinum Toxins
Ali Pirayesh, Dario Bertossi, Izolda Heydenrych in Aesthetic Facial Anatomy Essentials for Injections, 2020
The classic five-point pattern of injection for frown lines suggests 4 U aliquots per point (0.1 mL when the 1.25 mL dilution is used), the total dose being 20 U. This modality is an excellent guide for beginners. However, individualized patterns and doses will ensue with increasing experience. There are two golden rules for the treatment of frown lines: The first is to inject deeply at the bony origin of the medial corrugator, with the lateral injections being placed superficially. This will significantly reduce the risk of eyelid ptosis. The second is to keep the corrugator injection points close to the brow in order to minimize diffusion to the lower frontalis fibers. This will preserve brow position, preventing brow ptosis.
The ‘over-the-top’ modified Cutler–Beard procedure for complete upper eyelid defect reconstruction
Published in Orbit, 2019
Saul N. Rajak, Raman Malhotra, Dinesh Selva
The upper eyelid has a complex anatomical structure to enable it to make large excursions which protect the eye and spread tears while allowing vision. Reconstruction of large upper lid defects is challenging. The goal is to replace the anterior and posterior lamella with like-for-like tissue to restore function and cosmesis. Numerous surgical procedures are described in the literature. The Cutler–Beard lower lid flap is used for the reconstruction of defects of greater than 70% of the upper eyelid.1 The originally described procedure brings a full thickness lower lid flap harvested from 4 mm inferior to the lower lid margin under the remaining ‘bridge’ of lower lid to fill the upper lid defect. The flap is divided 6–8 weeks later. The potential limitations and complications of this procedure include prolonged occlusion, lower lid instability from lower lid retractor disruption and upper lid entropion from inadequate posterior lamella replacement. Various modifications have been described including the following: (1) early division (2 weeks) of the flap,2 (2) incorporation of an upper lid stiffener graft, such as ear cartilage and donor sclera,3 and (3) anterior only lower lid flap used to support a posterior lamella tarso-conjunctival graft from the contralateral upper lid.2
Differences of a Single Injection of Botulinum Toxin A between Infantile and Nonaccommodative Esotropia
Published in Journal of Binocular Vision and Ocular Motility, 2020
Rita Gama, Joana Chambel Santos, Tânia Yang Nom, Daniela Cândido da Costa
The widespread use of BTA for the treatment of children’s esotropia has found several obstacles especially related to the side-effects.2,6,18 The injection at the medial rectus will paralyze it temporarily, and the previous esodeviation became exo. Part of the product diffuses to the neighbor muscles, the levator palpebrae superioris muscle of the upper eyelid and the vertical recti, weakening their effect. Transient ptosis and vertical deviation are common, especially in smaller children with smaller orbit size, creating a disfiguring appearance on the first week after treatment (Table 3). All these side-effects have disappeared after 6 months. Our patients had a remarkably high rate of ptosis, even after recommending the patient’s head in upright position during the post-injection 4 hours. Ptosis and vertical deviation have never been reported as irreversible, and exotropia or overcorrection has been reported only in 2.8% to 4.8% of the cases.19–21 It has been demonstrated that the frequency of the side-effects increases in the dose of toxin injected higher than 10 U, which we haven´t used.18 The reversibility of these effects should be emphasized to the parents and relatives.
Single-stage repair of large full thickness lower eyelid defects using free tarsoconjunctival graft and transposition flap: experience and outcomes
Published in Orbit, 2022
Chau M. Pham, Kevin D. Heinze, Mariah Mendes-Rufino-Uehara, Pete Setabutr
Average patient follow-up time was 36.7 weeks (range 3–129, SD = 48.1). Flap complications were rare and included early necrosis in one patient in whom bolsters were used which resolved without issue. One patient experienced lower lid retraction post-operatively with 1.5 mm of lagophthalmos, while the others maintained good lid position and contour. Donor site complications were also rare and included one instance of pyogenic granuloma formation at post-operative month 3 which was excised. Mild asymmetry in upper eyelid appearance caused by a deepening of the sulcus or elevation of the ipsilateral eyelid crease was noted in most cases. Although blepharoplasty on the contralateral upper eyelid was offered, all patients were satisfied with their appearance and deferred further surgery.
Related Knowledge Centers
- Blinking
- Eye
- Eyelash
- Levator Palpebrae Superioris Muscle
- Nictitating Membrane
- Skin
- Tears
- Epicanthic Fold
- Vestigiality
- Plica Semilunaris of Conjunctiva