Ординатура / Офтальмология / Английские материалы / Applied Pathology for Ophthalmic Microsurgeons_Naumann, Holbach, Kruse_2008

Heuser D, Gieler J, Jehnichen R. Ein Verfahren zur kontinuierlichen Registrierung sagittaler Verschiebungen des Iris-Lin- sen-Diaphragmas im tierexperimentellen Modell. 1979. In Naumann GOH and Gloor B loc. cit.

Jonas JB, Holbach LM, Schönherr U, Naumann GOH. Sympathetic ophthalmia after three pars plana vitrectomies without prior ocular injury. Retina 2000; 20: 405 –406

Meythaler FH, Naumann GOH. Direkte Optikusund Retinaverletzung durch retrobulbäre Injektionen. Klin Monatsbl Augenheilkd 1987; 190: 201 – 204

Meythaler FH, Naumann GOH. Intraokulare ischämische Infarkte bei Injektionen in das Lid und parabulbär (ohne Bulbusperforation). Klin Monatsbl Augenheilkd 1987; 190: 474 – 477

Michelson G, Naujoks B, Ruprecht KW, Naumann GOH. Risikofaktoren für die vis a Tergo am “offenen Auge” bei Kata- rakt-Extraktionen in Lokalanästhesie. Fortschr Ophthalmol 1989; 86: 298 – 300

Naumann GOH and Gloor B (eds) Wound Healing of the Eye and its Complications, pp. 71 – 72; 73 – 75, Bergmann Verlag, München, 1980

Naumann GOH, Eisert S, Gieler J, Baur KF. Kontrollierte Hypotension durch Natrium-Nitroprussid bei der Allgemeinnarkose für schwierige intraokulare Eingriffe. Klin Monatsbl Augenheilkd 1977; 170: 922 – 925

Schwinn DA, Afshari NA. [ 1-Adrenergic Antagonists and Floppy Iris Syndrome: Tip of the Iceberg? Ophthalmology 2005; 112:2059 – 2060

Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM, McDonnell PJ. Acute endophthalmitis following cataract surgery. Arch Ophthalmol 2005; 123:613 – 620

Völcker HE, Naumann GOH. Morphology of uveal and retinal edemas in acute and persisting hypotony. Mod Probl Ophthalmol 1979; 20: 34 – 41

L.M. Heindl, L.M. Holbach

3.1.1

Surgical Anatomy

The anterior eyelid lamella includes the skin and orbicularis muscle (Fig. 3.1.1).

The eyelid skin is the thinnest in the body measuring less than 1 mm in thickness. The upper eyelid skin crease is located 6 – 10 mm from the lash line in an adult. It is due to the insertion of the levator aponeurosis into the orbicularis muscle at the superior border of

the upper tarsus. The main difference in the oriental eyelid is the low skin crease due to the low insertion of the levator aponeurosis close to the lashes in the upper eyelid. The lower eyelid crease is usually located 4 – 5 mm from the lash line along the lower border of the inferior tarsal plate.

The anterior eyelid margin holds the eyelashes. Trichiasis is a common and acquired misdirection of eyelashes arising from their normal site of origin. Sweat glands of Moll secrete between the lashes or into the ducts of the glands of Zeiss. The sebaceous glands of Zeiss secrete into the lash follicles. A gray line is visible within the eyelid margin between the anterior and posterior eyelid lamella along the mucocutaneous junction. The openings of the meibomian glands are posterior to the gray line within the posterior eyelid margin. Distichiasis is a rare, congenital growth of an additional row of eyelashes arising from the orifices of the meibomian glands.

The fibers of the orbicularis muscle lie beneath the thin eyelid skin and run circumferentially around the palpebral aperture. The palpebral part of the orbicularis muscle includes the pretarsal and preseptal areas. The orbital part lies over and beyond the orbital rim. Laterally, the pretarsal muscles insert by a common tendon into Whitnall’s tubercle. Medially, the superficial pretarsal muscle fibers contribute to form the anterior or superficial part of the medial canthal tendon which inserts medially on the frontal process of the maxilla immediately adjacent to the anterior lacrimal crest. Deep pretarsal muscle fibers insert into the posterior lacrimal crest immediately behind the lacrimal sac. During eyelid closure (blinking), contraction of the deep pretarsal muscle fibers (Horner’s muscle) pulls the eyelid medially and posteriorly. This leads to shorten-

ing of the canaliculi. The puncta close and tears in the ampullae of the canaliculi are forced medially into the sac.

The tarsal plates represent the skeleton of the eyelids. They lie deep to the orbicularis muscle and consist of dense collagenous connective tissue with elastic fibers and contain many sebaceous glands (meibomian glands). Laterally, they form the fibrous component of the lateral canthal tendon which is in connection with Whitnall’s tubercle inside the lateral orbital rim. Medially, they continue into the medial canthal tendon, which is attached to the anterior and posterior lacrimal crest (Fig. 3.1.2).

The septum fuses with the periosteum and periorbita at the orbital rim superiorly. It passes inferiorly into the eyelids to separate them from the orbit (preseptal and postseptal space) and fuses with the upper or lower eyelid retractors 2 – 4 mm from the tarsus.

The upper eyelid retractors include the striated levator muscle and Müller’s smooth muscle. The levator arises from the orbital roof next to the optic foramen and superiorly to the rectus muscle. It measures about 40 mm in length and ends anteriorly just behind the septum as an aponeurosis. Close to the origin of the aponeurosis the muscle sheath is thickened above the muscle to form the whitish Whitnall’s ligament, which acts as a fulcrum for the action of the levator, inserts into the trochlea of the superior oblique muscle medially and the fibrous capsule of the lacrimal gland and the orbital wall laterally.

The levator aponeurosis inserts anteriorly into the orbicularis muscle at the level of the skin crease and into the anterior surface of the lower tarsal plate. The medial and lateral horns of the levator aponeurosis insert near the canthal tendons (Fig. 3.1.2).

Müller’s smooth muscle arises from the undersurface of the levator near the transition of the striated muscle fibers into the aponeurosis about 15 – 20 mm superior to the upper border of the tarsal plate. It descends between the levator aponeurosis and the conjunctiva to insert into the upper border of the tarsal plate.

The fat pads of the upper eyelid include a medial fat pad that is whitish in color and a central fat pad. The medial palpebral artery is often visible coursing through the whitish medial fat pads of the upper and lower eyelids and should be anticipated in blepharoplasty and anterior orbital operations. The lateral preaponeurotic space is filled by the pinkish gray orbital lobe of the lacrimal gland, which can prolapse into the lateral eyelid due to involutional laxity of the supporting septa.

The lower eyelid retractors arise from the sheath of the inferior rectus muscle and include the capsulopalpebral fascia (equivalent of the levator) and the inferior tarsal muscle (Müller’s muscle). The latter consists mainly of fibrous tissue and a small amount of smooth muscle. The capsulopalpebral fascia arises from the sheath of the inferior rectus muscle, and runs forward to split and enclose the inferior oblique muscle. Thereafter it reunites to form Lockwood’s suspensory ligament, which inserts into the orbital walls near the canthal tendons. The orbital septum fuses with the lower lid retractors below their insertion into the lower tarsal border.

In the lower eyelid the anterior orbital (postseptal) fat is divided into three pockets (medial, central and lateral). The medial fat is whitish in color and lies medial to the inferior oblique muscle. The lateral fat pad extends up to the inferior border of the lacrimal gland. It can prolapse into the preseptal skin and the lateral conjunctival fornix due to tissue laxity.

3.1.1.1 Arterial Supply

The ophthalmic artery gives origin to the lacrimal artery lateral to the optic nerve, to the supraorbital artery and medially to the dorsal nasal and supratrochlear arteries.

In the eyelids the medial and lateral palpebral arteries anastomose to form tarsal arcades on the surface of the upper and lower tarsal plates 2 – 4 mm from the lid margins. In the upper eyelid a second arcade is present at the upper border of the tarsal plate.

Blood from the external carotid system reaches the eyelids through anastomoses with the infraorbital and facial arteries, mainly via the angular artery nasally and the superficial temporal artery. The dense vascular supply of the face includes a network of anastomosing arterial vessels connecting the area of the internal and external carotid artery. The risk of intraarterial injections containing crystalline corticosteroid material can be associated with embolization of the ciliary and cen-

tral retinal artery leading to ischemic infarctions of the retina via central artery occlusion or choroidal infarcts (Kröner, 1981).

3.1.1.2

Venous Drainage

The veins of the eyelids are located within the fornices and drain mainly to the venous network of the middle third of the face. The angular vein lies about 8 mm medial to the inner canthus and can often be seen through the skin. It is formed by the anastomoses of the supraorbital, supratrochlear and frontal veins at the upper nasal angle. It drains posteriorly into the superior orbital vein and inferiorly into the facial vein. In addition, venous blood drains to the inferior ophthalmic vein.

3.1.1.3

Lymphatic Drainage

The lateral two-thirds of the eyelids drain to the preauricular and parotid lymph nodes. The medial thirds drain to the submandibular nodes (Fig. 3.1.3).

3.1.1.4

Motor Nerve Supply

The orbicularis and frontal muscles are supplied by the zygomatic branches from the facial nerve. The levator muscle and the superior rectus muscle are supplied by the superior portion of the third cranial nerve. Müller’s muscle is supplied by the sympathetic nerves travelling along the arteries.

3.1.1.5

Sensory Nerve Supply

The eyelids and orbital contents are supplied by the ophthalmic and maxillary divisions of the fifth cranial nerve. The ophthalmic division of the trigeminal nerve

Fig. 3.1.3. Lymphatic drainage of the eyelids into the preauricular and submandibular nodes. (Modified from Völcker et al. 1980)

divides in the lateral wall of the cavernous sinus into the lacrimal, frontal and nasociliary nerves. These pass through the superior orbital fissure into the orbit. The lacrimal nerve runs forward along the superior border of the lateral rectus muscle to supply the lacrimal gland. It pierces the septum and supplies sensation to the lateral part of the upper lid and conjunctiva.

The frontal nerve runs forward between the periosteum of the orbital roof and the levator muscle. Anteriorly, it divides into the supratrochlear and supraorbital nerves. The supratrochlear nerve supplies the medial part of the eyelid, conjunctiva and skin of the forehead. The supraorbital nerve supplies the upper lid, conjunctiva, forehead and scalp.

The nasociliary nerve crosses medially above the optic nerve. It gives origin to several branches and then divides into the ethmoidal nerve and the supratrochlear nerve. The anterior ethmoidal nerve passes via the anterior cranial fossa to terminate as nasal nerves which supply the tip of the nose including the anterior part of the septum. The infratrochlear nerve passes below the trochlea to supply the medial ends of the lids, conjunctiva, the lacrimal sac and the root of the nose.

The infraorbital nerve is a main branch of the maxillary division of the trigeminal nerve. The maxillary nerve passes forward from the trigeminal ganglion to the foramen rotundum through which it enters the pterygopalatine fossa. The infraorbital nerve branches forward and travels in the floor of the orbita to reach the infraorbital foramen. It branches to supply the skin and conjunctiva of the lower lid, the lower part of the side of the nose and the upper lip.

3.1.2

Surgical Pathology

3.1.2.1

Disorders of Eyelid: Position and Movement

History and clinical examination are essential in the preoperative assessment of disorders in eyelid position and movement (Table 3.1.1). They are also essential for

Table 3.1.1. Differential diagnosis of disorders in eyelid position and movement

Ectropion

Involutional ectropion

Mechanical ectropion

Cicatricial ectropion

Paralytic ectropion (facial palsy)

Congenital ectropion

Entropion

Involutional entropion

Cicatricial entropion

Congenital entropion and epiblepharon

Trichiasis

Aberrant lashes

Distichiasis

Metaplastic lashes

Blepharoptosis

Aponeurotic blepharoptosis

Mechanical blepharoptosis (dermatochalasis, tumor, scar) Myogenic blepharoptosis (progressive external ophthalmoplegia, myasthenia gravis, ocular myopathies)

Neurogenic blepharoptosis (third nerve palsy, Horner’s syndrome, Marcus Gunn jaw-winking)

Dysgenetic blepharoptosis (congenital levator dystrophy with/without superior rectus weakness, blepharophimosis)

Eyelid retraction (commonly in thyroid eye disease)

the correct interpretation of histopathologic results obtained from surgical specimens.

History is essential in determining the duration and quality of symptoms. The position and movement of the eyelids are assessed using margin reflex distance and levator function. Further examination including Bell’s phenomenon, jaw winking phenomenon, exclusion of myasthenia gravis, exophthalmometry, eye displacement, and determining site of skin crease or eyelid laxity (horizontal or vertical) (Fig. 3.1.4) will be helpful. Examination of the outer eye, fundus and orbit may be necessary for final diagnosis.

Histopathologic studies of surgical specimens may confirm or elucidate certain diagnoses such as in blepharoptosis caused by localized amyloid deposits of immunoglobulin lambda-light chains or in myogenic ptosis characterized histopathologically by “ragged red

fibers.” They may also further elucidate the pathogenesis of disorders such as lax eyelids or floppy eyelid syndrome.

If there is entropion, look for cicatricial conjunctival changes to establish the cause (e.g., ocular pemphigoid) before considering surgery. Immunofluorescent studies of conjunctival biopsies may confirm the diagnosis of ocular pemphigoid in up to 50 % of cases. Horizontal laxity may include the medial and/or lateral canthus in both entropion and ectropion.

All symptoms and signs (e.g., levator function) are essential in the assessment of brow ptosis and blepharoptosis.

Surgical management of blepharoptosis may include aponeurotic repair, levator resection, frontalis suspension, and shortening of Müller’s muscle.

Complete preoperative assessment of symptoms and signs with the patient sitting is essential in choosing the type of operation (repair of brow ptosis, blepharoplasty, blepharoptosis and/or ectropion). Blepharoplasty includes the removal of skin, muscle and orbital fat in varying proportions.

3.1.2.1.1

Surgical Pathology and Anatomic Principles of Ectropion Repair

Different subtypes of eyelid laxity have been reported as underlying causes of chronic ocular irritation including papillary conjunctivitis, superficial punctate keratopathy and dry eye.

Ectropion is any form of everted lid margin and may affect both the lower and/or upper lid (e.g., floppy eyelid, lax eyelid syndrome). Involutional ectropion is most commonly due to ageing changes affecting the canthal tendons, the tarsus, the lid retractors and the orbicularis muscle. A reduced tension in the lid is most probably due to a loss of elastin fibers in certain forms of ectropion such as floppy eyelid syndrome (Figs. 3.1.5 – 3.1.8). The most common principles of surgical repair include tightening or shortening procedures centrally, laterally or medially. Successful surgical management depends on the appropriate correction of the underlying anatomical defect.

Fig. 3.1.8. Immunohistochemical localization of matrix metalloproteinases (MMPs) in the tarsal conjunctiva and tarsal plate of floppy eyelid syndrome (a, c) and control specimens (b, d) (original magnification × 50): a MMP-2 is expressed in the conjunctival epithelium (EP), in subepithelial areas of inflammatory infiltrations, in the periphery of blood vessels (arrow), and in stromal areas of lipogranulomatous inflammation (star) in floppy eyelid syndrome specimens. b Loss of MMP-2 expression in control specimens. c MMP-9 can be localized to the conjunctival epithelium (EP), to subepithelial inflammatory infiltrates, some blood vessel walls (arrows), and the stromal connective tissue adjacent to meibomian gland acini (MG) in a floppy eyelid syndrome specimen. d No MMP-9 expression in control specimens. (From SchlötzerSchrehardt et al. 2005)

a

c

b

d

Involutional Ectropion

1.Involutional ectropion centrally: modified Bick procedure (full thickness pentagon excision and direct closure 6 mm in from the lateral canthus)

2.Involutional ectropion laterally: lateral tarsal strip procedure (Fig. 3.1.9)

3.Involutional ectropion medially: syringe the nasolacrimal outflow system to exclude any obstruction prior to surgical correction of the ectropion.

a)Punctal ectropion without horizontal laxity: tarsoconjunctival diamond excision with a closing suture including the lower lid retractors

b)Punctal ectropion with tarsal laxity and an intact medial canthus: full-thickness pentagon excision lateral to the punctum combined with the tarsoconjunctival diamond excision (lazy T procedure)

c)Medial canthal tendon laxity with a punctum movable to the medial limbus: lazy T procedure

d)Medial canthal tendon laxity with a punctum movable lateral to the limbus: plication of the anterior limb of the medial canthal tendon (Fig. 3.1.10)

e)Medial canthal tendon laxity with a punctum movable laterally to the pupil: plication of the

posterior limb of the medial canthal tendon f) Medial canthal tendon laxity with a punctum

movable laterally beyond the pupil: medial canthal resection

Cicatricial Ectropion

Localized skin shortage: Z-plasty; if there is also horizontal laxity, combine with horizontal shortening procedure.

Diffuse Skin Shortage. Skin graft or myocutaneous flap; if there is also horizontal laxity, combine with horizontal shortening procedure (Fig. 3.1.11).

Paralytic Ectropion

Lid tightening procedure either laterally (lateral tarsal strip) (Fig. 3.1.12) or medially (medial canthal resection)

3.1.2.1.2

Surgical Pathology and Anatomic Principles of Entropion and Distichiasis Repair

Entropion of the lower or upper eyelids is any form of inverted lid margin (trichiasis). Determine if there is cicatricial entropion with conjunctival scarring and shortening of the posterior lid lamella. Try to determine its cause such as ocular pemphigoid. Involutional lower lid entropion is thought to be caused by horizontal laxity, disinsertion of the canthal tendons, vertical laxity with weakness of the lower lid retractors and overriding preseptal orbicularis muscle. Successful surgical management depends on the appropriate correction of the underlying anatomical defects. The most common principles of surgical repair include everting sutures, transverse lid split, retractor plication and horizontal shortening. Horizontal shortening is probably the most important factor in the surgical management of involutional lower lid entropion to prevent late recurrences.

Involutional Lower Lid Entropion

1.Involutional lower lid entropion without horizontal laxity:

a)Everting sutures (temporary cure!)

b)Transverse full thickness lid split and everting sutures (Wies procedure)

2.Involutional lower lid entropion with horizontal laxity and disinsertion of the canthal tendons (Fig. 3.1.13): determine if there is disinsertion or laxity of the canthal tendons. If yes, correct these using a tarsal strip procedure which can be combined with everting sutures.

3.Involutional lower lid entropion with horizontal laxity:

a)Transverse full-thickness lid split, everting sutures and horizontal shortening (Quickert procedure)

b)Retractor plication (Jones) and horizontal shortening (Fig. 3.1.14)

Cicatricial Lower Lid Entropion

1.Cicatricial lower lid entropion (minor shortening of posterior lamella): tarsal fracture and everting sutures.

2.Cicatricial lower lid entropion (major or recurrent shortening of posterior lamella) (Fig. 3.1.15): spac-