Ординатура / Офтальмология / Английские материалы / Atlas of Aesthetic Eyelid and Periocular Surgery_Spinelli, Lewis, Elahi_2004

Every patient should have a detailed history before undergoing a physical examination. In addition to eliciting a chief complaint or reason for seeking a surgical consultation from the patient, it is always helpful to have the patient describe his or her complaints while looking in a mirror. The surgeon should obtain a detailed history concerning a history of dry eyes or use of ophthalmic lubricants and artificial tears, contact lens wear and the type of lenses used, thyroid or Graves’ disease, previous refractive surgery, recurrent acute or chronic blepharitis, and other ocular or periocular conditions that are relevant. This detailed history may guide the surgeon in choosing an optimal procedure for the patient. For example, a patient with a history of dry eyes who wears contact lenses will certainly demand greater tear production and tolerate less evaporative loss than the patient who does not present with these underlying demands. A patient with Graves’ disease may have lid retraction, which can be confused with contralateral ptosis. Chronic blepharitis may be exacerbated by eyelid surgery, and prophylactic therapy including antibiotics may be warranted before embarking on eyelid surgery in these patients. Recurrent herpes zoster may serve as a contraindication to periocular laser therapy, and prophylactic antiviral agents may be indicated before embarking on surgical procedures in patients who are predisposed to these outbreaks. Refractive surgery, which has enjoyed recent popularity, predisposes some patients to dry eyes and glare, which may alter indications and choices for cosmetic procedures. The most important aspect of obtaining a good history is to tailor the surgical procedure to the individual patient. This

will serve to diminish the risks as much as possible and maximize the cosmetic and therapeutic aspects of any procedure.

PHYSICAL EXAMINATION

Gross physical examination of the patient can begin by simply viewing the patient at a comfortable distance and noting gross anatomic abnormalities and/or normalcy. For example, in viewing the general periocular region including the upper and lower eyelids, one may be looking for proper anatomic position of the upper and lower lids. The upper lid should divide the width of the upper iris in half. That is, the distance between the corneoscleral junction and the pupillary aperture should be bisected by the upper lid. The lower lid should lie above or at the corneoscleral junction, and upper and lower lids should have a smooth sweeping arch or contour. The highest point or maximal arch of the upper lid should lie at the most medial aspect of the pupillary aperture. This is especially relevant in correcting ptosis and/or lid retraction (discussed in detail later in this text). Inflammatory changes and crusting along the eyelid margins or within the eyelashes are indications of blepharitis. A clear glistening corneal surface and white scleral surface without injection is an indication of a healthy and “happy” eyeball. Conjunctiva that is glistening, flat, gossamer, and without injection or vascular engorgement is also an indication of adequate coverage, lid excursion, and adequate wetting

of the ocular surface. Look for symmetric lid folds that lie at an appropriate height for the patient’s sex and racial makeup. Look carefully at the patient’s superior sulcus and note the level of concavity or convexity and its relationship to eyelid movement. Look for lid margin positional abnormalities such as ectropion or entropion and whether these change with the blinking cycle. For example, patients with involutional entropion will usually present with lax lower eyelids, scleral show, and sometimes a tendency toward ectropion until they are asked to close their eyes forcibly. Almost immediately, their lower eyelid will briskly roll inward against the globe. A “hands on” examination can be initiated once the examining surgeon has a chance to view the patient grossly. It is the attentive observational stage of the examination that allows for a focused and detailed physical review. This will enable the surgeon to make anatomic and physiologic correlates to what is observed and to make a plan for surgery in an efficient manner.

It is appropriate to ascertain and document a baseline visual acuity whether using a standardized Snellen chart at a distance or a hand-held Snellen card. A visual acuity assessment is obtained of the right and left eye without correction and then with correction. It is not uncommon for patients to note or complain of visual acuity changes postoperatively, and it is, therefore, important to document presurgical visual acuity. Occasionally, more discriminating patients will note worsened or improved visual acuity after surgery, and I believe this may be caused by corneal curvature changes related to selective pressure alterations on the surface of the cornea. Astigmatism in a selective meridian can be either alleviated or induced by surgery. The patient is asked to grimace and contract the orbicularis oculi muscles so that facial nerve competence in this region can be assessed. Next, extraocular motion and pupillary function are assessed, with asymmetries being most notable. The lower eyelid is gently pulled down and distracted away from the globe and then allowed to retract back into its regular anatomic position. Delays or asymmetries in the rate or position of the lower lid snap back should be sought. A youthful and intact lower eyelid should position itself against the globe and revert to an

appropriate height within 1 second of distraction. I prefer to grade the snap back as weak, moderate, or brisk. In planning a procedure on a patient with anything but a brisk snap back, one must either increase intrinsic support factors or at least not increase extrinsic distraction forces. The level of zygomatic or malar support should be assessed by visualizing and palpating the orbital rim and malar eminence. On lateral view, one should compare the anterior projection of the eyeball and malar eminence. Patients whose malar eminence lies posterior to their cornea have poor lower lid support and are prone to malposition. In patients with lower eyelid malposition (scleral show) the lower eyelid should be digitally elevated and tightened while concomitantly visualizing the tension created on the suborbital soft tissues. The surgeon should try to assess which lamella (anterior, middle, posterior) is deficient. This will serve to assist the surgeon in planning complementary procedures to the canthopexy such as cheek or midface suspension, interposition grafts, or even skin grafts or external flaps. All patients should be assessed for the quantity of tears produced, and the surgeon should be familiar with how to assess the quality of tears in the difficult, problematic, or complex case.

Baseline tear production should be assessed with the Schirmer test utilizing topical anesthesia and precut standardized No. 41 filter paper strips, which may be obtained from a number of ophthalmic pharmaceutical houses. I prefer to place the patient in a dark room while testing baseline tear production to obviate the effect that ambient light has on tear production. As in the snap back test, one may divide the Schirmer test strip results into three categories, thereby labeling the patient as a low tear producer (0 to 9 mm), moderate tear producer (10 to 20 mm), or high tear producer (21 to 30 mm). Of course, in the case of very high tear producers, one should entertain the possibility of tear drainage problems induced by nasolacrimal obstructive problems. These patients usually present with a spectrum of complaints that may range from simply epiphora to recurrent medial canthal swelling and mucopurulent discharge on the other end of the spectrum.

The ability to withstand evaporation or its staying power is a simplistic assessment of precorneal tear film quality. The surgeon should be familiar with a simple method of evaluating tear film quality: the tear film break-up time. Basically, fluorescein is introduced onto a topically anesthetized eye and, after the patient is allowed to blink and disperse the agent, the eyelids are then held apart and the uniform tear film is visualized over the corneal surface through a cobalt blue filter. The

time period between holding the patient’s eye open and the deterioration of the tear layer (tear film breakup) is an assessment of tear film break-up time and is usually over 20 seconds. Of course, given the trilaminar structure of tears, quality is a multifactorial entity and no specific conclusions concerning the cause of poor tear film quality can be drawn from this quick office test (Fig. 2-1).

The bottom line in evaluating the history and physical examination in each patient is to first identify the problem and second to tailor the surgical procedure according to the specific patient’s findings. There are almost no contraindications to surgery in the periocular region but rather definitive historical and physical signs that indicate an appropriate surgical procedure of choice for an individual patient. Simply put, given four or five surgical procedures that make it possible to

achieve an objective for the patient and surgeon, there is likely only one procedure of choice a surgeon may entertain once the preoperative evaluative tools have been fully utilized. This statement is more likely to be applicable to aesthetic surgery in the periocular region than aesthetic surgery in any other region, given the high functional demands imparted by the globe and associated adnexal structures (Fig. 2-2).

1.A detailed history and physical examination assist the surgeon in choosing an optimal procedure for the patient.

2.It is helpful for patients to point out their aesthetic concerns in a mirror for the surgeon.

3.Chronic blepharitis, Graves’ disease, herpes zoster infection, and refractive surgery are some of the conditions that may predispose to surgical complications.

4.The surgeon can ascertain a significant amount of information by simply studying the macro and micro anatomy of the eyelids and periocular region.

5.A preoperative baseline visual acuity test and Schirmer’s test are useful in assisting the surgeon to choose the most ideal procedure and to follow and treat postoperative problems.

6.The lower lid intrinsic tone can be appreciated using a snapback test.

7.Upper lid position and excursion can assist the surgeon in determining levator function and whether and which ptosis procedure is indicated.

8.There are almost no contraindications to surgery in the periocular region, but an appropriate procedure of choice should be based on specific historical and physical signs.

REFERENCES

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Cheng J, Xu FZ: Anatomic microstructure of the upper eyelid in the Oriental double eyelid. Plast Reconstr Surg 107:16651668, 2001.

Della Rocca R, Bedrossian E, Arthurs B: Ophthalmic plastic surgery: Decision Making and Techniques. New York, McGraw-Hill, 2002.

Gallo SA, Wesley RE, Klippenstein KA, Biesman BS: Cosmetic eyelid surgery. Ophthalmol Clin North Am 13:749-764, 2000.

Gorla MS, Gorla RS: Nonlinear theory of tear film rupture. J Biomech Eng 122:498-503, 2000.

Kim P, Berdoukas P, Francis IC, et al: Kinetic observational exophthalmometry: A simple clinical method of assessing the relative axial positions of the eyes. Ophthalmic Surg Lasers 32:257-259, 2001.

Mulliken JB, Godwin SL, Prachanktam N, Altobelli DE: The concept of the sagittal orbital-globe relationship in craniofacial surgery. Plast Reconstr Surg 97:700-706, 1996.

Olver JM, Sathia PJ, Wright M: Lower eyelid medial canthal tendon laxity grading: An interobserver study of normal subjects. Ophthalmology 102:2321-2325, 2001.

Papas E: Tear break-up time: Clinical procedures and their effects. Ophthalmic Physiol Opt 19:274-275, 1999.

Van Den Bosch WA, Leenders I, Mulder P: Topographic anatomy of the eyelids and the effects of sex and age. Br J Ophthalmol 83:347-352, 1999.

Malpositions of the eyelid, specifically the lower eyelid, include ectropion (turning out of the eyelid margin), entropion (turning in of the eyelid), and retraction (scleral show) and can be grouped together despite a variety of causes. Classically, ectropion and entropion are classified as cicatricial, senile or involutional, mechanical, paralytic, or congenital. Despite these classifications, it is most useful to identify the pathophysiology in each instance and address it appropriately.

Involutional or senescent eyelid malpositions are the most common. Typically, the medial and lateral canthal tendons become lax or attenuated and there is usually an inferior canthal descent, noted especially in the lateral canthus. Clinically, the approximately 15-degree lateral canthal inclination compared with the medial canthus is lost with laxity of the lateral canthal tendon. Usually with frank lower eyelid malpositions, the lateral canthal tendon is at least coplanar with the medial canthal tendon or, in more severe cases, inferiorly declined by 5 to 15 degrees. Descent of the lateral canthal tendon leads to a shortening of the intercommissure distance (the distance between the medial and lateral

commissures). Secondarily, the lower eyelid and the inferolateral aspect of the orbital septum develops redundancy. This results in entropion, ectropion, scleral show, or some combination of the three. Pseudoherniation of orbital fat, most notably in the lateral inferior compartment, occurs from laxity of the orbital septum (Figs. 3-1 and 3-2).

Inferior lid retractor disinsertion or capsulopalpebral fascial dehiscence is associated with involutional or senescent changes. Remember the primary lower lid retractor is merely an extension of the inferior rectus and inferior oblique muscles. A loosening of the attachments of the preseptal orbicularis muscle may cause it to override the pretarsal orbicularis, converting pathophysiology appropriate for ectropion into involutional or senescent entropion. That is, on brisk blinking or forcible closure, the lax lower eyelid rolls in, causing an irritative entropion that may produce corneal ulceration, breakdown, and severe cosmetic deformities. In extreme cases, patients may be forced to tape their lower eyelids down to prevent the rolling-in process.

A

Figure 3-1 A to C, The lateral canthus is normally inclined cephalad by 10 to 15 degrees compared with the medial canthus. Attenuation with aging produces a descent of the lateral canthus so that the lateral canthus rotates (clockwise on the left and counterclockwise on the right) around the medial canthus. The end result is a lateral canthus that is coplanar or declined compared with the medial canthus. As the lateral canthus sags inferiorly, the intercommissure distance shortens (distance between medial and lateral canthus) and the lower lid and inferior lateral septum become lax. This produces scleral show, ectropion or entropion, orbital fat prominence especially laterally, and tear film distribution and drainage problems.

0° 0°

B

0° -10–15°

C

ECTROPION

There has been a plethora of procedures describing different procedures for the treatment of ectropion. In my view only a few are effective in addressing the underlying pathophysiology and that provide reproducibly good results. As described previously, the lower eyelid should spontaneously return back to a normal anatomic position when distracted inferiorly and away from the globe. Eyelid laxity of some degree is present when a spontaneous snap back is absent. The classically described pinch test, in which the examining surgeon can pull the lower eyelid more than 10 mm from the eyeball, may also demonstrate significant eyelid laxity. A positive pinch test is sometimes viewed as an indication for full-thickness lower eyelid shortening. This procedure may be performed transcutaneously or subcutaneously by first elevating a skin muscle flap. In either case, I do not advocate lower eyelid shortening procedures in the treatment of lower eyelid laxity. The pathophysiology of lower eyelid laxity as described previously is due to lateral and medial canthal attenuation along with attenuation of other supportive structures. Shortening the lower eyelid produces further inferomedial displacement of the lateral canthal complex and commissure along with a further diminution in the intercommissure distance. Although the lower eyelid may be tightened, the procedure in and of itself produces the exacerbation of the pathophysiologic processes that led to lower eyelid laxity in the first place. Anatomically tightening the lower eyelid by reversing the patho-

physiology of lower eyelid laxity is the method of choice and appropriate procedures will be described later.

A cicatricial etiology for lower eyelid malposition, especially in patients seeking aesthetic surgery, is rare. Examination of a lower eyelid malposition should include a thoughtful examination and assessment of the external, middle, or internal lamellae of the lower eyelid. Cases in which there is a frank deficiency require grafting of either skin (external layer), mucosa (internal layer), or structural support tissue such as tarsal analogues (middle layer). All other cases of lower eyelid malposition can be addressed using a canthopexy with or without other procedures (Figs. 3-3 and 3-4).

CANTHOPEXY AND

CANTHOPLASTY

Because the mainstay of treatment in almost all cases of lower eyelid malposition includes tightening of either the inferior crus of the lateral canthal tendon or repositioning the entire lateral canthal tendon, it would be most appropriate to elaborate on several techniques that are useful in achieving this end. Technically and for clarity of communication, I will term a procedure that tightens or suspends the lateral or medial canthus, without division of one or more of its elements, a canthopexy. Once division or disinsertion is performed, then I will use the term canthoplasty.