Ординатура / Офтальмология / Английские материалы / Comprehensive Ophthalmology_Khurana_2007

ii.Resection of skin, muscle and tarsus: It corrects moderate degree of entropion associated with atrophic tarsus. In this operation, in addition to the elliptical resection of skin and muscle, a wedge of tarsal plate is also removed (Fig. 14.19A).

iii.Modified Burrow’s operation. It is performed from the conjunctival side after everting the lid. A horizontal incision is made along the whole length of the eyelid, involving conjunctiva and tarsal plate (but not the skin), in the region of sulcus subtarsalis (2-3 mm above the lid margin). The temporal end of the strip is incised by a full thickness vertical incision. Pad and bandage is applied in such a way that the edge of lid is kept everted till healing occurs. After healing, the lashes are directed away from the eye.

iv.Jaesche-Arlt’s operation (Fig. 14.19B): The lid is

split along the grey line up to a depth of 3-4 mm, from outer canthus to just lateral to the punctum. Then a 4 mm wide crescentric strip of skin is removed from 3 mm above the lid margin. After suturing the skin incision, the lash line will be transplanted high. The gap created at the level of grey line may be filled by a mucosal graft taken from the lip.

v.Modified Ketssey’s operation (Transposition of tarsoconjunctival wedge) (Fig.14.20): A horizontal incision is made along the whole length of sulcus subtarsalis (2-3 mm above the lid margin) involving conjunctiva and tarsal plate. The lower piece of tarsal plate is undermined up to lid

margin. Mattress sutures are then passed from the upper cut end of the tarsal plate to emerge on the skin 1 mm above the lid margin. When sutures are tied the entropion is corrected by transposition of tarsoconjunctival wedge.

4. Senile entropion. Commonly used surgical techniques are as follows:

i.Modified Wheeler’s operation: A base down triangular piece of tarsal plate and conjunctiva is resected along with double breasting of the orbicularis oculi muscle (Fig. 14.21).

ii.Bick’s procedure with Reeh’s modification: It is useful in patients with associated horizontal lid laxity. In it a pentagonal full thickness resection of the lid tissue is performed.

iii.Weiss operation. An incision involving skin, orbicularis and tarsal plate is given 3 mm below the lid margin, along the whole length of the eyelid. Mattress sutures are then passed through the lower cut end of the tarsus to emerge on the skin, 1 mm below the lid margin. On tying the sutures, the entropion is corrected by transpositioning of the tarsus (Fig. 14.22).

Fig. 14.21. Modified Wheeler’s operation: A, resection of orbicularis and tarsal plate;

B, double breasting of orbicularis.

iv.Tucking of inferior lid retractors (Jones, Reeh and Wobig operation): It is performed in severe cases or when recurrence occurs after the above described operations. In this operation the inferior lid retractors are strengthened by tucking or plication procedure (Fig. 14.23).

ECTROPION

Out rolling or outward turning of the lid margin is called ectropion.

Types

1.Senile ectropion. It is the commonest variety and involves only the lower lids. It occurs due to senile laxity of the tissues of the lids and loss of tone of the orbicularis muscle (Fig. 14.24).

2.Cicatricial ectropion. It occurs due to scarring of the skin and can involve both the lids (Fig. 14.25). Common causes of skin scarring are: thermal burns, chemical burns, lacerating injuries and skin ulcers.

Fig. 14.24. Senile ectropion lower eyelid.

Fig. 14.25. Cicatricial ectropion lower eyelid.

3.Paralytic ectropion. It results due to paralysis of the seventh nerve. It mainly occurs in the lower lids. Common causes of facial nerve palsy are: Bell’s palsy, head injury and infections of the middle ear.

4.Mechanical ectropion. It occurs in conditions where either the lower lid is pulled down (as in tumours) or pushed out and down (as in proptosis and marked chemosis of the conjunctiva).

5.Spastic ectropion. It is a rare entity, seen in children and young adults following spasm of the orbicularis, where lids are well supported by the globe.

Clinical picture

Symptoms. Epiphora is the main symptom in ectropion of the lower lid. Symptoms due to associated chronic conjunctivitis include: irritation, discomfort and mild photophobia.

Signs. Lid margin is outrolled. Depending upon the degreeofoutrolling,ectropioncanbedividedintothree grades. In grade I ectropion only punctum is everted. IngradeIIlidmarginisevertedandpalpebralconjunctiva is visible while in grade III the fornix is also visible.

Signs of the etiological condition such as skin scars in cicatricial ectropion and seventh nerve palsy in paralytic ectropion may also be seen.

Complications

Prolonged exposure may cause dryness and thickening of the conjunctiva and corneal ulceration (exposure keratitis). Eczema and dermatitis may occur due to prolonged epiphora.

Treatment

1. Senile ectropion. Depending upon the severity, following three operations are commonly performed:

i.Medial conjunctivoplasty. It is useful in mild cases of ectropion involving punctal area. It consists of excising a spindle-shaped piece of conjunctiva and subconjunctival tissue from below the punctal area (Fig. 14.26).

ii.Horizontal lid shortening. It is performed by a full thickness pentagonal excision in patients with moderate degree of ectropion (Fig. 14.27).

iii.Byron Smith’s modified Kuhnt-Szymanowski operation. It is performed for severe degree of ectropion which is more marked over the lateral half of the lid. In it, a base up pentagonal full thickness excision from the lateral third of the eyelid is combined with triangular excision of the skin from the area just lateral to lateral canthus to elevate the lid (Fig. 14.28).

Fig. 14.26. Medial conjunctivoplasty.

Fig. 14.27. Horizontal lid shortening.

Fig. 14.28. Modified Kuhnt-Szymanowski operation.

2.Paralytic ectropion. It can be corrected by a lateral tarsorrhaphy or palpebral sling operation, in which a fascia lata sling is passed in the subcutaneous layer all around the lid margins.

3.Cicatricial ectropion. Depending upon the degree it can be corrected by any of the following operations:

i.V-Y operation. It is indicated in mild degree ectropion. In it a V-shaped incision is given, skin is undermined and sutured in a Y-shaped pattern (Fig. 14.29).

ii.Z-plasty (Elschnig’s operation). It is useful in mild to moderate degree of ectropion.

iii.Excision of scar tissue and full thickness skin grafting. It is performed in severe cases. Skin graft may be taken from the upper lid, behind

the ear, or inner side of upper arm.

4. Mechanical ectropion. It is corrected by treating the underlying cause.

Fig. 14.29. V-Y operation.

5. Spastic ectropion. It is corrected by treating the cause of blepharospasm.

SYMBLEPHARON

In this condition lids become adherent with the eyeball as a result of adhesions between the palpebral and bulbar conjunctiva.

Etiology

It results from healing of the kissing raw surfaces upon the palpebral and bulbar conjunctiva. Its common causes are thermal or chemical burns, membranous conjunctivitis, injuries, conjunctival ulcerations, ocular pemphigus and Stevens-Johnson syndrome.

Clinical picture

It is characterised by difficulty in lid movements, diplopia (due to restricted ocular motility), inability to close the lids (lagophthalmos) and cosmetic disfigurement.

Fibrous adhesions between palpebral conjunctiva and the bulbar conjunctiva and/or cornea (Fig. 14.30) may be present only in the anterior part (anterior symblepharon), or fornix (posterior symblepharon) or the whole lid (total symblepharon).

Complications

These include dryness, thickening and keratinisation of conjunctiva due to prolonged exposure and corneal ulceration (exposure keratitis).

Treatment

1.Prophylaxis. During the stage of raw surfaces, the adhesions may be prevented by sweeping a glass rod coated with lubricant around the fornices several times a day. A large-sized, therapeutic, soft contact lens also helps in preventing the adhesions.

2.Curative treatment consists of symblepharectomy. The raw area created may be covered by mobilising the surrounding conjunctiva in mild cases. Conjunctival or buccal mucosal graft is required in severe cases.

ANKYLOBLEPHARON

Itreferstotheadhesionsbetweenmarginsoftheupper andlowerlids.Itmayoccurasacongenitalanomalyor may result after healing of chemical burns, thermal burns,ulcersandtraumaticwoundsofthelidmargins. Ankyloblepharonmaybecompleteorincomplete.Itis usually associated with symblepharon.

Treatment. Lids should be separated by excision of adhesions between the lid margins and kept apart during healing process. When adhesions extend to the angles, epithelial grafts should be given to prevent recurrences.

BLEPHAROPHIMOSIS

In this condition the extent of the palpebral fissure is decreased. It appears contracted at the outer canthus.

Etiology. It may be congenital or acquired, due to formation of a vertical skin fold at the lateral canthus (epicanthus lateralis) following eczematous contractions.

Treatment. Usually no treatment is required. In marked cases, canthoplasty operation is performed.

LAGOPHTHALMOS

This condition is characterised by inability to voluntarily close the eyelids.

Etiology. It occurs in patients with paralysis of orbicularis oculi muscle, cicatricial contraction of the lids, symblepharon, severe ectropion, proptosis, following over-resection of the levator muscle for ptosis, and in comatosed patients. Physiologically some people sleep with their eyes open (nocturnal lagophthalmos)

Clinical picture. It is characterised by incomplete closure of the palpebral aperture associated with features of the causative disease.

Complications include conjunctival and corneal xerosis and exposure keratitis.

Treatment. To prevent exposure keratitis artificial tear drops should be instilled frequently and the open palpebral fissure should be filled with an antibiotic eye ointment during sleep and in comatosed patients. Soft bandage contact lens may be used to prevent exposure keratitis.

Tarsorrhaphy may be performed to cover the exposed cornea when indicated. Measures should be taken to treat the cause of lagophthalmos, wherever possible.

TARSORRHAPHY

In this operation adhesions are created between a part of the lid margins with the aim to narrow down or almost close the palpebral aperture.

It is of two types: temporary and permanent.

1. Temporary tarsorrhaphy

Indications : (i) To protect the cornea when seventh nerve palsy is expected to recover. (ii) To assist healing of an indolent corneal ulcer. (iii) To assist in healing of skin-grafts of the lids in the correct position.

Surgical techniques. This can be carried out as median or paramedian tarsorrhaphy (Fig. 14.31).

1.Incision. For paramedian tarsorrhaphy, about 5

mmlong incision site is marked on the corresponding parts of the upper and lower lid margins, 3-mm on either side of the midline. An incision 2-mm deep is made in the grey line on the marked site and the marginal epithelium is then excised taking care not to damage the ciliary line anteriorly and the sharp lid border posteriorly.

2.Suturing. The raw surfaces thus created on the opposing parts of the lid margins are then sutured with double-armed 6-0 silk sutures passed through

arubber bolster.

Fig. 14.31. Surgical technique of paramedian tarsorrhaphy

2. Permanent tarsorrhaphy

Indications. (i) Established cases of VII nerve palsy where there is no chance of recovery; and (ii) established cases of neuroparalytic keratitis with severe loss of corneal sensations.

Technique. It is performed at the lateral canthus to create permanent adhesions. The eyelids are overlapped after excising a triangular flap of skin and orbicularis from the lower lid and corresponding triangular tarso-conjunctival flap from the upper lid.

BLEPHAROSPASM

It refers to the involuntary, sustained and forceful closure of the eyelids.

Etiology. Blepharospasm occurs in two forms:

1.Essential (spontaneous) blepharospasm. It is a rare idiopathic condition involving patients between 45 and 65 years of age.

2.Reflex blepharospasm. It usually occurs due to reflex sensory stimulation through branches of fifth nerve, in conditions such as : phlyctenular keratitis, interstitial keratitis, corneal foreign body, corneal ulcers and iridocyclitis. It is also seen in excessive stimulation of retina by dazzling light, stimulation of facial nerve due to central causes and in some hysterical patients.

Clinical features. Persistent epiphora may occur due to spasmodic closure of the canaliculi which may lead to eczema of the lower lid. Oedema of the lids is of

frequent occurrence. Spastic entropion (in elderly people) and spastic ectropion (in children and young adults) may develop in long-standing cases. Blepharophimosis may result due to contraction of the skin folds following eczema.

Treatment. In essential blepharospasm Botulinum toxin, injected subcutaneously over the orbicularis muscle, blocks the neuromuscular junction and relieves the spasm. Facial denervation may be required in severe cases. In reflex blepharospasm, the causative disease should be treated to prevent recurrences. Associated complications should also be treated.

PTOSIS

Abnormal drooping of the upper eyelid is called ptosis. Normally, upper lid covers about upper one-sixth of the cornea, i.e., about 2 mm. Therefore, in ptosis it covers more than 2 mm.

Types and etiology

I. Congenital ptosis

It is associated with congenital weakness (maldevelopment) of the levator palpebrae superioris (LPS). It may occur in the following forms:

1.Simple congenital ptosis (not associated with any other anomaly) (Fig. 14.32A).

2.Congenital ptosis with associated weakness of superior rectus muscle.

3.As a part of blepharophimosis syndrome, which comprises congenital ptosis, blepharophimosis, telecanthus and epicanthus inversus (Fig. 14.32B).

4.Congenital synkinetic ptosis (Marcus Gunn jawwinking ptosis). In this condition there occurs retraction of the ptotic lid with jaw movements i.e., with stimulation of ipsilateral pterygoid muscle.

II. Acquired ptosis

Depending upon the cause it can be neurogenic, myogenic, aponeurotic or mechanical.

1.Neurogenic ptosis. It is caused by innervational defects such as third nerve palsy, Horner’s syndrome, ophthalmoplegic migraine and multiple sclerosis.

2.Myogenic ptosis. It occurs due to acquired disorders of the LPS muscle or of the myoneural junction. It may be seen in patients with

A

B

Fig. 14.32. Congental ptosis: A, simple;

B, blepharophimosis syndrome.

myasthenia gravis, dystrophia myotonica, ocular myopathy, oculo-pharyngeal muscular dystrophy and following trauma to the LPS muscle.

3.Aponeurotic ptosis. It develops due to defects of the levator aponeurosis in the presence of a normal functioning muscle. It includes involutional (senile) ptosis, postoperative ptosis (which is rarely observed after cataract and retinal detachment surgery), ptosis due to aponeurotic weakness associated with blepharochalasis, and in traumatic dehiscence or disinsertion of the aponeurosis.

4.Mechanical ptosis. It may result due to excessive weight on the upper lid as seen in patients with lid tumours, multiple chalazia and lid oedema. It may also occur due to scarring (cicatricial ptosis) as seen in patients with ocular pemphigoid and trachoma.

Clinical evaluation

Following scheme may be adopted for work up of a ptosis patient:

I. History. It should include age of onset, family history, history of trauma, eye surgery and variability in degree of the ptosis.

II. Examination

1.Exclude pseudoptosis (simulated ptosis) on inspection. Its common causes are: microphthalmos, anophthalmos, enophthalmos and phthisis bulbi.

2.Observe the following points in each case:

i.Whether ptosis is unilateral or bilateral.

ii.Function of orbicularis oculi muscle.

iii.Eyelid crease is present or absent.

iv.Jaw-winking phenomenon is present or not.

v.Associated weakness of any extraocular muscle.

vi.Bell’s phenomenon (up and outrolling of the eyeball during forceful closure) is present or absent.

3.Measurement of amount (degree) of ptosis. In unilateral cases, difference between the vertical height of the palpebral fissures of the two sides indicates the degree of ptosis (Fig. 14.33). In bilateral cases it can be determined by measuring the amount of cornea covered by the upper lid and then subtracting 2 mm. Depending upon its amount the ptosis is graded as

4. Assessment of levator function. It is determined by the lid excursion caused by LPS muscle (Burke’s method). Patient is asked to look down, and thumb of one hand is placed firmly against the eyebrow of the patient (to block the action of frontalis muscle) by the examiner. Then the patient is asked to look up and the amount of upper lid excursion is measured with a ruler (Fig. 14.34) held in the other hand by the examiner. Levator function is graded as follows:

5. Special investigations. Those required in patients with acquired ptosis are as follows:

i.Tensilon test is performed when myasthenia is suspected. There occurs improvement of ptosis with intravenous injection of edrophonium (Tensilon) in myasthenia.

Fig. 14.33. Measurement of degree of ptosis in millimetres.

Fig. 14.34. Assessment of levator function : A, Looking down; B, Looking up.

ii.Phenylephrine test is carried out in patients suspected of Horner’s syndrome.

iii.Neurological investigations may be required to find out the cause in patient with neurogenic ptosis.

6. Photographic record of the patient should be maintained for comparison. Photographs should be taken in primary position as well as in up and down gazes.

Treatment

I. Congenital ptosis. It almost always needs surgical correction. In severe ptosis, surgery should be performed at the earliest to prevent stimulus deprivation amblyopia. However, in mild and moderate ptosis, surgery should be delayed until the age of 3- 4 years, when accurate measurements are possible. Congenital ptosis can be treated by any of the following operations:

1.Fasanella-Servat operation. It is performed in cases having mild ptosis (1.5-2mm) and good levator function. In it, upper lid is everted and the upper tarsal border along with its attached Muller’s muscle and conjunctiva are resected (Fig. 14.35).

2.Levator resection. It is a very commonly performed operation for moderate and severe grades of ptosis. It is contraindicated in patients having severe ptosis with poor levator function.

Amount of levator resection required: Most of the surgeons find it out by adjusting the lid margin in

relation to cornea during operation on the table in individual case. However, a rough estimate in different grades of ptosis is as follows:

Moderate ptosis

Level of LPS Amount of LPS to be

Function resected Good 16-17 mm (minimal) Fair18-22 mm (moderate)

Poor 23-24 mm (maximum)

Severe ptosis

Fair levator 23-24 mm (maximum function LPS resected)

Techniques. Levator muscle may be resected by either conjunctival or skin approach.

i.Conjunctival approach (Blaskowics’ operation): This technique is comparatively easy but not suitable for large amount of resection. In it LPS muscle is exposed by an incision made through the conjunctiva near the tarsal border, after the upper lid is doubly everted over a Desmarre’s lid retractor (Fig. 14.36).

ii.Skin approach (Everbusch’s operation): It is a more frequently employed technique. It allows comparatively better exposure of the LPS muscle through a skin incision along the line of future lid

fold (Fig. 14.37).

3. Frontalis sling operation (Brow suspension): This is performed in patients having severe ptosis with no levator function. In this operation, lid is anchored to the frontalis muscle via a sling (Fig. 14.38). Fascia lata or some non-absorbable material (e.g., supramide suture) may be used as sling.

Fig. 14.37. Skin approach for levator resection.

Fig. 14.38. Frontalis sling operation.

II. Acquired ptosis. Efforts should be made to find out the underlying cause and if possible treat it. In neurogenic ptosis conservative treatment should be carried out and surgery deferred at least for 6 months. Surgical procedures (when required) are essentially the same as described for congenital ptosis. However, the amount of levator resection required is always less than the congenital ptosis of the same degree. Further, in most cases the simple Fasanella-Servat procedure is adequate.

TUMOURS OF THE LIDS

Almost all types of tumours arising from the skin, connective tissue, glandular tissue, blood vessels, nerves and muscles can involve the lids. A few common tumours are listed and only the important ones are described here.

Classification

1.Benign tumours. These include; simple papilloma, naevus, angioma, haemangioma, neurofibroma and sebaceous adenoma.

2.Pre-cancerous conditions. These are solar keratosis, carcinoma-in-situ and xeroderma pigmentosa.

3.Malignant tumours. Commonly observed tumours include squamous cell carcinoma, basal cell carcinoma, malignant melanoma and sebaceous gland adenocarcinoma.

BENIGN TUMOURS

1. Papillomas

These are the most common benign tumours arising from the surface epithelium. These occur in two forms: squamous papillomas and seborrhoeic keratosis (basal cell papillomas, senile verrucae).

i.Squamous papillomas occur in adults, as very slow growing or stationary, raspberry-like growths or as a pedunculated lesion, usually involving the lid margin. Its treatment consists of simple excision.

ii.Seborrhoeic keratosis occurs in middle-aged and older persons. Their surface is friable, verrucous and slightly pigmented.

2. Xanthelasma

These are creamy-yellow plaque-like lesions which frequently involve the skin of upper and lower lids near the inner canthus (Fig. 14.39). Xanthelasma occurs more commonly in middle-aged women. Xanthelasma represents lipid deposits in histiocytes in the dermis of the lid. These may be associated with diabetes mellitus or high cholesterol levels.

Treatment: Excision may be advised for cosmetic reasons; but recurrences are common.

3. Haemangioma

Haemangiomas of the lids are common tumours. These occur in three forms: