Ординатура / Офтальмология / Английские материалы / Moorfields Manual of Ophthalmology_Jackson_2007

Facial nerve palsy

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Treatment

■Systemic

1.Medical management of IFNP is controversial. Cochrane Database reviews indicate no significant benefit from either systemic steroids (2002) or aciclovir (2001).

■Ocular

1.Corneal protection

a. Topical lubricants, e.g. G. Viscotears hourly and Oc. Lacrilube nocte.

b. Botulinum toxin to the upper lid to induce temporary ptosis (5 iu Botox with a short, 27-gauge needle either transconjunctivally at the upper border of the tarsus, or transcutaneously through the skin crease).

c. Temporary tarsorrhaphy with sutures, cyanoacrylate glue, or surgery. A medial (pillar) surgical tarsorrhaphy is preferable to a lateral tarsorrhaphy, because the peripheral visual field is maintained.

d. Lower lid tightening (lateral tarsal strip, which may be ‘augmented’, i.e. placed higher on the orbital rim to aid tear drainage).

e. Lower lid elevation with autogenous fascia lata passed through the length of the lid and sutured medially to the medial canthal tendon, and laterally to the orbital rim periosteum.

f. Medial (Lee) canthoplasty, medial canthal fixation suture, or medial wedge resection (placing anchoring suture to the periosteum of the posterior lacrimal crest).

g. Upper lid loading with a gold weight (typically for nocturnal lagophthalmos).

h. Upper lid lowering (Müller’s muscle excision for 1–3 mm retraction, or posterior or anterior approach levator recession for larger degrees of retraction).

i. Sural nerve grafting to improve facial tone.

2. Epiphora

a. Residual epiphora is managed once ectropion or lid laxity has been addressed.

b. Gustatory epiphora: botulinum toxin to the lacrimal gland (Dysport 20 units transcutaneously, in three

divided doses in one clinic visit), or direct surgical denervation of the orbital lobe of the lacrimal gland.

c. Dacryocystorhinostomy (DCR) to reduce lacrimal outflow resistance.

d. Lester Jones tube if the patient remains symptomatic at least 9 months following DCR.

3. Aberrent regeneration syndromes

a. These often respond to low-dose botulinum toxin injections.

4. Cosmesis

a. External direct brow pexy (skin and muscle excision with anchoring suture to the periosteum) or endoscopic brow lift (incision above the hair line).

b. Lower lid blepharoplasty if there is tissue laxity and oedema.

c. Angular sling to raise the mouth.

d. Temporalis muscle transfer to create an encircling sling of fascia, passing laterally to medially in both lids.

e. Facial reanimation may be achieved by cross nerve anastomosis.

Follow-up If there is no recovery of Bell’s palsy within 6 weeks reconsider the diagnosis: 10% of patients with acute facial nerve palsy have a treatable lesion.

Discharge only when all factors contributing to corneal exposure have been addressed and the patient is stable on topical lubricants. This may take months to decades.

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Ptosis

Ptosis

Background Ptosis describes a low position of the upper lid on the globe. It is not a diagnosis. Children with ptosis are at risk of amblyopia if the eyelid covers any part of the pupil, and may require urgent brow suspension.

Aetiology

part of the upper visual field, then consider early intervention, because a full visual field is required for normal visual development. Where there is a mild to moderate ptosis without risk of amblyopia, correction may be delayed until the age of awareness (4–5 years). Otherwise, surgery may reasonably be delayed until early adult years. In adults, bilateral ptosis may cause functional blindness, and warrants early intervention. Surgical techniques depend on the cause:

■Congenital ptosis with levator function (LF) ≥5 mm: levator muscle advancement on the tarsus (anterior or posterior approach).

■Congenital levator dystrophy with poor LF (<5 mm): brow suspension with autogenous tissue in children >4 years of age (e.g. autogenous fascia lata). For the younger patient, use synthetic material, e.g. Nylon (Supramid) in children of a few months old, mersilene mesh in children up to 4 years old.

■Congenital levator dystrophy associated with jaw wink: bilateral levator disinsertion and autogenous fascia lata brow suspension. Informed discussion with the parents/carers is essential. Unilateral surgery may cause asymmetry.

■Involutional ptosis: repair/advancement of the levator aponeurosis onto the tarsus.

■Myopathy including chronic progressive external

ophthalmoplegia and myaesthenia gravis : brow suspension if LF < 8 mm (<5 mm in children) because of the risk of corneal exposure with an aponeurosis advancement (due to orbicularis

weakness, reduced Bell’s phenomenon, and reduced upgaze). Use local anaesthesia ± sedation, with nonautogenous material, due to the risk of cardiac conduction defects with general anaesthesia. If the patient has reasonable frontalis effort, brow suspension with mersilene mesh may be performed. Aim to leave the lid height similar to the preoperative level, allowing for frontalis lift to raise the lids above the visual axis. In the patient with a third nerve palsy, or any situation where there is a risk of diplopia in lifting the lid, silicone may be used because of its ease of removal.

Consent Risk of overor undercorrection, corneal exposure, lid oedema, infection, and asymmetrical skin creases.

Postoperative care G chloramphenicol q.d.s.; Oc. chloramphenicol nocte; p.r.n. topical lubricant.

Follow-up One week for removal of sutures, then 3 months. Consider early revision if overcorrected. Manage mild overcorrection with gentle lash traction twice daily.

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Chalazion

Chalazion

Background Lipogranulomatous inflammatory lid reaction to retained sebaceous secretions (meibomian glands or glands of Zeiss). Histology shows focal or diffuse involvement which may involve the whole lid. May become secondarily infected leading to abscess formation. Associated with lid margin disease (blepharitis), acne rosacea, and seborrhoeic dermatitis.

Differential diagnosis Sebaceous gland carcinoma is notorious in masquerading as recurrent chalazion or unilateral blepharoconjunctivitis. Also consider Merkel cell tumour (rare). Other infective lesions around the eyelids include acute staphylococcal infection of the meibomian gland, and infections of a lash follicle and associated gland of Zeiss or Moll. These present as tender swellings which may resolve spontaneously or discharge. Any swelling in the region above the medial canthal ligament suggests neoplasia of the lacrimal sac and requires urgent investigation (CT and biopsy).

History Lump in one or both eyelids. May resolve spontaneously or become intermittently inflamed.

Examination Focal or diffuse lesion(s) within the lid (Fig. 1.12), often with lid margin and tear film changes. Lid eversion may reveal an exophytic inflamed conjunctival granuloma.

Medical management

Options include:

■Twice daily warm compresses to the lids, and lid margin hygiene to improve the flow of meibomian gland secretions.

■Topical antibiotic ointment (Oc. chloramphenicol or Oc. fucithalmic b.d.).

■Oral doxycycline if rosacea is present (50 mg o.d. for 3 months).

■Intralesional steroid injection (0.1 mL triamcinolone with a 30gauge needle).

Surgical management (incision and curettage)

1.Mark the skin over the lesion with a surgical pen to aid localization.

2.Apply topical conjunctival anaesthesia then inject local anaesthetic into the lid (1 mL of lidocaine 2% with 1 : 200 000 epinephrine). Injecting slowly reduces patient discomfort.

3.Position a cyst clamp over the lid and tighten firmly before everting the lid.

4.Make a vertical incision (E11 blade) into the tarsus, no closer than 2 mm to the lid margin.

5.Curette out the granuloma, which may be firm. Larger lesions may require a cruciate incision with excision of tarsus.

6.Send material to histopathology in recurrent or atypical cases.

7.Instil Oc. chloramphenicol and cover the eye with a Vaseline gauze and an eye pad for 4–6 hours. Prescribe Oc. chloramphenicol q.d.s. 1 week.

Follow-up Not required for routine cases

OCULOPLASTICS 1 Chapter

Necrotizing fasciitis

Necrotizing Fasciitis

Background A group A streptococcus infection of the subdermal tissue planes with necrosis of the overlying skin. Complications include septicaemia, systemic organ failure, and death. Early recognition and prompt intervention are critical.

History Determine the risk factors. These include old age, trauma, and immunosuppression, including diabetes.

Examination Look for skin discoloration, or frank necrosis with sloughing tissue (Fig. 1.13). Check vital signs.

Differential diagnosis Preseptal cellulitis (without progression to orbital cellulitis or necrotizing fasciitis), chronic dacroadenitis (oedema limited to the periorbital region, tenderness in superotemporal quadrant, no skin necrosis).

Investigations FBC, acute-phase inflammatory markers, renal and hepatic profiles.

Management Start high-dose intravenous penicillin and ciprofloxacin, and debride necrotic tissue down to healthy (bleeding) tissue. Repeat surgical debridement if required. Send tissue for culture and sensitivity. Co-manage patients with a physician in the presence of systemic signs.

Subsequent reconstructive approaches include laissez faire (granulation), local myocutaneous flaps, and full-thickness skin grafting.

Benign Lid Lesions

Epithelial lesions

■Squamous papilloma : a sessile or pedunculated lesion of viral origin (Fig. 1.14). Manage by shave excision biopsy.

■Seborrhoeic keratosis (senile verucca): single or multiple plaques or pedunculated lesions occurring in middle-aged to older adults (Fig. 1.15). Perform excision biopsy.

■Keratoacanthoma : solitary, subacute nodule of possible viral origin characterized by a keratin-filled crater, or horn (Fig. 1.16). The differential diagnosis includes squamous cell carcinoma, basal cell carcinoma and seborrhoeic keratosis. Where there is no indication of spontaneous resolution, perform an excision biopsy which must include deep tissue.

Fig. 1.14: Squamous papilloma.

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