Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
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Eyelid Retraction 109
GRADING
Measuring of Upper Lid Retraction
•1.5 mm must be added to distance between lid margin and 12.00 o’clock limbus.
•Mild = 1-2 mm
•Moderate = 2-5 mm
•Severe = >5 mm
Measuring of Lower Lid Retraction
•Mild = 1-2 mm
•Moderate = 3 mm
•Severe = > 3 mm
DIFFERENTIAL DIAGNOSIS
•TED
•Familial
•Marcus Gunn jaw winking phenomenon
•Contralateral ptosis
•Parinaud’s syndrome
•Hydrocephalus
•High myopia
•Facial nerve palsy
•Postoperative following overcorrection of ptosis.
MANAGEMENT
Medical
Topical Sympatholytics (Adrenergic Blocker) (Guanethidine)
Side effects
• Miosis
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•Conjunctival injection
•Punctate keratitis
•Discomfort
Botulinum A Toxin (Local Injection)
Side effects
•Temporary effect
•Ptosis
•SRM paresis → diplopia
Lubricants, Patching, Moist Chamber
Used to avoid corneal changes.
Surgical
Failure of conservative measures to control corneal changes (Functional and cosmetic).
N.B. Euthyroid state for 6-12 months with a prolonged control of local ophthalmopathy
•Tarsorrhaphy
•Eyelid lengthening procedure (post-lamella).
Tarsorrhaphy
Temporary for globe protection for 10-14 days.
Levator Marginal Myotomy
For moderate or severe lid retraction to lengthen a fibrotic contracted Levator and Muller’s muscles.
Technique:
•Cut 40-50 % of the horizontal width of levator.
•Cut the levator apn Adhesions to nearby tissue.
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•Followed by deep-suture lid crease to prevent upward migration of levator postoperative.
Disadvantages:
•Postoperative ptosis.
•Exact titration is not possible.
•Further levator surgery is difficult (adhesion).
Advantages:
•No foreign material is used.
•No changes of lid contour
Levator Recession and Mullerectomy
Anterior approach:
•Familiar anatomical approach
•Allows simultaneous lacrimal gland suspension.
•Debulking of preaponeurotic fat.
•No corneal irritation due to conjunctival sutures.
Post-approach:
•Less direct anatomic exposure
•Experience
•Damage of lacrimal gland ductules
•Bleeding is more common
•In severe lid retraction
•Levator is recession with a spacer
•Sclera (Eye bank)
•Auricular cartilage
•Fascia lata
•Hard palate mucosa.
Blepharotomy
•Transcrease full thickness lid incision.
•Skin suturing only.
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Figure 1: Left blepharotomy
Figure 2: Left upper lid retraction
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Figure 3: Lower lid retraction in myopia
Figure 4: Postoperative—Levator recession and mullerectomy
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Figure 5: Postoperative—Left lower eyelid spacer (ear cartilage)
Figure 6: Postoperative—Levator recession and mullerectomy
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Figure 7: Postoperative—Levator recession and mullerectomy
Figure 8: Post-traumatic lower lid retraction
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Figure 9: Preoperative left lower eyelid retraction
Figure 10: Preoperative upper lid retraction
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Figures 11 and 12: Preoperative upper lid retraction in TO
Figure 13: Upper and lower lid retraction in thyroid orbitopathy
118 Oculoplasty and Reconstructive Surgery
Correction of Lower Lid Retraction
Posterior approach:
•Easier
•Elevation of L.L up to 3-4 mm by a spacer.
•Donor sclera
•Nasal septal cartilage
•Auricular cartilage
•Upper lid tarsus (Good)
•Hard palate mucosa (Good)
PROGNOSIS
God control of the thyroid status and proper choice of the surgical procedure are the important factors in prevention of recurrence.