Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
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INTRODUCTION
Most eyelid defects, full thickness or otherwise, come from cancers such as basal cell carcinoma or otherwise. In traumatic defects, the defect may be partial or full thickness and a simple inspection of the trauma site often reveals that slowly piecing the remnants together like a jigsaw puzzle will correct the defect. Most ophthalmic or oculoplastic surgeons must know the consistency and limitation of periorbital tissues to begin eyelid reconstruction. The same knowledge can also be applied for cosmetic surgery.
EYELID INJURIES
A careful history to evaluate the circumstances under which the injury was caused is mandatory. Some injuries are simple with only superficial lacerations of the lid while other facial trauma may involve injuries to the head and neck regions along with severe lid injury. The latter should be dealt with immediately as they may be life threatening. Hence, it is imperative to establish that the injury is localized only to the eyelid and surrounding adnexa before beginning management.
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Classification
The authors prefer to classify eyelid injuries into:
1.Simple lacerations
2.Complex injuries
3.Full thickness margin defects a) with tissue loss b) without tissue loss
4.Damage to levator aponeurosis
5.Associated with eye/orbital injuries
6.Canalicular lacerations
ANATOMY REVIEW
The upper eyelid can be broadly broken up into:
a.Anterior lamella
b.Posterior lamella
The anterior lamella is broadly made up by skin (thinnest in the body) and orbicularis oculi muscle. The posterior lamella is broadly made up by the tarsal plate, conjunctiva, Muller’s muscle and the levator aponeurosis in its posterior part.
An important surface anatomy landmark is the eyelid crease in the upper eyelid, which is formed by the attachment of a few fibers of the levator aponeurosis to the skin. A recession of the eyelid crease with ptosis and a good levator function may signify levator dehiscence.
Also important are the medial and central pads of fat that lie on and are important landmarks in finding the levator aponeurosis. The palpebral portion of the lacrimal gland replaces the lateral fat pad in the upper eyelid.
EXAMINATION
All examination should begin with a thorough search for any damage to the globe. In a conscious patient, visual acuity,
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intraocular pressure check, slit lamp bio microscopy and fundus examinations are mandatory. It is important to include assessment of ocular motility in the initial exam. Remember, even seemingly trivial eyelid injuries may be associated with underlying globe injuries. In patients with altered sensorium, a complete eye examination should be still carried out.
Assessment of Adnexal Injuries
In conscious patients complete and thorough evaluation of the eyelids and lacrimal system should be carried out. The levator muscle can be assessed by the eyelid crease, the margin reflex distance (MRD) and the levator function test. Medial lacerations may cause canalicular tears or canthal tendon disinsertion. The punctum may be displaced laterally.
Evaluation of the Orbit
Sometimes severe injuries may cause significant eyelid edema, which may hamper proper eye examination. Manipulation of the eyelids in these cases may exacerbate pre-existing globe damage. Such patients should be examined under anesthesia. Orbital injuries can be evaluated with CT scan with axial and coronal cuts to rule out associated orbital fractures and foreign bodies. CT scan may also help in assessing optic nerve compression or damage. A further MRI examination, after ruling out metallic foreign bodies in the orbit can be carried out if necessary for further optic nerve /muscle/adnexal studies.
If facial/nasal or head neck regions are affected, additional help from the concerned specialists should be sought.
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MANAGEMENT
The aim of all management is to restore function, vision and cosmesis to as close to normal as possible. If the patient is intoxicated or unconscious and immediate surgery cannot be performed, tissues should be washed and repositioned as close to normal as possible. A light dressing with topical antibiotics can be given. Intravenous steroids and antibiotics or oral antibiotics should be administered. Intra-muscular tetanus toxoid injection should also be administered. The surgeon can safely wait 24-48 hours before attempting surgical intervention.
Anesthesia
Minor lacerations can be repaired in the outpatient department itself under local anesthesia. 2% lidocaine with epinephrine 1:100,000 can be infiltrated locally before closure. General anesthesia should be administered for complex or deeper injuries. However, sedation with monitored care along with local infiltration with or without a regional nerve block will suffice in most cases.
Surgical Tips
•Examine globe thoroughly for perforations and injuries – if necessary, explore.
•Wash all wounds with saline and a solution of 1gm cefazolin in 250 ml saline.
•Prepping can be done with diluted solution of povidoneiodine.
•Remove all foreign bodies after thorough exploration of all affected tissues.
•Check anterior and posterior lamella
•Look for lid laxity, indicative of canthal tendon injury
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•Examine upper and lower canaliculi, lacrimal gland and levator muscle.
•To avoid lid notching, try to close wounds horizontally i.e. parallel to lid margin in the upper eyelid and vertically in the lower lid, i.e. perpendicular to lid margin
(Figures 1A and B).
Figures 1A and B: (A) Incorrect closure with lid notch,
(B)Correct closure
•Simple eyelid laceration can be closed directly with slight margin eversion. Care should be taken to avoid tension on wound edges. The authors prefer to close vertical lacerations in layers with 6/0 polyglactin and skin with 6/0 polypropylene. Horizontal lacerations spontaneously reapproximate themselves due to orbicularis sphincter action.
Disfigurement of the anterior lamella can cause complex
lacerations. We try to undermine the edges to mobilize the tissue to aid anatomically perfect apposition. Debridement should be minimal. After debridement, a “V” shaped
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Figures 2A and B: (A) Devitalized apex, (B) Y-shaped flap
laceration can be converted to a “Y” shaped configuration after removal of the devitalized apex (Figures 2A and B).
Lid Margin Repair
Proper and immaculate closure of lid margin injuries should be sought for rewarding results. Failure to do so will cause lid disfigurement and notching and may lead to corneal drying and complications.
Evaluate lid tissue loss by trying to approximate the cut edges of the margins and see if closure can be achieved without tension. If this is possible, the marginal defect has to be closed in layers separately, i.e. the anterior and posterior lamellae (Figures 3A and B).
If there is tissue loss and the wound cannot be closed without tension, a lateral cantholysis or canthotomy (Figure 4) in mild cases and a Tenzel type rotational flap in moderate tissue loss can be carried out (Figure 5). For upper eyelid, the arc of the circle is below the lateral canthus and for lower it is above the canthus. For severe tissue or lid loss, Mustarde type flaps or lid sharing procedures can be used.
While attempting closure of small lid margin lacerations, the wound has to be modified to avoid formation of lid notch.
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Figures 3A and B: (A) First silk suture through the tarsal plate is tied first. Second through the grey line. Third and fourth behind and in front of the lash lines, (B) Skin and muscles closed in layers
Figure 4: Tenzel rotation flap
The entire vertical portion of the tarsus has to be removed corresponding to the width of the deficit. The tarsal excision is carried out perpendicular to the lid margin. A “V” shaped defect is converted into a pentagon shaped defect before closure.
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Figure 5: Technique for lateral canthotomy and lid closure
Levator Muscle Dehiscence
In levator muscle disinsertion cases, the patient may present with mild to moderate ptosis with or without the presence of a laceration. If the orbital fat is seen in the wound, the same signifies damage to the orbital septum. Exploration is sought in such cases. The orbital septum is identified, exposed and fully opened and the levator aponeurosis is explored. Tears in the muscle can be repaired with 6/0 polyglactin sutures. The disinserted aponeurosis can be sutured to the tarsal plate with 3 6/0 polypropylene sutures Care should be taken to preserve the lid contour. All prolapsed lacrimal gland tissue should be repositioned before closure. There should be no ectropion or lagophthalmos after closure is complete.
Canalicular Lacerations
•Commonly missed injuries.
•Look carefully for the severed edges.
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Figure 6: Canlicular repair with stent
•Irrigation from the ipsilateral punctum with fluoroscein stained saline or injection of air may help identify the cut edge of the punctum.
•Authors prefer to use bicanalicular stents, left in place for 6 months for repair (Figure 6).
•The surrounding lid margin and adventitia can be repaired as described earlier.
•In our opinion the pigtail probe should be avoided.
•Before repairing the canaliculi it is important to determine the presence of any canthal tendon avulsion (Figure 7).
•Repair of the posterior horn of the medial canthal tendon is necessary to maintain the lacrimal pump function
(Figures 8 to 10).
•Approximation and suturing of the 2 cut edges of the tendon with 6/0 polypropylene is sufficient to maintain function.
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•The tendon can also be sutured directly to the periosteum.
•If both are absent micro-plating can be considered.
•Care must be taken to avoid inadvertent damage to the lacrimal sac during repair.
Figure 7: Eyelid avulsion preoperative
Figure 8: Eyelid injury with canalicular injury