Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
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Contents |
xxi |
21. |
Management of Orbital Trauma and Fractures ............ |
342 |
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Rania Abdel Salam, Essam El Toukhy (Egypt) |
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22. |
Preseptal Cellulitis and Orbital Cellulitis ..................... |
386 |
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Arif Adenwala, Mahesh Dalvi (India) |
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23. |
Miscellaneous Disorders ................................................... |
394 |
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Ranjit S Dhaliwal (India) |
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24. |
Update on Lasers in Oculoplasty ..................................... |
412 |
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Sunil Moreker, Mayur Moreker (India) |
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SECTION THREE |
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RECENT ADVANCES |
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25. |
Aesthetic Ophthalmoplastic with CO2 Laser ................ |
420 |
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Claudio Lucchini (Italy) |
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26. |
Endoscopic Dacryocystorhinostomy: |
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Recent Advances ................................................................. |
437 |
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Sunil Moreker, Sneha Kataria, MV Kirtane |
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Gauri Mankekar (India) |
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27. |
Special Oculoplasty Surgical Procedures ....................... |
448 |
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Daljit Singh (India) |
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28. |
Guided Sling Surgery: Jacob-Agarwal Technique ....... |
460 |
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of Frontalis Suspension with Single Stab Incision |
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Amar Agarwal, Soosan Jacob, Dhiya Ashok Kumar (India) |
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29. |
Modified Corrugated Intracystic Implant for .............. |
466 |
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Chronic Dacryocystitis: A Journey to Innovation |
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Anil M Shah (India) |
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30. |
Management of dysfunction of Meibomian ................. |
482 |
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Glands with Fugo Blade |
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Daljit Singh (India)
xxii Oculoplasty and Reconstructive Surgery
31. |
Fornix Reconstruction ........................................................ |
485 |
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Kirit Mody (India) |
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32. |
Sebaceous Gland Carcinoma and .................................... |
495 |
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Muir-Torre’s Syndrome |
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Sunil Moreker, Sneha Kataria, Mayur Moreker |
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Murad Lala (India) |
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33. |
Pediatric Oculoplasty—An Evidance-based Update ..... |
507 |
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Sunil Moreker, Milind Kirtane, Milind Navlakhe |
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Mayur Moreker (India) |
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34. |
Periocular Applications of Botulinum Toxin ................ |
544 |
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Pelin Kayank-Hekimhan (Turkey) |
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Index ....................................................................................... |
577 |
INTRODUCTION
Congenital lid anomalies are a heterogeneous group of disorders. Broadly they may be classified into malformations and malpositions of the eyelids. Some conditions may be innocuous, while others may have serious visual consequences, and need prompt attention.
DEVELOPMENT OF EYELIDS
The eyelids develop from lid folds that first appear in the surface ectoderm overlying the optic vesicle in the 16 mm stage of the embryo, and grow till the 32 mm stage. Between the 32 to 37 mm stages of the embryo, the upper and lower lid folds fuse together. They begin to separate at the fifth month of gestational age, starting at the nasal side, and the separation is completed by the sixth month.
CRYPTOPHTHALMOS
Etiology
Partial or complete failure of eyelid fold formation causes cryptophthalmos.
Congenital Eyelid Anomalies 3
Signs and Symptoms
Cryptophthalmos presents with three grades of severity.
•Complete cryptophthalmos is usually associated with other developmental anomalies, and often bilaterally symmetrical. A smooth skin passes from the forehead to the cheek. Eyebrows and lashes are usually absent (Figure 1A).
•Partial cryptophthalmos shows partially formed eyelids and a disorganized anterior segment. The lids are often colobomatous. Facial skin fuses with the medial aspect of the globe (Figure 1B).
•Abortive cryptophthalmos has a formed globe, with partial absence of the eyelids in some parts; symblepharon is seen
at these areas. Cornea is covered by keratinised and stratified epithelium (Figure 1C).
Associated ophthalmic features include microphthalmos, anterior segment anomalies such as small anterior chamber, absent trabecular meshwork, subluxated lens, posterior
Figure 1A: Clinical photograph of bilateral complete cryptophthalmos
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Figure 1B: Partial cryptophthalmos. There is a disorganized anterior segment and partial formation of eyelids
Figure 1C: Abortive cryptophthalmos, with incomplete formation of the nasal end of the eyelids, with symblepharon formation
segment anomalies like uveal coloboma, adnexal abnormalities like dermoids, supernumerary brow and absent lacrimal and accessory glands.
Cryptophthalmos may also have associated nonophthalmic abnormalities, including cleft lip or palate, hernia, aplasia of kidneys, malformed genitalia, meningo-myelocele, and mental retardation.
Hereditary transmission of an autosomal recessive nature has been reported.
Congenital Eyelid Anomalies 5
Differential Diagnosis
Complete cryptophthalmos has a characteristic appearance that is diagnostic. Incomplete cryptophthalmos needs to be differentiated from isolated lid colobomas.Causes of acquired symblepharon are to be differentiated fron abortive cryptophthalmos.
Investigation
Ultrasound B scan and computed tomography may help to assess the condition of the globe.
A thorough systemic evaluation is required to detect any associated anomalies.
Management
The management is surgical, with staged reconstruction of eyelids and the ocular surface. The visual outcome is poor.
LID COLOBOMAS
Etiology
Lid colobomas form due to delay in fusion of the mesodermal components of the fronto-nasal and maxillary processes of the face.
Signs and Symptoms
A coloboma is a partial or full thickness absence of the eyelid, which may be triangular, quadrilateral, W-shaped or irregular. The edges are rounded and covered with conjunctiva. The partial thickness coloboma may show the lid margin structures such as lashes. The upper lid colobomas are usually in the middle and the nasal third of the lid. The lower lid
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colobomas are often situated temporally. If situated at the medial end of the lower lid, they are associated with abnormalities of the lacrimal drainage system.
The cornea may be visible through the coloboma even when the lid is closed, and show exposure keratopathy on slit-lap examination (Figure 2A).
Differential Diagnosis
Congenital colobomas need to be differentiated from acquired coloboma caused by trauma.
A coloboma may be isolated, or be a part of the Goldenhar syndrome.
Investigation
The child requires systemic evaluation to rule out other congenital abnoamalities.
Management
The urgency of surgical repair of a coloboma depends on the severity of exposure caused by it. Any coloboma larger than one-third the horizontal extent of the eyelid poses danger to the cornea, and must have early surgical correction. Any smaller one may undergo elective correction, and have conservative management with lubricants, moist chambers or bandage contact lenses. The edges of the coloboma should be manually pulled together to assess the actual size of the coloboma, to plan appropriate surgery. Smaller ones may have direct closure. Larger ones may need more extensive reconstruction. When using a lid-sharing technique, the risk of amblyopia in a young child should be remembered (Figures
2A and B).
Congenital Eyelid Anomalies 7
Figure 2A: Clinical photograph of patient with right eye lateral canthal ectopia, congenital ptosis, and left eye upper lid coloboma with corneal scarring due to exposure
Figure 2B: Postoperative clinical photograph of the same patient, with well corrected coloboma
Goldenhar Syndrome
Lid coloboma is a common association with Goldenhar syndrome, in addition to corneal or epibulbar dermoids, and pre-auricular skin tags and external ear deformities (Figures
3A and B).
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A
B
Figures 3A and B: Goldenhar syndrome with left eye upper lid coloboma and pre-auricular and external nasal skin tags