Surgical excision: full-thickness wedge resection for focal trichiasis or excision of individual internal bulbs; highest success rate.

Laser ablation: argon red 700 mW, 0.5 second, 200 mm, is least effective treatment.

Lacrimal Surgery

CANALICULODACRYOCYSTORHINOSTOMY (CDCR) Useful for focal distal (i.e., common) canalicular obstruction with NLDO.

CANALICULAR TRAUMA Repair all recent lacerations before scarring (may wait a few days to decrease edema), and use silicone stent intubation with microanastomosis of the lacerated canalicular system. The longer the silicone stents remain, the greater the chance of permanent patency. Fifty percent of monocanalicular patients have symptomatic epiphora, so attempt repair or refer.

CONJUNCTIVODACRYOCYSTORHINOSTOMY, JONES TUBE Canalicular system is disrupted and inadequate for tear flow; a second passage is created from the conjunctiva into the lacrimal sac and stented with a Jones tube.

DACRYOCYSTORHINOSTOMY (DCR) Osteotomy created at middle meatus (often within 10 mm of the cribriform plate), and the lacrimal sac is divided and secured to the nasal mucosa. Very high surgical success rate (>90%). The most common reasons for failure is obstruction at the common canaliculus or bony ostomy site.

NASOLACRIMAL DUCT PROBING Enter punctum with probe vertically, then turn horizontally and pass into the lacrimal sac until a hard stop is felt. Swing the probe vertically, hugging the brow, and drop down into the NLD; may feel pop through obstructing membrane. Confirm placement in the nose with a second probe into the nares under the inferior meatus. May combine with silicone sent intubation (i.e., Crawford tubes), which are passed through the superior and inferior puncta into the nose; the ends of the tube are retrieved from the nose and tied together. The stent is left in place typically 6 to 12 months before removal.

Orbital Surgery

GENERAL Consider intraoperative steroids (e.g., dexamethasone 10 mg IV) and Ancef for orbital cases.

ANOPHTHALMIC SOCKET Loss of the eye causes loss of one sixth of the VF, loss of depth perception, fear of losing the other eye, job concerns, and

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88 ORBIT, EYELIDS, AND OCULAR ADNEXA

increased rate of accidents. Psychological issues: patients are dealing with loss of eye, fear of the normal eye, and self-image problems (especially children). Five percent of blind painful eyes harbor tumor.

Net orbital volume deficit of 0–6 cc: globe removal (7.0–7.5 cc) fat atrophy (0–4 cc) þ orbital implant (2–4 cc) þ prosthesis (2.0–3.5 cc). To optimally replace volume and improve prosthetic motility, maximize orbital implant size and minimize prosthesis size.

Implants: usually made of porous polyethylene (Medpore), hydroxyapatite (HA), or polymethylmethacrylate (PMMA); 16 mm size replaces 2 cc of orbital volume, and 18 mm gives 4 cc. May coat implant with sclera or Ocuguard to provide a smooth surface, increase volume, allow muscle suturing to the implant, and may help to prevent posterior migration. Can also place a motility peg in the orbital implant to maximize prosthesis motility.

Prosthesis: should be large enough to have good retention, but if the prosthesis is too big, it will have poor motility and cause more weight on lower lid and more drag on the upper lid.

DECOMPRESSION May be bony decompression, usually two wall (floor and medial wall), ‘‘balanced’’ (medial and lateral wall), three wall (medial and lateral wall and floor), or all four walls; also fat decompression (intraconal and orbital fat posterior to the globe). The sphenoid wing is thin in the inferior orbit and thicker higher up; thus, burr but do not infracture (may get cerebrospinal fluid leak).

ENUCLEATION Globe removed; Tenon’s capsule and muscles remain. Goals: remove pathology, preserve volume, retain conjunctival fornices, and achieve prosthetic movement.

Indications: large primary intraocular tumor, palliation for large tumor, blind painful eye, severe ocular trauma, and cosmesis of disfigured blind eye.

Procedure: perform 360-degree conjunctival peritomy under Tenon’s capsule (point scissors posterior), and isolate Tenon’s and muscle insertions. Detach the extraocular muscles, and cut the ON, remove the globe, and pack the orbit with cold-soaked gauze. Place ocular implant (with or without a covering), and suture the muscle tendons to the implant cover in a ‘‘splayed out’’ fashion (to allow anterior ciliary arteries to ingrow); close Tenon’s capsule and conjunctiva with interrupted sutures every 2 mm. Ensure that bleeding vessels are cauterized

and that closure is free of tension to prevent exposure and make watertight. Place conformer (smallest that fits), pressure patch for 5 days, antibiotic ointment, and follow up in 4 to 6 weeks. At that time may consult for prosthesis fitting and request that the ocularist vault the prosthesis (do not want the posterior surface in contact with the wound edge).

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If intraocular tumor is present, use a ‘‘no touch’’ technique with gentle peritomy; do not hook the rectus muscles or clamp the ON; may use cryotherapy around the base of the tumor if there is extension to emissary veins.

EVISCERATION Use in endophthalmitis and as an alternative for enucleation. Advantages: local anesthetic may be used, simpler than enucleation, and no muscle or fat manipulation. This technique may provide better prosthesis motility. Evisceration is contraindicated with intraocular tumors. Disadvantages include risk of sympathetic ophthalmia.

Procedure: perform 360-degree peritomy, incise sclera 2–3 mm from limbus to enter behind scleral spur, and remove cornea and entire uveal tract in one piece. Swab sclera with absolute alcohol, irrigate, then place implant (may need scleral relaxing incisions). Close sclera, followed by Tenon’s capsule, then conjunctiva, and place conformer. Socket looks like enucleation.

EXENTERATION Remove eye, lids, and intraorbital contents, with or without removal of the bony walls. Indications include extrascleral extension of intraocular tumor, intraorbital malignancy, severe infections (e.g., Mucor), and severe inflammatory orbits. A limited anterior exenteration uses a subciliary incision to remove the posterior globe, sparing a portion of the lids. May use skin graft or leave orbit open to granulate, packing for 10 days with daily peroxide cleaning. Radical exenteration removes periorbital skin and eyelids and will need mulage prosthesis.

FLOOR FRACTURE REPAIR Transconjunctival or subciliary approach with subperiosteal dissection. Dissect along the floor with a Freer-type elevator to find the posterior wall of the maxillary sinus (usually 4–6 mm anterior to the orbital apex). Reduce herniated soft tissues, repair defects with orbital implants supported on all sides by stable bone, and close periosteum without incorporating septum.

PHTHISICAL EYE Small, shrunken blind eye that is the end result of various pathologies; often an indication for enucleation. Pathology shows squaring of the posterior pole due to EOM position and thickened posterior sclera.

Other Surgery

BOTULINUM TOXIN TYPE A (BOTOX) Chemical muscle denervation by toxin binding to acetylcholine receptors of the motor nerve terminal. Effects last several months, but with chronic use, some patients may develop antibodies that decrease efficacy. Lyophilized toxin should be

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90 ORBIT, EYELIDS, AND OCULAR ADNEXA

kept frozen until time of use and reconstituted with unpreserved saline. Maximize concentration, and minimize the volume of injection. Use ice several minutes preand postinjection to aid in comfort and decrease spread of botulinum toxin.

Blepharospasm: 30 gauge needle on tuberculin syringe, 2.5–10.0 units per 0.1 cc subcutaneous injection superficially between skin and orbicularis (see rete pegs with formation of a small vesicle). Typically five to eight injection sites around each eyelid to cover distribution of spasms, especially junction of preseptal and orbital orbicularis muscle, just within the confines of the bony rim, avoiding the levator muscle, IO, and lid margin (may also inject into corrugator and procerus muscles; inject deeper into the muscle). Used also in dystonias with multiple superficial injections.

Chemical tarsorrhaphy as in Bell’s palsy: orbicularis injection with 30-gauge needle, deep through septum (do not want to see a good bleb, as in superficial injections for blepharospasm).

Rhytids (wrinkles): common request for cosmetic concerns. Inject superficially in glabella and lateral ‘‘crow’s-feet.’’

Overall 96% response rate; maximum effect 3 to 5 days, usual duration 3 to 6 months. Effects for benign essential blepharospasm last an average of 13 weeks, Meige’s syndrome 12 weeks, and hemifacial spasm 20 weeks. Gradual decreased effectiveness with multiple injections over time (may need to change concentration or injection sites). Lethal dose is several thousand units (much greater than the doses used for local injection).

Complications: ptosis, dry eye from lagophthalmos, photophobia, diplopia, epiphora, ectropion, or entropion.

CN VII PALSY MANAGEMENT (See Chapter 8); results in loss of orbicularis tone with decreased blink response, lagophthalmos, dry eye, failure of lacrimal pump, and paralytic ectropion. Treatment stages:

Supportive: find etiology (trauma, tumor, infection, HSV or HZV neuritis) or most often idiopathic Bell’s palsy. Treat with ocular lubrication and drops, no patching; may tape lower eyelid up or use moisture chamber.

Bell’s palsy: 75% of CN VII palsy; 85% regain function within 3 to 6 months. Image if not better by 6 months or if there are signs and symptoms of vestibular or hearing defect.

Treat Bell’s palsy with prednisone 1 mg/kg/day for 7 to 10 days plus acyclovir or valacyclovir 1 g PO 3 times per day for 7 days (many think Bell’s is not idiopathic but is actually a herpes viral infection).

Facial reanimation: if patient is an appropriate candidate, may perform cross facial nerve graft surgery followed 8 to 12 months later by muscle and neurovascular bundle graft from the gracilis, lateral dorsi, or

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pectoralis minor muscle; may improve facial tone (does not improve blinking).

Lower eyelid and canthal resuspension with or without suborbicularis oculi fascia (SOOF)/midface-lift with free hard palate mucosal graft (HPMG) or ear cartilage graft.

Passive upper lid animation: gold weight aids gravity-dependent closure.

Dynamic lid animation: Morel-Fatio palpebral sling, arion silicone sling or temporalis muscle transfer.

Soft tissue repositioning: brow lift, blepharoplasty if no dry eye or keratopathy.

Residual treatments: management of synkinesis due to aberrant regeneration and hypertonicity, blepharospasm, or crocodile tears. Treat with botulinum toxin or surgery.

LASER SKIN RESURFACING Best in Fitzpatrick types 1–3, caution in types 4–6 (Table 2–3). Consider pretreating with hydroquinone 4% cream.

Carbon dioxide laser: 10.6 mm with HeNe aiming beam. Laser energy is absorbed by water, and increased temperature causes cell destruction. Able to remove small tissue increments.

SUBORBICULARIS OCULI FASCIA (SOOF) LIFT Midface lift; SOOF is contiguous with superficial musculoaponeurotic system (SMAS) of the face. Levator labi superficialis muscle lies over the infraorbital nerve.

TEMPORAL ARTERY BIOPSY (TAB) With small incision, find artery, then open wound for full exposure. Pass 3.0 silk for double tie proximally then distally. Remove artery distally then proximally; close with 5.0 Vicryl subcutaneously and chromic suture or staples for skin.

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