Eyelids • 21 SECTION

COURSE/PROGNOSIS

●The majority of children of Asian ancestry will lose these folds during and after puberty, but the folds persist in 2% to 5% of whites.

●Surgical management relieves the condition in as many as 90% of cases.

●Surgical complications include visible scars, asymmetry, recurrence, and, rarely, infection.

DIAGNOSIS

●The diagnosis of epicanthus is easily made on external examination.

●Amblyopia is rare in association with epicanthus and is usually associated with other problems, such as anisometropia and astigmatism.

●No spinal abnormalities have been reported from patients who have had compensatory head tilt from blepharoptosis for many years.

Types of epicanthus

Epicanthus supraciliaris is a vertical fold of skin that extends from just below the brow to an area just over the infraorbital rim, usually obscuring the caruncle.

In epicanthus palpebralis, the skin fold extends from the medial aspect of the upper lid to the medial aspect of the lower lid in a nearly symmetric fashion and often obscures the caruncle. This is the most common configuration.

Epicanthus tarsalis refers to a condition in which a fold begins laterally and extends over the entire eyelid, ending in the medial canthus. This is the typical Asian upper lid configuration. Epiblepharon of the upper lids is distinguished from epicanthus tarsalis by its lack of true superior palpebral fold and the presence of a fold of skin that overlaps the eyelid margin and presses the lashes against the cornea.

Epicanthus inversus is similar to epicanthus tarsalis but involves the lower lid. It usually occurs as a part of Komoto’s tetrad of blepharoptosis, blepharophimosis, telecanthus, and epicanthus inversus; blepharophimosis refers to narrowing of the palpebral aperture in its horizontal dimension.

TREATMENT

Surgical

In general, epicanthus tarsalis, palpebralis, and supraciliaris will diminish with age as the child’s nasal dorsum becomes more prominent. If ptosis repair must be performed and significantly worsens the fold, the fold can be repaired simultaneously. Often, consideration is given to surgery before the child is of school age or soon after starting school to avoid or at least minimize some of the psychologic problems regarding body image and self-esteem that can arise. Older children can be operated on with mild sedation, and the results are more predictable.

●Skin resection should be avoided in the surgical management of epicanthus tarsalis, palpebralis, and supraciliaris because it can actually accentuate the anomaly. A preferred approach is to incise the skin directly over the fold, remove the orbicularis muscle in this area, and close the skin with deep attachments to maintain a crease and remove the fold. The crease will soften with time, but the fold should not recur.

●Epicanthus inversus typically shows little improvement with age. In these children, the skin tends to be very stiff

at an early age and difficult to work with surgically but becomes more amenable to intervention at a later age. This condition generally responds best to Verwey’s Y-to-V operation, double Z-plasty, Mustard’s technique, or the five-flap procedure. Spaeth’s technique, which involves excision of a portion of the fold of skin, is generally reserved for mild cases of epicanthus inversus.

●In 1989, Anderson and Nowinski described the five-flap technique, which they consider to be the best application for epicanthus inversus. This is a modified Y-to-V procedure combined with a double Z-plasty. It has the advantage of being simple to mark out on the lid, and the flaps are small and relatively easy to transpose.

●In cases in which there is associated telecanthus, it should be repaired at the same time with medial canthal tendon resection or transnasal wiring. It is important to avoid injuring the canaliculus or lacrimal sac. A lateral canthoplasty can be performed at the same time in cases of blepharophimosis.

COMMENTS

Epicanthus supraciliaris, palpebralis, and tarsalis tend to regress spontaneously with maturity and only occasionally require surgery. Typically, this requires only resection of underlying muscle and then deep skin fixation. Epicanthus inversus rarely improves with age and generally responds to surgical managements such as a Y-to-V procedure, Z-plasties, or the five-flap technique. Amblyopia can occur in these patients and should be checked for at regular examinations in the early years of the patient’s life.

REFERENCES

Callahan A: Surgical correction of the blepharophimosis syndromes. Trans Am Acad Ophthalmol Otolaryngol 77:687–695, 1973.

Hughes WL: Surgical treatment of congenital palpebral phimosis: the Y-V operation. Arch Ophthalmol 54:586–590, 1955.

Johnson CC: Epicanthus and epiblepharon. Arch Ophthalmol 96:1030– 1033, 1978.

Jordan DR, Anderson RL: Epicanthal folds: a deep tissue approach. Arch Ophthalmol 107:1532–1535, 1989.

Stromland K: Visual impairment and ocular abnormalities in children with fetal alcohol syndrome. Addict Biol 9:153–7, 2004.

240 EYELID CONTUSIONS 921.1, LACERATIONS 870.8, AND AVULSIONS 871.3

Robert C. Della Rocca, MD, FACS

New York, New York

David A. Della Rocca, MD

New York, New York

John Nassif, MD

Clearwater, Florida

John Koh, MD

Southfield, Michigan

Eyelid contusions, lacerations, and canthal avulsions may result in severe functional or structural abnormalities. Complete

Avulsions and Lacerations, Contusions, Eyelid • 240 CHAPTER

Eyelids • 21 SECTION

ocular evaluation and prompt determination of the extent of adnexal injury and the absence or presence of canalicular laceration allows for appropriate and timely repair of the injury. This will promote optimum functional and cosmetic results while limiting the possibility of early and late complications.

DIAGNOSIS

Clinical signs and symptoms

On inspection of the eyelids and periorbital region, ecchymosis and edema can be very significant, obscuring the location and extent of lacerations. It is important to rule out direct or indirect ocular injury. A careful history will help in raising suspicion that systemic, ocular or orbital injury may have occurred. Visual assessment, including visual acuity testing and pupil and ocular motility evaluation should be done, in addition to slit lamp microscopy, tonometry and ophthalmoscopy. This assessment, which should include adnexal evaluation, may be limited by significant periorbital and eyelid edema. Supportive measures including the use of cool compresses can be helpful prior to detailed ocular and adnexal examination. In some cases, thorough evaluation must be delayed until anesthesia is available in the operating room. Canalicular involvement and canthal displacement must be recognized to allow for appropriate surgical planning. Ptosis is common with upper eyelid lacerations and may be due to edema or direct injury to the levator complex.

Laboratory findings

Computed tomography scanning is advised if an orbital fracture is suspected. Orbital fractures are suggested by the presence of extraocular motility dysfunction, infraorbital anesthesia, globe displacement, marked periorbital edema or signs of orbital emphysema. Magnetic resonance imaging (MRI) gives excellent soft tissue contrast, but is less effective in defining orbital fractures. B-scan ultrasonography or the other scanning modalities listed above are helpful in evaluation of the globe and optic nerve if the eyelids can not be opened secondary to edema.

TREATMENT

Severe pain is uncommon with injury to adnexal tissue. If pain control is needed we recommend acetaminophen or acetaminophen in combination with codeine. Tetanus immunization may be necessary if the patient has not had a tetanus booster within the last 5 years. Broad-spectrum antibiotics are recommended, especially in the context of animal or human bites.

If a wound is older than 2 days, we consider debridement of the granulation tissue from the wound edges at the start of the case. We recommend primary repair of the tissues unless there is significant bacterial contamination or extensive tissue loss.

Simple partial lacerations of the skin can be repaired with 6-0 nylon or silk sutures in an interrupted fashion. Full thickness lacerations are repaired in a stepwise fashion. First, the lid margin is closed using 6-0 silk sutures in 3 interrupted passes through the meibomian gland orifices, lash line and at the grey line sequentially. It is important to make sure that the placement of the first silk suture approximates the tarsal plate neatly. These three sutures are tied and left long for later tying to the skin closing sutures (away from the cornea). Next, the tarsal

plate, distal to the lid margin, is closed with 5-0 absorbable suture. Last, the skin is closed with interrupted 6-0 silk sutures.

Full thickness tissue loss is uncommon and can be mimicked by edema and wound contracture. Minimal tissue loss characterized by loss of up to one-quarter of the eyelid may be managed by a full thickness closure combined with a lateral canthotomy and cantholysis. Moderate tissue loss (one quarter to one half of the eyelid) might necessitate a skin advancement flap of Tenzel to extend the length of the eyelid prior to closure. Severe tissue loss of greater than half of the eyelid length would usually necessitate an eyelid sharing procedure such as the Hughes procedure for inferior eyelid loss or the Cutler–Beard flap for upper eyelid loss.

Avulsions or lacerations of the canthus indicate the reattachment of the tissues to the appropriate level of periostium. Injury to the lateral canthus can be repaired by the creation of a lateral tarsal strip with or without a periostial flap. A medial avulsion requires the reattachment of the posterior limb of the medial canthal tendon to the posterior lacrimal crest periorbita. The use of transnasal wiring may be necessary if there is severe tissue or bone destruction.

COMPLICATIONS

●Ptosis: due to levator complex injury, severe traumatic edema (levator aponeurosis stretching and dehiscence), or on a neurogenic basis.

●Epiphora: due to canalicular laceration, lacrimal sac injury, or punctal eversion.

●Corneal exposure: due to post-repair eyelid malpositions or lagophthalmos.

●Eyelid malpositions: ectropion, entropion, eyelid retraction.

●Scar hypertrophy or depigmentation.

COMMENTS

On an emergent basis, concurrent with adnexal and canthal injuries, the presence of symptomatic and compressive orbital hemorrhage must be treated promptly with a lateral canthotomy and cantholysis. Following the cantholysis, the periorbita is opened to evacuate the hemorrhage and clots.

When possible, avoid discarding apparently devitalized tissue, whether partially or completely avulsed. Periorbital tissue has extensive vascularity and may survive trauma otherwise deemed unsurvivable. This tissue may be reattached at the site of the defect.

REFERENCES

Collin JR, Tyers AG: Colour atlas of ophthalmic plastic surgery. Churchill Livingstone, 1998:9–16:11–26.

Della Rocca RC, Bedrossian EH, Arthurs BP: Ophthalmic plastic surgery: decisions making and techniques. New York, McGraw-Hill, 2002:25–41:153–161:181–187.

Lemke BN, Della Rocca RC: Surgery of the eyelid and orbit an anatomical approach. Norwalk, Appleton and Lange, 1990:199–212.

Smith BC, Della Rocca RC, Nesi FA, Lisman RD: Ophthalmic plastic and reconstructive surgery. St Louis, CV Mosby, 1976:8–17:39–78:129– 140.

Disorders Movement Facial • 241 CHAPTER