Ординатура / Офтальмология / Учебные материалы / Color Atlas of Ophthalmology The Quick-Reference Manual for Diagnosis and Treatment
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1 Ocular Trauma 31
Posttraumatic Pulsating Exophthalmos
Th e classic clin ical pict ure of p ulsat ing exoph th alm os, w h ich is a rare con dit ion , can be produ ced by post t raum at ic carot id -cavern ou s fist u las. Cerebral t raum as accou n t for 
75%of carot id -cavern ous fist ulas, w h ich are in it iated by tears in th e w alls of th e in t racavern ou s in tern al carot id arter y or it s bran ch es. Th us ar terial blood m ay sh ort-circuit in th e ven ou s com plex of th e cavern ous sin uses. Oth er cau ses of pu lsat ing exoph th alm os are congen ital arterioven ous m alform at ion s, ar- teriosclerosis-related ret robulbar an eu r ysm s, an d n eu rofibrom atosis.
Presentation
Pat ien ts t yp ically com plain , days or w eeks after t raum a, of a severe an d su dden ceph alic an d orbital pain , a roaring sou n d in th e h ead syn ch ron ous w ith th e pulse, decreased vision , diplopia, an d op h th alm oplegia. Th e pulsat ing exoph th alm os is usually reducible. In sp ect ion reveals engorged an d ch em ot ic conju n ct iva. Palpa- t ion of th e eye discloses a th rill, an d auscu ltat ion reveals an ocu lar or ceph alic bruit syn ch ron ou s w ith th e pulse. Oth er ocular sign s in clu de dilated ret in al vein s, disk edem a, ret in al vein occlusion s, ven ou s st asis ret in opathy, an d in creased in t raocu lar pressure due to altered outflow in th e vor tex vein s (Fig. 1.25A,B).
A
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Fig. 1.25 (A) Post traumatic ca- |
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rotid cavernous fistula. (B) Engorged |
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vessels and chem otic conjunctiva in |
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a patient with a traum atic carotid |
B |
cavernous fistula. |
32 Color Atlas of Ophthalm ology
Differential Diagnosis
Pu lsat ing exop h th alm os th at is n ot t raum a related
Management
A com plete oph th alm ological exam in at ion sh ou ld be perform ed, in cluding dilated fun du scopic exam in at ion an d in t raocular pressu re m easu rem en t . Th e fun ct ion of cran ial n er ves III, IV, an d VI sh ou ld be tested . Th e diagn osis can be con firm ed by ech ography, digit al angiography, an d com pu ted tom ography. Th erapy is directed to th rom bosis of th e fist u la an d n orm alizat ion of orbital h em odyn am ics via t ran s- orbit al or t ran sven ou s em bolizat ion . Th e in crease in in t raocular pressu re can be in it ially t reated m edically.
2 Eyelids and Lacrimal System
Christopher I. Zoum alan, Andrea Olm os, and Kim berly P. Cockerham
Ectropion
Ect rop ion is a frequ en tly seen con dit ion in elderly people; it is an eyelid m alposi- t ion in w h ich th e eyelid (usu ally low er) is ever ted aw ay from th e globe.
Presentation
Many sym ptom s are a resu lt of ch ron ic irritat ion an d exposu re to th e eye an d eyelids. Pat ien ts can com plain of excessive tearing, conju n ct ivit is, corn eal epith eliopathy, an d kerat it is, all of w h ich can resu lt in decreased vision . Th e tarsal con - jun ct iva can be ch ron ically in flam ed, w ith secon dar y ch anges in cluding th icken ing an d kerat in izat ion . Th ere are five gen eral classificat ion s of ect ropion : involut ion al, cicat ricial, paralyt ic, congen ital, an d m ech an ical:
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Involut ional: At t ributed to age-related ch anges th at affect th e low er lids. Th ere |
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is loss of elast icit y of th e lid com par t m en t s, an d often th ere is m edial an d lateral |
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can th al ten don laxit y. Th e dist ract ion test an d th e sn ap -back test can determ in e |
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an abn orm alit y in h orizon tal lid laxit y. An terior lid dist ract ion greater th an 6 to |
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8 m m (w h ere th e cen t ral par t of th e eyelid can be pu lled aw ay from th e globe) |
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suggest s a posit ive lid dist ract ion test . If th e low er lid is pu lled in feriorly, th e lid |
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sh ould qu ickly ret u rn to it s previou s posit ion . If n ot , th is m ay be in terpreted as |
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an abn orm al sn ap -back test result (Fig. 2.1A). |
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Paralyt ic: Because of ipsilateral facial n er ve palsy, often associated w ith lid re- |
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t ract ion an d subsequ en t lagoph th alm os. Exposu re keratopathy an d epiph ora |
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are com m on com p licat ion s (Fig. 2.1B). |
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Cicat ricial: Often , scarring from ch ron ic in flam m at ion such as t rich iasis or sun |
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exposure can lead to a con t ract u re of th e anterior lam ellae (skin an d orbicularis |
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m uscle). Th ere is a sh or tage of an terior lam ellae skin such th at th e low er lid can - |
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not be superiorly lifted past th e in ferior lim bus in excess of 2 m m (Fig. 2.1C). |
Congenital ect ropion: May be seen in th e low er lid an d is gen erally seen in associat ion w ith con dit ion s such as bleph aroph im osis syn drom e an d ich thyosis.
Mechanical: Discrete eversion of th e eyelid du e to a lid lesion .
Differential Diagnosis
Make sure to rule out oth er cau ses of ect ropion such as floppy eyelid syn drom e described earlier.
Management
Depen ds on exten t of ect ropion an d sym ptom s. Con ser vat ive m easures in clu de aggressive lu bricat ion of th e ocu lar surface. Surger y is often n eeded for a defin ite solut ion .
Involut ion ect ropion: A variet y of su rgical opt ion s are available depen ding on th e exten t of ect ropion , h orizon tal lid laxit y, an d degree of can th al ten don laxit y. Gen eralized ect ropion can be corrected by h orizon t al lid sh or ten ing via fu llth ickn ess excision or reat tach ing it to th e lateral can th u s th rough a lateral t arsal st rip su spen sion tech n ique.
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34 Color Atlas of Ophthalm ology
A
B
C
Fig. 2.1 (A) Involutional ectropion (with punctal ectropion and stenosis). (B) Paralytic ectropion secondary to seventh nerve palsy (brow ptosis and lagophthalmos are also present). (C) Cicatricial ectropion caused by a lower eyelid scar. (Courtesy of Dr. Soosan
Jacob, Dr. Agarwal’s Eye Hospital, Chennai, India)
2 Eyelids and Lacrimal System 35
Paralyt ic ect ropion: Tem porar y t reat m en t w ith a t arsorrh aphy can h elp redu ce th e exten t of exposu re keratopathy. Perm an en t cases m ay require th e use of m edial can th oplast y, m edial w edge resect ion , an d/or lateral can th al su spen sion to redu ce th e h orizon t al an d ver t ical dim en sion s of th e palpebral aper t ure.
Cicat ricial ect ropion: Use of skin grafts or t ran sposit ion al flaps to restore th e n orm al an terior lam ellae
Congenital ect ropion: Recon st ru ct ing th e an terior lam ellae w ith th e u se of skin graft s or t ran sposit ion al flaps
Entropion
Inw ard rot at ion of th e eyelid
Presentation
Th e m argin of th e eyelid an d lash es m akes con tact w ith th e globe an d, in cert ain cases, can lead to corn eal epith eliopathy an d subsequ en t u lcerat ion or pan n u s for- m at ion . Irrit at ion an d epiph ora are com m on presen t ing sign s. Th ey can be involu - t ion al, congen it al, an d cicat ricial:
Involut ional: Age-related ch anges involving degen erat ion of th e elast ic an d fibrous t issu es, u sually affect ing th e low er lid . Th e lateral an d/or m edial h orizon -
tal laxit y is associated w ith in creased orbicu laris ton e causing inw ard rot at ion of th e eyelid (Fig. 2.2A).
Cicat ricial: Scarring from t raum a, Steven s-Joh n son syn drom e an d oth er cica- t rizing con dit ion s, ch em ical bu rn s, an d t rach om a can lead to sh or ten ing of th e posterior lam ellae (Fig. 2.2B).
Congenital: Often seen in low er lids, u sually related to th e lack of n orm al developm en t of th e ret ractor apon eu rosis.
Differential Diagnosis
Epibleph aron , dist ich iasis, t rich iasis, bleph arospasm , an d r uling ou t oth er cau ses of en t ropion already m en t ion ed
Management
Tem porar y t reat m en t can be ach ieved by ocular lu bricat ion an d lid taping. Bot u li- n um toxin h as been used w ith su ccess in involu t ion al or congen it al cases. Surgical correct ion is often used in severe cases.
Involut ional: If th ere is lit tle h orizon tal lid laxit y, t ran sverse evert ing su t ures can provide a tem porar y solu t ion . Horizon t al lid split t ing w ith in ser t ion of ever t ing sut ures provides a last ing correct ion . In cases w ith associated h orizon tal lid laxit y, h orizon tal lid sh orten ing can provide ben efit in addit ion to th e aforem en t ion ed procedures.
Cicat ricial: Mild cases can be corrected w ith a t ran sverse t arsotom y (tarsal frac- t u re) w ith an terior rotat ion of th e lid m argin . More exten sive cases w ill often em ploy th e use of com posite grafts (m ucou s m em bran e or palate) to recon - st ru ct th e dam aged posterior lam ellae.
Congenital: Can be corrected w ith excision of a st rip of skin an d u n derlying orbicularis m uscle an d w ith possible fixat ion of th e skin crease to th e tarsal plate.
36 Color Atlas of Ophthalm ology
Fig. 2.2 (A) Involutional entropion with trichiasis. (B) Cicatricial entropion with associated trichiasis.
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B
Ptosis
An abn orm ally low posit ion of th e upper eyelid, w h ich m ay be congen it al or acquired
Presentation
Pat ients com plain of a tired appearan ce and deficits in their superior visual field . To overcom e this, patien ts m ay elevate th eir ch in posit ion or subsequently contract their fron talis m uscle to raise th eir brow s. Certain m easurem en ts are key in the evaluation . Margin to lid reflex (MRD) is the distance from the m argin of th e upper lid to the central corn eal reflex (norm al is 4.0 to 4.5 m m ). Levator function m easures the distan ce of excursion of th e upper eyelid m argin from far dow ngaze to upgaze w h ile the fron talis m uscle is held still w ith th e exam in er’s th um b (n orm al is 14 m m or m ore). Th e palpebral fissure is th e distance from th e upper to th e low er eyelid m argin w h en the patient is in prim ar y gaze (norm al range can var y from 7 to 12 m m and is greater in w om en th an in m en ). Superior lid crease is th e vertical distan ce of th e superior lid m argin from th e lid crease in dow ngaze (norm al 8 to 10 m m ).
Th ere are variou s cau ses of ptosis, in clu ding th e follow ing:
Congenital: Failu re of n eu ron al m igrat ion w ith in th e levator com plex. Can be un ilateral or bilateral w ith variable severit y. Poor levator fu n ct ion an d absen t lid crease. Ptosis im proves on dow ngaze. Need to be evalu ated for am blyopia (Fig. 2.3A).
2 Eyelids and Lacrimal System 37
A
B
C
D
Fig. 2.3 (A) Congenital ptosis, right eye. (B) Bilateral ptosis, compensating with frontalis overaction. (C) Suprabrow and lid scars following conventional sling surgery (D) Presurgical and postsurgical pictures following Jacob Agarwal guided sling surgery. Note
only a single scar over the forehead. ([A] Courtesy of Deborah Alcorn, MD; [C–D] Courtesy of Soosan Jacob, Dr. Agarwal’s Eye Hospital, Chennai, India)
38 Color Atlas of Ophthalm ology
Aponeurot ic: Most com m on t ype of ptosis, u su ally seen in elderly pat ien ts. Can be bilateral or u n ilateral. Du e to a deh iscen ce or disin ser t ion of th e levator apo- n eu rosis, u su ally th e result of involu t ion al ch anges. Norm al levator fun ct ion bu t h igh superior lid crease (> 12 m m ) (Fig. 2.3B).
Neurogenic: In n er vat ion al defect du e to an ocu lom otor n er ve palsy
Myogenic: Seen in defects in th e n eurom u scular jun ct ion it self or w ith in th e
levator com plex; can be du e to m yasth en ia gravis or m uscu lar dyst rophy
Mechanical: Secon dar y to a gravit y m ass effect or con t ract ion from a scar
Differential Diagnosis
It is im port an t to differen t iate t ru e ptosis from pseudoptosis, w h ich can be caused by con t ralateral lid ret ract ion , ipsilateral hypot ropia, brow ptosis, an d derm atoch a- lasis. Oth er differen t ial diagn oses in clu de Marcu s- Gun n jaw w in king syn drom e, aberran t th ird or seven th n er ve regen erat ion , an d bleph arop h im osis syn drom e.
Management
Depen ds on th e severit y of th e ptosis an d its et iology. Usu ally severe ptosis w ith poor levator fu n ct ion w ill n eed to be addressed by a fron t alis-sling procedure. Levator resect ion is in dicated in cases w ith fair to good levator fun ct ion (at least 5 m m ). Cases w ith reason ably good or excellen t levator fu n ct ion can be addressed by eith er a posterior approach or an an terior apon eu rosis repair.
Congenital ptosis: Usu ally n eeds to be addressed early if am blyopia is a con cern , especially in u n ilateral cases. Depen ding on th e levator fu n ct ion , differen t procedu res can effect ively correct th e ptosis. Poor levator fun ct ion (< 4 m m ) w ill requ ire a fron talis-sling procedu re, w h ereas fair levator fu n ct ion (> 4 m m ) m ay be corrected w ith a levator resect ion .
Aponeurot ic ptosis: Several opt ion s are available, depen ding on th e severit y of th e ptosis. For in stan ce, a posterior approach (e.g., Fasan ella-Ser vat procedu re or Mü ller-conjun ct ival resect ion ) can correct m ild cases. Altern at ively, an an terior app roach w ith rein ser t ion or advan cem en t of th e apon eurosis can correct cases w ith excellen t levator fu n ct ion .
Ja cob-Aga rwa l Technique of Guided Sling Surgery with Single Sta b Incision Fron t alis m u scle su spen sion procedu re is th e gold st an dard for th e t reat m en t of congen ital ptosis w ith poor levator fun ct ion . It creates a lin k bet w een th e fron t alis m u scle an d th e tarsus of th e up per eyelid, w h ich allow s for a bet ter eyelid posit ion in prim ar y gaze. Th e Jacob-Agar w al tech n iqu e differs from th e conven t ion al p rocedu res by th e use of a single-stab in cision in m aking th e pen t agon an d guiding th e silicon e sling in th e su rgical plan e w ith on e extern al in cision w h ile suspen ding th e fron talis m uscle (Fig. 2.3C,D).
Surgica l Technique A pen t agon sh ape is m arked over th e skin w ith a m arker. A single su praeyebrow st ab in cision of ~2.5 to 3.0 m m is pu t on th e su perior m ark of th e pen t agon ~5 m m from th e eyebrow, an d a subp eriosteal pocket is dissected upw ard (Fig. 2.4). A sterile fron t alis su spen sion set (Seiff) dipped in an t ibiot ic is used as th e sling m aterial. Th is h as a long, solid silicon e rod/t u be w ith a length of 40cm¾in ) an(15da diam eter if .80m m (.032 in ), w ith a stain less steel n eedle on
eith×½2iner). Then ed silicon(20G e t ube is provided w ith a silicon e sleeve, w h ich is rem oved from th e t ube before su rger y begin s (Fig. 2.5).
Th e n eedle is first passed th rough th e ep i-t arsal t issu e bet w een th e m arks m ade on th e u p per eyelid . Th e lid is ever ted an d ch ecked to ascer t ain th at it h as n ot gon e th rough th e fu ll th ickn ess of th e t arsu s. W ith a lid gu ard beh in d th e lid, th e m edial en d of th e n eedle is th en in ser ted th rough th e m edial n eedle exit p oin t on
2 Eyelids and Lacrimal System 39
A B
C D
Fig. 2.4 (A) Upper eyelid elevation and contour checked preoperatively. (B) Pentagonal shape as in conventional sling surgery is m arked over the skin. (C) Single supraeye - brow stab incision of ~ 2.5 to 3.0 mm is put on the superior mark of the pentagon ~ 5 mm from the eyebrow. (D) Subperiosteal pocket dissected upward. (All images courtesy of
Soosan Jacob, Dr. Agarwal’s Eye Hospital, Chennai, India)
Fig. 2.5 Seiff Silicone frontalis suspension set (BD Ophthalmic Systems, Bidford on Avon, UK). (Courtesy of Soosan Jacob, Dr.
Agarwal’s Eye Hospital, Chennai, India)
40 Color Atlas of Ophthalm ology
th e eyelid an d advan ced u pw ard, dipp ing beh in d th e sept u m , to th e m ark m ade on th e m edial eyebrow . W h en th e u p per m edial corn er of th e p en t agon is reach ed, th e n eedle is th en t u rn ed an d gu ided in th e sam e su rgical plan e (w ith ou t exteriorizing), u sing a com bin at ion of visu alizat ion an d p alpat ion an d is brough t ou t th rough th e cen t ral su p rabrow in cision (Fig. 2.6). Th e sam e p rocedu re is repeated w ith th e n eedle on th e lateral side so th at it t races th e path of th e lateral lim b of th e pen t agon , dip s beh in d th e orbit al sept u m , t u rn s in direct ion above th e su - praorbit al rim , an d th en exter iorizes th rough th e cen t ral sup rabrow in cision . Th e su rgeon’s n on dom in an t in dex finger can be u sed to p alp ate th e n eedle as it is being advan ced . Th e t w o en ds of th e silicon e rod are th readed th rough th e silicon e sleeve, an d th e lid m argin an d con tou r are adju sted according to th e am ou n t of correct ion requ ired an d for m axim al cosm esis. Th e t w o en ds of th e silicon e rod s are also kn ot ted togeth er, an d a 6-0 silk su t u re is t ied bet w een th e kn ot s to p reven t late slip page. Th e sleeve w ith th e kn ot s is th en bu ried in to th e su bp eriosteal pocket . If n eed ed, on e m ay also h itch th e silicon e t u be kn ot to th e u n derlying periosteu m . Th e single su prabrow st ab in cision is closed w ith silk su t u re or fibrin
A B
C D
Fig. 2.6 (A) The needle is passed through the superficial tarsal tissue bet ween the marks made on the upper eyelid. (B) The medial end of the tube is advanced through the medial needle exit point on the eyelid and advanced upward, dipping behind the septum, to the mark m ade on the m edial eyebrow. (C) When the upper medial corner of the pentagon is reached, the needle is then turned and guided in the same surgical plane (without exteriorizing) using a combination of visualization and palpation. (D) The needle is brought out through the central suprabrow incision. The same is repeated on
the other side. (All images courtesy of Soosan Jacob, Dr. Agarwal’s Eye Hospital, Chennai, India)