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212 15 Revision Surgery
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the affected lid firmly in the appropriate direction (usually toward the lid margin)
with a thin smear of 1% hydrocortisone ointment. Ask them to do this at least
twice a day for five minutes during the first 2 months. Whether steroid is more
effective than ointment base or massage alone remains to be demonstrated. At best
such massage can obviate the need for further surgery. More commonly, however,
it is a useful delaying tactic.
15.6 Analyse
Analyse the factors that have led to the primary failure to ensure that you correct them with your revision surgery. For example, chronic traction stretches the
lid margin. At re-operation you must include lid margin shortening in addition to
traction release or the lid will simply not return to its intended position. Inadequate lid margin tightening is a cause of persistent cicatricial ectropion following
adequate skin grafting. Not recognising an anterior lamellar deficit (caused by mid
face drop) is the commonest cause of early involutional ectropion recurrence.
15.7 Lengthen
A lid margin peak (localized retraction) occurs in response to adjacent scar contraction. Lengthen a linear scar by dividing any deep fibrosis and bringing in tissue.
And remember to tighten the lid margin at the same time as mentioned above.
‘Z-plasty’ is a well described and popular technique for scar lengthening
(Fig. 15.4). It pulls in adjacent skin and transforms the original linear scar into
a zigzag. The latter breaks up the scar (visually this is more aesthetic than a long
straight scar). It also prevents further contraction along the original scar axis. But
Z-plasty creates additional scars and a scar plane under each flap. It can lengthen
the original scar by 50–70%.
The ‘Transverse release-plasty’ (below) is a radically simpler alternative that
lengthens the scar by any desired amount up to 100% at the expense of creating
dog-ears. While less aesthetic, it is simple to perform and useful for correcting
localized lid margin tethering within the eyelid area where the adjacent skin is
exceptionally elastic, mobile, and remodels well.
When there is insufficient adjacent laxity use a skin flap or insert a graft.
15.8 Transverse Release-Plasty (Fig. 15.5) 213
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a
C
1
A
B
1
B
A
1
C
b
A
1
B
1
A
B
c
C
1
B
B
1
A
A
1
C
Fig.15.4 Z-plasty. a Draw a Z with lines of equal length and its stem along the scar requiring
lengthening. b Incise the marked Z and raise two flaps. c Transpose the tips of the flaps, A and B
to points A
1
and B1and suture
15.8 Transverse Release-Plasty (Fig. 15.5)
15.8.1 Considerations
This ‘cheat’ operation can be used to quickly release a very localized lid scar to
restore lid closure when lax adjacent tissue is available. It has the advantage of
being incredibly simple and quick to perform, requiring no dissection. Its major
drawback is that it creates significant dog ears which may ultimately need late
revision.
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a
A
B
1
1
B
A
c
B
A
1
A
1
B
Fig.15.5 Transverse release-plasty. a Place a lid margin traction suture at the notch. Mark the
transverse incision, A–A
margin can be pulled straight. c Place an orbicularis suture from beyond the ends of the incision,
1
A–A
. d Tightening the deep suture lengthens the original scar, B–B1. Suture the skin
1
. b Make the incision making sure to release the underlying scar until the
b
A
B
1
B
1
A
d
B
A
1
A
1
B
15.8.2 Principle
Cut across the middle of the scar to release its pull. Close the resulting defect by
bringing the ends of your incision together, thereby pulling in adjacent tissue.
Useful for localized lid scar tethering causing a margin peak and incomplete
eye closure.
15.8.3 Steps
1. Place a lid margin traction suture at the peak that needs correcting. Pull on this
to make the scar stand proud (Fig. 15.5a).
2. Cut across the middle of the scar, parallel to the lid margin at that point
(Fig. 15.5b, A–A
1
relieved the traction. It is not essential to excise subcutaneous scar provided
you fully divide it (Fig. 15.5b).
3. While pulling on your lid margin traction suture, estimate the amount of lengthening required by measuring the separation between the cut edges of the
transected scar. Extend the transverse incision to equal this length.
). Deepen and lengthen the incision until you have fully
15.9 Take Home Message 215
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4. Place a magic suture along the length of the incision you made to bring its oppo-
1
site ends together (Fig. 15.5c A–A
scar edges move away from each other (Fig. 15.5cB–B
). As you tighten this suture the released
1
).
5. Complete the skin and orbicularis closure (Fig. 15.5d).
6. Keep the lid margin on suture traction overnight (remove at the first dressing).
Pad the eye with a pressure dressing.
15.8.4 Notes
A Z-plasty’s advantage is that it breaks up a linear scar into a zigzag one that
is less noticeable. Transverse release-plasty by contrast avoids undermining, has
fewer additional cuts, but creates more ‘dog ears’. The length of the transverse
1
incision (A–A
) determines the degree of lengthening (B–B1) in a 1:1 ratio.
15.9 Take Home Message
•
Avoid the need for revision surgery.
•
Delay revision as long as possible.
Watering Eyes
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16
16.1 Overview
•
Watering eye assessment
•
Lid related causes
•
Lacrimal syringing.
Watering of the eyes is a very common symptom which has a surprisingly
large impact on quality-of-life scores; surprising at any rate to those who have not
suffered from it. The mechanisms of normal tear drainage remain incompletely
understood. However, eyelid margin malposition (Chaps. 6, 7, and 8) or anything
which interferes with normal blinking (such as facial nerve palsy) is likely to
cause watering. Lacrimal syringing is commonly performed as a diagnostic test but
misleads when not performed correctly. The principles of lacrimal bypass surgery
will be outlined, but details are beyond the scope of this book.
16.2 Causes (Fig. 16.1)
Tear overflow occurs for only two reasons:
•
An excess production of tears or
•
Inadequate drainage.
Watering is a normal physiological response to emotion (crying) or to corneal
stimulation such as from a cold wind or when peeling onions. It is also a normal response to pathological corneal irritation, such as from ingrowing eyelashes
(trichiasis) or an entropion.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
V. Th a l l e r, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_16
217
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Fig.16.1 Flow balance. When inflow exceeds drainage, overflow occurs
Insufficient tear drainage is due to lid margin or punctal malposition, stenosis
or occlusion anywhere within the lacrimal drainage system, or failure of blink
associated lacrimal pumping.
16.3 Assessment
16.3.1 History
•
Onset–When did it start?
•
Association–Trauma? Nasal or sinus disease? Irritation (reflex watering)?
•
Do the tears overflow and run down the face (epiphora)?
•
What makes it worse? Does anything make it better?
•
Is a discharge associated (especially on waking)? Suggests a post lacrimal
sac obstruction (mucus collecting in the lacrimal sac) unless due to an acute
conjunctivitis.
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16.3.2 Examination
16.3.2.1 Marginal Tear Strip
An increase in the lower lid tear meniscus (marginal tear strip) objectively supports
a history of watering.
16.3.2.2 Lacrimal Punctal Size and Position
Tears enter the drainage system from the marginal tear strip through the lacrimal
puncta (small ~0.2 mm openings on the medial upper and lower lid margins). If
these are not positioned within the marginal tear strip, tears will not enter the
drainage system. Ectropic puncta become dry and shrink, and eventually occlude.
Punctal entropion (the punctum is not visible unless the lid is everted) is not written
about but is common. It can cause watering but is usually asymptomatic.
16.3.2.3 Lid Margin Position
Entropion will cause corneal irritation and reflex watering.
Ectropion, however slight, will create a trough between the eye and the lower lid
margin in which tears collect and from which they spill out.
16.3.2.4 Lacrimal Canalicular Appearance
The canaliculi run very close to the lid margin and medial canthal tendon where
they are prone to trauma. They are only visible when inflamed or distended. This
happens when a canaliculus is colonized by actinomyces bacteria and functionally obstructed. Confusingly the canaliculus may still be patent to syringing. The
expulsion of yellow ‘sulphur granules’ on squeezing a distended canaliculus is
pathognomonic of actinomyces canaliculitis.
16.3.2.5 Conjunctival Appearance
Conjunctivitis is associated with increased lacrimation. A papillary conjunctivitis,
particularly when associated with itching, points to allergy. The appearance of any
discharge present helps to distinguishing the likely cause:
•
A stringy discharge = allergic conjunctivitis.
•
Watery = viral conjunctivitis.
•
Purulent = bacterial conjunctivitis.
16.3.2.6 Corneal Appearance
Corneal punctate fluorescein staining, an epithelial defect, or a foreign body imply
reflex watering.
16.3.2.7 Lacrimal Sac
A visible bump between the bridge of the nose and medial canthus suggests a
distended lacrimal sac. Most commonly it is filled with mucus and is therefore
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called a mucocoele. The presence of a mucocoele indicates nasolacrimal obstruction beyond the level of the sac. If the lacrimal sac swelling is above the medial
canthal tendon, perform a CT scan to exclude a tumour.
16.3.3 Tests
16.3.3.1 Fluorescein Dye Tests
Fluorescein Meniscus Time [1]
Insert a single drop of 2% fluorescein dye in the lateral conjunctival fornix. It
stains the ocular surface a non-fluorescent orange/yellow. Observe the eye with
a slit-lamp using cobalt blue illumination. After a little while, fluorescence starts
laterally and progresses medially along the lower marginal tear strip as the fluorescein is diluted by tears. With normal tear production the meniscus fluorescence
reaches the centre of the lid within four minutes. It takes longer in dry eye patients
and is a useful indication of tear production.
Dye Clearance/Overflow
The time it takes for the yellow fluorescein colour to disappear from the eye is a
flow one can assume that the dye has been drained through the lacrimal drainage
system under physiological conditions. This test is simpler, cheaper, and at least
as informative as lacrimal scintigraphy.
Corneal Staining
Corneal fluorescein staining suggests reflex lacrimation (as already mentioned).
Dye Retrieval from the Nose (Jones’ Test)
Fluorescein dye retrieved from the nose confirms anatomical and physiological
patency of the drainage system. Ask the patient to blow their nose hard into a
clean tissue 5 min after ocular dye instillation. Only if blowing fails to show the
dye should you swab the nose under the inferior turbinate with a cotton bud to
look for dye (Jones 1 test). The latter is less comfortable than simply blowing the
nose.
16.3.4 Lacrimal Syringing (Fig. 16.2)
16.3.4.1 Principle and Considerations
Fluorescein dye tests assess the functional state of the lacrimal drainage system.
If these indicate a lacrimal drainage obstruction, perform syringing with saline to
check the anatomical patency of the passages. Because you inject saline into the
canaliculi under pressure, syringing is not a physiological test of function. It is
also operator and technique dependent. I have frequently had patients brought to
16.3 Assessment 221
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a b
c d
Fig.16.2 Syringing. a Put the lower canaliculus on stretch. b Insert the lacrimal cannula into the
vertical portion of the canaliculus through the punctum. c Rotate the cannula laterally through 90°.
d Gently inject physiological saline
me as obstructed in whom I found a patent lacrimal system when I performed the
syringing myself.
16.3.4.2 Case Selection
Epiphora patients without a mucocoele and no nasal fluorescein retrieval.
16.3.4.3 Steps
1. Anaesthetise the eye with a drop of Proxymetacaine Hydrochloride 0.5%.
2. Place a small cotton wool pledget on the medial canthus, soak it with proxymetacaine, and push it into the lower fornix behind the lower punctum using
the tip of the Minims® container. Wait several minutes for complete anaesthesia
before removing the pledget.
3. Filla2mlLuer lock syringe with sterile saline and lock in place a 26G lacrimal
cannula. This size of syringe combines optimum tactile pressure and plunger
movement feedback.
4. Straighten the lower canaliculus by pulling the lid laterally (Fig. 16.2a) and
insert the tip of the canula perpendicularly into the punctum (Fig. 16.2b).
5. If the canula cannot enter the punctum, clinically significant punctal stenosis
is present. Use a punctum dilator/seeker to gently stretch the punctum before
reattempting lacrimal canula insertion.
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6. As soon as the canula tip has engaged the punctum, rotate the syringe and
canula laterally through 90
5 mm into the horizontal part of the canaliculus. Maintain the lateral lid traction
throughout to keep the canaliculus straight. Do not attempt to force the canula
forwards as this can create a false passage. Do not try to enter the lacrimal sac
as it has not been anaesthetized.
7. Warn the patient to expect a feeling of pressure and possibly a salty taste in
their throat.
8. Apply gentle pressure to the plunger (Fig. 16.2d) and observe:
(a) The patient’s response. Swallowing indicates saline in the throat and
consequently patent lacrimal passages.
(b) The degree of plunger resistance. In a normal lacrimal system this should
be minimal.
(c) The extent of plunger movement which equates to the volume injected.
(d) Possible fluid regurgitation through the opposite punctum, or around the
canula. There should be none. The presence of regurgitation indicates
abnormal lacrimal system resistance. Look for mucus in the regurgitated
fluid. When present it suggests an obstruction beyond the sac (as mucus
has been able to reach the sac from the eye).
°
(Fig. 16.2c) and advance the canula approximately
16.3.5 Imaging
Lacrimal imaging seldom adds more information to a good clinical examination,
dye tests, and syringing. Image any atypical presentation that raises the possibility
of a tumour, specifically a medial canthal swelling that is predominantly above the
medial canthal tendon.
16.4 Treatment Options
Treatment should address the presumed cause of the watering.
16.4.1 Lacrimal Mucocoele Expression (Fig. 16.3)
A lacrimal sac full of mucus is prone to infection (dacryocystitis). To prevent
this, teach patients how to empty their mucocoele by pressing firmly on it. You
must first check whether you are able to empty the sac as not all mucoceles can
be expressed. The mucus usually refluxes back through the canaliculi onto the eye
from where it should be washed off. Occasionally it can be forced down a partially
obstructed nasolacrimal duct. Instruct the patient to express the sac at least twice
a day. This is particularly important in babies born with congenital nasolacrimal
obstruction, 90% of which will improve spontaneously within the first year of
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