Eye/Eyelid Flashcards

1
Q

In an adult patient, which of the following physical findings is most likely to support a diagnosis of involutional blepharoptosis of the upper eyelids?

A) Excess upper eyelid skin
B) Eyelid margin-to-reflex distance of 4.5 mm
C) Higher than normal tarsal crease
D) Less than 8 mm of levator function
E) Upper eyelid eversion upon downgaze

A

The correct response is Option C.

Blepharoptosis occurs as a result of acquired or congenital causes. Among the former causes is the most common one, involutional (senile), as well as traumatic, mechanical, neurogenic, and myogenic. The latter category includes myogenic or neurogenic causes only. Because surgical correction is the only effective, definitive therapy for acquired ptosis, it is important for the clinician to be able to differentiate between the causes. The involutional variety is due to attrition or dehiscence of the levator aponeurosis from the anterior upper part of the tarsal plate. Diagnosis of ptosis is confirmed when there is less than 2.5 mm of distance between the upper eyelid margin and the papillary light reflex. Physical findings that support the diagnosis of involutional ptosis include a lid drop during downgaze, a higher than normal upper lid crease, visibility of the eye through the thinned upper eyelid, and preservation of good levator excursion (greater than 10 mm). Rating the degree of ptosis is based on the upper eyelid margin to pupillary light reflex distance: greater than 4 mm is considered normal. Excess upper eyelid skin can obstruct visual field; however, it is not indicative of involutional ptosis.

2018

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2
Q

A 65-year-old woman comes to the office because she is concerned about the appearance of her lower eyelid. A photograph is shown. Which of the following maneuvers is most critical to improve her periorbital appearance?

A) Botulinum toxin type A injections in the “crow’s feet” area
B) Fat injection limited to the lower eyelid
C) Orbital malar ligament release and fat repositioning
D) Skin resection and lateral canthopexy
E) Skin resurfacing using a phenol-croton oil peel

A

The correct response is Option C. The primary factor contributing to the patient’s concern is the relationship of the orbital malar ligament, orbital septum and retroseptal orbital fat. Release of the orbital malar ligament and fat repositioning offers the best option for improvement. The retroseptal fat compartments appear to be full so that fat injection alone would risk creating unwanted prominent fullness in the area. Skin resection should be conservative after fat repositioning to avoid lower lid malposition. Phenol-croton oil peeling is an effective treatment for aging changes but would not correct the anatomical relationships that underlie this patient’s chief concern. Botulinum toxin type A injections would not adequately address this patient’s concerns.

2018

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3
Q

A 50-year-old woman comes to the office seeking cosmetic improvement of the lower eyelids. Transposition of a pedicled postseptal fat graft from the central compartment is planned through a transcutaneous approach. A preoperative photograph is shown. Which of the following is the most appropriate structure to release for transposition?

A) Capsulopalpebral fascia
B) Inferior oblique tendon
C) Lockwood ligament
D) Lower slip of the lateral canthal tendon
E) Orbicularis retaining ligament

A

The correct response is Option E.

The orbicularis retaining ligament or the orbital malar ligament is a bilaminar membrane that spans from the periosteum of the inferior orbital rim to the fascia on the underside of the orbicularis. During aging, this ligament accentuates the orbital malar depression and restricts the orbital fat from blending with the sub oribularis oculi fat (SOOF). This patient presents with a prominent orbitomalar sulcus and tear trough deformity. Release of the medial portion of the orbicularis oculi muscle and the orbicularis retaining ligament allows fat transposition over the orbital rim, thus softening and improving this deformity. This procedure can be performed through either a transcutaneous or transconjunctival approach.

The capsulopalprebral fascia is a retractor of the lower eyelid. It is incised during a transconjunctival fat excision. It is not incised in a transcutaneous approach.

The inferior oblique tendon of the inferior oblique muscle should be protected during lower eyelid surgery. Lockwood’s ligament is a supportive structure of the globe. The inferior limb of the lateral canthal tendon is not released for fat transposition. It may be released for canthal support and repositioning.

2017

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4
Q

A 53-year-old woman is evaluated 6 weeks after undergoing blepharoplasty. Physical examination shows 1 mm of lagophthalmos with no dry-eye symptoms. The patient returns 8 months later for evaluation of dry eye, which began one month after undergoing laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following is the most likely reason for this patient’s dry-eye symptoms?

A) Blunted blink reflex secondary to decreased corneal reflex arc
B) Chronic use of vasoconstrictive eyedrops
C) Transient decrease in functioning of the orbicular muscle of the eye secondary to stretching from lid traction during surgery
D) Transient decrease in tear production caused by lacrimal gland pressure injury
E) Transient hypersensitivity of the cornea

A

The correct response is Option A.

Minimal lagophthalmos in the postoperative period following blepharoplasty is not uncommon and generally self-correcting. Minimal lagophthalmos may persist but is often asymptomatic owing to compensatory blinking and increased tear production, both of which are the result of the mild exposure and resulting corneal stimulation.

Laser-assisted in situ keratomileusis (LASIK) procedure involves creation of a corneal flap that interrupts the long ciliary nerves of the ophthalmic division of the trigeminal nerve. The interruption of these nerves results in decreased sensation to the cornea and a decreased corneal reflex arc. Patients with compensated exposure from blepharoplasty may lose the compensatory blink in reaction to corneal irritation following LASIK. This may cause dry-eye symptoms. With time, the corneal reflex arc improves, and the transient neurotrophic keratopathy and dry-eye symptoms improve. The other options are unlikely to cause her symptoms of dry eyes.

2016

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5
Q

A 45-year-old woman comes to the office to discuss aesthetic improvement of the lower eyelids. Physical examination shows lower eyelid pseudoherniation of fat and fine skin wrinkles. A postseptal transconjunctival approach with skin pinch excision is considered. The most significant advantage of this approach compared with a transcutaneous skin-muscle flap is a lower risk of which of the following complications?

A) Capsulopalpebral fascia injury
B) Corneal injury
C) Hematoma
D) Infection
E) Lid malposition

A

The correct response is Option E.

Transconjunctival blepharoplasty preserves the middle lamella, which includes the orbicularis oculi muscle. Preserving this layer significantly decreases the incidence of ectropion and lower eyelid malposition. Disadvantages of this technique include more difficulty with visualization and access. Many authors believe that a cutaneous skin muscle approach is more effective in blending the lid-cheek junction and transposing fat.

Some studies have shown minor reductions in hematoma and infection rates with the transconjunctival approach; however, the differences are small and not the most significant advantage.

The potential for corneal injury is greater with the transconjunctival approach. Most surgeons use corneal shields to prevent this complication.

The capsule palpebral fascia is routinely cut to access the fat compartments during a transconjunctival blepharoplasty.

2016

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6
Q

When skin excisions are designed for upper blepharoplasty, carrying the medial extent past the punctum is most likely to result in which of the following adverse effects?

A) Inadequate vertical skin excision
B) jury to the lacrimal system
C) Lagophthalmos
D) Retrobulbar hematoma
E) Webbing of the nasal skin

A

The correct response is Option E.

Extending the skin incisions too far medially can create a webbing of the nasal skin. Carrying the incision medially does not promote inadequate skin excision, lagophthalmos, or retrobulbar hematoma. Injury to the lacrimal system is unlikely to occur with a more medial incision

2016

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7
Q

A 61-year-old woman is evaluated 7 hours after undergoing bilateral lower blepharoplasty with septal release and fat repositioning. She reports pain and diminished vision in the right eye. Physical examination shows more swelling on the right side than on the left and tender proptosis of the right eye. Which of the following is the most appropriate treatment?

A) Administration of stronger pain medication
B) Head elevation and ice packs
C) Lasix administration and observation
D) Orbital decompression
E) Tarsorrhaphy

A

The correct response is Option D.

The most appropriate treatment is orbital decompression for retrobulbar hematoma. Most complications after blepharoplasty are correctable and minor. However, postoperative bleeding into the orbit causes a retrobulbar hematoma. With a large enough hematoma, orbital pressure increases, causing increased swelling, eye pain, and proptosis. With continued pressure, the optic nerve is compressed, leading to reduction in vision and ultimately blindness. The cause of a retrobulbar hematoma is bleeding within the orbit. As such, the blepharoplasty technique would be one in which the orbital septum was opened. Nevertheless, this complication must be considered in all blepharoplasty patients.

The treatment for retrobulbar hematoma is emergent orbital decompression. The incision needs to be opened and the orbital space accessed for the hematoma and soft tissues to decompress and alleviate traction or pressure on the optic nerve. A lateral canthotomy is done as well to ensure maximal decompression. In the past, mannitol has been given as a diuretic for reduction of edema, but also as a free radical scavenger in hopes of protecting the optic nerve from compressive ischemia. Lasix is often administered as a quick controllable diuretic to lessen edema.

This is a very rare complication of blepharoplasty. Mejia et al. surveyed plastic surgeons in the United States and Great Britain and derived data from over 750,000 blepharoplasties. In this study, 25 patients had permanent visual loss and 14 had temporary loss of vision. The overall incidence of visual loss due to retrobulbar hematoma was 0.0052% or one in 20,000 cases, with permanent loss occurring in 0.0033% or one in 30,000. Symptoms as noted above occurred in all patients within the first 24 hours, and hypertension was found to be the most common risk factor.

All patients will develop postoperative swelling and ecchymosis to varying degrees. Head elevation and ice packs are appropriate for standard swelling noted without findings of orbital pain, proptosis, or changes in vision. Tarsorrhaphy is useful for patients with lagophthalmos or ectropion but has no role in globe protection for acute proptosis in the above setting. Lasix infusion is part of the treatment for retrobulbar hematoma, but as a stand-alone therapy it is inadequate. Provision of more pain medication is inappropriate in the presence of pain and reduced vision and will only serve to mask some symptoms related to the hematoma.

2016

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8
Q

A 62-year-old woman is evaluated for lower blepharoplasty. On examination, negative vector is noted. Postoperatively, this patient is at increased risk for which of the following conditions?

A) Dystopia
B) Ectropion
C) Enophthalmos
D) Lagophthalmos
E) Proptosis

A

The correct response is Option B.

The finding of a negative vector places the patient at an elevated risk for lower lid malposition and ectropion. The negative vector refers to the anatomic relationship on lateral view of the maximum projecting point of the globe and the maximum projecting point of the infraorbital malar prominence. If the globe projects less than the malar prominence, a negative vector exists. Conversely, if the malar prominence projects more than the globe, a positive vector exists.

The negative vector finding indicates potentially deficient globe and lid support based on skeletal anatomy. Such patients will often have minor scleral show or lateral lid lag. It is important to recognize these findings prior to blepharoplasty surgery in order to surgically address the risks of ectropion via primary lid suspension during the blepharoplasty. Occasionally, lower lid blepharoplasty may be avoided if a negative vector is present and other conditions such as dry eye exist. Other findings or conditions that are associated with postoperative ectropion and lower lid malposition are: orbicular weakness, anterior lamellar shortage, inferior eyelid/orbital volume deficit, and eyelid laxity. Excessive or prominent middle lamellar scarring can occur after surgery, which can also lead to lid malposition.

Lagophthalmos is the inability to lower the upper lid fully and is a negative consequence of upper blepharoplasty due to excessive tissue resection or fibrosis. Enophthalmos is interior retraction or displacement of the globe related to increased orbital volume. This is unrelated to lower blepharoplasty surgery. Proptosis is an external displacement of the globe giving the appearance that the eyeball is extruding from the obit. This is most often associated with Graves disease, head trauma, and increased intracranial pressure. It can also be due to a retrobulbar hematoma after blepharoplasty, which is a surgical emergency due to the risk of blindness.

Dystopia refers to malposition of the globe related to skeletal changes of the orbit. This would not be a result of blepharoplasty, but can occur after facial trauma or facial tumor resection.

2016

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9
Q

A 60-year-old man comes to the office because he desires improvement in the appearance of his lower eyelid and upper cheek area. Physical examination shows a prominent tear trough. Which of the following is the anatomic basis of the tear trough?

A) Attachment of the orbital septum to the arcus marginalis
B) Cleft between the palpebral and orbital parts of the orbicularis oculi
C) Osteocutaneous ligament arising from the medial portion of the maxilla
D) Prominence of the orbital rim following descent of the malar fat pad
E) Triangular confluence of the origins of the orbicularis oculi, levator labii superioris alaeque nasi, and levator labii superioris

A

The correct response is Option C.

Recent articles have greatly improved our understanding of the anatomy of the lower eyelid, tear trough, pre-zygomatic space, and the ligaments in the orbital area.

The tear trough ligament is a true osteocutaneous ligament between the palpebral and orbital portions of the muscle. It extends inferolaterally from the medial canthus to approximately the mid-pupillary line, where is connects with the bilayered orbicularis retaining ligament. Recent anatomic dissection work has shown that this ligament is the anatomic basis of the tear trough deformity.

Fillers should be placed inferior to the tear trough ligament; placing them superiorly will only serve to emphasize lower eyelid fat, and will emphasize the tear trough deformity.

2015

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10
Q

A 32-year-old Korean woman undergoes bilateral upper lid blepharoplasty for creation of a supratarsal crease. A partial incision technique is used. Which of the following is the most likely complication of this procedure?

A) Asymmetry
B) Epicanthal webbing
C) Fold loss
D) Lagophthalmos
E) Suture extrusion

A

The correct response is Option A.

Blepharoplasty is the most common facial cosmetic procedure performed on people of Asian descent. Unlike blepharoplasty in Caucasian faces, the goal of Asian blepharoplasty is to create a supratarsal fold. Asian eyelids are characterized by several key elements including absent or low lid crease, shorter tarsus, descending pre-aponeurotic fat, and minimal or absent connection between the levator aponeurosis and the upper lid dermis. The mainstay of surgical correction is creation of a permanent fixation point between the levator muscle and the supratarsal dermis and subdermal structures.

The most common complication after Asian blepharoplasty is asymmetry. It is important to remember that unlike Caucasian blepharoplasty, the motivation for Asian blepharoplasty is less frequently rejuvenation. Rather, Asian patients are typically younger and desire creation of a supratarsal fold or correction of a preexisting fold asymmetry. Asymmetry is a common preoperative finding and should be well documented and discussed with the patient before surgery. Small differences in positioning of the newly created crease can be very obvious to both patient and surgeon. When recognized immediately after surgery, early revision should be considered.

Other complications unique to Asian blepharoplasty include fold loss, suture extrusion, and epicanthal scarring. Lagophthalmos, which most often results from overresection of upper eyelid skin, is less frequent in Asian blepharoplasty because skin excision is typically more limited, particularly in a younger patient undergoing a partial incision technique. Fold loss may result from a technical error in securing the layers of dermis, epidermis, or levator aponeurosis, or from placing too few sutures. Revisional surgery would be required to correct this problem. Suture extrusion is not uncommon, given that permanent sutures are used for fixation. Meticulous placement of clear 7-0 nylon and trimming of suture ends will minimize the risk of this complication. If a suture becomes exposed in the first few months postoperatively, removal should be deferred until scarring is mature and fixation is more tenacious. Epicanthoplasty is commonly used is Asian patients with epicanthal folds undergoing blepharoplasty. Various techniques, including Y, W, and modified Z-plasties, have been reported. The epicanthal region is prone to hypertrophic scarring, particularly in Asians who have thick dermis.

2015

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11
Q

Which of the following is the function of secretions of the meibomian glands?

A) Coats cornea as inner layer of tear film
B) Lubricates eyelid skin
C) Prevents evaporation of tear film
D) Promotes control of infectious agents
E) Promotes dispersion of tear film

A

The correct response is Option C.

Tears are a trilaminar fluid. The precorneal layer is formed by mucin-secreting goblet cells in the conjunctiva. This inner layer of the tear film covers the cornea and promotes the dispersion of the overlying aqueous layer.

The lacrimal gland secretes the middle layer. This aqueous layer is made of water and proteins. This layer promotes osmotic regulation and the control of infectious agents.

The meibomian glands produce the outer lipid layer. This oil layer helps to prevent the evaporation of the tear film. As a result, dysfunction of the meibomian glands can lead to dry eyes.

2014

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12
Q

In a patient with facial proportions within the normal ranges, which of the following measurements best approximates intercanthal distance?

A) Eyebrow length
B) Nasal bone width
C) Orbital fissure width
D) Stomion-to-menton distance
E) Subnasale-to-stomion distance

A

The correct response is Option C.

Intercanthal distance most closely approximates orbital fissure width. Normal facial values are often described as proportions rather than absolute numbers. Many texts describe normal intercanthal distance as between 30 and 35 mm, but some studies have shown intercanthal distances of up to 40 mm in healthy cohorts. Thus, using the facial features as referents can be helpful. The face is often divided into fifths for analysis of width, and the intercanthal distance represents one fifth, as does the orbital fissure width. The nasal bone width is narrower than the intercanthal distance, and the eyebrow length extends lateral to the lateral canthus, representing greater than a fifth of the facial width. Subnasale, stomion, and menton distances are most often used to calculate facial height proportions. Although there is no reason why, theoretically, a measurement of facial height could not correspond to a measurement of facial width, these values do not.

2014

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13
Q

A 65-year-old woman comes to the office for follow-up 6 days after undergoing bilateral upper eyelid blepharoplasty and repair of the right levator aponeurosis. Preoperatively, the patient had bilateral levator excursion of 13 mm and 4 mm of ptosis of the right eyelid. No ptosis of the left eyelid was noted. Physical examination today shows 2 mm of ptosis of the left upper eyelid. The right upper eyelid is well positioned. Which of the following is the most likely explanation for these findings?

A) Hering law
B) Horner syndrome
C) Müller maneuver
D) Todd paresis
E) von Graefe sign

A

The correct response is Option A.

Hering law describes equal innervation to the eyelids in that the signal to the levator is the same despite the potential need for each eyelid to work independently. In the scenario described, the patient had obvious ptosis of the right eyelid, and the signal to raise the eyelids was strong. When the right ptosis was corrected, the signal to raise the eyelids decreased, and the more mild ptosis of the left eyelid was uncovered. To help avoid this problem, a Hering test or a patch test can be performed. The Hering test is performed by elevating the ptotic eyelid and observing whether the other eyelid becomes ptotic. A patch test is when the ptotic eyelid is covered for a period of time (usually 15 minutes) and then observed for whether the non-ptotic eye becomes ptotic. The key to both tests is to decrease the excessive signal to raise the eyelids.

Horner syndrome includes ptosis of the eyelid, constriction of the pupil, and decreased sweating due to disease in the sympathetic system. This can be due to a tumor, congenital or iatrogenic.

von Graefe sign is lagophthalmos in downgaze. This is related to Graves disease. Müller maneuver is the reverse of the Valsalva maneuver. After a forced expiration, an attempt at inspiration is made with closed mouth and nose, thereby creating negative pressure in the chest and lungs. This maneuver is used to find weakened areas of the airway.

Todd paresis is focal weakness following a seizure. This can affect eye position.

2014

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14
Q

A 48-year-old woman comes to the office because of pain and tearing of the right eye 1 week after undergoing upper eyelid blepharoplasty. Fluorescein stain test result is positive for corneal erosion. On physical examination, absence of which of the following is most likely to put this patient at risk for corneal ulceration?

A) Accommodation reflex
B) Bell phenomenon
C) Ocular convergence
D) Oculocardiac bradycardia
E) Pupillary light response

A

The correct response is Option B.

Transient lagophthalmos during sleep is not uncommon following blepharoplasty. During the first few weeks of recovery, it is important to protect the eyes with lubricating drops and ointment. Bell phenomenon, an upward and outer movement of the eye when the eye is closed, is a protective mechanism which keeps the cornea protected behind the upper eyelid. Bell phenomenon is absent in 10 to 15% of the population. Accommodation reflex, oculocardiac reflex, ocular convergence, and pupillary light response do not place the cornea at risk after blepharoplasty.

2014

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15
Q

A 45-year-old woman comes to the office because of puffiness of both lower eyelids. Physical examination shows little lower lid skin excess, but prominent eyelid fat pads. Lid tone, snap back, and distraction test results show no abnormalities. Lid-cheek junction is smooth. A retroseptal transconjunctival approach of the lower lid is planned. Regarding the operative approach, which of the following statements is most accurate?

A) Fat pad reduction without violating the orbital septum is performed
B) Lower eyelid skin resurfacing with laser or chemical peel should not be performed concurrently with a retroseptal approach
C) The incision should be placed 1 to 2 mm below the tarsal border
D) The inferior oblique muscle will be noted between the central and lateral fat pad
E) The plane of dissection is deep to the orbicularis, but superficial to the orbital septum

A

The correct response is Option A.

The incision for a retroseptal approach is usually placed 4 to 5 mm below the tarsal border, or about 8 mm for the lid margin. The plan of dissection for a retroseptal approach is, by definition, deep to both the orbicularis muscle and septum. Because the fat pads are retroseptal, modification does not require entry through the septum when a retroseptal approach is used.

The preseptal approach is typically chosen for modification of the lid-cheek junction, and facilitates fat pad redistribution and access to the midface. The retroseptal approach is used for reduction of fat pads only. The inferior oblique muscle is located between the central and medial compartments of fat.

Multiple authors have shown that is it indeed safe to perform skin resurfacing with either chemical peel or laser simultaneously with a transconjunctival blepharoplasty.

2014

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16
Q

Which of the following is associated with the transconjunctival blepharoplasty with the skin pinch technique, when compared with transcutaneous blepharoplasty with a skin-muscle flap?

A) Decreased incidence of scleral show
B) Easier access to the lateral fat compartment
C) Easier access when performing retinacular suture canthopexy
D) Increased incidence of middle lamellar scarring
E) Ineffective resection of lower eyelid skin

A

The correct response is Option A.

Transconjunctival blepharoplasty with the skin pinch technique has a low rate of scleral show, compared with rates seen in studies of the transcutaneous blepharoplasty using a skin-muscle flap. However, because it uses a transconjunctival approach to the fat compartments of the lower eyelid, access is not improved but can be challenging, particularly for the lateral fat pad. This is considered a disadvantage of the transconjunctival method. Skin resection is believed to be more thorough with the skin pinch method than with the classical skin-muscle flap. The incidence of middle lamellar scarring with the technique is believed to be less, since the orbicularis oculi muscle is not violated. Performance of canthopexy is not changed by the selection of this technique.

2019

17
Q

A 74-year-old woman comes to the office to discuss blepharoplasty. She has bilateral dermatochalasis and right lid ptosis secondary to levator dehiscence. She does not have dry eyes and states that her vision is much improved after recent corneal refractive surgery. Which of the following is the minimum amount of time after her corneal refractive surgery that this patient should wait before undergoing blepharoplasty?

A) 3 Months
B) 6 Months
C) 9 Months
D) 12 Months
E) None; this patient is not a candidate for blepharoplasty

A

The correct response is Option B.

The current accepted time frame between corneal refractive surgery and blepharoplasty is a minimum of 6 months. Early post-corneal refractive surgery puts the patient at risk for worsening dry eyes and/or keratopathy.

2019

18
Q

A 62-year-old woman with no medical or ophthalmologic history is scheduled for cosmetic bilateral upper and lower eyelid blepharoplasty under local anesthesia (1% lidocaine with 1/100,000 epinephrine) with intravenous sedation. The procedure is uneventful. At the end of the procedure, the patient develops new-onset bilateral mild lagophthalmos. Stimulation of which of the following structures is the most likely cause of this lagophthalmos?

A) Corrugator supercilii muscles
B) Levator palpebrae superioris muscle
C) Preseptal orbicularis oculi muscle
D) Superior rectus muscle
E) Superior tarsal muscle

A

The correct response is Option E.

Eyelid muscles are innervated by the facial nerve (cranial nerve VII), the oculomotor nerve (cranial nerve III), and sympathetic nerve fibers.

Sympathetic fibers contribute to upper eyelid retraction by innervation of the superior tarsal muscle, also known as the Müller muscle. Sympathetic fibers also innervate the inferior tarsal muscle, contributing to lower lid retraction. The superior tarsal muscle was stimulated by the epinephrine of the local anesthesia, causing temporary mild upper lid retraction.

The oculomotor nerve (cranial nerve III) innervates the main upper eyelid retractor, the levator palpebrae superioris muscle, via its superior branch. Oculomotor nerve is one of the four cranial nerves that transmit parasympathetic fibers.

The facial nerve (cranial nerve VII) innervates the orbicularis oculi, frontalis, procerus, and corrugator supercilii muscles, and supports eyelid protraction. The temporal and zygomatic branches of the facial nerve supply the orbicularis oculi, the main eyelid protractor. The facial nerve also supplies the corrugator supercilii and the procerus, both of which secondarily contribute to upper eyelid protraction.

2020

19
Q

A 65-year-old woman is evaluated for inferior scleral show appearing 4 weeks after undergoing lower eyelid blepharoplasty. Preoperative examination shows the presence of a positive lower eyelid vector, horizontal lid laxity, and a retropositioned globe. The patient is euthyroid and is treated for open-angle glaucoma. Which of the following findings is most likely to predispose to the development of post-operative lower lid malposition?

A) Euthyroid status
B) Horizontal lid laxity
C) Open-angle glaucoma
D) Positive lower eyelid vector
E) Retropositioned globe

A

The correct response is Option B.

Complications arising as a result of blepharoplasty can be categorized as early (occurring during the first postoperative week), intermediate (occurring between the first and sixth postoperative weeks), and late (occurring after the sixth postoperative week).

Among the intermediate post-blepharoplasty complications, lower eyelid malposition is the most commonly reported. It results from the imbalance in tension between the anterior and posterior lamellae. Widely regarded predisposing factors include: negative vector in which the orbital rim is retropositioned relative to the vertical plane of the cornea, excessive skin resection, aggressive imbrication of the orbital septum, thyroid ophthalmopathy (e.g. Graves disease) with exophthalmos, excessive and/or persistent edema, and hematoma.

Horizontal laxity of the tarsoligamentous sling is the most likely predictor of lower eyelid malposition after lower eyelid blepharoplasty. It reflects the loss of normal upward, posterior, and superior tension across the lower eyelid margin. When this condition exists, manifested by a “snap test” in which the lid can be manually distracted anteriorly more than 8 mm away from the globe, surgical correction of horizontal eyelid laxity should be addressed during the lower eyelid blepharoplasty. This is accomplished with a tarsal strip procedure or similar form of canthoplasty. The euthyroid status with or without globe retropositioning of this patient confers less risk than hyperfunctioning thyroid conditions such as Graves in which exophthalmos increases the potential for lower eyelid malposition. A retropositioned globe will not affect the lower lid as much as the upper lid. Medical conditions such as glaucoma do not influence lower eyelid position.

2020

20
Q

A 56-year-old woman presents for a consultation for upper and lower blepharoplasty. She notes that she has a history of dry eyes. Abnormal production of which of the following is the most likely contributor to this patient’s condition?

A) Lipids
B) Lymph
C) Mucin
D) Protein
E) Sebum

A

The correct response is Option A.

The tear film is comprised of three layers: an outer lipid layer, a middle aqueous layer, and an inner mucin layer. The meibomian glands produce the outer lipid layer, which prevents tears from evaporating. Thus, meibomian gland dysfunction can lead to dry eyes. Anatomically, Meibomian glands appear posterior to the tarsal plate with an opening at the eyelid margin. The aqueous layer lubricates the eye and helps clear debris. The mucin layer, closest to the cornea, both nourishes the cornea and allows smooth distribution of tears.

Although sebum is often confused with meibum, or meibomian gland secretions, it is not the same. Sebum blockage of the meibomian glands can cause meibomian gland dysfunction. Thus, sebum is incorrect because while sebum can block the Meibomian glands, it is specifically the Meibomian gland dysfunction which causes the dry eye.

2020

21
Q

A 62-year-old man with a history of pseudoherniation of the lower eyelid fat pad undergoes a bilateral blepharoplasty with a transconjunctival approach to manage the fat compartments and the pinch blepharoplasty technique to manage excess lower eyelid skin. During the procedure, the surgeon notes difficulty in locating the medial fat pad on the right side despite aggressive dissection. Three weeks postoperatively, the patient comes for follow-up and continues to have difficulty with elevating, abducting, and extorting the eye. Which of the following muscles was most likely injured during the procedure?

A) Inferior oblique
B) Inferior rectus
C) Pretarsal orbicularis oculi
D) Superior oblique
E) Superior rectus

A

The correct response is Option A.

The inferior oblique muscle is a thin, narrow skeletal muscle near the anterior margin of the floor of the orbit. This extraocular muscle is attached at its origin, maxillary bone, and the posterior, inferior, lateral surface of its insertion, and eye. The inferior oblique muscle receives its innervation by the inferior branch of the oculomotor nerve. This muscle moves the eye by extorsion, elevation, and abduction. The primary action of the inferior oblique muscle is extorsion/external rotation; secondary action is elevation; tertiary action is abduction. This muscle serves as the primary partition between the medial and central fat compartments of the lower eyelid. Careful identification and preservation of the muscle is important during lower eyelid surgery. In this case, the surgeon likely injured the muscle when having difficulty with fat resection of the medial fat pad.

The inferior rectus muscle is responsible for depressing, adducting, and extorting the eye. The orbicularis oculi muscle is responsible for closing the eye. The superior oblique muscle is responsible for intorsion, depression, and abduction. The superior rectus is responsible for elevation, adduction, and intorsion.

2020

22
Q

A 60-year-old woman presents to the emergency department with severe pain and pressure in her right eye. She is 12 hours postoperative from a transcutaneous lower blepharoplasty performed elsewhere. Her pain and pressure began very early postoperatively. Although she called the clinic to report her symptoms, she was told to “take more pain medication.” On physical examination, there is bruising around the right eye with proptosis, diminished range of motion of the eye with diplopia, and decreased visual acuity compared with the left eye. Which of the following is the most likely diagnosis?

A) Acute glaucoma
B) Extraocular muscle entrapment
C) Orbital cellulitis
D) Retrobulbar hematoma
E) Superior orbital fissure syndrome

A

The correct response is Option D.

This patient is presenting with signs and symptoms compatible with retrobulbar hemorrhage following her blepharoplasty procedure. This is an emergency requiring prompt treatment. Symptoms and signs include: severe pain and pressure, decreased visual acuity, and decreased range of motion of her extraocular muscles, which may cause diplopia and nausea. She has marked bruising and proptosis.

Retrobulbar hematoma is the most common cause of visual loss after blepharoplasty. Other eye emergencies, such as extraocular muscle entrapment and superior orbital fissure syndrome, typically occur in the setting of trauma, with orbital bony fractures. While acute glaucoma can present with a painful red eye with diminished visual acuity, especially in elderly patients, it is not typically seen in the early postoperative period following blepharoplasty. Orbital cellulitis is an urgent soft-tissue infection that usually presents with fever, as well as a painful, swollen eye. It has been rarely reported after blepharoplasty but presents about 4 to 6 days following the procedure.

Nahai and associates estimate the risk of visual loss following blepharoplasty at 1:20,000, based on a survey of members of American and British aesthetic surgeons. They found that 82% of patients developed symptoms within the first 24 hours, with more than half of these occurring in the first 6 hours postoperatively. Hypertension and use of aspirin were the two most common comorbidities. When a retrobulbar hemorrhage is suspected, suture removal and even lateral canthotomy should be performed at the bedside while the patient awaits an operating room.

Parallel to surgical measures, medical treatment can be commenced to lower intraocular pressure. Acetazolamide (500 mg intravenously), 20% mannitol (1.5 to 2 g/kg; 12.5 g over 3 min), methylprednisolone (100 mg), betaxolol hydrochloride ophthalmic suspension (one drop then twice daily), and 95% oxygen/5% carbon dioxide can be administered for this purpose. At the same time, an ophthalmology consult should be initiated. Prompt decompression of the orbit is required to avoid permanent visual loss.

2021

23
Q

Which of the following locations contains the extraocular muscle that is most likely to be injured during transconjunctival lower eyelid blepharoplasty?

A) Between the central and lateral compartments
B) Between the nasal and central compartments
C) Medial to lateral compartment
D) Medial to nasal compartment
E) Superior to central compartment

A

The correct response is Option B.

The inferior oblique muscle is the most commonly injured extraocular muscle during lower blepharoplasty and lies between the nasal and central fat pads. Injury can lead to diplopia typically seen postoperatively between 1 and 6 weeks. Initial treatment is conservative. Surgical repair can be attempted only after improvement stops.

Inferior oblique muscle is not found in the other locations.

The arcuate expansion of Lockwood ligament is located between the central and lateral fat pads.

2021

24
Q

A 45-year-old woman presents to the plastic surgeon’s office with complaints of dryness of the eyes and a burning sensation 1 week after a bilateral upper blepharoplasty with skin and muscle excision only by another surgeon. Her pre-operative history included use of contact lenses for over 20 years and laser-assisted in situ keratomileusis (LASIK) 3 months prior to surgery. Her pre-operative examination showed dermatochalasis of both upper eyelids, positive orbital vector, and normal upper eyelid position, and corneal protectors are used intraoperatively. Which of the following is the most likely cause of her postoperative symptoms?

A) Blepharoplasty technique used
B) History of contact lens use
C) History of laser-assisted in situ keratomileusis (LASIK)
D) Positive vector orbit
E) Use of intraoperative corneal protectors

A

The correct response is Option C.

Blepharoplasty should not be performed before 6 months following LASIK surgery. This delay is necessary to allow sensation to return to the cornea. The dryness is from the lack of sensation and decreased blinking leading to increased evaporation.

Transient dry eyes occur in up to 26% of patients after blepharoplasty. Initial treatment of dry eye consists of ocular lubrication. Patients with proptosis, exophthalmos, horizontal lid laxity, or a negative vector orbit are more prone to dry-eye syndrome.

Patients who wear contact lenses without difficulty have adequate tear production. If patients have been advised to not wear contact lenses, they should be evaluated for inadequate tear production.

Patients with prominent eyes have a negative vector orbit and are at increased risk of dry eyes. Positive vector indicates a posterior relationship of the anterior cornea to the malar eminence and does not increase the risk of dry eyes.

Blepharoplasty, upper or lower, will increase the risk of developing dry eye postoperatively. The risk is unrelated to technique and upper blepharoplasty may have less risk compared to lower blepharoplasty. When patients have risk factors for dry eyes postoperatively and want upper and lower blepharoplasty, consider staging the upper and lower blepharoplasties.

Intraoperative use of corneal protectors and lubricant is protective because it decreases ocular exposure.

2021

25
Q

A 55-year-old man presents for correction of periorbital puffiness under the eyes with a tear-trough deformity. Transconjunctival lower lid blepharoplasty, with release of the tear trough ligament, and fat redistribution are planned. Which of the following anatomical landmarks indicates entrance into the premaxillary space and release of the tear-trough?

A) Levator labii superioris
B) Levator labii superioris alaeque nasi
C) Orbicularis oculi
D) Zygomaticus major
E) Zygomaticus minor

A

The correct response is Option A.

Through a transconjunctival approach, the dissection begins in a preseptal plane and is then converted into a supraperiosteal dissection over the anterior orbital rim until the levator labii superioris is visualized. This ensures release of the tear-trough ligament and entrance in the premaxillary plane. Orbicularis oculi is the muscle that is released and is found more superficial, as are the zygomaticus major and minor, and levator labii superioris alaeque nasi.

2021

26
Q

A patient who is immediately postoperative forehead feminization as well as transconjunctival lower blepharoplasty complains of pain in the right eye and photophobia. On examination, she has marked swelling of both upper eyelids and increased epiphora and chemosis on the right. Which of the following is the most appropriate next step in management?

A) Administer topical anesthetic eye drops
B) Increase intravenous pain medication and serial examinations
C) Perform emergent bedside canthotomy and cantholysis
D) Perform emergent bedside canthotomy only
E) Return to the operating room for examination under anesthesia

A

The correct response is Option A.

The most likely diagnosis in this patient is a corneal abrasion. The cornea is highly innervated (300 to 400 times greater than skin) and any abrasion is associated with marked pain and epiphora. Topical anesthetic eye drops, such as proparacaine hydrochloride or tetracaine hydrochloride, can both treat the pain and be diagnostic. In the setting of a corneal abrasion, the patient would get relief within minutes after application and a formal ocular examination would then be possible. Treatment for a corneal abrasion would include symptom control with topical anesthetics as needed and prophylactic topical antibiotics. Eye patches should be avoided since they can decrease oxygenation of the cornea. Similarly, contact lenses should be omitted until the cornea is fully healed. The cause of corneal abrasions is any mechanical injury during induction, preparation, surgery, and emergence. Particular care should be taken by all team members during the entire surgery and up until the moment when the patient is coordinated enough to touch their face. A time that is particularly dangerous is the cleaning of the face at the end of surgery.

Camouflaging an acute pain episode with narcotics, without establishing and treating the root cause, is not sound medical care and can lead to a missed diagnosis with associated harm.

A return to the operating room, as a first step in management, is not indicated in this clinical scenario. If possible, an ophthalmological examination is best performed with an awake patient.

Both forehead feminization and lower blepharoplasty can lead to a retrobulbar hematoma, which may present similar to a corneal abrasion. Physical examination can distinguish between the two entities since a retrobulbar hematoma would present with proptosis. However, a canthotomy involves only the release of the lateral canthus without severance of the lateral canthal tendon that is found more posterior. This incision would inadequately treat a retrobulbar hematoma.

If topical anesthetic eye drops do not have an effect, then further escalation of care is warranted. If an acute retrobulbar hematoma is suspected, a canthotomy and cantholysis can be indicated. This is a procedure that can be done at bedside should the patient be unable to immediately return to the operating room. It is important that this is done properly and that the lateral canthal tendon is entirely released so that the retrobulbar pressure is released.

2022

27
Q

A patient reports diplopia 6 weeks after transconjunctival lower blepharoplasty. The best way to isolate the function of the muscle that is most likely injured is to have the patient move the eye in which of the following directions?

A) Inferior only
B) Lateral and inferior
C) Lateral and superior
D) Medial and inferior
E) Medial and superior

A

The correct response is Option E.

The inferior oblique muscle is the most commonly injured muscle during lower blepharoplasty.

The extraocular muscles include the lateral rectus, medial rectus, superior rectus, inferior rectus, superior oblique, and inferior oblique. Vertical movements require coordination between the superior and inferior rectus muscles as well as the oblique muscles. The contribution of each muscle group depends on the horizontal position of the eye.

When the eye is adducted, the oblique muscles are the primary vertical movers. The inferior oblique muscle causes elevation, and the superior oblique muscle causes depression.

When the eye is abducted, the rectus muscles are the primary vertical movers. Elevation is due to the superior rectus, and depression is due to the inferior rectus.

When the eye is looking straight, both of these groups contribute to the vertical movements.

2022

28
Q

Which of the following surgical site preparation products is most likely to cause significant eye injury and should be avoided for use in or around the eye?

A) 3% Chloroxylenol
B) 4% Chlorhexidine
C) 5% Povidone-iodine
D) Unscented baby shampoo with sterile water rinse

A

The correct response is Option B.

Chlorhexidine is a known ocular irritant at 4% strength and can cause severe corneal damage and corneal toxicity, especially if inadvertently left to dwell in the eye during a procedure. Thus, products like hexachlorophene and chlorhexidine gluconate should be avoided in and around the eye. Dilute chlorhexidine at 0.04% can be safely used as an eye treatment and is clinically prescribed for acanthamoeba keratitis, associated with contact lens use.

5% Povidone-iodine is available in a sterile ophthalmic variety and is used for ophthalmic procedures. 10% Povidone-iodine may also be used around the cheeks, brows, and eyelids. Unscented baby shampoo with a sterile rinse can be used for those with povidone-iodine allergies. While chloroxylenol is a mild eye irritant, it can be used with care around the eye.

2022

29
Q

A 6-year-old boy with right congenital corneal anesthesia and a history of multiple corneal abrasions and ulcerations is scheduled to undergo donor sural nerve grafting. Which of the following graft targets is most likely to provide the greatest improvement in corneal sensation?

A) Left supraorbital nerve to right corneal nerve
B) Left supraorbital nerve to right supraorbital nerve
C) Left supratrochlear nerve to right scleral limbus
D) Right frontal branch of facial (VII) nerve to right supratrochlear nerve
E) Right infraorbital nerve to right corneal nerve

A

The correct response is Option C.

The ipsilateral, supraorbital, and supratrochlear nerves provide sensation to the cornea. There are many causes for insensate cornea, including congenital and acquired conditions. Herpes infection is one of the leading causes. Chronic ulceration and injury can lead to corneal scarring that can lead to blindness. Corneal sensation is critical for protection of the cornea and sight. Reinnervation of the cornea may be possible with donor nerve grafts from the contralateral side to the sclera at the limbus. The fascicles can be divided and the individual fascicles distributed in a subconjunctival fashion to be sutures to the sclera at the edge of the cornea. Use of the ipsilateral, trochlear, or supraorbital nerve is not expected to regain innervation since these nerves themselves are involved. The infraorbital nerve and frontal branch do not provide sensation to the cornea.

2023

30
Q

A 55-year-old woman undergoes upper blepharoplasty for upper eyelid fullness. The upper eyelid soft tissue is resected and contoured. Two months after the procedure, the patient reports persistent unilateral dry eye, described as feeling like there is a foreign object in that eye. Which of the following is the mostly likely cause of this patient’s symptoms?

A) Canalicular system injury
B) Frey syndrome
C) Horner syndrome
D) Lacrimal gland injury
E) Sicca

A

The correct response is Option D.

During blepharoplasty, reshaping of the upper eyelid can be achieved by judicious contouring of the upper eyelid fat pads, usually the nasal and central. Lateral fullness in some patients may be caused by lacrimal gland prolapse and should be recognized by the surgeon to avoid resecting the lacrimal gland, risking dry eye syndrome. The surgeon should recognize that the upper eyelid does not have a lateral fat pad, and that the lacrimal gland is firmer and paler than the preaponeurotic fat that is more billowy and more yellow. Lacrimal gland prolapse should be resuspended, rather than excised, to minimize the risk for dry eye syndrome.

Horner syndrome, Frey syndrome, and canalicular system injury are not related to dry eye syndrome. Sicca can have dry eyes; however, it is an autoimmune disease unrelated to blepharoplasty’s postsurgical course.

2023

31
Q

A 65-year-old woman is scheduled to undergo concurrent upper eyelid blepharoplasty and levator advancement for correction of a superior visual field deficit. During dissection, the levator muscle and tendon are most likely to be located immediately deep to which of the following structures?

A) Capsulopalpebral fascia
B) Müller muscle
C) Orbicularis oculi
D) Orbital septum
E) Pre-aponeurotic fat

A

The correct response is Option E.

A levator advancement is performed to reinsert the tendon of the levator palpebrae superioris muscle into the tarsal plate to treat senile ptosis, and it can be performed concurrently with upper eyelid blepharoplasty. The levator muscle and tendon are located immediately deep to the pre-aponeurotic (central orbital) fat pad. The orbital septum serves as the intra- and extraorbital space. It is divided sharply before encountering the orbital fat. The capsulopalpebral fascia is the musculoaponeurotic structure responsible for retracting the lower eyelid tarsus and is analogous to the levator palpebrae. The Müller muscle is a parasympathetically innervated muscle that acts synergistically with the levator palpebrae and is located deep to it. The orbicularis oculi muscle of the eye is the sphincteric muscle responsible for eyelid closure. It is located in the anterior lamella of the eyelid superficial to the orbital septum.

2023

32
Q

A 78-year-old man is evaluated because of superior visual field obstruction and drooping eyelids. Physical examination notes a levator excursion of 10 mm and a margin-reflex distance 1 of 2 mm. A photograph is shown. Phenylephrine eye drops do not significantly change the position of the eyelid margin. Which of the following procedures is most appropriate for this patient?

A) Direct brow lift
B) Frontalis sling
C) Levator advancement
D) Tarsoconjunctival Müllerectomy
E) Upper eyelid blepharoplasty

A

The correct response is Option C.

This patient has acquired aponeurotic blepharoptosis. This is the result of dehiscence or disinsertion of the levator aponeurosis from the tarsal plate. This is characterized by ptosis of the eyelid margin, a high or absent lid crease, good levator function, and thin eyelid tissue. This patient has the following criteria that support the diagnosis: a margin-reflex distance 1 of 2 mm, a high eyelid crease noted on the photograph, and good (10 mm) levator function noted on examination.

The most appropriate operation in this patient is levator advancement. This operation uses an external approach to advance the levator muscle onto the tarsal plate, addressing the dehiscence. The operation can be performed through the approach for an upper eyelid blepharoplasty.

Upper eyelid blepharoplasty could treat dermatochalasis. Brow lift could address the eyebrow position, but in this case there is no skin overlying the eyelid margin that would impact the visual field. However, both upper eyelid blepharoplasty and direct brow lift will not correct the underlying problem, which is the dehiscence of the levator muscle.

A frontalis sling uses either a tendon graft or alloplastic material to suspend the upper eyelid complex to the frontalis muscle. Thus, the eyelid is elevated when the frontalis muscle is activated. A frontalis sling is indicated in patients with severe ptosis and little to no levator function, as in the case of congenital or paralytic ptosis.

Tarsoconjunctival Müllerectomy excises a portion of the conjunctiva and Müller muscle through a posterior approach. Phenylephrine eye drops used preoperatively can predict the success of a Müllerectomy. After drops are instilled, one looks for correction of the eyelid margin to within 1 mm of the desired end result. In this patient, Müllerectomy is not indicated because the phenylephrine drops did not significantly change the eyelid position.

2023

33
Q

A 64-year-old man with upper eyelid dermatochalasis and lower eyelid fat pad pseudoherniation with skin excess undergoes a bilateral skin-only upper blepharoplasty and lower blepharoplasty with a subciliary approach. During the next 12 weeks, the patient reports dry eye symptoms that worsen progressively. Which of the following glands is most likely dysfunctional in this patient?

A ) Lacrimal
B) Meibomian
C) Moll
D ) Wolfring
E) Zeis

A

The correct response is Option B.

Meibomian glands (also named tarsal glands, palpebral glands, and tarsoconjunctival glands) are sebaceous glands located inside the tarsal plate at the rims of the eyelid. Meibum is produced by the meibomian glands and is an oily substance that prevents evaporation of the eye’s tear film. Dysfunctional meibomian glands are believed to be the most common cause of dry eyes and can result from upper and lower blepharoplasty since there are about 25 such glands on the upper eyelid and 20 on the lower eyelid.

Glands of Zeis are unilobar sebaceous glands found on the margin of the eyelid. These glands produce an oily substance that is issued through the excretory ducts of the sebaceous lobule into the middle portion of the hair follicle and service the eyelashes. When infected, folliculitis may take place, leading to abscesses and sties. A Moll gland, also known as ciliary gland, is a modified sebum-secreting apocrine sweat gland found on the margin of the eyelid near the base of the eyelashes in the same region of the glands of Zeis, anterior to the meibomian glands within the distal eyelid margin. These glands are relatively large and tubular-shaped, and they empty into the adjacent lashes. Moll glands are prone to infection, and blockage of a gland’s duct causes swelling which can manifest as a stye. The lacrimal glands are paired exocrine glands located in the upper lateral region of each orbit that secrete the aqueous layer of the tear film. These glands produce tears, which are secreted by the lacrimal ducts and flow over the ocular surface into canals that connect to the lacrimal sac. Wolfring glands are accessory lacrimal glands located at the nonmarginal border of the tarsal plate. They are not typically affected during the named procedure and have a nominal contribution to aqueous production.

2023

34
Q

A 34-year-old man undergoes a four-lid blepharoplasty. Before he leaves the facility, he reports to the postanesthesia recovery nurse that he has severe pain in the right eye and visual acuity changes that include flashes and a sensation that a shade has been pulled over the eye. Preliminary diagnosis is retrobulbar hematoma. Which of the following is the most appropriate initial management of this patient?

A) Evacuation of the hematoma within the next 3 hours
B) Intravenous administration of acetazolamide 500 mg
C) Intravenous administration of mannitol 20% 1.5 to 2 g/kg
D) Lateral canthotomy
E) Three-dimensional CT scan of the orbits

A

The correct response is Option D.

The bony walls of the orbital canal in humans do not derive from a single bone; they are a mosaic of seven embryologically distinct structures. The orbits are conical, or four-sided pyramidal cavities, which open into the midline of the face and point back into the head. Each consists of a base, an apex, and four walls. During blepharoplasty, unabated hemorrhage can lead to a hematoma that compromises the structures that lie at the base and apex.

The incidence of postblepharoplasty retrobulbar hemorrhage causing visual loss is reported to be 0.04%, or one in 2500 cases. This corresponds to a one in 10,000 risk for permanent visual loss. The majority of hemorrhages occur within the first 24 hours after surgery (96%), and of these, more than half occur intraoperatively or within the first 6 postoperative hours.

Acute retrobulbar hematoma may compress neurovascular structures, leading to ischemia of the retina, central artery, and optic nerve. Symptoms include severe pain, visual changes including hemianopsia or amaurosis fugax (like a “window shade” over the lower half of the visual field), and scintillating scotomas (sparkles and flashes). Examination often shows a tense and protuberant periorbital area with diminished or absent extraocular movements.

Once a patient is diagnosed, treatment requires immediate attention, because 90 to 120 minutes of ischemia leads to irreversible blindness. First, all dressings should be removed and sutures released at bedside, and a lateral canthotomy should be performed immediately. Thepatient should be given mannitol 20% 1.5 to 2 g/kg intravenously (with the first 12.5 g over a 3-minute period and the remainder over a 30-minute period), 500 mg of acetazolamide intravenously, 95% oxygen/5% carbon dioxide to dilate intraocular vessels, methylprednisolone sodium succinate 100 mg intravenously, and betaxolol, one drop immediately, then twice daily. These actions should be taken while the patient is being taken back to the operating room for re-exploration.

The first step is to identify those hemorrhages that require surgery based on ophthalmic examination. When bleeding threatens the visual system or is worsening, surgical therapy is required. The incision is opened widely through the orbital septum to explore the surgical site and orbit for bleeding. Clots are evacuated, and cautery is applied. If the condition remains unresponsive, additional lateral canthotomy and cantholysis are performed. In severe cases, both the inferior and superior crus of the lateral canthal tendon can be released. When these measures fail, an emergent CT scan without contrast is warranted. If a posteriorly organized hemorrhage is identified, bony decompression may be warranted to relieve orbital apex compression. Treatment should be aggressive for the first 24 to 48 hours postoperatively, since vision has been reported to return in patients with “no light perception” that was present for 24 hours

2023

35
Q

A 30-year-old man presents with increased, rounded scleral show of the lateral triangle 4 months after undergoing open reduction and internal fixation of an orbital floor fracture. The patient reports no vision changes. Physical examination shows no ptosis. Which of the following is the most likely cause of the increased scleral show in this patient?

A) Cranial nerve III injury
B) Failure to suspend the lateral canthal tendon
C) Orbital floor plate malposition
D) Undiagnosed medial orbital wall fracture
E) Weakness of the inferior rectus muscle

A

The correct response is Option B.

Failure to suspend the lateral canthal tendon will cause rounding of the lower lid and increased lateral scleral show.

Orbital floor plate malposition and weakness of inferior rectus muscle are incorrect because the patient does not report vision changes or symptoms of malposition.

Cranial nerve III injury is incorrect because the patient does not have ptosis.

Undiagnosed medial orbital wall fracture is incorrect because the patient does not report vision changes because of medial rectus dysfunction. It is uncommon for medial orbital wall fracture to cause symptoms, but they can include enophthalmos, medial rectus entrapment, or fibrosis.

2023

36
Q

A 48-year-old woman presents to the office with chemosis in the right eye 17 days after undergoing bilateral upper and lower blepharoplasties with lateral canthopexy. Treatment with ocular lubrication and eye patching during the past 10 days has resulted in no improvement. On examination, she is able to close her eyes despite pronounced conjunctival prolapse. The color of the conjunctivae has a whitish appearance. Which of the following is the most appropriate next step to achieve the quickest resolution of chemosis in this patient?

A) Administration of celecoxib
B) Administration of methylprednisolone
C) Administration of tobramycin/dexamethasone eye drops
D) Conjunctival plication
E) Conjunctivotomy

A

The correct response is Option E.

The best option for this patient is a conjunctivotomy to drain the fluid. She may also benefit from a lateral tarsorrhaphy.

Chemosis can be classified as mild, moderate, or severe based on the degree of conjunctival prolapse between the eyelids. This patient had moderate chemosis based on significant conjunctival prolapse but maintaining the ability to close her eyelids.

Chemosis may develop intraoperatively and can be treated with conjunctival plication. It typically occurs within the first postoperative week. Initial treatment for mild chemosis includes lubricating drops and/or tobramycin/dexamethasone drops, which aim to decrease inflammation and potential infection. Moderate chemosis may benefit from the addition of eye patching.

After chemosis has been present for 2 to 3 weeks, the inflammatory phase has likely passed, as confirmed in this patient by the whitish appearance of the conjunctiva on examination. Antiinflammatory medications, whether topical or oral, are no longer beneficial. Patients are likely to benefit from conjunctivotomy to drain the fluid that has accumulated.

Oral steroids, such as methylprednisolone, are not indicated until after attempted treatment with conjunctivotomy and lateral tarsorrhaphy.

2023