Eyelid Flashcards

Question

Normal anatomical position of the ciliary margin of the upper eyelid

Answer 1

The normal anatomical position of the ciliary margin of the upper eyelid is 1 mm below the upper corneoscleral junction in straight gaze.

Answer 2

The upper limbus: the upper corneoscleral junction is the landmark for ptosis measurement

Answer 3

Patients with severe ptosis (3 mm or more) usually have poor levator function, therefore frontalis suspension is required.

Answer 4

In patients with moderate function (6 to 10 mm), levator advancement and resection is required.

Answer 5

For patients with excellentlevator function (10 mm or more) and mild ptosis, aponeurotic surgery (plication) is appropriate.

Answer 6

In levator advancement surgery, the eyelid will be elevated approximately 1 mm for every 3 mm of advancement.

Answer 7

In a Fasanella-Servat procedure, a portion of the posterior lamella of the eyelid is resected to improve mild eyelid ptosis by shortening the levator muscle. This procedure would not be used in a patient who requires a skin resection since it uses a posterior approach.

Answer 8

C ) Müller muscle The Müller muscle lies below the levator insertion to the superior border of the tarsus and is visualized during the levator muscle repair .The conjunctiva is located deep to the Müller muscle and should not be visualized during the muscle reinsertion to the tarsus. The orbital septum and retro-orbicularis oculi are anterior and superior to the levator tendon. The Whitnall ligament is also superior to the levator tendon.

Answer 9

the Muller muscle

Answer 10

The layers of the eyelid are the conjunctiva, Müller muscle, levator muscle, orbital fat, orbital septum, retro-orbicularis oculi fat, orbicularis oculi muscle, and skin.

Answer 11

The conjunctiva is deep to the Muller muscle, which is deep to the levator

Answer 12

The capsulopalpebral fascia is the extension of the lower eyelid retractors and fuses at the inferior aspect of the lower eyelid tarsus

Answer 13

D ) No removal of excess eyelid fold skin One of the major disadvantages of the Fasanella-Servat procedure is that it does not address excess skin of the eyelid fold. Dry eyes, incompletecorrection, overcorrection, and eyelid asymmetry are possible complications of both procedures.

Answer 14

The Fasanella-Servat does not address excess skin of the eyelid fold.

Answer 15

B ) Cheek advancement flap with composite graft for lining The most appropriate method of reconstruction is the cheek advancement flap with a nasal septal cartilage and lining graft for internal lining.

Answer 16

The most appropriate method of reconstruction is the cheek advancement flap with a nasal septal cartilage and lining graft for internal lining. The cheek advancement flap can be elevated widely and rotated without tension to provide anterior coverage of the defect, while the composite graft is used for lining and support of the lower eyelid.

Answer 17

Cantholysis, lateral canthotomy, and primary closure are most useful for defects that are less than 50%. Similarly, theHughes tarsoconjunctival flap is best used in defects that are less than 50%, as larger flaps would result in significant deformity of the upper eyelid.

Answer 18

Composite grafts from the ear are rarely used for lower eyelid reconstruction because the tissues are usually thicker than the lower eyelid and may be associated with partial or complete graft loss.

Answer 19

(B)Horizontal laxity of the lower eyelid

Answer 20

Physical examination findings of abnormal snap-back test and distraction test in the patient described suggest abnormal horizontal lid laxity

Answer 21

Causal factors leading to ectropion include horizontal laxity of the eyelid (involutional), vertical shortening of the anterior lamella of the eyelid (congenital or cicatricial), paralysis of the orbicularis oculi muscle (secondary to paralytic entropion) causing loss of eyelid muscular tone, and neoplasia within the lower eyelid pulling or forcing the eyelid away from the globe.

Answer 22

(A)Animation test of the orbicularis oculi muscle

Answer 23

Involutional entropion can be confused with involutional ectropion in the static state because of the associated lower eyelid laxity in both instances. The two conditions are completely distinguishable on animation of the orbicularis oculi muscle.

Answer 24

Inversion of the lower eyelid occurs on attempted eyelid closure in cases of involutional entropion.

Answer 25

Causal factors include orbicularis dysfunction with the preseptal portion overriding the pretarsal portion, upper eyelid “closure kick,” disinsertion of lower eyelid retractors, loss of horizontal and vertical eyelid support, and loss of orbital fat volume

Answer 26

(C)Placement of a graft to the lower eyelid Protection of the ocular surfaces is the primary goal in managing the cicatricial ectropion of the lower eyelid in the patient described.The patient’s lower eyelid lacks height. Scarring between the capsulopalpebral fascia (lower eyelid retractors) and the orbital septum because of trauma or following aggressive lower eyelid blepharoplasty can cause vertical contracture of the lower eyelid, resulting in corneal exposure. Lower eyelid position can only be restored by placement of an autogenous or alloplastic spacer graft (hard palate, donor sclera, auricular cartilage, tarsus, and others), as in the postoperative image shown. In conjunction,eyelid-tightening procedures such as lateral canthopexy and canthoplasty address horizontal skin laxity

Answer 27

Protection of the ocular surfaces is the primary goal in managing the cicatricial ectropion of the lower eyelid in the patient described.

Answer 28

Scarring between the capsulopalpebral fascia (lower eyelid retractors) and the orbital septum because of trauma or following aggressive lower eyelid blepharoplasty can cause vertical contracture of the lower eyelid, resulting in corneal exposure.

Answer 29

Senile ptosis

Answer 30

Myasthenia gravis

Answer 31

(A)Tear supplementation and massage of the scar At three weeks into the postoperative period, the wounds are still in the active phase of healing. Over the next six to nine months, as the collagen with the scar remodels, the lid may return to a more normal position. Therefore, during this time frame, the ectropion should be managed with scar tissue massage and a regimento prevent complications related to dry eyes, such as tear supplementation and eye patching. Surgical intervention is warranted if there is no improvement after this time frame or if conservative therapy is ineffective and there is a risk of visual compromise. Injection of a corticosteroid can reduce inflammation and soften the scar, allowing the eyelid to return to a better position. However, use of corticosteroids in the lower eyelid is not advocated because of the risks of tissue atrophy and skin discoloration

Answer 32

In general, ectropion is classified as involutional, cicatricial, or neurogenic.

Answer 33

Placing upward traction on the eyelid can identify scar contracture in this location. If adequate skin is present, the lower eyelid should reach at least the level of the midpupil. If this movement is restricted, midlamellar scarring is likely.

Answer 34

Lysis of scar adhesions and the placement of an interpositional graft are indicated for cases of midlamellar scar.

Answer 35

(A) Full-thickness skin grafting

Answer 36

Cicatricial ectropion can be prevented by early surgical intervention with burn excision and grafting, thereby avoiding the need for late reconstructive procedures.

Answer 37

Cicatricial ectropion is best treated by full-thickness skin grafting to replace the skin deficit. A tarsal support procedure, such as a lateral canthoplasty, may be needed to fully restore the tone and position of the eyelid. Depending on their thickness and distribution, scars may be released by incision or excision.

Answer 38

Most burn reconstruction should be delayed until scars have matured sufficiently, usually by one year after injury. Earlier intervention is needed when a vital skin function is impaired, such as corneal protection.

Answer 39

Scarred tissue does not expand effectively, limiting the role of tissue expansion in burned/scarred patients

Answer 40

(D) Relative lack of insertions from the levator aponeurosis into the dermis

Answer 41

In as much as 50% of the Asian population, there is a general lack of insertion of the levator aponeurosis into the dermis, causing a lack of a supratarsal fold.

Answer 42

The fusion of the orbital septum to the levator aponeurosis is typically more caudad and decreases the width of the pretarsal segment of the supratarsal lid fold when it is present.

Answer 43

There are generally increased amounts of retro-orbicularis oculi fat and suborbicularis oculi fat. T

Answer 44

The Asian eyelid has specific anatomic variations compared with the Occidental eyelid. First, in as much as 50% of the Asian population, there is a general lack of insertion of the levator aponeurosis into the dermis, causing a lack of a supratarsal fold. The fusion of the orbital septum to the levator aponeurosis is typically more caudad and decreases the width of the pretarsal segment of the supratarsal lid fold when it is present. There are generally increased amounts of retro-orbicularis oculi fat and suborbicularis oculi fat. The Asian eyelid is likely to have more epicanthal folds than is the Occidental eyelid.

Answer 45

(D) Horizontal shortening of the lower eyelid and lateral canthopexy

Answer 46

The snap-back test can be used to assess horizontal laxity of the eyelid.

Answer 47

Due to loss of skin

Answer 48

The use of tarsorrhaphy is a temporary means to protect the cornea from exposure. The suture itself will not prevent lower eyelid malposition.

Answer 49

(E) Redundancy of skin and orbicularis muscle

Answer 50

(D) Probing of the nasolacrimal duct

Answer 51

A child with congenital tearing is likely to have a nasolacrimal duct problem. Punctual agenesis, lacrimal sac fistula, and other rare abnormalities should be ruled out with dye disappearance testing, which usually is markedly asymmetric in a nasolacrimal duct problem.

Answer 52

Generally, a nasolacrimal duct problem should be treated with massage and antibiotic drops until the child is age 12 to 13 months. For about 70% of children with tearing at age 6 months, this conservative treatment leads to resolution by age 12 months. If tearing persists, probing of the nasolacrimal duct should be performed. The longer probing is delayed beyond age 13 months, the greater the number and complexity of the procedures needed to successfully treat congenital dacryostenosis.

Answer 53

If tearing persists beyond 12 months, probing of the nasolacrimal duct should be performed. The longer probing is delayed beyond age 13 months, the greater the number and complexity of the procedures needed to successfully treat congenital dacryostenosis. Therefore, initial probing and irrigation should be performed before age 13 months.

Answer 54

Probing should be performed between 12 and 13 months (after conservative management w/ antibiotic ointment and massage, and before greater risk of requiring more numerous and complex procedures.) If probing is unsuccessful, Silastic intubation should be done.

Answer 55

Probing should be performed between 12 and 13 months (after conservative management w/ antibiotic ointment and massage, and before greater risk of requiring more numerous and complex procedures.) If probing is unsuccessful, Silastic intubation should be done. Dacryocystorhinostomy is reserved for those rare cases that do not respond to Silastic intubation.

Answer 56

(D) Suspension to the frontalis muscle with fascia lata grafting This patient has traumatic ptosis as a complication of prior surgical procedures. At the time of debridement, either a portion of the levator muscle was excised or the muscle function is limited by scar tissue. In either case, the function as shown in the photographs is minimal, and the ptosis is best managed by a frontalis suspension procedure.

Answer 57

fascia lata

Answer 58

The Fasanella-Servat procedure involves excision of a portion of the conjunctiva, tarsus, orbital septum, levator aponeurosis, and Müller muscle. It can be used in cases of mild ptosis (1-2 mm). Levator function must be present.

Answer 59

The Kuhnt-Szymanowski procedure is used to correct lower eyelid ectropion. It involves a wedge excision of the lower eyelid.

Answer 60

(A) Anterior chamber

Answer 61

Hyphema is traumatic hemorrhage of the anterior chamber of the eye, typically resulting from blunt trauma to ocular structures. In patients with hyphema, vessels are torn in the iris or in the ciliary body, leading to onset of hemorrhage. The blood collects in the most inferior section of the anterior chamber, obscuring the lower portion of the iris

Answer 62

The anterior chamber of the eye is bordered by the cornea anteriorly and the iris and central portion of the lens posteriorly. This structure is filled with aqueous humor originating from the ciliary processes in the posterior chamber and flowing through the pupil into the anterior chamber.

Answer 63

Significant hyphema may result in increased ocular pressure and/or permanent staining of the cornea. Because of the potential for these complications, screening is recommended in patients with facial trauma, and ophthalmologic referral is indicated in any patient with positive findings.

Answer 64

Treatment involves administration of acetazolamide and corticosteroid eye drops to decrease ocular tension.

Answer 65

Bleeding that occurs in the bulbar or palpebral conjunctiva is referred to as subconjunctival hemorrhage. This condition is seen in patients with facial trauma and results from extravasation of conjunctival capillaries. It also occurs in association with zygomatic fractures that extend through the lateral orbital wall in which there is bleeding along the side of the orbit and into the subconjunctival interstitium. Treatment of the fracture is likely to resolve the hemorrhage.

Answer 66

Due to facial fractures - Treatment of the fracture is likely to resolve the hemorrhage.

Answer 67

The posterior chamber is located behind the iris and anterior to the suspensory ligament; it appears as a halo around the lens. Although this chamber adjoins the ciliary processes, which may hemorrhage, the blood is not retained within it, but instead flows into the anterior chamber.

Answer 68

The vitreous chamber is bordered by the lens and suspensory ligaments anteriorly and the retina posteriorly. It contains a dense, jelly-like fluid that maintains slight pressure and provides even contact of the retina against the choroid.

Answer 69

(D) Medial canthal tendon

Answer 70

The common canaliculus enters the lacrimal sac at a point posterior to the medial canthal tendon.

Answer 71

The medial canthal tendon is formed from the superficial heads of the pretarsal muscles and originates anterior to and above the lacrimal crest.

Answer 72

The anterior and posterior lacrimal crests border the lacrimal fossa, which contains the lacrimal sac. The crests lie posterior to the canalicular entrance to the sac.

Answer 73

The deep heads of the pretarsal muscles extend posterior to the lacrimal sac and join with the diaphragm of the scar to originate immediately behind the posterior lacrimal crest.

Answer 74

The deep head of the preseptal muscle originates from the posterior lacrimal crest, just above the deep heads of the pretarsal muscles

Answer 75

(E) Dacryocystorhinostomy

Answer 76

In patients with positive Jones II dye tests, dilation of the puncta should then be performed; any fluid that passes into the nose indicates that the obstruction of the nasolacrimal duct has been cleared, and further probing is unnecessary.

Answer 77

With this test, the nasolacrimal system is irrigated with 1 mL of saline via an irrigation cannula. When dye-stained fluid is found at the inferior turbinate, there is partial obstruction of the lower canalicular system, most likely at the nasolacrimal duct.

Answer 78

With this test, the nasolacrimal system is irrigated with 1 mL of saline via an irrigation cannula. When dye-stained fluid is found within the tear sac, obstruction of the nasolacrimal duct can be diagnosed; the canaliculus and lacrimal pump are unaffected.

Answer 79

ith this test, the nasolacrimal system is irrigated with 1 mL of saline via an irrigation cannula. When dye-stained fluid is found in the nose (a negative test), the obstruction is most likely at the canalicular level.

Answer 80

Negative findings on the Jones I test are indicative of functional obstruction; if this occurs, the Jones II dye test should be performed immediately.

Answer 81

In patients with positive Jones II dye tests, dilation of the puncta should then be performed; any fluid that passes into the nose indicates that the obstruction of the nasolacrimal duct has been cleared, and further probing is unnecessary. If probing does not clear the obstruction, dacryocystorhinostomy is indicated

Answer 82

Insertion of a Jones tube is indicated in patients who have complete obstruction of the lacrimal puncta.

Answer 83

Canaliculodacryocystorhinostomy, with intubation, is recommended for management of strictures found at the junction of the common canaliculus and thelacrimal sac, as well as for obstructions at the level of the canaliculus.

Answer 84

Conjunctivorhinostomy is indicated in patients who have absence or obliteration of the tear sac

Answer 85

Although conjunctivodacryocystostomy is appropriate for patients who have obstruction at the canalicular level, this technique is associated with disruption of the lacrimal sac, resulting in unreliable long-term patency.

Answer 86

(B) Traumatic aponeurotic

Answer 87

Traumatic aponeurotic ptosis is characterized by the physical examination findings of good levator function, elevation of the eyelid crease, and the ability to visualize the shadow of the iris with eyelid closure (positive Nesi sign). In this type of ptosis, the levator aponeurosis is detached from the tarsal plate. Early reattachment of the levator is most likely to produce the best result.

Answer 88

(D) Lower eyelid blepharoplasty with lateral canthopexy This 68-year-old woman has substantially diminished elasticity of the skin of the lower eyelids. Because of this, she is at increased risk for development of ectropion postoperatively if blepharoplasty with skin excision is performed alone and the laxity of the lower eyelid skin is not corrected. Therefore, the most appropriate management is lower eyelid blepharoplasty combined with lateral canthopexy, which will decrease the laxity of the lower eyelids and lower the risk for ectropion.

Answer 89

(A) Capsulopalpebral fascia

Answer 90

Lower eyelid retraction is defined as inferior malpositioning of the lower eyelid margin without eyelid eversion. Affected patients have round, sad-looking eyes, scleral show, and symptoms of ocular irritation, including photophobia, excessive tearing, and nocturnal lagophthalmos. Ocular lubricants typically provide only minimal relief.

Answer 91

Potential causes of lower eyelid retraction include scarring between the orbital septum and capsulopalpebral fascia, laxity of the lateral canthal tendon, and descent of the structures of the midface.

Answer 92

(D) Repositioning of the levator aponeurosis = levator plication This patient who has ptosis of 3.5 mm with good levator function (greater than 10 mm) is best managed with repositioning of the levator aponeurosis

Answer 93

Because injuries to the levator complex may be concealed by acute edema, the surgeon should allow for resolution of the edema, myoneural recovery, and scar softening. After this has occurred, the degree of ptosis and the extent of levator function can be measured in order to determine the appropriate surgical procedure.

Answer 94

Eyebrow suspension is most appropriate for patients who have poor levator function (less than 4 mm) and greater than 3 mm of ptosis.

Answer 95

The Fasanella-Servat procedure shortens the lower components of the eyelid (ie, the tarsus, conjunctiva, and MŸller's muscle). The modification of this procedure spares the muscle and is best for patients who have levator function of greater than 10 mm and ptosis of less than 2 mm

Answer 96

Levator resection is reserved for those patients who have levator function between 4 mm and 10 mm, and ptosis of greater than 3 mm.

Answer 97

[Levator function < 4 mm] + [Ptosis >3 mm] = eyebrow suspension [Levator function 4-10 mm] + [Ptosis 3 mm] = levator resection / levator advancement [Levator function > 10 mm] + [Ptosis ~3.5 mm] = levator plication / aponeurotic plication [Levator function > 10 mm] + [Ptosis 1-2 mm] = Fasanella-Servat

Answer 98

Blepharoplasty is appropriate in patients with excess skin andfat around the eyelids, but not in patients with true ptosis.

Answer 99

(A) Observation with massage and taping of the eyelid In this patient who has ectropion of the left lower eyelid and excessive tearing of the left eye one month after undergoing fracture repair, the most appropriate management is observation with massage and taping of the eyelid. Scleral show and ectropion of the lower eyelid occur frequently in patients who have undergone surgery involving the lower eyelid. These complications typically improve over time. At four weeks, collagen is not compact; it will remodel significantly over the following two to six weeks. Operative procedures, such as lateral canthopexy or lamellar release and grafting, are indicated only if there is permanent scarring

Answer 100

(A) Dehiscence of the levator aponeurosis

Answer 101

(E) Shortening of the posterior lamella Entrapment of Lockwood's ligament would lead to a loss of globe support, and inferior displacement of the cranial bone grafts and orbital floor would result in dystopia. Scleral show and ectropion resulting from excess skin excision are more typical of cosmetic blepharoplasty than internal fixation. Periorbital fat atrophy can result in scleral show and a change in globe position but rarely causes ectropion in patients with traumatic orbital injuries.

Answer 102

The lower eyelid is formed by the anterior, middle, and posterior lamellae: Anterior lamella: skin and orbicularis oculi muscle. Middle lamella: orbital septum Posterior lamella, or capsulopalpebral fascia: the tarsus muscle, lower lid retractors, and conjunctiva.

Answer 103

Shortening and scarring of the posterior lamella and septum are most common.

Answer 104

(D) Dacryocystorhinostomy

Answer 105

Dacryocystorhinostomy is used for correction of nasolacrimal duct obstruction. Many methods of dacryocystorhinostomy have been described. The single lacrimal flap technique, as well as other techniques that do not involve flaps, has produced long-term patency rates of 90%

Answer 106

Conjunctivodacryocystostomy and conjunctivodacryocystorhinostomy are procedures used for reconstruction in a patient who has obstruction at the canalicular level.

Answer 107

(B) Dry eye syndrome The patient shown in the photograph has minimal exophthalmos and moderate scleral show. Such clinical findings, as well as proptosis, hypotonia of the lower eyelids, and maxillary hypoplasia, are significant predictors of dry eye syndrome, while low tear film is less predictive of dry eye syndrome.

Answer 108

not as predictive

Answer 109

Exopthalmos, moderate scleral show, proptosis, hypotonia of the lower lids, maxillary hypoplasia

Answer 110

(A) Blepharochalasis

Answer 111

Patients with dermatochalasis have occasional episodes of visual obstruction resulting from excess eyelid skin.

Answer 112

Dry eye syndrome is caused by corneal exposure following blepharoplasty and manifests as pain, dryness, and blurred vision.

Answer 113

Pachydermoperiostosis, or idiopathic hypertrophic osteoarthropathy, is a familial condition of unknown cause characterized by progressive enlargement of the eyelids, hands, feet, and toes. The conjunctivae are covered by hypertrophic papillae. Ptosis and visual obstruction are common.

Answer 114

(A) Descending lacrimal glands In this patient who has undergone upper eyelid blepharoplasty, the persistent upper eyelid fullness is most likely a result of descending lacrimal glands. Appropriate management of this condition can include resuspension of the glands, which has been advocated by some surgeons

Answer 115

Excision of the glands is not recommended because it may result in the development of keratoconjunctivitis sicca

Answer 116

Eyebrow ptosis would most likely be seen over the entire eyebrow, not just the lateral third.

Answer 117

(C) Horner's syndrome

Answer 118

sympathetic denervation of the superior cervical ganglion

Answer 119

Blepharophimosis syndrome is a congenital condition consisting of ptosis, telecanthus, and phimosis of the upper eyelid fissure

Answer 120

(D) Retrobulbar hematoma

Answer 121

Retrobulbar hematoma is mostfrequently characterized by steady, severe, lancinating pain in the globe and orbit (mimicking symptoms of acute glaucoma), which can occur alone or with scintillating scotomas (ie, sparkles and flashes, mimicking the symptoms of severe migraine) and hemianopsia or amaurosis fugax (ie, findings similar to a "window shade" pulled over the lower half of the visual field, mimicking a transient ischemic attack). Other symptoms associated with the development of hematoma following blepharoplasty include early discharge from the eye, perioperative and postoperative vomiting, and coughing. The use of aspirin-containing products has also been associated

Answer 122

Appropriate management includes surgical exploration and lateral canthotomy, with ophthalmologic consultation. Mannitol and carbonic anhydrase inhibitors can also be administered to decrease intraocular pressure and reestablish blood flow

Answer 123

(A) Lateral canthal tendon

Answer 124

Eyelid structures such as the levator aponeurosis, orbicularis oculi muscle, and tarsal plate do not need to be released. Because these structures lie external to the support sling created by the lateral canthal tendon and Lockwood's suspensory ligament, they already have at least partial mobility

Answer 125

Tenon's capsule covers the globe and extraocular muscles, creating a barrier between these structures and the orbital fat. The lower portion of the capsule comprises Lockwood's suspensory ligament. Because of their position proximal to the globe, it is more prudent to detach the lateral canthal tendon from the bony rim in order to allow for advancement of the intraorbital contents. Surgical detachment of the lateral canthal tendon will disrupt the globe only minimally. Any loss of lower eyelid height can be restored later with lateral canthopexy.

Answer 126

(A) Ethmoid

Answer 127

The medial orbital wall is comprised primarily of the orbital plate of the ethmoid bone.

Answer 128

This bone is made up of a horizontal or cribriform plate, a midline perpendicular plate that forms the nasal septum, and symmetric lateral masses. The outer wall of each lateral mass is the medial orbital wall, the inner walls are the sidewalls of the nasal

Answer 129

Knowledge of the anatomy of the medial orbital wall is important when diagnosing and treating extensive orbital blowout fractures, which often include the orbital floor. These fractures can extend to involve the inferomedial hillock and central section of the medial orbital wall; if this occurs, the orbital contents may be displaced into the maxillary and ethmoid sinuses

Answer 130

If the anatomic volume of the bony orbit is not restored surgically, the patient may develop posttraumatic enophthalmos and diplopia. This will most likely occur in those patients who have an increase in bony orbital volume of greater than 5%

Answer 131

The orbital floor is comprised of the maxilla medially and the zygoma anteriorly.

Answer 132

(B) Nasolacrimal duct

Answer 133

the superior meatus

Answer 134

the inferior meatus

Answer 135

(B) blepharophimosis syndrome

Answer 136

Blepharophimosis syndrome, which is classified according to three types, is a form of congenital ptosis. Blepharophimosis syndrome, type 1: large epicanthal folds with epicanthus inversus, horizontally shortened eyelids, and severe ptosis. Blepharophimosis syndrome, type 2: telecanthus, absence of the epicanthal folds, severe bilateral ptosis, absence of levator function, and skin shortage involving all four lids. Blepharophimosis syndrome, type 3: absence of epicanthal folds, telecanthus, an antimongoloid slant of the palpebral fissures, severe ptosis, mild orbital hypertelorism, and skin deficiencies.

Answer 137

The presence of severe congenital ptosis leads to a diagnosis of blepharophimosis syndrome type 1

Answer 138

Surgical correction of blepharophimosis syndrome involves repair of the epicanthal folds and correction of eyelid ptosis. Levator resection, medial canthoplasty, and fascial suspension techniques have all been used in combination to correct the abnormalities. A five-flap technique that combines double Z-plasties and a Y-to-V flap is most often used for repair of the epicanthal folds. Ideally, the canthus should lie halfway between the pupil and the center of the nasal bridge following all repair procedures

Answer 139

Blepharospasm is a condition in which there is sustained, forced, involuntary closing of the eyelids.

Answer 140

(D) Levator advancement Bilateral blepharoplasty with fat pad removal and ptosis repair using levator advancement will address this woman's visual field defect and mild ptosis. These procedures are used for patients with normal levator function (defined as greater than 10 mm). Bilateral upper eyelid blepharoplasty alone or in conjunction with fat pad removal would not correct the ptosis, while repair of the ptosis only would not address the visual field obstruction. The Fasanella-Servat procedure is used to correct minimal ptosis but is a more difficult, complicated procedure than levator plication.

Answer 141

(A) Reassurance and continued follow-up examinations Although operative exploration is warranted in patients who have eyelid discrepancies following blepharoplasty, it would not be useful in this patient who did not initially undergo repair of the levator mechanism. Instead, surgical treatment in this patient should be delayed for two to six months to allow for spontaneous recovery.

Answer 142

Ptosis of a mild to moderate degree is a common finding following blepharoplasty; common causes include postoperative edema of the eyelids and hemorrhage into MŸller's muscle. Because these complications generally resolve spontaneously over time, reassurance and observation with frequent follow-up examinations are most appropriate.

Answer 143

(B) Full-thickness skin grafting

Answer 144

(C) Skin graft from the contralateral upper eyelid A skin graft from the contralateral upper eyelid should be used for full-thickness coverage of this patient's defect. Because older patients typically have dermatochalasia, there is often sufficient skin in the unaffected upper eyelid that can be harvested and used to cover small skin deficits. A cross-lid flap is more appropriate forcoverage of a full-thickness defect.

Answer 145

A) Involutional The most likely diagnosis is involutional or senile ptosis. In evaluating a patient requesting a blepharoplasty, one must also evaluate for blepharoptosis. If a blepharoplasty is performed without correction of ptosis, the patient will have continuing ptosis and potentially be dissatisfied. The most common type of blepharoptosis is involutional or senile ptosis. A thorough history and physical examination should assess ophthalmologic and neurologic causes. On physical examination, there is a characteristic high skin crease (greater than 7 mm), thinned upper eyelid, and lid drop on downward gaze. The levator function (amount of lid excursion with the brow and frontalis muscle held in neutral position) should be assessed. Normal function is greater than 10 mm, moderate function is 5 to 10 mm, and poor function is less than 5 mm. The etiology of ptosis can be classified into neurogenic (oculomotor nerve palsy, Horner syndrome, Marcus Gunn jaw-winking syndrome), myogenic (myasthenia gravis, myotonic dystrophy, mitochondriopathy), mechanical (edema or tumors), traumatic (birth trauma, muscle or nerve damage), congenital, or neurotoxic (such as in envenomation, snake bites, or botulism). None of these are likely, considering this patient’s history and physical examination.

Answer 146

E) Reconstruction with a lid switch flap A Cutler-Beard flap is a two-stage lid switch flap, taken from the lower lid. Some of its disadvantages include two-stage reconstruction requiring eye occlusion for a number of weeks, sacrifice of lower lid tissue (and, commonly, a subsequent ectopion), and lack of intrinsic support. Many modifications have improved on its design including those that provide support. There are many reports of other types of flaps, but for a defect of this size and the anatomic requirements, the best choice is a lid switch flap.

Answer 147

A) Alpha-2 adrenergic stimulation of the Müller muscle of the upper eyelid Apraclonidine is an alpha-2 receptor agonist and is believed to increase muscle tone of the sympathetically innervated Müller muscle located in the upper eyelid.

Answer 148

Apraclonidine is an alpha-2 receptor agonist and is believed to increase muscle tone of the sympathetically innervated Müller muscle located in the upper eyelid, for botox-induced ptosis

Answer 149

E) Zygomatic Anatomically, the orbicularis oculi muscle is divided into three segments: pretarsal, preseptal, and orbital. However, functionally, the orbicularis oculi muscle is divided into the medial inner canthal orbicularis and the extracanthal orbicularis. The medial inner canthal orbicularis is responsible for blinking, lower lid tone, and the pumping mechanism of the lacrimal system. Innervation to the inner canthal orbicularis is from the buccal branches of the facial nerve. The zygomatic branch of the facial nerve innervates the extracanthal orbicularis, which controls eyelid closure, voluntary squinting, and animation. The temporal, marginal mandibular, and cervical branches do not provide innervation to the orbicularis oculi muscle.

Answer 150

C) The antimicrobial property of the tear film 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 meibomian glands produce the outer lipid layer. This oil layer helps to prevent the evaporation of the tear film. 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. As a result, dysfunction can result in dryness and an increase in infections.

Answer 151

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. As a result, dysfunction can result in dryness and an increase in infections.

Answer 152

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.

Answer 153

The meibomian glands produce the outer lipid layer. This oil layer helps to prevent the evaporation of the tear film.

Answer 154

D) Mid pupil To achieve proper contour, the primary lifting suture should be placed on the vertical plane of the mid pupil. It is not uncommon for a patient with involutional ptosis to also have lateral displacement of the tarsal plate. If the central lifting suture is placed at the apex of the tarsal plate, the contour will be abnormally shifted laterally. The medial and lateral limbus position will also cause abnormal contour shifts. The midline of the central fat compartment has an inconsistent location in relation to the pupil.

Answer 155

A) Blepharophimosis syndrome Blepharophimosis syndrome is the only diagnosis listed that is associated with congenital ptosis. Blepharophimosis syndrome is associated with a tetrad of findings including ptosis, telecanthus, epicanthus inversus, and decreased horizontal lid fissure. In type I blepharophimosis, patients have epicanthus inversus and ptosis. In type II, findings include telecanthus, ptosis, ectropion of the lower lids, absent epicanthal folds, and insufficient skin in all lids. Type III is notable for telecanthus, ptosis, hypertelorism, slanting palpebral fissures, and insufficient eyelid skin. Correction involves a variety of techniques including, but not limited to, Z-plasty, transnasal wiring of the medial canthal tendon, and ptosis correction with frontalis suspension. Other abnormalities of the blepharophimosis syndrome include flattening of the nasal dorsum, hypoplasia of the superior orbital rim, as well as forehead and ear deformities. In epiblepharon, the eyelashes are vertical as a result of excess pretarsal muscle and skin overriding the margin of the eyelid, often affecting the lower lids. This causes corneal irritation. If the condition does not resolve spontaneously in the first few years of life, correction involves shortening of the anterior lamella through excision of a horizontal piece of skin and orbicular muscle. Epiblepharon may also be caused by trauma, burns, or fractures. Euryblepharon refers to widening of the palpebral fissure both laterally and vertically caused by a shortage of eyelid tissue. Treatment involves corneal protection and may require surgical correction with standard techniques used for ectropion repair. Cryptophthalmos is a failure in embryonic development of the lid fold. The eye is buried in the developing cover of the epithelium and does not differentiate normally. It may be associated with other congenital abnormalities such as syndactyly, cardiac, facial, and ear defects. Treacher Collins syndrome is a maxillary-zygomatic cleft with a coloboma of the lower eyelid and absent eyelashes.

Answer 156

Blepharophimosis syndrome is associated with a tetrad of findings including ptosis, telecanthus, epicanthus inversus, and decreased horizontal lid fissure.

Answer 157

In epiblepharon, the eyelashes are vertical as a result of excess pretarsal muscle and skin overriding the margin of the eyelid, often affecting the lower lids. This causes corneal irritation. If the condition does not resolve spontaneously in the first few years of life, correction involves shortening of the anterior lamella through excision of a horizontal piece of skin and orbicular muscle. Epiblepharon may also be caused by trauma, burns, or fractures.

Answer 158

Euryblepharon refers to widening of the palpebral fissure both laterally and vertically caused by a shortage of eyelid tissue. Treatment involves corneal protection and may require surgical correction with standard techniques used for ectropion repair.

Answer 159

Cryptophthalmos is a failure in embryonic development of the lid fold. The eye is buried in the developing cover of the epithelium and does not differentiate normally. It may be associated with other congenital abnormalities such as syndactyly, cardiac, facial, and ear defects.

Answer 160

B) MRI In most cases of congenital ptosis, a droopy eyelid results from a localized myogenic dysgenesis. Rather than normal muscle fibers, fibrous and adipose tissues are present in the muscle belly, diminishing the ability of the levator to contract and relax. Therefore, the condition is commonly called congenital myogenic ptosis. Most cases of congenital ptosis are idiopathic. Surgical correction of congenital ptosis can be undertaken at any age depending on the severity of the disease. Earlier intervention may be required if significant amblyopia or ocular torticollis is present. If intervention is not urgent, surgery is often delayed until age 3 to 4 years. Waiting until this age allows for more accurate measurements preoperatively. Congenital ptosis can also occur when the innervation to the levator is interrupted through neurologic or neuromuscular junction dysfunction. Nerve compression by external forces such as tumor must be ruled out. Specifically, when ptosis presents acutely or subacutely in a child over 1 year of age, compression of cranial nerve III is a concern. Rhabdomyosarcoma is the most common primary malignancy of the orbit in children. MRI shows a well-circumscribed mass that typically enhances with gadolinium. On T1-weighted imaging, the tumor usually appears isointense to extraocular muscles but hypointense to orbital fat. On T2-weighted imaging, the lesion appears hyperintense to extraocular muscles and orbital fat. This tumor can grow rapidly and is treated with combined chemotherapy and radiation.

Answer 161

In most cases of congenital ptosis, a droopy eyelid results from a localized myogenic dysgenesis. Rather than normal muscle fibers, fibrous and adipose tissues are present in the muscle belly, diminishing the ability of the levator to contract and relax. Therefore, the condition is commonly called congenital myogenic ptosis. Most cases of congenital ptosis are idiopathic.

Answer 162

E) Stimulation of alpha-adrenergic receptors in the superior tarsal (Müller) muscle The most important mechanism by which apraclonidine caused improvement of this patient’s eyelid ptosis as described is stimulation of alpha-adrenergic receptors in the superior tarsal (Müller) muscle. Botulinum toxin type A is a protease that, through degradation of the SNAP-25 protein within axonal terminals, prevents fusion of cytoplasmic vesicles to the presynaptic membrane and subsequent release of neurotransmitters, in particular acetylcholine (ACh). Release of ACh into the synaptic cleft is necessary for normal skeletal muscle contraction. Transient eyelid ptosis is a potential side effect of injection of botulinum toxin type A into the upper third of the face, with reported incidence between 2 and 11%. It occurs when the injected toxin migrates through the orbital septum and reaches the levator palpebrae superioris (LPS) muscle, a skeletal muscle innervated by the oculomotor (III) nerve. The superior tarsal (Müller) muscle acts in conjunction with LPS to elevate the upper eyelid. Müller muscle is a smooth muscle, innervated by the sympathetic nervous system via alpha-adrenergic receptors. Stimulation of these receptors (as caused by apraclonidine – a selective alpha-2 receptor agonist with weak alpha-1 activity) can compensate for partial LPS dysfunction, correcting 1 to 3 mm of eyelid ptosis. Apraclonidine is not known to cause significant displacement of botulinum toxin type A from its presynaptic receptors. Contraction of the LPS muscle, as for other skeletal muscles, occurs by stimulation of its cholinergic receptors within the neuromuscular junctions. Inhibition of alpha-adrenergic receptors in Müller muscle would cause it to relax, increasing the upper eyelid ptosis.

Answer 163

Botulinum toxin type A is a protease that, through degradation of the SNAP-25 protein within axonal terminals, prevents fusion of cytoplasmic vesicles to the presynaptic membrane and subsequent release of neurotransmitters, in particular acetylcholine (ACh). Release of ACh into the synaptic cleft is necessary for normal skeletal muscle contraction.

Answer 164

B) Injection of botulinum toxin type A Blepharospasm is an involuntary eye movement disorder characterized by frequent blinking and squeezing of the eyelids. Blepharospasm is treated with botulinum toxin type A. Treatment usually brings some relief, although patients require constant monitoring and re-treatment with botulinum toxin type A. Use of tinted glasses may reduce a trigger of essential blepharospasm but is not the primary treatment. Benzodiazepines are not used as the first-line management of essential blepharospasm. Myectomy and neurectomy are reserved for severe cases that are refractory to medical management and are therefore not indicated unless the patient fails all other forms of management.

Answer 165

C) Levator palpebrae superioris muscle The layers of the upper eyelid, in order from superficial to deep, are skin, orbicularis oculi muscle, retro-orbicularis oculi fat, orbital septum, orbital fat (central and nasal or medial in the upper eyelid), levator palpebrae superioris muscle and aponeurosis, Müller muscle, and the conjunctiva. In a Fasanella-Servat procedure for the correction of eyelid ptosis, the conjunctiva and Müller muscle are grasped between clamps just above the border of the tarsal plate. The tissue in the clamp is then excised and closed, thus resecting the Müller muscle and conjunctiva. At the base of the wound after the resection is the levator muscle. The capsulopalpebral fascia and Lockwood ligament are part of the lower eyelid and orbital contents. The capsulopalpebral fascia inserts on the inferior border of the tarsus. It makes up the anterior superior portion of the lower eyelid retractors distal to the Lockwood ligament. The Lockwood ligament is a fascial thickening that supports the globe. It surrounds the inferior rectus and inferior oblique muscles and fuses with the capsulopalpebral fascia. It is analogous to the Whitnall ligament in the upper eyelid.

Answer 166

The layers of the upper eyelid, in order from superficial to deep, are skin, orbicularis oculi muscle, retro-orbicularis oculi fat, orbital septum, orbital fat (central and nasal or medial in the upper eyelid), levator palpebrae superioris muscle and aponeurosis, Müller muscle, and the conjunctiva.

Answer 167

B ) Frontalis suspension with sling With more than 4 mm of the upper limbus covered by the eyelid margin, the ptosis is considered severe, and with levator function at 4 mm, it is considered poor. Therefore, a frontalis suspension is the appropriate procedure. It can achieve excellent symmetry and long-lasting results. Most patients with congenital ptosis have severe ptosis and poor levator function and will need frontalis suspension. Ptosis is defined by how much the upper limbus is covered by the lid margin at rest and forward gaze. It is 1 to 2 mm normally. Ptosis: Mild = 2 mm Moderate = 3 mm Severe = 4+ mm ``` Levator function: Excellent = 12–15 mm Good = 8–12 mm Fair = 5–7 mm Poor = 2–4 mm ``` In terms of treatment: Fasanella-Servat: mild ptosis and good levator function Frontalis suspension: severe ptosis and poor levator function Levator advancement: moderate ptosis and fair levator function Müller muscle resection: mild ptosis, fair to good levator function

Answer 168

Ptosis: Mild = 2 mm Moderate = 3 mm Severe = 4+ mm

Answer 169

``` Levator function: Excellent = 12–15 mm Good = 8–12 mm Fair = 5–7 mm Poor = 2–4 mm ```

Answer 170

Fasanella-Servat: mild ptosis and good levator function

Answer 171

Frontalis suspension: severe ptosis and poor levator function

Answer 172

Levator advancement: moderate ptosis and fair levator function

Answer 173

Müller muscle resection: mild ptosis, fair to good levator function

Answer 174

Fasanella-Servat

Answer 175

Frontalis suspension

Answer 176

Levator advancement

Answer 177

Muller muscle resection

Answer 178

C ) Dacryocystorhinostomy Abnormalities of tear drainage may be subdivided into functional and anatomical. Functional failure is related to poor lacrimal pump function, which may be due to a displaced punctum, eyelid laxity, weak orbicular muscle of the eye, or cranial nerve VII palsy. Anatomical obstruction may occur at any point along the lacrimal drainage pathway and may be congenital or acquired. Primary acquired lacrimal duct obstruction occurs in the elderly as a result of fibrosis. Secondary acquired obstruction causes include neoplastic, traumatic, and mechanical mechanisms. Conjunctivodacryocystorhinostomy is performed in cases of flaccid canaliculi, paralysis of lacrimal pump, and when the site of obstruction is proximal (punctum, canaliculi, lacrimal sac). It is not required when these structures are intact. The dacryocystorhinostomy procedure, which involves fistulization of the lacrimal sac into the nasal cavity, alleviates the symptoms of epiphora. The lacrimal probe demonstrates that the punctum and the sac are intact. The negative result on both Jones I and II – failure of any fluorescein dye to show up in the nasopharynx – demonstrates complete obstruction distal to the lacrimal sac. Dilation or stent placement is not possible. With a history of trauma and the laceration shown, this patient does not have epiphora secondary to excess tear production.

Answer 179

A ) Levator dehiscence Elderly patients most commonly have symptoms of ptosis from dehiscence of the levator aponeurosis insertion. The resting eyelid position migrates inferiorly as the supratarsal crease moves to a more superior position. Muscular dystrophy affecting the extraocular muscles, chronic progressive external ophthalmoplegia, may affect extraocular muscles and the levator. Nonetheless, this is infrequent relative to levator dehiscence. Myoneural dysfunction that worsens with fatigue or at the end of the day is pathognomonic for myasthenia gravis. This disorder primarily affects young women and may be identified by improvement with neostigmine or edrophonium administration. Paralysis of the Müller muscle may occur following injury to sympathetic inflow, as seen in Horner syndrome.

Answer 180

A ) Lockwood ligament The levator aponeurosis attaches to the tarsal plate and is detached or attenuated in senile ptosis. The levator aponeurosis is reattached in senile ptosis procedures. The Lockwood ligament is found in the lower eyelid. It forms a "hammock" stretching below the eyeball between the medial and lateral check ligaments and enclosing the inferior rectus and inferior oblique muscles. The Müller muscle is an accessory levator. The orbital septum lies anterior to the fat pads and the levator aponeurosis. The Whitnall ligament is a condensation of the sheath overlying the anterior superior part of the levator muscle. Injury to the levator muscle during cataract surgery and retractors to the open eye can cause traumatic dehiscence of the levator muscle.

Answer 181

A ) Perform a downward massage of the right eyelid The ability to predict postoperative levels in ptosis surgery has been refined over the years, but there is no completely reliable formula to predict the final tension of the upper eyelid that determines the final upper eyelid level. Revisions are common. Aponeurotic repair is not a measured resection procedure. It does not require patient cooperation and can be performed during general anesthesia. Early management of postoperative asymmetry includes conservative treatment with downward massage. Aggressive lubrication should be used to protect the cornea. The Tensilon test is useful in the diagnosis of ocular myasthenia. Skin grafting is not appropriate since there is no shortage in skin. Removal of the levator sutures will not correct the problem, and could result in ptosis recurrence. Revision of the left eyelid will lead to dry eye symptoms and unfavorable aesthetics.

Answer 182

Coloboma is a congenital ocular defect of the eyelid, iris, retina, choroid, or optic disk.

Answer 183

The defects can range in size from a small notch to a large structural cleft. Palpebral colobomas are thought to arise from a localized growth disturbance, while colobomas of the iris, retina, and optic disk arise from defective closure of the optic fissure.

Answer 184

B) Jones test The most appropriate choice is the Jones test, which evaluates the drainage component of the lacrimal system. There are two steps in this test. The first step involves instilling two drops of a 2% fluorescein solution into the conjunctiva and observing the appearance or absence of this dye in the ipsilateral middle turbinate by means of a curved, cotton-tipped applicator. When dye is noted on the applicator within 3 minutes, the drainage system is intact. Therefore, if no obstruction is noted, the epiphora is caused by hypersecretion. If no dye passes through the nasolacrimal duct, then a secondary dye test is performed by force-injecting 1 mL of saline through the punctum. If this is done and the dye appears in the nose, then a functional or incomplete block of the nasolacrimal duct is present; if no dye appears, then a complete block is diagnosed. Differentiating a canalicular block from a nasolacrimal duct block is done by cannulating and injecting 1 mL of saline through a canaliculus and observing the passage of clear fluid out the other canaliculus. A No. 00 Bowman probe can also be passed through the canaliculus, and the distance to the obstruction can be measured. Typical distances are 8 mm to common canaliculus, 10 to 12 mm to the tear sac, and 16 mm to the upper end of the nasolacrimal duct. CT scans are only useful in evaluating the nasal cavity. They cannot visualize the lacrimal drainage system unless the study is performed as a CT-dacryocystography, which is a specific subvariety of CT scanning, and is reserved as a confirmatory second-line test. Similarly, MRI can only identify abnormalities of the nasal cavity and not details of the drainage system. Nasal endoscopy can only examine the nasal cavity for an abnormal location of the meatus under the middle turbinate. It can also determine if there is a physical obstruction of the lower end of the nasolacrimal duct at that location because of polyps or granulation tissue. This test could be indicated if the Jones test were to show partial obstruction. The Schirmer test is considered a secretory test only and cannot be used to make any determination regarding tear excretion. The Schirmer test is most useful in diagnosing lacrimal hyposecretion. In the clinical scenario described, the epiphora appeared following the injury in the medial canthus; therefore, it is less likely to be related to hypersecretion. Yet a positive Jones test result (dye passes) in the presence of epiphora would clue the physician toward hypersecretion.

Answer 185

B) Inferior rectus The patient described has a fracture of the orbital floor with entrapment or paralysis of the inferior rectus muscle. The inferior rectus muscle is innervated by cranial nerve III (oculomotor nerve) and is responsible for downward rotation of the eye. The inferior oblique muscle is innervated by cranial nerve III and is responsible for upward and outward rotation of the eye. Entrapment or paralysis of the inferior oblique following orbital trauma limits downward gaze; it is difficult for patients to look down when walking down stairs. The superior oblique is innervated by the trochlear nerve (cranial nerve IV) and is responsible for downward and outward rotation of the eye. The superior rectus muscle is innervated by the oculomotor nerve and rotates the eye upward.

Answer 186

C) 12 to 16 mm

Answer 187

C) Levator aponeurosis plication in the left eye The normal anatomical position of the ciliary margin of the upper eyelid is 1 mm below the upper corneoscleral junction in straight gaze. The upper corneoscleral junction is the landmark for ptosis measurement. Position of the eyelid in straight gaze along with the levator function determines the required degree of correction and the type of surgery. Patients with severe ptosis (3 mm or more) usually have poor levator function, therefore frontalis suspension is required. In patients with moderate function (6 to 10 mm), levator advancement and resection is required. For patients with excellent levator function (10 mm or more) and mild ptosis, aponeurotic surgery (plication) is appropriate. In levator advancement surgery, the eyelid will be elevated approximately 1 mm for every 3 mm of advancement. The patient described has two distinct problems that require two different procedures. The upper eyelid skin redundancy can be addressed with a standard upper eyelid blepharoplasty with skin excision and, if needed, a slip of orbicularis muscle. The mild ptosis of her left upper eyelid will be accentuated after the blepharoplasty if left untreated. Since her levator function is excellent, her ptosis can be corrected with a simple plication of the distal levator aponeurosis. This can be accomplished through an upper blepharoplasty incision. In a Fasanella-Servat procedure, a portion of the posterior lamella of the eyelid is resected to improve mild eyelid ptosis by shortening the levator muscle. This procedure would not be used in a patient who requires a skin resection since it uses a posterior approach.

Answer 188

C) Osteocutaneous ligament arising from the medial portion of the maxilla 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.

Answer 189

A) Asymmetry 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.

Answer 190

C) Prevents evaporation of tear film 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.

Answer 191

C) Orbital fissure width 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.

Answer 192

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.

Answer 193

B) Bell phenomenon 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.

Answer 194

A) Fat pad reduction without violating the orbital septum is performed 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.

Answer 195

E) Zygomaticofacial nerve The zygomaticofacial nerve provides sensory innervation to the lateral fat pad of the lower eyelid. Branches of the trigeminal nerve provide sensation to the face. The infraorbital nerve, the second branch of the trigeminal nerve, supplies innervation to the lower eyelid, cheek, and upper lip. The lateral palpebral branch of the lacrimal nerve, a branch of the infraorbital nerve, supplies sensory innervation to the superior lateral portion of the upper eyelid. The infratrochlear nerve provides sensory innervation to the medial aspect of the upper and lower eyelid. The lacrimal nerve provides sensation to the upper eyelid through the first branch of the trigeminal nerve. The facial nerve is a motor nerve to the face and is not responsible for sensation in the face.

Answer 196

D) Dry eye syndrome Dry eye syndrome (dysfunctional tear syndrome) is a problem of tear deficiency and eye discomfort that may result in damage to the cornea. Combining upper and lower eyelid blepharoplasty relative to staged upper and lower eyelid surgery presents a greater risk for dry eye syndrome due to orbicularis oculi dysfunction after surgery. Women on hormone replacement therapy also have a higher risk for developing dry eye syndrome after blepharoplasty. Eye lubrication before and after surgery needs to be strongly considered. Patients with prior laser vision correction should wait at least 6 months before pursuing blepharoplasty because of the effects on corneal sensation and tear production. In this case, the patient’s Lasik procedure 1 year prior would not impair her surgical outcome with upper and lower eyelid blepharoplasty. Chemosis is characterized by conjunctival swelling and irritation after blepharoplasty surgery, requiring lubrication after surgery. Some surgeons advocate treatment of this condition with steroid drops. Eyelid malposition is more likely in patients with a negative vector, defined as those with a maxilla that does not project beyond the orbital rim. It is also common in patients who have poor eyelid tone, diagnosed by snap test or evident as ectropion. Major adverse postoperative events such as bleeding and loss of vision are rare. Bleeding is more risky with uncontrolled hypertension. Smoking history, diabetes, and hypothyroidism are not directly associated with specific complications of blepharoplasty

Answer 197

B) Brow ptosis A patient who undergoes blepharoplasty and ptosis repair in the context of a compensated brow ptosis is likely to experience worsened brow ptosis after the procedure. Evaluation of the blepharoplasty patient requires careful examination of the entire upper third of the face. Patients may have, in addition to excess upper eyelid skin, an eyelid ptosis. In addition to identifying the ptosis, it is important to recognize compensated brow ptosis. A compensated eyelid ptosis occurs when the patient uses the frontalis muscles to raise the eyebrows, which results in a functional improvement in visual fields. This is most easily identified by having the patient close her eyes, and evaluate the automatic raising of the eyebrow on eyelid opening. In this case, the change in the position of the brow on downward gaze and on frontal gaze indicates a compensated brow ptosis. After ptosis repair and blepharoplasty, brow ptosis can become more manifest as the need for compensation decreases.

Answer 198

E ) Thyroid ophthalmopathy The most appropriate answer is thyroid eye disease, or thyroid ophthalmopathy. This is the most common cause of proptosis and diplopia in adults. It affects women approximately 4 to 6 times more frequently than men. Puffy, swollen eyelids, injected conjunctivae, eyelid lag, and proptosis are common in thyroid ophthalmopathy. Optic neuritis is typically associated with visual loss, which is not a symptom in this scenario. Similarly, myasthenia gravis is associated with eyelid ptosis, worsening toward the end of the day—which is not a symptom in this scenario. Although both allergic conjunctivitis and Sjögren syndrome could cause conjunctival injection, neither would be associated with proptosis or eyelid lag. Vision loss, due to compression of the optic nerve, can occur in the most severe cases. Fortunately, this

Answer 199

D ) Orbitomalar ligament The orbitomalar ligament attaches the orbicular muscle of the eye to the orbital rim. It separates the lower eyelid from the mid face. Release of this structure is required to obtain access to the mid face when approaching it from the lower eyelid. The capsulopalpebral fascia inserts on the inferior border of the tarsus. It makes up the anterior superior portion of the lower eyelid retractors distal to the Lockwood ligament. The capsulopalpebral fascia is divided during the transconjunctival incision. This affords access to the lower eyelid for the blepharoplasty procedure. The Lockwood ligament is a fascial thickening that supports the globe. It surrounds the inferior rectus and inferior oblique muscles and fuses with the capsulopalpebral fascia. It is analogous to the Whitnall ligament in the upper eyelid. The orbital septum acts to contain the orbital contents. It attaches inferiorly to the periosteum at the arcus marginalis and superiorly to the eyelid margin. A transconjunctival blepharoplasty can be performed by a pre- or postseptal approach. The parotid masseteric fascia is within the mid face. It is distal to the orbitomalar ligament when approached from the eyelid. It does not need to be released to access the mid face.

Answer 200

B ) Müller muscle Knowledge of periorbital anatomy is critical for plastic surgeons who perform eyelid procedures, both cosmetic and reconstructive. The levator complex originates at the orbital apex at the lesser wing of the sphenoid and travels horizontally until it reaches the Whitnall ligaments, where it changes to a more vertical direction before its aponeurosis inserts on the tarsus, orbital septum, and skin. Above the level of the tarsus, the orbital septum lies anterior to the levator, and preaponeurotic fat lies posterior to the orbital septum. Retro-orbicularis oculi fat lies anterior to the septum and posterior to the orbicularis oculi. Müller muscle inserts directly on the tarsus and lies just posterior to the levator directly superior to the tarsus.

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