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Flashcards in Eyelid Reconstruction Deck (24):
1

A 50-year-old woman is evaluated after undergoing Mohs micrographic surgery of the lower eyelid to remove a basal cell carcinoma 2 days ago. On examination, a 65% defect of the lower eyelid involving both the anterior and posterior lamellae is noted. Nether canthi are involved. Which of the following is the most appropriate reconstructive option for this patient?

A) Hughes tarsoconjunctival flap and Tripier lid switch flap
B) Local cheek V-Y advancement flap and buccal mucosal graft
C) Mustardé flap and hard palate mucosal graft
D) Tenzel semicircular flap and periosteal flap
E) Upper eyelid Cutler-Beard flap and buccal mucosal graft

The correct response is Option A.

Eyelid reconstruction is often a challenging endeavor, and depends upon thorough knowledge of the local anatomy, reconstructive options, and extent of resection. Eyelid defects are commonly classified into three categories—less than 25%, 25 to 50%, and greater than 50%—in order to help the surgeon choose the best reconstructive options. Whenever reconstructing an eyelid defect, it is important to identify the structures involved and be sure to reconstruct the lamellae that have been resected. In this patient, there is a defect that involves both the anterior (skin and orbicularis) and posterior (conjunctiva and tarsus) lamellae, and both must be addressed. Of the available options, the only one that appropriately provides the correct amount and quality of anterior and posterior lamellae for a greater than 50% defect is a Hughes tarsoconjunctival flap and Tripier lid switch flap.

A Tenzel semicircular flap would be appropriate for a 50% or less defect of the lower eyelid, but would not be the best option for a 65% defect.

Although a local cheek V-Y advancement flap and a buccal mucosal graft provides both anterior and posterior lamellar reconstruction, a local V-Y advancement flap of the appropriate size would likely create a cosmetically unappealing contour, and using buccal mucosa for the posterior lamella would not provide the amount of support needed for the lower eyelid to prevent ectropion postoperatively.

Although the combination of a Mustardé flap and a hard palate mucosal graft is a possibility because it provides both anterior and posterior lamellar reconstruction, the use of a hard palate mucosal graft would incorporate keratinized epithelium into the reconstruction, and, therefore, would be less desirable than the use of conjunctiva because it can cause corneal irritation.

The Cutler-Beard flap provides both anterior and posterior lamellar reconstruction and, therefore, the buccal mucosal graft is redundant and unnecessary.

2

A healthy 65-year-old woman is evaluated because of drooping of the upper eyelids. Examination shows high eyelid creases and 3 mm of ptosis. Levator excursion measures 10 mm. Which of the following is most likely to correct the blepharoptosis in this patient?

A) Brow lift surgery
B) Fasanella-Servat procedure
C) Frontalis sling
D) Levator advancement
E) Upper eyelid blepharoplasty

The correct response is Option D.

The patient described has moderate acquired blepharoptosis characterized by a high eyelid crease and 3 mm of ptosis. Her levator palpebrae muscle excursion is excellent (10 mm). The most likely cause is disinsertion of the levator aponeurosis from the tarsal plate due to chronic stretching of the levator muscle or involutional changes associated with aging. Surgical treatment most commonly involves advancing and reattaching the levator muscle to the tarsal plate.

An upper eyelid blepharoplasty alone or with a browlift would not correct the underlying cause of the ptosis.

The Fasanella-Servat (tarsoconjunctival mullerectomy) procedure classically excises a portion of mucosa, Müller’s muscle, and superior tarsus, thereby shortening the posterior lamella. This can address mild ptosis (1 to 2 mm) in a patient with otherwise excellent levator function.

The frontalis sling procedure uses autologous or alloplastic material tunneled from the brow to upper tarsus to accomplish upper eyelid elevation when levator function is poor. The cause of ptosis in these cases is likely congenital.

 

3

A 65-year-old woman comes to the office for consultation on blepharoplasty and rhytidectomy. She notes that her eyelid creases are asymmetric, with the right upper crease higher than the left. She also has difficulty seeing out of her right eye when she is tired. She notes that these symptoms have worsened progressively over the past 5 years. She has levator function of 11 mm with the brow and frontalis muscle in neutral position. This patient most likely has which of the following types of ptosis?

A) Involutional
B) Mechanical
C) Myogenic
D) Neurogenic
E) Traumatic

The correct response is Option A.

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.

 

4

A 60-year-old man undergoes Mohs micrographic resection of an upper eyelid squamous cell carcinoma. A photograph is shown. Which of the following reconstruction procedures will provide the most functional and aesthetically pleasing result in this patient?

A) Free nasoseptal grafting
B) Reconstruction with a forehead flap
C) Reconstruction with a free flap
D) Reconstruction with a glabellar flap
E) Reconstruction with a lid switch flap

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The correct response is Option E.

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.

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5

A 50-year-old woman comes to the office 2 weeks after receiving botulinum toxin type A injections for forehead rhytids. She is pleased with the results but has developed unilateral eyelid ptosis. Apraclonidine 0.5% eyedrops are prescribed to improve upper eyelid function. Which of the following best describes the mechanism for improvement of upper eyelid ptosis in this patient?

A) Alpha-2 adrenergic stimulation of the Müller muscle of the upper eyelid
B) Beta-2 adrenergic stimulation of the levator palpebrae superioris
C) Muscarinic parasympathetic inhibition of the levator palpebrae superioris
D) Nicotinic parasympathetic inhibition of the Müller muscle of the upper eyelid

The correct response is Option A.

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.

Beta-2 adrenergic stimulation of the levator palpebrae superioris is not appropriate because apraclonidine does not act as the beta-2 receptor, and it is not believed to stimulate contraction of the levator palpebrae superioris.

Muscarinic parasympathetic inhibition of the levator palpebrae superioris is not appropriate because apraclonidine does not act as the muscarinic parasympathetic receptor.

Nicotinic parasympathetic inhibition of the Müller muscle of the upper eyelid is not appropriate because apraclonidine does not act as the nicotinic parasympathetic receptor.

 

6

A 49-year-old woman is evaluated because of a traumatic laceration of the right lower eyelid and cheek. Physical examination shows difficulty with eyelid closure, voluntary squinting, and animation. Which of the following branches of the facial nerve is most likely injured?

A) Buccal
B) Cervical
C) Marginal mandibular
D) Temporal
E) Zygomatic

The correct response is Option E.

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.

 

7

A 65-year-old woman has inadequate tear secretion because of a poorly functioning lacrimal gland. Which of the following aspects of this patient’s tear film is most likely to be affected?

A) The amount of lipid in the tear film
B) The amount of mucin in the tear film
C) The antimicrobial property of the tear film
D) The degree of evaporation of the tear film
E) The dispersion of the tear film

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 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.

 

8

A 65-year-old woman desires correction of her “sleepy eyes.” Physical examination shows bilateral moderate involutional ptosis of the upper eyelids. Mild lateral displacement of the tarsal plate is noted. Repair of the levator aponeurosis using an anterior approach is planned. Which of the following best describes the proper vertical plane to position the lifting suture in a single-suture technique?

A) Apex of the tarsal plate
B) Lateral limbus
C) Medial limbus
D) Mid pupil
E) Midline of central fat compartment

The correct response is Option D.

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.

 

9

A 4-year-old boy is brought to the office for treatment and evaluation of lid ptosis. On examination, bilateral lagophthalmos, poor levator excursion, and severe ptosis are noted. Which of the following is the most likely diagnosis?

A) Blepharophimosis syndrome
B) Congenital epiblepharon
C) Congenital euryblepharon
D) Fraser cryptophthalmos syndrome
E) Treacher Collins syndrome

The correct response is Option A.

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.

 

10

A 26-month-old boy is brought to the office for evaluation because of worsening congenital ptosis. A photograph is shown. Which of the following is the most appropriate next step in management?

A) Eye lubrication
B) MRI
C) Patching of the non-affected eye
D) Surgical correction
E) Observation only

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The correct response is Option B.

A drooping eyelid is called ptosis or blepharoptosis. In ptosis, the upper eyelid falls to a position that is lower than normal. In severe cases of ptosis, the drooping eyelid can cover part of or the entire pupil and interfere with vision, resulting in derivational amblyopia. The eyelids are elevated by the contraction of the levator palpebrae superioris.

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.

A history of difference in the size of the pupil may be helpful in diagnosing Horner syndrome. Patients with Horner syndrome have ptosis and miosis on the same side. Cervical or apical thoracic tumors can cause damage to the sympathetic chain and result in this condition. Neuroblastoma, which is one of the most common childhood cancers, should be ruled out with this presentation.

Intermittent patch therapy is indicated for strabismus to strengthen the weak rectus muscles.

11

A 48-year-old woman comes to the clinic with new left eyelid ptosis 1 week after receiving injections of botulinum toxin type A for treatment of glabellar rhytides. The patient is prescribed apraclonidine ophthalmic solution for the left eye. Complete resolution is noted 2 days later. Which of the following is the most important mechanism by which apraclonidine resulted in improvement of this patient's eyelid ptosis?

A) Displacement of botulinum toxin type A from its presynaptic receptors
B) Inhibition of alpha-adrenergic receptors in the levator palpebrae superioris muscle
C) Inhibition of alpha-adrenergic receptors in the superior tarsal (Müller) muscle
D) Stimulation of alpha-adrenergic receptors in the levator palpebrae superioris muscle
E) Stimulation of alpha-adrenergic receptors in the superior tarsal (Müller) muscle

The correct response is Option E.

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.

 

12

A 45-year-old man comes to the office because of frequent blinking and squeezing of the eyelids. Examination shows idiopathic blepharospasm. Which of the following is the most appropriate management?

A) Administration of a benzodiazepine
B) Injection of botulinum toxin type A
C) Myectomy
D) Neurectomy
E) Use of tinted glasses

The correct response is Option B.

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.

 

13

A 56-year-old woman undergoes resection of the conjunctiva and Müller muscle for treatment of blepharoptosis. Which of the following structures is encountered immediately anterior to the Müller muscle?

A) Capsulopalpebral fascia
B) Central fat pad
C) Levator palpebrae superioris muscle
D) Lockwood ligament
E) Retro-orbicularis oculi fat

The correct response is Option C.

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.

 

14

A 1-year-old male infant is brought to the office because of congenital ptosis of the left eye. On examination, the eyelid margin covers 4 mm of the upper limbus, and levator excursion is 4 mm. Which of the following is the most appropriate treatment?

A ) Fasanella-Servat procedure
B ) Frontalis suspension with sling
C ) Levator advancement
D ) Müller muscle resection
E ) Observation

The correct response is Option B.

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

15

A 55-year-old man comes for evaluation of epiphora in the right eye 6 months after sustaining a soft-tissue injury to the face in a motor vehicle collision. Physical examination shows that the punctum and lacrimal sac are open. A picture taken at the time of injury is shown. Results of Jones I and Jones II testing are negative. No other abnormalities are noted. Which of the following is the most appropriate next step in management?

A ) Botulinum toxin type A injections of lacrimal gland
B ) Conjunctivodacryocystorhinostomy
C ) Dacryocystorhinostomy
D ) Dilation of lacrimal apparatus
E ) Placement of lacrimal stent

The correct response is Option C.

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.

 

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16

A 76-year-old man comes to the office for consultation regarding a 5-year history of upper eyelid ptosis. He has no history of serious illness or trauma and takes no medications. Which of the following is the most likely cause?

A ) Levator dehiscence
B ) Muscular dystrophy
C ) Myoneural dysfunction
D ) Oculomotor (III) nerve palsy
s E ) Paralysis of the Müller muscle

The correct response is Option A.

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.

17

A 67-year-old woman undergoes bilateral reattachment of the levator muscles because of eyelid ptosis 6 months after undergoing cataract surgery. During the procedure, the levator aponeurosis is reattached to which of the following structures?

A ) Lockwood ligament
B ) Müller muscle
C ) Orbital septum
D ) Tarsal plate
E ) Whitnall ligament

The correct response is Option D.

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.

 

18

A 46-year-old woman comes to the office because she cannot completely close her right eye 1 week following bilateral upper eyelid blepharoplasty with levator advancement. Physical examination shows overcorrection of the right eyelid by 2 mm. Slit lamp examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A ) Perform a downward massage of the right eyelid
B ) Perform an edrophonium (Tensilon) test
C ) Perform skin grafting to the right eyelid
D ) Remove the skin and levator sutures
E ) Revise the left eyelid to obtain symmetry

The correct response is Option A.

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.

 

19

A 10-month-old boy is brought to the office because of the ocular defect shown in the photograph. Which of the following is the correct term for this anomaly?

A) Anophthalmia
B) Coloboma
C) Congenital cataract
D) Palpebral fissure
E) Tessier No. 6 cleft

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The correct response is Option B.

Coloboma is a congenital ocular defect of the eyelid, iris, retina, choroid, or optic disk. 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. Upper eyelid coloboma rarely affects vision; large defects of the lower eyelid can lead to corneal ulceration.

Anophthalmia is total absence of the eye. A congenital cataract is a lens opacity that is present in 1:4000 to 1:10,000 newborns. The size and location determine the effect on vision. The palpebral fissure is the natural opening between the upper and lower eyelids. A Tessier No. 6 cleft involves the inferolateral aspect of the lower eyelid, inferior orbital rim, and the zygoma. This cleft often has an associated lower eyelid coloboma and is related to Treacher Collins syndrome.

 

20

A 30-year-old man comes to the office because of excessive tearing of the left eye 3 months after repair of a deep laceration of the left medial canthus. Physical examination confirms epiphora of the left eye. A missed injury to the lacrimal drainage system is suspected. Which of the following is most appropriate to evaluate the suspected injury?

A) CT scan
B) Jones test
C) MRI
D) Nasal endoscopy
E) Schirmer test

The correct response is Option B.

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.

 

21

An 18-year-old man comes to the emergency department 2 hours after being punched in the right eye during a fistfight. Physical examination shows swelling, diplopia, and a significant limitation of downward gaze in the affected eye. He is able to rotate the eye in all other directions. This finding is most consistent with dysfunction of which of the following extraocular muscles?

A) Inferior oblique
B) Inferior rectus
C) Superior oblique
D) Superior rectus

The correct response is Option B.

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.

 

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A 23-year-old man comes to the office for evaluation of unilateral blepharoptosis. On examination, the excursion of the eyelid margin is measured from downgaze to upgaze while the eyebrow is manually fixed against the supraorbital rim. Which of the following would best approximate the normal excursion distance of levator function for this patient?

A) 2 to 6 mm
B) 7 to 11 mm
C) 12 to 16 mm
D) 17 to 21 mm
E) 21 to 25 mm

The correct response is Option C.

 

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A 46-year-old woman comes to the office for consultation about improving the appearance of her “saggy” upper eyelids. Physical examination shows moderate skin redundancy in both upper eyelids. The ciliary margin of the upper eyelid is located 1 mm below the superior limbus on the right and 3 mm below the superior limbus on the left. Levator excursion is 14 mm bilaterally. In addition to excision of excess skin bilaterally, which of the following is the most appropriate treatment?

A) Brow lift surgery on the left
B) Frontalis suspension in the left eye
C) Levator aponeurosis plication in the left eye
D) Orbicularis plication in the left eye

The correct response is Option C.

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.

 

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