Table Of ContentEssentials in Ophthalmology Oculoplastics and Orbit
R. F. Guthoff J. A. Katowitz
Editors
Essentials in Ophthalmology Glaucoma
G. K. Krieglstein R. N. Weinreb Cataract and Refractive Surgery
Series Editors
Uveitis and Immunological Disorders
Vitreo-retinal Surgery
Medical Retina
Oculoplastics and Orbit
Pediatric Ophthalmology,
Neuro-Ophthalmology, Genetics
Cornea and External Eye Disease
Editors Rudolf F. Guthoff
James A. Katowitz
Oculoplastics
and Orbit
With 301 Figures, Mostly in Colour
and 12 Tables
123
Series Editors Volume Editors
Günter K. Krieglstein, MD Rudolf F. Guthoff, MD
Professor and Chairman Professor of Ophthalmology
Department of Ophthalmology University of Rostock
University of Cologne Department of Ophthalmology
Kerpener Straße 62 Doberaner Straße 140
50924 Cologne 18057 Rostock
Germany Germany
Robert N. Weinreb, MD James A. Katowitz, MD
Professor and Director Professor of Ophthalmology
Hamilton Glaucoma Center Oculoplastic and Orbital Surgery Service
Department of Ophthalmology The Children’s Hospital of Philadelphia and
University of California at San Diego The Edwin and Fannie Gray Hall
9500 Gilman Drive Center for Human Appearance
La Jolla, CA 92093-0946 University of Pennsylvania
USA 34th Street and Civic Center Blvd.
Philadelphia, PA 19104
USA
ISBN 978-3-540-33675-4 ISSN 1612-3212
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Foreword
The series Essentials in Ophthalmology was initi- to discuss clinically relevant and appropriate top-
ated two years ago to expedite the timely trans- ics. Summaries of clinically relevant information
fer of new information in vision science and have been provided throughout each chapter.
evidence-based medicine into clinical practice. Each subspecialty area now has been covered
We thought that this prospicient idea would be once, and the response to the first eight volumes
moved and guided by a resolute commitment in the series has been enthusiastically positive.
to excellence. It is reasonable to now update our With the start of the second cycle of subspecialty
readers with what has been achieved. coverage, the dissemination of practical informa-
The immediate goal was to transfer informa- tion will be continued as we learn more about
tion through a high quality quarterly publication the emerging advances in various ophthalmic
in which ophthalmology would be represented by subspecialties that can be applied to obtain the
eight subspecialties. In this regard, each issue has best possible care of our patients. Moreover, we
had a subspecialty theme and has been overseen will continue to highlight clinically relevant in-
by two internationally recognized volume edi- formation and maintain our commitment to ex-
tors, who in turn have invited a bevy of experts cellence.
G. K. Krieglstein
R. N. Weinreb
Series Editors
Preface
Ophthalmic plastic and reconstructive surgery Another area of development has been the use
continues to evolve as an important subspecialty of minimally invasive approaches for the surgi-
dealing with a large variety of complex chal- cal repair of lid, lacrimal, and orbital problems,
lenges. Despite close relationships and overlap including the use of filler materials and inject-
with other surgical and nonsurgical disciplines, it able self-inflating pellets for augmenting orbital
has developed into a distinct identity, while also volume.
achieving a high level of patient satisfaction. Chapters dealing with complications such as
The second volume of Oculoplastics and Or- orbital implant exposure or problems with sali-
bit in the Essentials of Ophthalmology series ad- vary gland transposition surgery are openly dis-
dresses a wide spectrum of disorders including cussed and will hopefully stimulate efforts to find
oncology, ophthalmic manifestations of systemic better techniques for further reducing surgical
diseases, as well as functional and aesthetic con- side effects and complications.
cerns involving orbital, periorbital, and facial The editors have selected specific topics for
structures. this volume in an effort to provide an up-to-date
In order to achieve optimal results, a full un- review of various eyelid, lacrimal, and orbital
derstanding of the surgical anatomy, as described problems including aesthetic concerns regarding
in Chapter 5, should be combined with recent the aging face. This volume is intended not only
surgical advances, including microsurgical ap- for subspecialists, but also for comprehensive
proaches. Newer techniques using various allo- ophthalmologists and other healthcare profes-
plastic and autologous materials have also been sionals with an interest in oculoplastic disorders.
developed to provide or replace orbital volume. It is our hope that the information presented may
Various clinical applications that are depen- be useful in improving the understanding and
dent upon the stage of each disorder and the management of these complex problems.
experience of the surgeon have significantly im-
proved patient outcomes. R. F. Guthoff
J. A. Katowitz
Editors
Contents
Chapter 1 1.4.4 Exposure of the Inferior
Repair of Involutional Ectropion Tarsal Border ................ 7
and Entropion: Transconjunctival 1.4.5 Suture Technique ............ 7
Surgery of the Lower Lid Retractors 1.4.6 Correction of Horizontal
Laxity ...................... 9
Markus J. Pfeiffer
1.5 Surgical Technique
1.1 Introduction ................ 1 for Entropion Repair ........ 10
1.2 Surgical Anatomy 1.5.1 Principle of Retractor
of the Lower Lid ............. 1 Fixation .................... 10
1.2.1 Lower Lid Position 1.5.2 Access to the Lower Lid
and the Intercanthal Line .... 2 Retractors ................. 10
1.2.2 Posterior Lamella 1.5.3 Suture Technique ........... 10
of the Lower Lid ............. 2 1.6 Repair of Complicated
1.2.3 Anterior Lamella Cases and Complications
of the Lower Lid ............. 2 of Retractor Surgery ........ 10
1.2.4 Relationship Between 1.6.1 Complicated Involutional
the Anterior and Posterior Ectropion .................. 10
Lamellae .................... 2 1.6.2 Complicated Involutional
1.2.5 Lower Lid Crease ............ 4 Entropion .................. 10
1.2.6 Orbital Septum 1.6.3 Complications of Retractor
and the Orbitomalar Septum 4 Surgery .................... 12
1.2.7 Lid Margin Shape
and the Lid Margin Angle Chapter 2
at the Lacrimal Punctum . . . . . 4 Update on Mohs Micrographic
1.3 Preoperative Evaluation Surgery Techniques for Excision
and Surgical Planning ........ 4 and Reconstruction of Periocular
1.3.1 Evaluation Tumors: A Multidisciplinary Approach
of the Intercanthal Line ...... 5
Christopher J. Miller, William R. Katowitz
1.3.2 Evaluation of the anterior
and posterior Surface ........ 5 2.1 Introduction ............... 14
1.3.3 Evaluation of the Three 2.1.1 Role of Mohs Micrographic
Vectors Influencing Lid Surgery in Treating
Function .................... 5 the Patient with Periocular
1.3.4 Evaluation of the Lid Margin Malignancy ................ 14
and the Punctum ............ 5 2.1.2 History of Mohs
1.4 Surgical Technique Micrographic Surgery in
for Ectropion Repair ......... 6 the Treatment of Periocular
1.4.1 Principle of Retractor Malignancies ............... 14
Fixation ..................... 6 2.1.3 Clarification of the Meaning
1.4.2 Access to the Medial of Clinical, Surgical,
Retractors .................. 6 and Pathologic Margins ..... 14
1.4.3 Access to the Central 2.2 Steps of Mohs Micrographic
Retractors .................. 7 Surgery .................... 15
Contents
2.2.1 Step 1: Determination 2.6.2.2 History of Prior Irradiation ... 24
of Clinical Margins .......... 15 2.6.2.3 Immunosuppressed Patient 24
2.2.2 Step 2: Debulking 2.6.2.4 Additional Historical Risk
of the Tumor ............... 15 Factors .................... 24
2.2.3 Step 3: Excising the Initial 2.6.2.5 Size and Location ........... 24
Mohs Specimen ............ 17 2.6.2.6 Histologic Subtypes ........ 24
2.2.4 Step 4: Gross Sectioning 2.6.2.7 Perineural Involvement ..... 25
and Inking the Fresh Tissue 2.6.3 Mohs Micrographic Surgery
Mohs Specimen ............ 18 for Sebaceous Carcinoma ... 25
2.2.5 Step 5: Mapping the Mohs 2.6.4 Mohs Micrographic Surgery
Specimen .................. 18 for Melanoma .............. 26
2.2.6 Step 6: Embedding, 2.7 Reconstruction of Periocular
Sectioning, and Staining Defects after Mohs
the Pieces of the Mohs Micrographic Surgery ....... 27
Specimen .................. 18 2.7.1 Preoperative Considerations 27
2.2.7 Step 7: Interpretation 2.7.2 Periocular Reconstruction ... 27
of the Pathologic Margins 2.7.3 Eyelid Reconstruction ....... 29
by the Mohs Surgeon ....... 18 2.7.3.1 General Principles of Eyelid
2.3 Advantages of Mohs Reconstruction ............. 29
Micrographic Surgery ....... 19 2.7.3.2 Upper Eyelid Reconstruction 29
2.3.1 High Cure Rates ............ 19 2.7.3.3 Reconstruction of Lower
2.3.2 Tissue Conservation ........ 20 Lid Defects After Mohs
2.3.3 Optimal Division of Labor ... 20 Micrographic Surgery ....... 34
2.4 Differences Between Mohs 2.7.3.4 Reconstruction of Medial
Micrographic Surgery Canthal Defects After Mohs
and Common Standard Micrographic Surgery ....... 34
Excision Techniques ........ 20 2.8 Conclusion ................. 40
2.4.1 Determining Appropriate
Surgical Margins: How Does Chapter 3
One Decide Where to Cut? .. 20 Upper Eyelid Retraction:
2.4.2 Comparing and Contrasting Current Concepts in Management
Methods of Microscopic
James Kirszrot, Peter A.D. Rubin
Margin Evaluation .......... 21
2.4.3 Dual Vs. Separate Roles 3.1 Introduction ............... 45
of Surgeon and Pathologist 21 3.2. Differential Diagnosis
2.5 Potential Pitfalls of Mohs of Upper Lid Retraction ..... 45
Micrographic Surgery ....... 22 3.3 Etiology of Thyroid-related
2.6 Periocular Tumors: Upper Lid Retraction . . . . . . . 46
Indications for Mohs 3.4 Physical Examination ....... 46
Micrographic Surgery ....... 23 3.5 Sequelae of Upper Lid
2.6.1 Choosing a Management Retraction ................. 47
Plan Based on Risk 3.6 Medical Management
Assessment of the Periocular of Thyroid-related Upper Lid
Malignancy ................ 23 Retraction ................. 47
2.6.2 Mohs Micrographic Surgery 3.7 Important Considerations
for Basal Cell and Squamous Before Addressing Surgery
Cell Cancers ................ 23 for Upper Lid Retraction .... 48
2.6.2.1 Recurrent Versus Primary 3.8 Basic Principles for Surgical
Tumors .................... 24 Correction of Retraction .... 48
Contents I
3.9 Preoperative Medication .... 50 5.3 Orbital Periosteum ......... 77
3.10 Surgical Recession: 5.4 Orbital Contents ........... 77
Posterior Approach ......... 51 5.4.1 Eyeball .................... 78
3.11 Surgical Recession: 5.4.2 Optic Nerve ................ 78
Anterior Approach ......... 54 5.4.3 Orbital Muscles ............ 78
3.11.1 Levator Disinsertion/ 5.4.3.1 Levator Muscle of the Upper
Mullerectomy .............. 54 Eyelid (Levator Palpebrae
3.11.2 Graded Full-Thickness Superioris Muscle) .......... 78
Anterior Blepharotomy ..... 54 5.4.3.2 Oculomotor Muscles ........ 79
3.12 Conclusion ................. 58 5.4.3.3 Supernumerary Muscles .... 80
5.4.4 Muscular Fascias ........... 80
Chapter 4 5.4.5 Main Lacrimal Gland ........ 81
Lower Eyelid Retraction: Current 5.4.6 Orbital Arteries ............. 81
Concepts in Management 5.4.6.1 Ophthalmic Artery ......... 81
5.4.6.2 Infraorbital Artery .......... 88
Scott M. Goldstein
5.4.6.3 Anastomosis Between
4.1 Introduction ............... 61 the Two Carotid Systems .... 88
4.2 Over-action of the Upper Lid 5.4.7 Orbital Veins ............... 89
Retractors ................. 61 5.4.7.1 Superior Ophthalmic Vein ... 89
4.3 Facial Palsy and Lid 5.4.7.2 Inferior Ophthalmic Vein . . . . 89
Retraction ................. 62 5.4.7.3 Medial Ophthalmic Vein .... 89
4.4 Lower Lid Retraction ........ 63 5.4.7.4 Organization of Orbital
4.5 Nonsurgical Approaches .... 64 Venous Drainage ........... 90
4.6 Surgical Approaches ........ 66 5.4.8 Orbital Lymphatics ......... 90
4.7 Recession of Retractors ..... 66 5.4.9 Orbital Nerves .............. 90
4.8 Spacer Graft ............... 67 5.4.9.1 Intraorbital Oculomotor
4.9 Midface Surgery ............ 68 Nerves ..................... 91
4.10 Lateral Tarsal Strip . . . . . . . . . . 70 5.4.9.2 Intraorbital Branches
of the Trigeminal Nerve ..... 91
Chapter 5 5.4.9.3 Ciliary Ganglion . . . . . . . . . . . . 92
Surgical Orbital Anatomy 5.4.10 Orbital Fat ................. 93
5.5 Anatomical Orbital
A. Ducasse
Topography ................ 93
5.1 Introduction ............... 73 5.5.1 Intraconal Space ........... 93
5.2 Bony Orbit ................. 73 5.5.2 Superior Extraconal Space .. 94
5.2.1 Embryology ................ 74 5.5.3 Lateral Extraconal Space .... 94
5.2.2 Dimensions of the Orbit ..... 74 5.5.4 Inferior Extraconal Space .... 94
5.2.3 Description ................ 74 5.5.5 Medial Extraconal Space .... 95
5.2.3.1 Upper Orbital Wall ......... 74 5.6 Conclusions ................ 95
5.2.3.2 Lateral Orbital Wall ......... 74
5.2.3.3 Inferior Orbital Wall ......... 74 Chapter 6
5.2.3.4 Medial Orbital Wall ......... 75 Periocular Capillary Hemangioma:
5.2.4 Orbital Margins or Angles ... 75 New Concepts in Natural History
5.2.4.1 Superior and Medial Margin 75 and Response to Glucocorticoids
5.2.4.2 Inferior and Medial Margin .. 75
David H. Verity, Geoffrey E. Rose
5.2.4.3 Superior and Lateral Margin 76
5.2.4.4 Inferior and Lateral Margin . . 76 6.1 Introduction .............. 100
5.2.5 Orbital Rim ................ 76 6.1.1 Etiology .................. 100
5.2.6 Orbital Apex ............... 76 6.1.2 Investigation .............. 100
