An accurate history
must be taken of the patient's physical health to rule out any health problems.
(ex. thyroid disease may make the patient look like they need cosmetic surgery).
On physical examination notation should be recorded on the patient's eyebrows,
upper eyelids and lower eyelids.
In the eyebrow
examination we should determine any ptosis of the brow. A measurementfrom the
central upperlid margin tothe central inferiorbrowedge is less than 10 mm. surgical
correction many be needed.
There are many
ways of measuring the amount of lifting desireable for ptosis of the eyebrow.
These measurements aid the physician in determining the amount of skin to be
removed to raise the brow. The lateral third of the brow is its least fixed
part, thus more prone to ptosis.
In the upper eyelid
examination, a determination is made of excessive redundant eyelid skin and
herniated orbital fat. Identifying the crease in the upper eyelid assists us
in measuring the (MCD) margin crease distance (9-11 mm.). If the measurment
is less than 9 mm. the patient should consider reconstruction of the lid crease
(tarsal fixation).
Ptosis of the upper eyelid is suspected when the measurement of the palpebral
fissure width is less than 10 mm. and the margin reflex distance is less than
4 mm.
A prolapsed lacrimal
gland should be considered when fullness of the upper lid in the temporal region
is seen. (No fat is found in this area.)
Herniated obital
fat of the lower eyelid is determined by having the patient look upward. The
application of pressure to the eye (at the upper lid) causes an increased fullness
(herniated fat) in the lower eyelid. If no fullness is seen edema is suspected.
Redundency or laxity
of the lower lid is seen when the physician pulls the lower lid downward to
see how quickly it snaps back into position. By pulling the lateral canthus
nasally, the physician can determine the laxity of the lateral canthus.
Visual fields are
indicated when the overhang of the upper eyelids is obscuring the patient's
vision. Accurate documentation from the opthamologist will help when billing
the insurance company for payment for upper eyelid surgery.
Photographs provide
a permanent visual record of the patient preoperatively. The photograph may
show problems that were not seen on the initial eye examination. They also will
help in demonstrating to the patient their postoperative improvement.
Corneal evaluation
of the patient will help in determining any contradictions to cosmetic eyelid
surgery.
PATIENT SELECTION
In the preoperative
evaluation of the patient particular attention should be paid to:
1 - the patient's
behavior
2 - patient's expectations of the surgery
3 - patient's appearance (unkept or unclean) may indicate poor self image
If for any reason
the physician is uncomfortable with the patient, it would be wise not to propose
surgery to the patient.
PSYCHOLOGICAL
STATES
Certain mental
disorders are contraindications to cosmetic surgery. If the patient is unable
to give clear answers to questions and avoids eye contact schizophrenia should
be considered. Physicians should be alert to patients that are:
1. intensely anxious
and constantly asking the same questions repeatedly
2. paranoid, suspicious,
distrustful
3. hypochondriacs
4. depressed
Careful selection
of patients will keep a good prognosis post operatively and dissatisfaction
vall be minimized.
DERMATOPHATHOLOGY
The first noticeable
signs of aging of the skin are:
1. Looseness
2. Droopiness
The greatest offender
of skin aging is sunrays, which causes premature aging of the skin.
Dermatochalsis
loss of elasticity of the skin and results in loosening and wrinkling of the
skin. This condition which is very common with aging is enhanced by sun exposure.
Dermatochalasis
is not reversible and surgical correction is the only remedy.
ANESTHESIA
A careful medical
history preoperatively will determine the safest anesthesia for the patient
undergoing cosmetic oculoplastic surgery.
Premedication of
the patient will help alleviate some of the patient's anxiety prior to the surgical
procedure. The following premedication has proven to be very successful:
Demerol 50-75 mg.
1M
Robinul 0.2 mg.
1M
Versed 2 mg. 1M
The combination
is given 45-60 minutes preoperatively. In those patients allergic or sensitive
to demeral, Morphine Sulfate 10-15 mg. IM is given.
Prior to local
infiltration of the eyelids the following is given intravenously to the patient:
Fentanyl 1cc.
Versed 1 mg.
Inapsine 1.25 mg.
The Fentanyl and
Versed may be repeated in 30 minutes if necessary. When administering Versed
note the potency is approximately three to four times that of diazepam. Initial
dose of 1 mg IV will give an amnesic effect and the intravenous dose may be
titrated with 0.5-1 mg. every 30-45 minutes if needed. Titrating Versed in lower
doses will minimize respiratory depression. In the elderly or debilitated patient,
Versed is titrated slowly over a 2-3 minute period. Using the titrating method
I have encountered no respiratory depression.
INAPSINE (DROPERIODOL)
Inapsine lowers
the incidence of nausea and vomiting and produces marked tranquilization and
sedation. The initial dose of 1.25 mg IV at the onset of surgery will produce
the desired effect. This dose may be repeated in 3-4 hours intravenously. Mild
hypotension may be seen, but this subsides without treatment.
LIDOCAINE
Lidocaine is the
most commonly used local agent used for local infiltration of the eyelids and
surrounding area. A solution of 1 percent with Epinephrine (dosage not to exceed
500 mg.) is injected for the desired effect.
Overdosage is suspected
if the patient shows signs of increased irritability, drop in blood pressure
and convulsions.
EPINEPHRINE
Epinephrine slows
the absorption of lidocaine and any other infiltrating anesthetic you may be
using, by acting as a vasoconstrictor, and therefore decreasing toxicity systemically.
Concentrations of 1:100,000 will help provide the hemostasis needed.
Epinephrine is
a combined non selective Alpha and Beta agonist. It can therefore be arrythmogenic
and cause hypertension. Patients who are Beta blocked are deprived of the peripheral
vasodilatory effects of ephinephrine (Beta agonist property) and experience
primarily the (Alpha) agonist effect - sometimes resulting in serious hypertension.
Moreover, patients who are Beta blocked are usually being treated for hypertension,
coronary artery disease with angina, or tachyarrythmias. The use of adrenalin
in these patients would therefore defeat the pharmacologic objective of Beta
blockage.
ANTIBIOTIC
An antibiotic (Ancef,
Keflin, Vibramycin) given intravenously at the beginning of the surgical procedure
eliminates the need for antibiotics orally in the post operative period. I have
seen no infections in a 2 year period employing this therapy.
ANTIBIOTIC
Patients are seen
frequently during the first 4 week period. Ecchymosis and edema usually disappear
during this time. Female patients are encouraged to reapply makeup after 10
days. Contact lenses, hard, soft and extended wear can be reinserted after 2
weeks. If the patient encounters any eye irritation they are instructed not
to wear the lenses until they can be worn without eye irritation.
Itching and irritation
of the eye is relieved by neodecadron opthalomic solution.
TECHNICAL
CONSIDERATION IN UPPER BLEPHAROPLASTY
Marking: This is
done usually with the patient in a sitting position. The author has done and
still does the markings with the patient in supine position. First a line is
drawn about 6 mm from the lashes on the upper eyelid. This approximately follows
free lid margin. At the medial area it gets closer to the lid margin. At the
medial aspect the tip is drawn upward. Then the upper incision line is determined
by the amount of excess skin and position of eyebrow. The amount of skin excision
is critical at mid and medial upper eyelid and less critical at the lateral
1/3 of the eyelid and laterally beyond the eyelid fissure. The upper incision
lines are connected laterally with an oblique line drawn from the lateral angle
of the eyelids in direction of the temple to meet upper incision line. (Fig.
1)
Both upper eyelids
are marked together and carefully checked for symmetry.
Skin Excision:
Local anesthesia injection and skin excisions are done. Excess muscle, if needed
is removed. In most cases, unattractive protruding fat is present at the medial
part of the upper eyelid. This is removed. Fat deposits at the mid upper eyelid
is not always necessary to be removed and should be individualized.
At time, ptosis
of lacrimal gland may be present. This should be suspended. There is no fat
deposits at the lateral upper eyelid region and removal of lacrimal gland can
have grave consequences (dry eye and corneal ulceration).
In patients with
ptosis of the eyebrows it should be corrected with or without upper blepharoplasty.
Repair: 5.0 nylon
running pull out suture is used on the orbicularis muscle and 6.0 nylon running
suture is used on the skin edge.
Some Technical
Points un Upper Blepharoplasty
It is important
to remove all the small dots of the secretary glands that are usually left on
the skin edges. These, in the author's opinion, are major cause of post operative
cyst formation in the eyelid surgery as opposed to the common belief that suture
tracts cause this.
At the medial part
of the incision line, it should curve upward. The upper incisions curvature
determines the amount of the skin to be removed. If more skin needs to be removed
the upper incision line at this area is less curved. (Fig. 1)
Downward extensions
of the medially incision can cause unsightly contracture.
It is wise not
to transgress to the angle between the nose and eyelid. This will give rise
to contracture and at the least to an unnatural look.
Some excess skin
in medial upper eyelid is well tolerated. This area is very sensitive to excess
skin excisions and will not tolerate it well. This may be due to the fact that
medial eyebrow is fixed and also the area is concave.
Medial 1/3 and
middle 1/3 of the upper eyelid does not tolerate excess skin excisions and lagophthalmos
will result and also punctum will not fuction properly. Lateral 1/3 tolerates
excess skin excision much better (while mobile lateral eyebrow may compensate).
Adequate upper and lower blepharoplasty will correct Crow's feet deformity nicely,
but not completely.
PTOTIC BROW
Ptotic brows may
be seen alone or in conduction with redundant upper eyelids. This condition
is seen in both men and women.
The brow lift is
the most common approach to this problem. Scarring is kept to a minimum if the
incision is placed inside the cephalic-most line of brow hairs. The patient
must realize the scars are permanent, but they can be concealed with makeup.
Temporal and forehead
lifts will give a more favorable result, for ptotic brows, and leave no noticeable
scarring.
Complications such
as hematoma, hair loss and hyperesthesia are rarely encountered.
These procedures
can safely be done with local infiltration in an outpatient setting.
SKIN,
SKIN-MUSCLE FLAP TECHNIQUE IN LOWER BLEPHAROPLATY
This utilization
of most conservative surgical approach. Surgical dissection and anatomical disturbances
is the least while on the other hand correction of anatomical derangement due
to aging is done in a very effective and aesthetically sound manner.
By creation of
a skin flap over the pretarsal portion of orbicularis occuli muscle, intimate
anatomical relationship of the muscle and tarsal plate is preserved. It is only
below the tarsal plate that the flap is changed to a skin muscle flap with easy
access to herniated fat pad. Then only preseptal portion of orbicularis occuli
muscle (the skin muscle flap) is toned by suspension of muscle and its overlying
skin still attached, superiorly and laterally. The anatomical correction is
achieved with excellent aesthetic results resembling youthful lower eyelid cheek
unit. A report of 260, bilateral inferior blepharoplasty utilizing this method
in the last nine years (since 1979) is discussed.
In the past, skin
flap is used extensively with success with its own drawbacks. Presentation of
skin muscle flap while eliminating some of these drawbacks created its own drawbacks.
Later utilization of a separate skin flap and muscle flap while correcting some
of the problems associated with either technique posed its own negative points.
Most importantly, unnecessary dissection of one of the most delicate structures
in the human body.
Skin, skin-muscle
flap technique on the other hand avoids most of the drawbacks associated with
either of the three previous methods effectively. It minimizes the dissection
and anatomical disturbance.
Briefly, it utilizes
advantageous points of all previous methods while avoiding most of the disadvantages
of each. The technique is easy and fast with less bleeding due to limited dissection.
Correction is superb as compared to any method utilized before. (fig. 2)
TECHNIQUE
A horizontal incision
is made at the lateral canthal area, then a tenotomy scissors is used to separate
the skin from pretarsal portion of the orbicularis muscle. Skin flap is completed
by incising skin close to eyelashes leaving just enough skin superiorly to place
suture (less than 1 mm) few bands are separated and skin flap is carried down
below the inferior edge of the tarsal plate. At this point, the muscle flap
is raised above bloodless areolar tissue over septum orbitale and herniated
fat pads. This done by incising preseptal orbicularis muscle laterally and continuing
medially. The level of incision is about 8 mm from subciliary incision. Couple
of bleeders from the incised muscle edge are coagulated. From here on dissection
of skin muscle flap over the loose areolar tissue is easy and fast. Herniated
fat is removed as with other methods. Repair is started by draping the entire
flap upward and lateral over the eye and upper eyelid. Flap usually stays in
a comfortable level without any traction. The lateral cut edge of the preseptal
portion of orbicularis muscle is grasped with forceps and moved laterally and
superiorly looking at the correction thus visualized in infra orbital fold and
preseptal area on the skin. Then one 5.0 PDS (or vicryl) suture is placed at
this point between the muscle and lateral canthal area deep to periosteum, or
close enough to give a firm suspension point. This tissue is firm and doesn't
move downward when pulled after placing the needle. This suture should be placed
with just enough traction to effect a good firmness without undue tension. The
lower eyelid is pushed upward and then left free to settle in a comfortable
position. At this time, the lower eyelid is covering at least a part of the
iris if patient is looking directly forward. Excision of excess flap is done
at the level of the lower lid margin (not incision) to safeguard against excessive
excisions. It is tempting to remove all excess looking flap down to the incision
line. This is dangerous and should be avoided. Generally, excision of the skin
in the lid margin is small; while more skin is excised laterally. Following
the excision the lower lid is gently pushed up and skin edges fall in place,
then few more sutures are placed laterally, suspending preseptal orbicularis
muscle from the lateral canthal area. Some muscle fibers of the preseptal area
will overlap the pretarsal muscle fibers. This is more pronounced laterally.
This overlap is advantageous in several ways. Most importantly, it supports
the lower lid and tones the lid margin in particular at the lateral aspect of
it. This corrects mild forms of senile ectropion effectively. In our series,
use of K-Z procedure is uncommon and only in extreme laxity of lower eyelid
and on senile ectropion it may be needed. The muscle overlap helps to increase
the bulk at the lower lid below the lashes correcting attenuated lid margin
visible in older patients especially in fair skin persons with senile atrophy
of muscle and skin. If a full lower eyelid border is desireable as expressed
by sheen. This is simply done by overlapping the pretarsal orbicularis muscle
with preseptal orbicularis muscle. We do not necessarily recommend full pretarsal
eyelid; but simply indicate an easy way to create it. If no muscle overlapping
is desired or needed, excess muscle is simply trimmed. Author prefers very conservative
trimming of the muscle at this point.
If the eyelid margin
is weak and lax, tightening the pretarsal muscle could be considered. This is
done by embricating the muscle at the lateral canthal area. In severe cases
of senile ectropion, V-excision of the free margin is done if all above procedures
have failed to correct it. This is determined by intra operative checking of
the lower eyelid tone. Skin repair is done with running 6.0 nylon suture. Running
sutures are quite adequate and easy to remove. At times during skin repair fine
trimming of skin edges may be necessary. A word of caution seems due regarding
skin excisions and the amount of tension at the lateral canthal area.
Too much tension
laterally may cause ectropion, if the direction of tension is not upward enough
during initial suturing of preseptal muscle. It should be tried to have the
direction of traction more cephalic than lateral.
The correct angle
of suspension is somewhat different from case to case. Also according to the
direction of muscle pull the amount of lateral skin and subciliary skin to be
removed will vary. In the author's experience, the more lateral tension the
less subciliary skin will be available for excisions. This variability is a
major reason to delay skin and muscle excisions to the end part of the operation
after a satisfactory correction is achieved. If not, sutures on the muscle must
be removed and directions and tensions of the skin muscle flap changed. This
interrelationship between the direction and tension of the lateral suspensions
and quantity of skin excess at the subciliary area demands judgement and skill
while gives the artistic plastic surgeon a tool for further creativity in his
pursuit for excellence. Then he can individualize each case and direct his efforts
according to his patient's condition and anatomical properties.
Some Technical
Points In Skin, Skin-Muscle Flap Techique
- the horizonal
incisions at the lateral canthal area usually turns oblique due to tension
of the muscle repair. This helps to improve Crow's feet deformity.
- a upper Blepharoplasty
helps a good tightness of skin at lateral canthal area improving Crow's feet
further. In cases that just lower Blepharoplasty is done a hood of excess
skin of the lateral canthal area may persist. This is especially a problem
in progressed cases of blepharocholesia.
- any trimming
of skin and muscle should be done after lateral suspension sutures location
is finalized.
 |
 |
 |
 |
| Fig
2. (A) Basic concept of skin and skin-muscle flap technique. (Dashes indicate
lines of dissection.) (B) Dissection of skin flap over pretarsal portion
of the orbicularis muscle and skin-muscle flap over the septum orbitale.
(C) Excess muscle excised or (D) excess muscle overlapped (see text). (E)
Front view showing the pretarsal part of the orbicularis muscle intact and
preseptal muscle raised together with the skin, over the septum orbitale. |
 |
 |
| Fig. 3.
Operative technique. (A) Horizontal incision at the lateral canthal area.
(B) Elevation of skin flap over pretarsal part of the orbiculazis muscle
with tenotomy scissors. (C) Subciliary incision completed, (D) Skin flap
completed. (E) Muscle incised and skin muscle flap raised (F) Excess orbital
fat removed. (G), (H) Excess muscle excised laterally and superiorly; lateral
toning of the preseptal orbicularis muscle done. (I) if the operation has
been done correctly, opening the mouth, pressing the orbit, and similar
maneuvers will not change the position of the skin flap appreciably. (J)
Excess skin removed along the margin of the lower eyelid (not at the incision
line). (K) Lateral excision. Usually more skin is removed laterally than
at the infraciliary area. (L) Repain completed with 6-0 continuous nylon
sutures. |
CHEMICAL PEELING (Phenol)
Chemical peeling
with phenol solution removes fine wrinkling of the skin. I have seen no cardiac
or respiratory problems using phenol. Complications that have been reported
are mostly scarring. This can be avoided by applying the chemical superficially;
lightening of the skin color and ectropion of the lower eyelids can also happen.
Prior to application
of phenol the area to be treated is cleaned with skin degreaser or alcohol to
remove any residue of oil. The phenol solution is applied with 6" cotton
tip applicators in even distribution. The area treated is taped with waterproof
adhesive tape for 48 hours. The patient is maintained on oral narcotics (after
the first 8 hour discomfort is minimal). Following removal of the tapes antibiotic
powder is dusted to the area. The patient applies the powder twice daily till
the areas are dry. The treated area may be washed after three days with a mild
soap and cool water. When the skin is completely dry an antibiotic ointment
(polysporin) is applied for 5 days. The new skin must be protected from the
sunrays for at least 6 months. I recommend to my patients that they apply sun
block and wear a wide brimmed hat when they are out of doors.
Makeup and moisturizers
may be applied in approximately 10 days to 2 weeks following chemical peeling.
The pink coloring
of the skin gradually disappears within an 8 week period.
COMPLICATIONS
IN UPPER BLEPHAROPLASTY
The following list
points out some of the complications in upper blepharyplasty:
- Hematoma
- Crease Abnormalities
- Visual Loss
- Bleeding
- Severe Pain
- Corneal Injury
- Excessive skin
removal, Lagophthalmos
- Post-operative
ptosis
- Diplopia
- Residual skin
- Lacrimal gland
injury
- Epicanthal
Fold
- Dellen formation
and Conjuctival swelling
- Brow Drop
- Localized skin
abnormalities
- Post operative
Epiphora
- Suture tracks,
cysts, keloid and hypertrophic scarring
- Dissatisfied
patient
POST OPERATIVE
COMPLICATIONS UPPER BLEPHAROPLASTY
Early complications
of upper blepharoplasty are hematoma, visual loss and severe pain.
Hematomas occur
if hemostasis is not adequately obtained during surgery, if ice compresses are
not immediately applied or if patient has a severe vomiting spell. If the hematoma
cannot be controlled, it may be necessary to return the patient to the operating
room to identify and stop the source of bleeding.
Vision loss can
be detected by the nursing personnel in the recovery room. Vision loss in blepharoplasty
is a medical emergency and immediate measures must be instituted. Vision loss
is caused by increased orbital pressure that produces pressure on the optic
nerve and the blood vessels supply to the nerve and globe. The orbit must be
decompressed to relieve globe pressure. Temporary measures such as mannitol,
and steriods may be initiated intravenously to help relieve orbital pressure.
Severe pain post
operatively should alert the recovery room staff and physician to the possible
presence of the following:
1 - Glaucoma (coincidental)
2 - Corneal Abrasion
3 - Orbital Hematoma
Late post operative
complications are diplopia, lacrimal gland injury, Dellen formation and conjunctival
swelling, epighora and the dissatisfied patient.
Diplopia (Superior
Oblique Palsy) is a rare occurance and is caused by marked bleeding at the area
of the superior nasal fat pad that required blind cauterization in the upper
nasal quadrant. Injury to the superior oblique may take place for it is located
directly below this area.
Injury to the lacrimal
gland occurs when the gland prolapses to the preaponeurotic fat pad level and
is inadvertenly identified as the fat pad and excised. This results in dry eyes.
There is no fat pad at the lateral superior orbital area. (see heading on dry
eye syndrome).
The persistence
overflow of tears (epiphora) may occur in the first several days post operatively.
This condition is temporary and caused by post operative edema. Reassure the
patient that this condition will correct itself, in several days, as the swelling
subsides.
On some occasions
the patient will be dissatified with their post operative appearance. It may
be necessary to correct small imperfections surgically. If the surgical result
is satisfactory the patient may need to see and compare their pre and post-operative
photographs, and giving the patient emotional support and encouragement in the
post-operative recovery period may eliminate dissatisfaction. Even in the absence
of any detectable imperfection, do not argue with the patient. This is hard
to resist since the surgeon feels right and ready to challenge. This in turn
may turn the patient angry and ready to prove her point, even to the extreme
of visiting a lawyer!
COMPLICATIONS
OF LOWER BLEPHAROPLASTY
The three most
common complications post-operatively of lower blepharo- plasty are:
1 - Ectropion
2 - Lower lid retraction
3 - Lateral canthal ptosis
Eversion of the
lower eyelid (ectropion) can be caused by excessive skin or muscle excisions.
This could also be due to too much tightening of skin and muscle laterally,
pushing the lower part of the tarsus posteriorly and upper border anteriorly.
This creates a space between the eyeball and the lid. Even if the level of the
eyelid is high enough, this separation of the eyeball from the eyelid will cause
severe eye irritation. Mild forms of it will subside with patching and observation
and severe forms may need surgical correction (K-Z procedure).
ORBITAL COMPLICATIONS LOWER BLEPHAROPLASTY
The inferior oblique
muscle is easily injured if the fat pad is not identified before excision and
cauterization. Injury to this muscle will cause double vision (diplopia) which
usually subsides over several days. Surgical correction is usually not required.
Excision of the
orbital fat pad may lead to orbital hemorrhage if the fat pad is not clamped
and cauterized properly. If the hemorrhage is not treated immediately vision
loss can be come permanent and blindness may occur.
There are other
less severe complications. The following list points out some of them:
- Inferior Oblique
Muscle Injury
- Lateral Canthal
Ptosis
- Orbital Hemorrhage
- Epiphora
- Excessive Concavity
of Lower Eyelid
- Subconjunctival,
Hemorrhage or Swelling
- Ectropion, Schieral
Show
- Skin Problems,
cysts, Hypertorphic Scars
- Lower Lid Retraction
- Neglected Fat
Deposits
PROLAPSED LACRIMAL
GLAND
Lacrimal gland
prolapse is the direct result of loosening of the suspensory ligaments of the
orbital septum of the lacrimal gland. Repositioning the gland eliminates the
noticeable bulge in the upper eyelid and gives the patient a more pleasing aesthetic
look.
DRY
EYE SYNDROME (KERATOCONJUNCTIVEIUTIES SICCA)
Tears are a mixture
of secretions from the lacrimal gland, goblet cells, and meibomian glands. The
tear fluid under normal circumstances form a thin layer of tear fluid about
7-10 microns thick. This covering of the cornea and conjunctiva is necessary
to maintain corneal integrity and to inhibit growth of microorganisms.
The normal tear
volume is estimated to be about 6 ml in each eye with a turnover of 1.2 ml per
minute. Three fractions of tears are demonstrable by paper electrophoresis,
albumins, globulins, and lysozyme.
The tear film covering
the corneal and conjuctival epithelium is composed of a superficial lipid layer
derived from the secretions of the meibomian glands, a middle aqveous layer
secreted by the lacrimal glands, and an inner mucinous layer composed of glycoprotein
and mucin which covers the cornea and conjunctiva. The tears are responsible
for the integrity of the eye surface and resurfacing of tear film is accomplished
by blinking the eyes.
Deficiency in any
of the tears film components may lead to the loss of the film's stability. This
causes rapid breakdown of the tear film and dry spots will appear on the cornea
and conjuctival epithelium and this is commonly referred to as dry eye syndrome.
ETIOLOGY
1. Conditions characterized
by hypofunction of the lacarimal glands.
A. Sjogren's Syndrome; dry eye associated with connective tissue diseases.
B. Congenital alacrima
C. Surgical removal of lacrimal gland
D. Mumps
E. Neurogenic lesions; (usually associated with trigeminal nerve) remember VI
innervates the lacrimal gland
F. Systemic diseases with lacrimal gland involvement; sarcoidosis, lymphoma,
leukemia, amyloidosis, lemochom
G. Drug effects; atropine dicrotics
2. Conditions characterized by excessive drying
A. Exposure keratitis
B. Living in dry climates
C. Deficiency of the superficial lipid layer of tear film which commonly occurs
during any type of lid surgery.
3. Mucin deficiency
A. Chemical burns
B. Avitamintosis A
C. Chronic bacterial or viral conjuctivitis
SYMPTOMS AND SIGNS
People will complain
about a scratchy or foreign body sensation. Others
include (symtoms) of itching, excessive mucus secretion, decreased tears, burning
and photosensitivity. Also pain, redness and difficulty closing the lids. Damaged
corneal epithelium is readily seen with 1% rose benyaland corneal epithelial
defects stain with Flourescein.
DELLEN LESION
A dellen is a reversible
localized area of corneal shomal dehydration and corneal thinning owing to a
break in the continuity of the tear film layer secondary to elevation of surrounding
structures. This is commonly seen with pterygium, filtering bleb, suture granuloma,
or limbal tumor.
The histology consists
of a partial or full thickness epithelial defect with the underlying stromal
tissues shrinking or even collapsing from dehydration.
SCHIRMER TEST
The Schirmer test
is a good screening test and the simplest for the assessment of tear production.
This test involves taking a strip of filter paper.5 cm X 3.5 cm in the conjunctival
sac in each eye and obscuring the extent of filter paper wetting by the respective
eye. Schirmer test without topical anesthesia measures the function of the lacrimal
gland whose secretary activity is stimulated by the irritating nature of the
filter paper. Schirmer tests performed after topical anesthesia (1% Tetracaine)
measures the function of the accessory lacrimal glands. A Schirmer test showing
less than 15 mm of wetness in 5 minutes is considered abnormal.
IMMEDIATE POST
OPERATIVE CARE
The patient is
instructed to apply a ziploc freezer bag filled with crushed ice to the eyelids
for 48 hours. A gauze covering is placed over the eyes before the ice is applied.
The application of ice reduces the edema and discomfort associated with oculplastic
eyelid surgery.
A lens lubricant
or balanced salt opthalmic solution may be helpful in the post operative period.
During the recovery
room the nurse should check the patient at 15 minute intervals for bleeding,
unusual swelling and pain, loss of vision (blurred vision is common in the first
72 hour period) and proptosis.
Edema may be reduced
with the patients head elevated at least 30 degrees higher than the rest of
the body.
The patient should
be instructed to keep the eye area clean. Following the initial 24 hour period
the patient may use cotton tip applicators and cool water to clean the eyelid
area.
Patients are advised
to irrigate the eyes out with a saline eye wash solution.
Following the removal
of the sutures, 1/4 inch steri-strips are applied, for at least 10 days, to
the lateral canthal incisions.
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