Which of the following is the most appropriate next step in management?

(A) Schirmer's testing
(B) Slit-lamp examination
(C) Corneal lubrication
(D) Skin grafting
(E) Tarsorrhaphy

The correct response is Option C.

In this patient who has developed lagophthalmos after blepharoplasty and browlifting, the most appropriate next step in management is corneal lubrication. This can be accomplished by applying a bland ointment before bedtime and using saline solution and/or artificial tears during the day. This regimen may be required for weeks to months before the eyelids return to their natural state during sleep.

Schirmer's testing can be used to measure the quantity of tear production, while slit-lamp examination will indicate any ulceration on the cornea or conjunctiva. Both tests may be necessary for evaluation of this patient's condition but are not the logical first step. Ophthalmologic consultation may also be indicated at a later date.

Skin grafting would not be the next best step but may be required in the future if the amount of skin shortage is excessive and corneal dryness leads to keratitis and ulceration. Although lateral tarsorrhaphy was used in the past to treat lagophthalmos associated with facial paralysis, it is rarely indicated in patients who develop the condition following eyelid surgery. If surgery is required, horizontal eyelid shortening and medial or lateral canthoplasties would be more appropriate.

References
1. Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and Problems in Aesthetic Plastic Surgery. New York, NY: Gower Medical Publishing; 1992:1-31.
2. Lisman RD, Barna N. Blepharoplasty: postoperative considerations and complications. In: Rees TD, LaTrenta GS, eds. Aesthetic Plastic Surgery. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1994;2:597-599.
3. Rees TD, Aston SJ, Thorne CH. Blepharoplasty and facial plasty. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;3:2320-2414.

In the upper eyelid, the fat pads are found directly anterior to which of the following structures?

(A) Anterior lamella
(B) Levator aponeurosis
(C) MŸller's muscle
(D) Orbicularis
(E) Orbital septum

The correct response is Option B.

Two fat pads (nasal and central) are found in the upper eyelid. The preaponeurotic fat pads are located anterior to the levator aponeurosis and posterior to the orbital septum. The three fat pads in the lower eyelid are located anterior to the inferior retractors. In the lower eyelid, the inferior oblique muscle separates the nasal (medial) and central (middle) fat pads, while a fascial sheath separates the central and temporal (lateral) fat pads. In general, the nasal fat pad in the upper and lower eyelids is more pale in color than are the central or temporal fat pads.

References
1. Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;2:1679.
2. Klatsky SA. Blepharoplasty. In: Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. Boston, Mass: Little, Brown & Co; 1994;3:1923.

A 50-year-old woman has excessive tearing of the left eye three days after undergoing four-eyelid blepharoplasty. On examination, a silk suture from the lower eyelid is touching the globe. Which of the following structures is the most likely cause of the excessive tear secretion?

(A) Accessory lacrimal glands
(B) Conjunctival goblet cells
(C) Glands of Zeis and Moll
(D) Main lacrimal gland
(E) Meibomian glands

The correct response is Option D.

The most likely cause of the excessive secretion seen in this patient is the action of the main lacrimal gland. The main and accessory lacrimal glands provide the aqueous portion of the tear film; however, the accessory glands are primarily responsible for basal secretion, which supplies a constant liquid film. In contrast, reflex secretion, which occurs as a result of the action of the main lacrimal gland, can be stimulated by either a foreign body or by emotion.

The goblet cells contribute to the mucous layer of the tear film. The Meibomian glands produce the outer lipid layer of the tear film, while the glands of Zeis and Moll also provide a contribution to the lipid layer.

References
1. Doxanas MT. Surgical anatomy of the eyelids and orbit. In: Wright DW, ed. Color Atlas of Ophthalmic Surgery. Philadelphia, Pa: JB Lippincott Co; 1992:1-16.
2. Kikkawa DO, Lemke BN. Orbital and eyelid anatomy. In: Dortzbach RK, ed. Ophthalmic Plastic Surgery: Prevention and Management of Complications. New York, NY: Raven Press; 1994:1-29.