(A) Advancement of MŸeller's muscle
(B) Eyebrow suspension
(C) Fasanella-Servat procedure
(D) Repositioning of the levator aponeurosis
(E) Levator resection

The correct response is Option D.

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. In patients who develop ptosis following an operative procedure or trauma, multiple etiologic mechanisms, including neurologic, myogenic, and mechanical, may be the cause. 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.

Advancement of MŸeller's muscle will not correct 3.5 mm of ptosis. Eyebrow suspension is most appropriate for patients who have poor levator function (less than 4 mm) and greater than 3 mm of ptosis. 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. Levator resection is reserved for those patients who have levator function between 4 mm and 10 mm, and ptosis of greater than 3 mm.

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;2:1671-1784.
2. McCord CD. The evaluation and management of the patient with ptosis. Clin Plast Surg. 1988;15:169-184.

A 6-year-old boy has eyelid ptosis. Examination shows 4 mm of ptosis and 2 mm of levator excursion. Facial nerve function is normal. Which of the following is the most appropriate management?

(A) Blepharoplasty
(B) Frontalis suspension
(C) Placement of gold weights in the eyelids
(D) Levator plication
(E) Levator resection

The correct response is Option B.

Frontalis suspension is the most appropriate procedure for correction of the poor levator function and severe ptosis seen in this 6-year-old boy. Appropriate preoperative evaluation should be performed in any patient with ptosis to classify the type and severity of the ptosis and the amount of levator function. Ptosis is classified as congenital or acquired. Patients with congenital ptosis often have poor function of the levator muscle, characterized by absence of eyelid excursion and a static eyebrow. In acquired ptosis, levator function is typically moderate to good. The amount of levator function is critical to determine the appropriate surgical correction.

Blepharoplasty is appropriate in patients with excess skin and fat around the eyelids, but not in patients with true ptosis. Placement of gold weights in the eyelids is indicated for patients with facial paralysis to assist with eyelid closure. Plication and/or resection of the levator muscle is appropriate for patients who have moderate ptosis and levator function that is rated as fair to good.

References
1. Anderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch Ophthalmol. 1979;97:1123-1128.
2. Carraway JH. Reconstruction of the eyelids and correction of ptosis of the eyelid. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:529-544.

A 25-year-old man has ectropion of the left lower eyelid and excessive tearing of the eye one month after undergoing reduction of an orbital floor fracture through a subciliary approach. The conjunctiva does not appear to be markedly irritated. Which of the following is the most appropriate management?

(A) Observation with massage and taping of the eyelid
(B) Injection of a corticosteroid
(C) Lateral canthopexy
(D) Scar release and grafting of the conjunctiva using a mucosa graft
(E) Skin-muscle blepharoplasty of the lower eyelid

The correct response is Option A.

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.

Corticosteroid injections are associated with unnecessary risks, such as orbital puncture and tissue thinning, and are not indicated when improvement is to be expected. Blepharoplasty procedures would only worsen the ectropion.

References
1. Klatsky SA. Blepharoplasty. In: Cohen M, ed. Mastery of Plastic Surgery. Boston, Mass: Little, Brown & Co; 1994;2:1920-1940.
2. Manson PN. Facial fractures. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia Pa: Lippincott-Raven; 1997:397-398.
3. Yaremchuk MJ, Kim WK. Soft tissue alterations associated with acute extended open reduction and internal fixation of orbital fractures. J Craniofac Surg. 1992;3:134-140.

What is the approximate percentage of patients undergoing reconstruction of fractures of the orbital floor through a transconjunctival approach who will develop ectropion?

(A) 0%
(B) 10%
(C) 20%
(D) 30%
(E) 40%

The correct response is Option A.

In one study of 80 patients undergoing reconstruction of orbital blowout fractures and fractures of the zygomaticomaxillary complex via a preseptal transconjunctival approach, ectropion was not identified as a complication. Only one case of transient entropion was identified, and only 2% of patients in this study reported any complications. Another study of 35 patients who were undergoing secondary orbital procedures reported that 4% of these patients subsequently developed ectropion. In a third study of 400 patients, one patient was identified as having ectropion. In contrast, the rate of ectropion in patients undergoing the traditional subciliary approach to reconstruction has been shown to be as high as 25%.

References
1. Baumann A, Ewers R. Use of the preseptal transconjunctival approach in orbit reconstruction surgery. J Oral Maxillofac Surg. 2001;59:287-291.
2. Lorenz HP, Longaker MT, Kawamoto HK. Primary and secondary orbit surgery: the transconjunctival approach. Plast Reconstr Surg. 1999;103:1124-1128.
3. Mullins JB, Holds JB, Branham GH, et al. Complications of the transconjunctival approach: a review of 400 cases. Arch Otolaryngol Head Neck Surg. 1997;123:385-388.
4. Wray RC, Holtmann B, Ribaudo JM, et al. A comparison of conjunctival and subciliary incisions for orbital fractures. Br J Plast Surg. 1977;30:142-145.

A 62-year-old woman has visual obstruction of the right eye. On examination, she has ptosis of 3 to 4 mm of the right upper eyelid and an elevated supratarsal crease. These findings are most consistent with which of the following conditions?

(A) Dehiscence of the levator aponeurosis
(B) Facial nerve injury
(C) Horner's syndrome
(D) Myasthenia gravis
(E) Periorbital fat atrophy

The correct response is Option A.

The findings in this patient are most consistent with dehiscence of the levator aponeurosis, which is the most common cause of ptosis in elderly persons. Attenuation of the levator aponeurosis typically results. Levator advancement is performed for correction.

Facial nerve injury is a sequela of trauma and may be characterized by eyebrow ptosis.

Horner's syndrome occurs as a result of sympathetic denervation of the superior cervical ganglion. It is characterized by ptosis, myosis, and anhidrosis. The eyelid creases and levator muscle are typically unaffected.

Unilateral or bilateral ptosis secondary to myasthenia gravis is exacerbated with fatigue and can present in young women and elderly men. Neostigmine testing is used to establish the diagnosis.

Periorbital fat atrophy results in pseudoptosis and enophthalmos of the globe.

References
1. Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty patient: bypassing the pitfalls. Clin Plast Surg. 1993;20:213.
2. Martin JJ Jr, Tenzel RR. Acquired ptosis: dehiscences and disinsertions - are they real or iatrogenic? Ophthal Plast Reconstr Surg. 1992;8:130-132.

The photograph shown above is of a 56-year-old man who underwent open reduction and internal fixation of a malar complex fracture on the right and cranial bone grafting of the right orbital floor three months ago after sustaining bony injuries in a motor vehicle collision. He had no skin lacerations at the time of injury.

Which of the following is the most likely cause of the lower eyelid deformity?

(A) Entrapment of Lockwood's ligament
(B) Inferior displacement of the orbital floor
(C) Loss of skin elasticity
(D) Periorbital fat atrophy
(E) Shortening of the posterior lamella

The correct response is Option E.

This patient's lower eyelid deformity is most likely caused by shortening of the posterior lamella. The lower eyelid is formed by the anterior, middle, and posterior lamellae. The anterior lamella consists of skin and orbicularis oculi muscle. The orbital septum comprises the middle lamella. The posterior lamella, or capsulopalpebral fascia, is comprised of the tarsus muscle, lower lid retractors, and conjunctiva. Injury or scarring of any of these structures can result in malpositioning of the lower eyelid, as seen in this patient. Shortening and scarring of the posterior lamella and septum are most common.

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.

References
1. Baylis HI, Wilson MC, Groth MJ. Complications of lower blepharoplasty. In: Putterman AM, ed. Cosmetic Oculoplastic Surgery. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1993:356-363.
2. Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg. 1991;18:183.
3. McCord CD. Eyelid Surgery: Principles and Techniques. Philadelphia, Pa: Lippincott-Raven; 1995.

A 45-year-old woman has had severe epiphora on the right side for the past four months. She sustained a comminuted naso-orbital ethmoid fracture when she was struck in the face by a softball six months ago; open reduction and internal fixation were performed immediately after injury. Dacryocystography shows obstruction of the nasolacrimal duct.

Which of the following is the most appropriate operative management?

(A) Conjunctivodacryocystostomy
(B) Conjunctivodacryocystorhinostomy
(C) Conjunctivorhinostomy
(D) Dacryocystorhinostomy
(E) Dacryocystostomy

The correct response is Option D.
This patient has developed nasolacrimal duct obstruction as a complication following open reduction and internal fixation of a comminuted naso-orbital ethmoid fracture. The level of obstruction must be determined in order to correctly bypass the stricture or damaged portion of the lacrimal system. This can be accomplished by various methods, including canalicular injection and/or intubation, fluorescein staining of the eye, and radiologic testing.
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%.

Conjunctivodacryocystostomy and conjunctivodacryocystorhinostomy are procedures used for reconstruction in a patient who has obstruction at the canalicular level. Conjunctivorhinostomy is used in patients who have absence or obliteration of the tear sac. Dacryocystostomy involves intubation of the tear sac, which would not be beneficial in this patient.

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;2:1725-1737.
2. Nesi FA, Siddens JD, Waltz KL. Correction of traumatic ptosis of the eyelid and reconstruction of the lacrimal system. In: Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. Boston, Mass: Little, Brown & Co; 1994;2:1105-1108.

The patient shown in the photograph above will be at increased risk for development of which of the following complications following four-eyelid blepharoplasty?

(A) Diplopia
(B) Dry eye syndrome
(C) Entropion
(D) Hematoma
(E) Ptosis
The correct response is Option B.

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. Therefore, appropriately cautious management is critical in patients who have these anatomic findings and are considering blepharoplasty. Surgery can still be performed with the necessary modifications and adequate ocular protection. One study reported that 65% of patients who developed dry eye syndrome following blepharoplasty had normal findings on preoperative Schirmer's testing.
This patient would not be at risk for diplopia, which is more closely related to edema, hematoma, and wound infection. Entropion occurs as a result of damage to the ciliary margins of the eyelid resulting from an excessively close incision (leading to angulation of the upper border of the tarsal plate) or spasm of the upper portion of the orbicularis oculi muscle. However, this patient's findings are not indicative of postoperative entropion. Development of hematoma is rarely predictable. The findings are not consistent with ptosis, which can be worsened postoperatively if it is not identified before the procedure.

References
1. Rees TD, Aston SJ, Thorne CH. Blepharoplasty and facioplasty. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa. WB Saunders Co; 1990;3:2320-2414.
2. Rees TD. Blepharoplasty. In: Rees TD, ed. Aesthetic Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1980;2:525-580.
3. Rees TD, LaTrenta GS. The role of the Schirmer's test and orbital morphology in predicting dry-eye syndrome after blepharoplasty. Plast Reconstr Surg. 1988;82:619.

The photographs shown above are of a 58-year-old man who has recurrent painless edema of the eyelids. Three upper eyelid blepharoplasty procedures over the past 30 years have not resolved this condition. On physical examination, the skin of the upper eyelids is thin, and results of snap testing are poor.

These findings are most consistent with which of the following?

(A) Blepharochalasis
(B) Dermatochalasis
(C) Dry eye syndrome
(D) Pachydermoperiostosis
(E) Senile ptosis

The correct response is Option A.

This 58-year-old man has findings consistent with blepharochalasis, a condition of unknown cause that results from a developmental deficiency of elastic tissue within the eyelids. It most often occurs during early adulthood. Patients with blepharochalasis, or dermatopysis palpebrum, have recurrent episodes of mild to moderate, painless edema of the eyelids. Over time, the episodes become more frequent, resulting in a permanent "baggy" appearance of the eyelids with thinning and wrinkling of the eyelid skin. Herniation of orbital fat occurs, leading to an exacerbation of symptoms. Excision of redundant tissue is indicated for management of visual obstruction.

Patients with dermatochalasis have occasional episodes of visual obstruction resulting from excess eyelid skin. Dry eye syndrome is caused by corneal exposure following blepharoplasty and manifests as pain, dryness, and blurred vision. 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. Senile ptosis results from progressive attenuation of the levator aponeurosis. Levator advancement is appropriate management.

References
1. Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty patient: bypassing the pitfalls. Clin Plast Surg. 1993;20:213.
2. Nesi FA. Smith's Ophthalmic Plastic and Reconstructive Surgery. Saint Louis, Mo: Mosby Ð Year Book, Inc; 1998:375, 511.

A 45-year-old woman is being evaluated after undergoing upper eyelid blepharoplasty. Examination shows persistent fullness involving the lateral third of the upper eyelids. These findings are most consistent with which of the following?

(A) Descending lacrimal glands
(B) Eyebrow ptosis
(C) Lateral compartment fat
(D) Subcutaneous fat deposits
(E) Supraorbital bony prominences

The correct response is Option A.

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. However, excision of the glands is not recommended because it may result in the development of keratoconjunctivitis sicca.

Eyebrow ptosis would most likely be seen over the entire eyebrow, not just the lateral third. Lateral fat compartments are found in the lower eyelids but not in the upper eyelids. Although subcutaneous fat deposits can cause lateral fullness of the eyelids, they typically pass beyond the region of the canthus. Bony prominences would most likely involve the entire eyebrow.

References
1. Beer GM, Kompatscher P. A new technique for the treatment of lacrimal gland prolapse in blepharoplasty. Aesthetic Plast Surg. 1994;18:65.
2. Horton CE, Carraway JH, Potenza AD. Treatment of a lacrimal bulge in blepharoplasty by repositioning the gland. Plast Reconstr Surg. 1978;61:701.

A 43-year-old woman has miosis, anhidrosis, and blepharoptosis measuring 2 mm. On examination, the eyelid crease is normal and function of the levator muscle is good. Which of the following is the most likely diagnosis?

(A) Blepharophimosis syndrome
(B) Congenital ptosis
(C) Horner's syndrome
(D) Involutional ptosis
(E) Myasthenia gravis

The correct response is Option C.

This 43-year-old woman has Horner's syndrome, which is caused by sympathetic denervation of the superior cervical ganglion. Typical findings include ptosis, miosis, and anhidrosis. The eyelid creases and levator muscle are typically unaffected.

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

Congenital ptosis is a developmental dystrophy that affects the levator muscle. In patients with congenital ptosis, eyelid creases are poorly defined and levator function is poor. These patients are at increased risk for the development of strabismus and amblyopia.

Involutional ptosis is the most common type of acquired ptosis. This condition results from progressive thinning of the levator aponeurosis and subsequent downward shifting of the tarsal plate. The function of the levator muscle is good despite its progressive thinning. The eyelid creases are typically raised.

Patients with ptosis due to myasthenia gravis frequently have unilateral or bilateral ptosis that is exacerbated with fatigue. This disorder is most frequent in young women and elderly men. Neostigmine testing is used to establish the diagnosis.

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;2:1671-1784.
2. McCord CD. Evaluation of the ptosis patient. In: Eyelid Surgery: Principles and Techniques. Philadelphia, Pa: Lippincott-Raven; 1995:99-112.

A 40-year-old woman has steady, lancinating pain in the globe and orbit and episodes of vomiting six hours after undergoing blepharoplasty of the lower eyelids. She says that she sees sparkles and flashes and has the sensation similar to a "window shade" closing over the lower half of her range of vision.

These findings are most consistent with which of the following?

(A) Acute glaucoma
(B) Adverse effects of anesthesia
(C) Migraine
(D) Retrobulbar hematoma
(E) Transient ischemic attack

The correct response is Option D.

This patient has findings consistent with retrobulbar hematoma, a complication of blepharoplasty that, if untreated, can result in loss of vision. Retrobulbar hematoma is most frequently 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. A positive finding on Valsalva's maneuver may be diagnostic.

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.

Although eye pain following surgery may result from abrasion of the cornea during anesthesia, scotomas and loss of vision would not be associated.

References
1. Rees TD, LaTrenta GS, eds. Aesthetic Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1994;2:601-606.
2. Wolfort FG, Vaughan TE, Wolfort SF, et al. Retrobulbar hematoma and blepharoplasty. Plast Reconstr Surg. 1999;104:2154.

After undergoing repair of an orbital fracture, a patient has progressive loss of vision resulting from the development of a retrobulbar hematoma. In order to immediately relieve intraocular pressure, which of the following structures should be released?

(A) Lateral canthal tendon
(B) Levator aponeurosis
(C) Orbicularis oculi muscle
(D) Tarsal plate
(E) Tenon's capsule

The correct response is Option A.

Intraocular pressure is similar to compartment syndrome in that an excessive amount of pressure on the optic nerve resulting from bleeding or edema can increase intraorbital pressure and ultimately lead to blindness. An acute increase in intraorbital pressure can occur following orbital fracture repair, blepharoplasty, or other surgical procedures. Physical examination in an affected patient will show visual loss associated with a pupillary defect, such as a loss of pupillary reaction to light. Increased intraocular pressure can be measured at the bedside using a tonometer. Lateral canthotomy, or release of the lateral canthal tendon, should be performed immediately to relieve pressure and restore sight. Any proptosis that is present will be accentuated immediately after surgery and can thus be diagnosed at this time; it can be measured to confirm adequate release of the check-rein ocular support. Surgical exploration can also be performed after lateral canthotomy to control any persistent bleeding.
In contrast, 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.

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.

References
1. Pick TP, Howden R, eds. Gray's Anatomy. New York, NY: Bounty Books; 1977:824-848.
2. Wolfort FG, Gross SC, Kanter WR. Pearls and pitfalls: how to avoid and manage complications. In: Wolfort FG, Kanter WR, eds. Aesthetic Blepharoplasty. Boston, Mass: Little, Brown & Co; 1995:189-218.
3. Zide BM, Jelks GW, eds. Surgical Anatomy of the Orbit. New York, NY: Raven Press; 1985:47-50.

Which of the following bones comprises the greatest portion of the medial orbital wall?

(A) Ethmoid
(B) Lacrimal
(C) Maxilla
(D) Palatine
(E) Sphenoid

Reproduced with permission of McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;2:1577.

The correct response is Option A.

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

The lacrimal and palatine bones give off smaller contributions to the medial orbital wall, as does the lesser wing of the sphenoid bone. The orbital floor is comprised of the maxilla medially and the zygoma anteriorly.

References
1. Dolynchuk K, Tadjalli H, Manson P. Orbital volumetric analysis: clinical application in orbitozygomatic complex injuries. J Craniomaxillofac Trauma. 1996;2:56-63.
2. Netter FH. Atlas of Human Anatomy. Summit, NJ: Ciba-Geigy Corp; 1989:1.
3. Pick TP, Howden R, eds. Gray's Anatomy. New York, NY: Bounty Books; 1977:77-80, 113-115.

A 48-year-old man has traumatic telecanthus after sustaining a naso-orbito-ethmoid fracture. Open reduction and internal fixation are performed with transnasal wiring of the fracture fragments surrounding the medial canthal tendon. At follow-up examination one year after the initial injury, the patient has epiphora of the right eye. Findings on Jones I dye testing are negative and Jones II dye testing are positive.

Which of the following anatomic sites is the most likely origin of this patient's findings?

(A) Canaliculi
(B) Nasolacrimal duct
(C) Lacrimal gland
(D) Punctum
(E) Superior meatus

Reproduced with permission of Fingeret M, Casser L, Woodcome HT. Atlas of Primary Eyecare Procedures. Norwalk, Ct: Appleton & Lange; 1990:120-121.

The correct response is Option B.

The Jones I dye test involves the instillation of fluorescein dye into the conjunctival sac. A cotton pledget is placed inside the nose close to the orifice of the nasolacrimal duct; staining of the pledget, also known as a positive test, indicates that flow through the lacrimal system is uninhibited. In patients who have both a positive Jones I test and epiphora, hypersecretion of the lacrimal gland is the most likely cause. Negative findings on the Jones I test are indicative of obstruction; however, the test does not localize the obstruction to the upper or lower system.

With the Jones II dye test, the punctum is anesthetized and dilated, and an irrigation cannula is inserted; the system is then irrigated with saline. If dye-stained fluid is collected from the nose, which indicates a positive test, there is partial obstruction of the nasolacrimal duct; the upper system, from the conjunctiva to the lacrimal sac, is not obstructed. If no dye-stained fluid is found in the nose (a negative test), but there is reflux through the opposite canaliculus, obstruction of the lower system, and not the upper system, can be diagnosed. In contrast, if findings on the Jones II test are negative, and there is reflux through the irrigated canaliculus, the obstruction can be localized to the upper system. Therefore, a patient who has negative findings on the Jones I dye test but positive findings on the Jones II dye test has a partial obstruction of the nasolacrimal duct.

The nasolacrimal duct empties into the inferior meatus; in contrast, the posterior ethmoid air cells empty into the superior meatus and are not connected to the lacrimal system.

References
1. Fingeret M, Casser L, Woodcome HT. Jones Dye tests 1 and 2. In: Atlas of Primary Eyecare Procedures. Norwalk, Ct: Appleton & Lange; 1990:120-121.
2. Hold JE, Holt GR. Reconstruction of the lacrimal drainage system. Arch Otolaryngol. 1984;110:211-220.

A 2-year-old child is being evaluated because he has deformities of the eyelids and upper face. Examination shows large epicanthal folds of the lower eyelids with epicanthus inversus, horizontal shortening of the eyelids, and 5 mm of ptosis bilaterally. Levator excursion is 4 mm.

These findings are most consistent with

(A) blepharochalasis
(B) blepharophimosis syndrome
(C) blepharospasm
(D) congenital epicanthus
(E) epiblepharon
The correct response is Option B.

Blepharophimosis syndrome, which is classified according to three types, is a form of congenital ptosis. Patients with blepharophimosis syndrome, type 1 have large epicanthal folds with epicanthus inversus, horizontally shortened eyelids, and severe ptosis. Patients with type 2 have telecanthus, absence of the epicanthal folds, severe bilateral ptosis, absence of levator function, and skin shortage involving all four lids. Blepharophimosis syndrome, type 3 involves absence of epicanthal folds, telecanthus, an antimongoloid slant of the palpebral fissures, severe ptosis, mild orbital hypertelorism, and skin deficiencies. As with many congenital syndromes, the malformations are isolated. Forehead and ear anomalies are also common. Although epicanthus and epiblepharon comprise a portion of this patient's condition, the presence of severe congenital ptosis leads to a diagnosis of blepharophimosis syndrome type 1.

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.

Blepharochalasis and blepharospasm are not seen in patients with blepharophimosis syndrome.

References
1. Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990,2:1774-1780.
2. Nakajima T, Yoshimure Y, Onishi K, et al. One-stage repair of blepharophimosis. Plast Reconstr Surg. 1991;87:24.

A 68-year-old woman seeks correction of drooping eyelids and impaired upward gaze. Physical examination shows excessive hooding of the upper eyelid skin; visual field testing confirms obstruction in the upper fields. Levator excursion is 14 mm bilaterally. There is 2 mm of ptosis of the left eyelid; the right eye is unaffected.

In addition to blepharoplasty, which of the following is the most appropriate management?

(A) Division of MŸller's muscle
(B) Fasanella-Servat procedure
(C) Fascial sling
(D) Levator advancement
(E) Resection of the levator muscle

The correct response is Option D.

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.

This patient has a common problem that requires thorough preoperative evaluation. Visual field obstruction is evaluated clinically and verified using standard visual field testing. Examination of levator function involves stabilizing the brow and measuring the excursion of the upper eyelid margin from downward gaze to upward gaze with the eyes fixed on a distant point. The normal distance between the upper and lower limbi across the pupil is 11 mm. The upper limbus should rest 2 mm below the superior edge of the iris and 2 mm above the superior edge of the pupil.

Division of Muller's muscle would not correct the ptosis.

The Fasanella-Servat procedure is used to correct minimal ptosis but is a more difficult, complicated procedure than levator plication. Accessibility to involved structures is limited with this procedure.

Bilateral blepharoplasty combined with fat pad removal and ptosis repair using a fascial sling is recommended to correct congenital ptosis, defined as ptosis of more than 4 mm and levator function of less than 5 mm.

Resection of the levator muscle is excessive and unnecessary in patients with minimal acquired ptosis.

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;2:1765-1772.
2. Klatsky SA. Blepharoplasty. In: Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. Boston, Mass: Little, Brown & Co; 1994;3:1920-1940.

A 50-year-old woman has right eyelid ptosis of 2 mm two days after undergoing uncomplicated four-eyelid blepharoplasty under local anesthesia. On physical examination, there is moderate edema of the upper and lower eyelids.

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

(A) Reassurance and continued follow-up examinations
(B) Eyelid massage and stretching exercises
(C) Administration of phenylephrine eyedrops
(D) Immediate operative exploration of the eyelid
(E) Levator plication seven days after the initial procedure

The correct response is Option A.

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.

Eyelid massage and stretching exercises are effective for management of early ectropion of the lower lids. Phenylephrine eyedrops are only indicated if the ptosis is caused by Horner's syndrome. 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.

References
1. Flowers RS. Optimal procedure in secondary blepharoplasty. Clin Plast Surg. 1993;20:225-237.
2. Kulwin DR, Kersten RC. Blepharoplasty and brow elevation. In: Dortzbach RK, ed. Ophthalmic Plastic Surgery: Prevention and Management of Complications. New York, NY: Raven Press; 1994:91-112.

A 25-year-old man has ectropion and excessive scleral show one year after sustaining a chemical burn of the lower right eyelid, which was allowed to heal without surgical intervention. He currently uses ocular ointments daily. Which of the following is the most appropriate management?

(A) Scar massage and intralesional injection of a corticosteroid
(B) Full-thickness skin grafting
(C) Insertion of a gold eyelid weight
(D) Lateral canthoplasty
(E) Lateral tarsal wedge excision

The correct response is Option B.

Ectropion involves eversion of the eyelid margin; it frequently occurs in the lower eyelid as a result of the pull of gravity on the unsupported eyelid tissue. It is usually the result of mechanical (involutional or senile), cicatricial, or neurogenic causes.

This patient has classic cicatricial ectropion, which has resulted from abnormally healing burn wounds. The ectropion has occurred as a result of scar contracture of the anterior lamella of the lower eyelid, leading to excessive scleral show and exposure keratopathy. Full-thickness skin grafting is recommended to replace lost tissue and prevent secondary contracture. In addition, complete release of contracted soft tissues and use of added supporting materials such as cartilage should be considered.

Scar massage and intralesional injection of a corticosteroid would not improve a fixed, foreshortened lower eyelid.

Neurogenic ectropion is best treated by correction of the associated upper eyelid lagophthalmos using inserted prosthetic devices (eg, gold eyelid weights).

In patients with involutional ectropion, there is progressive laxity of the lower eyelid; the lower eyelid retractors or capsulopalpebral fascia becomes disinserted from the inferior border of the tarsal plate. Corrective surgical procedures include lateral canthoplasty, lateral wedge excision, and the Kuhnt-Szymanowski technique, which involves excision of a full-thickness wedge from the region of the lateral canthus. The skin excision is then hidden under a subciliary incision.

References
1. Fox SA. A modified Kuhnt-Szymanowski procedure for ectropion and lateral canthoplasty. Am J Ophthalmol. 1966;62:533.
2. Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;2:1737-1752.
3. McLeish WM, Anderson RL. Cosmetic eyelid surgery and the problem eyelid. Clin Plast Surg. 1992;19:357.

A 70-year-old woman has a skin defect with a diameter of 1 cm after undergoing resection of a basal cell carcinoma of the right upper eyelid. Primary closure of the defect is not possible. Which of the following is most appropriate for cutaneous full-thickness coverage of the defect?

(A) Cross-lid flap
(B) Retroauricular skin graft
(C) Skin graft from the contralateral upper eyelid
(D) Supraclavicular skin graft
(E) Wedge resection and primary closure of the remaining eyelid

The correct response is Option C.

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 for coverage of a full-thickness defect. Grafts harvested from the retroauricular and supraclavicular regions are better used for skin grafting of the face due to their optimal color match; however, this skin is often too thick for use in the upper eyelid. Wedge resection is an excessive, unnecessary procedure.

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;2:1671-1784.
2. Warpeha RL. Resurfacing the burned face. Clin Plast Surg. 1981;8:255.