(A) Anterior chamber
(B) Conjunctiva
(C) Lens
(D) Posterior chamber
(E) Vitreous chamber

The correct response is Option A.

Hyphema is traumatic hemorrhage of the anterior chamber of the eye, typically resulting from blunt trauma to ocular structures. The anterior chamber of the eye is bordered by the cornea anteriorly and the iris and central portion of the lens posteriorly. This structure is filled with aqueous humor originating from the ciliary processes in the posterior chamber and flowing through the pupil into the anterior chamber. In patients with hyphema, vessels are torn in the iris or in the ciliary body, leading to onset of hemorrhage. The blood collects in the most inferior section of the anterior chamber, obscuring the lower portion of the iris.

Significant hyphema may result in increased ocular pressure and/or permanent staining of the cornea. Because of the potential for these complications, screening is recommended in patients with facial trauma, and ophthalmologic referral is indicated in any patient with positive findings. Treatment involves administration of acetazolamide and corticosteroid eye drops to decrease ocular tension.

Bleeding that occurs in the bulbar or palpebral conjunctiva is referred to as subconjunctival hemorrhage. This condition is seen in patients with facial trauma and results from extravasation of conjunctival capillaries. It also occurs in association with zygomatic fractures that extend through the lateral orbital wall in which there is bleeding along the side of the orbit and into the subconjunctival interstitium. Treatment of the fracture is likely to resolve the hemorrhage.

The lens is an avascular structure that does not retain blood. Instead, it may subluxate or dislocate and cause a premature cataract.

The posterior chamber is located behind the iris and anterior to the suspensory ligament; it appears as a halo around the lens. Although this chamber adjoins the ciliary processes, which may hemorrhage, the blood is not retained within it, but instead flows into the anterior chamber.

The vitreous chamber is bordered by the lens and suspensory ligaments anteriorly and the retina posteriorly. It contains a dense, jelly-like fluid that maintains slight pressure and provides even contact of the retina against the choroid. In patients with retinal hemorrhages, the blood typically remains within the retinal tissue. Debris or blood that is released into the vitreous body is consumed by phagocytic cells or remains as vitreal floaters within the chamber.

References
1. Duguid IM. Ophthalmic injuries. In: Williams JL, ed. Rowe and Williams’ Maxillofacial Injuries. 2nd ed. Edinburgh, Scotland: Churchill Livingstone, Inc; 1994;2:827-843.
2. Tortora GJ, Grabowski SR, eds. The special senses. In: Tortora GJ, Grabowski SR, eds. Principles of Anatomy and Physiology. 9th ed. New York, NY: John Wiley & Sons, Inc; 2000:512-529.

The common canaliculus enters the lacrimal sac at a point posterior to which of the following structures?

(A) Deep head of the preseptal muscle
(B) Deep head of the pretarsal muscle
(C) Lacrimal crest
(D) Medial canthal tendon
(E) Medial horn of the levator muscle

The correct response is Option D.

The common canaliculus enters the lacrimal sac at a point posterior to the medial canthal tendon. The medial canthal tendon is formed from the superficial heads of the pretarsal muscles and originates anterior to and above the lacrimal crest. The anterior and posterior lacrimal crests border the lacrimal fossa, which contains the lacrimal sac. The crests lie posterior to the canalicular entrance to the sac.

The deep head of the preseptal muscle originates from the posterior lacrimal crest, just above the deep heads of the pretarsal muscles. The deep heads of the pretarsal muscles extend posterior to the lacrimal sac and join with the diaphragm of the scar to originate immediately behind the posterior lacrimal crest. The medial horn of the levator muscle lies superior to the medial canthal tendon.

References
1. Della Rocca RC, Arthurs B, Silverstone P. Nasolacrimal disorders and their treatment. Clin Plast Surg. 1988;15:195-207.
2. Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;2:1671-1784.

A 25-year-old man has excessive tear secretion and a chronic mucocele of the lacrimal sac. Jones I dye testing shows no dye, while Jones II dye testing shows dye within the tear sac. Dilatation of the puncta with probing and irrigation does not restore the patency of the lacrimal system. In order to restore nasolacrimal drainage in this patient, which of the following is the most appropriate operative procedure?

(A) Insertion of a Jones tube
(B) Canaliculodacryocystorhinostomy
(C) Conjunctivodacryocystostomy
(D) Conjunctivorhinostomy
(E) Dacryocystorhinostomy

The correct response is Option E.

Jones dye testing is performed initially in this patient who has excessive tear secretion. The Jones I dye test involves the instillation of 2% fluorescein dye into the conjunctival fornices. Recovery of the dye (a positive test) indicates that flow through the lacrimal system is uninhibited. Negative findings on the Jones I test are indicative of functional obstruction; if this occurs, the Jones II dye test should be performed immediately. With this test, the nasolacrimal system is irrigated with 1 mL of saline via an irrigation cannula. If dye-stained fluid is found at the inferior turbinate, there is partial obstruction of the lower canalicular system, most likely at the nasolacrimal duct. If there is dye within the tear sac, obstruction of the nasolacrimal duct can be diagnosed; the canaliculus and lacrimal pump are unaffected. If no dye-stained fluid is found in the nose (a negative test), the obstruction is most likely at the canalicular level.
In patients with positive Jones II dye tests, dilation of the puncta should then be performed; any fluid that passes into the nose indicates that the obstruction of the nasolacrimal duct has been cleared, and further probing is unnecessary. However, probing and irrigation do not restore patency in this situation. Therefore, this patient has negative findings on the Jones I dye test but positive findings on the Jones II dye test, indicating a partial obstruction of the nasolacrimal duct. In this patient who has duct obstruction resulting from a chronic mucocele of the lacrimal sac, dacryocystorhinostomy is indicated.

Insertion of a Jones tube is indicated in patients who have complete obstruction of the lacrimal puncta.

Canaliculodacryocystorhinostomy, with intubation, is recommended for management of strictures found at the junction of the common canaliculus and the lacrimal sac, as well as for obstructions at the level of the canaliculus.

Although conjunctivodacryocystostomy is appropriate for patients who have obstruction at the canalicular level, this technique is associated with disruption of the lacrimal sac, resulting in unreliable long-term patency.

Conjunctivorhinostomy is indicated in patients who have absence or obliteration of the tear sac.

References
1. Della Rocca RC, Arthurs B, Silverstone P. Nasolacrimal disorders and their treatment. Clin Plast Surg. 1988;15:195-207.
2. Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic Surgery. Philadelphia Pa: WB Saunders Co; 1990;2:1671-1784.

A 42-year-old woman has drooping of the left eyelid two weeks after undergoing upper eyelid blepharoplasty and injection of botulinum toxin into the forehead. Physical examination shows 3 mm of ptosis of the left eyelid and 13 mm of levator excursion. When the left eyelid is closed voluntarily, the iris shadow can be visualized through the eyelid. The left tarsal crease is elevated 3 mm when compared with the right tarsal crease.

Which of the following types of ptosis is the most likely cause of these findings?

(A) Botulinum toxin-induced
(B) Traumatic aponeurotic
(C) Traumatic mechanical
(D) Traumatic myogenic
(E) Traumatic neurogenic

The correct response is Option B.

This patient has traumatic aponeurotic ptosis, which is characterized by the physical examination findings of good levator function, elevation of the eyelid crease, and the ability to visualize the shadow of the iris with eyelid closure (positive Nesi sign). In this type of ptosis, the levator aponeurosis is detached from the tarsal plate. Early reattachment of the levator is most likely to produce the best result.

Patients with botulinum toxin-induced ptosis will have a more prominent decrease in levator function. In patients with mechanical, myogenic, or neurogenic ptosis, the shadow of the iris cannot be visualized through the eyelid.

References
1. 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.
2. Wilson M, Groth M, Baylis H. Complications of upper blepharoplasty. In: Putterman A, ed. Cosmetic Oculoplastic Surgery. Philadelphia, Pa: WB Saunders Co; 1993:342.

A 68-year-old woman desires rejuvenation of the eyelids. Physical examination shows excessive skin of the lower eyelids and 2 mm of scleral show bilaterally. Which of the following is the most appropriate management?

(A) Injection of botulinum toxin (Botox) into the lateral canthal region
(B) Carbon dioxide laser resurfacing of the lower eyelids
(C) Lower eyelid blepharoplasty with excision of skin
(D) Lower eyelid blepharoplasty with lateral canthopexy
(E) Transconjunctival blepharoplasty

The correct response is Option D.

This 68-year-old woman has substantially diminished elasticity of the skin of the lower eyelids. Because of this, she is at increased risk for development of ectropion postoperatively if blepharoplasty with skin excision is performed alone and the laxity of the lower eyelid skin is not corrected. Therefore, the most appropriate management is lower eyelid blepharoplasty combined with lateral canthopexy, which will decrease the laxity of the lower eyelids and lower the risk for ectropion.

Injection of botulinum toxin will not rejuvenate the lower eyelids, and carbon dioxide laser resurfacing of the lower eyelids will only increase the risk for ectropion if canthopexy is not performed concomitantly. Transconjunctival blepharoplasty alone will not correct the excessive skin of the lower eyelids.

References
1. Guyuron B. Blepharoplasty and ancillary procedures. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations and Outcomes. Saint Louis, Mo: Mosby - Year Book, Inc; 2000:2539-2543.
2. Tebbetts JB. Blepharoplasty: a refined technique emphasizing accuracy and control. Clin Plast Surg. 1992;19:329-349.

Three months after undergoing bilateral lower eyelid blepharoplasty, a 45-year-old woman has scleral show, round, sad-looking eyes, and symptoms of ocular irritation, including photophobia and excessive tearing. The most likely cause of these findings is scarring between the orbital septum and which of the following structures?

(A) Capsulopalpebral fascia
(B) Inferior oblique muscle
(C) Orbicularis oculi muscle
(D) Orbital rim
(E) Tarsal plate

The correct response is Option A.

The findings seen in this patient are consistent with retraction of the lower eyelids, a common complication following surgery of the lower eyelids and midface. Lower eyelid retraction is defined as inferior malpositioning of the lower eyelid margin without eyelid eversion. Affected patients have round, sad-looking eyes, scleral show, and symptoms of ocular irritation, including photophobia, excessive tearing, and nocturnal lagophthalmos. Ocular lubricants typically provide only minimal relief.

Potential causes of lower eyelid retraction include scarring between the orbital septum and capsulopalpebral fascia, laxity of the lateral canthal tendon, and descent of the structures of the midface. Appropriate management is based on patient findings, which may include relaxation of the tarsal margin, skin shortening, and/or deep lamellar scar contracture.

References
1. Carraway JH, Miller JR, Lewis BK. Reoperative blepharoplasty. In: Grotting JC, ed. Reoperative Aesthetic & Reconstructive Surgery. Saint Louis, Mo: Quality Medical Publishing, Inc; 1995:205-244.
2. Patipa M. The evaluation and management of lower eyelid retraction following cosmetic surgery. Plast Reconstr Surg. 2000;106:438-453.