Inservice Exam - 2005
Eye Reconstruction

A 2-year-old boy is brought to the office by his parents for evaluation of ptosis of the upper eyelids. On examination, there are no abnormalities of the right upper eyelid. Examination of the left eye shows 3.5 mm of ptosis of the upper lid, absence of the eyelid crease, and 3 mm of levator muscle function. Which of the following is the most appropriate management of the left eye?

(A) Observation
(B) Application of a patch
(C) Frontalis sling, upper eyelid
(D) Levator resection/advancement, upper eyelid
(E) Resection of Müller’s muscle, upper eyelid

The correct response is Option C.

The patient has 3.5 mm of ptosis of the left upper eyelid, which partially obstructs vision. Absence of the eyelid crease and 3 mm of levator function are highly suggestive of congenital ptosis. A frontalis sling of the left upper eyelid can correct these abnormalities by resetting the position of the affected eyelid.

Observation is not appropriate because the partial obstruction of vision could lead to amblyopia in the left eye. Application of a patch is inappropriate because it would deprive the left eye of all visual input, exacerbating the problem. Resection of Müller’s muscle from the left upper eyelid is an acceptable treatment of a small amount of ptosis (such as 1 mm) in an adult but would not correct this severe ptosis. Levator resection and advancement of the upper eyelid are the most common method of treating levator dehiscence in adults but would not be appropriate to treat a child with minimal levator function.

References:
1. Caraway JA. Reconstruction of the eyelid and correction of ptosis of the eyelid. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith’s Plastic Surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins;1997:529-544.
2. Ramirez OM, Pena G. Frontalis muscle advancement: a dynamic structure for the treatment of severe congenital eyelid ptosis. Plast Reconstr Surg. 2004;113(6):1841-1851.




A 57-year-old woman comes to the office for evaluation of drooping of the eyelids. Physical examination shows ptosis of the upper eyelids, high eyelid crease, margin to reflex distance (MRD) of 0 mm, and excellent levator function. Which of the following techniques is most appropriate for surgical correction of this patient=s abnormality?

(A) Fasanella-Servat
(B) Plication of the levator muscle
(C) Reanastomosis of the dehisced levator aponeurosis
(D) Resection of the orbicularis muscle
(E) Unilateral frontalis suspension using autogenous fascia lata

The correct response is Option C.

This patient has classic signs of blepharoptosis secondary to acquired dehiscence of the levator aponeurosis, such as high eyelid crease, excellent levator function, and an MRD of 0 mm. The MRD quantifies the distance between the lid margin and the pupillary reflex. To correct this blepharoptosis in the most anatomically correct fashion, surgery should be done to reanastomose the dehisced end of the levator aponeurosis to the superior aspect of the tarsus.

The other surgical options are used for different indications. A Fasanella-Servat procedure takes a posterior conjunctival approach to correct mild ptosis without levator disinsertion. Plication of the levator muscle alone does not provide long-lasting results and is a valid option only if the distal end of the muscle is not dehisced. Resection of the orbicularis muscle will not correct the ptosis. Unilateral frontalis suspension is the procedure of choice for patients with absent levator function and severe ptosis.

References:
1. Caraway JA. Reconstruction of the eyelid and correction of ptosis of the eyelid. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith’s Plastic Surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 1997:529-544.
2. Gonnering RS. Upper eyelid blepharoplasty. In: Tse DT, Wright KW, eds. Color Atlas of Ophthalmic Surgery: Oculoplastic Surgery. Philadelphia: JB Lippincott; 1992:175-188.





A 6-year-old child who has had chronic bilateral epiphora since birth has been treated with corneal lubrication for the past year. Slit-lamp examination by the child’s pediatric ophthalmologist one week ago showed bilateral corneal staining. On physical examination, the lashes on both lower eyelids rub against the inferior cornea (shown above). Which of the following is the most appropriate management?

(A) Daytime taping of the margin of the lower lid
(B) Initiate nighttime lubrication of the eyes
(C) Lateral tarsal strip with repositioning of the eyelid margin
(D) Reinsertion of the retractors at the base of the tarsus and subtotal excision of the preseptal orbicularis
(E) Resection of redundant pretarsal skin and orbicularis muscle

The correct response is Option E.


The most common cause of epiblepharon is excess pretarsal skin and orbicularis oculi muscle at the lower eyelid margin. In this congenital anomaly, a fold of skin and underlying orbicularis muscle override the eyelid margin, often pushing the cilia against the globe. The eyelid margin and tarsus are stable and maintain the proper orientation. Epiblepharon usually affects the lower eyelids, is more common among Asians, and may be accentuated on downward gaze. Most cases resolve with facial growth during childhood. Surgical correction is needed when the lashes cause significant corneal injury. Epiblepharon requires resection of the redundant pretarsal skin and orbicularis muscle as well as placement of sutures between the tarsal plate and the subcutaneous tissue to create adhesions.

Taping of the lower eyelid is not practical in a child. Nighttime lubrication of the eyes is not sufficient treatment because the lashes continue to cause damage during the day, which may cause permanent corneal scarring. Lateral tarsal strip and repositioning of the eyelid margin are a common treatment for ectropion. Reinsertion of the retractors at the base of the tarsus and subtotal excision of the preseptal orbicularis are the treatment of choice for involutional entropion with horizontal laxity from the tarsus, vertical laxity due to attenuation or disinsertion of the lower eyelid retractors or orbital septum, and migration of the preseptal orbicularis in the pretarsal position.


References:
1. Woo KI, Yi K, Kim YD. Surgical correction for lower lid epiblepharon in Asians. Br J Ophthalmol. 2000;84(12):1407-1410.
2. Jeon S, Park H, Park YG. Surgical correction of congenital epiblepharon: low eyelid crease reforming technique. J Pediatr Ophthalmol Strabismus. 2001;38(6):356-358.





A 44-year-old woman has the defect shown above three days after undergoing excision of a squamous cell carcinoma from the lower eyelid. The resultant defect of the lower lid is 60%. Which of the following reconstructions is the most appropriate management?

(A) Composite contralateral lower lid graft
(B) Cutler-Beard flap
(C) Direct closure with cantholysis
(D) Hughes tarsoconjunctival flap
(E) Skin graft

The correct response is Option D.

This defect requires prompt surgical correction, because allowing the wound to granulate would result in a severely dysfunctional eyelid. With such a defect, a Hughes tarsoconjunctival flap is best used for reconstruction. This reconstruction involves taking a tarsoconjunctival flap from the upper eyelid, leaving 3 to 4 mm of the upper tarsus intact, and advancing the remaining tarsus and conjunctiva to the lower eyelid defect. This provides the posterior lamella of the eyelid. The anterior lamella is reconstructed by advancement of a skin-muscle flap from the lower eyelid or cheek.

Direct closure with cantholysis is appropriate for defects of less than 25% of the eyelid. The Cutler-Beard flap, which uses skin and muscle from the lower eyelid, is inappropriate for a patient with a lower eyelid defect. Because this patient=s defect affects more than 50% of the lower eyelid and because the eyelid requires a supportive base, a skin graft or composite contralateral lower eyelid graft would not provide adequate support.
References:
1. Caraway JA. Reconstruction of the eyelid and correction of ptosis of the eyelid. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith’s Plastic Surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 1997:529-544.
2. Rohrich RJ, Zbar RIS. The evolution of the Hughes tarsoconjunctival flap for lower eyelid reconstruction. Plast Reconstr Surg. 1999;104:518-523.
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