Involutional Lateral Entropion of the Upper Eyelids a New Physical Finding in Asian Patients
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Blepharoplasty, Ptosis and Canthoplasty
ENVOLVE VISION BENEFITS, INC. INCLUDING ALL ASSOCIATED SUBSIDIARIES CLINICAL POLICY AND PROCEDURE DEPARTMENT: Utilization DOCUMENT NAME: Blepharoplasty, Ptosis Management and Canthoplasty PAGE: 1 of 8 REFERENCE NUMBER: OC.UM.CP.0007 EFFECTIVE DATE: 01/01/2017 REPLACES DOCUMENT: 118-UM-R6 RETIRED: REVIEWED: 10/25/2017 SPECIALIST REVIEW: Yes REVISED: 11/7/2016 PRODUCT TYPE: COMMITTEE APPROVAL: 01/09/2018 IMPORTANT REMINDER: This Clinical Policy has been developed by appropriately experienced and licensed health care professionals based on a thorough review and consideration of generally accepted standards of medical practice, peer-reviewed medical literature, government agency/program approval status, and other indicia of medical necessity. The purpose of this Clinical Policy is to provide a guide to medical necessity. Benefit determinations should be based in all cases on the applicable contract provisions governing plan benefits (“Benefit Plan Contract”) and applicable state and federal requirements including Local Coverage Determinations (LCDs), as well as applicable plan-level administrative policies and procedures. To the extent there are any conflicts between this Clinical Policy and the Benefit Plan Contract provisions, the Benefit Plan Contract provisions will control. Clinical policies are intended to be reflective of current scientific research and clinical thinking. This Clinical Policy is not intended to dictate to providers how to practice medicine, nor does it constitute a contract or guarantee regarding results. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. SUBJECT: Medical necessity determination of eyelid procedures for treatment of dermatochalasis and ptosis. -
Extraocular Muscles Orbital Muscles
EXTRAOCULAR MUSCLES ORBITAL MUSCLES INTRA- EXTRA- OCULAR OCULAR CILIARY MUSCLES INVOLUNTARY VOLUNTARY 1.Superior tarsal muscle. 1.Levator Palpebrae Superioris 2.Inferior tarsal muscle 2.Superior rectus 3.Inferior rectus 4.Medial rectus 5.Lateral rectus 6.Superior oblique 7.Inferior oblique LEVATOR PALPEBRAE SUPERIORIOS Origin- Inferior surface of lesser wing of sphenoid. Insertion- Upper lamina (Voluntary) - Anterior surface of superior tarsus & skin of upper eyelid. Middle lamina (Involuntary) - Superior margin of superior tarsus. (Superior Tarsus Muscle / Muller muscle) Lower lamina (Involuntary) - Superior conjunctival fornix Nerve Supply :- Voluntary part – Oculomotor Nerve Involuntary part – Sympathetic ACTION :- Elevation of upper eye lid C/S :- Drooping of upper eyelid. Congenital ptosis due to localized myogenic dysgenesis Complete ptosis - Injury to occulomotor nerve. Partial ptosis - disruption of postganglionic sympathetic fibres from superior cervical sympathetic ganglion. Extra ocular Muscles : Origin Levator palpebrae superioris Superior Oblique Superior Rectus Lateral Rectus Medial Rectus Inferior Oblique Inferior Rectus RECTUS MUSCLES : ORIGIN • Arises from a common tendinous ring knows as ANNULUS OF ZINN • Common ring of connective tissue • Anterior to optic foramen • Forms a muscle cone Clinical Significance Retrobulbar neuritis ○ Origin of SUPERIOR AND MEDIAL RECTUS are closely attached to the dural sheath of the optic nerve, which leads to pain during upward & inward movements of the globe. Thyroid orbitopathy ○ Medial & Inf.rectus thicken. especially near the orbital apex - compression of the optic nerve as it enters the optic canal adjacent to the body of the sphenoid bone. Ophthalmoplegia ○ Proptosis occur due to muscle laxity. Medial Rectus Superior Rectus Origin :- Superior limb of the tendonous ring, and optic nerve sheath. -
Inferior Rectus Paresis After Secondary Blepharoplasty
Br J Ophthalmol: first published as 10.1136/bjo.68.8.535 on 1 August 1984. Downloaded from British Journal of Ophthalmology, 1984, 68, 535-537 Inferior rectus paresis after secondary blepharoplasty EDUARDO ALFONSO, ANDREW J. LEVADA, AND JOHN T. FLYNN From the Bascom Palmer Eye Institute, Department of Ophthalmology, University ofMiami School ofMedicine, Miami, Florida, USA SUMMARY A 52-year-old woman underwent a secondary cosmetic blepharoplasty for repair of residual dermatochalasis. Afterthis procedure vertical diplopia was noted. Ultrasound examination and the findings at operation were consistent with trauma to the inferior rectus muscle. We present this as an additional complication of cosmetic blepharoplasty. Numerous complications ofblepharoplasty have been The patient was examined by an ophthalmologist reported. They include blindness, orbital and eyelid and observation was recommended. One year later haematoma, epiphora, ectropion, lagophthalmos, she was examined by a second ophthalmologist in ptosis, incision' complications, scar thickening, Munich. A left hypertropia of 260 and exotropia of incomplete or excessive removal of orbital fat, 12° were found, and both inferior recti were thought lacrimal gland injury, exposure keratitis, and corneal to be involved. The patient could fuse only in gaze up ulcer. '-" Disturbances of ocular motility are and left. On 21 October 1981 she underwent a 5 mm uncommon, but superior oblique palsy,2 inferior recession ofthe right superior rectus muscle combined oblique injury,- superior rectus incarceration in the with release of conjunctival scar inferiorly, myotomy to ofthe inferior rectus muscle, and insertion of a Teflon wound,4 and restriction secondary retrobulbar http://bjo.bmj.com/ haemorrhage5 have been reported. -
Policy 96018: Blepharoplasty, Blepharoptosis Repair, and Brow
Policy: 96018 Initial Effective Date: 11/22/1996 SUBJECT: Blepharoplasty, Blepharoptosis Repair, and Annual Review Date: 11/16/2020 Brow Ptosis Repair Last Revised Date: 11/16/2020 Prior approval is required for some or all procedure codes listed in this Corporate Medical Policy. Definition: The term blepharoplasty refers to a collection of surgical procedures that involve removal of redundant eyelid tissue (skin, muscle, and fat). Although the primary indication for blepharoplasty is to improve the eyelid appearance, redundant lax eyelid tissue (dermatochalasis) can obstruct the superior visual field and interfere with activities of daily living in some individuals. In these cases, blepharoplasty may be considered in order to produce functional improvement in vision. The pathophysiology of dermatochalasis has not been well described, but much of the process appears to involve skin changes associated with the aging process. Less commonly, systemic disorders such as Ehlers-Danlos syndrome may predispose patients to develop dermatochalasis at a younger age. Clinical manifestations are mainly cosmetic, but in severe cases eyelid tissue may obstruct the superior visual field. The most common symptoms include difficulty reading and loss of peripheral vision when driving. Blepharoplasty may help to improve function for patients with clinically significant dermatochalasis. Blepharochalasis is sometimes confused with dermatochalasis. Though similar in nomenclature, these two disorders are quite different in presentation and etiology. Blepharochalasis is a rare condition characterized by intermittent, recurrent eyelid edema, resulting in relaxation of the eyelid tissue and resultant atrophy. The lower eyelids are less commonly involved. Blepharochalasis typically presents in adolescence or young adulthood, with intermittent attacks that occur less commonly as the person ages. -
Eyelash Inversion in Epiblepharon: Is It Caused by Redundant Skin?
ORIGINAL RESEARCH Eyelash inversion in epiblepharon: Is it caused by redundant skin? Hirohiko Kakizaki1 Purpose: To evaluate the effect of redundant lower eyelid skin on the eyelash direction in Igal Leibovitch2 epiblepharon. Yasuhiro Takahashi3 Materials and methods: Asian patients with epiblepharon participated in this study. The Dinesh Selva4 lower eyelid skin was pulled downward in the upright position with the extent just to detach from eyelash roots, and the direction of the eyelashes was examined. These evaluations were 1Department of Ophthalmology, Aichi Medical University, Nagakute, repeated before surgery while the patients were lying supine under general anesthesia. Aichi 480-1195, Japan; 2Division of Results: The study included 41 lower eyelids of 25 patients (17 females, 8 males, average age; Oculoplastic and Orbital Surgery, 5.6 years, 16 cases bilateral, 9 unilateral). In the upright position, without downward traction Department of Ophthalmology, Tel-Aviv Medical Center, of the skin, the eyelashes were vertically positioned and touching the cornea. The redundant Tel-Aviv University, Tel-Aviv, Israel; skin touched only the eyelash roots and had minimal contribution to eyelash inversion. With 3 Department of Ophthalmology downward skin traction, there was no signifi cant change in the eyelash direction. In the spine and Visual Sciences, Osaka City University Graduate School position, the eyelashes were touching the cornea, and there was marked redundant skin that was of Medicine, Osaka 545-8585, Japan; pushing the eyelashes inward. With downward skin traction, there was no signifi cant change. 4 South Australian Institute Conclusions: The direction of lower eyelashes in patients with epiblepharon was less infl uenced of Ophthalmology and Discipline For personal use only. -
Required List of Bones and Markings
REQUIRED LIST OF BONES AND MARKINGS Axial Skeleton Skull Cranial Bones (8) Frontal Bone (1) Supraorbital foramina Supraorbital ridges or margins Parietal Bones (2) Temporal Bones (2) External auditory meatus Mastoid process Styloid process Zygomatic process Mandibular fossa Foramen lacerum Carotid foramen Jugular foramen Stylomastoid foramen Internal auditory meatus Occipital Bone (1) Foramen magnum Occipital condyles Ethmoid Bone (1) Cribriform plate Olfactory foramina in cribriform plate Crista galli Perpendicular plate (forms superior part of nasal septum) Middle nasal concha Superior nasal concha Sphenoid Bone (1) Foramen ovale Foramen rotundum Sella turcica Greater wing Lesser wing Optic foramen Inferior orbital fissure Superior orbital fissure Pterygoid processes Skull (cont’d) Facial Bones (14) Lacrimal Bones (2) Lacrimal fossa Nasal Bones (2) Inferior Nasal Conchae (2) Vomer (1) (forms inferior portion of nasal septum) Zygomatic Bones (2) Temporal process (forms zygomatic arch with zygomatic process of temporal bone) Maxillae (2) Alveoli Palatine process (forms anterior part of hard palate) Palatine Bones (2) (form posterior part of hard palate) Mandible (1) Alveoli Body Mental foramen Ramus Condylar process (mandibular condyle) Coronoid process Miscellaneous (Skull) Paranasal sinuses are located in the ethmoid bone, sphenoid bone, frontal bone, and maxillae Zygomatic arch (“cheekbone”) is composed of the zygomatic process of the temporal bone and the temporal process of the zygomatic bone 2 pairs of nasal conchae (superior and middle) are part of the ethmoid bone. 1 pair (inferior) are separate facial bones. All the scroll-like conchae project into the lateral walls of the nasal cavity. Hard palate (“roof of mouth”) is composed of 2 palatine processes of the maxillae and the 2 palatine bones (total of 4 fused bones). -
Freedman Eyelid Abnormalities
1/16/2018 1 1/16/2018 Upper Lid Lower Lid Protractors Retractors: Levator m. 3rd nerve function Muller’s m. Cranial Nerve VII function Sympathetic Function Inferior Tarsal Muscle Things to Note Lid Apposition to Globe Position of Lid Margins MRD = 3‐5 mm Canthal Insertions Brow Positions 2 1/16/2018 Ptosis Usually age related levator dehiscence, but sometimes a sign of neurologic, mechanical orbital or inflammatory disease Blepharospasm Sign of External Irritation or Neurologic Disease 3 1/16/2018 First Consider Underlying Orbital Disease Orbital Cellulitis, Pseudotumor, Wegener’s Graves Ophthalmopathy, Orbital Varix Orbital Tumors that can mimic inflammatory process: Lacrimal Gland CA, Lymphoma, Lymphangioma, etc. Lacrimal Gland – Dacryoadenitis or tumor Sinus Mucocele Without Inflammatory Appearance, consider above but also… Allergic Eyelid Edema Hormonal Shifts Systemic Disorder – Cardiac, Renal, Hepatic, Thyroid with edema Cutaneous Lymphoma Graves Ophthalmopathy –can just have lid edema w/o inflammatory appearance Lymphedema after trauma, surgery to lids or orbit (e.g. lymphatics in lateral canthus) Traumatic Leak of CSF into upper eyelid (JAMA Oph 2014;312:1485) Blepharochalasis Not True Edema, but might mimic it: Dermatochalasis, Hidden Eyelid or Sub‐Conjunctival Mass, Prolapsed Orbital Fat When your concerned about: Orbital Cellulitis Orbital Pseudotumor Orbital Malignancy Vascular – e.g. CC fistula Proptosis Chemosis Poor Motility Poor Vision Pupil abnormality – e.g. RAPD Orbital Pseudotumor 4 1/16/2018 Good Vision Good Motility -
Strabismus Surgery and Its Complications
Strabismus Surgery and its Complications von David K Coats, Scott E Olitsky 1. Auflage Springer-Verlag Berlin Heidelberg 2007 Verlag C.H. Beck im Internet: www.beck.de ISBN 978 3 540 32703 5 Zu Inhaltsverzeichnis schnell und portofrei erhältlich bei beck-shop.de DIE FACHBUCHHANDLUNG Part I Surgical Management of Strabismus Chapter Surgically Important Anatomy 1 1 A clear grasp of the relevant anatomy and an understanding leys, and by transmitting forces generated by contraction of the of important anatomical variations are obvious prerequisites extraocular muscles indirectly to the sclera. Even a “lost” rec- for the strabismus surgeon. The strabismus surgeon must not tus muscle may continue to have a minor to moderate ability only be familiar with the anatomy of the extraocular muscles, to move the eye through these secondary attachments with the but must also be cognizant of adjacent structures in the orbit globe, despite complete disruption of the normal anatomical and the ocular adnexa. Much of the anatomy that the strabis- insertion. mus surgeon must be familiar with is covered routinely during This chapter will highlight key elements of ocular and or- the normal course of training in an ophthalmology residency bital anatomy that are important for the strabismus surgeon program. This standard training should be considered as an in- to understand. Major structures of anatomical importance in- troduction. The strabismus surgeon needs to understand many volving the eyelids, conjunctiva, Tenon’s fascia, and other or- intricacies of the ocular anatomy as they relate to cause and bital tissues will be reviewed, concluding with an assessment surgical treatment in order to both effectively plan and execute and review of key elements of the ocular and orbital anatomy surgery to correct strabismus. -
The Management of Congenital Malpositions of Eyelids, Eyes and Orbits
Eye (\988) 2, 207-219 The Management of Congenital Malpositions of Eyelids, Eyes and Orbits S. MORAX AND T. HURBLl Paris Summary Congenital malformations of the eye and its adnexa which are multiple and varied can affect the whole eyeball or any part of it, as well as the orbit, eyelids, lacrimal ducts, extra-ocular muscles and conjunctiva. A classification of these malformations is presented together with the general principles of treatment, age of operating and surgical tactics. The authors give some examples of the anatomo-clinical forms, eyelid malpositions such as entropion, ectropion, ptosis, levator eyelid retraction, medial canthus malposition, congenital eyelid colobomas, and congenital orbital abnormalities (Craniofacial stenosis, orbi tal plagiocephalies, hypertelorism, anophthalmos, microphthalmos and cryptophthalmos) . Congenital malformations of the eye and its as echography, CT-scan and NMR, enzymatic adnexa are multiple and varied. They can work-up or genetic studies (Table I). affect the whole eyeball or any part of it, as Surgical treatment when feasible will well as the orbit, eyelids, lacrimal ducts extra encounter numerous problems; age will play a ocular muscles and conjunctiva. role, choice of a surgical protocol directly From the anatomical point of view, the fol related to the existing complaints, and coop lowing can be considered. eration between several surgical teams Position abnormalities (malpositions) of (ophthalmologic, plastic, cranio-maxillo-fac one or more elements and formation abnor ial and neurosurgical), the ideal being to treat malities (malformations) of the same organs. Some of these abnormalities are limited to Table I The manag ement of cong enital rna/positions one organ and can be subjected to a relatively of eyelid s, eyes and orbits simple and well recognised surgical treat Ocular Findings: ment. -
Anatomy of the Periorbital Region Review Article Anatomia Da Região Periorbital
RevSurgicalV5N3Inglês_RevistaSurgical&CosmeticDermatol 21/01/14 17:54 Página 245 245 Anatomy of the periorbital region Review article Anatomia da região periorbital Authors: Eliandre Costa Palermo1 ABSTRACT A careful study of the anatomy of the orbit is very important for dermatologists, even for those who do not perform major surgical procedures. This is due to the high complexity of the structures involved in the dermatological procedures performed in this region. A 1 Dermatologist Physician, Lato sensu post- detailed knowledge of facial anatomy is what differentiates a qualified professional— graduate diploma in Dermatologic Surgery from the Faculdade de Medician whether in performing minimally invasive procedures (such as botulinum toxin and der- do ABC - Santo André (SP), Brazil mal fillings) or in conducting excisions of skin lesions—thereby avoiding complications and ensuring the best results, both aesthetically and correctively. The present review article focuses on the anatomy of the orbit and palpebral region and on the important structures related to the execution of dermatological procedures. Keywords: eyelids; anatomy; skin. RESU MO Um estudo cuidadoso da anatomia da órbita é muito importante para os dermatologistas, mesmo para os que não realizam grandes procedimentos cirúrgicos, devido à elevada complexidade de estruturas envolvidas nos procedimentos dermatológicos realizados nesta região. O conhecimento detalhado da anatomia facial é o que diferencia o profissional qualificado, seja na realização de procedimentos mini- mamente invasivos, como toxina botulínica e preenchimentos, seja nas exéreses de lesões dermatoló- Correspondence: Dr. Eliandre Costa Palermo gicas, evitando complicações e assegurando os melhores resultados, tanto estéticos quanto corretivos. Av. São Gualter, 615 Trataremos neste artigo da revisão da anatomia da região órbito-palpebral e das estruturas importan- Cep: 05455 000 Alto de Pinheiros—São tes correlacionadas à realização dos procedimentos dermatológicos. -
Mythbusters All Droopy Eyelids Are Created Equal
Financial disclosures Mythbusters Oculoplastic Edition Jed T. Poll, M.D. Utah Optometric Association June 3, 2016 Myth #1 Seriously…They’re all the same • Causes of “Droopy Eyelids” • Dermatochalasis All droopy • Blepharoptosis • Brow ptosis eyelids are • Pseudoptosis created equal I’m still not convinced… Different kinds-o-ptosis? Most common Usually congenital Dermatochalasis Ptosis Stretched tendon Weak muscle Excess skin problem Eyelid muscle problem High lid crease Absent lid crease Weighs down eyelid Lid margin / lashes low Involutional Myogenic Normal lid function Possible lid dysfunction Uncommon Uncommon Myasthenia / Botox Lesion / Mass Fluctuating Treat mass effect Many patients have both Neurogenic Mechanical 1 So…They’re not all the same Myth #1 • Correct Dx = Correct treatment – Not always surgical • Potential comorbidities All droopy – Droopy lid with… eyelids are • Anisocoria - Horner’s syndrome / CN III palsy • Fluctuations - Myasthenia Gravis created equal Myth #2 Will my insurance cover this? • Most common question for dermato and ptosis • 3 Elements: All eyelid – Complaint of visual impairment that improves with eyelid elevation surgery is – Supported by clinical exam – Documented with clinical photographs and cosmetic taped/untaped visual fields Dermatochalasis Evaluation Ptosis Evaluation • Exam: PF: lid margin to lid margin – “Grading” the amount of dermatochalasis MRD: light reflex to lid margin • 1+ to 4+ scale or mild to severe 1+ 2+ 3+ 4+ Dermatochalasis continuum Barely any Barely seeing 2 Ptosis Evaluation -
Blepharoplasty Fact Sheet
FACT Blepharoplasty SHEET LCD L33944 Medicare does not cover cosmetic surgery or expenses Any procedure(s) involving blepharoplasty and billed to this contractor MUST be supported by incurred in connection with documented patient complaints which justify functional surgery. such surgery. This exclusion This documentation must address the signs and symptoms commonly found in association does not appy to surgery in with ptosis, pseudoptosis, blepharochalasis and/or dermatochalasis. connection with the treatment These include, but are not limited to: of an accidental injury or for the improvement of the • Significant interference with vision or superior or lateral visual field (i.e.. difficulty seeing functioning of a malformed objects approaching from the periphery) body member. (CMS • Difficulty reading due to superior visual field loss Publication 100-2, chapter • Looking through the eyelashes or seeing the upper eyelid skin 16, section 120, http://www. cms.gov/Regulations-and- Guidance/Guidance/Manuals/ Downloads/bp102c16.pdf) Visual Field Testing • Demonstrate a significant loss of superior visual field and potential correction of the visual field by the proposed procedure(s). • A minimum 12 degree OR 30 percent loss of upper field of vision with upper lid skin and/ or upper lid margin in repose and elevated (by taping of the lid) to demonstrate potential correction by the proposed procedure or procedures is required. • Testing of eye(s) both at rest and with lid elevation (taped, manually retracted) • When planned procedure is for ptosis or the ptosis is concurrent with dermatochalasis; the visual field study should be repeated with the true eyelid taped, so the eyelid margin assumes the correct anatomic position • Include Patient name, date of testing and eye(s) tested • When both eyes are tested the test MUST clearly distinguish right (OD) from left (OS) Visual field studies are not required when the indication for surgery is entropion or extropion.