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Fundamentals of Clinical Ophthalmology Plastic and Orbital Surgery Fundamentals of Clinical Ophthalmology Series

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Fundamentals of Clinical Ophthalmology Plastic and Orbital Surgery Fundamentals of Clinical Ophthalmology Series Fundamentals of Clinical Ophthalmology Plastic and Orbital Surgery Fundamentals of Clinical Ophthalmology series Glaucoma Edited by Roger Hitchings Neuro-ophthalmology Edited by James Acheson and Paul Riordan-Eva Paediatric Ophthalmology Edited by Anthony Moore Scleritis Edited by Peter McCluskey Uveitis Edited by Susan Lightman and Hamish Towler Forthcoming: Cataract Surgery Edited by David Garty Cornea Edited by Douglas Coster Strabismus Edited by Frank Billson Fundamentals of Clinical Ophthalmology Plastic and Orbital Surgery Edited by Richard Collin Consultant Ophthalmic Surgeon, Moorfields Eye Hospital, London, UK and Geoffrey Rose Consultant Ophthalmic Surgeon, Moorfields Eye Hospital, London, UK Series Editor Susan Lightman Professor of Clinical Ophthalmology, Institute of Ophthalmology/Moorfields Eye Hospital, London, UK © BMJ Books 2001 BMJ Books is an imprint of the BMJ Publishing Group All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers. First published in 2001 by BMJ Books, BMA House, Tavistock Square, London WC1H 9JR www.bmjbooks.com British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0-7279-1475-8 Typeset by FiSH Books Printed in Malaysia by Times Offset Contents Contributors vii Preface to the Fundamentals of Clinical Ophthalmology series viii Preface viii 1 Anatomy and general considerations 1 Fiona Robinson 2 Eyelid trauma and basic principles of reconstruction 7 John Pitts 3 Ectropion 15 Michèle Beaconsfield 4 Entropion 24 Ewan G Kemp 5 Ptosis 32 Ruth Manners 6 Tumour management and repair after tumour excision 44 Brian Leatherbarrow 7 Seventh nerve palsy and corneal exposure 67 Anthony G Tyers 8 Cosmetic surgery 78 Richard N Downes 9 Socket surgery 89 Carole A Jones v CONTENTS 10 Investigation of lacrimal and orbital disease 98 Timothy J Sullivan 11 Dysthyroid eye disease 112 Carol Lane 12 Benign orbital disease 123 Christopher J McLean 13 Malignant orbital disease 140 Michael J Wearne 14 Orbital trauma 150 Brett O’Donnell 15 Basic external lacrimal surgery 161 Cornelius René 16 Laser-assisted and endonasal lacrimal surgery 168 Jane M Olver 17 Specialist lacrimal surgery and trauma 174 Alan A McNab Index 182 vi Contributors Michèle Beaconsfield Consultant Ophthalmic Surgeon, Moorfields Eye Hospital, London, UK Richard N Downes Consultant Ophthalmic Surgeon, General Hospital, St Helier, Jersey, CI Carole A Jones Consultant Ophthalmic Surgeon, Kent County Ophthalmic and Aural Hospital, Maidstone, UK Ewan G Kemp Consultant Ophthalmologist, Gartnavel General Hospital, Glasgow, UK Carol Lane Consultant Ophthalmic Surgeon, University Hospital of Wales, Cardiff, UK Brian Leatherbarrow Consultant Ophthalmic, Oculoplastic and Orbital Surgeon, Manchester Royal Eye Hospital, Manchester, UK Christopher J McLean Consultant Ophthalmic Surgeon, Royal Surrey County Hospital, Guildford, UK Alan A McNab Consultant Ophthalmic Surgeon, Royal Victorian Eye and Ear Hospital, The Royal Melbourne Hospital and the Royal Children’s Hospital, Melbourne, Australia Ruth Manners Consultant Ophthalmic Surgeon, Southampton General Hospital, Southampton, UK Brett O’Donnell Consultant Ophthalmic Surgeon, Royal North Shore Hospital and St Vincent’s Hospital, Sydney, Australia Jane M Olver Consultant Ophthalmic Surgeon, The Western Eye Hospital, London, UK John Pitts Consultant Ophthalmologist, Barts and the London NHS Trust, London, UK Cornelius René Consultant Ophthalmic Surgeon, Addenbrooke’s Hospital, Cambridge, UK Fiona Robinson Consultant Ophthalmologist, King’s College Hospital, London, UK Timothy J Sullivan Clinical Associate Professor and Head, Department of Ophthalmology, Royal Brisbane Hospital, Brisbane, Australia Anthony G Tyers Consultant Ophthalmologist, Salisbury District Hospital, Salisbury, UK Michael J Wearne Consultant Ophthalmic Surgeon, Eastbourne District Hospital, Eastbourne, UK vii Preface to the Fundamentals of Clinical Ophthalmology series This book is part of a series of ophthalmic monographs, written for ophthalmologists in training and general ophthalmologists wishing to update their knowledge in specialised areas. The emphasis of each is to combine clinical experience with the current knowledge of the underlying disease processes. Each monograph provides an up to date, very clinical and practical approach to the subject so that the reader can readily use the information in everyday clinical practice. There are excellent illustrations throughout each text in order to make it easier to relate the subject matter to the patient. The inspiration for the series came from the growth in communication and training opportunities for ophthalmologists all over the world and a desire to provide clinical books that we can all use. This aim is well reflected in the international panels of contributors who have so generously contributed their time and expertise. Susan Lightman Preface This book covers the whole field of eyelid, lacrimal, orbital and socket surgery. As part of the series of ophthalmic monographs it is written for ophthalmologists in training and general ophthalmologists wishing to update their knowledge of oculoplastic surgery. It aims to provide a practical guide to the management of basic oculoplastic problems. It does not try to give didactic details of a systematic series of surgical procedures, but rather to present an outline of the different options which are available to the surgeon with their advantages and disadvantages.This is achieved by a team of contributors practising in different countries throughout the world who have all worked at Moorfields Eye Hospital with the editors, but who have adapted their practice to their current local circumstances. In this way we hope to have provided a surgical guide which will be of value throughout the world. Richard Collin Geoffrey Rose viii CHAPTER TITLE 1 Anatomy and general considerations Fiona Robinson A sound understanding of the basic anatomy between conjunctiva which covers tarsus and of the eyelids, lacrimal system and orbits is squamous epithelium which covers orbicularis. essential in order to perform successful In plastic surgery, procedures are often surgery.This chapter presents a basic overview described as involving the anterior or posterior together with general considerations relative lamella. to oculoplastic and orbital surgery. The upper lid margin lies 1 to 2mm below the superior limbus, the peak lying just nasal Whitnalls ligament to the centre of the pupil. The lower lid Orbicularis Pre-Aponeurotic fat margin sits at the corneal limbus, its lowest pad portion lying slightly temporal to the pupil. Orbital septum The upper lid crease is 8 to 12mm above the Levator palpebrae superioris lashes and is formed by the subcutaneous Levator aponeurosis insertion of the terminal fibres of the levator Post- aponeurosis. The lower lid crease is more Aponeurotic space poorly defined as there are no subcutaneous Superior rectus Mullers insertions corresponding to those of the muscle upper eyelid. The nasojugal fold extends Tarsus inferior and laterally from the medial canthal Inferior rectus angle along the side of the nose and the Tarsus angular blood vessels will generally be located in this fold. Orbital septum Inferior oblique Pre-Aponeurotic fat pad Skin Orbicularis Eyelid skin is thin allowing good mobility of Figure 1.1 Sagittal view of the eyelid structures. the eyelids. In part due to this thinness, it has a tendency to stretch with age. The resultant The eyelids excessive skin can be used for full thickness skin grafts. Such skin grafts take well as there The eyelids may be divided into anterior is little subcutaneous fat. It should be noted and posterior lamellae. The anterior leaf is that the lower lid has no vertical excess skin composed of skin and orbicularis and the and one should excise lesions from the lower posterior of tarsus and conjunctiva. The “grey lid as vertically as possible to avoid a cicatricial line” of the lid margin marks the separation ectropion. 1 PLASTIC and ORBITAL SURGERY Orbicularis Orbital septum The orbicularis muscle surrounds the eye The septum is a tough inelastic sheet of and closes the lids. The concentrically placed fibrous tissue that divides the eyelids from the fibres are divided into three parts: the outer orbit. It is a multilaminated structure that orbital and two inner palpebral portions – arises from the orbital rim (arcus marginalis) preseptal and pretarsal – and these contribute and attaches loosely to the eyelid retractors. It to the superficial and deep portions of the acts as an important barrier to the spread of medial and lateral canthal tendons. Deep infection from the lids to the orbit. extensions at the medial canthus insert onto the fascia overlying the lacrimal sac and Pre-aponeurotic fat pad posterior lacrimal crest and aid in the lacrimal pump mechanism.When cut orbicularis fibres Lying behind the orbital septum and in contract and pull skin edges apart. One must front of the retractors is the pre-aponeurotic pull wound edges together before deciding on fat pad. Knowledge of its position is invaluable any lid repair. in identifying the retractors during surgery. The upper lid has nasal and central fat pads and care must be taken to distinguish the Medical canthal tendon latter from the lacrimal gland.
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