Color Atlas of Oculoplastic and Orbital Disorders

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AWARD WINNING VIDEOS

1. Intermittent Proptosis—Once in a Lifetime Experience 2. Medial Wall Fracture—Fate of Nature

ANIMATION CLIPS

1. Blowout Fracture—The Mechanism of Injury 2. Frontalis Sling Surgery 3. External Dacryocystorhinostomy with Scleral Patch Graft Bridge 4. Repair of Orbital Floor Fracture

SHORT SURGICAL VIDEOS OF SURGICAL STEPS

1. Fascia Lata Extraction 2. Fascia Lata Sling Surgery for Severe Ptosis 3. Synthetic Suture (Prolene) Frontalis Sling Surgery 4. Involutional Entropion Correction (Jone’s Procedure) 5. Cicatricial Entropion Correction with Hard Palate Graft* 6. Lateral Tarsal Strip in Lower Lid Laxity* 7. Endoscopic DCR Surgery* 8. Gold Implant in Lagophthalmos* 9. Free Tarsal Strip Graft Retrieval from Upper Lid 10. External Dacryocystorhinostomy** 11. Wrapping of Ball Implant with Banked Donor Sclera 12. Wrapping of Ball Implant with Autogenous Fascia Lata 13. Dermis Fat Graft Retrieval with Socket Reconstruction** 14. External Dacryocystorhinostomy with Scleral Patch Graft Bridge

ILLUSTRATIONS IN HIGH RESOLUTION

In addition to the DVD videos, the disc contains photographs that have been included in the book in high resolution for printing or embedding in CD. Contributors to surgical videos: Special thanks to *Dr Saptagirish Rambhatla, Consultant Oculoplastic Surgeon, Rotary Narayan Netralaya, Kolkata for generously permitting to use his videos. **Dr Sourav Sanyal, Director Disha Hospital, Seoraphully and Consultant Oculoplastic Surgeon for generously permitting to use his videos.

Copying is permitted under the condition that no change is made in any parts of the program and its presentation. Using part of this program is permitted with acknowledgment of the source “Color Atlas of Oculoplastic and Orbital Disorders: Dr Arnab Biswas; DVD Supplement to the book”. For correspondence: [email protected] Color Atlas of Oculoplastic and Orbital Disorders

Arnab Biswas MBBS DOMS FICO FRCS (Glasgow) Fellow University of Limoges (France) Consultant Oculoplastic and Orbital Surgeon

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First Edition: 2009 ISBN 978-81-8448-460-1

Typeset at JPBMP typesetting unit Printed at Ajanta Offset Oculoplastic surgery is a fascinating mix of science and art. With its vast canvas, it takes a lifelong learning experience to fathom its intricacies. However, all the efforts and frustrations of learning experience are overcome by the smiles and gratitude of the patients you meet along the way. This book is dedicated to all of them.

To My mother and father who brought me up, and guided me all these years

My dear wife, Sejuti My pillar of strength who has been there, by my side all along. She has had to face the maximum burnt of this project–Inattentiveness, sleepless nights, editor, reviewer, proofreader, babysitter and what not

My son, Rudra from whom I am learning to live life

Foreword ......

Georg Eisner, M.D. Professor of Ophthalmology University of Bern Switzerland

To pass on our knowledge is one of the paramount endeavors in our profession.

With his well written and richly illustrated book—Color Atlas of Oculoplastic and Orbital Disorders—Dr Arnab Biswas follows this noble tradition. With great skill, he divulges his great expertise in oculoplastic surgery, displays the wide field of casuistics, and explains the appropriate therapeutic procedures.

His contribution deserves a warm welcome by the ophthalmic com- munity and we all are grateful for his accomplishment.

I congratulate him on his work and I wish him all the success he merits.

Georg Eisner Acknowledgements......

Special acknowledgements to those who have contributed during the process of writing and production of this book:

Gobinda Mallik Supratim Biswas Consultant Ophthalmologist Consultant Ophthalmologist Kolkata Alo Eye Care, Kolkata

Partha Biswas Satyajit Bhattacharya Consultant Ophthalmologist Consultant Ophthalmologist BB Eye Foundation, Kolkata Alo Eye Care, Kolkata

Saptagirish Rambhatla Jitendar P Vij Consultant Oculoplastic Surgeon Chairman and Managing Director Rotary Narayan Netralaya, Kolkata Jaypee Brothers Medical Publishers New Delhi Sourav Sanyal Sunita Katla Consultant Oculoplastic Surgeon Jaypee Brothers Medical Publishers Director Disha Hospital, Seoraphully New Delhi West Bengal Sumit Kumar Surya Gupta Artist Consultant Ophthalmologist Jaypee Brothers Medical Publishers Alo Eye Care, Kolkata New Delhi

Preface......

When I entered into ophthalmology more than a decade ago, I was fascinated by the sketches of operative steps that were there in the textbooks and atlases. At that time, the digital revolution had not boomed. Documenting and archiving interesting cases was a difficult proposition. We were using the film camera then, and had to be extremely cautious of not wasting any extra unwanted film. So taking as many shots of a surgical step or photographing a patient from different angles to get the best shot, was a practical no-no. With the advent and advancement of digital technology, most of our past difficulties have been curtailed. This book Color Atlas of Oculoplastic and Orbital Disorders has been the outcome of digital archiving and documentation of over a decade. This book is aimed for all budding ophthalmologists who want to take up Oculoplasty as a future superspeciality practice. This book will also help guide a general ophthalmology practitioner to perform oculoplasty and orbital cases that one may encounter in his day-to-day experience. This is a photographic journey through the beautiful and challenging world of oculoplasty and orbital disorders. I hope this small endeavor, instills in all budding ophthalmologists, the will power to say: “Yes I can also diagnose the condition and do the necessary surgical procedure.” There are very good textbooks on this topic and there is no substitute of a textbook, but an atlas on this topic will give one the visual insight into the intricacies of surgical steps, which are sometimes difficult to understand on reading a text. During the last decade I have had the opportunity to see, work and learn from the doyens in this field all over the world. Prof Jean Paul Adenis, from University of Limoges, France has been my mentor, who taught me the intricacies of this subject. He instilled in me to love this form of art. My senior colleague Dr Partha Biswas has been my guiding force from the day I entered into this domain, without whose help and guidance this book would not have seen the light. The list would become endless if I start writing about all of them, but I have to express my sincere gratitude and respect to my friend senior and also my anesthetist, Dr Krishna Poddar, who has been there all these years in the operation theater with me, giving valuable suggestions in difficult time, encouraging me when in trouble and of course waiting patiently when I was taking multiple photographs of the surgical steps to get the best view and not grudging for time wasting. I am also indebted to Emile Holmen, Professor of Anatomy of Stanford Medical University, USA and Robert P Chase, the curator of the famed Basset’s Anatomy Dissection collection, who did not hesitate to share with us ophthalmologists such a gifted collection. This book would have remained in the archives, had it not been for Shri Jitendar P Vij, CMD of Jaypee Brothers Medical Publishers. He has been encouraging and helpful with suggestions all along the process from conceptualizing this project to making it a reality. I have tried to include most common day-to-day disorders as well as someone in a life time/rare and interesting cases for reference. In trying to cover such a vast area, there will be some omissions and flaws. I would welcome advice, suggestions as well as critical comments from everybody who reads this book. This will help me to produce better results in the future. I sincerely hope, this atlas bridges a gap between the textbook and the practical reality, and benefits all.

Arnab Biswas e-mail: [email protected]

Contents......

1. Anatomy of the Orbit and its Adnexae...... 1 • Eyelids...... 2 • Lacrimal System ...... 8 • Orbit ...... 9

2. Ageing Eye ...... 15 • Surface Anatomy ...... 16 • Signs of Ageing in the Lid and Midface ...... 17 • Changes in Anatomical Landmarks as One Grows Old ...... 21

3. Clinical Examination Techniques ...... 23 • Ptosis Examination ...... 24 • Eyelid Measurements ...... 25 • Orbit Examination ...... 26 • Pupillary Examination ...... 27 • Medial Canthal Laxity Test ...... 28 • Lateral Canthal Laxity Test ...... 28 • Snap-Back Test ...... 29 • Levator Palpebrae Superioris Function Test ...... 30 • Orbicularis Muscular Tone Check ...... 31 • Fluorescein Corneal Stain Test ...... 32 • Bell’s Phenomenon Assessment ...... 32 • Schirmer Test ...... 33 • Lacrimal System Irrigation Assessment ...... 33 • Thyroid Status Assessment ...... 34 • Exophthalmometry ...... 35

4. Congenital Anomalies ...... 37 • Cryptophthalmos ...... 38 • Ankyloblepharon ...... 39 • Lid Coloboma ...... 40 • Euryblepharon ...... 42 • Blepharophimosis Syndrome ...... 44 • Congenital Microphthalmos and Anophthalmos ...... 45 • Epicanthus ...... 46 • Congenital Entropion ...... 48 • Epiblepharon ...... 50 • Congenital Cystic Eyeball ...... 51 • Telecanthus ...... 52 • Hypertelorism ...... 53 • Craniofacial Dysostosis ...... 54 Color Atlas of Oculoplastic and Orbital Disorders

5. Inflammatory Disorders of the Lid ...... 57 • Blepharitis ...... 58 • External Hordeolum (Stye) ...... 59 • Internal Hordeolum ...... 60 • Chalazion ...... 61 • Surgical Management of Chalazion ...... 62 • Superior Lid Crease Approach for Chalazion ...... 63 • Pyogenic Granuloma ...... 64 • Milia ...... 65 • Herpes Zoster Ophthalmicus ...... 66 • Poliosis ...... 67 • Madarosis ...... 68

6. Ectropion ...... 71 • Congenital Ectropion ...... 73 • Mechanical Ectropion ...... 74 • Involutional Ectropion...... 75 • Kuhnt-Szymanowski (Smith’s Modification) ...... 77 • Lateral Tarsal Strip ...... 79 • Medial Conjunctival Spindle Procedure ...... 81 • Paralytic Ectropion ...... 83 • Medial Canthal Stabilization and Tightening...... 87 • Tarsorrhaphy ...... 89 • Cicatricial Ectropion ...... 91 • Z-plasty in Cicatricial Ectropion...... 94 • Full-Thickness Skin Grafts ...... 96 • Upper Lid Rotational Graft ...... 99 • Very Severe Cicatricial Ectropion ...... 101 • Split-Thickness Skin Grafts ...... 102

7. Entropion ...... 105 • Epiblepharon ...... 107 • Congenital Entropion ...... 108 • Surgery for Congenital Entropion ...... 109 • Cicatricial Entropion ...... 111 • Spastic Entropion ...... 112 • Involutional Entropion ...... 113 • Lid Everting Sutures ...... 115 • Modified Wheelers Operation for Lower Lid Involutional Entropion ...... 117 • Jone’s Procedure...... 119 • Surgical Correction of Mild Upper Lid Entropion ...... 121 • Trichiasis ...... 122 • Electroepilation ...... 123

8. Lid Tumors ...... 127 • Sudoriferous Cysts (Retention Cysts, Hydrocystomas) ...... 128 • Epidermal Inclusion Cysts ...... 129 xii • Sebaceous Cysts ...... 130 Contents

• Actinic Keratosis...... 131 • Seborrheic Keratoses ...... 132 • Nevus ...... 133 • Localized Hemangioma/AV Malformation ...... 135 • Feeder Vessel Treatment of Hemangioma/AV Malformation ...... 137 • Capillary Hemangiomas (Eyelid) ...... 138 • Sclerotherapy for Lid Hemangioma ...... 140 • Nevus Flammeus (Port-Wine Stain) ...... 142 • Neurofibromatosis...... 144 • Plexiform Neurofibromatosis ...... 145 • Debulking of Plexiform Neurofibromatosis ...... 146 • Meibomian Gland Carcinoma ...... 149 • Squamous Cell Carcinoma...... 151 • Basal Cell Carcinoma ...... 153 • Xanthelasma ...... 157

9. Basics of Lid Reconstruction ...... 159 • Upper Eyelid Reconstruction ...... 160 • Direct Closure ...... 161 • Lateral Canthotomy ...... 162 • Tenzel Rotational Flap (Upper Lid) ...... 163 • Sliding Tarsoconjunctival Flap (Posterior Lamellar Reconstruction) ...... 164 • Glabellar Rotational Flap ...... 166 • Cutler-Beard (Bridge) Flap ...... 168 • Pedicle Flap from Lower Lid ...... 170 • Lower Eyelid Reconstruction ...... 171 • Sliding Flap ...... 172 • Direct Lower Lid Closure ...... 173 • Tarso-Conjunctival Flap ...... 175 • Tenzel Rotational Flap ...... 178 • McGregor Cheek Flap ...... 179 • Mustarde’s Cheek Rotational Flap ...... 180 • Nasolabial Rotational Flap ...... 184 • Lateral Canthus Reconstruction ...... 186 • Canalicular Involved Lid Repair ...... 188

10. Classification of Ptosis...... 191 • Congenital Simple Ptosis ...... 192 • Blepharophimosis Syndrome ...... 194 • Marcus-Gunn Jaw-Winking Ptosis ...... 195 • Congenital Third Nerve Palsy ...... 199 • Total Progressive External Ophthalmoplegia ...... 200 • Kearns-Sayre Syndrome ...... 202 • Mechanical Ptosis ...... 203 • Horner’s Syndrome...... 205 • Acquired Third Nerve Palsy ...... 206 • Myasthenia Gravis ...... 209 • Aponeurotic Ptosis...... 212 • Pseudoptosis ...... 214 xiii Color Atlas of Oculoplastic and Orbital Disorders

11. Surgical Management of Ptosis ...... 219 • Fasanella-Servat Procedure ...... 220 • Levator Advancement or Resection ...... 223 • Levator Aponeurotic Dehiscence Repair...... 227 • Frontalis Sling (Fascia Lata) ...... 229 • Frontalis Sling (Silicon Tube) ...... 232 • Surgery for Marcus-Gunn Jaw-winking Ptosis ...... 235 • Surgery for Blepharophimosis Syndrome ...... 239 • Cantholysis ...... 242 • Ptosis Crutch ...... 244

12. Lacrimal System ...... 249 • Congenital Nasolacrimal Duct Obstruction ...... 250 • Congenital Fistulae ...... 252 • Lacrimal Fistulae ...... 253 • Double Punctum...... 254 • Centurian Syndrome ...... 255 • Punctal Stenosis ...... 256 • Three Snip Procedure for Punctal Stenosis ...... 257 • Canaliculitis ...... 259 • Acute Dacryocystitis ...... 260 • Mucocele ...... 262 • Chronic Dacryocystitis ...... 263 • External Dacryocystorhinostomy ...... 264 • Stents ...... 267 • Trans-canalicular Laser Dacryocystorhinostomy ...... 268 • Lacrimal Sac Tumors ...... 272 • Surgery for Lacrimal Sac Tumor ...... 274 • Lymphoma of Lacrimal Sac ...... 276

13. Socket Reconstruction...... 277 • Healthy Socket with Prosthesis ...... 278 • Post-Enucleation Socket Syndrome ...... 279 • Inadequate Lower Fornix in the Anophthalmic Socket ...... 281 • Fornix Forming Sutures ...... 282 • Exposed Orbital Implant ...... 283 • Migrated Orbital Implant ...... 284 • Healthy Socket ...... 286 • Contracted Socket ...... 287 • Evisceration ...... 288 • Enucleation ...... 292 • Exenteration ...... 297 • Wrapping the Ball Implant ...... 299 • Secondary Orbital Implant ...... 302

14. Inflammatory Disorders of the Orbit ...... 305 • Preseptal Cellulitis ...... 306 xiv • Orbital Cellulitis ...... 308 Contents

• Orbital Abscess ...... 310 • Drainage of Orbital Abscess ...... 311 • Complications/ Sequela of Orbital Cellulitis—Persisting Sinus Tract ...... 314 • Orbital Fungal Infection ...... 315 • Orbital Abscess (Cysticercosis) ...... 316 • Pseudotumors ...... 318 • Sarcoidosis ...... 319 • Orbital Myositis ...... 320 • Lacrimal Gland Inflammation ...... 321 • Diffuse Orbital Intraconal Inflammation ...... 323

15. Orbital Tumors...... 325 • Cystic Lesions (Dermoid Cysts, Teratoma) ...... 326 • Temporal Fossa Dermoid Cyst with Orbital Extension ...... 328 • Lymphangioma ...... 329 • Rhabdomyosarcoma ...... 331 • Optic Nerve Gliomas ...... 333 • Cavernous Hemangioma ...... 334 • Orbital Varices ...... 337 • Orbital A-V Malformation ...... 338 • Orbital Meningiomas ...... 339 • Schwannomas ...... 341 • Lymphoid Tumors ...... 342 • Lacrimal Gland Tumors ...... 345 • Orbital Osteoma ...... 347 • Paranasal Sinus Masses ...... 349 • Metastatic Tumors ...... 351 • Localized Orbital Extension of Ocular Malignancy ...... 353

16. Surgical Approaches to Orbit ...... 355 • Lateral Orbitotomy ...... 356 • Superomedial Orbitotomy ...... 360 • Inferior Orbitotomy ...... 362 • Superior Orbitotomy ...... 364 • Superolateral Orbitotomy ...... 366 • Medial-transconjunctival Orbitotomy ...... 367

17. Thyroid Ophthalmopathy ...... 369 • Thyroid-associated Orbitopathy ...... 370 • Mulerectomy ...... 376 • Non-thyroid Lid Retraction ...... 378 • Spacers for Lid Retraction ...... 380 • Orbital Decompression ...... 382

18. Lid and Orbital Trauma...... 383 • Lid Laceration ...... 384 • Eyebrow Laceration ...... 387 xv Color Atlas of Oculoplastic and Orbital Disorders

• Injuries of the Canaliculi ...... 388 • Burn Injury...... 391 • Hematoma of the Eyelid (Black Eye) ...... 392 • Post-traumatic Scar ...... 393 • Post-repair Scar ...... 394 • Orbital Floor Fracture ...... 395 • Orbital Floor and Inferior Wall Repair ...... 398 • Medial Wall Fractures ...... 399 • Lateral Orbital Wall Fractures ...... 400 • Lid Foreign Body ...... 402 • Intraorbital Foreign Body ...... 403 • Carotido-Cavernous Sinus Fistula ...... 404

19. Anesthesia ...... 407 • Topical Anesthesia ...... 408 • Contact Anesthesia ...... 408 • Infiltration Anesthesia ...... 409 • Regional Block ...... 410 • Lacrimal Nerve Block...... 410 • Supraorbital Nerve Block...... 410 • Supratrochlear Nerve Block ...... 411 • Infratrochlear Nerve Block...... 411 • Zygomaticofacial Nerve Block ...... 412 • Infraorbital Nerve Block ...... 412 • Size of Needles ...... 413

20. Basic Principles and Techniques ...... 415 • Pre-operative Evaluation ...... 416 • Incision ...... 417 • Hemostasis ...... 418 • Wound Closure ...... 419 • Tension Releasing Sutures ...... 419 • Dressing ...... 420 • Wound Healing ...... 421 • Hypertrophic Scars and Keloids ...... 422 • Flaps ...... 423 • Advancement Flap ...... 424 • ‘Z’ Plasty ...... 426 • ‘V-Y’ Plasty ...... 427 • Grafts ...... 428 21. Basic Instrumentation in Oculoplastic, Lacrimal and Orbital Surgery...... 429 • Ophthalmic Plastic Surgery: General Instruments...... 430 • Enucleation Set/Evisceration Set ...... 431 • Ptosis Special Instruments ...... 432 • Lacrimal Surgery Set ...... 433 • Lacrimal Stents and Tubes ...... 434 xvi • Orbital Surgery Set ...... 435 • Bone Cutters and Plates ...... 436 Contents

• Skin Grafting Set ...... 436 • Special Instruments for Lid Surgery ...... 437 • Sutures ...... 438 22. Grafts in Oculoplasty ...... 439 • Full-Thickness Skin Graft ...... 440 • Split-Thickness Skin Graft ...... 442 • Mucous Membrane Graft ...... 443 • Dermis-Fat Graft in Orbital Surgery ...... 444 • Post-auricular Cartilage ...... 447 • Fascia Lata ...... 449