12/1/2012
Lid Surgery: Blepharoplasty Neoplasms, Chalazia, Ptosis, and Entropion Indications Ptosis Cause of Ptosis must be determined! Michelle Welch, O.D. Associate Dean
Ptosis Neurogenic Ptosis
History is key to help Third nerve palsy determine etiology Horner syndrome Congenital Neurogenic Marcus Gunn jaw-winking syndrome Myogenic Third nerve misdirection Aponeurotic Mechanical
Myogenic Ptosis Aponeurotic Ptosis
Myasthenia gravis Involutional Myotonic dystrophy Postoperative Ocular myopathy Simple congenital
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Mechanical Ptosis Pseudoptosis
Lid retraction, Hypotropia, Brow Ptosis, GPC Dermatochalasis
Tumours Oedema Anterior orbital lesions Scarring
Pre-Op Measurements MRD
Measurements can help to Margin Reflex Distance distance between the upper determine type of surgery needed lid margin and the corneal reflection Skin removal only In primary gaze Skin + Levator repair Normal around 4-4.5mm Brow ptosis repair
Palpebral Fissure Levator Function
Distance between the upper and lower lid margins Excursion of upper lid Upper lid margin normally rests about 2mm below the upper limbus and the lower 1mm above the lower limbus Put 0 point of ruler at Less in males (7-10mm) than in females (8-12 mm) margin in downgaze Unilateral ptosis can be quantified by comparison with the contralateral side Ptosis is may be graded as mild (up to 2mm), moderate (3mm) and severe (4mm Then have patient look up or more). as far as possible and measure the distance the margin moved Normal =15mm or more Good = 12-14mm Fair = 5-11mm Poor = 4mm or less If lid margin can’t move and did before (not congenital defect) – is now dehised.
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Upper Lid Crease Brow Assessment
Pretarsal Show Palpate brow Distance between the lid margin and Eyebrow should be at the level of the the skin fold with the eyes in the superior orbital rim and not below. If primary position, normal 8 – 12 mm the brow has fallen below the rim will need more advanced procedure Look for wrinkles/creases on the forehead
Fatigue Test Visual Field Testing
To rule out MG Tangent screen Patient look up for 30 secs or Taped and untaped Patient look up and down or Superior only Squeeze eyes shut and try not to Carriers vary allow them to be forcibly opened Example – defect of superior must be Re-measure palpebral fissure – if within 15 degrees of fixation and lowers by 2 mm considered relieved with taping significant
Blepharoplasty Technique Overview Entropion
Concerns Inward turn of eyelid – usually lower lid Blood thinners For mild entropion, repair by suture is a viable Clear up blepharitis first! option Can patient lay flat for 45 min? Get pre-op photos
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Lid Anatomy Structural Changes Upon Suture Placement
Entropion Repair by Suture Video
Management of Eyelid Neoplasms
Michelle Welch, O.D. NSU Oklahoma College of Optometry
Characteristics of Malignant Tumors of the Eyelids Epithelial Malignancies
“Pearls” Ulceration – benign lesions do not Most periocular tumors are derived ulcerate from epidermis or adnexae Induration – malignant lesions often Main goal – rule out malignancy very firm Identify characteristics of malignancy Irregularity – malignancies have (HABCDs) irregular shapes and borders BIOPSY ALL SUSPICIOUS LESIONS!
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Characteristics of Epithelial Malignancies Epithelial Malignancies
Tenderness – malignant lesions are Basal cell carcinoma not painful Most common malignancy of the eyelid Telangectasias – focal telangectasia (90%+) suggests malignancy Types Nodular Pearly borders, rolled, translucent Ulcerative margins – think basal cell CA Sclerosing, morpheaform
Basal Cell Carcinoma BASAL CELL CARCINOMA
Rarely metastasize Medial canthal area most dangerous Mortality rate unknown, quoted 1-3% Orbital invasion Iowa series (1992) 1.7%
Mayo clinic series 2.4% Extenteration necessary 1.4 – 3.8% of cases
BASAL CELL CARCINOMA PIGMENTED BASAL CELL
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Nodular Basal Cell Carcinoma Ulcerative Basal Cell Carcinoma
Epithelial Malignancies Squamous Cell Carcinoma
Squamous cell carcinoma Confused with: Relatively rare, Wilmer series 4.2% Sebaceous cell carcinoma, basal (Doxanas 1987) cell carcinoma Seborrheic keratosis, inverted Small tendency to metastasize (0.23 – follicular keratosis, papilloma 0.25%) If rapid onset and inflammation Frequently misdiagnosed clinically present, think of: Keratoacanthoma, pseudoepitheliomatous hyperplasia
Squamous Cell Carcinoma Squamous Cell Carcinoma
Photo Courtesy of Ellman Int’l.
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Characteristics of Pigment Cell Malignancy (Melanoma) Pigmented Lesions
New onset or recent change Asymmetric shape Irregular margins Color change or multiple colors Large size - > 5mm
Pigmented Lesions: Melanoma MALIGNANT MELANOMA
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Differential Diagnosis
verruca molluscum
Basal cell carcinoma Squamos cell carcinoma
Pick your lesion carefully! Pick your lesion carefully!
Chalazion Molluscum
Squamos Cell Carcinoma Basal Cell Carcinoma
Verruca
Pick your lesion carefully! Biopsy Techniques
Shave Biopsy
Excisional Biopsy
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Excision Mechanism Options Papilloma Removal
Excision with Scalpel Indications Excision with Scissors Risks and complications Excision with Radiofrequency Recurrence Scarring Infection Risks associated with injection of anesthetic
Excision with Scalpel Excision Techniques
Excision Techniques Excision Techniques
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Excision Techniques Excision Techniques
Papilloma Removal Excision Techniques
If excising lesion try to put incision in same direction as natural skin lines.
Excision with Radiofrequency Contraindications
Do NOT perform shave excision on pigmented lesion unless certain is not melanoma!!! Advantages of Radiosurgery Don’t use in presence of flammable fumes/liquids Quick and easy (to do and to learn) Pacemaker “Do not work near the heart and place the antenna (or Nearly bloodless field grounding) plate well away from the heart. Use the least power possible. Activate the handpiece intermittently rather than continuously. The cutting mode is the most Minimal Post-op pain risky, so avoid it if possible. Use another form of treatment if it is an option. The pacers are purportedly Rapid healing “shielded” and the current in the ESUs should not affect them, but all things are not perfect! Therefore caution is Fine control with variety of tips needed. Asystole and tachycardia are potential adverse outcomes.” No muscle contractions or nerve Pfenninger and Fowler's Procedures for Primary Care, 3rd Edition. John L. Pfenninger, MD, FAAFP and Grant C. stimulation from radiowaves (Farraday Fowler, MD effects)
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Electromagnetic Spectrum Ellman Unit
Excision Techniques Feathering Technique
Instruments
Yeager Plate
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Asepsis Asepsis Aseptic technique sterile equipment scrub hands sterile gloves
Bloodborne Pathogens Informed Consent
Universal Precautions: Indications for treatment Do not recap contaminated needles Description of treatment in layman’s Needle stick safety terms Needle stick policy Alternatives to treatment You will have to be aware of these Risks and benefit of treatment things if doing procedures in your Expected and unexpected outcomes office Patient must request procedure
Pre-Operative Activities Procedure Technique
check patient allergies Pre-op (photos, consent, BP and Pulse, VA) check vital signs (pulse, respiration, BP) Anesthetize (infiltrative usually) informed consent Clean area, drape if needed Betadine needs 3 mins on skin! handling patient fear Turn on Ellman unit: warm up for at least 30 set up equipment seconds Inspection of equipment Choose appropriate waveform Inspection of medication - discard if Choose initial power setting (will often need cloudy, expired, or container damaged to adjust depending on tissue response to Photodocument lesion energy level chosen)
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Procedure Technique Procedure Technique
Have assistant turn on/position Electrode tip should be applied vacuum unit – USE vacuum and perpendicularly to allow even masks! distribution of energy Have isolated HPV and HIV in smoke Press footplate activator when Place yourself in ready to begin procedure comfortable/stable position to Move in expeditious but do procedure controlled fashion: always keep Brace your handpiece wrist on electrode moving when patient for stability contacting tissue
Procedure Technique Procedure Technique
Keep surgical site moist (saline gauze) to avoid tissue drag; also wipe energized tip to Clean area of betadine remove tissue stuck to it For removing mass lesions, use loop Apply antibiotic ung electrode/grab with opposite hand forceps/have specimen jar ready for lab Don’t let patient jump and run as you submission sit them up! When feathering down a lesion with a loop, keep perpendicular---remove until healthy Blood pressure and pulse post-op tissue seen (particularly helpful with lesions on gray line) Write op report in chart along with Can use forceps closed tips to touch end of patient instructions on wound care area of bleeding, touch electrode to forceps and follow-up schedule to transfer energy to area to stop bleeding
Chalazion Presentation Chalazion Presentation
Patient Exam Signs complaints Lesion within Non-tender lesion tarsus – not (may have started easily as a tender lesion) moveable Size varies No lash loss Length of time Non-tender, no present varies discharge upon Location varies palpation
www.redatlas.com
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Differential Diagnosis Differential Diagnosis
Sebaceous Hordeolum Gland Tender Carcinoma May have Must r/o in discharge any recurrent chalazion May be lash loss Appearance can be varied – be cautious
Chalazia Management Options
Give each patient all options for treatment! Conservative Approach Hot compress with digital massage
Can add Doxycycline if not contraindicated Intralesional Steroid Injection Incision and Curettage
Conservative Approach Intralesional Steroid Injection
Indications Indications Over 6 months old Small lesion (< 6 mm) Large (4 – 6 + mm) Located in medial aspect of lid (won’t be able to Less present less than 6 months do I & C) Lesion in medical aspect of lid where would not Patient choice want to perform I & C Contraindications Patient choice of treatment Allergy/sensitivity to steroid Contraindications Risks and Complications Doxycycline allergy, liver and/or kidney dz Depigmentation Risks and Complications Infection No resolution of lesion No resolution of lesion
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Intralesional Steroid Injection Technique Instruments
Multiuse Vial Alcohol top Put air in syringe Push air into vial Load syringe with med Alcohol top of vial Dilute kenalog 40 to 20 or 10
Chalazion Clamp
Instruments Intralesional Steroid Injection Technique
Curette
Intralesional Steroid Injection Technique Chalazion Incision and Curettage
Indications Same as for injection plus: Failure of injection to resolve lesion Contraindications Allergy/Sensitivity to anesthetic Risks and Complications Incomplete removal Infection Risks associated with injection of anesthetic If recurs in same spot will need biopsy could be sebaceous gland carcinoma!
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Chalazion Incision and Curettage Chalazion Incision and Curettage
Chalazion Chalazion Incision and Curettage
Chalazion Chalazion Video
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Patient Education Patient Education
May be small amount of bruising Watch for signs of infection Can use ice pack if needed As scab forms, don’t rub, scrub or Pain Relief pick – keep moist. Don’t use Use same meds use to alleviate headache agents that will dry it - alcohol, Keep area clean and dry peroxide, etc. Don’t wash for 24 hrs Discuss suture removal timeline No make up, lotions, powders for 5 – 7 days Limit exposure to sunlight Use medication as directed Long term moisturizer use (with Usually topical antibiotic ung Thin film over area for 4 – 5 days spf) Keep moist – don’t want hard dry scabs
Immediate Post-Op Care Long Term Post-Op Care
Wound Healing Follow-up schedule Medications Revision? Antibiotic ung Wound healing OTC pain meds Protect from sun Ice Packs Moisturizer! Follow-up schedule Suture Removal Technique
Coding for Minor Surgery Websites for Lesions or Diseases
Approximate Allowables: 67840 $247.90 Total Exc lid lesion 67810 $198.92 Biopsy/Part Exc lid lesion www.rootatlas.com 11200 $78.56 Removal <16 skin tags www.redatlas.org 11310 $78.42 Shave Exc < .5 cm 11900 $52.02 Chal injection www.kellogg.umich.edu/theeyeshaveit 67800 $115.43 Chal I & C /index.html 67801 $148.92 Chal Mult S Lid www.atlasophthalmology.com/ 67805 $184.80 Chal Mult D Lid XXXXX Repair of entropion, suture dro.hs.columbia.edu/
www.gonioscopy.org
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