12/1/2012

Lid Surgery: Blepharoplasty , Chalazia, Ptosis, and  Indications  Ptosis  Cause of Ptosis must be determined! Michelle Welch, O.D. Associate Dean

Ptosis Neurogenic Ptosis

 History is key to help  Third palsy determine etiology  Horner syndrome  Congenital  Neurogenic  Marcus Gunn jaw-winking syndrome  Myogenic  Third nerve misdirection  Aponeurotic  Mechanical

Myogenic Ptosis Aponeurotic Ptosis

 Involutional   Postoperative  Ocular myopathy  Simple congenital

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Mechanical Ptosis Pseudoptosis

 Lid retraction, Hypotropia, Brow Ptosis, GPC 

 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 – usually lower lid  Blood thinners  For mild entropion, repair by suture is a viable  Clear up 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

[email protected]

Characteristics of Malignant Tumors of the 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  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 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

 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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