MANUAL OF OPHTHALMIC PLASTIC AND RECONSTRUCTIVE SURGERY Editor and author: Guilherme Castela Proofreading: Guilherme Castela, Filipa Ponces e Nádia Lopes Linguistic review: Jean Burrows Cover image: Hugo Castela Illustrations on Chapter 1: Ana Fonseca Illustrations on Chapter 2 and 3: Ricardo Correia 1st Edition - October 2016 Design and layout: Ricardo Correia ISBN: 978-989-98118-5-0 Legal deposit: 415575/16 Circulation: 1,100 copies Printed at: Ondagrafe - Artes Grácas, Lda. Loures - Portugal Published by: Sociedade Portuguesa de Oftalmologia Campo Pequeno, 2 - 13º 1000-078 Lisboa All rights reserved. No part of this book shall be reproduced, stored in a retrieval system, or transmitted by any means – electronic, mechanical, photocopying, recording, or otherwise – without written permission from the publisher and the author. All texts, diagrams and images in this book are responsability of their authors. All the content of this book was published without any interference from éa Portugal S.A. 2 MANUAL OF OPHTHALMIC PLASTIC AND RECONSTRUCTIVE SURGERY Editor and Author Guilherme Castela 3 4 Authors Editor and Author Guilherme Castela Head of the Orbit and Oculoplastics Unit, Department of Opthalmology, Centro Hospitalar e Universitário de Coimbra, Portugal. Invited assistant professor of Ophthalmology, Medical School, University of Coimbra, Portugal. Co-authors Ana Amaro Orbit and Oculoplastics Unit, Department of Ophthalmology, Centro Hospitalar de Lisboa Central, Portugal. Ana Cabugueira Ophthalmology Resident, Department of Ophthalmology, Centro Hospitalar de Lisboa Central, Portugal. Ana Duarte Fellow of Oculoplastic and Orbit at the Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, School of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil. Ana Magriço Orbit and Oculoplastics Unit, Department of Ophthalmology, Centro Hospitalar de Lisboa Central, Portugal. Ana Paula Pina Orbit and Oculoplastics Unit, Department of Ophthalmology, Centro Hospitalar de São João, Porto, Portugal. Ana Rosa Pimentel Associated Professor, Head of Ophthalmology and Otorhinolaryngology department, Medical School, Federal University of Minas Gerais, Belo Horizonte, Brazil. Head of the Oculoplastics, Orbit and Lacrimal Unit, Hospital São Geraldo, Belo Horizonte, Brazil. Andreia Silva Ophthalmology Resident, Department of Ophthalmology, Centro Hospitalar Universitário de Coimbra, Portugal. Antonio Augusto Velasco e Cruz Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Hospital das Clínicas of Ribeirão Preto School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil. Cátia Azenha Ophthalmology Resident, Department of Ophthalmology, Centro Hospitalar Universitário de Coimbra, Portugal. 5 Authors Cecília Ramos Orthoptist, Association for Innovation and Biomedical Research on Light and Image (AIBILI), Coimbra, Portugal Ocularist, S. Martinho Óptica, Coimbra, Portugal. Célia Simões Cardoso de Oliveira Stathler Head of the Oculoplastic Unit, Hospital de Olhos Paulista, São Paulo, Brazil. Oculoplastic unit, Hospital da Santa Casa de Misericórdia de São Paulo, Brazil. Consuelo Prada Sánchez. Ophthalmologist, Oculoplastics. International Institute of Orbit and Oculoplastics, Centro Oftalmologico Moreiras, Santiago de Compostela, Spain. Cristina Fonseca Ophthalmology Resident, Department of Ophthalmology, Centro Hospitalar Universitário de Coimbra, Portugal. Diana Carolina Ortegate Páez Medical ophthalmologist, Sanitas University Foundation. Filipa Ponces Orbit and Oculoplastics Unit, Department of Opthalmology, Centro Hospitalar e Universitário de Coimbra, Portugal. Invited assistant professor of Immunology, Medical School, University of Coimbra, Portugal. João Aragão Rodrigues School of Medicine, University of Porto, Porto, Portugal. João Barbosa-Breda Ophthalmology Resident, Department of Ophthalmology, Centro Hospitalar de São João, Porto, Portugal. João Cabral Department of Ophthalmology, Hospital da Luz, Lisboa, Portugal. João Gil Ophthalmology Resident, Department of Ophthalmology, Centro Hospitalar Universitário de Coimbra, Portugal. Joana Providência Ophthalmology Resident, Department of Ophthalmology, Centro Hospitalar Universitário de Coimbra, Portugal. José Costa Ophthalmology Resident, Department of Ophthalmology, Centro Hospitalar Universitário de Coimbra, Portugal. José Vicente Perez Moreiras. Professor of Medicine and Surgery at the University of Santiago de Compostela, Spain. Ex president of the SECPOO. International Institute of Orbit and Oculoplastics, Centro Oftalmológico Moreiras, Santiago de Compostela, Spain. Mara Ferreira Department of Ophthalmology, Hospital da Luz, Lisboa, Portugal. Marco Marques Ophthalmology Resident, Department of Ophthalmology, Centro Hospitalar Universitário de Coimbra, Portugal. Marco Rego Ophthalmology Resident, Department of Ophthalmology, Centro Hospitalar Universitário de Coimbra, Portugal. 6 María Angélica Salazar Román Ophthalmologist, School of Ophthalmology Barraquer Institute of America, Colombia. Oculoplastic Specialist São Geraldo Hospital, Minas Gerais, Brazil. Professor of Oculoplastic, Sanitas University Foundation, Oculoplastic National Institute of Ophtalmology and Plastic Surgery. Maria Araújo Ophthalmologist, Department of Neurosciences, Hospital de Santo António, Centro Hospitalar do Porto, Portugal. Maria Shekhovtsova School of Medicine, University of Porto, Porto, Portugal. Maria Varela Ophthalmologist, International Institute of Orbit and Oculoplastics, Centro Oftalmológico Moreiras, Santiago de Compostela, Spain. Margarida Anastácio Anesthesiologist consultant, Department of Anesthesiology, Centro Hospitalar Universitário de Coimbra, Portugal. M. Tomé Endocrinologist, Hospital Clínico Universitário de Santiago de Compostela, Santiago de Compostela, Spain. Nádia Lopes Oculoplastics Unit, Department of Opthalmology, Centro Hospitalar do Médio Tejo, Tomar, Portugal. Renata Rothwell Ophthalmology Resident, Department of Ophthalmology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal. Ricardo Dias Orbit and Oculoplastics Unit, Department of Ophthalmology, Centro Hospitalar de São João, Porto, Portugal. Rui Tavares Head of the Oculoplastics and Lacrimal Unit, S. Teotónio Hospital, Viseu, Portugal. Consultant of Oculoplastic and Lacrimal Surgery of the Centro Cirúrgico de Coimbra, Portugal. Sandra Prazeres Chief of the Oculoplastics and Reconstructive Surgery, Department of Ophthalmology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal. Sara Marques Ophthalmology Resident, Department of Ophthalmology, S. Teotónio Hospital, Viseu, Portugal. Sara Ribeiro Orbit and Oculoplastics Unit, Department of Ophthalmology, Hospital de Braga, School of Health Sciences, University of Minho, Braga, Portugal. Department of Ophthalmology, Hospital Lusíadas, Porto, Portugal. School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil. Vera Soares ENT surgeon, Rhinology and Sinus Surgery, Lacrimal Surgery Unit, S. Teotónio Hospital, Viseu, Portugal. Vitor Leal Orbit and Oculoplastics Unit, Department of Ophthalmology, Centro Hospitalar de São João, Porto, Portugal. 7 8 Index Preface 11 Introductory note and acknowledgements 13 BASIC PRINCIPLES 1. Anatomy and Clinical Examination of the Eyelids 17 2. Anatomy and Clinical Examination of the Lacrimal Drainage System 29 3. Anatomy and Clinical Examination of the Orbit 37 4. Instruments in Ophtalmic Plastic Surgery 49 5. Sutures and Needles in Ophtalmic Plastic Surgery 57 6. Anesthesia for Orbit and Oculoplastic Surgery 63 7. Graft Harvesting in Ophtalmic Plastic Surgery 69 EYELIDS 8. Ectropion 91 9. Entropion 99 10. Blepharoptosis 105 11. Trichiasis 119 12. Facial Palsy and Lagophthalmos 125 13. Eyelid Tumors 135 14. Superior Eyelid Reconstruction 145 15. Inferior Eyelid Reconstruction 155 16. Cosmetic Blepharoplasty 167 17. Periorbital Rejuvenation Fillers and Botulinum toxin 173 LACRIMAL DRAINAGE SYSTEM 18. Congenital Nasolacrimal Duct Obstruction 185 19. External Dacryocystorhinostomy 195 20. Endonasal Dacryocystorhinostomy 199 21. Transcanalicular Laser Dacryocystorhinostomy 205 ORBIT 22. Enucleation and Evisceration 217 23. Anophthalmic socket 223 24. Congenital Anophthalmia 229 25. Orbital Inammatory Disease 241 26. Bacterial Orbital Cellulitis 249 27. yroid Orbitopathy 261 28. Adult Orbital Tumors 273 29. Pediatric Orbital Tumors 285 30. Ocular Prosthesis 301 9 10 Preface e Manual of Ophthalmic Plastic and Reconstructive Surgery is a very important book for all ophthalmologists, not only for those who are beginning their career in this exciting clinical area. We are fortunately seeing interest growing in this subspecialty, which in the past was almost abandoned by the majority of ophthalmologists. Recent advances and the growing interest in this area are factors that have stimulated the writing of this work. Ophthalmologists commencing orbit and oculoplastic surgery commonly nd the anatomy of the eyelids, lacrimal drainage system and orbit dicult, even though they may know the theory well. e rst part of this manual presents the relevant anatomy and clinical examination to help readers to acquire detailed knowledge so that they can start the learning process in this eld. e other three parts have been written with the intention of providing a complete approach to the diagnosis and management of patients with oculoplastic, orbital and lacrimal problems. is book also contains a great many illustrations,