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 1 12/1/2012 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. 2 12/1/2012 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 3 12/1/2012 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 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! 4 12/1/2012 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 5 12/1/2012 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. 6 12/1/2012 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 7 12/1/2012 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 8 12/1/2012 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 9 12/1/2012 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) 10 12/1/2012 Electromagnetic Spectrum Ellman Unit Excision Techniques Feathering Technique Instruments Yeager Plate 11 12/1/2012 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) 12 12/1/2012 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 13 12/1/2012 Differential