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Copyright © 2001 by Thieme Medical Publishers, Inc. This book, including all parts thereof, is legally protectedby copyright. Any use, exploitation or commercialization outside the narrow limits set by copyright legislation,without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostatreproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, andelectronic data processing and storage.Important note: Medical knowledge is everchanging. As new research and clinical experience broaden ourknowledge, changes in treatment and drug therapy may be required. The authors and editors of the materialherein have consulted sources believed to be reliable in their efforts to provide information that is completeand in accord with the standards accepted at the time of publication. However, in view of the possibility ofhuman error by the authors, editors, or publisher of the work herein, or changes in medical knowledge, neitherthe authors, editors, publisher, nor any other party who has been involved in the preparation of this work,warrants that the information contained herein is in every respect accurate or complete, and they are notresponsible for any errors or omissions or for the results obtained from use of such information. Readers areencouraged to confirm the information contained herein with other sources. For example, readers are advisedto check the product information sheet included in the package of each drug they plan to administer to becertain that the information contained in this publication is accurate and that changes have not been made in therecommended dose or in the contraindications for administration. This recommendation is of particularimportance in connection with new or infrequently used drugs

FM 3/26/01 8:59 AM Page i FM 3/22/01 2:47 PM Page ii FM 3/22/01 2:47 PM Page iii Oculoplastic Surgery The Essentials William P Chen, M.D., F.A.C.S Associate Clinical Professor Department of Ophthalmology UCLA School of Medicine Los Angeles, CA; Senior Attending Surgeon Ophthalmic Plastic Surgery Service Department of Ophthalmology Harbor-UCLA Medical Center Torrance, CA; Associate Clinical Professor Department of Ophthalmology University of California Irvine College of Medicine Irvine, CA 2001 Thieme New York • Stuttgart FM 3/22/01 2:47 PM Page iv Thieme New York 333 Seventh Avenue New York, NY 10001 Editor: Esther Gumpert Editorial Assistant: Owen Zurhellen Developmental Editor: Felicity Edge Director, Production & Manufacturing: Anne Vinnicombe Marketing Director: Phyllis Gold Sales Manager: Ross Lumpkin Chief Financial Officer: Peter van Woerden President: Brian D Scanlan Cover Designer: Kevin Kall Compositor: Emilcomp Prepare, Inc Printer: Canale Library of Congress Cataloging-in-Publication Data Chen, William Pai-Dei Oculoplastic surgery : the essentials / William P Chen p ; cm Includes bibliographical references and index ISBN 1-58890-027-4 (hardcover : alk paper) Ophthalmic plastic surgery I Title [DNLM: Ophthalmologic Surgical Procedures Eyelids surgery Surgery, Plastic WW 168 C518o 2001] RE87 C466 2001 617.7'1 dc21 2001027297 Copyright © 2001 by Thieme Medical Publishers, Inc This book, including all parts thereof, is legally protected by copyright Any use, exploitation or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage Important note: Medical knowledge is ever-changing As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may be required The authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accepted at the time of publication However, in view of the possibility of human error by the authors, editors, or publisher of the work herein, or changes in medical knowledge, neither the authors, editors, publisher, nor any other party who has been involved in the preparation of this work, warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information Readers are encouraged to confirm the information contained herein with other sources For example, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this publication is accurate and that changes have not been made in the recommended dose or in the contraindications for administration This recommendation is of particular importance in connection with new or infrequently used drugs Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain Printed in the United States of America TNY ISBN 1-58890-027-4 GTV ISBN 3-13-127451-4 FM 3/22/01 2:47 PM Page v Contents CONTRIBUTORS vii PREFACE x Ophthalmic Facial Anatomy, Don O Kikkawa and Sunil N Vasani ……………………………………… Fundamentals of Oculoplastic Surgery, Dipak N Parmar and Geoffrey E Rose ………………………… 21 Entropion, Jan W Kronish …………………………………………………………………………………… 41 Ectropion, David T Tse and Ann G Neff …………………………………………………………………… 55 Trichiasis, Jeffrey A Nerad and Annie Chang ………………………………………………………………… 67 Ptosis Management: A Practical Approach, Steven Dresner ……………………………………………… 75 Ptosis: Levator Muscle Surgery and Frontalis Suspension, Philip L Custer …………………………… 89 Facial Nerve Paralysis, Steven Dresner ……………………………………………………………………… 101 Essential Blepharospasm, John McCann, Stanley Saulny, Robert A Goldberg, and Richard L Anderson 10 Upper Blepharoplasty and Eyebrow Surgery, Clinton D McCord ……………………………………… 125 11 Lower Blepharoplasty and Midface Descent, Norman Shorr and Julian D Perry ……………………… 147 12 Laser Blepharoplasty, Jemshed A Khan……………………………………………………………………… 165 13 Laser Skin Resurfacing, Jemshed A Khan …………………………………………………………………… 179 14 Laser Facial Resurfacing: Dual Mode, Cary E Feibleman ………………………………………………… 195 15 Asian Blepharoplasty, William Chen ………………………………………………………………………… 211 16 Periocular Skin Lesions and Common Eyelid Tumors, Gloria M Bertucci ……………………………… 225 17 Full-Thickness Eyelid Reconstruction, Ralph E Wesley, Kimberly A Klippenstein, Samuel A Gallo, and Brian S Biesman …………………………………………………………………………………………… 243 18 Lacrimal System, Marc J Hirschbein and George O Stasior………………………………………………… 263 19 Thyroid Ophthalmopathy: Eyelid Retraction, J Justin Older …………………………………………… 289 20 Thyroid Opthalmopathy: Restrictive Myopathy, Sherwin J Isenberg …………………………………… 297 21 Thyroid Ophthalmopathy: Compressive Optic Neuropathy, Clinton D McCord ……………………… 305 111 v FM 3/22/01 2:47 PM Page vi vi • CONTENTS 22 Thyroid Ophthalmopathy: Orbital Decompression for Aesthetic Indications, Mark A Codner ……… 315 23 Enucleation, William Chen …………………………………………………………………………………… 327 24 Evisceration, William Chen …………………………………………………………………………………… 347 25 Exenteration, William Chen…………………………………………………………………………………… 355 26 Anophthalmic Socket, Richard A Burgett and William R Nunery ………………………………………… 369 27 Orbital Diseases, Joseph A Mauriello Jr …………………………………………………………………… 387 28 Orbital Surgery, John Shore…………………………………………………………………………………… 419 29 Craniofacial and Neurosurgical Approaches to the Orbit, M Douglas Gossman, Dale M Roberts, and George Raque …………………………………………………………………………………………… 451 30 Management of Orbital Injuries, Stuart R Seiff …………………………………………………………… 475 Index ………………………………………………………………………………………………………………… 490 FM 3/22/01 2:47 PM Page vii Contributors Richard L Anderson M.D Salt Lake City, UT Gloria M Bertucci, M.D Associate Pathologist Department of Pathology Long Beach Memorial Medical Center Long Beach, CA Brian S Biesman, M.D Director of Laser Research Center for Eyelid and Aesthetic Surgery Nashville, TN Richard A Burgett, M.D Assistant Professor Department of Ophthalmology Indiana University Indianapolis, IN Annie Chang, M.D Eye Surgery Center of Colorado North Denver, CO Mark A Codner, M.D Clinical Assistant Professor Department of Plastic Surgery Emory University Atlanta, GA Philip L Custer, M.D Professor Department of Ophthalmology and Visual Sciences Washington University School of Medicine St Louis, MO Steven Dresner, M.D Assistant Clinical Professor Doheny Eye Institute University of Southern California Los Angeles, CA Cary E Feibleman, M.D Assistant Clinical Professor of Dermatology, Emeritus Department of Medicine Division of Dermatology University of California at Los Angeles Medical School Long Beach, CA Samuel A Gallo, M.D Department of Ophthalmology University of Tennessee Health Sciences Center Memphis, TN Robert A Goldberg, M.D Associate Professor of Ophthalmology Department of Ophthalmology Jules Stein Eye Institute University of California Los Angeles, CA M Douglas Gossman, M.D Associate Professor Department of Ophthalmology and Visual Sciences University of Louisville Louisville, KY Marc J Hirschbein, M.D Clinical Instructor Wilmer Eye Institute Department of Ophthalmology The John Hopkins University Sinai Hospital of Baltimore Baltimore, MD Sherwin J Isenberg, M.D Professor of Ophthalmology and Pediatrics Vice Chairman Department of Ophthalmology Jules Stein Eye Institute University of California Los Angeles, CA Jemshed A Khan, M.D Clinical Professor Department of Ophthalmology Kansas University School of Medicine Kansas City, KS Don O Kikkawa, M.D Associate Professor Department of Ophthalmology UCSD School of Medicine La Jolla, CA vii FM 3/22/01 2:47 PM Page viii viii • CONTRIBUTORS Kimberly A Klippenstein, M.D Assistant Clinical Professor of Ophthalmology Vanderbilt Medical Center Nashville, TN Jan W Kronish, M.D Clinical Associate Professor Department of Ophthalmology Bascom Palmer Eye Institute University of Miami School of Medicine Delray Eye Associates Delray Beach, FL Joseph A Mauriello, Jr., M.D Clinical Associate Professor Department of Ophthalmology University of Medicine and Dentistry—New Jersey Medical School Summit, NJ John McCann, M.D., Ph.D Assistant Professor Department of Ophthalmology Jules Stein Eye Institute University of California Los Angeles, CA Clinton D McCord, M.S., M.D Paces Plastic Surgery Atlanta, GA Ann G Neff, M.D Assistant Professor Department of Ophthalmology University of Miami Bascom Palmer Eye Institute Miami, FL Jeffrey A Nerad, M.D Professor Department of Ophthalmology University of Iowa Iowa City, IA William R Nunery, M.D Clinical Associate Professor Department of Ophthalmology Indiana University, Midwest Eye Institute Indianapolis, IN J Justin Older, M.D Clinical Professor Department of Ophthalmology University of South Florida College of Medicine Tampa, FL Dipak N Parmar, B.Sc(Hons.), M.B.B.S., F.R.C.Ophth Specialist Registrar in Ophthalmology Adnexal Department Moorfields Eye Hospital London, UK Julian D Perry, M.D Department of Ophthalmic Plastic and Orbital Surgery Cole Eye Institute Cleveland Clinic Cleveland, OH George Raque, M.D Associate Professor and Vice Chair Department of Neurosurgery University of Louisville Louisville, KY Dale M Roberts, M.D Clinical Associate Professor Department of Plastic Surgery University of Louisville Louisville, KY Geoffrey E Rose, M.D., M.R.C.P., F.R.C.Ophth Consultant Ophthalmic Surgeon Orbital and Adnexal Department Moorfields Eye Hospital London, UK Stanley Saulny, M.D Resident Physician Department of Ophthalmology Jules Stein Eye Institute University of California Los Angeles, CA Stuart R Seiff, M.D., F.A.C.S Professor of Ophthalmology Director of Ophthalmic Plastic and Reconstructive Surgery University of California San Francisco, and Chief, Department of Ophthalmology San Francisco General Hospital San Francisco, CA John Shore, M.D Texas Oculoplastic Consultants Austin, TX Norman Shorr, M.D., F.A.C.S Clinical Professor of Ophthalmology, Director, Fellowship in Orbital Facial Plastic Surgery Jules Stein Eye Institute University of California at Los Angeles Los Angeles, CA FM 3/22/01 2:47 PM Page ix CONTRIBUTORS • ix George O Stasior, M.D., F.A.C.S Clinical Professor Department of Ophthalmology Albany Medical College Albany, NY Sunil N Vasani, M.D Clinical Instructor Department of Ophthalmology UCSD School of Medicine La Jolla, CA David T Tse, M.D Professor Department of Ophthalmology University of Miami Bascom Palmer Eye Institute Miami, FL Ralph E Wesley, M.D Clinical Professor of Ophthalmology Vanderbilt University Medical College Nashville, TN, and Clinical Professor of Ophthalmology University of Tennessee Health Sciences Center Memphis, TN CHEN30-475-489.I 3/22/01 2:43 PM Page 486 486 • OCULOPLASTIC SURGERY: THE ESSENTIALS A B FIGURE 30–19 (A) CT scan demonstrating pellet in right lateral rectus muscle (B) Surgical removal of pellet P EARL However, if the orbital foreign body is affecting function, such as within an extraocular muscle, or causing compression, consideration should be given to removal (Fig 30–19) TRAUMATIC OPTIC NEUROPATHY Traumatic optic neuropathy can be caused by a direct or indirect injury to the optic nerve Direct injuries typically arise from devastating penetrating orbital trauma as described above Unfortunately, little can be done for a transected optic nerve Indirect injury to the optic nerve typically occurs in the setting of blunt frontal trauma An afferent pupil defect will be present with or without significant vision loss EARL Fractures of the optic canal P or adjacent bones are not necessary to make the diagnosis, but may be present Studies show that the energy resulting from a frontal blow is focused at the orbital apex where it is absorbed by the optic nerve tissue.42 The exact mechanism of injury to the nerve in any given case may be unclear However, compression (via edema or bone fragments) and ischemia may play a role Instances of “contusion necrosis,” or crushed nerve, have been documented.43 Many such cases will not regain vision regardless of treatment Others may have damage either limited (ischemia) or reversed (compression) with therapy The literature suggest that between 25 and 35% have some spontaneous improvement in vision.44–46 Data from previous uncontrolled studies suggest that high-dose corticosteroids46, 47 or surgical decompression of the optic canal may improve the outcome in selected cases.48–51 Recently, the International Optic Nerve Trauma Study looked at the outcomes in 133 patients with indirect traumatic optic neuropathy Visual acuity increased by three or more lines in 57% of the untreated patients, 52% of those treated with steroids, and 32% of patients receiving optic canal decompression Patients with no light perception also regained vision in many cases The number of patients studied was sufficient to rule out major effects in the treatment groups; thus, no treatment has emerged as a reasonable option for all patients with this condition EARL It is reasonable to decide P to treat, or not treat, traumatic optic neuropathy on an individual patient basis.52 Currently, intravenous methylprednisolone is a recommended therapy, similar to that used in the treatment of acute spinal cord injuries.53 A loading dose of 30 mg͞kg is administered as soon after the injury as possible Then, 5.4 mg͞kg is given each hour over the next 24 hours If there is no visual improvement at that point, the methylprednisolone is stopped If there has been improvement, the steroids are continued for another 24 hours (48 hours total) and then stopped (Fig 30–20) Surgical decompression of the optic canal is recommended by some, although this and the preferred CHEN30-475-489.I 3/22/01 2:43 PM Page 487 MANAGEMENT OF ORBITAL INJURIES • 487 Blunt frontal trauma Vision loss c/w optic nerve injury CT imaging No treatment Megadose methylprednisolone Load 30 mg/kg IV 5.4 mg/kg IV q h x 24 h Follow natural history If no improvement in 24 h If improvement in 24 h Stop corticosteroids Continue corticosteroids to 48 h No additional treatment Consider surgical decompression (if improvement not adequate) from to days post injury* Consider risk benefit ratio Decompress optic canal for edema Decompress anterior canal for compression Transorbital, trans-sinus approach No additional treatment (if improvement adequate) Decompress intracranial compression Transcranial approach * In unusual circumstances of obvious compression of the optic nerve and failing vision, urgent decompression may be appropriate under corticosteroid coverage FIGURE 30–20 Clinical pathway for the management of indirect traumatic optic neuropathy surgical approach remain controversial In cases of intracranial bone fragment compression, a transcranial approach is likely to be most effective In cases where an intraorbital or intracanalicular bone fragment is noted, an anterior approach through the orbit, ethmoids, and sphenoid sinuses is preferred Similarly, when no fragment is seen, but the goal of the procedure is to relieve possible compression within the canal, an anterior approach is suggested by most authors.48, 54, 55 Earlier studies had indicated that a delay in vision loss after the injury may be a good prognostic sign, suggesting that intervention may be more successful in such cases.43 This has not been found to be true in more recent series46, 52 CONCLUSION The management of orbital injuries continues to pose challenges to ophthalmologists as well as orbital surgeons A meticulous understanding of orbital anatomy and its variations, up-to-date knowledge of pathophysiologic mechanisms of injury to soft tissues, bone, and nerves, and a competent surgical skill level need to be combined in the evaluation and treatment of these patients with head and orbital trauma CHEN30-475-489.I 3/22/01 2:43 PM Page 488 488 • OCULOPLASTIC SURGERY: THE ESSENTIALS REFERENCES 10 11 12 13 14 15 16 17 18 Zizmor J, Lombardi G: Atlas of Orbital Radiography Birmingham, AL: Aesculapius, 1973 Guyon JJ, Brant-Zawadzki M, Seiff SR: CT demonstration of optic canal fractures AJR 1984;143:1031–1034 Seiff SR, Berger M, Guyon J, Pitts L: CT evaluation of the optic canal in sudden traumatic blindness Am J Ophthalmol 1984;98:751–755 Kennerdell JS, Cjockerham KP: Conventional radiology of the orbit and computed tomography of the orbit In: Nesi FA, Lisman RD, Levine MR, eds Smith’s Ophthalmic Plastic and Reconstructive Surgery, 2nd ed St Louis: CV Mosby, 1998:727–806 Green BF, Kraft SP, Carter KD, et al: Intraorbital wood Detection by magnetic resonance imaging Ophthalmology 1990;97:608-611 Wilson WB, Dreisbach JN, Lattin DE, et al: Magnetic resonance imaging of nonmetallic orbital foreign bodies Am J Ophthalmol 1988;105:612-617 Le Fort R: Etude experimentale sur les fractures de la machoire superieure Rev Chir 1901;23:208,360,479 Cole HP III, Couvillion JT, Fink AJ, Haik BG, Kastl PR Exophthalmometry: a comparative study of the Naugle and Hertel instruments Ophthalmic Plast Reconstr Surg 1997;13:189–194 Manson PN: Facial injuries In: McCarthy JG, ed: Plastic Surgery Philadelphia: WB Saunders, 1990: 867–1141 Freeman LN, Seiff SR, Aguilar GL, et al: Self-compression plates for orbital rim fractures Ophthalmic Plast Reconstr Surg 1991;7:198–207 McLachlan DL, Flanagan JC, Shannon GM: Complications of orbital roof fractures Ophthalmology 1982;89: 1274–1278 Burm JS, Chung CH, Oh SJ: Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture Plast Reconstr Surg 1999;103: 1839–1849 Hunts JH, Patrinely JR, Holds JB, Anderson RL: Orbital emphysema: staging and acute management Ophthalmology 1994;101:960–966 Dobler AA, Nathenson AL, Cameron JD, et al: A case of orbital emphysema as an ocular emergency Retina 1993;13:166–168 Jordan DR, White GL Jr, Anderson RL, et al Orbital emphysema: a potentially blinding complication following orbital fractures Ann Emerg Med 1988;17: 853–855 Linberg JV: Orbital emphysema complicated by acute central retinal artery occlusion: case report and treatment Ann Ophthalmol 1982;14:747–749 Carter KD, Nerad JA: Fluctuating visual loss secondary to orbital emphysema Am J Ophthalmol 1987;104: 664–665 Greene D; Murr AH: Factitious orbital emphysema: an unusual presentation of Munchausen’s syndrome Otolaryngol Head Neck Surg 1998;119:512–514 19 Rosenberg PN, Krohel GB, Webb RM, Hepler RS: Ocular Muchausen’s syndrome Ophthalmology 1986;93: 1120–1123 20 Koornneef L: Current concepts on the management of blow out fractures Ann Plast Surg 1982;9:185 21 Linberg JV: Orbital compartment syndromes following trauma Adv Ophthalmic Plast Reconstr Surg 1987;6: 51–62 22 Lisman RD, Smith BC, Rodgers R: Volkmann’s ischemic contractures and blowout fractures Adv Ophthalmic Plast Reconstr Surg 1987;7:117–131 23 Smith B, Regan WF Jr: Blowout fracture of the orbit: mechanism and correction of internal orbital fracture Am J Ophthalmol 1957;44:733–739 24 Fujino T: Experimental “blowout” fracture of the orbit Plast Reconstr Surg 1974;54:81 25 Fujino T: Mechanism of orbital blowout fracture Jpn J Plast Surg 1974;17:427 26 Fujino T, Makino K: Entrapment mechanisms and ocular injury in orbtial blow out fracture Plast Reconstr Surg 1980;65:571 27 Hawes MJ, Dortzbach RK: Surgery on orbital floor fractures: influence of time of repair and fracture size Ophthalmology 1983;90:1066–1070 28 Gilbard SM: Management of orbital blowout fractures: the prognostic significance of computed tomography Adv Ophthalmic Plast Reconstr Surg 1987;6:269–280 29 Gilbard SM, Mafee MF, Lagouros PA, et al: Orbital blowout fractures The prognostic significance of computed tomography Ophthalmology 1985;92:1523–1528 30 Goldberg RA, Lessner AM, Shorr N, et al: The transconjunctival approach to the orbital floor and orbital fat A prospective study Ophthalmic Plast Reconstr Surg 1990;6:241–246 31 Seiff SR: Cyanoacrylate fixed silicone sheet in medial blowout fracture repair Ophthalmic Surg 1989;20: 674–676 32 Cole HG, Smith B: Eye muscle imbalance complicating orbital floor fractures Am J Ophthalmol 1963;55:930–935 33 Harley RD: Surgical management of persistent diplopia in blowout fractures of the orbit Ann Ophthalmol 1975; 7:1621–1626 34 Seiff SR, Good WV: Hypertropia and the posterior blow out fracture: mechanism and managment Ophthalmology 1996;103:152–156 35 Stranc, MF: The pattern of lacrimal injuries in nasoethmoid fractures Br J Plast Surg 1970;23:339 36 Harris GJ, Fuerste, FH: Lacrimal intubation in the primary repair of midfacial fractures Ophthalmology 1987; 94:242 37 Seiff SR: Trauma and the optic nerve Ophthalmol Clin North Am 1992;5:389–394 38 Dalley RW, Robertson WD, Rootman J: Globe tenting: a sign of increased orbital tension Am J Neuroradiol 1989; 10:181–186 CHEN30-475-489.I 3/22/01 2:43 PM Page 489 MANAGEMENT OF ORBITAL INJURIES • 489 39 Dolman PJ, Glazer LC, Harris GJ: Mechanisms of visual loss in severe proptosis Ophthalmic Plastic Reconstr Surg 1991;7:256–260 40 Seiff SR: Ocular and orbital trauma In: Trunkey D, Lewis F, eds: Current Therapy of Trauma, 3rd ed Philadelphia: BC Decker 1991:195–203 41 Kersten RC, Rice CD: Subperiosteal orbital hematoma: visual recovery following delayed drainage Ophthalmic Surg 1987;18:423–427 42 Anderson RL, Panje WR, Gross CE: Optic nerve blindess following blunt forehead trauma Ophthalmology 1982;89:445–455 43 Walsh FB: Pathological-clinical correlations: I Indirect trauma to the optic nerves and chiasm II Certain cerebral involvements associated with defective blood supply Invest Ophthalmol 1966;5:433–449 44 Edmund J, Godtfredsen E: Unilateral optic atrophy following head injury Acta Ophthalmol 1963;41:693–697 45 Hooper RS: Orbital complications of head injury Br J Surg 1951;39:126–138 46 Seiff SR: High dose corticosteroids for treatment of vision loss due to indirect injury to the optic nerve Ophthalmic Surg 1990;21:389–395 47 Spoor TC, Hartel WC, Lensink DB, et al: Treatment of traumatic optic neuropathy with corticosteroids Am J Ophthalmol 1990;110:665–669 48 Call NB: Decompression of the optic nerve in the optic canal Ophthalmic Plast Reconstr Surg 1986;2:133–137 49 Fukado Y: Results in 400 cases of surgical decompression of the optic nerve Proceedings of the Second International Symposium on Orbital Disorders Mod Probl Ophthalmol 1975;14:475–481 50 Joseph MP, Lessell S, Rizzo J, et al: Extracranial optic nerve decompression for traumatic optic neuropathy Arch Ophthalmol 1990;108:1091–1093 51 Niho S, Niho M, Niho K: Decompression of the optic canal by transethmoidal route and decompression of the superior orbital fissure Can J Ophthalmol 1970; 5:22–40 52 Levin LA, Beck RW, Joseph MP, et al: The treatment of traumatic optic neuropathy: the international optic nerve trauma study Ophthalmology 1999;106:1268–1277 53 Braken MB, Shepard MJ, Collins WF, et al: A randomized controlled trial of methylprednisolone or naloxone in the treatment of acute spinal cord injury N Engl J Med 1990;332:1405–1411 54 Seiff SR: Extracranial optic nerve decompression for traumatic optic neuropathy Arch Opthhalmol 1991; 109:610 55 Seiff SR, Carter SR: Optic canal decompression In: Albert DM, ed Ophthalmic Surgery: Principles and Techniques Malden, MA: Blackwell, 1999;1529–1536 Index 3/26/01 10:18 AM Page 490 Index Page numbers followed by f and t represent figures and tables respectively Abducens nerve, in orbital anatomy, 13 Absorbable sutures, 27t Accessory lacrimal glands, 16 Accutane (isotretinoin), laser skin resurfacing and, 184 Acne, after laser skin resurfacing, 191 Acquired immunodeficiency syndrome, Kaposi sarcoma of eyelid in, 239, 239f Acquired myopathies, ptosis in patients with, 91 Acrochordon, periocular, 227 Actinic damage, evaluation of, 198–199 Actinic keratoses, periocular, 233–234, 234f Adenomas, periocular pleomorphic, 231 sebaceous, 231 Adnexal tumors, periocular, 230–231, 230f–231f Aesthetics, thyroid ophthalmopathy and See Orbital decompression AIDS patients, Kaposi sarcoma of eyelid in, 239, 239f Alloplastic implants, in orbital rim reconstruction, 38, 39f, 438–440, 439f–440f Alveolar soft-part sarcoma, pediatric, 408 Anesthesia, 23–24 for enucleation, 331 for evisceration, 347–348 for laser skin resurfacing, 187 Animation, muscles of, 126, 127f, 128, 128f See also Facial reanimation Anlage tumor, retinal pediatric, 407–408 Anophthalmic socket clinical pathway for evaluation and treatment of, 384f congenital, 382–383 implants in See Ocular implants, for anophthalmic socket orbital volume and See Orbital volume, inadequate ptosis in patients with, 91 surgical goals in, 369 490 Anterior orbital compartment surgery, 457–458, 457f–458f Antibiotics, topical, laser skin resurfacing and, 184 Antivirals, laser skin resurfacing and, 201 oral forms, 185 topical preparations, 184 Apex, orbital, 9–10, 10f surgery involving, 462–465, 462f–465f Apraxia of eyelid opening, 116 Artificial tears, in facial nerve paralysis management, 106 Asepsis, 24 Asian blepharoplasty complications of, 221–223, 222f, 223f debulking of eyelid tissues in, 218–220, 218f, 219f defined, 214 described, 214–215 in elderly patients, 220, 220f, 221f suboptimal results from, 221–223, 222f, 223f technique of, 215–218, 215f–218f Asian patients blepharoplasty procedure in See Asian blepharoplasty upper eyelid anatomy in, 211, 212f, 213–214, 213f–214f Autogenous fascia lata suspension, for ptosis, 83, 83f Autogenous materials for grafts, 34 use in enucleation technique, 336, 337 Autologous fascia, for ptosis, 38 Axial proptosis, in orbital disease evaluation, 387 Azithromycin (Zithromax), laser skin resurfacing and, 184–185 Balloon dacryocystoplasty, 272–274 for nasolacrimal stenosis, 275–276 Basal cell carcinoma, periocular, 235–236, 235f–236f Beam focus, in laser blepharoplasty, 166 Bell’s palsy, facial reanimation surgery in, 110, 110f–111f Benign essential blepharospasm See Essential blepharospasm Benign Essential Blepharospasm Research Foundation (BEBRF), 119 Bicoronal incision, in orbital lesion surgery, 454–455, 454f, 455f Bio-eye system, 339 Biomaterials, in oculoplastic surgery, 38–39, 39f Bleaching agents, laser skin resurfacing and, 185 Bleeding, after laser blepharoplasty, 174 Blepharophimosis, in children ptosis in, 91 treatment of, 98–99, 98f, 99f Blepharoplasty in Asian patients See Asian blepharoplasty ectropion after, 63–64, 63f laser See Laser blepharoplasty laser facial resurfacing after, 200, 200f lower eyelid See Lower eyelid blepharoplasty upper eyelid See Upper eyelid blepharoplasty Westernizing, 213 Blepharospasm, benign essential See Essential blepharospasm Blepharospasm-oromandibular dystonia, 113, 116 Blink activity, control center for, 118 Blowout fractures, orbital, 480–482, 481f–482f Blue nevus, periocular, 229 Bone orbital, 387 surgical repair of, 435–442 See also Orbital lesion surgery, osseous exposure in tumors of, 401–402, 402f Bone grafting, 38 in orbital rim reconstruction, 439–440 Index 3/22/01 2:46 PM Page 491 INDEX • 491 BoneSource cement, in orbital rim reconstruction, 437 Bone substitutes, in orbital rim reconstruction, 436–438 Bony orbit expansion, for congenital ophthalmia, 382–383 Botulinum toxin (Botox) for essential blepharospasm, 120–121, 121f versus surgical management, 121–122, 122f prior to laser facial resurfacing, 200–201, 201f Brow See Eyebrow Brown-Beard split-level grafting, in upper eyelid reconstruction, 255–256, 255f Browplasty, 141–143, 142f–144f Browpexy, internal, 125, 129–130, 129f–130f Brueghel’s syndrome, 113f, 116 Calcification epitheliomas of Malherbe and, 230–231, 231f localized dystrophic periocular, 233 orbital and intraocular, 389–390 Caldwell-Luc maxillary antrostomy, for thyroid ophthalmopathy, 321, 321f Canalicular obstruction, 280–282, 281f–282f Canaliculitis, 285 Canaliculodacryocystorhinostomy, 280–281, 281f Candida infections, after laser skin resurfacing, 191 Canthal ligaments, Canthofornix incision, in orbital surgery, 456–457, 456f Canthoplasty, for facial nerve paralysis lateral, 106–107, 107f medial, 107 Canthus lateral See Lateral canthal entries medial See Medial canthal entries Carbon dioxide (CO2) laser, for facial resurfacing, 195–196 Carcinoma, periocular basal cell, 235–236, 235f–236f eyelid reconstruction and See Fullthickness eyelid reconstruction Kaposi sarcoma, 239, 239f malignant melanoma, 236–238, 237f Merkel cell, 238–239, 239f sebaceous, 238, 238f small cell, 238–239, 239f squamous cell, 236, 237f Carotid arteries, Cartilage grafts, 37–38 in enucleation technique, 337 Cast placement, in correction of lower eyelid retraction, 162, 162f–163f Cataract, blepharospasm and, 117 Cellulitis, after laser skin resurfacing, 191 Central orbital compartment surgery, 458–462, 459f–462f Cerebrospinal fluid leaks, Chalazion, periocular, 232, 233f Cheek defect, and eyelid reconstructive technique, 258, 259f Cheek elevation, in correction of lower eyelid retraction, 159–160, 160f Chemomyectomy, for essential blepharospasm, 123–124 Children alveolar soft-part sarcoma in, 408 blepharophimosis in, 91, 98–99, 98f, 99f ectopic brain in, 404 encephalocele in, 404, 404f intravascular papillary endothelial hyperplasia in, 404 optic nerve glioma in, 391 orbital disease in, 387 extraconal, 401–402, 402f orbital tumors in, 403–407, 403f–407f ptosis in, surgical options for, 90–91, 91f retinal anlage tumor in, 407–408 with retinoblastoma, modified enucleation technique for, 338 tumor imaging in, 405–406, 406f–407f Cicatricial ectropion, 62–63, 63f Cicatricial entropion, 43 surgical management of, 48–51, 49f–51f Ciliary muscle, parasympathetic nerve supply to, 14 Ciprofloxacin (Cipro), laser skin resurfacing and, 184 Classic incision, in lateral orbitotomy, 433–434 Composite graft, in upper eyelid reconstruction, 252, 254–255, 254f Computed tomography See Imaging studies Computer pattern sequence, in laser facial resurfacing, 203–204, 204f Congenital anophthalmia, 382–383 Congenital ectropion, 64 Congenital entropion, 42 Congenital orbital anomalies, 407–408 microphthalmia, treatment of, 469–471, 470f Conjunctival cysts, in anophthalmic socket, 381 Conjunctival dacryocystorhinostomy, 281–282, 281f–283f Conjunctival fornix in anophthalmic socket, 377–380 in enucleation, 334–335, 334f–335f resection, 360–361, 361f transcaruncular or medial incision in anterior orbitotomy, 426–427 in combined lateral/medial orbitotomy, 447 Conjunctival incision, in anterior orbitotomy, 423–426, 425f Conjunctival lacerations, repair techniques, 282–285, 284f Conjunctival prolapse, as ptosis surgery complication, 100 Conjunctivitis, giant papillary, in anophthalmic socket, 381 Conjunctivorhinostomy, 281f, 286 Contraction, in wound healing process, 23, 23f Cornea in evisceration excision See Corneal excision sparing procedures, 348–350, 348f–351f laser injury to, 173–174, 174f Corneal abrasions, as ptosis surgery complication, 100 Corneal excision, in evisceration procedure posterior equatorial sclerotomy, 351–352 posterior implant placement and, 352 relaxing scleral cuts, 350–351, 352f Corrugator muscle in eyebrow anatomy, 128, 128f resection, in endoscopic assisted eyebrow forehead lift, 131–133, 134f Cosmetic zones, in laser skin resurfacing, 188, 188f Cranial nerves in facial nerve paralysis, 103–104, 104f in orbital anatomy, 13 Cranioplastic implant, for orbital rim reconstruction, 438–439, 439f–440f Creutzfeldt-Jakob disease, blepharospasm in, 115 Cryotherapy for distichiasis, 73 for trichiasis, 70 Cutler-Beard bridge flap, in upper eyelid reconstruction, 252, 253f Cysts conjunctival, in anophthalmic socket, 381 periocular, 231–232 Dacryocystectomy, 285–286 Dacryocystitis, 285 Dacryocystography, digitally subtracted, 268, 269f Dacryocystoplasty, balloon See Balloon dacryocystoplasty Dacryocystorhinostomy canalicular, 280–281, 281f conjunctival, 281–282, 281f–283f for nasolacrimal duct obstruction complete, 276–280, 276f–278f, 280f congenital, 274 Dacryoscintigraphy, 268, 268f Debris, from laser skin resurfacing, 181, 181f, 182, 202 Debulking, of upper eyelid in Asian blepharoplasty, 218–220, 218f, 219f in upper lid blepharoplasty, 140–141, 140f–141f Deep temporal fascia, in eyebrow anatomy, 126, 127f, 128f De Gaper (painting by Brueghel), 113f Dehiscence of levator palpebrae superioris, 4, 4f of lower eyelid retractors, 60–62 Dependent drainage, in deep orbital surgery, 445 Derma K dual mode laser, for facial resurfacing, 196–197, 208f Dermatochalasis, 41 in elderly Asian blepharoplasty candidates, 220, 220f Dermis, laser skin resurfacing and, 179, 180f Dermis-fat grafts, 38 autogenous, use in enucleation technique, 336 for extruded implant in anophthalmic socket, 377 for reconstruction after exenteration, 365 Dermoid cysts pediatric orbital, 403–404, 403f periocular, 231–232 Digitally subtracted dacryocystography, 268, 269f Diplopia following orbital decompression, 324–325 Index 3/22/01 2:46 PM Page 492 492 • INDEX Diplopia (continued) thyroid-related strabismus and, 297 torsional, before and after strabismus surgery, 303 Direct closure for eyelid defect repair, 244–245, 245f for lateral canthal repair, 257, 258f Direct eyebrow lift, 125, 135–137, 137f Direct incision, in anterior orbitotomy, 421, 421f Dissection, in deep orbital surgery, 442–443 Distichiasis, 41, 68, 68f treatment of, 71–73 Distraction test, in lower eyelid evaluation, 150 Divided nevus, of eyelid, 229, 229f Double convexity deformity, lower eyelid, 149, 149f Double vision, thyroid-related strabismus and, 297 Downgaze, exotropia in, 303 Drainage, in deep orbital surgery, 444–445 Drugs, blepharospasm associated with, 117 Dye disappearance test, 266 Dysthyroid compressive optic neuropathy, 305–312 clinical pathway for, 312f Dystonia, 113, 116 Ear cartilage, autogenous, use in enucleation technique, 337 Ectopic brain, in children, 404 Ectropion after entropion repair, 52, 52f after laser skin resurfacing, 189, 189f, 193 after lower eyelid blepharoplasty, 156 laser technique for, 175 cicatricial, 62–63, 63f congenital, 64 disinsertion of lower eyelid retractors causing, 60–62 horizontal eyelid laxity causing, 55–58 management of, 65f medial canthal tendon laxity causing, 58–59, 58f–59f paralytic, 64 postblepharoplasty, 63–64, 63f punctal, 16 treatment of, 274, 275f punctal eversion with, 59–60, 59f–60f Elderly patients, Asian blepharoplasty in, 220, 220f, 221f Electrolysis, for trichiasis, 70 Electromyography, in blepharospasm differential diagnosis, 116 Embarc, for orbital rim reconstruction, 437 Emphysema, orbital, 480, 481f Encephalitis, 116 Encephalocele, in children, 404, 404f Endoscopic procedures eyebrow forehead lift, 125, 130–133, 131f–135f, 135 laser-assisted dacryocystorhinostomy, 279–280, 280f Enophthalmos, 389 Entropion after lower eyelid blepharoplasty, 156 cicatricial See Cicatricial entropion classification of, 42–43 clinical features of, 43 as complication of surgical repair, 51–52, 52f conditions mimicking, 41 congenital, 42 evaluation of, 43–44 eyelid anatomy and, 41, 42t involutional See Involutional entropion marginal, 68–69, 68f–69f medical management of, 44 pathophysiology of, 42–43, 43t recurrence of, 51–52, 52f spastic, 43 surgical management of, 44–51, 45f–49f, 51f clinical pathway for, 53f Enucleation anatomy of, 330–331 in children with retinoblastoma, modified technique for, 338 clinical pathway for, 343f with conjunctival fornix resection, 360–361, 361f contraindications for, 328–329 described, 327 implants and See Orbital implants indications for, 327–328 materials for, 329 with myoconjunctival attachments, 331–336, 332f–337f physiology of, 331 preoperative preparation for, 329–331, 329f–330f principles of, 331 with socket ablation, indications for, 356t and sympathetic ophthalmia risk, 328 techniques of, 329 future directions, 341–342 modified, in pediatric retinoblastoma, 338 variations, 336–338 Epiblepharon, 41, 42, 67, 68f treatment of, 71–73, 72f–73f Epicanthal folds, 41 Epidermal inclusion cyst, periocular, 231, 232f Epidermis, in laser skin resurfacing, 179, 180f desiccated debris from, 181, 181f Epilation, for trichiasis, 70 Epileptic seizures, blepharospasm associated with, 117 Epiphora See Tearing Epithelial breakdown, as exenteration complication, 364, 364f Epithelial tumors, periocular, 227–228, 227f Erbium:YAG laser, for facial resurfacing, 196 Erythema, after laser skin resurfacing, 192–193, 192f, 197, 197f, 206 Essential blepharospasm, 114 defined, 113, 115 differential diagnosis of, 115–117, 115t etiology of, 117–119 evaluation of, 114–115 historical perspective on, 113–114, 113f patient control over, 119 treatment options for, 119, 119t circuit in, 118f, 119 conservative, 119f, 119t interventional, 119t, 122f medical, 119–121, 119f, 120t, 121f, 122f surgical, 121–124, 122f–124f Ethmoidectomy, 464 pitfalls in, 15 Ethmoid sinuses, anatomy of, 15, 15f, 453 Eversion eyelid See Ectropion punctal, 59–60 Evisceration clinical pathway for, 353f contraindications for, 328–329 described, 347 hydroxyapatite implant at time of, 349–350, 351 indications for, 327–328, 347 postoperative care in, 352–353 preoperative preparations for, 347–348 surgical steps in, 348–349, 348f–349f and sympathetic ophthalmia risk, 328 Ewing’s sarcoma, metastatic, 408 Excretory system, lacrimal gland, 16–17, 17f Exenteration anatomy and, 357, 357f clinical pathway for, 361f complications of, 362–364, 363f–364f described, 355 and enucleation with conjunctival fornix resection, 360–361, 361f indications for, 355–356, 355f, 356t in orbital surgery, 468–469, 469f, 470f postoperative care in, 361–362, 362f–363f preoperative preparation for, 356–357 reconstructive techniques following, 365 rehabilitation following, 364 clinical pathway for, 366f subtotal, 359–360, 360f techniques of, 357–361, 358f–361f total, 357–359, 358f–359f wound coverage in, 360 Exophthalmos, treatment options for, 325f Exotropia in downgaze, after strabismus surgery, 303 Extended lateral canthotomy, in orbital lesion surgery, 455–456 Extended Lynch incision, in combined lateral/medial orbitotomy, 446–447 External tarso-aponeurectomy of McCord, 85–87, 86f, 87f Extraocular muscle enlargement, orbital disease with, 400–401, 400f–401f Extraocular muscles, 15 Eyeball, removal of See Enucleation Eye-bank sclera, 337–338 Eyebrow age-associated changes, 128, 129f procedures suitable for, 141–143, 142f–143f anatomy of, 1, 2, 4f, 125–126, 127f–128f, 128 in frontalis suspension for ptosis correction, 97 procedures involving, 129–137 See also individual procedures decision tree for, 145f in females, versus males, 143–144, 145f lateral brow, 141–143, 142f–144f used with upper eyelid blepharoplasty, 125, 141–143, 142f–143f and upper eyelid, 125 Eyebrow forehead lift, endoscopic assisted See under Endoscopic procedures Index 3/22/01 2:46 PM Page 493 INDEX • 493 Eyebrow ptosis decision tree for management of, 145f development of, 128, 129f in facial paralysis patient, surgical management of, 109, 109f Eyelash abnormalities See Trichiasis Eyelid crease in Asian population, 211, 213 postoperative problems, 222–223, 223f types of, 213–214, 214f in blepharoplasty complications of, 222–223, 223f techniques for creating, 215–218, 215f–217f dynamic versus static, 217 as ptosis surgery complication, 100 Eyelid crease incision in anterior orbitotomy, 421–422, 422f in lateral orbitotomy, 430–431 upper, in orbital surgery, 455 Eyelid defects, repair techniques advanced See also individually named techniques for lower eyelid, 247–251 for upper eyelid, 251–256 combination defects, 258, 259f, 260 direct closure, 244–245, 245f lateral cantholysis, 245–246, 246f lateral canthus and, 257–258, 258f–259f medial canthus and, 256–257, 257f Tenzel semicircular flap, 246–247, 246f Eyelid laxity horizontal See Horizontal eyelid laxity repair of in involutional entropion, 45 lower eyelid blepharoplasty with, 152–153, 153f risks associated with, 150 Eyelid margin destruction, 41 Eyelid margin orbitotomy, 427, 428f Eyelid opening, apraxia of, 116 Eyelid retraction correcting See under Reconstructive surgery, of eyelid for facial nerve paralysis lower, 107–108, 108f upper, 108–109, 108f–109f thyroid disease and See under Thyroid disease Eyelid(s) anatomy of, 2–4, 4f, 41 development of, 2, 3f everted See Ectropion and eyelash abnormalities See Trichiasis full-thickness reconstruction of See Full-thickness eyelid reconstruction inner double, 213–214, 214f inverted See Entropion in levator aponeurotic resection, 94, 95 lower See Lower eyelid outer double, 213–214, 214f protractors in, retractors in, 2, 4, 5f, 41, 42t, 43f disinsertion of, 60–61 reinsertion of, 61–62 removal pitfalls, sparing during exenteration, 359–360, 360f spasm of See Essential blepharospasm symmetrical supraplacement in orbital decompression, 321 taping of, in facial nerve paralysis management, 106 topography of, 2f tumors and lesions of See Periocular skin lesions upper See Upper eyelid Face reanimation, 110, 110f–111f surface anatomy of, 1–5 topography of, 1–2, 2f Facial expression, muscles of, 5, 5f Facial nerve, anatomy of, 103–104, 104f branches of, 5, 5f, 104f eyebrow anatomy and, 126, 127f misdirection of, 117 vulnerability of, 104 Facial nerve paralysis described, 103 etiology of, 104–105 evaluation of, 105–106 management of, 106–110, 107f–111f clinical pathway for, 111f presenting symptoms of, 105 Facial reanimation surgery, 110, 110f–111f Facial resurfacing history of, 195 lasers used in, 195–197 See also Laser skin resurfacing Fasanella-Servat procedure, 77, 78–80, 79f–80f Fascia orbital, 10–11, 11f temporal, in eyebrow anatomy, 126, 127f, 128f Fascia bulbi See Tenon’s capsule Fascia lata, autogenous for ptosis, 83, 83f, 97–98 use in enucleation technique, 336–337 Fascial sheaths, orbital, 11, 11f Fat eyebrow, caution with, orbital, 11–12, 12f retro-orbicularis oculi brow See Retroorbicularis oculi brow fat suborbicularis oculi See Suborbicularis oculi fat Fibroblastic phase, in wound healing, 22 Fibroconnective tissue septae, 11, 11f Fibroma, ossifying, 401–402, 402f Fibrous dysplasia, 401–402, 402f Fine-needle aspiration biopsy, orbital lesions, 394 Fistulas, as exenteration complication, 362–363, 363f Fitzpatrick’s skin type classification scheme, 185, 185t, 197 Flaps, for reconstructive surgery, types of, 32–34, 33f–35f See also specific forms of flaps Floor, orbital See Orbital floor Forced duction tests, in thyroid-related strabismus, 298, 298f Forehead trauma, optic neuropathy and, Foreign body, orbital, 486, 486f Fornix (fornices) in enucleation technique, 334–335, 334f–335f resection, 360–361, 361f shallow inferior conjunctival, in anophthalmic socket, 377–380 Free myocutaneous grafts, in upper eyelid reconstruction, 256 Frontalis muscle in eyebrow anatomy, 126, 127f suspension, for ptosis correction, 96–98, 97f with autogenous fascia lata, 83, 83f, 97–98 using silicone (silastic) rod, 84–85, 84f–85f, 96–97, 97f, 100 Frontal sinus anatomy of, 453 expansion of, 15 Frown lines, incisions within, 453, 454f Full-thickness eyelid reconstruction canthal defects lateral, 257–258, 258f–259f medial, 256–257, 257f clinical pathways for, 261f combination defects, 258, 259f, 260 factors in, 243–244 lower eyelid, 247–251 clinical pathway, 261f repair techniques in, 244–247 upper eyelid, 251–256 clinical pathway, 261f Full-thickness skin grafts, 36 in medial canthal reconstruction, 256–257 Functional blepharospasm, 117 Galea, in eyebrow anatomy, 126, 127f Ganglion block, superior cervical, for essential blepharospasm, 123, 124f Giant papillary conjunctivitis, in anophthalmic socket, 381 Gingival-buccal sulcus incision, in orbital surgery, 457 Glabellar flap, in medial canthal reconstruction, 257, 257f Glass orbital implant, 38, 39f Glioma See Optic nerve glioma Globe, 15 laser injury to, 173–174, 174f removal of See Enucleation structures supporting, 11 Globe tenting, 13, 13f Glomus tumor, periocular, 228 Gold weights, 38 Grafts/Grafting in anophthalmic socket for exposed implant, 375–376 for extruded implant, 377 for inferior conjunctival fornix reconstruction, 379–380, 379f cartilage, 37–38 for cicatricial ectropion repair, 63 dermis-fat See Dermis-fat grafts failure of, as exenteration complication, 363 full-thickness See Full-thickness skin grafts in medial canthal reconstruction, 256–257 mucous membrane See Mucous membrane grafts split-thickness See Split-thickness skin grafts types of, 34, 36–38 in upper eyelid reconstruction, 252, 254–256, 254f, 255f Granuloma, periocular pyogenic, 228 Index 3/22/01 2:46 PM Page 494 494 • INDEX Graves’ disease See Thyroid disease Graves’ orbitopathy, orbital decompression for See Orbital decompression Gray line, visibility of, 57 Habit spasm, 116 Hasner, valve of, 17, 17f Healing by secondary intention, medial canthal defect, 256 Hemangioma, periocular capillary, 228, 228f subcutaneous pediatric, 405, 405f cavernous, 228 Hematoma orbital, 484, 484f upper eyelid, after laser blepharoplasty, 174 Hemifacial spasm, 116 Hemorrhage intraorbital or subconjunctival, 388 orbital, 388 Hemostasis, 26 in deep orbital surgery, 443–444 in laser blepharoplasty, 166–167, 166f Herpetic infections, after laser skin resurfacing, 191, 207 Hertel exophthalmometer, 477 Hidrocystomas, periocular, 231 Hordeolum, periocular, 232 Horizontal eyelid laxity evaluation of, 55–56, 55f, 56f surgical techniques in treatment of, 56–58, 56f–57f Horizontal shortening, in correction of lower eyelid retraction, 160–161 Horizontal tarsal kink syndrome, 42 Hotz procedure, 50 Hughes tarsoconjunctival flap, in lower eyelid reconstruction, 247–249, 248f Huntington’s disease, blepharospasm in, 115 Hutchinson’s freckle, periocular See Lentigo maligna Hydrocortisone cream, laser skin resurfacing and, 185, 192 Hydroxyapatite orbital implant, 38, 39f at enucleation, 338–341 at evisceration, 349–350, 351 Hyfercation, for trichiasis, 70 Hyperpigmentation, after laser skin resurfacing, 191–192 Hypertrophic scarring, after laser blepharoplasty, 174–175, 175f Hypoglobus, following orbital decompression, 325 Hypopigmentation, after laser skin resurfacing, 193, 206, 207f Hysterical blepharospasm, 117 Imaging studies in dysthyroid compressive optic neuropathy, 306, 308f, 311f of lacrimal gland enlargement, 411f orbital, 485, 485f in orbital disease evaluation, 387–390, 388f–389f, 389, 390 diffuse tumors, 395f–396f with extraocular muscle enlargement, 401, 401f inflammatory processes, 396–398, 396f–398f lymphoid tumors, 398–400, 399f–400f optic nerve meningioma, 392–393, 392f of orbital injuries with foreign body, 486, 486f hematoma, 484f ocular “tenting,” 484f posterior blowout fracture, 483f in orbital tumor exposure, 467–468 of pediatric orbit, 405–406, 406f–407f in tearing patient, 268, 269f in thyroid ophthalmopathy evaluation, 315–317, 316f in thyroid-related strabismus, 298–299, 299 Impetiginization, after laser skin resurfacing, 191 Incident angle, in laser blepharoplasty, 166 Incisions, 24–25, 24f–25f See also individually named incisions for anterior orbitotomy, 421–429 depth of, in laser blepharoplasty, 166, 166f for orbital lesion surgery, 453–457 Induced ocular hypertension test, in thyroid-related strabismus, 298 Infection risk after laser blepharoplasty, 174 after laser skin resurfacing, 191 clinical pathway for, 191f epidermal debris and, 182, 202 prophylactic measures, 184–185 Inferior forniceal antroethmoidal decompression, 319–321, 319f, 320f Inferior fornix orbitotomy, 427–429, 428f, 429f Inferior ophthalmic vein, 13 Inferior rectus, in strabismus surgery, 299–302, 300f–302f postoperative complications of, 303 Inferior turbinate infracture, 271–272, 272f Inflammatory disease, orbital, 306f–398f, 396–398 Inflammatory lesions, periocular, 232–233 Inflammatory phase, in wound healing, 22 Infracture, inferior turbinate, 271–272, 272f Inner canthus See Medial canthal entries Inner double eyelid, 213–214, 214f Innervation following orbital decompression, 325 orbicularis oculi, Instruments, for oculoplastic surgery, 25–26 laser blepharoplasty, 166, 166f Internal browpexy, 125, 129–130, 129f–130f Intraconal tumors, 390–394, 391f, 392f Intraocular calcifications, 389 Intraorbital hemorrhage, 388 Intravascular papillary endothelial hyperplasia, pediatric, 404 Intubation bicanalicular, for conjunctival laceration repair, 282–284, 284f in dacryocystorhinostomy, 279 in nasolacrimal duct obstruction, 272, 273f in nasolacrimal stenosis, 275 Involutional entropion, 42–43, 43f pathophysiologic mechanisms in, 42t surgical management of, 44–45, 45f Irrigation in congenital nasolacrimal obstruction, 269, 271, 271f in nasolacrimal stenosis, 274–275 in tearing patient, 268 Island myocutaneous flap, in medial canthal reconstruction, 257 Isotretinoin (Accutane), laser skin resurfacing and, 184 Itching, after laser skin resurfacing, 192, 207 Jaw-winking ptosis, 90 Jones I/Jones II tests, 266–268 Kaposi sarcoma, periocular, 239, 239f “Kissing nevus,” 229, 229f Krause, accessory lacrimal glands of, 16 Lacerations, conjunctival, 282 Lacricath system, use in nasolacrimal duct obstruction, 272–274 Lacrimal glands, 16, 17f obstruction of, 483 Lacrimal gland tumor, 408–412 causes of, 408 differential diagnosis o, 410–411, 411f as exenteration complication, 363–364, 364f management of, 411–412, 411f–412f presentation of, 408–410, 409f–411f special considerations in, 410 Lacrimal irrigation test, 268 Lacrimal patency tests, 266–268 Lacrimal pump failure, management of, 274 physiology of, 264 Lacrimal sac, 17 lymphoid tumors of, 394 Lacrimal sac tumor, 412–415, 413f Lacrimal system anatomy of, 263–264, 263f, 264f evaluation of, 264–269 See also Tearing excretory, 16–17, 16f, 17f in eyelid reconstruction, 244 obstruction in See Nasolacrimal duct obstruction pump physiology in, 264 secretory, 15–16, 16f surgical treatments for, 274–286 See also specific procedures and conditions Lagophthalmos as ptosis surgery complication, 99 surgical procedure for, 64 Laser blepharoplasty clinical pathways for, 176f described, 165 hemostasis in, 166–167, 166f incision depth in, 166, 166f instrumentation for, 166, 166f lower eyelid (transconjunctival), 170–173, 170f–173f clinical pathway for, 176f complications of, 175 technical considerations in, 166 upper eyelid, 167–169, 167f–169f clinical pathway for, 176f complications of, 173–175, 174f–175f wound healing after, 167 Index 3/22/01 2:46 PM Page 495 INDEX • 495 Laser epilation, for trichiasis, 70 Laser skin resurfacing, 179–183, 179f–183f, 197 CO2 laser for, 195–196 complications of, 191–193, 191f–192f, 206–207, 207f Derma K dual mode laser for, 196–197 erbium:YAG laser for, 196 postoperative wound care in, 182–183, 182f–183f, 185, 185t, 189–191 long-term follow-up, 206 open versus closed, 205–206, 205f preparations and dressings for, 190–191, 190t principles of, 190t preoperative considerations in, 183–203, 184t, 185t, 186f techniques of, 187–189, 188f, 190f laser settings, 203–205 Laser-tissue interactions, in laser skin resurfacing, 179–181, 179f–, 181f Lateral canthal incision, extended, in lateral orbitotomy, 431–432 Lateral canthal reconstruction, 257–258, 258f–259f in correction of lower eyelid retraction, 161, 161f with lower lid involvement, 260 versus medial canthal reconstruction, 243, 244 with upper lid involvement, 260 Lateral cantholysis, for larger eyelid defects, 245–246, 246f Lateral canthoplasty, for facial nerve paralysis, 106–107, 107f Lateral canthotomy for correction of lower eyelid retraction, 158–159, 158f–159f extended, in orbital surgery, 455–456 “Laugh lines,” 1–2 Le Fort fractures, 475–477, 476f Lentigines, laser treatment of, 207, 208f Lentigo maligna, periocular, 234, 234f melanoma arising from, 237 Levator aponeurotic repair, for ptosis, 77, 80–81, 81f, 82f, 93–96, 94f–96f evaluation and timing for, 89–90 maximal advancement See Whitnall sling Levator function, surgical options for ptosis based on, 76–77, 89 Levator palpebrae superioris, 4, 4f medial dehiscence, 4, 4f Lids See Eyelid(s); Lower eyelid; Upper eyelid Lid-splitting procedure, for distichiasis, 71–73 Lockwood’s ligament, 11, 11f, 61, 148 Lower eyelid, age-related changes in, 148–149, 149f anatomy of, 147–150, 148f–149f defects of See Eyelid defects malposition after blepharoplasty See Scleral show subciliary incision in anterior orbitotomy, 422–423 Lower eyelid blepharoplasty complications of, 155–156 management, 156–162 See also Scleral show described, 147 postoperative care in, 155 preoperative evaluation of, 150–151, 150f with repair of eyelid laxity, 152–153, 153f transconjunctival, 153–155, 154f–155f laser use for, 170–173, 170f–173f, 175, 176f transcutaneous, 151–152, 151f–153f Lower eyelid posterior lamella graft, in involutional entropion repair, 50–51, 51f Lower eyelid retraction after strabismus surgery, 303 anatomy of, 156–157 for facial nerve paralysis, 107–108, 108f and postblepharoplasty ectropion, 63–64, 63f in thyroid disease, surgical management of, 294–295 Lower eyelid retractor repair, in entropion anterior approach to, 45–47, 46f, 47f posterior approach to, 47–48, 47f, 48f Lymphangioma, periocular, in children, 405, 405f, 406 Lymphatics, in facial anatomy, 6–7 Lymphoid tumors lacrimal sac, 394 orbital, 398–400, 399f–400f Lynch incision in anterior orbitotomy, 422, 424f extended, in combined lateral/medial orbitotomy, 446–447 “Madame Butterfly” procedure, 64 Magnetic resonance imaging See Imaging studies Malar folds, Malherbe, calcifying epitheliomas of, 230–231, 231f Malignant lesions, periocular, 234–239, 235t See also individual types Marginal entropion, 68–69, 68f–69f Marginal rotation technique, in involutional entropion repair, 48–50, 49f Margins, orbital, 7–8, 7f Margin-to-reflex distance, in ptosis assessment, 75–76, 76f Matrix metalloproteinases, in wound healing process, 23 Maturation phase, in wound healing, 22–23 Maxilla, Le Fort fractures of, 475–477, 476f Maxillary bone, 317 role in orbital decompression, 318 Maxillary nerve, 13, 14 Maxillary sinus, anatomy of, 14–15, 14f, 15f, 452–453 McCord, external tarso-aponeurectomy, 85–87, 86f, 87f Mechanical epilation, for trichiasis, 70 Medial canthal reconstruction, 256–257, 257f lateral canthal reconstruction versus, 243, 244 with lower lid involvement, 260 with upper lid involvement, 260 Medial canthal tendon laxity, 58–59, 58f–59f Medial canthoplasty, for facial nerve paralysis, 107 Medial spindle, in punctal eversion repair, 59–60, 60f, 274, 275f Median forehead flap, in upper eyelid reconstruction, 255 MEDPOR (Medpor) polyethylene implant, orbital, 339, 340f for rim reconstruction, 438–440, 439f–440f Meibomian glands carcinomas of, 238, 238f metaplasia of, 70 Meige’s syndrome, 113, 116 Melanoma, periocular, 236–238, 237f Melanosis, oculodermal, 230 Melanotic freckle, periocular See Lentigo maligna Melanotic neuroectodermal tumor of infancy, 407–408 Melasma, laser treatment of, 207 Meningioma cranio-orbital, resection of, 465–466, 465f optic nerve See Optic nerve meningioma Meningitis, as exenteration complication, 363 Meningocele, in children, 404, 404f Merkel cell carcinomas, periocular, 238–239, 239f Metaplasia, of Meibomian glands, 70 Metastasis(es) Ewing’s sarcoma, 408 neuroblastoma, 408 Methyl methacrylate, for reconstruction after exenteration, 365 Microphthalmia, congenital, treatment of, 469–471, 470f Midface anatomy of, 5, 5f fractures of, 483 Milia, after laser skin resurfacing, 191 Monocanalicular stent, for conjunctival laceration repair, 284–285 Motility-enhancing orbital implant See Hydroxyapatite orbital implant Mucous membrane grafts, 36–37, 36f–37f for inferior conjunctival fornix reconstruction in anophthalmic socket, 379–380, 379f Müller’s muscle, 4, 4f lacrimal system and, 15 in levator aponeurotic repair, 94, 94f, 95f Müller’s muscle conjunctival resection in facial paralysis management, 110 for ptosis, 77 evaluation and timing for, 89–90 technique, 77–78, 78f–79f Muscle(s) See also individually named muscles extraocular, 15 eyebrow, 126, 127f, 128, 128f eyelids, 4f, 5f, 13–4 midface, 5, 5f Müller’s See Müller’s muscle of Riolan, Mustarde cheek flap, in lower eyelid reconstruction, 249–251, 249f, 250f Myectomy, for essential blepharospasm, 122–123, 122f, 123f Myoconjunctival attachments, enucleation with, 331–336, 332f–337f Myocutaneous flaps in correction of lower eyelid retraction, 159–160, 160f Index 3/22/01 2:46 PM Page 496 496 • INDEX Myocutaneous flaps (continued) in medial canthal reconstruction, 257 for reconstruction after exenteration, 365 in upper eyelid reconstruction, 256 Myokymia, ocular, 116 Myopathies, acquired, ptosis in patients with, 91–92 Myotonic dystrophy, 117 Nasal cavity, anatomy of, 14–15, 14f Nasojugal folds, Nasolacrimal duct, Nasolacrimal duct obstruction complete, management of, 276–280, 276f–278f, 280f congenital form, evaluation and management of, 269, 271–274 Nasolacrimal stenosis, 274–276 Neck, laser treatment of, 204 Necrotizing fasciitis, after laser blepharoplasty, 207 Nerves in facial anatomy, 6–7 injury to, orbital, 13–14, 13f Neuroblastoma, metastatic, 408 Neurodegenerative diseases, blepharospasm in, 115 Neuroendocrine carcinoma, periocular, 238–239, 239f Neurofibromas, periocular, 232, 232f Neurofibromatosis optic gliomas associated with, 391 ptosis in pediatric patient with, 91, 91f Nevi, periocular, 228–230, 229f Nonabsorbable sutures, 27t Nonoptic nerve tumors, 390–391, 391f Norian, in orbital rim reconstruction, 437–438 Nose, nonosseous tumors originating in, 402 NovaBone-C/M, in orbital rim reconstruction, 438 Numbness facial, 105 following orbital decompression, 325 Obstruction canalicular, 280–282, 281f–282f nasolacrimal duct See Nasolacrimal duct obstruction Occupational safety requirements, for laser skin resurfacing, 186–187, 186f Ocular disease, blepharospasm associated with, 117 Ocular examination in facial nerve paralysis evaluation, 106 in ptotic patient, 75 Ocular implants, for anophthalmic socket exposure of, 375–376 with inadequate orbital volume, 370–375, 370t, 371f–374f secondary for implant extrusion management, 376–377, 378f for implant migration management, 372f, 375 inadequate orbital volume and, 374–375, 374f Ocular myokymia, 116 Ocular “tenting,” 484, 484f Oculodermal melanosis, 230 Oculomotor nerve, 6, 13 Ophthalmia, sympathetic, 328 Ophthalmic nerve, 13 Ophthalmoplegia, progressive external, blepharospasm in, 115 Optic foramen, 9–10, 10f Optic nerve, 13 during enucleation, 333–334, 334f Optic nerve glioma, 391–394, 392f, 393f Optic nerve meningioma, 391–392, 392f management of, 394 Optic nerve tumors, 391–394, 392f Optic neuropathy in Graves’ disease See Dysthyroid compressive optic neuropathy transient, after orbital lesion surgery, 468 traumatic, 486–487 clinical pathway for, 487f Orbicularis oculi, innervation of, Orbit apex of, 9–10, 10f bony anatomy of, 317–318, 317f, 318f congenital anomalies involving See Congenital orbital anomalies during enucleation, 333–334, 334f exenteration of, 468–469, 469f, 470f fascia of, 10–11, 11f fat around, 11–12, 12f foreign body in, 486, 486f lesions of, surgical management See Orbital lesion surgery margins of, 7–8, 7f medial strut of, 11 nerves of, 13–14, 13f periorbita, 10 secondary tumors of, 402–403, 403f shape and dimensions and, soft tissues of, 11–14 surgical osteology of See Orbital lesion surgery, osseous exposure in tumors of See Orbital tumors ultrasound of, 485, 485f Orbital calcifications, 389–390 Orbital compartment surgery anterior, 457–458, 457f–458f apical, 462–465, 462f–465f central, 458–462, 459f–462f Orbital decompression for dysthyroid compressive optic neuropathy, 309–310, 309f, 310f–312f, 312 for thyroid ophthalmopathy See Thyroid ophthalmopathy, orbital decompression for Orbital disease distribution of, 387 evaluation, 387 extraconal, 401–403, 402f–403f with extraocular muscle enlargement, 400–401, 400f–401f forms of, 388–390 inflammatory processes, 396–398, 396f–397f with osseous exposure See Orbital lesion surgery Orbital emphysema, 480, 481f Orbital fat removal, in orbital decompression, 320 Orbital fissure, 9, 10f Orbital floor, 8–9 dissection complications associated with, Orbital fractures, 475–483 blowout type, 480–482, 481f–482f Le Fort patterns, 475–477, 476f midface, 483 orbital roof, 479–480, 479f–480f posterior floor, 482–483, 483f repair complications, 483–484 zygomatic, 477–478, 477f–478f Orbital hematoma, 484, 484f Orbital hemorrhage, 388 Orbital implants, 328f coupling of, 339–341, 340f, 342 in enucleation, 334, 334f exposure of, prevention and management, 340–341 hydroxyapatite See Hydroxyapatite orbital implant motility and, 338–339, 342 pegging of, 339–341, 340f, 342 posterior placement after evisceration, 352 preoperative counseling about, 329–330, 329f–330f prion disease risk and, 330 secondary, 339–341, 340f titanium motility post with, 339–341, 340f types, 327, 327f wraps for, 341, 342f Orbital lobe, lacrimal gland, 16, 17f Orbital pain, 388–389 Orbital rim reconstruction, 435–440, 439f–441f augmentation, for thyroid ophthalmopathy, 323–324, 323f–324f Orbital roof, subperiosteal dissection and, traumatic optic neuropathy and, Orbital roof fractures, 479–480, 479f, 480f Orbital septum, 2–3 in Asian blepharoplasty, 216, 216f cauterization risks, 152 Orbital space, removal of contents from See Exenteration Orbital surgery, 434–446, 434f–437f, See also Orbitotomy clinical pathways for, 472f complications of, 468 imaging studies in, 467–468 incision selection for, 453–457 orbital exenteration and, 468–469, 469f, 470f osseous exposure in, 451–452, 452f osseous and soft tissue reconstruction in, 466–467, 467f techniques of, 457–466 anterior compartment, 457–458, 457f–458f apical compartment, 462–465, 462f–465f central compartment, 458–462, 459f–462f for cranio-orbital and sino-orbital lesions, 465 for soft tissue and tumor resection, 465–466, 466f Orbital trauma, 484–487, 484f, 485f, 487f considerations in, 475 fractures See Orbital fractures Orbital tumors, 387, 388f in children, 403–407, 403f–407f congenital, 407–408 Index 3/22/01 2:46 PM Page 497 INDEX • 497 diffuse, 394–396, 395f–396f intraconal See Intraconal tumors lymphoid, 398–400, 399f–400f removal of, 443 Orbital volume, inadequate, in anophthalmic socket with implant, 374–375 without implant, 370–373, 370f, 371f See also Ocular implants, for anophthalmic socket Orbital wall, 7f, 8, 8f lateral, 9, 9f medial, 8–9 reconstruction of, 440, 442 subperiosteal dissection and, Orbitomalar ligament, Orbitotomy anterior (without bone removal), 419 clinical pathway for, 448f incisions for, 421–429 principles of, 420–421 eyelid margin, 427, 428f inferior fornix, 427–429, 428f, 429f transconjunctival, inferior orbital fat in, 13, 13f vascular supply and, lateral (with bone removal), 9, 9f, 419 clinical pathway for, 448f incisions for, 429–434 variations on, 446–447 medial, 446–447 postoperative considerations, 447–448 preoperative considerations, 420 principles of, 419 safety considerations in, 419 swinging lower eyelid, 427–429, 428f, 429f Orofacial-cervical dystonia, 113, 116 Oropharynx, nonosseous tumors originating in, 402 Osseous exposure, orbital See Orbital lesion surgery, osseous exposure in Ossifying fibroma, 401–402, 402f Osteotomy, in orbital surgery, 434–435, 434f–437f Ota, nevus of, 230 Outer canthus See Lateral canthal entries Outer double eyelid, defined, 213–214, 214f Overcorrection as ptosis surgery complication, 100 in strabismus surgery, 302–303 O-Z plasty, 34, 35f Pain, orbital, 388–389 Palatine bone, orbital floor, 317 Palpebral fissures, Palpebral lobe, 16, 17f Papilloma, periocular squamous, 227 Parallel eyelid crease, 213–214, 214f Paralytic ectropion, 64 Paranasal sinus(es) anatomy of, 14–15, 15f nonosseous tumors originating in, 402 Parasympathetic nerve supply, to ciliary muscle, 14 Parkinson’s disease, blepharospasm in, 115 Patch grafting, for exposed implant in anophthalmic socket, 375–376 Patient expectations, from laser skin resurfacing, 198, 199 Penetrating orbital trauma, 484–485, 485f Pentagonal wedge resection, for trichiasis, 70–71, 71f Periocular skin lesions See also individually named lesions benign, 226–233, 226t–227t clinical versus pathologic diagnoses, 225t histopathology of, 225 malignant, 234–239, 235t preinvasive, 233–234, 233t, 234f Periocular tumors adnexal, 230–231, 230f–231f epithelial, 227–228, 227f malignant, 234–239, 235t vascular, 228, 228f Periorbita, 10, 11 Pharmacotherapy, for essential blepharospasm, 119–120, 120t Pigmented retinal choristoma, 407–408 Pilomatricomas, periocular, 230–231, 231f Polyglactin mesh, for orbital implants, 341, 342f Polyp, periocular fibroepithelial, 227 Porous polyethylene implant, orbital, 339, 340f for rim reconstruction, 438 Posterior equatorial sclerotomy, for corneal excision in evisceration procedure, 351–352 Posterior orbital floor fractures, 482–483, 483f Preaponeurotic fat pad, upper eyelid, 12, 12f in Asian blepharoplasty, 216 debulking of, 218–220, 218f, 219f Preseptal fat, in Asian patients, 213, 213f Pretarsal fat, in Asian patients, 213, 213f Pretarsal orbicularis excision, in Asian blepharoplasty, 217, 217f Prion disease, orbital implant and, 330 Probing in congenital nasolacrimal obstruction, 269, 271, 271f in nasolacrimal stenosis, 274–275 in tearing patient, 268 Procerus muscle in eyebrow anatomy, 128, 128f resection, in endoscopic assisted eyebrow forehead lift, 131–133, 134f Progressive external ophthalmoplegia, blepharospasm in, 115 Proptosis after strabismus surgery, 302 in orbital disease evaluation axial, 387 bilateral, 389 Ptosis bilateral, 77 congenital, surgical correction of, 90–91, 91f described, 75 evaluation of, 75–77 synkinetic (“jaw-winking”), 90 Ptosis surgery, 77–87 in anophthalmic socket, 380–381, 380f clinical pathways for, 87f, 101f complications of, 99–100 contraindications for, 89t evaluation and timing for, 89–92 in facial paralysis management, 109–110, 110f historical perspective on, 89 incision planning for, 92–93, 93f indications for, 89 levator function and, 76–77 postoperative care in, 99 preoperative preparation for, 92–93 risks associated with, 92t Punctal ectropion, 16 treatment of, 274, 275f Punctal stenosis, treatment of, 274 Pupillary dilation, cause of, 13 Pyogenic granuloma, periocular, 228 Radiography See Imaging studies Radiotherapy, for dysthyroid compressive optic neuropathy, 307–309, 307f–308f Reading difficulty, after strabismus surgery, 303 Reconstructive surgery, 32–39 after exenteration, 365 in anophthalmic socket, 378–380, 379f correcting lower lid retraction, 158–162, 158f–163f full-thickness defects See Full-thickness eyelid reconstruction Rectangular debulking, of eyelid tissue, 218–220, 218f, 219f Reflex blepharospasm, 115 Rehabilitation, after exenteration, 364 clinical pathway for, 366f Relaxed skin tension lines, incisions within, 453, 454f Relaxing scleral cuts, in evisceration procedure, 348–351, 348f–351f Retinal anlage tumor, pediatric, 407–408 Retinal choristoma, pigmented, 407–408 Retinoblastoma, pediatric, modified enucleation technique for, 338 Retraction technique, in deep orbital surgery, 442 Retractor repair, in entropion See Lower eyelid retractor repair, in entropion Retro-orbicularis oculi brow fat, 2, 141, 142f age-related changes in, 148, 149f excision of, 141–143, 142f–144f Rhinophyma, laser treatment of, 207, 208f Rhomboid-type flaps, for lateral canthal repair, 258, 259f Rhytids, laser skin resurfacing for, 187, 198–199, 199f Botox injection prior to, 200–201, 201f Riolan, muscle of, ROOF See Retro-orbicularis oculi brow fat Roof, orbital See Orbital roof Rosenmüller, valve of, 17, 17f Rotational flaps, for lateral canthal repair, 258, 258f–259f Round eye See Scleral show Safety issues, in laser skin resurfacing, 186–187, 186f Sarcoidosis, periocular, 233, 233f Sarcoma, pediatric, 408 Scar/Scarring after laser blepharoplasty, 174–175, 175f after laser skin resurfacing, 193 management of, 30–31 revision of, technique, 31–32, 31f–32f Sclera, eye-bank, 38, 337–338 Scleral cuts, relaxing, in evisceration procedure See Relaxing scleral cuts Index 3/22/01 2:46 PM Page 498 498 • INDEX Scleral show, management of evaluation and planning in, 157–158 lower eyelid retraction anatomy in, 156–157 McCord algorithm for, 163 SOOF anatomy in, 157 surgical correction in concept, 157–158 technique, 158–162, 158f–163f Sclerotomy, posterior equatorial, for corneal excision in evisceration procedure, 351–352 Sebaceous carcinoma, periocular, 238, 238f Sebaceous hyperplasia, periocular, 231 Seborrheic keratosis, periocular acanthotic, 227–228, 227f Secondary intention, healing by, medial canthal defect, 256 Secondary wound healing, 23, 23f Secretory system, lacrimal, 15–16, 16f, 17f Seizures, blepharospasm associated with, 117 Septum, orbital, in surgery, Shirmer’s testing, 266 Silicone (silastic) rod suspension, for ptosis, 84, 84f, 96–97, 97f complications from, 100 technique of, 84–85, 84f–85f Sinus(es) anatomy of, 452–453 involvement in orbital disease, 387 tumors of, 401–402, 402f Skin classification scheme, 185, 185t of eyelid, periocular, small cell carcinomas of, 238–239, 239f Skin flaps, types of, 32–34, 33f–35f See also specific forms of flaps Skin folds, around eye, 1–2 Skin resurfacing See Laser skin resurfacing Skin tag, periocular, 227 Skin thickness, in laser skin resurfacing, 188, 188f Sliding tarsoconjunctival flap, in upper eyelid reconstruction, 251, 252f Small cell carcinomas of skin, periocular, 238–239, 239f SMAS See Superficial musculoaponeurotic system Snap test, in lower eyelid evaluation for blepharoplasty, 150, 150f for laser skin resurfacing, 184 Soft tissue expansion, for congenital ophthalmia, 382 Soft tissues, orbital, 11–14 in orbital lesion surgery, 465–466 Solar keratoses, periocular, 233–234, 234f SOOF See Suborbicularis oculi fat Spasm blepharospasm See Essential blepharospasm habit, 116 hemifacial, 116 Spastic entropion, 43 Sphenoid sinus, anatomy of, 15, 15f, 453 Spitz nevus, periocular, 229 Splinting, in correction of lower eyelid retraction, 162, 162f–163f Split-thickness skin grafts, 36 for reconstruction after exenteration, 365 Spurious blepharospasm, 117 Squamous cell carcinoma, periocular, 236, 237f Static symmetry, as anophthalmic surgery goal, 369 Stent, for conjunctival laceration repair, 284–285 Steroids, for dysthyroid compressive optic neuropathy, 306–307, 307f Stone-Jordan orbital implants, 327, 327f Strabismus following orbital decompression, 325 thyroid-related, 297–299 Strabismus surgery fibroconnective tissue septae in, 11 in thyroid disease patient, 299–303, 300f–302f Strawberry nevus, periocular, 228, 228f Streptococcal infections after laser blepharoplasty, 174, 207 after laser skin resurfacing, 207 Sub-brow incision, in orbitotomy anterior, 422, 423f lateral, 432–433, 433f Subciliary lower eyelid incision, in anterior orbitotomy, 422–423 Subconjunctival hemorrhage, 388 Submuscular fat in the eyebrow region See Retro-orbicularis oculi brow fat Suborbicularis oculi fat, 2, 6, 6f age-related changes in, 149 anatomy of, 148, 148f, 149f, 157 Subperiosteal myocutaneous flap, in correction of lower eyelid retraction, 159–160, 160f Subperiosteal volume augmentation, in anophthalmic socket, 374–375, 374f Subtotal exenteration, 359–360, 360f indicati§ons for, 356t Suction drainage, in deep orbital surgery, 445 Superficial musculoaponeurotic system, 3, age-related changes in, 149 eyebrow anatomy and, 126, 127f in lower eyelid anatomy, 148, 149f Superficial temporal fascia, in eyebrow anatomy, 126, 127f, 128f Superior cervical ganglion block, for essential blepharospasm, 123, 124f Superior ophthalmic vein, 12–13 Supervoltage radiotherapy, for dysthyroid compressive optic neuropathy, 307–309, 307f–308f Suprabrowpexy, 135–137, 137f Supraorbital nerves, in eyebrow anatomy, 126, 127f Supratrochlear nerves, in eyebrow anatomy, 126, 127f Sutura notha, Suture(s) for involutional entropion repair, 44–45, 45f ligation method in elderly Asian blepharoplasty patients, 220 materials for, 26–27, 27t stabilization in correction of lower eyelid retraction, 162, 162f–163f for wound closure, 28–30, 29f, 30f “Swinging lower eyelid orbitotomy,” 427–429, 428f, 429f Sympathetic nerve supply in eyelids, to orbit, 14 Sympathetic ophthalmia, 328 Synkinesis, 117 Synkinetic ptosis, 90 Synthetic wraps, use in enucleation technique, 337 Syringomas, periocular, 231, 231f chondroid, 231 laser treatment of, 207, 207f Taping of eyelids, in facial nerve paralysis management, 106 Tardive dyskinesia, 116–117 Tarsal strip, for horizontal eyelid laxity management, 57–58, 57f Tarsoconjunctival flap, in eyelid reconstruction lower lid, 247–249, 248f upper lid, 251, 252f Tarsoligamentous band, Tarsorrhaphy, facial nerve paralysis and, 106 Tarsus, operations involving, for trichiasis, 71, 72f Tear function tests, 266 Tearing clinical pathway for management of, 267f diagnostic testing in, 266–269, 268f–270f differential diagnosis of, 265t lacrimal system evaluation prompted by, 264–265 patient examination in, 265–266, 267f and workup, 268, 270f Tear trough abnormality, lower eyelid, 150 Temporal fascia, in eyebrow anatomy, 126, 127f, 128f Temporal forehead lift, 125 Temporalis muscle use in facial reanimation surgery, 110, 110f–111f use in reconstruction after exenteration, 365 Tendon laxity, medial canthal, 58–59, 58f–59f Tenon’s capsule, 10–11 in anterior orbitotomy, 418 Tenon’s layers, during enucleation, 334–335, 334f–335f Tenzel semicircular flap, for eyelid defect repair, 246–247, 246f Teratoma, pediatric orbital, 407 Terminal tarsal rotation operation, for trichiasis, 71 Tetanus/Tetany, 117 Thermal relaxation time, in laser skin resurfacing, 181 “Three-snip” procedure, for punctal stenosis, 274 Thyroid disease eyelid retraction associated with, surgical management of, 289–295, 290f–294f optic neuropathy in See Dysthyroid compressive optic neuropathy strabismus in See Strabismus; Strabismus surgery Thyroid ophthalmopathy anatomy of, 317–318, 317f, 318f orbital decompression for complications, 324–325 Index 3/22/01 2:46 PM Page 499 INDEX • 499 indications, 316 inferior forniceal antroethmoidal, 319–321, 319f, 320f maxillary ostium role in, 318 and orbital anatomy, 318, 318f orbital fat removal in, 320 orbital rim augmentation, 323–324, 323f–324f postoperative care, 324 pre- and postoperative appearance, 325f preoperative evaluation, 315–316 surgical procedures, 319–324, 325f symmetrical supraplacement of eyelids in, 321 transantral antroethmoidal, 321–323, 321f–323f treatment options in, 325f Tissue, in laser skin resurfacing, 179–182, 179f–181f Tissue flaps, types of, 32–34, 33f–35f See also specific forms of flaps Tissue glue, 30 Tissue handling, 25–26 Tissue heating, in laser skin resurfacing, 180–181 Tissue penetration, in laser skin resurfacing, 180 Titanium motility post, with orbital implant, 339–341, 340f Torsional diplopia, before and after strabismus surgery, 303 Total exenteration, 357–359, 358f–359f indications for, 356t postoperative care in, 361–362, 362f–363f Tourette’s syndrome, 116 Trabecular carcinoma, periocular, 238–239, 239f Transantral antroethmoidal decompression, 321–323, 321f–323f Transantral transoral decompression, 317 Transconjunctival blepharoplasty, lower eyelid, 153–155, 154f–155f laser use for, 170–173, 170f–173f clinical pathway for, 176f complications of, 175 Transcutaneous blepharoplasty, lower eyelid, 151–152, 151f–153f Trapezoidal debulking, of eyelid tissue, 218–220, 218f, 219f Trauma orbital See Orbital trauma trichiasis resulting from, 69 Tretinoin (Retin-A(r)), laser skin resurfacing and, 185, 201 Triangular debulking, of eyelid tissue, 218–220, 218f, 219f Trichiasis, 41 anatomy of, 67, 68f classification of, 67–70, 68f–69f described, 67 traumatic, 69 treatment of, 70–73, 71f–73f clinical pathway for, 73f Trichilemmomas, periocular, 230 Trichoepitheliomas, periocular, 230, 230f Trigeminal nerves in eyebrow anatomy, 126, 127f in eyelids, in orbital anatomy, 13 Trochlear nerve, in orbital anatomy, 13 Tumors facial, laser treatment of, 207–208, 207f–208f intraconal, 390–394, 391f, 392f optic nerve See Optic nerve tumors orbital See Orbital tumors periocular See Periocular tumors Turbinates, function of, 14 Tutoplast, use in enucleation technique, 338 Two-wall antroethmoidal decompression, for thyroid ophthalmopathy, 316 Ultrasonography See Imaging studies Undercorrection as ptosis surgery complication, 100 in strabismus surgery, 302–303 Upper eyelid, anatomy of, Asian versus Caucasian, 211, 212f, 213–214, 213f–214f debulking of, in upper lid blepharoplasty, 140–141, 140f–141f defects See Eyelid defects and eyebrow, 125 Upper eyelid blepharoplasty in Asian patients See Asian blepharoplasty described, 137–138 eyebrow procedures used with, 125 lateral brow, 141–143, 142f–143f in females, versus males, 137–138, 138f, 145f goal of, 125, 137 laser use for, 167–169, 167f–169f clinical pathway for, 176f complications of, 173–175, 174f–175f technique of, 138–141, 138f–141f Upper eyelid dermatochalasis, decision tree for management of, 145f Upper eyelid retraction for facial nerve paralysis, 108–109, 108f–109f in thyroid disease, surgical management of, 289–295, 290f–294f Upper eyelid tarsal advancement flap, in involutional entropion repair, 50, 50f Valves, of Hasner and Rosenmüller, 17, 17f Vascular tumors, periocular, 228 Vasculature, in facial anatomy, 6–7 orbital, 12–13 Vision loss, following orbital decompression, 324 Volume augmentation, orbital, 38 subperiosteal, in anophthalmic socket, 374–375, 374f Wall, orbital See Orbital wall Wedge resection, pentagonal, for trichiasis, 70–71, 71f Westernizing blepharoplasty, 213 Wetfield cautery, in Asian blepharoplasty, 216 Whitnall’s ligament, 11, 11f Whitnall sling, for ptosis, 82–83 Wies procedure, 48–50, 49f Wilson’s disease, blepharospasm in, 115 Wolfring, accessory lacrimal glands of, 16 Wound care and dressings, after oculoplastic surgery, 30–32 See also Laser skin resurfacing, postoperative wound care in Wound closure after blepharoplasty, 217–218, 217f in deep orbital surgery, 445–446 principles of, 27–30, 28f Wound contraction, 23, 23f Wound dehiscence, after laser blepharoplasty, 174 Wound healing after laser skin resurfacing See Laser skin resurfacing, postoperative wound care in matrix metalloproteinases in, 23 phases in, 22–23 secondary, 23, 23f Wound infection See Infection risk W-plasty, for scar revision, 32, 33f Wrinkles See Rhytids Xanthelasma, periocular, 233, 233f Y-V plasty, 33–34, 34f Zeis gland carcinomas, periocular, 238, 238f Zithromax (azithromycin), laser skin resurfacing and, 184–185 Z-plasty, for scar revision, 31–32, 31f–33f Zygomatic arch, eyebrow anatomy and, 126, 127f, 128f Zygomatic bone, orbital floor, 317 Zygomatic fractures, 477–478, 477f, 478f Index 3/26/01 10:19 AM Page 500