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Learning Points.pptx
1. ILOCOS TRAINING AND REGIONAL MEDICAL CENTER
Department of Ophthalmology Dept
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LEARNING POINTS!
PRIMARY REPAIR OF LID LACERATION
• Prior to suturing, wounds should be properly cleaned and disinfected, and isolate
the area with a sterile drape
• Administer subcutaneous anesthesia to affected area and may provide sedation to
uncooperative patients prior to suturing
• Close the wound with small sutures for better cosmesis
• Avoid deep sutures between the tarsus and the orbital rim
2. ILOCOS TRAINING AND REGIONAL MEDICAL CENTER
Department of Ophthalmology Dept
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LEARNING POINTS!
LEVATOR ENHANCEMENT
• For patients with good levator function
• Approaches:
• External/Transcutaneous Levator Enhancement
• Internal/Transconjunctival/Tarsus/Müller Levator Enhancement
• When levator function is poor, frontalis muscle is recruited
• Undercorrection is the most common complication of ptosis repair, which is seen
in 10–15% of cases.
• As some component of post-operative undercorrection may be mechanical
secondary to post-op eyelid edema, these patients should be observed until
edema has resolved and the eyelid position has stabilized.
3. ILOCOS TRAINING AND REGIONAL MEDICAL CENTER
Department of Ophthalmology Dept
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LEARNING POINTS!
REPAIR OF LID MARGIN LACERATION
• First steps involve:
• Identify the tarsus, grey line and anterior lash line, and
mucocutaneous junction
• Lateral canthotomy with cantholysis may be done if tension is
too high
• Align the tarsus along its vertical axis and place 6-0 silk sutures
through the grey line on either side of the wound
• Use vertical mattress 5-0 or 6-0 Vicryl sutures to approximate the
tarsus along its vertical axis, with three sutures for upper eyelid
lacerations and two sutures for lower eyelid lacerations
• Tie, trim, and bury the tarsal sutures along the vertical tarsal
border. Place another 6-0 silk marginal sutures along the anterior
lash line and possibly the mucocutaneous junction
4. ILOCOS TRAINING AND REGIONAL MEDICAL CENTER
Department of Ophthalmology Dept
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LEARNING POINTS!
QUICKERT PROCEDURE
• Quickert sutures are “everting sutures” employed to treat entropion
• Most often used in: Spastic Entropion and Early Involutional Entropion
• Quickert sutures tighten lower lid retractors
• Safe, simple and quick procedure that gives overall patient satisfaction
• Use: Vicryl 6.0
• Suture enters the inferior fornix and then directed through the eyelid to exit through the lash
follicles
• Addition of Quickert sutures to the inverted T and lateral tarsal strip procedures decreases
the recurrence rate of entropion when compared to the Quickert procedure alone
5. ILOCOS TRAINING AND REGIONAL MEDICAL CENTER
Department of Ophthalmology Dept
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LEARNING POINTS!
SQUAMOUS CELL CARCINOMA of the Eyelid
• Malignant epidermal carcinoma
• 2nd most common eyelid malignancy (5% of malignant eyelid neoplasms)
• Risk factors include
• Aging, UV exposure, cigarette smoke exposure, HPV, HIV, immunosuppression, and etc..
• Orbital invasion may occur up to 5.9%, and metastasis rates for the eyelid vary
from 1-21%
• History: Suspicious skin lesions with actinic keratosis
• Diagnosis: Excision Biopsy
6. ILOCOS TRAINING AND REGIONAL MEDICAL CENTER
Department of Ophthalmology Dept
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LEARNING POINTS!
SQUAMOUS CELL CARCINOMA of the Eyelid
• Treatment of choice: Surgical Excision
• Moh’s micrographic surgery
• Excision with frozen-section
• Sentinel Lymph Node Biopsy with radical dissection
• Large and extensive lesions with perineural invasion
• Recurrent lymph nodes
• Exenteration
• Orbital involvement with poor visual potential provided that the cavernous sinus is not
involved
• Systemic Chemotherapy
• For advanced SCC that metastasized to other parts of the body
7. ILOCOS TRAINING AND REGIONAL MEDICAL CENTER
Department of Ophthalmology Dept
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LEARNING POINTS!
BASAL CELL CARCINOMA of the Eyelid
• Malignant epidermal carcinoma
• Most common eyelid malignancy accounting for over 90% of malignant eyelid
neoplasms
• Risk factors include
• UVB light exposure, radiation, immunosuppression
• Complete eye examination, including ocular motility and assessment of proptosis
to assess for orbital extension.
• This is especially relevant for medial canthal lesions
• Assessment of facial sensation
• Diagnosis: Excision Biopsy
• Management : (Medical) Imiquimod 5% cream; (Surgery) Complete surgical
excision with margin control
Editor's Notes
Prior to suturing, wounds should be properly cleaned (irrigate with normal saline to delineate the full extend of the wound) and disinfected (preferably with Betadine), and isolate the area with a sterile drape.
simple, interrupted sutures or vertical/horizontal mattress sutures if the wound is under tension. Subcuticular sutures are preferred to simple, interrupted sutures to repair triangular flap tips to prevent tissue necrosis. When repairing ragged wound edges, focus on approximating key areas first, followed by the rest of the wound.[17] Avoid deep sutures between the tarsus and the orbital rim because they can incorporate into or perforate the orbital septum.
When levator function is normal (greater than 10), this indicates that the levator muscle itself is strong and functioning normally. Tightening the levator muscle will elevate the eyelid margin.
When levator function is poor (less than 5mm), the levator muscle is not strong enough to lift the eyelid, no matter how it is manipulated, so the frontalis muscle is recruited.
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Careful and methodical repair of eyelid margin lacerations is exceedingly important for maintaining both the function and aesthetic integrity of the eyelid.
When preparing to repair a laceration of the lid margin, the first steps include identifying the tarsus, grey line, anterior lash line, and the mucocutaneous junction.
Once these important landmarks are delineated, the wound edges can be approximated with the appropriate instruments and the wound tension assessed (
if the tension is too high when the wounds are approximated with instruments, a lateral canthotomy with cantholysis may be required).
Align the tarsus along its vertical axis and place 6-0 silk sutures through the grey line on either side of the wound 2 millimeters from the wound edge, leaving the tails long.
Next, use vertical mattress 5-0 or 6-0 Vicryl sutures to approximate the tarsus along its vertical axis, with three sutures for upper eyelid lacerations and two sutures for lower eyelid lacerations
Tie, trim, and bury the tarsal sutures along the vertical tarsal border. Place another 6-0 silk marginal sutures along the anterior lash line and possibly the mucocutaneous junction
The Quickert procedure employs Quickert sutures for the treatment of Entropion.
It is most often used in the setting of spastic entropion or early involutional entropion and was first described by Quickert and Rathbun in 1971.
Quickert sutures tighten lower lid retractors.
Accordingly, the safety, simplicity, quickness, and overall patient satisfaction have been cited as reasons to consider the Quickert procedure for patients in whom these features would be valuable, or patients with higher operative risk
*3 sutures are done and may be removed after 7-10 days
Squamous Cell Carcinoma (SCC) of the eyelid is malignant epidermal carcinoma. SCC is the second most common eyelid malignancy, accounting for less than 5% of malignant eyelid neoplasms
Surgical Excision – Frozen Section to determine if margins are tumor free
Sentinel LN Biopsy – Rule out distant metastasis
BCC is the most common eyelid malignancy, accounting for over 90% of malignant eyelid neoplasms
BCC is nearly always a locally invasive disease.
Treatment with topical imiquimod 5% cream has been shown to be effective, although not as effective as surgical excision, in several case serie
