Applied Surgery of the Eyelids

Abstract

The anatomy of the eyelids is briefly outlined. The most common eyelid disorders, i.e., dermatochalasis, blepharoptosis, entropion, ectropion, and eyelid tumors—and their management are discussed.

FormalPara Learning Objectives

• Observation of the eyelids, globe position, and pupillary reflex may uncover life-threatening conditions.

• Upper eyelid surgery can best be approached from the skin crease.

• Lower fornix incision as done in orbital fracture surgery carries the risk of creating a cicatricial entropion.

• Intermittent eyelid edema is seen in patients with the blepharochalasis syndrome, a diagnosis that is often missed.

Introduction: Anatomy

The eyelids are composed of two lamellae, the outer (or: anterior) lamella consists of the skin and the orbicularis muscle, whereas the inner (or: posterior) lamella consists of a firm plate, called the tarsal plate, and the conjunctiva. The conjunctiva of the eyelids is continuous with the conjunctiva of the bulbus via a curved bobby-pin-like structure called the fornix.

Horizontally, the eyelids are medially connected via de medial canthal tendon to the periosteum of the medial ridge of the orbit. The medial canthal tendon consists of an anterior and a posterior crus, which enfold the lacrimal sac.

Laterally, the eyelids are connected via the lateral canthal tendons to a small elevation on the lateral wall just posterior to the orbital ridge, called Whitnall’s tubercle. Vertically, the eyelids are connected to the lid retractors. The upper contains two retractors: the levator muscle, innervated by the oculomotor nerve, and Müller’s muscle, which is innervated by orthosympathetic neurons. The origin of the levator muscle is the annulus tendineus communis (or: annulus of Zinn). Whitnall’s suspensory ligament stretches from the fascia around the trochlea horizontally to the fascia of the lacrimal gland and supports the eyelid and the levator aponeurosis. It allows for a vector change of the levator muscle, enabling the upper eyelid to be elevated rather than directly retracted posteriorly. Anterior to the retractors lies yellow fat, called preaponeurotic fat, not to be mistaken with the fat underneath the eyebrow. In the lower eyelid, the retractors are less well developed and connected to the inferior rectus muscle. The orbital septum (Fig. 22.1) is a thin, but firm, fibrous structure stretched out between the orbital rim and the transition of the eyelid retractors to the tarsal plate. Extensions of the levator tendon, called aponeurosis, fuse with the medial and lateral canthal ligaments and insert into the skin, creating a skin or eyelid crease. This skin crease determines someone’s looks. In Asian people, the skin crease is often hidden by a skin fold (and fat). Asymmetry of the skin crease, and as a consequence asymmetry of the pretarsal area, is almost always experienced as a cosmetically disturbing feature [1] (Fig. 22.2). In adults, the horizontal eyelid aperture measures approximately 35 mm and the vertical aperture 8–11 mm. The border of the inferior eyelid touches the corneal limbus at 6 o’clock, whereas the upper lid covers the cornea for about 2 mm at the 12 o’clock position [2]. The eyelid aperture is determined by the tension of the retractors on the one hand, and the tension of the orbicularis muscle at the other hand. The orbicularis muscle is innervated by the facial nerve (CN VII). The tarsal plate of the upper eyelid (8–10 mm) is about twice as high as that of the lower eyelid. The eyelid borders contain rows of eyelashes. Medially to them, the lacrimal puncta arise, which are the beginning of the canaliculi transporting tear fluid to the lacrimal sac and, ultimately, to the nose. Within the eyelids, a series of small glands are found, which are essential for the permanent lubrication of the eye. The lacrimal gland is located in the upper lateral corner of the orbit and consists of an intraorbital and a palpebral part.

Fig. 22.1

Sagittal intersection of the orbit and eyelids. See the text for a description

Fig. 22.2

The skin crease partly covered by a skin fold at the lateral side

Some Disorders of the Eyelids and Their Management

The most common disorders of the eyelids, apart from a chalazion, are dermatochalasis, blepharoptosis, entropion, ectropion, floppy eyelids, and tumors of the eyelid. Common problems in Graves’ orbitopathy are retraction of the upper and/or lower eyelids (either too high or too low), whereas in orbital fractures, entropion is regularly seen after surgery. There is an abundance of techniques to operate upon eyelids. For instance, hundreds of techniques alone exist for the correction of entropion of the lower lid. The eyelid can be approached from either the anterior (skin) side or the posterior (conjunctival) side. We prefer the anterior approach in order to avoid surgery to the posterior lamella, because lesions of the palpebral conjunctiva may be associated with temporary or lasting ocular irritation. Moreover, an anterior approach can easily be combined with skin resection (blepharoplasty). Upper eyelid surgery can best start at the eyelid crease, whereas the lower eyelids can best be approached with a subciliary incision, the scar of which becomes almost invisible after some weeks to months.

Dermatochalasis

Dermatochalasis is an excess of eyelid skin and/or fat. It is seen especially in older people and in smokers. The bleparochalasis syndrome [3] is a disorder of unknown etiology, in which the upper and/or lower eyelids, on one or both sides, swell due to edema. Swelling disappears after a few days, but repeated swelling stretches the skin and finally disrupts eyelid architecture. The disorder can start at any time of life (Fig. 22.3).

Fig. 22.3

Patient with blepharoochalasis syndrome of recent onset

Blepharoptosis

Cosmetic or functional blepharoptosis (ptosis, drooping eyelid) is one of the most common disorders in oculoplastic surgery. The ptosis can be present from birth (congenital) or appear at a later age (acquired). To examine ptosis, after excluding abnormal globe position and gaze abnormalities, the distance between the pupillary reflex and the margin of the upper eyelid is measured with a ruler, while the patient assumes the primary sitting position (body and head straight up, shoulders back, and looking forward). This distance is called margin reflex distance 1 (MRD1). (MRD2 is the reflex distance to the border of the lower eye lid.) Normally, MRD1 is approximately 3 mm. In the Netherlands, insurance companies reimburse ptosis surgery if MRD1 is less than 1 mm. It should be noted that ptosis is not a diagnosis, but a symptom, of which the cause must be determined.

Congenital Ptosis

Ptosis becomes visible at a young age and is more often unilateral than bilateral. Sometimes, there is a long-standing family history of ptosis. Typically, an eyelid lag is present at downgaze. When the levator function is less than 5 mm, a frontalis suspension is indicated. Ptosis in young children can cause significant amblyopia. Therefore, ptosis should be corrected as soon as possible. The blepharophimosis syndrome is an autosomal dominant disorder including bilateral congenital ptosis, blepharophimosis, telecanthus, and epicanthus inversus [4]. It can be associated with infertility, microphthalmos, and other conditions.

Aponeurotic Ptosis

This is by far the most frequent cause of ptosis, in which innate weakness of the aponeurotic transition to the tarsal plate with our without mini-traumas is assumed to contribute to its origin. It is typically seen in patients wearing contact lenses [5], in some families and at old age. Typically, the skin crease has moved upwards, resulting in an abnormally increased distance between the eyelid border and the skin crease. A deep superior sulcus also fits the condition. Aponeurotic ptosis, because of its presentation at a somewhat older age, often presents in combination with dermatochalasis. Hence, in order to get a satisfactory surgical outcome, ptosis correction should be combined with a blepharoplasty in many cases.

Myogenic Ptosis

This is a rare form of ptosis and it is caused by external ophthalmoplegia or ocular myopathies, in which often not only the levator muscle is involved but also other extraocular and non-extraocular muscles. Hence, the risk of a postoperative corneal ulcer is much higher than in other forms of ptosis surgery. Especially the Kearns-Sayre syndrome—a mitochondrial muscle disorder—is of interest, because of its associated heart rhythm abnormalities, which can lead to a sudden cardiac arrest. The retina shows pigmentary alterations typical for retinitis pigmentosa. Myasthenia is another cause for ptosis. The disease itself should be treated. Surgery on the levator is not very beneficial.

Neurogenic Ptosis

A lesion of the oculomotor nerve (CN III), in particular involving the branch to the levator muscle, causes complete ptosis. Surgery is usually not possible because of the other manifestations of oculomotor nerve palsy. Damage to the orthosympathetic innervation causes 1–2 mm ptosis in combination with a miosis (smaller-than-normal pupil), which is called Horner’s syndrome. An important factor causing this syndrome is a carcinoma on the apex of the lung.

Mechanical Ptosis

Tumors of the eyelid can cause ptosis by their weight, while cicatricial conjunctival conditions may draw the eyelid downwards.

Marcus-Gunn Jaw-Winking Ptosis

This is a form of ptosis occurring during movements of the mouth and is caused by aberrant nerves branches.

Brow Ptosis

This is a condition in which the eyebrow is sagging below the superior margin of the orbit. It often presents with dermatochalasis.

Lash Ptosis

This is a condition in which the lashes of the upper eyelid are directed downwards. The patient has to look through his lashes.

The choice of ptosis surgery is determined by the function of the levator muscle. The patient is asked to look down and up. The excursion of the eyelid is a proxy of levator muscle function (normally more than 15 mm). Check that the frontal muscle is not involved in elevation of the upper eyelid. When levator muscle function is more than 5 mm, levator reinsertion or plication can be done. When levator muscle function is less than 5 mm, a frontalis suspension may be effective.

Blepharoplasty

In case of an excess of skin with or without too much eyelid fat, excessive skin and fat can be excised. Although some patients report a number of subjective complaints (“heavy eyelids”), the most common indication for blepharoplasty is cosmetic. However, one must not trivialize the impact of a blepharoplasty on a patient’s well-being. Dermatochalasis causes a tired look and is sometimes mistakenly associated with alcohol abuse or an exhausted physical state. Dermatochalasis is sometimes associated with a lacrimal gland prolapse. Soft lesions in the upper lateral part of the eyelids may be palpable, and these can also look like small eyelid tumors. Treatment consists of repositing and fixing the prolapsed part of the gland to the periosteum of the superior margin of the orbit [6].

Levator Reinsertion/Plication

Preferably, levator reinsertion or plication is done under local anesthesia, because during surgery the eyelid aperture has to be checked (Fig. 22.4). If general anesthesia is absolutely necessary, the result of surgery is less predictable. After having marked the skin crease with a dermomarker, a few subcutaneous injections with xylocaine plus epinephrine are given. A skin and orbicularis muscle incision are made with a surgical knife or—after having wetted the skin—with a monopolar electrocautery needle along the skin crease. The septum is opened with a pair of Wescott scissors, the preaponeurotic fat becomes visible and it will be retracted with a Desmarres retractor. Next, the tarsal plate and the aponeurosis are exposed and a 6.0 Daclon suture (Daclon, because of the particular shape of its needle that easily cuts through the stiff tarsal plate) is placed through the upper part of the tarsal plate anterior to the conjunctiva and through the aponeurosis. When the suture knot is temporarily tied, the eyelid comes up. The patient is put in a supine position, and the eyelid aperture is inspected. If the eyelid is still too low, the suture is tightened; if the eyelid is too high, the suture is loosened. If the eyelid contour is still not satisfying, a second suture is placed next to the first one. The skin is closed with a 6.0 Nylon suture which can be removed after 7 days. This technique takes only 20–30 min in experienced hands and yields satisfying results in almost all patients with a levator muscle function of more than 5 mm. Only a few patients need a second procedure, during which an incision through the previous scar is made and the sutures are adapted. No absorbable sutures should be used, because of the risk or a recurrence of the ptosis.

Fig. 22.4

A 54-year-old woman with dermatochalasis and bilateral blepharoptosis

Frontalis Suspension

After six stab incisions (three through the skin of the upper lid (2–3 mm above the lash line), one at the medial border, one at the lateral border of the eye brow, and the sixth 1–2 cm above the eye brow right above the pupil in the primary position), a silastic sling or a fascia lata strip is passed underneath the skin and sutured at the top end. At the end of the surgery, the tension of the strip should be sufficient to put the eyelid margin at the level of the limbus at 6 o’clock, with the patient lying flat. The disadvantage of this technique (that has to be taken for granted) is some degree of lagophthalmos. Hence, one has to use lubricants, sometimes forever.

(External) Browlift

A semi-ellipse of skin and subcutis just above the brow is excised between the frontal nerve medially and the bifurcation of the facial nerve laterally. The wound is sutured with 5.0 Vicryl and 5.0 Nylon (intracutaneously). This extremely successful procedure has only one disadvantage: It takes 3–6 months before the scars become less visible (Fig. 22.5).

Fig. 22.5

Male, 64 years of age, 3 months after external brow lift

Complications of Ptosis Surgery

Because of the enlarged eyelid aperture, there is an increased risk of dry eye and even of corneal ulcer. Therefore, lubricants must be used and slowly tapering off according to the postoperative course. In operations, in which the orbital septum is opened, there is a small risk of retrobulbar hemorrhage (see Chap. 13).

Ectropion and Entropion and Floppy Eyelids

In both ectropion and entropion, the two lamellae of the eyelid are dissociated. In ectropion, the posterior lamella moves upwards, whereas in entropion it is the anterior lamella that moves upwards. Ectropion and entropion of the upper eyelid are rare in Western countries and will not be discussed. An ectropion (outward rotation of the lid margin) of the lower lid is mostly involutional, i.e., caused by slackening of the underlying connective tissue in the lower eyelid. Other types of ectropion are congenital, cicatricial, or paralytic. The outward rotation of the eyelid can be more prominent at the medial side (so-called medial ectropion).

Involutional ectropion is seen in elderly people and often associated with horizontal laxity and retractor weakness. A commonly used therapeutic procedure is horizontal shortening of the eyelid by excising part of the lateral tarsal plate and creating a new lateral canthal tendon. This is called the lateral tarsal strip procedure. The lateral canthal tendon, however, is not always found as nicely as depicted in textbooks. Reconstruction requires that the upper eyelid, which may be also rather lax, covers the lower lid in the lateral corner. Sometimes, a small lateral tarsorrhaphy helps to reach the desired outcome. Provided that there is no significant canthal laxity, the eyelid can simply be tightened by excision of a full-thickness eyelid pentagon. This is especially effective in medial ectropion. In ectropion with predominant retractor weakness, characterized by poor eyelid movement in downgaze, reinsertion or shortening of the retractors can add to the positive outcome of surgery. Cicatricial ectropion is caused by a shortage of skin, as seen in a number of skin diseases (such as ichthyosis) and after trauma or surgery. Sometimes, if the traction is superficial, a Z-plasty will be sufficient, but more often a skin flap or a free skin graft is needed to correct this kind of ectropion.

Involutional entropion is typically seen in aging people. Due to the inward rotation of the eyelid, the lashes point to the cornea and can easily damage the corneal epithelium. Treatment, therefore, should not be delayed. A bandage lens to protect the cornea against the lashes can be inserted before surgery takes place. (N.B.: Trichiasis is a condition in which not the whole eyelid, but only one or more individual lashes point to the cornea. (Repeated) coagulation of the hair follicles of these lashes cures the problem.) Similar to involutional ectropion, horizontal laxity plays an important role. However, horizontal shortening alone will not last in the long run. The shortening has to be combined with everting sutures [7].

Cicatricial entropion is seen in diseases of the conjunctiva or after (surgical) trauma. In severe cases, the scar tissue has to be excised and replaced by mucous membrane or hard palate mucosa.

Floppy eyelids are lax eyelids that can easily be everted. The phenomenon was first described as the floppy eyelid syndrome in middle-aged obese men and related to the obstructive sleep apnea syndrome, but later it got a wider appreciation as a premature aging of the eyelid [8, 9]. Floppy eyelids easily cause chronic eye irritation. Association with different conditions has been described. Full-thickness excision of a pentagon of the eyelid can result in lasting improvement (Fig. 22.6).

Fig. 22.6

Floppy eyelid

Eyelid Tumors

There are numerous eyelid tumors, both benign and malignant. Basal cell skin carcinoma is most often seen in oculoplastic clinics. Mohs surgery has become immensely popular. However, basocellular carcinomas involving the eyelids and in particular the eyelid margin should not be left to a Mohs surgeon alone, who has no experience with reconstruction of (large) eyelid defects. Close cooperation from the start between a Mohs surgeon and an oculoplastic surgeon is advisable to prevent “unforeseen” situations. Very small tumors on the margin of the eyelid can be removed by a shaving excision, larger lesions by a full-thickness excision. If primary closure is possible, it is the method of first choice. If not, pedicled flaps can be used to close the defect. A tarsoconjunctival flap (Hughes procedure) is ideal to reconstruct a lower eyelid defect, a glabella flap can be used to reconstruct medial defects, and with a frontalis flap (in combination with oral mucosa) a completely absent upper eyelid can be reconstructed (Fig. 22.7). Essential in eyelid reconstruction is the recreation of both the anterior lamella and the posterior lamella. The inner (posterior) side should always be lined with mucosa, for which buccal or labial mucosa can be taken. Stability requires cartilage, for example, auricular cartilage from the flattest part of the helix of the pinna. The advantage of a hard palate mucosal graft is that it offers both stability and mucosal lining. Replacement of the orbicularis muscle is never needed. Skin can be taken from other eyelids or from the retro-auricular area or the inner side of the arm. To prevent graft rejection, in composite reconstructions at least one layer should be vascularized, but the second layer may be a free flap. A frontalis flap is firm, so that it does not need any additional support of cartilage or another material.

Fig. 22.7

Full upper eyelid reconstruction with oral mucosa and frontalis flap

Eyelid Retraction

Eyelid retraction is seen in 90% of patients with Graves’ orbitopathy, but can also—although very sporadically—be seen in other disorders. If the retraction does not spontaneously disappear, the eyelid must be lengthened. This can be attained in the upper lid by a “reverse” ptosis operation. The aponeurosis and Müller’s muscle are dissected from the tarsal plate until the desired position is achieved. A non-absorbable hang-back suture has to be placed between the tarsal plate and the aponeurosis to prevent overcorrection [10]. To correct lower eyelid retraction, a spacer between the tarsal plate and the retractors is often needed. This spacer can be either donor sclera or auricular cartilage.

Epilogue

This overview of eyelid disorders and their management is far from complete and highly subjective. It mirrors the experience of the author in a tertiary clinic in the Netherlands over a period of more than 30 years.