Page 15 - May 2024 SAM PDF

EYE CARE AND
EYE CARE AND EYE CARE AND
QUALITY OF LIFE
QUALITY OF LIFE QUALITY OF LIFE

Combined Approach to Eyelid Surgery in Graves’ Disease dissection, starting at the center of the tarsus and progressing medial
The phenomenon of eyelid retraction in patients with euthroid and lateral from this point, spares the medial and lateral horns of the
Graves’ Disease presents unique cosmetic and functional problems for levator muscles. It is important to dissect all fibers off the conjunctive
the blepharoplasty patient. The cosmetic appearance of bulging eyes, until all Mueller’s fibers are removed. The bluish cornea seen through
or exophthalmos, is due in part to true proptosis (forward displace- the transparent conjunctiva is an indication that this dissection is com-
ment of the globe from the orbit), and accentuated by retraction of pleted. It is essential to the process to use the bipolar micro tip cautery
upper and lower lids. This increased exposure of the cornea, partic- and, for complete corneal protection, a corneal shield.
ularly in sleep when the eyelid closure is incomplete, leads to corneal To evaluate the new level of the lowered lid margin by the dissec-
ulceration if not corrected. In lesser degrees of exposure, the symptoms tion, the patient is placed in the full upright sitting position to mea-
of tearing, photophobia and foreign body sensation greatly hamper sure the lid margin position in the straight-ahead eye position. The lid
the patient’s visual comfort. The orbital fat pads in both upper and margin should lie approximately 2 mm below the superior limbus at
lower lids are excessive due to infiltration with abnormal lymphocytes the 12:00 position.
and deposition of collagen and mucopolysaccharide material. This The blepharoplasty portion of this operation is completed by
deposition produces fibrosis and also leads to marked enlargement exposing the preaponeurotic and medial fat pads, carefully dissecting
of the lacrimal gland and extracurricular muscles. Severe strabismus the multilayered abnormally thickened orbital septum from the pure
with marked diplopia occurs frequently because of this orbital process fat lobules and resecting only fat. This is a very important point of
involving the rectus muscles. technique in all blepharoplasty surgery, but particularly crucial to the
This article will be confined to the combined approach of bleph- success in the eyelid of the patient with Graves’ Disease. The orbital
aroplasty with levator aponeurosis recession with Mueller’s muscle septum, usually thin and translucent, is quite thickened and opales-
extirpation for the upper lid retraction problem, and blepharoplasty cent from the process of fibrosis that characterizes the eyelid problem
with cartilage augmentation of the lower lid retraction. The technique in thyroid ophthalmopathy. Failure to dissect only pure fat from this
to be described is one of several accepted techniques for management multilayered envelope of tissue will result in a shortening effect to the
of this condition, but in my hands has proved to be the best approach lid, essentially producing further retraction. It is also believed that too
Thyroid Eye Disorders for solving this problem, both cosmetically and functionally. much cautery, dissection or hematoma formation in the orbital septum
near Whitnall’s ligament causes postoperative lagophthalmos, which
Upper Lid Retraction
can be long-lasting and compromise any eyelid procedure.
of Graves’ Disease lid is my choice of combining the blepharoplasty with surgery for thickened with fibrosis and is visible preoperatively, a fixation suture
The external approach via the blepharoplasty incision to the upper
If the lacrimal gland in the lateral third of the upper lid is quite
retraction. A portion of the excessive skin marked for removal by the to the underside of the superior orbital rim can reposit it higher in
By William R. Thornton, MD, FACS usual “pinch” technique is preserved to avoid shortening the lid ante- the orbit after dissection of the thickened orbital septal fibers. Of
riorly, since the lid is actually lengthened by 3 to 5 mm to correct for course, the palpebral lobe cannot be resected without loss of reflex
the amount of retraction. Local anesthesia combining lidocaine and tearing, and most lacrimologists believe it is responsible for a sig-
bupivacaine without epinephrine is used subcutaneously in the lid. nificant portion of basal secretion of tears. It is, of course, better to
Epinephrine is omitted because it will stimulate Mueller’s muscle (the leave this enlarged gland in place despite the cosmetic appearance
smooth muscle underlying the levator aponeurosis) and create false lid of ultimately a severe dry eye only complicates the functional result.
retraction and an undercorrection. Due to the depth of the dissection In usual fashion, 6-0 nylon interrupted sutures are used to close the
and the shorter action of the anesthetic agent effect because epineph- blepharoplasty incision.
he normal thyroid gland produces thyroid hormones, which Initial treatment is done with systemic steroids and antithyroid rine is omitted, intravenous monitored anesthesia is required to keep
regulate body metabolism. Hyperthyroidism is the state of medications to relieve hyperthyroid symptoms of hypertension, tachy- the patient free of pain and yet alert enough to monitor lid margin Lower Lid Retraction
Toverproduction of these hormones; hypothyroidism, the cardia and anxiety/insomnia; to promote complete relief of overactive positions. The lower lid is usually retracted on 1 to 3 mm, but it is important
under production of these regulatory body hormones. thyroid gland dysfunction, radioactive iodide (RAI ablation) and/or The skin is resected carefully with a Bard-Parker 15 blade, spar- to correct even a small amount of retraction in the lower lid to reduce
Thyroid function is determined through laboratory tests measur- surgical removal of enlarged glands or rare tumors. ing the underlying orbicularis muscle fibers. The preseptal orbicularis the exposure of the cornea and bulbar conjunctiva, both in the closed
ing if TSH (thyroid stimulating hormone) is low and gland is overac- Despite all of the above treatment, even months to years later, the muscle fibers are resected with straight Iris scissors. The best technique and open lid positions. Retraction of the lower lid margin of 1 mm
tive, with T3 and T4 elevated above normal thyroid hormone levels. Graves’ Disease signs and symptoms may reoccur. This article to follow to avoid the levator aponeurosis in this excision is to place the scis- exposes approximately 27 to 33 mm2 of conjunctival surface. The less
Thyroid-related eye symptoms early in this disorder are a noted will emphasize a team approach to diagnose and treat and follow the sors flat to the muscle plane and open the blades and press downward white of the eye showing above and below the corneal limbus gives the
staring appearance, dry irritation of eyes, swelling (edema) of eyelids thyroid patient with Graves’ Disease. gently, taking only the muscle that is pressed into the blades across illusion of less proptosis.
and orbital fat pads surrounding the eyes, creating a bulging out of the The relatively new intravenous therapy, monthly for seven months the lid margin length of the incision. The exposed levator aponeurosis The incision is placed in the usual subciliary line and carried out
eyes (proptosis), and eyelid retraction preventing full eyelid closure. with Tepezza (Teprotumumab), costs as much as $16,000 per treat- with the underlying Mueller’s muscle is then resected superiorly from onto the lateral canthus. Lidocaine and bupivacaine with epinephrine
This inflammation of orbital fat, and extraocular eye muscles and ment. Some patients have reported complications of severe hearing the superior edge of the tarsus approximately 10 mm with a cutting are permissible as local anesthesia in the lower lid. The myocutaneous
eyelid muscles worsens proptosis and exposure symptoms of the eyes loss, severe hyperglycemia, inflammatory bowel disease, and fear of and stripping action of the Wescott sharp pointed scissors. To aid in flap is dissected to the orbital rim. The three fat pads are again dissect-
including corneal abrasions, double vision and vision blurring with fetal effects in pregnant women. Some patients have reported a return the dissection, the lid is everted on a Desmarres retractor, and a bolus ed free of the abnormal orbital septum, as described in the upper lid
pain. Secondary glaucoma, which potential loss of visual fields can go of symptoms. of 0.5 cc of local anesthesia is placed subconjunctivally just above the procedure. A minimal amount of lower lid skin is resected at the sub-
unrecognized without a complete eye exam, is produced by stretching At this time, this eye specialist recommends for patients with eye superior edge of the tarsus. This not only blocks orbital innervation ciliary incision, just enough to close the incision smoothly. To prevent
and compression of the optic nerve and potential loss of central vision disorders of Graves’ Disease to have an experienced medical and sur- to the subconjunctival space, but hydrolytically dissects the Mueller’s contact of suture ends with the cornea, 6-0 silk is the preferred suture
and blindness. gical team to treat this complex lifetime disorder in a timely manner. fibers from the adherence to the conjunctiva. The somewhat tedious for the lower lid closure.

14 SAN ANTONIO MEDICINE • May 2024 Visit us at www.bcms.org 15