Minimally Invasive Management of Eyelid Malposition and Asymmetry

Educational Objectives

The goal of this program is to improve management of patients undergoing ophthalmic procedures. After hearing and assimilating this program, the clinician will be better able to:

1. Select appropriate candidates for nonsurgical treatment of malposition of the eyelid.

Summary

Overview: increasing number of noninvasive treatments that may be performed in clinic, rather than operating room, are replacing some surgical procedures

Retraction of lower eyelid: once thought to be caused by shortening of middle lamella; while shortening does play role, volume collapse also important; surgical approach — surgically reinflating eyelid may be effective, as opposed to lengthening; minimally invasive technique recommended; en-glove lysis performed through tiny incision in lateral canthal crease of eyelid; scar tissue released from within eyelid, and dermis harvested from behind ear to replace volume; dermal strip positioned through small incision by guarding Keith needle with intravenous tubing and passing needle into dissection pocket; nonsurgical approach — same result may be accomplished with hyaluronic acid gels; ophthalmic viscoelastic gels problematic because endogenous hyaluronidase breaks material down; however, when viscoelastic materials cross-linked chemically, hyaluronidase less effective, so injection may last for 1 to 5 yr; injected material composed of safe polysaccharide material; gel stretches retractors of lower eyelid and provides buffer by recreating fluid space between orbicularis oculi and retractors; gel sometimes used with 5-fluorouracil; gel can stent and may release some scar tissue; patients with multiple eyelid surgeries, extensive scarring, and congenital ichthyosis may benefit from hyaluronic acid gel; gel placed intradermally to stretch tight dermis and decrease scleral show; repeated injections may preserve vision

Retraction of upper eyelid: common in patients with thyroid orbitopathy; for these patients, hyaluronic acid gel injected in levator plane; gels used off label, but long experience indicates injection safe; may be used for patient with acute condition in whom thyroid disease still developing; surgery may not be best option because condition may improve spontaneously; injection of hyaluronic acid gel into levator plane may be done at first visit to improve cosmetic and functional result; injection helps patients through acute unstable phase

Facial palsy: levator muscle may work when orbicularis nonfunctional, producing lagophthalmos; addition of volume within aponeurosis of levator and weight of gel improve function of eyelid and allow eye to close; for patient with new onset of facial palsy in whom function may return, gel good option for temporary use

Congenital ectropion and retraction: threatens cornea in infants; to avoid surgery, hyaluronic acid may be injected into levator and subcutaneous planes to improve closure and protect cornea; gel may help skin to stretch so that surgery becomes unnecessary; some patients need repeated injections and some outgrow deformity

Hollowing of orbital rim: cosmetic issue related to aging; paradigm changing to include approaches that add volume; results after filling often better than results after surgery because filling more directly addresses loss of volume with aging; similar approach possible in superior sulcus; after eyebrow surgery, fat pad may be reinflated to treat dermatochalasis; in East Asian patients, loss of volume with aging may unveil contour of superior orbital rim and can be treated with hyaluronic acid gel

Summary: hyaluronic acid gel may be used to address upper and lower retraction of eyelid, congenital malposition of eyelid, and hollowing of orbital rim and superior sulcus

Readings

Chang HS et al: “En-glove” lysis of lower eyelid retractors with AlloDerm and dermis-fat grafts in lower eyelid retraction surgery. Ophthal Plast Reconstr Surg 2011 Mar-Apr;27(2):137-41; Goldberg RA et al: Treatment of lower eyelid retraction by expansion of the lower eyelid with hyaluronic acid gel. Ophthal Plast Reconstr Surg 2007 Sep-Oct;23(5):343-8; Papageorgiou KI et al: Thyroid-associated periorbitopathy: eyebrow fat and soft tissue expansion in patients with thyroid-associated orbitopathy. Arch Ophthalmol 2012 Mar;130(3):319-28; Taban M et al: Efficacy of “thick” acellular human dermis (AlloDerm) for lower eyelid reconstruction: comparison with hard palate and thin AlloDerm grafts. Arch Facial Plast Surg 2005 Jan-Feb;7(1):38-44.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Goldberg was recorded at the Ophthalmic Anesthesia Society 2016 Annual Scientific Meeting, held September 9-11, 2016, in Chicago, IL. For information about courses sponsored by the Ophthalmic Anesthesia Society, visit www.eyeanesthesia.org. The Audio Digest Foundation thanks the speakers and the Ophthalmic Anesthesia Society for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OP542403

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.