Oculoplastic Surgeries

Eyelid Surgeries - Lid Lifters & Fixers

• Corrective procedures for eyelid malpositions (ptosis, entropion, ectropion) and aesthetic enhancement (blepharoplasty). Surgical choice depends on underlying cause and severity.

• Blepharoplasty:

  • Upper: Excision of redundant skin (dermatochalasis) ± orbicularis muscle/fat. Improves visual field obstruction.
  • Lower: Addresses fat prolapse (bags) & skin laxity via transconjunctival or transcutaneous approach.

• Entropion Repair (Inward lid turn):

  • Aims to evert lid margin. Common: Lateral Tarsal Strip, Wies procedure, Quickert sutures.

• Ectropion Repair (Outward lid turn):

  • Aims to invert lid margin. Common: Medial Spindle, Lateral Tarsal Strip, Bick's procedure.

⭐ Gold standard for severe congenital ptosis with poor levator function (<4mm) is frontalis sling surgery using autologous fascia lata.

Lacrimal Surgeries - No More Tears!

• Goal: Relieve epiphora from Nasolacrimal Duct Obstruction (NLDO).
• Congenital NLDO (CNLDO): If massage fails by 6-12 months → Probing. Persistent → DCR/Intubation.
• Acquired NLDO:
  • Dacryocystorhinostomy (DCR): Anastomosis between lacrimal sac & nasal mucosa.
    • External DCR: Gold standard, success >90%.
    • Endonasal DCR: No external scar.
  • Dacryocystectomy (DCT): Sac removal (e.g., tumor, severe dry eye, failed DCRs). Epiphora persists.
  • Canalicular Obstruction: Requires specific repair (e.g., Canaliculodacryocystorhinostomy (CDCR) with Jones Tube).

⭐ External DCR is the gold standard for acquired NLDO, creating an anastomosis between the lacrimal sac and nasal mucosa, with success rates typically exceeding 90%.

Orbital Surgeries - Deep Dive Rescues

• Indications: Trauma (blowout #), tumors, Thyroid Eye Disease (TED) (compressive optic neuropathy/severe proptosis), orbital abscess.
• Orbital Decompression:
  • Goal: ↑ Orbital volume, ↓ Intraocular Pressure (IOP), relieve optic nerve compression.
  • Sites: Medial/floor (common), lateral wall (balanced decompression), fat removal.
  • Primarily for Graves' orbitopathy.
• Orbitotomy:
  • Surgical entry into the orbit.
  • Approaches: Anterior (transconjunctival/transcutaneous), lateral (e.g., Stallard-Wright), transcranial.
  • Uses: Tumor biopsy/excision, foreign body removal, abscess drainage.
• Blowout Fracture (#) Repair:
  • Common sites: Orbital floor (inferior wall), medial wall.
  • Signs: Diplopia, enophthalmos >2mm, muscle entrapment (restricted movement), infraorbital nerve anesthesia.
  • Timing: Ideally within 2 weeks to prevent fibrosis.
• Key Complications: Vision loss (e.g., Optic Nerve Head ischemia, retrobulbar hemorrhage), persistent diplopia, Cerebrospinal Fluid (CSF) leak, infection, paresthesia.

⭐ > In orbital floor blowout fractures, entrapment of the inferior rectus muscle can cause restricted upgaze and a positive forced duction test.

Socket Surgeries - The Empty Eye Story

• Indications: Blind painful eye, intraocular malignancy (retinoblastoma, melanoma), severe trauma, phthisis bulbi, sympathetic ophthalmia prevention, cosmesis.
• Procedures:
  • Evisceration: Intraocular contents removed; sclera +/- cornea, Extraocular Muscles (EOMs) preserved.
    • Avoid if malignancy suspected.
  • Enucleation: Entire globe + optic nerve portion removed; EOMs detached & reattached to implant.
    • For tumors, severe trauma.
  • Exenteration: Globe + all orbital contents removed (eyelids, EOMs, fat). For invasive orbital malignancies.
• Orbital Implants: Restore volume, aid motility. Types: Polymethylmethacrylate (PMMA) (non-porous), Hydroxyapatite, Porous Polyethylene (porous).
• Complications: Post-Enucleation Socket Syndrome (PESS), contracted socket, implant exposure/extrusion, ptosis.
• Rehabilitation: Ocular prosthesis; conformer used for 4-6 weeks post-operatively before prosthetic fitting.

⭐ Enucleation within 2 weeks of severe penetrating ocular trauma is considered prophylactic against sympathetic ophthalmia in the fellow eye.

High‑Yield Points - ⚡ Biggest Takeaways

• DCR for NLDO; External DCR has higher success than Endoscopic.
• Involutional entropion: Wies procedure; Ectropion: lateral tarsal strip.
• Ptosis surgery: Levator resection if levator function >4mm; frontalis sling if <4mm.
• Enucleation: globe removal; Evisceration: preserves sclera; Exenteration: all orbital contents.
• Orbital decompression for compressive optic neuropathy in Thyroid Eye Disease.
• Chalazion: Incision & Curettage (I&C) for persistent lesions_._