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MORAN - Oculoplastics OKAP

Terms in this set (64)

- What is the common eyelid cancer that is misdiagnosed as a chalazion?
- Why does it look like papillary conjunctivitis?
- Management?
- Tissue handling/ pathology staining**?
- Why are cells vacuolated on the slides?
- Sebaceous cell carcinoma
- Pagetoid spread (aka upward spreading)
- Management: Excision with sentinel node biopsy
- Tissue handling/staining: Fresh tissue + Oil Red O stain
- Vacuolated because fat/lipid removed by EtOH during processing
Which glands does sebaceous cell carcinoma come from?
Where is the most common location?
Why is the upper lid more common?
Meibomian and Zeiss
Upper lid
2 times as many meibomian glands on upper lid
Kid with ptosis and superonasal lid fullness associated with a bruise... what are you thinking?
- Where is it derived from? Which recti muscle?
- At what age does this usually present?
- What is the treatment?
- What is the prognosis if it hasn't metastasized?
- What is the pathological stain for this disease?
Rhabdomyosarcoma
- Undifferentiated pluripotent mesenchymal cells (NOT the recti muscle)
- Usually presents at age 8
- Chemo and Radiation
- Prognosis: 95% cure
- Desmin
- What is the most type of rhabdomyosarcoma?
- Where is the location most commonly?
- What type is most lethal and what is the % survival?
- Where is the location of the most lethal type?
- Which type has the best survival?
- Embryonal in 80% of cases
- Superonasal
- Alveolar (10% survival), usually lower orbit
- Pleiomorphic best survival (97%)
What is the mnemonic for rhabdomyosarcoma for most common, most lethal, and best survival types?
"Everyone has Embryonal, Awful Alveolar, and Please give me Pleiomorphic"
Which parts of the orbit have the sphenoid wing?
- What is the roof made of?
- What is the medial wall made of?
- What is the lateral wall made of?
- What is the floor made of?
All except the floor have a sphenoid wing involved!

Roof = lesser wing + frontal
Medial = lesser wing + maxillary, ethmoid, lacrimal
Lateral = greater wing + zygomatic

Floor = Palatine + Maxillary + Zygomatic
Medial canthal swelling in an infant...
- If it's above the MCT, what are you suspecting and what do you do?
- If below the MCT and bluish? Where is there a blockage? What is it secondary to? What do you do for them?
- What is the second one commonly filled with? What if it doesn't go away?
- What is the management if preseptal cellulitis or dacryocystitis develops?
Above MCT = Encephalocele (get MRI)

If below then dacryocystocele. There's a blockage superiorly and inferiorly. It's secondary to congenital NLDO. You massage it for 1-2 weeks to see if it goes away.
- Filled with amniotic fluid or mucous

If no improvement then probing...

If preseptal cellulitis/dacryocystitis then:
- Admit + IV ABX + probe
What portion of the orbicularis muscle is responsible for:
- Forced eyelid closure?
- Involuntary eyelid closure?
Forced = Orbital
Involuntary = Pretarsal
Muller's muscle
- How many mm of elevation do you get if you do a Mullerectomy?
- Where does it insert?
- 2 mm
- Superior border of the tarsal plate
Levator
- Where does the Levator insert?
- Inferior one half of the anterior tarsus
Which portion of the optic nerve is most susceptible to injury from blunt trauma to the head?
Intracanalicular
Which bone makes up the optic canal?
- Lesser wing of the sphenoid
Lacrimal system
- What is the NLD trajectory?
- Where does it enter the nose? Where does it enter the nose if you do a DCR?
- Which 2 bones are you removing when you do a DCR? What makes up both of these?
Inferiorly —> Posteriorly —> Laterally

Inferior meatus.... If DCR then middle meatus

DCR removes anterior lacrimal crest (maxillary bone) and posterior lacrimal crest (lacrimal bone)
What's the most common sign of TED?
Lid retraction
Canaliculitis
- What's the usual bacteria?
Actinomyces israelii
Which muscle is not affected when doing a retrobulbar block? Why?
Superior oblique because CN4 (trochlear) is outside the muscle cone. CN3 and CN 6 are inside the cone
What is the eye movement maintained after a retrobulbar block?
Incyclotorsion
What is the structure between the greater and lesser wings of the sphenoid?
Superior Orbital Fissure
What structures go through the superior orbital fissure?
- Inside vs outside Zinn
Inside (Naso SC^2 are in)
- CN3
- Nasociliary nerve (V1)
- CN 6
- Sympathetics

Outside (LFTs are out)
- CN 6
- Lacrimal nerve (V1)
- Frontal nerve (V1)
- Superior ophthalmic vein
Frontal nerve
- Is a branch of which nerve?
- What does it branch into?
- Ophthalmic division V1
- Supraorbital and supratrochlear
What structures pass through the inferior orbital fissure?
Maxillary nerve (CN V2)
Inferior ophthalmic vein
What structures pass through the optic canal?
Optic nerve
Ophthalmic artery
Sympathetics
Which sinus is directly adjacent to the optic nerve?
Sphenoid sinus
What is the eyelid venous drainage? (hint: 3 different parts)
Medial pretarsal —> Angular vein
Lateral pretarsal —> Superficial temporal vein

Post-tarsal —> Orbital veins + Deep branch of anterior facial vein + pterygoid plexus
Orbital septum
- Where does it arise from?
- Where does it fuse in caucasians in the upper lid?
- Lower lid?

- Where does the orbital septum fuse in the upper lid, in asians?
- Arises from the —> Periosteum
- Upper lid —> Fuses to levator ~2-5 mm above the tarsus
- Lower lid —> Inferior border of tarsus

In asians = Between margin and upper border of tarsus (low crease)
What is the minimum amount of skin you have to leave with a blepharoplasty?
20 mm of skin between the inferior border of the brow and the upper eyelid margin
When doing a lower lid bleph, you need to be careful when removing fat because the _________________ is positioned between the _________ and __________ fat pads.
The inferior oblique is positioned between the central and medial fat pads.
What are the 3 main causes of involutional entropion?

What surgery will correct all 3?
- Horizontal laxity
- Disinsertion of lower eyelid retractors
- Overriding orbicularis

Lateral tarsal strip + retractor advancement
The lateral canthus is positioned about ______ mm higher than the __________ canthus
2 mm higher than the medial canthus
Peripheral arterial arcade is sandwiched between the _______________ and ______________ and is situated just superior to ___________________.
Sandwiched between the Muller's muscle and levator and situated just superior to the superior tarsal plate
What is the thinnest portion of the maxillary bone in the orbital floor?

Which bone is the most commonly fractured?
Posteromedial

Lamina paprycea of the ethmoid
Molds:
- Which mold is septated?
- Which is non-septated?
Septate = Aspergillus + Fusaria

Non-septate = Mucor + Rhizopus
What should you not use intraop in an oculoplastics procedure if you see an ECG with a pacemaker?
Monopolar cautery
What is the mechanism of action of lidocaine?
Blocks sodium channels
What's the mechanism of action of botox?
Inhibits release of ACh at the neuromuscular junction
Clostridium botulinum
- Gram positive or negative?
- Shape?
- Aerobic or anaerobic?
Gram positive
Rod
Anaerobic
DCR 4 weeks post-op and you see a bunch of red dots in multiple foci along the NLD. What organism are you concerned about?
Atypical myobacteria
Orbital metastases:
- Most common in men?
- Women?
- Men = lung
- Women = breast
Most common cause of unilateral proptosis?
- Bilateral?
- What about kids?
Unilateral adults = TED

Bilateral = TED

Kids = Orbital cellulitis
EOM enlarged on imaging:
- Tendon sparing —> ?
- Tendon-involving —> ?
Tendon-sparing = TED
Tendon-involving = Orbital Pseudotumour
What's the lower eyelid structure that's analogous to the levator in the upper lid?
- What does it arise from?
- Where does it insert?
Capsulopalpebral fascia

Arises from the Inferior Rectus

Inserts at the lower tarsal border
What are the accessory lacrimal glands and where are they located?
- What type of secretory gland are they?
Wolfring —> Non-marginal tarsal borders
Krause —> Fornices (deeper)

They're exocrine glands
Where is the location of blockage in the following scenarios:
- Difficult to advance cannula and reflex through same canaliculus
- Difficult to advance and you get reflux through OPPOSITE canaliculus (What % of people have this structure?)
- What if you're able to advance to the sac but with reflux of saline and mucopupulent stuff?
- Same canaliculus = Canalicular blockage
- Opposite canaliculus = Common canaliculuar blockage (90% of people have this)
- NLD
What is the most common epithelial tumour of the lacrimal gland?
- What is the treatment?
Benign mixed tumour (pleiomorphic adenoma)

Complete excision because of malignancy!
What is the most common ocular finding in Parkinson disease?
Decreased blink
Most common primary malignancy of the lacrimal sac?
Squamous cell carcinoma
Organism most commonly responsible for necrotizing fasciitis?
- Treatment?
Group A Streptococcus

Treatment: IV ABX + limited debulking to preserve as much tissue as possible. You just keep cutting until it bleeds
Marcus Gunn Jaw Winking occurs when which two muscles are synkinetic?
Pterygoid + Levator
Meibomian glands
- Where are the mostly located?
- What type of gland is it?
- What type of secretion is it?
Superior tarsus 2x > Inferior tarsus

Sebaceous gland

Holocrine glands
What's the volume of the orbit?
Which part is the widest?
What's the shortest wall of the orbit?
Orbital volume = 30 ccs
Widest part = 1 cm post to orbital rim
Shortest wall = floor
Orbital lymphoma
- Where's the most common location?
- What type is the vast majority of them?
- and of which variety?
- How do you send the biopsy?
- Lacrimal gland fossa
- Non-Hodgkin B-cell
- MALT
- Fresh tissue because of flow cytometry
A lymphoproliferative lesion arising at this periocular site gives the highest risk of developing a systemic Non-Hodgkin's Lymphoma
Eyelid
List the locations of eyelid basal cell carcinomas from most common to least common
Most common: Lower lid
Next most: Medial canthus
Next most: Upper lid
Least common: Lateral canthus
What's the medication you can use for basal cells if you can't excise them?
- What's the most common side effect of this medication
Sonic Hedgehog inhibitor

S/E = Hair loss + skin changes
Malignant melanoma of the eyelid:
- What's the most important prognostic factor for patient survival?
Tumour thickness
What is a big blue scleral lesion that's commonly seen?
Oculodermal melanocytosis (Nevus of Ota)
Nevus of Ota:
- What's the risk of uveal melanoma?
- What %tage get glaucoma?
- Risk of uveal melanoma among general population?
- 1 in 400
- 10%
- 6 in 1 000 000
What is this common lower eyelid congenital abnormality in a kid?
- Management?
Epiblepharon
- Observe them because they tend to resolve on their own
What's this called?
Ankyloblepharon
What's this called? How do you treat it?
Euryblepharon —> lengthening of horizontal palpebral fissure

Treatment: Lateral tarsal strip or skin graft
What's this?
Epicanthus inversus —> fold of skin perpendicular to and overlying medial canthal tendon
What are the components of blepharophimosis syndrome?

What is the inheritance?
Blepharophimosis
Ptosis
Telecanthus
Epicanthus inversus

Autosomal dominant
Which eyelid reconstruction technique would you use for each of these scenarios:
- Defect less than 33%
- 33% to 50%
- Defect greater than 50% for upper and lower
- Less than 33% = Direct closure
- 33% to 50% = lateral canthotomy and semicircular flap (tenzel)
- Greater than 50%
—Upper lid = Cutler-Beard
—Lower lid = Hughes flap
TED
- What cell is responsible for orbital pathophysiology?
- What is the product synthesized by fibroblasts and deposited in orbital tissues?
- What sex is it more common in?
- How many times more common in this sex?
- Fibroblasts
- GAGs
- Females
- 6 times
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