12.4  Oculoplastics Procedures

12.4.1 Dacryocystorhinostomy (DCR)

Y (Why Have the Procedure)

“You have a blockage in the duct that drains tears from your eye into your nose”

Aims:

“Unblock the tear drainage duct to fix your watery eye (and reduce the risk of infection)”

M (Mechanism, What is the Procedure)

“A DCR involves making a new larger passage to allow the tears to drain from your eye into your nose (where the tears normally drain). There are two options”:

External
~95% success

  1. Easier access / technically
  2. No need for special equipment
  3. May be performed under LA

Endonasal (“Keyhole Surgery Through Your Nose”)
~90-95% success (improving with learning curve / equipment)

  1. No scar
  2. Faster recovery, less pain
  3. Can directly visualise nasal pathology

But may need to convert to external (1%)

  • “The operation can be done to one side at a time or both sides at once. The operation takes about 60 minutes per side, during which time you have to lie still under a surgical drape (blanket). External DCR may be performed under LA (small injection around your eye) or GA. Endonasal DCR is performed under GA. Your anaesthetist will explain this further.”
  • Pre-operation: Fasting, stop anticoagulants
  • Post-operation: Usually day only, dressings, drops, oral antibiotics, resume anticoagulants

C (Complications)

Although DCR has very good success rates, complications may occur:

More Common

  1. Failure

Approximately 5% chance the passage will close again.

Watery eyes may be a result of a number of factors. Relieving the blockage will improve symptoms due to the blockage but will not relieve symptoms from other causes such as eyelid inflammation.

  1. Bleeding

No nose blowing, stop anticoagulants, head up, avoid hot fluids. Usually stops spontaneously but may need nose packing / admission

  1. Scar

Small 1cm scar on the side of your nose (not with endoscopic DCR)

  1. Infection

No nose blowing, stop anticoagulants, head up, avoid hot fluids. Usually stops spontaneously but may need nose packing / admission

  1. Tubes

No nose blowing, try not to remove yourself (usually removed at about 6 weeks)

Less Common (May Need Further Surgery)

  1. Loss of Vision

Small 1cm scar on the side of your nose (not with endoscopic DCR)

  1. Anaesthetic Risks

No nose blowing, stop anticoagulants, head up, avoid hot fluids. Usually stops spontaneously but may need nose packing / admission

Stress compliance, follow-up, need for urgent review if develop constant bleeding.

A (Alternatives)

  1. Observation. Ongoing epiphora and small risk of dacryocystitis
  2. (Endoscopic DCR)

Confirm that the patient understands. Any questions?

12.4.2 Eyelid Malposition Surgery

Y (Why Have the Procedure)

Eyelid malposition surgery is performed for a large number of different conditions. Broadly speaking, indications and possible procedures include:

  1. Entropion
  2. Ectropion
  3. Trauma or post-surgical malposition
  4. Congenital abnormalities
  5. Lateral or medial canthal abnormalities

Usually the aim is to correct an aesthetic problem, improve protection of the ocular surface, or to address epiphora related to lid malposition.

M (Mechanism, What is the Procedure)

Eyelid surgery is generally performed under local anaesthetic, although larger or longer procedures may be more appropriately conducted under general anaesthetic. Depending on the type of surgery required, incisions will usually be made on the skin, but can be made on the insides of the eyelids if required. The malposition is corrected using a variety of techniques.

Skin incisions generally heal well with minimal and well concealed scars. After surgery antibiotic ointment and possibly oral antibiotics will be prescribed. Follow up will generally be a week or two after surgery.

C (Complications)

Serious complications from eyelid surgery are rare.

More Common

  1. Minor bruising and swelling (usually resolves over 2 weeks)
  2. Scarring (all skin incisions leave a visible but subtle scar. Keloid scarring is possible but uncommon.)
  3. Wound infection or breakdown
  4. Dry eye – most eyelid procedures will cause some subjective dryness. Prophylactic can be given to minimise this.

Less Common

  1. Severe bleeding (retrobulbar haemorrhage) – this is the most feared complication with post-septal eyelid surgery and can rarely lead to the need for an emergency second operation or even blindness. Anticoagulants should be discontinued if possible, and meticulous haemostasis is mandatory.
  2. Ptosis or altered eyelid contour
  3. Altered sensation (usually transient)
  4. Asymmetric appearance of the eyelids (depending on the type of operation performed)
  5. The need to perform a second operation, either in the short or long term

A (Alternatives)

This depends on the pathology. Epiphora is often multifactorial and if the primary goal of the surgery is to address this then alternatives include lubricant drops, punctoplasty or DCR surgery.

Confirm that the patient understands. Any questions?

12.4.3 Orbital Floor Fracture Repair

Y (Why Have the Procedure)

You have a fracture in the bones of your eye socket. Without treatment this can lead to double vision and the appearance of your eye being sunken.

Aims:

  1. Maximise binocular single vision (BSV) in primary / downgaze (reading).
  2. Cosmesis.

M (Mechanism, What is the Procedure)

“An orbital floor fracture repair involves gaining access to the bones of the eye and covering the break with an “artificial bone” (implant).”

  • “The operation is usually performed under a GA in the operating theatre- your anaesthetist will explain this further. The operation usually takes about 60 to 90 minutes.”
  • Pre-operation: Fasting, stop anticoagulants
  • Post-operation: Admit overnight, monitor optic nerve function overnight, drops ± course of steroids, oral antibiotics
  • “It will take a few weeks for the swelling to settle down and the success of the operation to be known”

C (Complications)

As with all operations, complications may occur:

Common

  1. Persisting diplopia: May need secondary strabismus surgery to correct
  2. Bleeding
  3. Infection : Wound, orbital cellulitis
  4. Cheek numbness: Sensation can take months to recover or may not recover

Less Common

  1. Orbital haemorrhage: Can lead to permanent loss of vision. Observe post-operatively for this complication.
  2. Damage to the optic nerve
  3. Implant extrusion: Need for further surgery
  4. Eyelid changes: Ptosis / retraction, ectropion / entropion
  5. General anaesthetic risks

Stress compliance, follow-up.

A (Alternatives)

Observation

Confirm that the patient understands. Any questions?

12.4.4 Orbital Surgery

Y (Why Have the Procedure)

Orbital surgery is performed for a large number of different conditions.

Aims:

1. Diagnostic incisional biopsies
2. Diagnostic and therapeutic excision biopsies
3. Decompression surgery
4. Foreign body removals
5. Rehabilitative surgery
6. Optic nerve sheath fenestration.

The specific benefits of the surgery depend on the proposed procedure.

          

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