Surgical technique

The transconjunctival procedure is performed with the patient under local anesthesia. Two percent lidocaine (Xylocaine) with 1 : 100,000 epinephrine is injected subcutaneously at the center of the lower eyelid just beneath the lashes. An additional anesthetic agent is injected into each fat pad. To inject the anesthetic into the nasal, central, and temporal fat pad, the surgeon inserts a 25-gauge, 0.8-cm needle just above the inferior orbital rim and directs it downward slightly until it penetrates its entire length (0.8 cm). The barrel of the syringe is withdrawn to make sure that no blood has been entered, and approximately 0.5 ml of the agent is injected into each of the three fat pads.

A 4-0 black silk traction suture is placed through skin, orbicularis muscle, and superficial tarsus at the center of the eyelid. The surgeon pulls the eyelid downward with a traction suture as the assistant everts the lower eyelid over a small Desmarres retractor to expose the inferior palpebral conjunctiva. Additional anesthetic is injected subconjunctivally over the inferior palpebral conjunctiva across the eyelid. Topical tetracaine is instilled over the eye, and a scleral lens is placed over the eye to protect it. Two percent lidocaine with epinephrine is also injected subcutaneously over the center of the upper eyelid, and a 4-0 black silk traction suture is placed through skin, orbicularis muscle, and superficial tarsus to pull the upper eyelid upward.

A Colorado needle or disposable cautery (Solan Accu-Temp, Xomed Surgical Products, Jacksonville, FL) is applied to the inferior palpebral conjunctiva. The Colorado needle or cautery are used to cut conjunctiva from the medial to temporal end of the eyelid halfway between the inferior palpebral fornix and the inferior tarsal border (Fig. 14-1). The surgeon grasps the inferior edge of the severed palpebral conjunctiva while the assistant grasps the adjacent, more superior edge with forceps and the assistant pulls the Desmarres retractor downward (Fig. 14-2). The two forceps are pulled apart. Further dissection with the Colorado needle or disposable cautery is carried out through Müller’s muscle and capsulopalpebral fascia until fat is seen.

Figure 14-1 A Colorado needle is applied to the inferior palpebral conjunctiva halfway between the fornix and the inferior tarsal border and is used to severe the conjunctiva from medial to temporal end of the eyelid.

Figure 14-2 With forceps, the surgeon and surgeon’s assistant grasps the inferior and superior edges, respectively of the severed palpebral conjunctiva to facilitate dissection of Müller’s muscle and capsulopalpebral fascia with the Colorado needle.

A 4-0 black silk double arm suture is passed through the inferior edge of conjunctiva, Müller’s muscle, and capsulopalpebral fascia and the suture arms are pulled upward and clamped to the drape (Fig. 14-3).

Figure 14-3 A 4-0 double-armed black silk suture is placed through the inferior edge of conjunctiva, Müller’s muscle, and capsulopalpebral fascia and is pulled upward and clamped and taped to the drapes.

A small Desmarres retractor is placed over the lower eyelid and is pulled downward and outward to expose the orbital fat. With the use of cotton-tipped applicators, disposable cautery, and Westcott scissors, blunt dissection is carried out to isolate the three orbital fat pads. The central and nasal fat pads are divided by the inferior oblique muscle, which can be easily seen through the internal approach and should be identified to avoid injury to the structure. Also, the nasal and central fat pads are found in a slightly more temporal position than when they are isolated through an external approach.

The temporal herniated orbital fat is isolated, and the fat that prolapses with gentle pressure on the eye is clamped with a hemostat and cut along the hemostat blade with a No. 15 Bard–Parker blade. Then cotton-tipped applicators are placed underneath the hemostat as a Bovie cautery is applied over the fat stump. The surgeon grasps the fat with a forceps before it is allowed to slide back into the orbit to make sure that there is no residual bleeding that might cause a second retrobulbar hemorrhage.¹

After the first temporal fat pad is removed, the surgeon applies additional pressure to the eye to determine whether there is a second temporal fat pad.² If a second temporal fat pad is found, it is also removed. The central and nasal fat pads are then removed in a similar manner (Fig. 14-4).

Figure 14-4 The surgeon removes the temporal, central, and nasal orbital fat pads by cutting along the hemostat blade with a #15 Bard-Parker blade and then applying a Bovie cautery to the fat stump.

The 4-0 silk suture that attaches conjunctiva, Müller’s muscle, and capsulopalpebral fascia to the superior drape is then removed. Conjunctiva is reapproximated with three 6-0 plain catgut buried sutures (Fig. 14-5). Gentamicin (Garamycin) is applied over the eye.

Figure 14-5 The conjunctiva is reapproximated with three 6-0 plain catgut buried sutures.

Postoperative care

No dressings are used after surgery. The patient is instructed to apply ice cold compresses on the eyelids. Pads 4 by 4 inches, soaked in a buckle of saline and ice are applied with slight general pressure to the lids. When the pads become warm, they are dipped again into the saline and ice and reapplied. This process is repeated for 24 hours. The application should be fairly constant for the few postoperative hours. After that the compresses are applied for about 15 minutes with a 15-minute rest period in between until bedtime. The applications are resumed on awakening.

To reduce edema postoperatively the patient lies in bed with the head approximately 45° higher than the rest of the body. Nurses should check for bleeding associated with proptosis, pain, or loss of vision every 15 minutes for the first two to three hours postoperatively or until the patient leaves the surgical facility. Every hour thereafter until bedtime, the family or patient should monitor the patient’s ability to count fingers and should check for residual proptosis and pain. If the patient cannot count fingers or has marked proptosis or pain, the family should take him or her to the emergency room. If loss of vision occurs secondary to retrobulbar hemorrhage, it could easily be detected by opening the incision involved.¹ Garamycin ointment is applied to the eyes twice a day for the first two weeks.

Complications

Several patients in whom I performed the transconjunctival approach had postoperative residual dermatochalasis, which needed to be removed through an external approach or a laser skin resurfacing. Better patient selection or combined initial procedure with skin flap excision or orbicularis muscle plication could have prevented this problem.

Although this procedure has not caused any motility problems, in several patients in whom this procedure was combined with a tarsal strip procedure, ocular motility restriction and diplopia occurred secondary to scar tissue that developed between the globe and the temporal inferior orbital wall.³ There is also the possibility of residual herniated orbital fat in which case a second transconjunctival approach removal is indicated. Although a sunken lower eyelid is possible, it is fortunately rare with good patient selection. If it occurs, it can be treated with a cheek mid-face lift (Chapter 23), or fat injections, or grafts.

Results

I have performed the transconjunctival approach in more than 1000 patients (Figs 14-6 & 14-7). The procedure has the advantage of causing less eyelid retraction and ectropion than with the skin flap or skin muscle flap approaches because the external lamellae is not manipulated. I believe that there is less ecchymosis because the orbicularis muscle and skin are not severed. There tends to be more conjunctival chemosis immediately postoperatively with this procedure than with the external technique. If it occurs, it is treated with pressure applied over the closed eyelids.⁴

Figure 14-6 A, Preoperative appearance of a patient with herniated orbital fat of both lower eyelids with no significant dermatochalasis (excessive skin). B, Postoperative appearance after resection of orbital fat using the transconjunctival approach.

Figure 14-7 A, Thyroid ophthalmopathy patient with lower eyelid fat associated with exophthalmas and eyelid retraction. B, Same patient after transconjunctival lower eyelid fat removal. Patient also had upper eyelid Müller’s muscle excision, lower eyelid hard palate graft, lateral tarsorrhaphies and upper eyelid nasal fat removal.

Because the procedure is more difficult to master than the external approach, a surgeon should not perform this procedure without prior exposure to it.