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Year : 2020  |  Volume : 58  |  Issue : 3  |  Page : 174-179

The dirty dozen: Myths in oculoplasty

Ophthalmic Plastic Surgery Services, L V Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission02-May-2020
Date of Acceptance14-May-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
Dr. Milind Naik
L V Prasad Eye Institute, Road No 2, Banjara Hills, Hyderabad - 500 034, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_47_20

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Medical myths develop when existing beliefs are not challenged. They remind us that we can be mistaken and need to question ourselves. Oculoplasty, a vital branch of ophthalmology, has been of interest to surgeons since olden days. This field has seen transformative changes in the last few years in light of new understanding and sophisticated techniques. In this write-up, we wish to address a dozen of these “unchallenged” myths which may not be wrong concepts but conventional approaches that need renewed thinking.

Keywords: Chalazion, dermoid, dacryocystorhinostomy, myths, orbital abscess, oculoplasty

How to cite this article:
Desai A, Naik M. The dirty dozen: Myths in oculoplasty. TNOA J Ophthalmic Sci Res 2020;58:174-9

How to cite this URL:
Desai A, Naik M. The dirty dozen: Myths in oculoplasty. TNOA J Ophthalmic Sci Res [serial online] 2020 [cited 2020 Oct 20];58:174-9. Available from: https://www.tnoajosr.com/text.asp?2020/58/3/174/294994

  Introduction Top

Populations around the world more so those in India with different cultural backgrounds are strongly influenced by myths. Myth refers to believed knowledge, faith in an idea, or an assumption that a community considers true enough to transmit over generations using stories. These myths are likely to determine an individual's way of living as well as their preferences in seeking treatment during illness.

Medical myths develop when existing beliefs are not challenged. These myths are a reminder that we can be wrong and need to question ourselves.

At the beginning of the 3rd century, a strange story was told by Claudius Aelianus, pseudo-Galen and Leonidas of Alexandria reporting that cataract couching originated when a goat with cataract skillfully punctured its eye with a thorn.[1] This understanding of cataract and its treatment witnessed in the third century has seen a sea change over time.

One of the most popular superstitions revolves around the twitching of the eyelid. Foreboding implications have been attributed to the twitches of the left eyelid. It is considered to be a harbinger of ominous events. In modern medicine, however, involuntary eyelid spasms are categorized under the terms such as orbicularis myokymia, blepharospasm, and hemifacial spasm. Oculoplasty, a vital branch of ophthalmology, has been of interest to surgeons since the olden days. Over the years, the diagnosis and management of various oculoplasty conditions have seen transformative changes in the light of new understanding and more sophisticated approaches and techniques. However, there are several unchallenged “myths” or beliefs in this field too, which we wish to address in this write-up. They may not actually be wrong concepts, but traditional approaches, that need renewed thinking in this century.

  Myth 1 Top

Chalazion warrants curettage if it has not resolved with warm compresses and eyelid massage

Chalazia are chronic lipogranulomatous inflammations of eyelids caused by plugged  Meibomian gland More Detailss.[2] Cosmetically, they can be unsightly and occasionally cause local symptoms such as irritation and visual complains due to astigmatism or mechanical ptosis. Most ophthalmologists treat them conservatively first, and when they do not respond, advice incision and curettage. There is good middle path though, with anti-inflammatory injections [Figure 1]. Ben Simon et al. reported that a single triamcinolone acetonide injection may be as effective as incision and curettage and also more tolerable.[3] Triamcinolone may be more advantageous in multiple chalazia or the ones situated near lacrimal puncta so as the circumvent functional problems associated with excessive scarring.[4]
Figure 1: A 20-year-old male with left lower lid chalazion (a). He received 0.4 ml of intra-lesional triamcinolone acetate injection trans-conjunctivally (b). Reduction in size of the lesion noted after 4 weeks (c and d). A second injection would flatten the lesion completely

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  Myth 2 Top

Lower canaliculus is more important

There is no definite proof of relative contribution of each canaliculus to lacrimal drainage. Although some reports state that lower canaliculus contributes more, others have found almost equal drainage by both superior and inferior canaliculus.[5] The dominance may be different between individuals and even between eyes.[6] Hence, the practice of ignoring upper canalicular lacerations is without any scientific basis. Both lower and upper canaliculi are of equal importance and should be intubated when involved in a laceration [Figure 2].
Figure 2: A middle-aged man with lower eyelid laceration involving the canaliculus. There is no evidence that lower canaliculus drains more tears than the upper, hence either should be repaired when injured

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Previously, an intravenous canula was used as a stent. With the availability of mini-monoka (silicone), the use of an intravenous canula is unwarranted. Mini-monoka has a collar which snugly fits the punctum and has less propensity for extrusion.[7]

  Myth 3 Top

A dacryocystorhinsostomy cannot be performed in acute purulent dacryocystitis

While an external incision can be difficult, an endonasal dacryocystorhinostomy (DCR) can be performed in acute purulent dacryocystitis [Figure 3]. It not only treats the underlying cause, which is nasolacrimal duct obstruction but also avoids the disruption of lacrimal pump mechanism.[8] Hence, referring the patient to an oculoplastic surgeon who performs endonasal DCR is better than waiting for external inflammation to settle.
Figure 3: Acute dacryocystitis in a 3-year-old child with bony NLD obstruction. An endonasal dacryocystorhinostomy is possible without having to wait for the external inflammatory process to subside

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  Myth 4 Top

Gold-weight implant is required for facial palsy (“Inside the Box” thinking)

Although many studies have demonstrated gold weight implant as a safe and reliable procedure to reduce lagophthalmos and protect the cornea, it does have the chances of exposure or extrusion. We need to think “Outside the Box,” and consider use of other efficacious options such as hyaluronic acid (HA) gel. HA gel can be injected using a feathered-layered approach throughout the length of the upper eyelid. The end point is the resolution of lagophthalmos without obstruction of the visual axis.[9]

HA gel is a safe, nonsurgical option to manage lagophthalmos and associated exposure keratopathy. As some causes of facial palsy are temporary (Bell's palsy), HA gel offers protection while we await recovery of the seventh nerve [Figure 4]. However, a multiplanar, feathered layered technique, involving preseptal and postseptal tissue planes as illustrated by Goldberg and Fiaschetti[10] is crucial to avoid lumpiness and contour irregularities.
Figure 4: A 53-year-old lady with right facial palsy and resultant lagophthalmos (a and b). Considerable improvement in her lagophthalmos after 0.6 ml of hyaluronic acid gel injection in her right upper eyelid to “add weight.” Despite being temporary, this is a good alternative to gold weight implant (c and d)

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  Myth 5 Top

Corticosteroids can reverse proptosis in thyroid eye disease

Unfortunately, this myth is rampant among ophthalmologists and endocrinologists alike. Patients are pumped with steroids in the hope to reverse proptosis, sometimes long after the active phase of the disease is over.

The fact is that steroids merely reduce the length of the active phase. In cases of dysthyroid optic neuropathy, steroids can avoid as surgical intervention. However, for the common signs of thyroid eye disease (TED) such as proptosis and eyelid retraction, steroids have no significant role in their reduction [Figure 5].[11],[12] Therefore, it is prudent to not promise reversal of thyroid signs with steroids. Normalization of appearance almost always requires surgical intervention.
Figure 5: A 55-year-old patient in the active (a) and inactive (b) phase of thyroid eye disease. Note that despite good control of thyroid levels and adequate steroid therapy, findings such as proptosis and eyelid retraction persist and can only be reversed by the surgery

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  Myth 6 Top

Control of T3 and T4 can reverse exophthalmos

Although thyroid ophthalmopathy is most commonly associated with Graves' disease, active phase of TED can occur in hyperthyroidism, hypothyroidism, and euthyroidism.[13] Many ophthalmologists are unaware, that systemic thyroid disease and TED take their independent course. Although there is some relation of systemic control and severity of TED, in most cases, the eye disease takes its own course since onset. The active phase of TED is therefore measured not from the onset of systemic disease, but from the onset of first sign of eye disease. On similar lines, control of T3 and T4 levels is not likely to pacify eye disease, which follows the Rundle's curve.

  Myth 7 Top

Less than 4 mm levator muscle action needs frontalis sling surgery

This has been the classic text-book teaching: Severe ptosis requires sling surgery. In unilateral congenital ptosis, outcome of frontalis sling is unlikely to be satisfactory and parents are often not convinced of bilateral sling surgery.[14],[15]

Whitnalls sling or supramaximal levator surgery can be an alternative option in this case (References). Whitnall's ligament works as a fulcrum to change the direction of levator muscle action from anteroposterior to vertical.[16],[17] This gives an opportunity to symmetrize eyelid fold, remove excess eyelid skin, and avoids brow incisions. Although this option may not last for the patient's lifetime, it is a good first option to exhaust before moving onto frontalis sling surgery [Figure 6].
Figure 6: Pre- and post-operative photographs of patients with severe eyelid ptosis (levator muscle function <4 mm) treated with maximal levator muscle resection. The eyelid fold symmetry is better than that seen with closed technique of suture sling surgery

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  Myth 9 Top

Following evisceration, an Ideal orbital implant is one that “fits well”

Earlier, orbital implants were often not placed for the fear of infection or extrusion. Now that ophthalmologists are aware of its advantages, choosing the ideal size is still a challenge. Implant “sizers” are proposed to be used intraoperatively to choose the implant size. Superior sulcus deformity and enophthalmos are the consequences of poor volume replacement. Therefore, rather than choosing the one that “fits well”, understanding the science of volumetrics is important.

Preoperative estimation of an accurate implant size has been addressed in the literature.[18] From [Figure 7], it is clear that adults with normal bony development should receive an orbital implant sizes 20 mm or above, for adequate volume replacement.[19]
Figure 7: The logic behind using a large-sized orbital implant. When the eyeball of 7cc volume is removed, approximately 4.5cc is to be replaced by the orbital implant, and 2.5cc by the custom prosthesis. By calculating the volumes of implants, it is clear that only implant of size 20 mm diameter or greater would adequately replace the required volume of 4.5 cc

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  Myth 9 Top

Lateral orbitotomy requires the removal of the orbital rim!

Lateral orbitotomy is a surgical technique used to access lateral orbit as well as retrobulbar space. Conventionally, lateral orbitotomy has involved an access through a Stallard Wright sub-brow incision, followed by the removal of lateral orbital rim. This was often touted as necessary to provide good access the posterior orbit. However, most current-day orbital surgeons are able to reach orbital apex or extract intraconal tumors without the need of this step. This ensures a minimally invasive and shorter surgery with faster recovery. So the question arises: Is removal of the lateral orbital rim elegant? And more importantly is it necessary? The answer in most cases, is “no”. Lateral orbital masses such as lacrimal gland tumour or even lateral retrobulbar masses can be accessed through a lid crease or transconjunctival approach without the classical amputation of the bony lateral orbital rim.[20]

In addition, navigation systems which use preoperative image data of patients and three-dimensional reconstruction through electromagnetic induction position on instruments help determine the accurate position and extent of the lesion intraoperatively thereby improving the safety.[21] Such minimally invasive techniques require a hidden and small incision with limited surgical trauma and this ensures a faster patient recovery.

  Myth 10 Top

A dermoid always has to be removed intact without spilling its contents

The authors have seen several experienced teachers preach this myth! “Don't spill the contents, or patient would have inflammation” it is said. Not true! Inflammation in a ruptured dermoid happens if the rupture happens naturally, and enough time is given for the contents to stay within surrounding tissues. Intraoperatively, rupture of dermoid also allows the spilling contents to be aspirated of washed with saline. In fact, the authors' advice deliberates incision on the dermoid, aspiration of the contents, and then, delivery of the collapsed cyst wall through a smaller incision [Figure 8]. A lid crease approach is certainly aesthetically appealing as it precludes visible scarring. For large periorbital dermoids, an excision is not required since visible scarring cannot be prevented. In such rare cases, the dermoid can be aspirated and sclerosed to attain an aesthetic outcome.[22]
Figure 8: A young female with right external angular dermoid (a). The dermoid was exposed through a small incision, punctured, and its contents aspirated to collapse the wall (b). The collapsed wall was then excised through the incision (c). This allowed the removal of the dermoid through an incision much smaller than the lesion (d)

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  Myth 11 Top

External dacryocystorhinostomy gives a visible scar

The gold standard surgical treatment for primary acquired nasolacrimal duct obstruction has been external DCR. A conspicuous scar near medial canthus has been touted as its' major disadvantage, and has even led to the evolution of endonasal techniques. The anatomic ease of an external DCR if it can be clubbed with the absence of a visible scar, would be ideal. In this regard, transconjunctival DCR has been reported, although the surgical access requires expertise.[23]

The subciliary skin incision approach [Figure 9] used for other eyelid and orbital surgeries gives excellent cosmetic results and at the same time maintains the advantages of external DCR.[24]
Figure 9: External dacryocystorhinostomy incisions. Conventional j-shaped incision along the anterior lacrimal crest leaves a visible scar. Subciliary incision can be cosmetically far superior, with no visible scar left

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  Myth 12 Top

An abscess always has to be drained

An abscess is infrequently encountered in ophthalmology practice, as a lacrimal abscess or orbital sub-periosteal abscess.[25] Orbital involvement of sinusitis is either due to direct extension of infection or due to thrombophlebitis along valve-less veins. An orbital SPA presents with proptosis, chemosis, motility limitation, and in extreme cases visual compromise.

In children below 9 years of age with small-to-moderate-sized medial subperiosteal abscesses (<10 mm), can be treated medically. Garcia and Harris defined criteria for medical management versus surgical intervention of patients with radiographically suspected SPA. In a group of carefully selected children under 9 years of age, their prospective study found a 93% response rate.[26] Cultures taken from the surgical specimens of children <9 years of age have been found to be negative or have shown to grow one aerobic bacterial species and are hence preferred for intravenous antibiotics as the first line of management.

In situations where lacrimal abscess drainage is indeed required, a wide-bore needle aspiration can do an equally good job rather than following the traditional surgical principles of cruciate incision followed by the breaking of loculi in our limited periorbital space [Figure 10].
Figure 10: Technique of aspirating orbital or lacrimal abscesses with an 18G needle instead of incision and drainage

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To summarize, myths can be pervasive and we, as ophthalmologists need to alter our practice patterns in light of developing scientific knowledge.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Leffler CT, Schwartz SG, Peterson E, Busscher J. Cataract couching and the goat's eye. Acta Ophthalmol 2018;96:755-6.  Back to cited text no. 1
Perry HD SR. Conservative treatment of chalazia. Ophthalmology 1980;87:218-21.  Back to cited text no. 2
Ben Simon GJ, Rosen N, Rosner M, Spierer A. Intralesional triamcinolone acetonide injection versus incision and curettage for primary chalazia: A prospective, randomized study. Am J Ophthalmol 2011;151:714-80.  Back to cited text no. 3
Bothra N, Ali MJ, Naik MN. To know when to prick!! Saudi J Ophthalmol 2017;31:203-5.  Back to cited text no. 4
White WL, Glover AT, Buckner AB, Hartshorne MF. Relative canaliculus tear flow as assessed by dacryoscintigraphy. Ophthalmology 1989;96:167-9.  Back to cited text no. 5
Murgatroyd H, Craig JP, Sloan B. Determination of relative contribution of the superior and inferior canaliculi to the lacrimal drainage system in health using the drop test. Clin Exp Ophthalmol 2004;32:404-10.  Back to cited text no. 6
Naik MN, Kelapure A, Rath S, Honavar SG. Management of canalicular lacerations: Epidemiological aspects and experience with Mini-Monoka monocanalicular stent. Am J Ophthalmol 2008;145:375-80.  Back to cited text no. 7
Lee TS, Woog JJ. Endonasal dacryocystorhinostomy in the primary treatment of acute dacryocystitis with abscess formation. Ophthalmic Plast Reconstr Surg 2001;17:180-3.  Back to cited text no. 8
Martín-Oviedo C, García I, Lowy A, Scola E, Aristegui M, Scola B. Hyaluronic acid gel weight: A nonsurgical option for the management of paralytic lagophthalmos. Laryngoscope 2013;123:E91-6.  Back to cited text no. 9
Goldberg RA, Fiaschetti D. Filling the periorbital hollows with hyaluronic acid gel: Initial experience with 244 injections. Ophthalmic Plast Reconstr Surg 2006;22:335-41.  Back to cited text no. 10
Vannuchi G, Covelli D, Campi I, Origo D Curro N, Cirello V, et al. The therapeutic outcome to intravenous steroid therapy for active Graves' orbitopathy is influenced by the time of response but not polymorphisms of the glucocorticoid receptor. Eur J Endocrinol 2013;170:55-61.  Back to cited text no. 11
Tu X, Dong Y, Zhang H, Su Q. Corticosteroids for graves' ophthalmopathy: Systematic review and meta-analysis. Biomed Res Int 2018;2018:4845894.  Back to cited text no. 12
Brownlie BE, Newton OA, Singh SP. Ophthalmopathy associated with primary hypothyroidism. Acta Endocrinol (Copenh) 1975;79:691-9.  Back to cited text no. 13
Callahan A. Correction of unilateral blepharoptosis with bilateral eyelid suspension. Am J Ophthalmol 1972;74:321-6.  Back to cited text no. 14
Anderson RL, Jordan DR, Dutton JJ. Whitnall's sling for poor function ptosis. Arch Ophthalmol 1990;108:1628-32.  Back to cited text no. 15
Ettl A, Zonneveld F, Daxer A, Koornneef L. Is Whitnall's ligament responsible for the curved course of the Levator palpebrae superioris mus-cle? Ophthalmic Res 1998;30:321-6.  Back to cited text no. 16
Kakizaki H, Takahashi Y, Nakano T, Ikeda H, Selva D, Leibovitch I. Whitnall ligament anatomy revisited. Clin Exp Ophthalmol 2011;39:152-5.  Back to cited text no. 17
Kaltreider SA, Jacobs JL, Hughes MO. Predicting the ideal implant size before enucleation. Ophthalmic Plast Reconstr Surg 1999;15:37-43.  Back to cited text no. 18
Kaltreider SA. The ideal ocular prosthesis: Analysis of prosthetic volume. Ophthalmic Plast Reconstr Surg 2000;16:388-92.  Back to cited text no. 19
Rosen N, Priel A, Simon GJ, Rosner M. Cryo-assisted anterior approach for surgery of retroocular orbital tumours avoids the need for lateral or transcranial orbitotomy in most cases. Acta Ophthalmol 2010;88:675-80.  Back to cited text no. 20
Zhou G, Ju X, Yu B, Tu Y, Shi J, Wu E, et al. Navigation-guided endoscopy combined with deep lateral orbitotomy for removal of small tumors at the lateral orbital apex. J Ophthalmol 2018;2018:2827491.  Back to cited text no. 21
Naik MN, Batra J, Nair AG, Ali MJ, Kaliki S, Mishra DK. Foam sclerotherapy for periorbital dermoid cysts. Ophthalmic Plast Reconstr Surg 2014;30:267-70.  Back to cited text no. 22
Kaynak-Hekimhan P, Yilmaz OF. Transconjunctival dacryocystorhinostomy: Scarless surgery without endoscope and laser assistance. Ophthalmic Plast Reconstr Surg 2011;27:206-10.  Back to cited text no. 23
Dave TV, Javed Ali M, Sravani P, Naik MN. Subciliary incision for external dacryocystorhinostomy. Ophthalmic Plast Reconstr Surg 2012;28:341-5.  Back to cited text no. 24
Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970;80:1414-28.  Back to cited text no. 25
Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: Analysis of outcomes 1988-1998. Ophthalmology 2000;107:1454-6.  Back to cited text no. 26


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]


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