Pre-operative planning in MMS (Eyelid Tumors)

It is generally best to see all patients who require eyelid surgery before the date of Mohs Surgical Excision because doing so allows proper planning for surgery. All records from the referring physician should be present including the biopsy report if any, previous photos, previous slides, and report of the eye examinations Patients with larger or more difficult cancers should have visual acuity exams so that any change in vision can be documented. Eyelid lesion should be measured and photographed, and the precise location measured and recorded about important landmarks (for example, upper and lower puncta or lateral commissary).

Instruments

Mohs surgery for the eyelid requires a variety of instruments that are different from those used in routine cases. The complex architecture, the thinness of the skin, and the need to protect the eye account for these differences.

• A scalpel
• A spring-action Castroviejo scissors
• Strabismus scissors
• Delicate toothed forceps
• Delicate needle driver
• Fine tipped hemostats
• Chalazion clamps
• Ocular shields
• Lid plates or Retractors
• A suction device

Antisepsis

The standard antiseptic used by the ophthalmologist surgeons for eye and conjunctiva is 5% aqueous povidone-iodine. It has the advantage of being active against a broad spectrum of bacteria and viruses, and bacterial resistance has not been seen.

Anesthesia

Excellent anesthesia of the eye is especially important in periocular surgery.

Topical ocular anesthesia

Tetracaine HCL (0.05%) is an excellent topical ocular anesthesia. Because it has a short duration of the activity, it is beneficial when one wishes to have protective reflexes return to the eye as soon as possible.

Periocular anesthesia

Local infiltration using Lidocaine 2% with epinephrine provides excellent periocular anesthesia.

Ocular Protection

Ocular protection can be accomplished in the following ways:

Manual shielding

When treating simple, uncomplicated tumors of the eyelids, manual shielding of the eyelids can be used to protect the globe.

Scleral or Ocular shields

Ocular shields of various sizes and shapes, with posts or suction cup removal devices, are readily available.

Chalazion clamp

The chalazion clamp can be useful for small to medium tumors of the eyelids. The chalazion clamp is useful because it not only protects the eye but also provides a bloodless field.

Lid plate

Lid plates, such as the Jaegar lid plate, can be inserted into the conjunctival fornix and protect the globe and backing and stabilization for the surgery on the eyelid.

Surgical Exposure

Atraumatic surgical exposure of the eyelid can be accomplished in the following ways:

Manual retraction:

For small lesions, the assistance may simply place gauze on the skin and retract the lid with his or her fingers. Retraction can also be accomplished with a dry cotton bud.

Desmarres lid retractor:

The Desmarres lid retractor is deeply is a deeply hooked, atraumatic retractor designed for lid retractor. Variations on this lid retractor can also be found.

Suture retraction

In cases where a high level of eyelid control is necessary, sutures may be placed in strategic locations to allow retraction of the eyelid.

MOHS Excisions

The principles of Mohs Surgery of the eyelid are no different from those of Mohs Surgery in any other part the tissue must be excised so that all margins can be examined under the microscope. There are slight variations in how the tissue is harvested in the periocular region. A small suction is very helpful in deep canthal excisions because visibility is more important. Along with the above mentioned tools, HEMOSTASIS, and SPECIAL ANATOMICAL CONSIDERATIONS (Lacrimal ducts) are of great importance. If coordinated care is anticipated, the patient should also be scheduled to see the oculoplastic or plastic surgeon.

Categorized in: MOHS, Pre-op Planning