Transconjunctival approaches

Transconjunctival lower-eyelid approaches are performed in several ways:

A) Transconjunctival (inferior fornix transconjunctival using a retroseptal or preseptal route)

B) Retrocaruncular (= medial transconjunctival)

C) Transconjunctival with lateral skin extension (lateral canthotomy/“swinging eyelid”)

D) Combination of inferior (A) and medial (B) transconjunctival

E) C-shaped incision (ie, combination of inferior (A) and medial transconjunctival (B) plus lateral skin extension (C))

The advantage of transconjunctival incisions is the superior cosmetic outcome due to the lack of cutaneous scarring.

A disadvantage may be the limited access of non-extended or non-combined approaches in comparison to lower-eyelid skin incision.

The typical (lower fornix) transconjunctival approach in the lower eyelid exposes the floor of the orbit, the infraorbital rim, and the upper edge of the anterior maxilla (A).

Via a retrocaruncular incision, the medial wall of the orbit behind the posterior lacrimal crest can be exposed (B).

Combining the lower fornix and the retrocaruncular approach provides simultaneous access to the floor, inferior orbital rim, and medial and lateral orbital walls.

If a canthotomy is performed in conjunction with the lower fornix transconjunctival approach, the lateral orbital rim and wall can also be accessed (C).

The C-shaped incision combines the medial and inferior transconjunctival approach with the lateral canthotomy and provides the maximal exposure of the medio-inferolateral orbit and the zygomatic body.

Transconjunctival approaches demand surgical precision because several complications can occur:

• Damage and abrasion to the cornea
• Damage to extraocular muscles
• Eyelid malposition

A thorough evaluation is essential to choose the appropriate lower eyelid approach (eg, a snap-back test to assess the laxity of the eyelid).

Vasoconstrictors can be used to the surgeon’s preference according to the location of the various incision lines.

Ready-made corneal shields can be inserted for the protection of the globe with adequate lubrication.

Alternatively, the conjunctival flap can be sutured to the upper lid margin as soon as the approach to the infraorbital rim is completed.

Conjunctival flap developed.

Conjunctival flap sutured to the upper lid to ensure corneal protection.

Click the following links to read a detailed description of the transconjunctival lower-eyelid approaches:

A) Transconjunctival (inferior fornix transconjunctival using a retroseptal or preseptal route)

B) Retrocaruncular (= medial transconjunctival)

C) Transconjunctival with lateral skin extension (lateral canthotomy/“swinging eyelid”)

D) Combination of inferior (A) and medial (B) transconjunctival

E) C-shaped incision (ie, combination of inferior (A) and medial transconjunctival (B) plus lateral skin extension (C))