Treading the fuzzy line between ophthalmic and plastic surgery

Colour Atlas of Ophthalmic Plastic Surgery
By AG Tyers and JRO Collin
Butterworth & Heinemann, Oxford, UK, Second Edition 2001
Hardback / 355 pages / Colour photographs
ISBN: 0-7506-4254-8 / £130.00

If you have a squeamish partner don’t leave this book lying around. For some, even the cover may seem explicit, but the contents definitely will make most casual observers queasy. The many high quality photographs that make up more than 50% of this book are the largest collection of disgustingly explicit photos about eye surgery I have ever seen.

There’s nothing wrong with that. The title of the book — and quite an adequate title it is — warns us. Full-colour, atlas-style photographs appear throughout, ophthalmic obviously, and plastic surgery – with relatively clean-looking flesh and blood free. It is a full-size hardback text, not ideal reading on the train home either; it’s heavy to carry and the pictures might not ingratiate you to your fellow passengers.

The authors are two well-established British ophthalmic surgeons. Anthony Tyers, FRCS, FRCOphth, qualified in London in 1970. He currently works as a consultant ophthalmologist in the District Hospital in Salisbury, and as a private practitioner in nearby New Hall Hospital. His co-author, Richard Collin, FRCS, FRCOphth, qualified at Cambridge University in 1967 and currently works at Moorfields Eye Hospital in London.

He also has private patients at a clinic in Harley Street. Both have an interest in ophthalmic plastic surgery and eyelid surgery, and publish regularly in the British Journal of Ophthalmology.

This Atlas was a successful collaboration first published by Churchill Livingstone in 1995. During the intervening years, the field of plastic surgery in connection with the eye has evolved more than enough to justify a new edition. Surgeons have developed new procedures and discarded others. Curiously, one of the trends that has changed direction since the first edition is the preference for repairing procedures using autologous materials, away from preserved tissues, in accordance with the perception of increased risk of infection transmission.

This second edition could already be considered a successful one. It was runner-up for a prize for the best second edition of a medical book awarded by the Society of Authors and the Royal Society of Medicine in 2001. That’s not a mean feat considering the enormous number of technical books published every year on the full range of medical specialties. The winner (damn them!) was about the histopathologic diagnosis of tumours.

The Atlas feels like a textbook for the specialist. It follows a step-by-step approach to a surgical intervention, but leaves out all the fundamentals that you will know if you already do quite a lot of ophthalmic surgery. It also assumes you are very familiar with specific vocabulary and current ophthalmic pathology management.

It is addressed to the trainee ophthalmic surgeon or plastic surgeon, assuming that either of the two – in principle, different disciplines — will perform plastic surgery around the eye. <The publisher even tells us on the back that the text is concise and practical, “making this an ideal text for use in the theatre!”>

The authors seem to have up-dated the second edition with care. None of the photographs seem dated. The procedures, too, are fresh and practical. The further reading lists — given at the end of most chapters — have also been updated. There is a direct relationship between every step of the process and what it aims to achieve. Surgical gymnastics are not encouraged.

The book’s emphasis on carefully analysing anatomy before moving on is very refreshing. There is a section detailing recommended measurements, although with very simple instruments in most cases. Several chapters have tips to assess the situation before intervention. Then you are encouraged to choose the most appropriate technique. New techniques added since the last editions include lower lid blepharoplasty, upper and lower lid retraction, and gold weight implants.

The contents pages are very detailed. There is also a fairly comprehensive index. Occasional line drawings highlight the anatomy involved in procedural details that are not easily illustrated by the photographs.

Through boxes with blue background and the heading, “Complications and management,” the authors write about postoperative care. The boxes appear at the end of most sections; although very brief, they provide useful pointers.

The book starts with a chapter on anatomy, as expected, with different sections for orbit, eyelid surface, skin, muscles, fascias, tarsal plates, blood and nerve supplies and the lachrymal glands. The chapter also includes a section on the oriental eyelid and another one on lid changes with ageing.

Basic techniques in oculoplasty follow, in detail. The “grafts” sections are particularly clear, including descriptions of harvesting the skin, hard palate, and fascia lata. The usual sections on pre-operative evaluation, anaesthesia and instrumentation are included. Ectropion in all its flavours has two long chapters dedicated to it.

Eyelid abnormalities are dealt with briefly under the headings trichiasis and distichiasis. Several procedures to treat ptosis are presented, with short but clear rationales for the choice of approach suggested. Before and after photos are well used. Blepharoplasty is presented as a different chapter, but cross-referenced with ptosis. Eyebrow retraction and correction of every muscle around the orbit all find a section or sub-section to themselves.

Chapters 12 and 13 deal with evisceration and the anophthalmic socket, with secondary implants explained in some detail. Orbital problems such as a contracted socket are also dealt with. The four following chapters are dedicated to eyelid reconstruction; the last chapter gets the miscellaneous conditions not covered anywhere else.
Teachers and trainers of ophthalmic surgery would love this book. Indeed, any ophthalmic or plastic surgeon who even occasionally needs to perform plastic surgery or do a lid repair will find this clear and visual book interesting and useful.

Want to read previous "In your good books" columns. Visit the archive here.

Top