International Council of Ophthalmology

Ophthalmic Education:

Principles and Guidelines of a Curriculum for Education of the Ophthalmic Specialist: Chapter 10. Oculoplastic Surgery and Orbit

Basic Level Goals: PGY-2

A. Cognitive Skills

Describe basic eyelid, lacrimal, and orbital anatomy and physiology (e.g., eyelid, orbicularis, orbital structures, meibomian glands, lacrimal glands, Zeis glands, Whitnall's ligament, Muller's muscle, Lockwood's ligament, canaliculi, puncta, orbital bones, orbital foramina, paranasal sinuses, annulus of Zinn, arterial and venous vascular supply, lymphatics, nerves, extraocular muscles).
Describe basic mechanisms and indications for treatment of eyelid, orbital, and lacrimal trauma.
Describe epidemiology, clinical features, evaluation, and management of fetal alcohol syndrome.
Perform preoperative and postoperative assessment of patients with common oculoplastic disorders.
Recognize simple orbital trauma (e.g., orbital foreign body, retrobulbar hemorrhage).
Recognize and treat floppy eyelid syndrome.
Recognize and treat localized trichiasis.
Recognize blepharospasm and hemifacial spasm.
Describe the differential diagnosis of common orbital tumors in children and adults.
Describe the differential diagnosis of lacrimal gland mass (e.g., inflammatory, neoplastic, congenital, infectious).
Identify normal orbital anatomy on imaging studies (e.g., magnetic resonance imaging, computed tomography, ultrasound).
Describe the differential diagnosis of proptosis in children and adults.
Describe techniques and complications of minor operating room procedures (e.g., incision and drainage of chalazia, excision of small eyelid lesions).
Describe typical features of orbital cellulitis.

B. Technical/Surgical Skills

Describe indications for and perform the basic office examination techniques for the most common oculoplastic and orbital abnormalities.
Perform the basic assessment of the eyelids, eyebrows and eyelashes (e.g., eversion, double eversion, margin to reflex distance, lid crease, levator function, eyelid/brow malpositions).
Identify indications for and to perform the basic lacrimal assessment (e.g., dye testing, punctal dilation, canalicular probing, lacrimal irrigation).
Identify indications for and perform the basic assessment of the orbit (e.g., Hertel exophthalmometry, inspection, palpation, auscultation).
Identify indications for and perform the basic socket assessment (e.g., types of implants, socket health).
Perform minor lid and conjunctival procedures (e.g., removal of benign eyelid skin lesions, chalazion curretage or excision, conjunctival biopsy).
Treat complications of minor operating room procedures (e.g., incision and drainage of chalazia, excision of small eyelid lesions).
Perform punctal plug insertion or removal.
Recognize and treat trichiasis (e.g., epilation, cryotherapy, surgical therapy).
Perform a simple enucleation or evisceration under supervision.

Standard Level Goals: PGY-3

A. Cognitive Skills

Describe more advanced eyelid, lacrimal, and orbital anatomy and physiology (e.g., lacrimal apparatus, orbital vascular anatomy).
Describe the genetics (where known), clinical features, evaluation, and treatment of congenital eyelid deformities (e.g., coloboma, distichiasis, epicanthus, telecanthus, blepharophimosis, ankyloblepharon, epiblepharon, euryblepharon, and Goldenhar syndrome, Treacher-Collins syndrome, Waardenburg syndromes).
Describe the clinical features, evaluation and management of congenital orbital deformities (e.g., synophthalmia, anophthalmia, microphthalmia, cryptophthalmia, hypertelorism, hypotelorism).
Describe the genetics, clinical features, evaluation, and management of common craniosynostoses and other congenital malformations (e.g., Crouzon and Apert syndromes).
Treat (or refer for treatment) congenital eyelid abnormalities (see Basic Level, above).
Perform preoperative and postoperative assessment of patients with simple and more serious oculoplastic disorders (e.g., multi-disciplinary procedures).
Describe the mechanisms and indications for treatment of more advanced eyelid, orbital, and lacrimal trauma (e.g., full thickness lid laceration, chemical burns to the face).
Describe features of, evaluate, and treat more complicated cases of nasolacrimal duct obstruction, canaliculitis, dacyrocystitis, acute and chronic dacryoadenitis, preseptal cellulitis, and orbital cellulitis.
Recognize, evaluate and treat thyroid ophthalmopathy (e.g., epidemiology, symptoms and signs, associated systemic diseases, orbital imaging, differential diagnosis, surgical, medical and radiation indications side effects of treatment).
Recognize, evaluate, and treat orbital inflammatory pseudotumor (e.g., symptoms and signs, orbital imaging, differential diagnosis, biopsy indications, choice of treatments).
Recognize, treat, or refer blepharospasm or hemifacial spasm.
Recognize less common orbital tumors (e.g., metastatic lesions).

B. Technical/Surgical Skills

Describe indications for and perform more advanced examination techniques for less common oculoplastic and orbital abnormalities (e.g, measurement of levator function, orbital ultrasound intepretation).
Identify indications for and perform more advanced assessment of eyelids and eyebrows (e.g., hypoglobus, facial asymmetry, brow ptosis).
Identify indications for and to perform more advanced lacrimal assessment (e.g., interpretation of dye testing, canalicular probing in trauma).
Identify indications for and to perform more advanced assessment of the orbit (e.g., enophthalmus, interpretation of orbital ultrasound in common conditions).
Identify indications for and to perform more advanced socket assessment (e.g., extrusion of implants, anophthalmic socket complications).
Perform more complicated minor lid procedures (e.g., larger benign skin lesions) or surgery (e.g., recurrent or multiple chalazion).
Recognize the indications and complications and perform more complex minor operating room or limited operating room procedures (e.g., incision and drainage of recurrent or larger chalazia, excision of moderate sized benign eyelid lesions).
Recognize and treat orbital trauma (e.g., intraorbital foreign body, retrobulbar hemorrhage, fracture).
Identify common orbital pathology (e.g., orbital fractures, orbital tumors) on imaging studies (e.g, magnetic resonance imaging, computed tomography, ultrasound).
Treat common presentations of preseptal or orbital cellulitus.
Describe, recognize the indications for and complications of, and perform the basic lacrimal procedures below:
1. Lacrimal drainage testing (irrigation, dye disappearance test)
2. Lacrimal intubation
3. Dacryocystorhinostomy (external)

Advanced Level Goals: PGY-4

A. Cognitive Skills

Describe the most advanced eyelid, lacrimal, and orbital anatomy and physiology.
Evaluate and treat simple and more advanced eyelid, orbital, and lacrimal trauma (e.g., full thickness lid laceration, chemical burns to the face).
Perform preoperative and postoperative assessment and coordination of care of patients with more advanced or complex oculoplastic disorders (e.g., systemically ill patients, multi-disciplinary procedures).
Describe the etiology, evaluation, and medical and surgical treatment of the following eyelid diseases:
1. Complex ectropion (e.g., congenital, paralytic, involutional, cicatricial, mechanical, allergic).
2. Complex entropion (e.g., involutional, cicatricial, spastic, congenital).
3. Complex myogenic ptosis (e.g., chronic progressive external ophthalmoplegia).
4. Complex differential diagnosis for dermatochalasis (e.g., blepharochalasis).
5. Benign, pre-malignant, or malignant eyelid tumors (e.g., papilloma, keratoacanthoma, seborrheic keratosis, epidermal inclusion cyst, molluscum contagiosum, verruca vulgaris, actinic keratosis, basal cell carcinoma, squamous cell carcinoma, sebaceous cell carcinoma, melanoma).
6. Single or recurrent inflammatory lesions (e.g., recurrent chalazion or its mimics).
7. Facial dystonia (e.g., blepharospasm, hemifacial spasm).
8. Facial nerve palsy with exposure keratopathy (e.g. tarsorrhaphy, gold weights).
9. Complex lid and orbital trauma cases.

B. Technical/Surgical Skills

Describe the indications for and perform more complicated and advanced "in office" examination techniques for less common but important oculoplastic and orbital abnormalities.
Perform preoperative and intraoperative assessment of the eyelids and eyebrows (e.g., intraoperative adjustments).
Recognize and treat more complex or difficult socket-related problems and complications (e.g., extrusion of implants, anophthalmic socket complications).
Perform more complicated lid procedures (e.g., larger benign, recurrent, or multiple skin lesions).
Perform more advanced lacrimal assessment (e.g., intraoperative and postoperative testing, more complex trauma to lacrimal system).
Describe management of and treat lacrimal system abnormalities, including:
1. More complex congenital disorders (e.g., canalicular stenosis)
2. More complex acquired disorders and their treatment (e.g., conjunctivo- dacryocystorhinostomy with Jones tube)
3. Complex moderate trauma (e.g., requiring lacrimal intubation)
Recognize typical and atypical features and to describe the differential diagnosis, clinical features, and treatment of more complicated orbital disease, including:
1. More complex orbital infections (e.g., preseptal and orbital cellulitis, mucormycosis, aspergillosis)
2. Congenital tumors (e.g., dermoid)
3. Fibro-osseus disorders and tumors (e.g., fibrous dysplasia, osteoma, chondrosarcoma, osteosarcoma, Paget's disease)
4. Vascular tumors (e.g., capillary hemangioma, cavernous hemangioma, hemangiopericytoma, lymphangioma, Kaposi's sarcoma)
5. Xanthomatous tumors (e.g., xanthelasma, juvenile xanthogranuloma)
6. Lacrimal gland tumors (e.g., benign mixed tumor, adenoid cystic carcinoma, malignant mixed tumor, lymphoma)
7. Neural tumors (e.g., optic nerve glioma/meningioma, neurofibromatosis, neuroblastoma)
8. Rhabdomyosarcoma
9. Orbital pseudotumor
10. Lymphoid lesions (e.g., lymphoid hyperplasia, lymphoma, leukemia)
11. Thyroid-related orbitopathy
12. Metastatic tumors (e.g., from breast, lung, prostate, colon, melanoma)
13. Trauma (e.g., orbital fractures, traumatic optic neuropathy)
14. Anophthalmic socket - implant exposure, volume augmentation
Describe, recognize the indications for and complications of, and perform the eyelid procedures listed below:
1. Basic biopsy techniques
2. Lateral tarsal strip
3. Specialized lid suture procedures (e.g., Quickert sutures)
4. Medial spindle
5. Retractor reinsertion
6. Levator advancement
7. Eyelid laceration/margin repair
8. Tarsorrhaphy
9. Lateral canthoplasty (canthotomy and cantholysis)
10. Blepharoplasty
11. Facial nerve palsy – gold weight placement in the lid
12. Simple eyelid reconstruction
13. Orbital approaches and incisions (e.g., Kronlein, Caldwell-Luc, transconjunctival, transnasal)
Describe, recognize the indications for and complications of, and perform basic orbital skills and procedures, including:
1. Anterior orbitotomy for tumor biopsy/excision
2. Orbital floor fracture repair
Describe the indications for and interpret CT and MRI scans (e.g., orbital trauma, orbital lesions and tumors).
Perform botulinum toxin injections (e.g., blepharospasm).
Identify more advanced orbital pathology (e.g., complex orbital fractures, orbital tumors) on imaging studies (e.g, magnetic resonance imaging, computed tomography, ultrasound).