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Age related medial ectropion of the lower eyelid
Abstract
A simplified procedure is proposed for the repair of medial lower eyelid age-related ectropion.
A posterior horizontal incision is made in the medial half of the lower eyelid at the inferior border of tarsus. The lower eyelid retractors are exposed and then plicated to the tarsus without excision of posterior lamellae or the use of everting sutures. The lid is then shortened horizontally with excision of a pentagonal section or lateral tarsal strip procedure.
The procedure was performed in six patients successfully without complication.
This is an effective method for repair of lower lid medial age-related ectropion.
... Lateral distraction test (LDT) was the gold traditional method for assessing the laxity of MCT, which was performed by pulling the lower eyelid laterally along a horizontal direction and observing how far the lower punctum can be pulled in relation to the cornea nasal limbus [6,7] Results may vary depending on the subject of the issue, and quantitative analysis is difficult. Several studies [4,[6][7][8][9][10][11][12] have investigated the grading method of MCT laxity. ...
... Lateral distraction test (LDT) was the gold traditional method for assessing the laxity of MCT, which was performed by pulling the lower eyelid laterally along a horizontal direction and observing how far the lower punctum can be pulled in relation to the cornea nasal limbus [6,7] Results may vary depending on the subject of the issue, and quantitative analysis is difficult. Several studies [4,[6][7][8][9][10][11][12] have investigated the grading method of MCT laxity. However, no universally grading scale or format is accepted at present for recording the laxity, and the result is usually just noted as being present or not. ...
... B between-measurement variance; W within measurement variance; [7] D difference between measurements; N number of eyes or subjects measured; X1 mean for rater 1 (session 1, or session 2 of capture 1); X2 mean for rater 2 (session 2, or session 2 of capture 2); X3 grand mean. ...
Background:
Assessment of MCT laxity is critical to the surgery options. Our study aimed to analyze the reliability of measuring medial canthal tendon (MCT) laxity by using a novel standardized three-dimensional lateral distraction test (3D-LDT).
Methods:
Forty-eight Caucasian volunteers (25 males and 23 females, 96 eyes) between 22 and 84 years of age (55.6 ± 18.6 years old) were included in our study. From a neutral position, the lower eyelid was gently pulled laterally along a horizontal line to define the most distracted position of the lower punctum. Both in the neutral and distracted position, standardized 3D images were acquired for each subject by two observers, and each image were measured twice by two raters. Four landmarks and six corresponding linear measurements were evaluated for intra-rater, inter-rater, and inter-method reliability.
Results:
Intra-rater, inter-rater and inter-method reliability analyses of 3D-LDT revealed an intraclass correlation of more than 95%, a mean absolute difference of less than 1 mm, and a technical error of measurement of less than 1 mm. Measurements of relative error (2.59-12.04%) and relative technical error (1.83-16.05%) for the inter-landmarks distance from pupil center to the lower punctum were higher than those from limbus nasal center to the lower punctum (6.13-30.39 and 4.34-26.85%, respectively).
Conclusions:
This study provided high reliability of the three-dimensional lateral distraction test (3D-LDT) for assessing medial canthal tendon (MCT) laxity, which were never evaluated by digital imaging system.
Level of evidence iv:
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
... El reposicionamiento del canto lateral es un elemento compensatorio clave que debe asociarse a cualquier procedimiento reconstructivo en el párpado inferior con el que se prevea la formación de ectropión. Dos técnicas quirúrgicas que logran prevenir o corregir la eversión palpebral mediante reposicionamiento cantal son la cantopexia y la cantoplastia 13 . ...
... El tratamiento del ectropión posquirúrgico en pacientes con laxitud palpebral asociada (componente involutivo) busca el tensado palpebral horizontal que se consigue mediante el reposicionamiento del canto lateral a través de una cantopexia o cantopastia 13 . La cantopexia consigue Cantoplastia. ...
... d y e) Buen resultado funcional y estético a las 8 semanas. . 7) y se emplea en casos de hiperlaxitud leve 13 . Por el contrario, la cantoplastia se utiliza para corregir hiperlaxitudes más severas y requiere una cantotomía previa al anclaje del canto externo ( fig. ...
Ectropion, or eyelid eversion, is the most common form of eyelid malposition. By impairing the eyelid's protective function, ectropion can cause epiphora, lagophthalmos, keratinization, chronic irritation, pain, and ulceration. There are 5 types of ectropion, each with a different cause: congenital, paralytic, involutional, cicatricial, and mechanical. The most common presentation in dermatology is involutional eversion with a mechanical or tractional element. Several options exist for the surgical repair of ectropion and choice of technique will depend on the main pathogenic component. We review the basic anatomy of the eyelid and describe examination techniques for assessing risk and preventing ectropion and for identifying the main pathogenic component in order to select the most suitable repair technique.
Copyright © 2019 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.
... The transconjunctival approach to plicate the lower eyelid retractors to the tarsus with horizontal eyelid shortening was first described by Tse et al. (1991) and has since been reported by O'Donnell (1994) and Shah-Desai & Collin (2001). The advantage of this approach is that excision of posterior lamella tissue is not necessary and it addresses the dehiscence of the retractors in a more purposeful approach. ...
... The approach described by Tse et al. (1991) to the retractors was also transconjunctival but included the use of inverting sutures. Our approach to repairing the retractors was broadly similar to that described by O'Donnell (1994) and Shah-Desai & Collin (2001). However, we made no effort to close or suture the conjunctival incision as we believe that this is not necessary. ...
We describe the technique and our results in managing lower eyelid involutional medial ectropion using a combination of lateral tarsal strip to address horizontal eyelid laxity, and transconjunctival inferior retractor plication to address inferior retractor dehiscence.
Patients with symptoms of epiphora or signs of medial ectropion were offered this procedure. All had the following characteristics: medial lower eyelid eversion, punctal eversion >3 mm, medial canthal tendon laxity <4 mm, significant horizontal eyelid laxity and lacrimal systems that were patent to syringing.
A total of 24 eyelids of 17 patients underwent this procedure over a 12-month period. The mean age of the patients was 79.7 years; 11 were male and six were female. The mean follow-up time was 18 months. Two eyes had undergone previous surgery. All patients had restoration of the eyelid margin to the globe and relief of symptoms. No complications were noted.
These results suggest that excision of posterior lamellar tissue is not necessary for correction of involutional medial ectropion. Transconjunctival plication or reattachment of retractors is easy to perform and allows for the repair of more than the medial portion of the retractors if required.
... Tese tests evaluate the laxity of the median canthal tendon and lateral canthal tendon [17]. Several studies [17][18][19][20] have investigated the grading method of MCT laxity. Te methods for measuring lacrimal punctum shift have been demonstrated [12,20]. ...
In this prospective observational study, we aimed to examine improvements in horizontal laxity after lower eyelid retractor advancement and transcanthal canthopexy for involutional lower eyelid entropion. The study included 19 sides in 15 patients with involutional entropion who underwent transcanthal canthopexy with the advancement of the lower eyelid retractor. Using the pinch test, the distance from the lowest part of the corneal limbus to the eyelid margin was measured using callipers. All measurements were performed preoperatively and at postoperative 3 and 6 months. Using the pinch test, the distance from the lowest part of the corneal limbus to the lower eyelid margin was significantly shortened during each postoperative follow-up period. None of the included cases experienced recurrence. Our results indicated that transcanthal canthopexy could preserve postoperative horizontal tightness.
... Conclusion Double-frequency YAG laser applied to lower medial palpebral conjunctiva is a simple, easy, safe, and effective procedure which can be used as a solo treatment in early cases of punctal eversion with no or mild medial canthal tendon laxity. lid (the 'lazy-T' procedure) or the medial spindle procedure, both of which require excision of posterior lamella tissue [1,[4][5][6][7][8]. ...
Purpose
To describe a simple and minimally invasive technique using double-frequency YAG laser for correction of mild medial lower eyelid ectropion with punctal eversion and assess the efficacy of the technique by measuring the tear film meniscus pre- and post-laser treatment using imageJ software.
Methods
This study included 23 eyes of 19 patients with lower eyelid ectropion with punctal eversion. All patients were treated by double-frequency YAG laser applied to lower medial conjunctiva. Tear film thickness was assessed using imageJ software pre- and post-argon laser treatment.
Results
There was a highly significant change detected after argon laser treatment as regarding the mean of the height of tear film which was found to be significantly lower after argon laser treatment compared to before it (81.1 pixels versus 193.1 pixels, respectively) (P < 0.001).
Conclusion
Double-frequency YAG laser applied to lower medial palpebral conjunctiva is a simple, easy, safe, and effective procedure which can be used as a solo treatment in early cases of punctal eversion with no or mild medial canthal tendon laxity.
... Diminished lower lid excursion on downgaze, absence of lower lid skin crease on downgaze and tarsal ectropion in the absence of horizontal eyelid laxity are clues towards lower lid retractor disinsertion [10][11][12]. ...
Many oculoplastic conditions like ectropion, entropion, ptosis, lid lacerations, canalicular trauma and dacryocystitis are commonly seen in everyday practice of any ophthalmologist. Delay in treatment of entropion and ectropion can lead to blindness due to development of secondary changes in cornea. Neglecting a child with severe ptosis can result in irreversible visual loss. Incorrect primary repair of lacerated lid and failure to repair the torn canaliculi are difficult to handle at a later stage even by an expert surgeon. Long-standing blocked distal lacrimal passages may result in suppurative infections with skin excoriation. This review elucidates the correct approach to some common oculoplastic diseases so as to achieve a timely intervention and referral and thereby avoid preventable complications.
... It is not uncommon for involutional changes to coexist with a secondary cause such as facial paralysis or cicatrization. 1,16,17 Various surgical options described in the literature [17][18][19][20][21][22][23][24][25][26][27][28][29][30] have shown that targeting the respective aetiological factors is crucial for achieving good lid-globe apposition and normal eyelid function. ...
This study reviews the differences in demographics and surgical outcomes between ectropion in Asian and non-Asian eyes.
Medical records of surgically corrected ectropion cases from January 2002 to December 2006 were reviewed. Preand postoperative lid-globe apposition was graded: grade 0 with normal lid-globe apposition, grade 1 with punctal ectropion, grade 2 with partial lid eversion and scleral show, grade 3 with conjunctival hyperemia and thickening and grade 4 as for grade 3 with exposure keratitis.
Sixty-nine eyes in 50 patients underwent surgical correction of lower lid ectropion, making up 3.3% of all lid procedures performed. Eighty-four percent of patients were above 50 years of age, 72% were males and 88% were Chinese. Involutional change was the commonest aetiology, accounting for the majority of bilateral cases. The mean duration to surgery was 10.0 ± 16.0 months. The most frequent preoperative severity grade was 2. Lateral tarsal strip (LTS) was the commonest procedure performed, comprising 91.3% of eyes. The mean duration of postoperative review was 19.4 ± 19.2 months (range, 1 to 74 months). Postoperative improvement of at least one grade was observed in 98% while normal lid-globe apposition was achieved in 76% of eyes.
Involutional change is the most common cause of ectropion amongst both Asians and non-Asians. Ectropion is less prevalent amongst Asians as a result of anatomical differences and possibly reduced sun exposure. The LTS procedure is the most commonly performed surgical procedure for the successful correction of ectropion in both Asians and non-Asians.
Purpose: To describe a new, simple and minimally invasive technique for correction of mild medial lower lid ectropion with punctal evrsion and measuring the efficacy of the technique by measuring the tear film meniscus pre and post argon laser treatment using imagej software.
Methods: This study included 23 eyes, 19 patients with lower eyelid punctal eversion. All patients were treated by argon laser of lower medial conjunctiva. Tear film thickness was assessed using imagej software pre and post argon laser treatment.
Results: There was a highly significant difference between before and after argon laser treatment as regarding the height of tear film which was found to be significantly lower after argon laser treatment compared to before it (81.1pixels versus 193.1pixels respectively) (p< 0.001).
Conclusion: In conclusion, argon laser to lower medial palpebral conjunctiva is a simple, easy, safe, and effective procedure which can be applied as a sole treatment in early cases of punctal eversion with no or mild medial canthal tendon laxity.
Clinical Trials Registration no clinical trial registration.
Purpose
Involutional Ectropion is commonly prevalent disorder of eyelid malposition caused by age-related degeneration of the periocular tissues. This study conducted to provide a summary and review of surgical practice for the management of lower eyelid involutional ectropion and enlist various causative factors that explain the pathogenesis.
Methods
The review of literature on risk factors and surgical approaches for involutional lower eyelid ectropion, searched on PubMed from 1980 onwards.
Result
Multiple factors contribute to horizontal and vertical lower eyelid involutional ectropion. Several surgical practices have been described over the last years to address these factors. Lateral tarsal strip is the most used and effective surgery to treat horizontal laxity.
Conclusion
Knowledge of various contributing factors and surgical procedures will enable to design the most effective therapeutic management for lower eyelid involutional ectropion. surgical approaches are individualized depending on preoperative clinical evaluation of possible causative factors and concerning the predominant location of the ectropion will result in a high success rate.
Purpose
Few studies quantitatively investigated the degree of medial canthal tendon (MCT) laxity using three-dimensional (3D) stereophotography as two-dimensional (2D) imaging systems are still widely used in periocular anthropometry. Hence, in this study, we aimed to compare 2D and 3D technique in assessing medial canthal tendon (MCT) laxity and to investigate the correlation between them.
Methods
A cross-sectional study was conducted in randomly recruited healthy volunteers with no history of eyelid disease and surgery. Predictor variables were the linear measurements derived from 2D and 3D images, respectively, and the outcome variable was MCT laxity. Covariates including age and sex were also included in our correlation observations. One-side measurements for each image were randomly selected for our study. Bivariate correlation was applied to evaluate the correlation between 2D and 3D measurements. Linear regression was used to investigate the correlation between the predictor and outcome variables.
Results
Ninety-five Caucasian volunteers (50 men and 45 women, 95 eyes) between 22 and 84 years of age (58.5±16.0 years) were included in our study. The two sets of measurements for MCT laxity were 3.13±0.75 mm and 2.62±1.50 mm on 2D images (P = 0.18) and 2.49±1.58 mm and 2.58±1.72 mm on 3D images (P = 0.23). A significant correlation was observed between 3D measurements and MCT laxity (P <0.01), while no significant correlation was found between 2D measurements and MCT laxity (P = 0.64).
Conclusions
Our results revealed that measurements on 3D images could be predictors of MCT laxity and might be applied as a base and a reference for speculating the 3D MCT laxity in further research and clinical evaluation.
Ectropion, or eyelid eversion, is the most common form of eyelid malposition. By impairing the eyelid’s protective function, ectropion can cause epiphora, lagophthalmos, keratinization, chronic irritation, pain, and ulceration. There are 5 types of ectropion, each with a different cause: congenital, paralytic, involutional, cicatricial, and mechanical. The most common presentation in dermatology is involutional eversion with a mechanical or tractional element. Several options exist for the surgical repair of ectropion and choice of technique will depend on the main pathogenic component. We review the basic anatomy of the eyelid and describe examination techniques for assessing risk and preventing ectropion and for identifying the main pathogenic component in order to select the most suitable repair technique.
Centurion syndrome is an uncommon, idiopathic medial canthal anomaly that causes epiphora due to the forward displacement of the lacrimal punctum out of the tear lake associated with the abnormal anterior insertion of the medial canthal tendon and enophthalmos. A case of Centurion syndrome is presented together with the description of a previously unreported surgical treatment: The combined surgical techniques of medial canthal tendon release and lower eyelid retractor plication. © 2006 Royal Australian and New Zealand College of Ophthalmologists.
To evaluate the effects of the modified medial spindle and the lateral tarsal strip procedure in involutional ectropion patients.
To describe a simple technique to correct tarsal lower eyelid ectropion with or without marked eyelid laxity (The Leicester Modified Suture technique).
A retrospective interventional case series of patients undergoing correction of tarsal ectropion with inverting sutures. The study adhered to the principles of the Declaration of Helsinki.
Twenty patients (25 eyelids) met the inclusion criteria. The success of the procedure was assessed by improvement of symptoms, eyelid position, and the need for reoperation. The mean postoperative follow up was 3.6 months (range 2-15 months). Eighteen patients (90%) had a successful outcome, while in 2 patients (10%) the outcome was satisfactory, as there was mild residual eversion of the eyelids. None of the patients required reoperation.
Tarsal lower eyelid ectropion can be surgically challenging to correct via the transconjunctival plication or subciliary reattachment of retractors. This method is simple to use, resulting in an excellent outcome with no tissue dissection. This technique is easy to learn and implement for oculoplastic surgeons at all levels of experience.
BACKGROUND: Simple forms of involutional ectropion may be corrected by a horizontal shortening and a medial retractor-advancement procedure. In long-standing cases secondary changes of the skin and lid margin have to be corrected. This requires additional surgical steps. A complicated ectropion can develop to gross deformities of the lid margins so that resection and reconstruction of the margins become necessary. This study differentiates the indication of simple or complicated ectropion surgery and elucidates the surgical options for the complicated ectropion. MATERIALS AND METHODS: We reviewed our corrected ectropion cases operated between January 2000 and December 2008. The cases were categorised according to the indicated surgical technique into simple (grade 1), simple combined (grade 2), complicated (grade 3) forms and complicated forms with major lid margin deformities (grade 4). RESULTS: Out of the 1101 corrected lids, we found 19 % to be simple ectropion cases (grade 1) that received a lateral tarsal strip procedure. An additional retractor advancement to correct the medial punctual eversion was necessary in 38 % of the cases of combined ectropion (grade 2). About the same number of the lids (41 %) was staged as complicated ectropion (grade 3) and required a subciliary skin graft and a lid margin reshaping. The remaining 2 % (grade 4) needed a lid margin reconstruction. CONCLUSIONS: In ectropion cases we find progressive pathological changes due to the duration of the everted lid position. Such changes vary from simple forms of ectropion to more complicated forms. In order to achieve good postoperative results and avoid recurrences, the surgical correction should be based on the degree of lid alteration. In the initial stage of simple ectropion (grade 1) it is sufficient to correct the lid laxity. More advanced stages of simple combined ectropion require a medial, inverting retractor correction in addition to the lid shortening procedure (grade 2). These two surgical steps are insufficient to manage the complicated ectropion stage (grade 3), where additional skin grafting and lid margin reshaping are required. Sometimes the lid margin cannot be reshaped if a major deformity is found (grade 4). The solution in such cases is to excise and reconstruct the lid margin.
Objective
To describe a simple grading system for medial canthal tendon (MCT) laxity and measure its reproducibility.
The aim of this study was to describe the prevalence of eyelid ectropion and its associations with sunlight-related and other ocular variables, plus systemic factors, in an older Australian population. The Blue Mountains Eye Study examined 3654 persons aged 49–97 years. Examination recorded ectropion and other ocular signs. The questionnaire assessed sunlight-related and systemic variables. Ectropion was present in either eye of 143 subjects (3.9%) and was bilateral in 101 (70.6%). A marked age-related increase in prevalence was observed with ectropion found in 0.3% of persons aged < 60 years, 1.2% of ages 60–69 years, 6.7% of ages 70–79 years and 16.7% of those aged 80 years or older. Ectropion prevalence was higher in men (5.1%) than women (3.0%), age-adjusted odds ratio 2.1 (95% confidence interval 1.5–3.0). Statistically significant associations were found between ectropion and history of skin cancer removal, increased skin sun sensitivity, lighter iris colour and presence of pingueculum, as well as current smoking, hypertension, diabetes and stroke.
Purpose: To evaluate the effectiveness of eyelid retractor repair in cicatricial ectropion of the lower eyelid.
Methods: The study design was a prospective case series. One hundred and twenty eight eyelids were operated on in 100 consecutive patients with cicatricial ectropion. All patients underwent lower eyelid retractor repair via a conjunctival approach combined with skin replacement to the anterior lamella with or without a horizontal lid tightening procedure. When only medial ectropion was present, a medial-based transpositional skin flap was used to repair the anterior lamella (26 eyelids). The remaining eyelids with ectropion involving all or most of the eyelid underwent upper-to-lower eyelid lateral-based transpositional skin flap repair (92 eyelids), or full thickness free skin grafting (10 eyelids). Horizontal lid tightening was performed by lateral canthoplasty in 123 eyelids.
Results: Relief of cicatricial ectropion symptoms was reported in 90% of patients overall. A normal punctum position was achieved in 70% of eyelids, overall, and was highest (88%) with a medial-based transpositional skin flap.
Conclusions: Eyelid retractor repair combined with skin replacement and horizontal lid shortening is an effective procedure for cicatricial ectropion.
This study describes and tests in a cadaveric model a new method of fixation designed for potential stabilization of the posterior limb of the medial canthal tendon, using biodegradable Tag anchors.
Study of the possibility of performing surgery to repair medial ectropion using biodegradable polyglyconate Tag anchors was commenced in the sheep cadaveric head model, and in the whole dry human skull model. This was then performed using five preserved human cadaveric whole heads, and pullout tensions were estimated in four of these. Computed tomography and magnetic resonance imaging were obtained for this model in the fifth head, and computed tomography was performed on the whole dry human skull. Dissections were carried out to establish the site of the bony defect in each of the heads.
It was possible to obtain good Tag anchor fixation in bone overlying the maxillary and ethmoidal sinuses of the sheep, and in a young human skull. It was also possible to place adequately the anchor in the medial wall of the orbit close to the posterior lacrimal crest in all cases in the human cadaveric model. Pullout strengths were evaluated and found to range from 3.5 N to 12.4 N (mean, 7.5 N). Computed tomography and magnetic resonance imaging failed to demonstrate the biodegradable anchors in both the dry human whole skull and in the fifth cadaveric head, but did demonstrate the bony defects in the medial orbital walls through which the anchor passed.
We have shown, for the first time, the stability of biodegradable Tag anchor fixation in a human cadaveric head model using pullout tensions and dissection studies. This method would allow adequate strength and stability to provide for control of fixation of the medial end of the lower eyelid in patients with medial ectropion and medial canthal tendon laxity.
A new operation to correct lower eyelid laxity was evaluated.
A new transcaruncular, orbital approach to posterior medial canthal tendon plication was performed on eight orbits of four cadavers, which were then analyzed with computed tomography or histologic techniques. The procedure was also performed on 23 eyelids of 15 patients with lower eyelid medial canthal tendon laxity, alone or in conjunction with other procedures. These patients were followed up for a mean of 12 months.
Improved postoperative eyelid position, epiphora, and superficial punctate keratopathy were found. Radiographic and histologic analysis demonstrated consistency of suture placement without involvement of contiguous anatomical structures.
This procedure appears to be a safe, reproducible, and effective corrective procedure for medial canthal tendon laxity and lagophthalmos. When combined with lateral lower eyelid tightening, it is also an effective treatment for lower eyelid retraction and superficial punctate keratopathy. Other potential advantages and complications of this procedure are described in comparison to other reported surgical methods used to address medial canthal tendon laxity and malpositions of the medial lower eyelid.
A method to stabilize the posterior limb of the medial canthal tendon (MCT), using a transcaruncular medial orbitotomy (TMO) approach, is described in a stepwise fashion. The technique described is a modified version of procedures published by Ritleng, Crawford and Collin, and Fante and Elner
A prospective clinical evaluation of MCT stabilization via the TMO approach was undertaken in I I consecutive patients who presented with MCT laxity as one of the features of their ectropion. These cases are initially described in detail in two representative case reports, and summarized in 11 cases. The stepwise surgical approach is outlined.
All patients had improved symptomatology in terms of epiphora and comfort. Furthermore, in all cases the lid position was improved or normalized. In four of the I cases (36%) the lower punctum did not ultimately reside in the lacrimal ake, but the punctal position was nevertheless improved and the MCT was stabilized.
The TMO procedure provides both excellent MCT stabilization and adequate placement of the lower lacrimal punctum onto the globe. It does not require canalicular resection, and avoids continued anterior displacement of the medial lower lid which may occur when only the anterior limb of the MCT is addressed surgically.
AIM. To outline the role of the lower lid retractors in correction of involutional ectropion. METHODS. Eight eyelids with a tarsal ectropion were included in the study. Clinical clues to help identify weakness of the lower lid retractors were documented. A transconjunctival lower lid retractor reattachment with concommitant correction of horizontal lid laxity and lamellar dissociation was performed. RESULTS. Stable eyelid position was obtained in 7 of the 8 cases. One case had a lateral ectropion due to a wound dehiscence. CONCLUSIONS. This small study helps better define the clinical presentations of retractor weakness and provides evidence of a systematic approach in correcting involutional ectropion.
Medial involutional ectropion without excessive lateral canthal tendon laxity is often corrected using the lazy-T procedure. This procedure however carries a potential risk of canalicular damage, and locating the lower lid retractors can be difficult. We have developed a modification. Replacing the tarso-conjunctival diamond with a subconjuctival pocket posterior and inferior to the punctum, into which the lower lid retractors are advanced from the base of the wedge excision, which effectively ensures plication of the lower lid retractors while maintaining a straightforward procedure. The follow-up data on five procedures showed surgical and symptomatic success in all patients, without complications. These results confirm the efficacy of this modification of the lazy-T procedure in the correction of medial lower lid ectropion.
A bstract
Centurion syndrome is an uncommon, idiopathic medial canthal anomaly that causes epiphora due to the forward displacement of the lacrimal punctum out of the tear lake associated with the abnormal anterior insertion of the medial canthal tendon and enophthalmos. A case of Centurion syndrome is presented together with the description of a previously unreported surgical treatment: the combined surgical techniques of medial canthal tendon release and lower eyelid retractor plication.
To assess the efficacy of a comprehensive technique for correction of severe punctal and medial lower eyelid ectropion and lower eyelid retraction associated with medial canthal ligament (MCL) laxity.
A comprehensive technique that plicates the anterior and posterior crura of the MCL was performed on 8 eyelids of 6 patients with punctal ectropion and MCL laxity. Preoperative and postoperative symptoms, punctal ectropion, medial lower eyelid ectropion, lower eyelid retraction, lagophthalmos, and exposure keratopathy were evaluated.
At an average of 13 months (range, 8-17 months), preoperative symptoms of epiphora and discomfort improved or resolved in all eyes. Punctal ectropion improved in all eyes and completely resolved in 75% of eyes. Medial lower eyelid ectropion was corrected in all eyes, when present. Lower eyelid retraction, lagophthalmos, and exposure keratopathy improved in all eyes. In 1 case, edema of the caruncle and semilunar fold persisted for 6 months.
Combined anterior and transcaruncular MCL plication is an effective and safe procedure for addressing severe punctal and medial lower eyelid ectropion that accompanies MCL laxity and is difficult to correct by other methods. This procedure provides stable, 3-dimensional support to the medial lower eyelid and punctum.
• Lower-eyelid tarsal ectropion is an unusual form of eyelid malposition in which the entire lid is everted. The cause is most likely the disinsertion of the lower-eyelid retractors. In 12 eyelids of six patients, a transconjunctival approach was used to reunite the retractors with the inferior tarsal border. In eight eyelids, a horizontal tightening procedure was also needed. The looping passage of fornix sutures through the full thickness of the eyelid created a vector force that helped rotate the lid margin inward. The subsequent formation of an inflammatory cicatrix induced by the absorbable sutures also contributed to maintain the lid in an upright posture. During follow-up periods ranging from 8 to 36 months, there were no instances of overinversion, recurrent ectropion, or suture abscess.
We have developed a procedure that is particularly useful for (1) paralytic or senile upper and lower eyelid laxity, (2) lateral canthal tendon laxity or malposition, and (3) iatrogenic phimosis associated with recurrent entropion or ectropion after traditional lid-shortening procedures. Lateral canthal tendon laxity or elongation is the primary problem in the majority of these cases, and eyelid tightening with use of lateral tarsal strips corrects this deformity. The midtarsal portion of the eyelid, which is usually resected in traditional lid-shortening procedures, is seldom elongated, and recurrences of laxity are common secondary to further stretching of lax tendons. The technique involves a lateral canthotomy and transection of the appropriate crus of the lateral canthal tendon. The eyelid is then split into anterior and posterior lamellae, and tarsal strips are fashioned from the posterior lamella. The tarsal strips are sutured to periosteum at the lateral orbital wall, adjusting the height and tension of the lateral canthus. This technique gives a normal appearance to the lateral canthal angle and has yielded good results in 51 cases.
A patient developed severe lower eyelid ectropion after a bilateral levator aponeurosis and Müller's muscle advancement-and-truck blepharoptosis procedure and bilateral attachment of the lateral canthi to the lateral canthal tendons. The cause of this ectropion was detachment of Müller's muscle and capsulopalpebral fascia from the inferior tarsus and recession of these tissues into the orbit. This left the inferior tarsal border with only redundant conjunctiva attached to it, which could not maintain it in a downward direction; thus, an ectropion occurred. Müller's muscle and capsulopalpebral fascia were detached from the inferior tarsus and recessed 15 mm into the orbit. Reattaching Müller's muscle and capsulopalpebral fascia to the inferior tarsus relieved the ectropion.
The "lazy-T" technique consists of a surgical horizontal and vertical shortening of the involved portion of the lower eyelid. As a result of the surgical procedure, the lid margin is restored to its normal relationship with the globe. The punctum is reestablished into its normal anatomical position in the proximity of the lacrimal lake. The cosmetic blemish resulting from the surgical scar is insignificant.
Lower-eyelid tarsal ectropion is an unusual form of eyelid malposition in which the entire lid is everted. The cause is most likely the disinsertion of the lower-eyelid retractors. In 12 eyelids of six patients, a transconjunctival approach was used to reunite the retractors with the inferior tarsal border. In eight eyelids, a horizontal tightening procedure was also needed. The looping passage of fornix sutures through the full thickness of the eyelid created a vector force that helped rotate the lid margin inward. The subsequent formation of an inflammatory cicatrix induced by the absorbable sutures also contributed to maintain the lid in an upright posture. During follow-up periods ranging from 8 to 36 months, there were no instances of overinversion, recurrent ectropion, or suture abscess.
The classical operations to treat either medial canthal tendon laxity or punctal aversion occurring alone possess drawbacks if they are used to treat these conditions when they occur simultaneously. A simplified procedure is described whereby tissue is removed via a posterior eyelid approach so that the eyelid may be tightened both horizontally and vertically, thus inverting the punctum and fixating it in the lacrimal lake. This procedure is quite easy to perform and can be done under local anesthesia in the office.
Involutional medial ectropion responds poorly to traditional ectropion procedures. Eversion of the lacrimal punctum must be functionally corrected to reestablish normal corneal wetting physiology as well as tear-lake drainage. We describe our retropunctal approach with emphasis on a new, enhanced closure that utilizes the lower eyelid retractors. This stabilizes the medial eyelid margin in order to obtain and maintain good functional and cosmetic results. This procedure allows a predictable anatomic approach that is easily performed and can be combined with other procedures, such as a lateral tarsal strip, medial canthal tendon plication, or skin graft or flap, when required.
In 17 eyelids of 14 patients a disinsertion of the lower eyelid retractors from the lower tarsus was identified and repaired through the conjunctiva. The disinserted lower eyelid retractors were isolated in the inferior fornix with forceps, the redundant conjunctiva was excised, the lower eyelid retractors were reattached to the inferotarsal border, and the eyelid was tightened horizontally. During follow-up periods ranging from six to 26 months, there have been no recurrences and no cases of cicatricial entropion.
Twenty-two normal lower eyelids were studied microscopically to examine the normal anatomy of the lower eyelid retractors. Eight lower eyelid specimens from patients with involutional entropion and five from patients with involutional ectropion were studied also. In the normal eyelids, the inferior tarsal muscle consisted of scattered smooth-muscle fibers and did not insert on the tarsus. The orbital septum fused with the capsulopalpebral fascia 5 mm beneath the lower tarsal border to form a single, complex fascial layer. In the involutional entropion and ectropion cases, the fused capsulopalpebral fascia-orbital septum complex was attached to the tarsus in all specimens. The first identifiable smooth-muscle strands of the inferior tarsal muscle averaged 3.9 mm from the lower tarsal border in entropion cases, 4.5 mm in ectropion cases, and 2.5 mm in the normal eyelids.