Ординатура / Офтальмология / Английские материалы / Moorfields Manual of Ophthalmology_Jackson_2007

Box 1.2: Lateral tarsal strip (LTS)—cont’d

12.Place 6/0 Vicryl grey line (buried knot) and lash line sutures (external knot) through the upper and lower lids before tying the strip suture (firm, but do not overtighten – watch the position of the lid on the globe).

13.As the LTS suture ends are pulled upwards, the noose tightens on the strip which is drawn onto the orbital rim, tucked upwards to lie within upper lid grey line split. This provides further vertical support.

14.Close orbicularis and skin with interrupted 7/0 Vicryl sutures.

15.Apply Oc. chloramphenicol, Vaseline gauze, and a firm dressing for 24 hours.

16.Review in 2 weeks for removal of skin sutures, then discharge.

A B

Fig. 1.5: Lateral tarsal strip.

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Floppy Eyelid Syndrome

Background Typically presents in middle-aged obese men with unilateral or bilateral chronic papillary conjunctivitis, marked upper lid tissue laxity, and spontaneous tarsal eversion at night. Frequently associated with sleep apnoea syndrome. The aetiology is unknown but histology shows decreased elastin in the tarsus.

Symptoms Irritable red eye. Upper lid eversion at night (on the sleeping side).

Signs Easily everted tarsus (Fig. 1.7) with rubbery consistency, lash ptosis, papillary conjunctivitis, and superior punctate keratitis.

History and examination The patient’s partner may report heavy snoring, apnoea and lid eversion at night. Horizontal lid laxity is usually marked. Keratitis may be subtle.

Differential diagnosis Allergic conjunctivitis, chlamydial conjunctivitis, and age-related lid laxity.

Investigations Refer to a respiratory physician for sleep studies.

Treatment

■Casualty : Topical lubricants, mild topical steroid for keratitis.

■Clinic : Consider surgical options:

1. Anterior lamellar reposition for lash ptosis.

2. Upper lid shortening with wedge excision.

3. Medial and lateral canthal tendon plication.

Surgical risks include inflammation, infection, scarring, and need for further lid.

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Lower lid entropion

Lower Lid Entropion

Background Similar aetiology to age-related ectropion (p. 9). Exclude chronic conjunctival disease and cicatrization of the posterior lamella.

Classification

■Congenital.

■Acquired: age-related, cicatricial.

Symptoms Epiphora, mucous discharge and red eye.

Signs All or part of the lower lid may be inverted. Other features include: subtarsal mucous strands, lash–cornea touch, punctate epithelial keratopathy, conjunctival cicatricial changes, punctal stenosis, skin laxity, preseptal orbicularis riding upwards (‘spastic entropion’).

History and examination Ask about previous lid surgery and cicatrizing disease, e.g. Steven-Johnson’s syndrome, ocular mucous membrane pemphigoid (OMMP) and allergy to topical medication. Forced lid closure may elicit subtle entropion. Exclude effacement of the plica, an early sign in OMMP. Lower lid entropion may simulate distichiasis. In the former, the meibomian gland orifices are always found posterior to the lashes.

Investigations Conjunctival biopsy if OMMP suspected.

Treatment: In patients unfit for surgery, or as a temporising measure, the following may be appropriate:

■Transverse lid sutures : 3–4 double-ended 5/0 Vicryl sutures are passed through the lower lid just beneath the tarsus, brought out through the skin, and tied to create a slight ectropion. Sutures may be left to absorb.

■Everting sutures : Pass 3 double-ended 5/0 Vicryl sutures through the lower fornix and out through the skin. Shorteracting than transverse lid sutures (Fig. 1.8).

■Botulinum toxin A : Inject into the preseptal orbicularis (3 injections of Dysport 20 units, 1 cm from the lower lid margin). May need to be repeated.

Surgery :

■Horizontal lid laxity must be addressed (lateral tarsal strip or pentagon wedge excision, p. 10–13) to reduce the risk of recurrence. Everting sutures, or, in more severe cases,

plicating sutures to the lower lid retractors (Jones procedure), are placed at the same time. The Weiss procedure involves a

B

Everting suture resulting in mild ectropion

Fig. 1.8: Everting sutures (A and B).

■The Quickert operation is effectively a Weiss procedure with horizontal lid shortening.

■The Jones procedure directly plicates the lower lid retractors to the tarsus and anterior lamella via an incision level with the lower border of the tarsus. Avoid lower lid retraction from overtightening. Use adjustable sutures if surgery is under general anaesthesia.

■Posterior lamella graft (e.g. buccal mucosa) is indicated in cicatricial cases. Aggressive control of conjunctival inflammation should precede surgery in cases of OMMP.

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Upper lid entropion

Upper Lid Entropion

Background Upper lid entropion is frequently due to a posterior lamella cicatricial process, e.g. chronic conjunctivitis, trachoma, ocular mucous membrane pemphigoid (OMMP). In sockets, it is usually due to a shortage of lining.

Symptoms Ocular irritation, epiphora.

History and examination Ask about trauma, and chronic ocular surface inflammation (e.g. OMMP). Exclude blepharospasm, posterior lamella cicatricial changes, and corneal pannus or epithelial changes.

Differential diagnosis Lash ptosis without lid entropion, e.g. floppy eyelid syndrome.

Management For mild cases, an anterior lamella reposition may suffice. A skin crease incision is made down to the tarsus, and three double-armed 5/0 Vicryl sutures are placed through the upper tarsus, brought out through the skin above the lashes and tied. With all procedures, recession of the retractors off the anterior tarsal plate, with or without division of the lateral horn, may also be required. Greater eversion is achieved with a grey line split, and, if required, a horizontal wedge excision of the anterior tarsus. More severe cases may require a lamella division, i.e. splitting the anterior and posterior lamellae via the grey line as far as the superior fornix and recessing the retractors. Where there is keratin on the posterior aspect of the tarsus, a terminal tarsal rotation may be required.

Trichiasis

Eyelash follicles are in a normal position (unlike distichiasis) but directed towards the globe (Fig. 1.9). Causes include chronic lid margin disease and conjunctival cicatricial diseases, e.g. StevensJohnson syndrome and ocular mucous membrane pemphigoid. Treat small numbers of lashes with electrolysis (Box 1.3), but up to half may re-grow, and treatment may cause tarsal scarring and further trichiasis. Full-thickness lid excision with repair of the defect is a more permanent treatment for localized trichiasis. Manage more extensive areas with cryotherapy (Box 1.4), but be aware that this may cause localized skin depigmentation in darkskinned patients; electrolysis and correction of any lid margin malposition may be preferable in such patients.

Fig. 1.9: Trichiasis.

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Trichiasis

Box 1.3: Electrolysis

1.Inject local anaesthesia and use a microscope.

2.Grasp the lid margin with large toothed forceps (e.g. Adson’s forceps) and direct the fine electrolysis needle alongside the hair shaft down to the lash follicle.

3.Deliver the current until gentle blanching occurs. Power and time settings differ from one unit to another, e.g. the Ellman Surgitron

radiofrequency device uses ‘cut/coagulation’ setting with power <1 unit.

4.Adequately treated lashes are then easily epilated and the hair bulb visualized.

Box 1.4: Cryotherapy

1.Some units have a thermocouple needle that is inserted into the

tissue to check temperature, but this is not essential, if the average time it takes to reach −20ºC has been assessed on a previous series of patients using the same cryo probe.

2.Inject local anaesthesia and protect the eye with a plastic lid guard.

3.Use the lid cryoprobe to apply a double freeze–thaw cycle (to −20˚C) with spontaneous thawing between treatments.

4.Prescribe topical antibiotic ointment for 5–7 days.

Distichiasis

Clinical features

In contrast to trichiasis, distichiasis is a congenital disorder in which a separate and more posterior row of metaplastic lashes exists (often growing out of the meibomian gland orifices). The lid margin is in a normal position (Fig. 1.10).

Management

■If only a few lashes are affected, evert the eyelid with a meibomian clamp, use a microscope and incise the shaft of the eyelash through the partial thickness of the tarsus to the hair bulb. Electrolyse it under direct vision.

■More extensive areas can be treated by splitting the lid at the grey line, freezing the posterior lamella, and suturing the lamella back together. The posterior lamella must be advanced to compensate for the shrinkage after cryotherapy, which could lead to subsequent entropion formation.

Fig. 1.10: Distichiasis.

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