Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
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Figure 9: Weis procedure 1
Figure 10: Weis procedure 2
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Figure 11: Lid notching after extensive electrolysis
Figure 12: Madarosis and pigmentation after cryo
INVOLUTIONAL ENTROPION
Is the most common variety encountered.
It affects only the lower lids and is associated with aging.
Pathophysiology
It is due to:
•Laxity of the tarsal ligaments
•Weakness of retractors.
•Overriding and preseptal on pretarsal orbicularis.
Medical Treatment
•Patients with blephrits and meibomitis should by treated.
•Patients with dry eyes should by treated by artificial tears.
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Surgical Treatment
1.Three suture technique.
2.Direct anatomic surgical approach.
3.Weis procedure.
4.Weis procedure with lateral tarsal strip.
Three Suture Technique
•It is best suited for poor risk patients at the bed side or in the office.
•The lid should not be too lax.
A.Suture technique, sagittal view of 5-0 vicryl sutures passed through the retractor complex.
B.The suture is brought out just anterior to the inferior tarsal border through orbicularis muscle to emerge 3 to – 4 mm below the lower lid cilia. This brings the retractors back to their normal anatomic position.
Figures 13A and B: Suture techniques (sagittal view)
Direct Anatomic—Surgical Approach
This approach seeks to correct the three main causative.
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Figures 14A to C: Causative factors for surgical approach
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Factors
•Overriding of orbicaularis.
•Weakness of retractors.
•Horizontal lid laxity.
Direct anatomic approach:
A.A subciliary incision exposing the tarsal plate, dehisced edge of the lower eyelid retractors, preaponeurotic. fat, orbital fat, and orbicularis muscle.
B.A lateral tarsal strip is fashioned and sutured to: Periosteum of the inner aspect of the frontal process of the zygoma.
C.The edge of the lower evelid retractor is advanced and sutured to the inferior tarsal border or to the cut edge of the pertarsal prbicularis with 6-0 silk.
Weis Procedure
A.Three double—armed 5-0 vicryl sutures are placed along the lower eyelid, through conjunctiva and retractors, anterior to the tarsal plate, exiting through the orbicularis and skin at the level of the lashes.
Figures 15A and B: Weis procedure
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B.The tarsal edge of the horizontally shortened lid is sutured to periosteum. The 5-0 vicryl sutures have already been preplaced through conjunctiva and retractors, exiting anterior to the trasal plate through orbicularis and skin.
Weis procedure with lateral tarsal strip:
Used in weakens of retractors combined with congenital lid laxity.
Lateral tarsal strip procedure:
•Horizontal canthotomy .
•Inferior cantholysis.
•Excision of a part of skin and orbicularis
•Excision of a part of lid margin—according to lid laxity.
•Peeling of conjunctiva to prevent postoperative inclusion cyst.
•Suturing of tarsal strip by double armed vicryl 5/0 to the periosteum of frontal process of the zygoma.
•Closure of skin by interrupted sutures.
Ectropion
INTRODUCTION
It is one of the most common malpositions of the eyelid, defined as rolling-out “eversion” of the lid margin away from the eye-ball. The lower lid is commonly involved.
PATHOPHYSIOLOGY
According to the mechanism of the defect “pathological factor” the ectropion was classified to different types.
1.When the anterior lamella is shortened either postoperatively, trauma (burns or injuries), or ulceration, the resultant cicatricial ectropion will take place.
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2.Supporting of the lower eyelid in its normal position depending on the orbicularis oculi muscle tone and loss of this support will lead to paralytic ectropion as in case of facial nerve palsy.
3.Senile or involutional which is caused by a horizontal lid laxity as a result of lengthening of medial and lateral canthal tendons with ageing changes, it is the most common type of ectropion and has a continuous pathological process that is aggravated by conjunctivitis and epiphora.
4.When the eyelids are well supported by a big eye-ball relative to its orbital cavity in presence of blepharospasm well cause a spastic ectropion and on the other hand when eyelids are less supported by a less prominent inferior orbital rim will lead to a midfacial hypoplasia with resultant ectropion as in case of exophthalmos and children.
5.Mechanical ectropion is caused by eversion of the lower lid by a tumor or a mass.
6.Congenital ectropion is a rare condition due to shortage of skin as in congenital ichthyosis or blepharophimosis.
Note: The condition of ectropion “during sleep” due to floppy eyelid syndrome should be suspected by exclusion in which the skeleton of lids “tarsus is lengthened and become more lax.
CLINICAL SIGNS AND SYMPTOMS
History
Patients with ectropion will complain of tearing, burning sensation and redness of the involved eye, however the age
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of the patient is an important clue in which the congenital ectropion is an infancy condition , epiphora is a less complaint of the elderly , but more common with young patients due to adequate tears production. Involutional ectropion is the most common type with patients while paralytic ectropion is more apparent in elderly rather than youngs with 7th C.N. Palsy.
Examination
It should be directed towards recognition of the ectropion and its severity .
1.Severity of ectropion:
•Mild : The lower punctum is everted
•Moderate : The tarsal conjunctiva is exposed
•Severe : The lower fornix is exposed
2.Extent of ectropion: Medial or lateral or involving the entire lower eyelid.
3.Presence of any traumatic or surgical scar tissue.
4.Presence of a horizontal lid laxity. Which is demonstrated by:
a. Eyelid snap test: Pull the eyelid inferiorly.
•If the eyelid springs to its normal position without a blink it means no lid laxity.
•If it remains away from the eye for a time; it means a lax lid. Then the degree of lid laxity will be determined by the. Number of blink required to bring the lid on contact to the eye.
b.Eyelid distraction test: By pulling the eyelid away from the eye, the lower lid should not move more than 6 mm from the eye.
5.Signs of lower facial nerve palsy as brow ptosis, lid retraction with incomplete blink, lagophthalmos and absence of nasolabial fold.
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6.Weakness of the preseptal orbicularis oculi is tested by closure of the eyelids.
7.Examination of corneal sensation is a must .
TREATMENT OF ECTROPION
The management of ectropion depends on the cause, extent and presence or absence of a horizontal lid laxity.
1. Involutional ectropion:
a.With no horizontal lid laxity: Medial conjunctivoplasty (medial spindle operation)
“ Excision of a diamond of tarsoconjunctiva”
•With mild horizontal laxity:-lazy-T procedure (medial conjunctovoplasty and full thickness lid excision)
•With severe horizontal laxity;-medial canthal tendon plication.
b. Entire lid Ectropion
•If no excess skin; Horizontal lid shortening .
•If with excess skin; horizontal lid shortening plus blepharoplasty.
•Lateral tarsal strip procedure.
2.Treatment of cicatricial ectropion
a. If mild |
: Z-plasty |
b. If severe |
: Skin grafts or flaps |
3.Treatment of paralytic ectropion.
a.Temporary method:
•Conservative (Artificial tears and ointment).
•Surgical (Tarrsoraphy).
b.Permanent methods:
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•With ectropion
i.Medical canthoplasty.
ii.Lateral canthoplasty.
4.Medial canthoplasty with lateral tarsal strip.
5.Encirclement (with prosthetic silicon sling).
a.Without ectropion
•Upper lid weight (gold).
•Graded levator recession.
•Brow lift to correct brow ptosis.
6.Treatment of mechanical ectropion “Removal of the cause”
7.Treatment of congenital ectropion
Skin graft + horizontal lid shortening as appropriate
8.Treatment of spastic ectropion:
a.Treatment of biepharospasm (Botulinum toxin injeciton
b.Snellen’s sutures: in which three double-armed sutures are passed from the lower fonix through the periostium of the inferior orbital margin to emerge on the skin of cheek and tied over small pieces of rubber of removed after 2 weeks.
PROGNOSIS
It is usually good with preservation of corneal wetting and clarity. Surgery results in long-term cure in functional obstruction.