6Lower eyelid ectropion

introduction

Eyelid ectropion is an eyelid malposition in which the eyelid margin is turned away from its normal apposition to the globe. This more frequently affects the lower eyelid. Upper eyelid ectropion is more unusual. The condition may be classified into four categories according to the underlying etiology.

classification

1.Involutional ectropion (Fig. 6.1A)

2.Cicatricial ectropion (Fig. 6.1B)

3.Paralytic ectropion (Fig. 6.2A)

4 Mechanical ectropion (Fig. 6.2B)

It should be recognized, however, that more than one etiological factor may be present in an individual patient: e.g., in a patient with a chronic facial palsy and a lower lid ectropion, all four etiological factors may coexist (Fig. 6.3). An ectropion affecting the upper eyelid is less commonly encountered and may be seen following eyelid trauma, herpes zoster ophthalmicus, icthyosis, and burns (Fig. 6.4).

It is important to be able to classify the type of ectropion that is seen so that the correct treatment is directed at the underlying cause. Involutional ectropion is by far the most common type of ectropion but a cicatricial cause of lower lid ectropion is often overlooked (Fig. 6.5). Such an ectropion will only respond to the addition or recruitment of skin into the lower eyelid using a full thickness skin graft, a mid-face lift, or with the use of soft tissue expansion.

Failure to recognize this leads to poor results from inappropriately selected surgical procedures (Fig. 6.6).

key point

A cicatricial cause of lower lid ectropion should not be overlooked.

The initial sign of a lower lid ectropion is inferior punctal eversion (Fig. 6.7).

This can lead to a vicious cycle of secondary events and needs to be addressed early. Eversion of the inferior punctum leads to exposure and drying of the punctum, which becomes stenosed. Epiphora ensues, which may lead to excoriation and contracture of the skin of the lower eyelid that further exacerbates the ectropion. In addition, the patient tends to continually wipe the tears from the lower eyelid, which in turn results in eyelid and medial canthal tendon laxity that further exacerbates the lower eyelid ectropion. If the condition is neglected, the tarsal conjunctiva becomes exposed and eventually thickened and keratinized (Fig. 6.8). Lower lid ectropion often results in a corneal epitheliopathy, especially in the inferior third of the cornea.

patient evaluation

The patient’s history may point to a number of dermatological disorders which may be responsible for a cicatricial ectropion, e.g., eczema, lamellar icthyosis (Fig. 6.9). A drug history may reveal topical medications the patient may be taking to which there may be an allergy with a secondary chronic dermatitis, e.g., topical glaucoma medications (Fig. 6.10). This is not an infrequent cause of lower lid ectropion in elderly patients attending glaucoma clinics and is frequently overlooked or misdiagnosed.

Patients who have previously undergone a lower eyelid blepharoplasty, laser skin resurfacing, or a chemical peel may be reluctant to divulge such information (Fig. 6.11).

key point

A chronic allergic dermatitis is not an infrequent cause of a lower lid ectropion in elderly patients attending glaucoma clinics and is frequently overlooked or misdiagnosed.

When examining the patient, the whole of the patient’s face should be scrutinized for evidence of a dermatological disorder, connective tissue disorder, facial weakness, scars from previous surgery or trauma, or evidence of malignant cutaneous lesions (Figs. 6.12–6.14).

The degree of eyelid laxity is assessed by drawing the eyelid away from the globe and releasing it (the “snap” test) (Fig. 6.15).

The distance that the lid can be pulled away from the globe using the thumb and forefinger can also be measured in millimeters using a ruler (the “pinch” test).

The eyelid is drawn laterally and the position of the punctum is observed (the “lateral distraction” test). If the punctum can be drawn lateral to the medial limbus with the globe in the primary position, the medial canthal tendon will probably require attention during the surgical repair of the ectropion (Fig. 6.16). Rounding of the lateral canthus indicates lateral canthal tendon laxity or dehiscence.

If a cicatricial component of the ectropion is not obvious, the lower eyelid skin should be observed for tension lines seen when the patient blinks. The patient is asked to look up and to open the mouth to see whether or not these maneuvers exacerbate the ectropion (Fig. 6.17).

key point

Failure to recognize a cicatricial component is a common cause of surgical failure in the management of lower lid ectropion.

management

It is important to recognize dermatological causes of cicatricial ectropion that may be amenable to medical management

alone, e.g., chronic contact or allergic dermatitis. Removal of the offending substance, e.g., replacement of a topical glaucoma medication with a preservative-free preparation along with a short course of a weak topical steroid cream to the eyelid skin, may be all that is required.

The choice of surgical procedure depends on a number of factors:

1.The degree of ectropion

2.The location of the ectropion

3.The degree of laxity of the medial and lateral canthal tendons

4.The horizontal laxity of the eyelid

5.The tone of the orbicularis muscle

6.The nature of any cicatricial forces

7.The presence of any mechanical force

8.The age and general health of the patient

The surgical procedure(s) should be selected to address these factors in each individual patient. Although an abundance of

surgical procedures has been described for the management of lower eyelid ectropion, the choice of procedure can in practice be made from a relatively small number. The procedures utilized in the author’s practice are:

1.Retropunctal cautery

2.Medial spindle

3.Medial spindle with medial wedge resection

4.Medial canthal tendon plication

5.Medial canthal resection

6.Lateral wedge resection

7.Lateral wedge resection with skin–muscle blepharoplasty

8.Lateral tarsal strip procedure

9.Z-plasty

10.Lateral wedge resection or lateral tarsal strip with skin graft

11.Posterior approach retractor reinsertion with medial spindle with lateral tarsal strip

Figure 6.3 A right lower eyelid ectropion in a patient with a chronic lower motor neuron facial palsy. In this patient all the etiological factors coexist and should be addressed in his management.

Figure 6.5 A right lower lid cicatricial ectropion due to photo-damaged, aged, and “weather-beaten” skin.

Figure 6.6 A disastrous result from a K–Z procedure inappropriately performed on a patient who presented with epiphora and a medial ectropion. His mild cicatricial ectropion was due to eczema.

12.Fascia lata sling

13.Removal of lesion causing mechanical ectropion

14.Local tissue flap

15.Mid-face lift

16.Soft tissue expansion with local tissue flap

Figure 6.8 A patient with a bilateral complete tarsal ectropion with keratinization of the chronically exposed conjunctiva.

Figure 6.10 A patient with a left lower eyelid cicatricial ectropion. The patient was allergic to the topical glaucoma medication prescribed for the left eye only. The ectropion (and ptosis) resolved completely after a short course of topical steroid applied to the periocular skin.

Figure 6.11 A right lower eyelid ectropion in a patient who had undergone a 4-lid blepharoplasty with laser skin resurfacing 10 years previously by a plastic surgeon. The secondary hollowing of the lower eyelids from excessive fat removal and the smooth lower lid skin contrasting with the rest of the periorbital skin texture are tell tale signs that indicate the reason for the development of the lower lid cicatricial ectropion.

Involutional Ectropion

Involutional ectropion can be further classified into the following subtypes:

1.Punctal ectropion

2.Medial ectropion without horizontal eyelid laxity

Figure 6.12 A patient with a bilateral lower eyelid ectropion. The patient has Ehlers–Danlos syndrome.

3.Medial ectropion with horizontal eyelid laxity

4.Medial ectropion with medial canthal tendon laxity

5.Ectropion of the whole length of the lower eyelid

6.Complete tarsal ectropion

Punctal Ectropion

Retropunctal Cautery

Where the lower lid ectropion is very early, it is simple to apply retropunctal cautery.

Surgical procedure

1.One to two milliliters of 2% lidocaine with 1:80,000 units of adrenaline are injected subcutaneously and subconjunctivally into the medial aspect of the lower eyelid.

2.Using a disposable cautery device, deep burns are applied to the conjunctiva 3 to 4 mm below the punctum. The effect on the punctal position is observed and titrated by the number of burns applied and the depth of the burn. Great care should be taken when using such a device close to the globe, and inflammable swabs should be kept away from the surgical field.

3.Antibiotic ointment is instilled into the eye

Postoperative care. Antibiotic drops are instilled into the eye three times per day for a week.

Medial Ectropion Without Horizontal Eyelid Laxity

Medial Spindle Procedure

Where the punctal ectropion is more pronounced, a medial spindle procedure is performed. It is usually necessary to dilate the punctum with a Nettleship dilator at the same time, as this is often stenosed. It is not usually appropriate

Figure 6.16 Medial canthal tendon laxity demonstrated with a lateral distraction test.

(A)

to perform any destructive procedures on the punctum, e.g., a 3-snip punctoplasty, as the punctum, may resume its normal appearance and function once it has been repositioned against the globe. Alternatively, a perforated punctal plug, or a Crawford bi-canalicular or monocanalicular stent can be placed temporarily to maintain patency of the punctum. If a stenosed punctum needs to be surgically enlarged, it is preferable to do this using a Kelly punch.

Surgical procedure

1.One to two milliliters of 2% lidocaine with 1:80,000 units of adrenaline are injected subcutaneously and subconjunctivally into the medial aspect of the lower eyelid.

(B)

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2.A 00 Bowman probe is inserted into the inferior canaliculus. This step is omitted when experience has been gained.

3.The conjunctiva is lifted just below the inferior punctum using Paufique forceps. A diamond-shaped excision of conjunctiva is performed using Westcott scissors. A cut is made through the tented conjunctiva in a horizontal plane medial and then lateral to the forceps creating a diamond-shaped excision (Fig. 6.18).

4.A double-armed 5/0 Vicryl suture on a 1/4-circle needle is passed through the lower eyelid retractors at the base of the conjunctival wound, with the needle being rotated toward the globe.

5.The needle is then reverse mounted and passed away from the globe through the superior edges of the conjunctival wound on either side of the apex of the diamond.

6.Again the needle is reverse mounted and is then passed back through the inferior edges of the conjunctival wound on either side of the apex of the diamond and out through the skin of the lower lid at the junction of eyelid and cheek skin (Fig. 6.19). The effect of the suture is to attach the inferior retractors to the superior aspect of the wound, to pull

(A)

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the punctum posteriorly against the globe, and to close the wound. The tension on the suture is titrated against the effect on the position of the punctum. Ideally the punctum should be slightly over-inverted against the globe.

Postoperative care. Postoperatively topical antibiotic ointment is prescribed three times a day for 2 weeks and the patient is instructed not to pull the eyelid down to instill this. The ointment should simply be smeared across the medial aspect of the eyelid. The suture should be removed in clinic after 2 to 3 weeks.

Medial Ectropion with Horizontal Eyelid Laxity

Medial Spindle Procedure with a Medial Wedge Resection

In this situation a medial spindle procedure is combined with a medial wedge resection of the lower eyelid (Fig. 6.20). The wedge resection is positioned to remove thickened keratinized conjunctiva. It is important that sufficient eyelid is left medial to the resection to enable vertical mattress sutures to be placed across the eyelid margin without risking damage to the punctum or to the inferior canaliculus.

Surgical procedure

1.One to two milliliters of 2% lidocaine with 1:80,000 units of adrenaline are injected subcutaneously

(B)

and subconjunctivally into the medial aspect of the lower eyelid.

2.The medial spindle procedure is performed first but the suture is not tied until the wedge resection has been performed.

3.The eyelid margin is held with Paufique forceps and a vertical incision is made with a no. 15 Bard Parker blade through the eyelid margin to a depth of approximately 2 mm. The blade is passed away from the globe for safety.

4.A vertical incision is then made to the base of the tarsus using straight iris scissors.

5.Hemostasis is achieved using bipolar cautery.

6.A second pair of Paufique forceps is then used to overlap the medial and lateral edges of the cut eyelid in order to assess the amount of eyelid that can safely be removed without placing undue tension on the wound.

7.The eyelid margin is again held with Paufique forceps and another vertical incision made with the no. 15 Bard Parker blade through the eyelid margin at the point of overlap.

8.A vertical incision is then made to the base of the tarsus using straight iris scissors.

9.The wedge excision is completed by angling the iris scissors at 45° at the base of the eyelid wounds and cutting inferomedially and inferolaterally.

10.A 5/0 Vicryl suture on a half circle needle is then passed through the tarsus just below the eyelid margin ensuring that the suture lies above the surface of the conjunctiva posteriorly and just beneath the skin anteriorly. The suture is tied with a single throw and the alignment of the eyelid checked. If it is not satisfactory, the suture is replaced. Once the alignment is satisfactory, the suture is loosened and used for traction by fixating it to the head drape using an artery clip. This elongates the wound making it easier to place further sutures in the tarsus.

11.Further 5/0 Vicryl sutures are placed horizontally through the tarsus and orbicularis muscle below the tarsus and tied.

12.The initial suture is now tied.

13.A 6/0 black silk suture is now passed horizontally through the gray line 2 to 3 mm from the wound edge and brought out through the gray line a similar distance from the wound edge. The needle is then reverse mounted and passed back as a horizontal mattress suture through the wound edges. The suture is tied causing the wound edges to evert slightly. A further 6/0 black silk suture is passed in the same way through the lash line and tied. The suture ends are cut leaving these long. The ends are incorporated in the skin closure sutures to keep the suture ends away from the cornea.

14.The skin edges are closed with interrupted 7/0 Vicryl sutures or with the 6/0 black silk sutures.

15.Antibiotic ointment is instilled into the eye.

Postoperative care. Postoperatively topical antibiotic ointment is prescribed three times a day for 2 weeks and the patient is instructed not to pull the eyelid down to instill this. The ointment should simply be smeared across the medial aspect of the eyelid. The sutures should not be removed for at least 2 weeks.

Medial Ectropion with Medial Canthal Tendon Laxity

In the majority of elderly patients with medial canthal tendon laxity, no specific measures are necessary to address this. A moderate degree of lateral punctal displacement is well tolerated and it may be inappropriate to subject the patient to a longer operative procedure. Where the degree of medial canthal tendon laxity is very pronounced, however, this can be addressed with a medial canthal resection procedure. In general, medial canthal tendon plication procedures do not tend to achieve adequate long-lasting results but may be attempted in those deemed fit enough to tolerate the surgery.

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Medial Canthal Tendon Plication

Surgical procedure

1.One to two milliliters of 2% lidocaine with 1:80,000 units of adrenaline are injected subcutaneously and subconjunctivally into the medial aspect of the lower eyelid and plica semilunaris, and a further 1 to 2 mls are given as a regional infratrochlear nerve block.

2.A conjunctival incision is made with Westcott scissors between the caruncle and the plica semilunaris and extended to the medial end of the inferior tarsal plate (Fig. 6.21).

3.Stevens tenotomy scissors are then used to dissect bluntly down to the posterior lacrimal crest. Small Wright’s retractors are then used to aid visualization of the periosteum of the crest.

4.A double-armed 5/0 Ethibond suture on a 1/2-circle needle is passed through the posterior lacrimal crest (Fig. 6.22).

5.Next, each needle of the Ethibond suture is passed through the exposed medial aspect of the tarsal plate (Fig. 6.23). The Ethibond suture is tied, bringing the eyelid into contact with the globe.

6.7/0 Vicryl sutures are positioned across the conjunctival wound and tied to ensure that the Ethibond suture is not left exposed.

7.Antibiotic ointment is instilled into the eye.

8.Tincture of benzoin is applied to the cheek and forehead skin and a firm compressive dressing is applied. Tape is applied to the cheek and drawn superomedially to ensure that tension is reduced on the wound.

Postoperative care. The dressing is not removed for 4 to 5 days. Antibiotic ointment is prescribed three times a day for 2 weeks, and the patient is instructed not to pull the eyelid down to instill this. The ointment should simply be smeared across the medial aspect of the eyelid. Suture removal is not required.

Medial Canthal Resection

Surgical procedure

1.One to two milliliters of 0.5% Bupivacaine with 1:200,000 units of adrenaline mixed 50:50 with 2% lidocaine with 1:80,000 units of adrenaline are injected subcutaneously and subconjunctivally into the medial aspect of the lower eyelid.

2.A full-thickness vertical incision is made through the eyelid adjacent to the caruncle (Fig. 6.24).

3.A conjunctival incision is made with Westcott scissors between the caruncle and the plica semilunaris and extended to the medial end of the inferior tarsal plate (Fig. 6.21).

4.Stevens tenotomy scissors are then used to bluntly dissect down to the posterior lacrimal crest. Small Wright’s retractors are then used to aid visualization of the periosteum of the crest.

5.A double-armed 5/0 Ethibond suture on a 1/2-circle needle is passed through the posterior lacrimal crest (Fig. 6.22).

6.Next, a triangular section of medial eyelid is removed, sufficient to allow the wound to be closed without undue tension (Fig. 6.25).

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Figure 6.21 A conjunctival incision is made between the caruncle and the plica semilunaris.

Figure 6.22 A double-armed 5/0 Ethibond suture on a 1/2-circle needle is passed through the medial aspect of the tarsus and through the periosteum of the posterior lacrimal crest.

7.The canaliculus is opened and marsupialized into the conjunctiva sac using interrupted 8/0 Vicryl sutures.

8. A Crawford style mono-canalicular silicone stent can be passed into the canaliculus.

9.Next, each needle of the Ethibond suture is passed through the cut end of the tarsus and tied, bringing the eyelid into contact with the globe.

10.7/0 Vicryl sutures are positioned across the conjunctival wound and tied to ensure that the Ethibond suture is not left exposed.

11. The skin is then closed with interrupted 6/0 silk sutures to aid in support of the wound.

12.Antibiotic ointment is instilled into the eye.

13.Tincture of benzoin is applied to the cheek and forehead skin and a firm compressive dressing is applied. Tape is applied to the cheek and drawn

Figure 6.24 The extent of the excision in a medial canthal resection is demonstrated.

Figure 6.25 The deep suture placement for a medial canthal resection procedure is illustrated.

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superomedially to ensure that tension is reduced on the wound.

Postoperative care. The dressing is not removed for 4 to 5 days. Antibiotic ointment is prescribed three times a day for 2 weeks and the patient is instructed not to pull the eyelid down to instill this. The ointment should simply be smeared across the medial aspect of the eyelid. The sutures are removed after 2 weeks.

Ectropion of the Whole Length of the Lower Eyelid with Lateral Canthal Tendon Laxity

The choice of procedure for a more extensive lower eyelid ectropion depends on a consideration of the following factors:

1.The degree of rounding of the lateral canthus

2.The presence of excess lower eyelid skin

3.The degree of horizontal eyelid laxity

4.The degree of upper eyelid laxity

5.The general health of the patient

If there is significant lateral canthal tendon laxity with rounding of the lateral canthus and a narrowing of the horizontal palpebral aperture, a wedge resection of the lateral aspect of the eyelid will further exaggerate the problem and will not address the underlying anatomical abnormality. A lateral tarsal strip procedure is preferable for such a patient. A lateral tarsal strip procedure is also more convenient as this avoids the need for suture removal but may leave an unsatisfactory overlap of the upper lid at the lateral canthus if the upper eyelid is very lax. The lateral tarsal strip procedure is also more problematic to perform in the obese, hypertensive patient, or in the patient who is unable to discontinue the use of aspirin preoperatively. If the patient has excess lower eyelid skin, a lateral wedge resection or a lateral tarsal strip procedure can be combined with a lower lid skin–muscle blepharoplasty or a skin pinch blepharoplasty.

These procedures can also be combined with a medial spindle procedure for a punctal ectropion that is not corrected by a lateral eyelid-tightening procedure. The medial spindle procedure should be performed prior to completing the repair of any lateral eyelid-tightening procedure.

Lateral Wedge Resection

The wedge resection is performed at the junction of the lateral third with the medial two-thirds of the eyelid. It is important to ensure that a retraction of the lower eyelid is not caused by too aggressive a resection of eyelid tissue.

Surgical Procedure

This is as described above.

Lateral Wedge Resection with Skin–Muscle Blepharoplasty

The vertical cutaneous scar created by a simple wedge resection can be avoided by creating a skin–muscle blepharoplasty flap and performing the wedge resection beneath this.

Surgical procedure

1.Two to three milliliters of 0.5% Bupivacaine with 1:200,000 units of adrenaline mixed 50:50 with 2% lidocaine with 1:80,000 units of adrenaline are injected subcutaneously along the entire length of the eyelid.

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2.A 4/0 silk traction suture is placed through the gray line and fixated to the head drapes using an artery clip.

3.A subciliary skin incision is made with a Colorado needle extending inferolaterally at the lateral canthus in a skin crease.

4.A skin–muscle flap is dissected inferiorly from the orbital septum for approximately 8 to 9 mm and extended laterally.

5.The traction suture is now removed.

6.Next, a wedge resection of the underlying posterior lamella is performed and the wound closed as described above.

7.The skin–muscle flap is drawn laterally and the excess skin and muscle are resected as a base-down triangle.

8.The subciliary skin incision is closed with interrupted 7/0 Vicryl sutures (Fig. 6.26).

9.The 6/0 silk sutures are sewn to the skin of the lower eyelid with interrupted 7/0 Vicryl sutures.

Postoperative care. Postoperatively topical antibiotic ointment is prescribed three times a day for 2 weeks and the patient is instructed not to pull the eyelid down to instill this. The ointment should simply be smeared across the eyelid margin. The sutures should not be removed for at least 2 weeks. Cool packs can be applied intermittently for 24 hours.

Lateral Tarsal Strip Procedure

Surgical procedure

1.Three to four milliliters of 0.5% Bupivacaine with 1:200,000 units of adrenaline mixed 50:50 with 2% lidocaine with 1:80,000 units of adrenaline are injected subcutaneously into the lateral aspect of the upper and lower eyelids and into the lateral canthus.

2.A lateral canthotomy is performed using straight blunt-tipped scissors (Fig. 6.27). The canthotomy is extended to the lateral orbital rim. (A Colorado needle can be used instead if available.)

3.The lower eyelid is then lifted in a superotemporal direction and the inferior crus of the lateral canthal tendon is cut using blunt-tipped Westcott scissors (Fig. 6.28).

4.The septum is also freed with the Westcott scissors until the eyelid becomes loose. Care is taken to avoid excessive bleeding by using bipolar cautery. It is easier to perform the initial steps of this procedure sitting at the head of the patient. It is then preferable to move to the side of the patient to complete the remainder of the procedure.

5.Once the lower eyelid has been freed of its canthal

attachments, the anterior and posterior lamellae are split along the gray line using Westcott scissors (Fig. 6.29). This is aided by holding the skin and orbicularis muscle taut at the lateral end of the eyelid with Paufique forceps.

6.The lateral tarsal strip is then formed by cutting along the inferior border of the tarsus (Fig. 6.30). Next, the eyelid margin of the tarsal strip is excised (Fig. 6.31).

7.The tarsal strip is then drawn to the lateral orbital margin to determine the extent of any redundant tarsal strip. This is then excised (Fig. 6.32).

Figure 6.27 A lateral canthotomy is performed using straight blunt-tipped scissors (surgeon’s view).

8.The tarsal strip is then positioned over the handle of a Paufique forceps with the conjunctival side exposed and the conjunctiva scraped from the tarsal strip using a no. 15 blade (Fig. 6.33). Alternatively

this can be achieved by the gentle application of bipolar cautery using a sweeping motion.

9.The redundant anterior lamella is excised with the Westcott scissors (Fig. 6.34).

10.Next, a double-armed 5/0 Vicryl suture on a 1/2-circle needle is passed through the periosteum of the lateral orbital wall, the needles each being passed from inside the orbital rim exiting at the rim, leaving a loop (Fig. 6.35A).

11.The end of the tarsal strip is passed through the loop. The needle is then reverse mounted and passed from the under surface of the tarsal strip exiting on the anterior surface lateral to the loop. This is repeated with the second needle. As the suture is pulled, the loop is then tightened, drawing the tarsal strip in a posterior direction against the globe (Fig. 6.35B,C).

12.The suture is then tied avoiding excessive tension.

13.A single 7/0 Vicryl suture is passed through the gray line at the edges of the lateral aspects of the upper

and lower eyelids reforming the angle of the lateral commissure.

14.The lateral canthotomy wound is then closed using interrupted 7/0 Vicryl sutures subcutaneously ensuring that the 5/0 Vicryl suture is buried, followed by interrupted 7/0 Vicryl sutures to the skin wound (Figs. 6.35D and 6.36).

The lateral tarsal strip procedure can also be combined with a skin–muscle blepharoplasty or a lateral skin pinch blepharoplasty procedure where necessary.

Postoperative care. Postoperatively topical antibiotic ointment is prescribed three times a day for 2 weeks, and the patient is instructed not to pull the eyelid down to instill this.

The ointment should simply be smeared across the eyelid margin. Any remaining sutures can be removed after 2 weeks. Cool packs can be applied intermittently for 24 hours.

Complete Tarsal Ectropion

This type of lower eyelid ectropion, in which the tarsal plate is completely everted, is rare. The diagnosis is reserved for

those patients who have no cicatricial element and little horizontal eyelid laxity. The condition is thought to be due to disinsertion of the lower eyelid retractors from the lower border of the tarsal plate. The malposition is managed by a combination of a posterior approach retractor reinsertion, a medial spindle procedure and a lateral tarsal strip procedure.

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Posterior Approach Retractor Reinsertion with Medial Spindle with Lateral Tarsal Strip Procedure

Surgical procedure

1. Three to four milliliters of 0.5% Bupivacaine with 1:200,000 units of adrenaline mixed 50:50 with 2% lidocaine with 1:80,000 units of

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adrenaline are injected subcutaneously and subconjunctivally into the lower eyelid along its entire length.

2.A 4/0 silk traction suture is placed through the gray line and the eyelid is everted over a medium sized Desmarres retractor.

LOWER EYELID ECTROPION

3.A conjunctival incision is made with either a no. 15 Bard Parker blade extending from a point 2 to 3 mm lateral to the punctum to the lateral canthus. The conjunctiva is undermined inferiorly for 6 to 7 mm using blunt-tipped Westcott scissors.

4.The lower eyelid retractors are now visible and are dissected from the orbital septum and orbicularis muscle with Westcott scissors.

5.Next, the retractors are advanced and reattached to the inferior border of the tarsal plate with interrupted 5/0 Vicryl sutures (Fig. 6.37).

6.The conjunctival flap is repositioned and closed with interrupted 7/0 Vicryl sutures, taking care to bury the sutures beneath the conjunctival wound (Fig. 6.38).

Next, a medial spindle procedure is performed followed by a lateral tarsal strip procedure as described above (Fig. 6.39).

Antibiotic ointment is instilled into the eye and a compressive dressing is applied.

Figure 6.38 The conjunctival wound is closed ensuring that the suture knots are buried.

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Postoperative care. The dressing is removed after 48 hours. Postoperatively topical antibiotic ointment is prescribed three times a day for 2 weeks, and the patient is instructed not to pull the eyelid down to instill this. The ointment should simply be smeared across the eyelid margin. The sutures are removed after 2 weeks. Cool packs can be applied intermittently for 24 hours.

Cicatricial Ectropion

A cicatricial lower eyelid ectropion is caused by scarring or contracture of the skin and/or orbicularis muscle, causing a vertical shortening of the eyelid. The causes are numerous:

1.Actinic damage from chronic sun exposure

2.Acute/chronic dermatitis, e.g., allergy to topical glaucoma medications, eczema

3.Morphoeic basal cell carcinoma of the lower eyelid/ medial canthus (Fig. 6.14)

4.Tumor irradiation therapy

5.Thermal/chemical burns

6.Specific dermatological disorders, e.g., lamellar ichthyosis

7.Trauma

8.Iatrogenic, e.g., following lower lid blepharoplasty or laser skin resurfacing/chemical peel, blowout fracture repair with scarring of the orbicularis muscle/orbital septum to the orbital margin, over-correction of lower eyelid entropion (Fig. 6.40).

Medical treatment alone may suffice for some of the many causes of cicatricial ectropion, e.g., discontinuation of topical glaucoma drops causing allergic dermatitis and the short-term application of topical steroid cream to the affected periocular skin. Although some patients will benefit from soft tissue rearrangement techniques for a very specific localized scar, e.g., a Z-plasty, such situations are not encountered very frequently. A full-thickness skin graft is more often required. A mid-face lift can recruit skin into the lower eyelid in some patients who have a mid-face ptosis. This procedure is preferable to a skin graft in patients who would find the postoperative appearance of the skin graft unacceptable.

A small medial ectropion will usually require a small skin graft alone, although this can be combined with a medial spindle procedure. Where the ectropion is more extensive a horizontal eyelidshortening procedure, either a wedge resection or a lateral tarsal strip, should be combined with the skin graft, to prevent a recurrence of the ectropion. A cicatricial ectropion affecting children is an exception to this rule.

A skin graft may be taken from a variety of sites:

1.The upper eyelid

2.The preauricular region

3.The postauricular region

4.The supraclavicular fossa

5.The upper inner arm

Each site has its advantages and disadvantages. The upper eyelid skin provides the best quality skin. It provides a good color match. It is easy to remove and has no subcutaneous fat. It is therefore very quick to prepare. The wound is simple to close. The upper lid, however, may not be a suitable site in some patients. It may show extensive actinic damage. There may be insufficient skin available to remove without risking a secondary lagophthalmos. It may leave an obvious asymmetry. It may exaggerate an associated brow ptosis.

The hairless preauricular also provides a good color match and is an easy site to access. The site may not, however, yield sufficient skin. It may also be affected by actinic damage. The postauricular site provides good skin but is unsuitable for patients who wear a hearing aid. The wound is rather more problematic to close because of difficulties with easy access and closure may alter the position of the ear.

The supraclavicular fossa skin tends to be rather pale. It can leave an unsightly scar and is best avoided in female patients who wear open-necked clothing.

The upper inner arm skin is pale but can yield a good result, particularly if the grafts are placed bilaterally. The skin is protected from solar damage. It is easy to access and large grafts can be harvested. The wound edges can be undermined to facilitate easy closure. If the wound breaks down, it can be left to heal by secondary intention. The scar is then far less obtrusive. The additional advantage is that the skin graft harvesting and the wound closure can be performed by a surgical assistant while the surgeon is working on the eyelid. This can save a great deal of valuable surgical time.

Lateral Wedge Resection or Lateral Tarsal Strip Procedure with Skin Graft

Surgical procedure

1.Three to four milliliters of 0.5% Bupivacaine with 1:200,000 units of adrenaline mixed 50:50 with 2% lidocaine with 1:80,000 units of adrenaline are injected subcutaneously into the lower eyelid along its entire length, and at the lateral aspect of the upper lid.

2.Seven to ten milliliters of the same solution are injected subcutaneously at the skin graft donor site.

3.Two 4/0 silk traction sutures are placed through the gray line and fixated to the head drapes using artery clips.

4.A subciliary skin incision is made with a no. 15 Bard Parker blade from a point 2 to 3 mm medial to the

Figure 6.40 A marked cicatricial ectropion following the use of a Wies procedure for a lower eyelid involutional entropion.

Figure 6.41 A template is taken of the lower eyelid skin defect using a piece of Steridrape.

punctum to a point 3 to 4 mm lateral to the lateral commissure.

5.A skin flap is dissected inferiorly from the orbicularis muscle using blunt-tipped Westcott scissors for a distance of approximately 7 to 8 mm. The eyelid margin should now rise with the pull from the traction sutures. If there is scarring at a deeper level, however, the eyelid will remain in the same position. Westcott scissors are now used to dissect the scar tissue away from the eyelid retractors or from the conjunctiva if the retractors are scarred.

6.The traction sutures are released.

7.Next, a wedge resection of the underlying posterior lamella is performed or, alternatively, a lateral tarsal strip procedure is performed as described above

8.The traction sutures are gently tightened again using the artery clips, exaggerating the anterior lamellar defect.

9.Next, a template is taken of the skin defect using a piece of Steridrape and a gentian violet marker pen (Fig. 6.41).

10.The template is transferred to the skin graft donor site and outlined with a gentian violet marker pen (Fig. 6.42A).

11.The skin is incised with a no. 15 Bard Parker blade along the mark.

12.The skin graft is then raised at one end with a skin hook or forceps while counter traction is applied. The graft is then peeled away using a sweeping action with the blade (Fig. 6.42B).

13.The donor site is closed with a continuous interlocking 4/0 nylon suture. If the wound is under tension, the margins are undermined, and interrupted 4/0 nylon sutures are placed in a vertical mattress fashion. Antibiotic ointment is applied to the wound and a sterile dressing is applied.

14.The skin graft is placed over the tip of the surgeon’s forefinger. Westcott scissors are used to remove all subcutaneous tissue meticulously until the “rete pegs” are visible (Fig. 6.43).

15.The graft is then transferred to the lower eyelid and sutured into the defect using four 6/0 silk bolster sutures. Interrupted 7/0 Vicryl sutures are placed in between the silk sutures (Fig. 6.44A).

16.The graft is then covered in topical antibiotic ointment, a piece of Jelonet and a piece of sterile sponge shaped from the template. The bolster sutures are tied over the sponge with only a moderate degree of tension (Fig. 6.44B). The bolster sutures can be omitted in small grafts, and a piece of rolled up Jelonet applied to the graft instead.

17.Tincture of benzoin is painted on the forehead and allowed to dry. The lower lid traction sutures are fixated to the forehead with Steri-strips. The suture is folded down and further Steri-strips are applied. The suture is folded up and yet further Steri-strips are applied.

18.Topical antibiotic ointment is liberally applied to the eyelids.

Figure 6.43 The skin graft is placed over the tip of the surgeon’s forefinger with the subcutaneous surface uppermost. Westcott scissors are used to remove all subcutaneous tissue meticulously.

19.A firm compressive dressing with a supporting bandage is applied.

Postoperative care. The bandage is removed by the patient after 48 hours, but the underlying dressing is not removed until 5 days postoperatively, along with the donor site dressing. The silk bolster sutures are carefully removed. Topical antibiotic ointment is prescribed three times a day for 2 weeks and the patient is instructed to smear this across the graft. The Vicryl sutures are removed after 2 weeks, along with the donor site sutures. The patient is then instructed to commence massage to the skin graft in a horizontal and upward direction for

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3 min, three times a day for at least 6 to 8 weeks after applying Lacrilube ointment to the graft. A silicone gel may be applied to help to prevent any thickening of the graft e.g., Kelocote or Dermatix, but this adds expense (Fig. 6.45).

Mid-face Lift

This is described in chapter 15 on “Blepharoplasty”.

Soft Tissue Expansion

This is described in chapter 12 on “Eyelid Reconstruction”.

Mechanical Ectropion

The diagnosis of mechanical lower eyelid ectropion is made where a mass lesion or a mid-face ptosis is responsible for pushing or pulling the eyelid out of its normal position. The ectropion is managed by directing treatment at the underlying cause (Fig. 6.46).

If a mid-face ptosis is causing the ectropion, as may be seen in a chronic facial palsy, the ptosis itself may be addressed in a number of ways, depending on the individual circumstances.

OCULOPLASTIC SURGERY

Treatment may be by facial suspension techniques, e.g., fascia lata graft suspension, temporalis muscle transfer, or by nerve substitution techniques, e.g., facial hypoglossal nerve anastomosis, or cross facial nerve grafting with gracilis or pectoralis muscle transplantation, performed by plastic surgery or ENT colleagues. Alternatively, the cheek may be raised by a suborbicularis oculi fat lift or a subperiosteal mid-face lift procedure, performed via a swinging lower eyelid approach and combined with a lateral tarsal strip procedure (see chap. 15).

In elderly patients, the mid-face ptosis can instead be accepted and the ectropion, whose etiology may be multifactorial, may be addressed by means of a combination of eyelid procedures only, e.g., a medial spindle, a posterior approach retractor recession, a full-thickness skin graft, and a lateral tarsal strip procedure (Fig. 6.47).

Paralytic Ectropion

The surgical management of paralytic ectropion depends on the degree of ectropion, and on the additional etiological factors that may be responsible for the ectropion,

LOWER EYELID ECTROPION

e.g., cicatricial changes from chronic epiphora, mechanical changes from a mid-face ptosis. A mild degree of paralytic ectropion in a patient with exposure keratopathy may benefit from a simple lateral tarsorrhaphy. A mild degree of ectropion alone may be managed with a lateral tarsal strip procedure. A chronic paralytic ectropion with medial canthal tendon laxity would be best managed with a medial canthal tendon resection procedure.

A mild degree of paralytic medial ectropion can be managed by means of a simple medial canthoplasty.

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Medial Canthoplasty

Surgical procedure

1.A vertical incision is marked just medial to the medial commissure using a gentian violet marker pen (Fig. 6.48A).

2.One to two milliliters of 0.5% Bupivacaine with 1:200,000 units of adrenaline mixed 50:50 with 2% lidocaine with 1:80,000 units of adrenaline are injected subcutaneously into the medial aspects of the upper and lower eyelids.

3.The eyelid skin is incised medial to the puncta and anterior to the canaliculi using a no. 15 Bard Parker blade and Paufique forceps. The canaliculi are protected by inserting 00 Bowman probes (Fig. 6.48B).

4.The skin is undermined using blunt-tipped Westcott scissors.

5.A vertical relieving incision is made inferiorly at the medial aspect of the inferior skin flap.

6.Two 7/0 Vicryl sutures are passed though the pericanalicular tissue and tied (Fig. 6.49A).

7.The inferior skin flap is drawn medially and the dog-ear removed with Westcott scissors (Fig. 6.49B).

8.The skin is closed with interrupted 7/0 Vicryl sutures (Fig. 6.49C).

Postoperative care. Postoperatively topical antibiotic ointment is prescribed three times a day for 2 weeks. The sutures can be removed after 2 weeks.

Congenital Lower Eyelid Ectropion

The majority of patients with congenital ectropion of the lower eyelid have additional facial abnormalities, e.g., patients with Down’s syndrome (Fig. 6.50A), blepharophimosis-ptosis-epican- thus inversus syndrome (Fig.6.50B),Möbius syndrome (Fig.6.13), or lamellar ichthyosis (Fig. 6.9). The patient’s ectropion is usually either cicatricial or paralytic in etiology. The majority of such patients require a full-thickness skin graft in conjunction with a lateral tarsal strip procedure. The cosmetic results of such surgery are poor in comparison to the results in adults as skin grafts tend to thicken and be much more obtrusive in young patients.

further reading

1.American Academy of Ophthalmology. Basic and Clinical Science Course: Orbit, Eyelids, and Lacrimal System, section 7. San Francisco: The American Academy of Ophthalmology, 2006/7: 201–5.

2.Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol 1979; 97: 2192–6.

3.Bosniak SL, Zilkha MC. Ectropion. In: Nesi FA, Lisman RD, Levine MR, eds. Smith’s Ophthalmic, Plastic and Reconstructive Surgery, 2nd edn. St Louis: Mosby, 1987: 290–307.

4.Dutton JJ. Atlas of clinical and surgical orbital anatomy. Philadelphia, PA: WB Saunders, 1994.

5.Fong KCS, Mavrikakis I, Sagili S, Malhotra R. Correction of involutional lower eyelid medial ectropion with transconjunctival approach retractor plication and lateral tarsal strip. ACTA Ophthalmol Scand 2006; 84: 246–9.

6.Gilbard SM. Involutional and paralytic ectropion. In: Bosniak S, ed. Principles and Practice of Ophthalmic Plastic and Reconstructive Surgery, Vol 1. Philadelphia, PA: WB Saunders, 1996: 422–37.

7.Giola VM, Linberg JV, McCormick SA. The anatomy of the lateral canthal tendon. Arch Ophthalmol 1987; 105: 529–32.

8.Goldberg et al. Ectropion repair. In: Wobig JL, Dailey RA, eds. Oculofacial Plastic Surgery, Face, Lacrimal System, and Orbits. New York, NY: Thieme, 2004: 97–102.

9.Jordan DR, Anderson RL. The lateral tarsal strip revisited: the enhanced tarsal strip. Arch Ophthalmol 1989; 107: 604–6.

10. Kahana A, Lucarelli MJ. Adjunctive transcanthotomy lateral suborbicularis fat lift and orbitomalar ligament resuspension in lower eyelid ectropion repair. Ophthal Plast Reconstr Surg 2009; 25: 1–6.

11. Marshall JA, Valenzuela AA, Strutton GM, Sullivan TJ. Anterior lamella actinic changes as a factor in involutional eyelid malposition, Ophthal Plast Reconstr Surg 2006; 22(3): 192–4.

12. Nerad JA, Carter KD, Alford MA. Ectropion. In: Rapid Diagnosis in Ophthalmology: Oculoplastic and Reconstructive Surgery. Philadelphia, PA: Mosby Elsevier, 2008: 80–91,

13. Nowinski TS, Anderson RL. The medial spindle procedure for involutional medial ectropion. Arch Ophthal 1985; 103: 1750–3.

14. Penne RB. Ectropion. In: Color Atlas and Synopsis of Clinical Ophthalmology: Oculoplastics. New York, NY: McGraw-Hill, 2003: 62–9.

15. Robinson FO, Collin JRO. Ectropion. In: Yanoff M, Duker J, eds., Ophthalmology. Philadelphia, PA: Mosby, 2004: 676–83.

16. Tse DT. Ectropion repair. In: Levine MR, ed. Manual of Oculoplastic Surgery, 2nd edn. Boston, MA: Butterworth-Heinemann, 1996: 147–56.