Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 850 - файл
.pdf
98 9Ectropion
https://t.me/medicina_free
9.4.2 Medial Canthal Tendon and Lateral Canthal Tendon
Integrity
Grasp the lower lid close to the lashes, between your thumb and forefinger and pull
it laterally, away from the medial canthus, while observing the movement of the
lower lid punctum relative to the corneo-scleral limbus. Any movement past the
medial limbus (in straight ahead gaze) suggests significant medial canthal tendon
laxity.
Repeat this manoeuvre again but this time pulling the lid medially while observing the movement of the lateral canthus. A significant drift of the lateral canthus
medially towards the lateral limbus suggests lateral canthal tendon dehiscence.
Correct canthal tendon dehiscence before contemplating lid margin resection.
If you do not, you will erroneously excise excessive lid margin to the detriment of
lid stability.
9.4.3 Anterior Lamellar Insufficiency
Attempt to correct (reduce) the lower lid ectropion by pulling the lid margin laterally and upwards with your finger. Observe whether tightness of the skin prevents
return of the lid margin to its normal position. Alternatively, while the patient is
looking upwards, gently pull the mid cheek slightly up and down and look for coupled movement of the lid margin. Such movement confirms a significant anterior
lamellar deficit. Normally the cheek and lid move independently.
9.4.4 Orbicularis Tone
Place your forefingers on gently closed upper lids and your thumbs on the lower
lids and ask the patient to squeeze their eyes tightly shut. Try to open the eyes
with your fingers. This should only be possible with strong effort. Compare the
two sides. A weak orbicularis suggests a paralytic component.
9.5 Temporary Management
The management of ectropion is surgical. While awaiting surgery ask the patient
to massage their lower lid upwards, towards the lid margin with a thin smear
of Hydrocortisone 1% skin ointment (for three minutes, three times a day). This
softens the skin, treats tear overflow eczema, and prevents further skin shrinkage,
optimizing conditions for surgery. On rare occasions it can even cure the ectropion.
You can temporarily correct a tarsal ectropion by placing inverting sutures, but
this is seldom justified (Fig. 9.2).
9.6 Surgical Management 99
https://t.me/medicina_free
a
Fig. 9.2 Inverting sutures. a Insert 3 double armed absorbable sutures transconjunctivally at the
lower edge of the tarsal plate, bringing them out through the skin 5 mm below the lash line.
b Tightening the sutures inverts the lid margin
b
9.6 Surgical Management
Factors requiring potential surgical correction are:
1. The relative laxity of the eyelid against the eye (invariably present),
2. Any apparent anterior lamellar shortage (caused by mid face descent, skin
shrinkage or scarring).
3. Significant lower lid retractor laxity ( for tarsal ectropion).
4. Lack of muscle tone.
They are present in various combinations and to various degrees. The decision
chart Fig. 9.3 may help you plan the appropriate combination of techniques during
surgery.
The mainstay of ectropion correction is lid margin tightening. This may require
canthal tendon repair and/or lid margin shortening.
In the presence of an anterior lamellar deficit first decouple the lid margin from
the mid face with a horizontal skin and orbicularis incision about 5 mm below the
lash line, extending it medially and laterally past the canthi. Once released, carry
out the necessary lid margin tightening to restore the lid to its correct position.
This reveals the true amount of anterior lamellar deficit.
If the lid is flipped completely inside out (‘tarsal ectropion’) with the proximal
tarsal plate edge forming the new margin, plicate the lower lid retractors to the
bottom of the tarsal plate to pull it downwards.
If an anterior lamellar defect remains after margin tightening, fill it with a skin
graft or flap, sized to allow for post-operative contraction. Use a temporary tarsal
traction suture to pull the lid margin upwards to expand the graft bed when sizing.
Tape this suture on tension to immobilize the graft during healing.
Finally, where there is significant orbicularis weakness consider performing a
small medial canthoplasty and lateral tarsorrhaphy to transfer active upper lid lift
to the lower lid.
100 9Ectropion
https://t.me/medicina_free
Tight Anterior lamella?
No
Canthal tendon laxity?
No
Lid margin lax?
No
Tarsal ectropion?
No
Anterior lamellar deficit?
No
Orbicularis weakness
No
End of operation
Yes
Subciliary anterior
release
Yes
Canthal tendon repair
Yes
Shorten lid margin
Yes
Retractor plication
Yes
Skin graft/flap
Yes
Medial canthoplasty &
Lateral tarsorrhaphy
Fig. 9.3 Ectropion decision chart. Use this to determine the appropriate combination of procedures for a particular case
9.7 Operations
9.7.1 Lid Margin Wedge Resection and Bick Repair
9.7.1.1 Principle and Considerations
‘Tightening’ the lid margin by partial resection or canthal tendon plication stabilizes a lid until it stretches again. Being a static repair, it fails in time. Full
thickness lid margin shortening may be carried out anywhere along the lid margin
(Fig. 9.4). Some argue that for a medial ectropion the resection should be carried
out medially, the merit being that the hypertrophied and inflamed section of the
lid is excised. However, this need not be an important consideration as the hypertrophy quickly settles once you restore the lid margin to its normal orientation.
9.7 Operations 101
https://t.me/medicina_free
Medial resection may be combined with medial lower lid retractor plication, as
in the Lazy T repair, or the medial plication can be separate from say a lateral
resection. I believe the lateral Bick resection to be the most elegant lid margin
shortening and the least likely to lead to margin notching or a noticeable scar.
a
b
c
Fig. 9.4 Shorten anywhere. a Lateral canthal lid margin resection. b Lateral lid margin resection.
c Medial lid margin resection
102 9Ectropion
https://t.me/medicina_free
9.7.1.2 Steps
1. Load two double ended 6/0 absorbable sutures and prepare them for instant
use.
2. Grab the full-thickness lid margin laterally with Adson’s forceps and place
the lateral canthus on stretch by pulling the lid medially. Detach the lower lid
margin from the lateral canthus by cutting infero-laterally at 45° from the lateral
canthus for approximately 5–6 mm with Steven’s tenotomy scissors (Fig. 9.5a).
Note: Cut slowly to crush the vessels and reduce bleeding.
3. Without delay (before the bleeding starts) grab the cut lateral canthal tendon
(LCT) with toothed forceps and insert the first of the two prepared double
armed 6/0 sutures as close to the canthus as possible with a double pass
(Fig. 9.5b). Confirm correct placement by tugging on the suture firmly. There
should be no give. Apply a bulldog clip to the pair of suture ends.
Note: Get an assistant to stretch the canthal tissues apart to improve visualization.
4. Place the second 6/0 suture 2 mm below the first in a similar fashion and again
confirm strong fixation in the tendon. If there is any ‘give’ replace the suture
more deeply. Clip both ends together.
5. Ask your assistant to pull the upper of the two lateral canthal tendon sutures
medially to put the lateral canthus on medial stretch. Grasping the cut edge
of the lid margin with toothed Adson’s forceps pull it laterally to overlap the
lateral canthus until the lid margin is straight. Mark the extent of the overlap
with a marking pen (Fig. 9.5c). Measure this overlap. It should be between 7
to 15 mm. In the unlikely event that it is less, there was either no lid margin
laxity or the lid was not being pulled firmly enough. If greater than 15 mm,
undiagnosed canthal tendon laxity is present and needs to be treated before
continuing.
6. Excise the excess lid margin with tenotomy scissors as a wedge or pentagon
(Fig. 9.5d).
7. Insert the two pairs of pre-placed LCT 6/0 sutures in sequence through the
cut edge of the tarsal plate, starting with the uppermost (Fig. 9.5e). Insert
them from behind, trans-conjunctivally, through the full thickness of the tarsal
plate, exiting through its anterior surface and bring them out of the wound
edge before engaging the orbicularis or skin. Place each suture 1 mm below
the previous one. Clip the corresponding pairs of suture ends together again,
temporarily. This results in two horizontal mattress sutures reattaching the lid.
8. Before tying the above sutures, place a single ended 7/0 absorbable suture in
the lid margin as a horizontal mattress (Fig. 9.5f). This time insert the suture
through the orbicularis to exit the skin through the lash line, 1-2 mm from the
wound edge.
9.7 Operations 103
https://t.me/medicina_free
a b
c d
e f
g h
i
Fig. 9.5 Bick resection ectropion. a Divide the lower lid from the lateral canthus. b Pre-place 2
double armed absorbable sutures into the lateral canthal tendon (LCT) stump. c Overlap the wound
edges and mark the excess lid margin. d Excise the excess lid margin. e Insert the LCT pre-placed
sutures into the cut edge of the tarsal plate. f Insert a lid margin horizontal mattress 7/0 absorbable
suture. g Tighten and tie the LCT sutures. h Tighten and tie the lid margin mattress to bury the
knot. i Close the orbicularis and skin
104 9Ectropion
https://t.me/medicina_free
9. Then, with the same needle, re-enter the lid through the meibomian orifice
line and exit through the tarsal plate just above the top, already placed, 6/0
suture bite (taking care not to inadvertently engage it with your needle).
10. Now enter the lateral canthal wound with the same needle, engage the upper
lid tarsal plate, and bring the needle out through the meibomian orifice line
1–2 mm from the lateral canthus.
11. Re-enter the upper lid lash line and exit the wound through the orbicularis to
complete this lid margin mattress suture. Clip its two ends together.
12. Now that you have placed the sutures under direct vision, pull the ends of the
lower of the two 6/0 sutures laterally (Fig. 9.5g). Use their pulley action to
pull the lid margin laterally towards the LCT to close the posterior lamella.
Tie the suture with no less than three throws and cut the ends no shorter that
2 mm (to prevent spontaneous unravelling).
13. Tie and cut the upper 6/0 suture similarly.
14. Tie the 7/0 pre-placed margin suture (Fig. 9.5h). This aligns the lid margin at
the lateral canthus. Cut the ends flush with the skin so that the knot becomes
buried and does not irritate.
15. Close the anterior lamella with two or three horizontal mattress 7/0 absorbable
sutures passed through the skin and orbicularis (Fig. 9.5i).
9.7.1.3 Notes
•
The tightened lid margin will slip below the globe and appear retracted. This is
usually only temporary and resolves within a couple of weeks.
•
For tarsal ectropion correction combine the lid margin shortening with lower lid
retractor plication. It is easier to identify the retractor aponeurosis and preplace
the sutures before performing the Bick repair.
9.7.2 Medial Lower Lid Retractor Plication (Fig. 9.6)
9.7.2.1 Principle and Considerations
Punctal ectropion is a common occurrence. Even an ectropion of as little as 1 mm
can give rise to disproportionally symptomatic watering. Traditionally a ‘tarsoconjunctival diamond’ excision is performed below the lower punctum. Such diamond
excision is pointless for two reasons. Firstly, there is next to no tarsal plate to
excise in that area, so what is excised is conjunctiva. Secondly, excision of conjunctiva achieves nothing, as conjunctiva stretches. A better alternative is to make
a horizontal conjunctival incision through which the lower lid retractors are identified and plicated to the inferior edge of the tarsal plate below the punctum to pull
it inwards as an active repair.
9.7 Operations 105
https://t.me/medicina_free
9.7.2.2 Case Selection
•
Punctal ectropion
•
Medial ectropion if you combine the plication with a lid margin tightening
9.7.2.3 Steps
1. Evert the lower lid and make a 5 mm long, horizontal, conjunctival incision
below the lacrimal punctum and the inferior edge of the tarsal plate (Fig. 9.6a).
a b
c d
Fig. 9.6 Medial lower lid retractor plication. a Evert the lower lid and make a 5 mm long, hori-
zontal, conjunctival incision below the lacrimal punctum and the inferior edge of the tarsal plate.
b Bluntly dissect infero-laterally between the conjunctiva and the lower lid retractors. c Withdraw the retractor aponeurosis from the pocket with toothed Jayles forceps and tag it with a 6/
0 absorbable suture before letting go. d Bring the suture needle out through the inferior edge of
the tarsal plate and upper conjunctival edge, below the punctum and take the needle back into the
wound through the inferior conjunctival edge. e Tie the suture tightly and cut the ends to 2 mm. so
that the knot becomes fully buried
e
106 9Ectropion
https://t.me/medicina_free
2. Hold the inferior conjunctival edge on upward stretch with Moorfields forceps
while bluntly dissecting infero-laterally between the conjunctiva and the lower
lid retractors with Westcott spring scissors (Fig. 9.6b).
3. Keeping the conjunctiva on stretch insert toothed Jayles forceps into the pocket,
aimed infero-laterally, and grab and withdraw the retractor aponeurosis. Tag it
with a 6/0 absorbable suture before letting go (Fig. 9.6c).
4. Check the retractor pull by putting the suture on gentle upward traction while
the patient is looking up, and then asking the patient to look maximally downwards. You should feel a tug on the suture. If it is not felt, repeat the manoeuvre
but this time asking the patient to follow your hand into downgaze. If there is
still no pull on the suture, remove and replace it.
5. Bring the suture needle out through the inferior edge of the tarsal plate and
conjunctiva, below the punctum.
6. Take the needle back into the wound through the inferior conjunctival edge
(Fig. 9.6d). Ensure that both ends are on the same side of the suture loop (to
allow the knot to retract once tied). Tie the suture tightly and cut the ends to
2 mm. Encourage them to retract into the wound so that the knot becomes fully
buried (Fig. 9.6e). This single suture both plicates the retractors to the tarsal
plate and closes the conjunctival incision. Whenever the patient looks down the
retractors pull the punctum inwards.
9.7.2.4 Note
•
Tightening the lid margin laterally (Bick repair) can also resolve a mild punctal
ectropion without a retractor plication.
9.7.3 Central Lower Lid Retractor Posterior Plication (Fig.9.7)
9.7.3.1 Principle and Considerations
When the lower lid tarsal plate flips out completely (by 180°) a ‘tarsal ectropion’
is said to exist. Reattaching the lower lid retractors to the inferior tarsal edge
anchors it downwards stabilizing the lid. However, it is still advisable to tighten
the lid margin as well as addressing any anterior lamellar shortage.
9.7.3.2 Case Selection
Lower lid tarsal ectropion.
9.7 Operations 107
https://t.me/medicina_free
9.7.3.3 Steps
1. Evert the lower lid over a Desmarres retractor and make a 10 mm long hori-
zontal conjunctival incision centrally, just below the proximal tarsal plate edge
(Fig. 9.7a).
a b
c d
e
Fig. 9.7 Central lower lid retractor plication. a Evert the lower lid over a Desmarres retractor and
make a 10 mm long horizontal conjunctival incision centrally, just below the tarsal plate edge.
b Bluntly dissect on the under surface of the conjunctiva. c Grab and withdraw the retractor fascia
using toothed Jayles forceps and tag it with a 6/0 absorbable suture. d Bring the suture needle out
through the edge of the tarsal plate and conjunctiva, and then back into the wound through the inferior conjunctival edge. e Tie the suture tightly and cut the ends to 2 mm to retract into the wound.
Perform a lid margin shortening
Соседние файлы в папке @xirurgi_2025