Technique for horizontalization of downward bowed, subluxated and ectropionic lower eyelids

Abstract

Downward bowing and/or subluxation of the lower eyelid for reasons of paresis, tissue redundancy, or downward and outward push from behind and above (as in the shallow orbits of Crouzon's or trisomy 21 patients) but not from cicatrization is addressed surgically here with a new technique, designated 'horizontalization'. Herein, the geometric principle of three points of tension establishing a plane, beyond the confines of which deforming forces are hard put to act, is utilized.Starting with the 'tarsal strip procedure' of Anderson et al,16 18 an additional suture is passed through the disinserted and foreshortened lateral end of the inferior tarsotendinous sling. One of these sutures is then passed far posteriorly on the lateral orbital wall, to adhere to the periosteum about 1 cm behind the lateral orbital rim while the other is attached more or less at the orbital rim itself-both at the level of the normal lateral canthal attachments. When both of these sutures have been tied and cut, the inferior tarsotendinous sling behaves like a taut hammock and its edge tends to remain in a horizontal, axial plane despite downward pressure from the corneal bulge in downward gaze. It also follows the lower limbus in gaze upward rather than lag behind and below it.Patients with inferior corneal exposure problems benefit from this method both functionally and cosmetically (i.e, there are no skin incisions or palpebral deforming qualities as in tarsorrhaphies, tarsal pillar procedures, or lower lid elevating implants).