Anterior Lamellar Repositioning Research Articles

Eyelid Skin Grafting in Young Patients with Facial Nerve Palsy.

Background: The aim of this study is to report outcomes of eyelid full-thickness skin grafting augmentation in facial nerve palsy (FNP) patients younger than 50 years of age. Methods: In a retrospective, consecutive case series, nine eyelid skin grafts performed on eight FNP patients with skin contraction (five females; median age 42 years [range, 17-47]) are presented. In most cases, upper eyelid skin grafting was combined with levator recession and anterior lamellar repositioning. Lower eyelid skin grafting was combined with lower retractors recession in all cases. Functional and cosmetic outcomes were measured preoperatively and at early (1-3 months), intermediate (3-6 months), and late (≥12 months) follow-up. Results: The corneal score improved at early follow-up (p = 0.03) and remained improved at late follow-up (p = 0.042). The gentle closure lagophthalmos was improved at late follow-up (p = 0.042). (p = 0.048). The grades of graft color, edge/skin interface, and size improved at 3-6 months post-grafting and remained improved at late follow-up (p < 0.05). Over the follow-up, four patients (50%) were recommended to have further surgical procedures. Conclusions: The preliminary results from this small cohort suggest that eyelid skin grafting is a viable option for young patients prioritizing cosmesis. This technique warrants consideration for its functional benefits.

Involutional Entropion of The Upper Eyelid: A Rare Case Report

Introduction : Entropion is a condition in which the eyelid folds inward or the edge of the eyelid folds inward, causing the eyelashes, eyelid margin, and skin to touch the eyeball. The most common entropion is involutional which caused by the aging process, but reports of cases of involutional entropion in the upper eyelid are rare.&#x0D; Case Illustration : A 66-years-old woman presented with redness, foreign body sensation and teary on both eyes. No history of trauma or foreign body exposure. She had a history with similar complaint 2 years ago. Upper eyelid turn inward, dermatochalasis, and corneal abrasion of both eyes were found in ophtalmic examination. Patient was diagnosed with involutional entropion of the left upper eyelid and treated with anterior lamellar repositioning (ALR). A week after the ALR procedure, on examination it was found that the position of the left eye's upper eyelid was good, there was still minimal swelling, with intact sutures.&#x0D; Discussion : Involutional entropion generally occurs in elderly patients over 60 years old and is more common in women. Progressive senile changes in the structure of the eyelid cause the occurrence of involusional entropion. Involutional entropion in the upper eyelid is associated with dermatochalasis. One management option for involutional entropion is ALR, which aims to pull the folded-in eyelid margin outward.&#x0D; Conclusion : This case shows that involutional entropion on the upper eyelid can still occur, albeit very rarely. ALR can be a simple and safe surgical option for patients with involutional entropion on the upper eyelid.

Anterior Lamellar Repositioning in the Management of Meibomian Gland Inversion Secondary to Meibomian Gland Dysfunction.

To describe a simple alternative surgical approach to treat patients with Meibomian gland inversion (MGI; posterior migration of the Meibomian gland orifices) in the upper eyelid, secondary to cicatricial Meibomian gland dysfunction (MGD) not responding to maximal medical management. This was a retrospective, noncomparative, interventional case series of all patients with MGI not responding to conservative MGD treatment who underwent anterior lamellar repositioning through a skin crease incision with or without Blepharoplasty, between July 2017 and July 2019. Eleven eyes of 7 patients were included in the study. All patients had a diagnosis of MGD with MGI and had been treated on average for 32 months with intensive medical therapy. Treatment included lubricants, topical ciclosporin 0.1%, topical steroids, and doxycycline. Despite intensive treatment, these patients remained symptomatic with persistent superior ocular surface staining. Following surgery, on average, the patients were followed for 23 months. Ten eyes (91%) had improvement of symptoms and superior ocular surface staining. All patients (100%) demonstrated improvement in the anatomical eversion of the eyelid margin and Meibomian gland orifice. A simple upper eyelid everting surgery with anterior lamellar repositioning can be effective in managing patients with MGI giving them symptomatic relief when all medical treatment fail. To the best of the authors' knowledge, this is the first case series describing this simple surgical technique in the management of this subgroup of patients.

Systematic review of the incidence of post-operative trichiasis in Africa

BackgroundSurgery for trichiasis is one of the pillars of the World Health Organization’s strategy for global elimination of trachoma as a public health problem. A high incidence of post-operative trichiasis or other poor surgical outcomes could jeopardize these efforts. In this review, we aimed to summarize the reported incidence of post-operative trichiasis and other poor outcomes of trichiasis surgery in Africa.MethodsWe conducted a systematic literature search using PubMed, Academic Search Premier, Africa-Wide Information, CINAHL and Health Source Nursing through EBSCOhost, Web of Science, and the Cochrane Central Register of Controlled Trials. Reference lists of included studies were also reviewed to identify further potentially relevant publications. All observational and interventional studies that measured post-operative trichiasis in Africa as an outcome of trichiasis surgery were included.ResultsThirty-five papers reporting on 22 studies (9 interventional,13 observational; total 13,737 participants) met the inclusion criteria. The reported incidence of post-operative trichiasis in the included studies ranged from 2% (at 6 weeks after bilamellar tarsal rotation) to 69% (at 3 weeks after anterior lamellar repositioning). The incidence varied by surgical procedure, study design, and length of follow-up.ConclusionTrichiasis surgical outcomes should be improved. National trachoma programmes could benefit from identifying and adopting strategies to improve the performance and quality of their surgical service.

Recognising meibomian gland inversion in patients with facial palsy to improve the ocular surface

ABSTRACT Background: Facial nerve palsy (FNP) is known to worsen Meibomian gland dysfunction on the affected side. Chronic Meibomian gland dysfunction leads to a variant of upper eyelid marginal entropion associated with excessive tarsal curling, termed Meibomian gland inversion (MGI). Surgical correction with grey line split, tarsoplasty and anterior lamellar repositioning (GLS surgery) appears to further improve the ocular surface in these patients who have previously undergone upper eyelid loading. Methods: Retrospective, 3 year, non-comparative, single-centre study of patients with FNP identified as having MGI and treated by GLS surgery under the supervision of a single surgeon. We present specific examination findings and a useful test (cotton tip test) to determine suitability for GLS surgery. We assessed changes in symptoms and CADS (Cornea, static Asymmetry, Dynamic function and Synkinesis) score, along with cosmetic grading of lash loss and contour and report complications. Results: 23 patients with acquired FNP underwent GLS surgery for MGI with or without lash ptosis. 17 out of the 23 patients (74%) demonstrated an improvement in their CADS score after GLS surgery. Seven patients had insufficient records with scores missing and no conclusion could be reached for this group. Improvement of corneal staining, static and dynamic symmetry were all statistically significant. No patient worsened. The cosmetic outcome including lashes, lid contour and lid margin appearance is acceptable. Whilst it is possible to achieve minimal difference between the operated and unoperated eyelids, many patients will have a small difference. Conclusion: We report outcomes of MGI treatment and useful diagnostic features.

Primary Lash Ptosis.

Lash ptosis is often an overlooked sign that may coexist with congenital and acquired blepharoptosis. This is a report of case series of patients presented in an oculoplastic clinic with visual field loss associated with lash ptosis. On examination, the primary pathology was attributed to lash ptosis dehiscence. All patients underwent anterior lamellar repositioning and were followed for an average of 15 (10-24) months. All patients had resolution of visual field loss and heaviness of eyelids. Lash ptosis is associated with abnormalities such as floppy eyelid syndrome. However it may be a primary condition, with no background eyelid pathology and no external explanation for the eyelash ptosis. The condition might result from anatomical changes in the orbicularis oculi, Riolan's muscle, and tarsal plate. Patients in this series complained of upper lid visual field restriction. Anterior lamellar repositioning resulted in complete resolution of complaints. Additional studies are needed to learn about the pathophysiology of this entity.

A comparative study between anterior lamellar repositioning and anterior lamellar repositioning with blepharoplasty in management of upper eyelid entropion trichiasis

Background: Entropion is the inward turning of the lid margin that brings both lashes and external keratinized skin into contact with the globe. Aim of the study: It was to compare the surgical outcome and aesthetic appearance between anterior lamellar repositioning only and anterior lamellar repositioning with blepharoplasty in management of upper eye lid entropion trichiasis. Patients and Methods: This was prospective interventional study includes 20 lids of 13 patients with upper eyelid cicatricial entropion selected from the ophthalmology outpatient clinic of "Ain Shams University" Hospitals. Patients were randomly divided in 2 groups: group A: Ten lids had an anterior lamellar reposition technique (ALR) with grey line split (GLS) technique. Group B: Ten lids had an anterior lamellar reposition with GLS technique and blepharoplasty. All surgeries were performed by one surgeon (third author) in Ain Shams University hospital. Results: Our study showed that after 3 month follow up, success rate of first group was 70 %, patient satisfaction was 60% and final aesthetic outcome was 30% excellent, 30% fair and 40% poor results. The second group success rate was 100%, patient satisfaction was 100% and final aesthetic outcome was 100% excellent results. Conclusion: Combining the procedure of ALR with GLS technique with blepharoplasty in surgical correction of upper eye lid cicatricial entropion has excellent both functional and aesthetic outcome and a higher success rate with minimal complication than anterior lamellar reposition only.

A comparative study between anterior lamellar repositioning and anterior lamellar repositioning with blepharoplasty in management of upper eyelid entropion trichiasis

Background: Entropion is the inward turning of the lid margin that brings both lashes and external keratinized skin into contact with the globe. Aim of the study: It was to compare the surgical outcome and aesthetic appearance between anterior lamellar repositioning only and anterior lamellar repositioning with blepharoplasty in management of upper eye lid entropion trichiasis. Patients and Methods: This was prospective interventional study includes 20 lids of 13 patients with upper eyelid cicatricial entropion selected from the ophthalmology outpatient clinic of Shams Hospitals. Patients were randomly divided in 2 groups: group A: Ten lids had an anterior lamellar reposition technique (ALR) with grey line split (GLS) technique. Group B: Ten lids had an anterior lamellar reposition with GLS technique and blepharoplasty. All surgeries were performed by one surgeon (third author) in Ain Shams University hospital. Results: Our study showed that after 3 month follow up, success rate of first group was 70 %, patient satisfaction was 60% and final aesthetic outcome was 30% excellent, 30% fair and 40% poor results. The second group success rate was 100%, patient satisfaction was 100% and final aesthetic outcome was 100% excellent results. Conclusion: Combining the procedure of ALR with GLS technique with blepharoplasty in surgical correction of upper eye lid cicatricial entropion has excellent both functional and aesthetic outcome and a higher success rate with minimal complication than anterior lamellar reposition only.

Septal chondromucosal grafts in paralytic lagophthalmos

ObjectiveThe risk of sight-threatening complications related to facial paralysis makes palpebral fissure management a priority. Surgery must take account of and adapt to the clinical signs of paralytic lagophthalmos. This therefore presupposes that a sufficient therapeutic arsenal is available. In this report, we propose a technique for palpebral lengthening (lower and/or upper), reconstructing the posterior lamella using a chondromucosal graft harvested from the nasal septum, combined with anterior lamellar repositioning. Patients and MethodA 5-year single center retrospective study was conducted, including sixteen patients for a total of nineteen septal chondromucosal grafts. The only inclusion criterion was paralytic lagophthalmos. Functional ophthalmic deficits were recorded (main outcome measure), first preoperatively, then postoperatively. Additionally, the degree of lagophthalmos was measured in order to infer palpebral fissure elongation gain. Surgical consequences and complications were recorded. ResultsA rapid regression in functional ophthalmic deficits was observed in 87% of patients, improving in stability over time (mean follow-up interval of 34 months). Mean palpebral fissure elongation gain was 3 mm. 53% of patients suffered from complete occlusion of the palpebral fissure. Surgical consequences were uncomplicated. 38% of patients eventually underwent revision surgery. ConclusionPalpebral fissure lengthening using septal chondromucosal grafts serves as an alternative to existing treatment methods for paralytic lagophthalmos. Robust functional and cosmetic results, combined with very low morbidity, make this a simple and efficient technique whose indications may be extended.

Correction of Lower Eyelid Marginal Entropion by Eyelid Margin Splitting and Anterior Lamellar Repositioning

There is a paucity of data in the literature on the surgical management of lower eyelid marginal entropion. In this study, the authors report outcomes of a surgical technique of eyelid margin splitting and anterior lamellar reposition in patients with lower eyelid marginal entropion. The medical records for 30 eyelids from 22 patients with lower eyelid marginal entropion who had undergone eyelid margin splitting and anterior lamellar repositioning at Seoul National University Hospital from January 2004 to December 2012 were retrospectively reviewed. Success was defined as the lack of any lash in contact with the globe, no need for a second procedure, the complete resolution of symptoms, and acceptable cosmesis at the final follow up. The mean follow-up duration was 16.7 months. The split eyelid margin exhibited good wound healing in each case, but trichiasis recurred postoperatively in 3 of 30 eyelids, even though the eyelid margin was ultimately well positioned. That is, the overall success rate was 90%. Of the 3 eyelids with recurrent trichiasis, 2 required additional electrolysis to remove irritated cilia, but the other did not require to be treated. In the latter case, the trichiasis observed was fine, focal, and unaccompanied by symptoms or corneal lesions. There was no significant complication such as secondary ectropion or eyelid retraction. Eyelid margin splitting and anterior lamellar repositioning achieve success with a low rate of complications among patients with lower eyelid marginal entropion.

Comparison of trichiasis recurrence after primary bilamellar tarsal rotation or anterior lamellar repositioning surgery performed for trachoma

To compare the trichiasis recurrence rate following bilamellar tarsal rotation or anterior lamellar repositioning, performed as primary surgery for trachomatous trichiasis. Retrospective consecutive case series. All cases of trachomatous trichiasis undergoing primary surgical correction at Alice Springs Hospital, Alice Springs, Northern Territory, Australia, between 1 June 2001 and 11 June 2011 were included. Retrospective chart review. Key baseline, operative and outcome details were collected from the notes. Recurrent trichiasis was defined as one or more lashes touching the cornea, resulting in recurrent symptoms of trichiasis and warranting further surgery in the opinion of the treating ophthalmologist. Sixty-seven BTR and eighteen ALR procedures were performed, with BTR being performed from 2001 to 2008, and ALR from 2008 to 2011. The mean follow-up times were significantly different for the BTR group (1654 days) and for the ALR group (673 days)(P < 0.001). Kaplan-Meier survival analysis did not reveal any significant differences in recurrence rate between the two procedures overall (P = 0.935). Analysis of the 2008 calendar year (the only year where both procedures were performed and therefore had equal follow-up times) suggested that ALR might have a lower recurrence rate (1/10 ALR recurrences vs. 4/6 BTR recurrences, P = 0.181). The results do not demonstrate a difference in the recurrence rate between the two techniques. Inconsistent follow times however leave uncertainty in this result, and a larger prospective randomised study is warranted to address this question.

Eyelid Surgery in Ocular Myopathies

ABSTRACTObjective: To retrospectively analyse surgical outcome and complications in patients with ocular myopathy undergoing ptosis correction and to introduce preoperative prophylactic lower lid elevation in this group.Methods: The medical records of all ocular myopathy patients who had undergone oculoplastic surgery between June 1995 and May 2006 were obtained. Patients’ demographics, surgical details and measurements, and complications were recorded.Results: 29 patients were identified; 21 with chronic progressive external ophthalmoplegia (CPEO), 7 with myotonic dystrophy (MD) and 1 with oculopharyngeal muscular dystrophy (OPMD). Then, 61 procedures to adjust eyelid height were performed, comprising levator resection, brow suspension, anterior lamellar repositioning, lower lid elevation and upper lid lowering. Palpebral aperture was significantly increased in all patient groups, by procedure and diagnosis, more significantly following brow suspension compared with levator resection. The patients’ feedback was very positive. Post-operative complications were few, included corneal exposure and ulceration, ptosis recurrence, arched brow, and sling infection, all of which were successfully treated.Conclusion: Our results demonstrate subjective and objective benefit following surgery in these patients, with a low complication rate. The use of pre-operative prophylactic lower lid elevation procedures is a promising modality.

Outcomes of Lower Eyelid Cicatricial Entropion With Grey-Line Split, Retractor Recession, Lateral-Horn Lysis, and Anterior Lamella Repositioning

To report indications and outcomes of a technique for the correction of lower eyelid cicatricial entropion using a lower eyelid gray-line split, inferior retractor recession, lateral-horn lysis, and anterior lamella repositioning. Retrospective, 5-year, single-center, consecutive case series of patients with lower eyelid cicatricial margin entropion undergoing the above procedure. Patients with significant inferior fornix contraction or symblepharon undergoing concurrent fornix reconstruction with buccal mucosal grafts at the same time as lamella repositioning were excluded. Outcomes were assessed based on the review of medical case notes and clinical photographs assessed independently. Success was defined by: 1) improvement in eyelid position and 2) improvement in lower eyelid retraction. Twenty-one eyelids of 19 patients (mean age 57.7 ± 22.6 years, range 5-95 years, 8 men and 11 women) were included. The mean follow up was 27.4 ± 16.8 (range 3.2-59.6) months. The causes of cicatricial entropion were as follows: ocular cicatricial pemphigoid (6), Stevens-Johnson syndrome (3), previous eyelid reconstruction (2), socket scarring (2), thermal burn (1), chemical burn (3), postradiotherapy (1), and meibomian gland dysfunction (1). A second procedure was carried out in 38% (8/21) of eyelids within 1 year. Within 3 years, 10% (2/21) and 5% (1/21) of eyelids required a third and fourth procedure, respectively. The most common lower eyelid revision procedures included anterior lamellar repositioning. Other procedures required included buccal mucous membrane grafts, everting sutures, and lateral tarsorrhaphy. Three patients with loss of >50% inferior fornix depth were included. Two had previously undergone mucosal grafts and 2 required subsequent mucosal grafts. Overall, 90% (19/21) of eyelids eventually achieved improvement in lower eyelid position following repeat surgery, including mucosal grafts in 3 eyelids. Mid-pupil lower eyelid elevation was 1 mm in 6 of 19 (32%) patients and lower eyelid lateral retraction significantly improved in 9 of 19 (47%) patients. Based on the principles of lamella repositioning and posterior middle lamella release with formal retractor recession through a gray-line incision, this technique is of value as a lash-preserving procedure in moderate-to-severe cicatricial lower eyelid entropion, particularly where tarsoconjuctival contraction or eyelid margin distortion exists.

Lid margin split in the surgical correction of epiblepharon

To describe the technique of splitting the lid margin combined with the excision of redundant skin and muscle during the surgical correction of epiblepharon and to report its clinical outcome. A combined procedure that included splitting the lid margin to repair lower eyelid epiblepharon was performed on 31 eyes of 19 consecutive patients. Lid margin splitting was performed along the grey line on the medial third or half of the lower eyelid by making a 1 mm-deep incision. Having made a transverse subciliary skin incision and a dissection between the tarsus and the orbicularis oculi muscle, the subcutaneous tissue of the superior edge of the incision was secured to the tarsus with interrupted sutures to evert the cilia. An excision of the redundant skin and orbicularis tissue was made and the skin was closed. The patients were followed for direct inspection of the wound, the split lid margin, the direction of the lashes and the status of the cornea. The mean postoperative follow-up period was 29.4 weeks. Symptoms disappeared in all patients. In 30 eyelids of 19 patients the cilia did not touch the cornea, even in the down-gaze. In one eyelid the cilium touched the medial conjunctiva, but not the cornea. The cosmetic outcome of the lower lid was satisfactory in all cases and the wounds of the split lid margin healed without scarring. To date, there have been no complications such as wound dehiscence, ectropion or eyelid retraction. The lamellar splitting of the lid margin is a beneficial addition to the repair of prominent lower lid epiblepharon, especially on the medial aspect of the eyelid. This simple technique ensures easier eversion of the cilia in epiblepharon repair, without disturbing the posterior lamella or causing unfavourable results.

Modified Grey Line Split With Anterior Lamellar Repositioning for Treatment of Cicatricial Lid Entropion

To determine the success rate of surgery of modified grey line split with anterior lamellar repositioning in patients with cicatricial lid entropion and to determine the risk factors of failure of the procedure, 40 patients (84 lids) with either lid involvement caused by cicatricial lid entropion of different etiologies were enrolled in this study. All the lids were operated on using the technique of modified grey line split and anterior lamellar repositioning. The success of the procedure was assessed by restoration of anatomical and physiological functioning of the lid without any residual symptom to the patient. Patients were examined initially at weekly intervals for 1 month and subsequently followed up at 2, 3, and 12 months following surgery. Among the various causes for cicatricial lid entropion, infectious etiology (72/84 lids) was found to be the most common one. A success rate of modified grey line split with anterior lamellar repositioning was 88.09% (74/84 lids). The underlying etiology of cicatricial lid entropion was the sole predictor of failure of surgery. Those with the etiology of infection had more than 6 times the odds of surgery failure (OR: 6.73; 95% CI: 2.79-16.73) as compared to a patient without infectious etiology. The role of other factors such as the age of the patient, degree of entropion, previous entropion surgery, the lid (upper or lower) involved, irregular lid margin, and defective lid closure were statistically insignificant. The underlying etiology of cicatricial lid entropion is the only risk factor that significantly influences the outcome of surgery with this technique. Otherwise, this procedure gives good results with fewer complications in patients with cicatricial lid entropion.

Floppy eyelid syndrome and mental retardation

Objective To report four subjects with a combination of floppy eyelid syndrome, mental retardation, and increased mechanical stimulus to the affected side. Design Retrospective, noncomparative case series. Participants The authors retrospectively reviewed the charts of four mentally retarded subjects with floppy eyelid syndrome. Intervention Surgical tightening of three upper lids and one lower lid was performed in three subjects. Main outcome measure Relief of symptoms. Results The affected eyelids were treated surgically; in case 1 by anterior lamellar repositioning and lateral and medial canthal tightening, in case 2 by horizontal upper lid shortening, and in case 3 by horizontal lid shortening of both upper and lower lids. There was marked relief from symptoms in all three cases. In case 4, surgery was deferred at parental request. Conclusions These cases support the role of mechanical factors in the pathogenesis of floppy eyelid syndrome. Subjects with mental retardation may cooperate poorly with examination, and we believe that there should be a careful search for floppy eyelid syndrome in the presence of chronic conjunctivitis or unexplained epitheliopathy.

Correction of blepharoconjunctivitis-related upper eyelid entropion using the anterior lamellar reposition technique.

Upper eyelid entropion is a complication of chronic blepharoconjunctivitis which may be easily missed unless careful examination of the lid margin of patients with trichiasis is carried out. Many patients undergo years of unsuccessful treatment for trichiasis because the underlying upper eyelid entropion has not been detected. We would like to recommend the already established procedure of anterior lamellar repositioning as a more permanent solution to this distressing condition and present the results of this procedure on 19 consecutive patients (28 lids). Our surgical technique is described and the results in this group of patients reported. The procedure was successful in 24 of 28 eyelids (85%), with success being defined as complete resolution of symptoms for a follow-up period of at least 10 months. Anterior lamellar repositioning is easy and relatively quick to perform and provides good functional and cosmetic results.