Eyelid Margin Position Research Articles

SIE BOEN LIAN (SBL) SURGICAL TECHNIQUE FOR CICATRICIAL ENTROPION AFTER STEVENS-JOHNSON SYNDROME

Introduction : Stevens-Johnson Syndrome (SJS) can cause keratinization of the tarsal conjunctiva, conjunctival scarring and inverted eyelid margin, resulting to cicatricial entropion, causing skin and lashes to brush against the eye. This condition can occur in 27-59% of cases in ocular SJS. The surgical treatment for cicatricial entropion is to repair the position of eyelid margin. One of the procedures that can be used is Sie Boen Lian (SBL) technique.
 Case Illustration : A 70-year-old woman complained of inversion of the left upper eyelid, which caused foreign body sensation, redness, and lacrimation since 4 months ago. The patient had a history of SJS caused by the use of quinolone antibiotic. Anterior segment examination revealed entropion in the left upper eyelid with palpebral margin keratinizing. The patient was diagnosed with cicatricial entropion post- SJS. SBL surgical technique was chose to manage this condition. Post-operative ophthalmological examination showed a relieved symptoms and an improvement in the position of the eyelid margin.
 Discussion : The primary goal of therapy in cicatricial entropion is to reduce the occurrence of chronic ocular irritation by reverting the structure of the eyelids to a physiological position. The anterior lamellar shortening was performed with a modified tarsotomy, known as the SBL surgical technique. The post-operative evaluation was implemented to assess the reposition of the eyelid margin.
 Conclusion : The SBL surgical procedure is effective to manage cicatricial entropion post-Steven-Johnson Syndrome.

Lateral eyelid island flap for reconstruction of large central and medial full-thickness defects of the lower eyelid.

To report our experience with lateral eyelid island flaps for reconstruction of large central and medial full-thickness defects of lower eyelid. Retrospective case series of patients with large central and medial full-thickness lower lid defects repaired with medial transposition of the lateral lower lid combined with a temporal myocutaneous flap. Preoperatively the authors collected demographic data, etiology and percentage of the defects. Postoperatively the lids were assessed for flap viability and lower eyelid margin position and contour. The sample was comprised of 10 patients (5 females) with a mean of age 60.10 (SD 13.75) years. The defects ranging from 50% to 75% of the lid width resulted from excision of eight basal cell carcinomas, one (10%) malignant schwannoma and one (10%) squamous cell carcinoma. The median follow-up was 1.58 years (IQR 2.58). Flap ischemia was not observed in any eyelid. One mild ectropion was observed in just one lid. All patients were satisfied with the esthetic results. Medial transposition of the lateral lower lid island flap combined with horizontal myocutaneous advancement flap is an excellent one-stage procedure that avoids the drawbacks of the two-stages procedures.

Upper eyelid blepharoplasty, tarsal margin rotation, and posterior lamellar super-advancement for correction of severe upper eyelid cicatricial entropion and dermatochalasis

Objective: To report the long-term efficacy and safety of simultaneous correction of upper eyelid cicatricial entropion and dermatochalasis. Method: A retrospective non-comparative chart review of consecutive patients with severe upper eyelid cicatricial entropion and dermatochalasis who underwent surgical correction from July 2012 to July 2014 at a tertiary referral centre by a single surgeon. Results: Twelve eyes of 10 patients aged 80±7 (range, 65-92) years old received upper eyelid blepharoplasty, tarsal margin rotation, and graded posterior lamellar super-advancement. All eyes resumed normal upper eyelid margin position with no recurrence over a mean follow-up of 48.3±18 (range, 9-70) months. Complications including suture granuloma (n=1), transient lagophthalmos (n=1), mild lid notching (n=2) and residual peripheral asymptomatic trichiasis or distichiasis (n=3) were managed conservatively successfully. No patients developed exposure keratopathy after surgery, and the number of lubricants required was statistically significantly reduced (p=0.005). Conclusion: Our pilot study showed that combining upper lid blepharoplasty, tarsal margin rotation and graded posterior lamellar super-advancement is safe and effective in achieving long-term correction of severe upper eyelid cicatricial entropion and dermatochalasis.

Surgical Correction of Upper Eyelid Ectropion Presenting Dry Eye Symptoms.

Upper eyelid ectropion occurs as a post-blepharoplasty complication or involution change, and it causes dry eye symptoms that cannot be resolved with conservative management. The aim of this study is to describe the authors' surgical technique of anatomical correction of upper eyelid ectropion, including tarsal scoring incision. The technique involves the following 4 steps: (1) adhesiolysis at the preaponeurotic layer; (2) undermining and redraping of the pretarsal flap in a pretarsal plane; (3) optional, partial thickness tarsal scoring incision over the central two-thirds; and (4) downward repositioning of the pretarsal flap and lower fixation to the tarsus. Outcomes were assessed based on the position of eyelid margin and the improvement of the dry eye symptoms. A retrospective review of 54 cases of patients who underwent ectropion correction, including tarsal scoring incision, was performed. The eyelid margin was well positioned in 51 patients (94.4%). Of the 32 patients involved in the study assessed with the 7-point Patient Global Impression of Improvement, 29 (90.6%) reported the resolution of dry eye symptoms. Furthermore, in the 22 patients assessed with the Ocular Surface Disease Index, the mean score significantly decreased from 43.2 ± 24.1 before surgery to 29.8 ± 23.3 (P = 0.006) after surgery. The combination of partial-thickness tarsal plate scoring and lower flap redraping surgical techniques resolved the upper eyelid ectropion, reducing the dry eye symptoms.

Epiblepharon outcomes: comparing apples and oranges

Epiblepharon, a common occurrence among children of East Asian descent, is a congenital anomaly whereby a horizontal skin fold across the eyelid (upper or lower) overlaps the eyelid margin resulting...

Posterior Medial Canthal Thermoplasty

To describe a new, simple, quick, and minimally invasive surgical technique for managing medial canthal tendon laxity. The technique works by creating a directed posterior lamellar scar. Sutures are preplaced in firm medial canthal tissue, and a triangular diathermy burn is made between this fixation point and the medial tarsal plate (sparing the canaliculus). This area is then plicated horizontally by bringing the preplaced sutures through the medial tarsal plate. The authors report a retrospective case note review of a consecutive case series of 55 patients (59 procedures). All patients with moderate to severe medial canthal tendon laxity underwent a medial thermoplasty procedure in addition to standard surgery for correcting their eyelid malposition (entropion, ectropion, or symptomatic lax eyelids). The study cohort included 30 men and 25 women, with a mean age of 77 years (range 51-93). Epiphora was the commonest presenting complaint (47%) followed by ocular irritation (44%), with the remainder heaving a combination of symptoms. Lower eyelid ectropion (n = 30, 51%) and entropion (n = 26, 44%), constituted the most common indications for surgery. The average postoperative follow-up period was 16 months (range 3-63 months). Fifty-three eyes (90%) had complete resolution of symptoms, while 2 (3.4%) had partial reduction of epiphora. With regard to the eyelid margin position, 57 eyelids (96.6%) were anatomically in a normal position, while 2 operations failed despite early satisfactory results. In terms of correction of medial canthal tendon laxity, 49 cases (83%) were deemed successful. There were no major complications, nor any significant long-term sequelae. Posterior medial canthal thermoplasty provides a simple, effective, and safe option for addressing medial canthal tendon laxity.

Clinical trial comparing autogenous fascia lata sling and Gore-Tex suspension in bilateral congenital ptosis.

PurposeTo study the effect of autogenous fascia lata sling (AFLS) versus Gore-Tex suspension (GTS) regarding the functional and aesthetic outcomes in patients with bilateral congenital ptosis.Patients and methodsA prospective comparative randomized single-center study enrolled 110 patients with bilateral congenital ptosis. One group (n=55) underwent AFLS and the second group (n=55) underwent GTS. Exclusion criteria were good levator function, absent Bell’s phenomenon, and abnormal ocular motility. Follow-up period was 2 years. Functional outcome was measured from digital photos by analysis of upper eyelid margin position relative to the superior limbus and classified as very good (<3 mm), good (3–5 mm), poor (>5 mm), and recurrent. Aesthetic outcome was assessed in terms of lid contour, symmetry of eyelid height, and lid crease presence. Complications were also reported.ResultsFailure rate (recurrence and complications) was less in AFLS (P=0.035). Symmetrical lid height and good contour were more frequently attained by AFLS (P=0.007 and 0.047, respectively). However, the frequency of very good, good, poor, recurrence, lagopthalmos, ectropion, infection, and formed lid crease individually showed no statistically significant difference (P=0.252, 0.482, 1, 0.489, 0.438, 1, 0.618, and 0.506, respectively).ConclusionAFLS is a better choice in surgery for patients with bilateral congenital ptosis because it has fewer complications and a lesser recurrence rate than GTS.

One-Stage Alternatives to the Hughes Procedure for Reconstruction of Large Lower Eyelid Defects: Surgical Techniques and Outcomes.

To present the results of 1-stage surgical advancement flaps for the repair of large full thickness lower eyelid defects. These avoid the disadvantages of the 2-stage Hughes procedure and provide favorable functional and aesthetic outcomes. A retrospective case series of 36 lower eyelid repairs performed on 31 patients by a single surgeon in Sydney, Australia is presented. The selection criterion was a horizontal defect size 10 mm or greater that could have "classically" been repaired with a 2-stage Hughes procedure. Three different 1-stage surgical repair techniques were utilized, all incorporating local advancement-type flaps: 1) a lateral-based full thickness advancement flap; 2) a vertical tarsal plate advancement flap combined with a full thickness skin graft; and 3) a vertical skin advancement flap combined with a mucosal graft. The postoperative outcomes evaluated included flap viability, lower eyelid margin position and contour, characteristics of the new eyelid margin and patient satisfaction. Thirty-six lower eyelid repairs were performed in 31 patients. There were no cases of flap ischemia, necrosis, or failure. There was 1 case (3%) of postoperative eyelid retraction, 1 case (3%) of eyelid entropion requiring surgical repair, 1 case (3%) of pyogenic granuloma, 2 cases (6%) of eyelid margin cyst, and 7 cases (19%) of eyelid distichiasis. In 34 cases (94%), the patient was satisfied with the aesthetic result. The techniques described provide successful alternatives to the Hughes procedure. They are 1-stage and do not render the patient temporarily monocular, or alter the upper eyelid anatomy or function. All maintained favorable long-term functional and aesthetic outcomes for the reconstructed lower eyelid.

Gold weight implants for management of thyroid-related upper eyelid retraction.

To evaluate the use of gold weight implantation in the upper eyelid in the treatment of upper eyelid retraction caused by thyroid ophthalmopathy as regards the cosmetic and functional results and the safety of the procedure. This is a surgical intervention case series study. The study was carried out in Ophthalmology Department in El-Minya University Hospital between January 2013 and January 2014. The study was approved by the ethical committee board of El-Minya University. Test weights were applied to the skin of the upper eyelid using special adhesive tape in the sitting position to determine the suitable implantable weight. Three interrupted nonabsorbable sutures (5/0 Dacron) were used to secure the gold weight to the tarsus. The orbicularis was closed using interrupted 6/0 vicryl sutures. The skin was closed using interrupted 6/0 nylon sutures. As regards the postoperative results, by the end of the follow-up period, improvement of eyelid retraction was present in all cases. Normal upper eyelid margin position (covering 2 mm of the cornea) was attained in 10 eyelids (76.92%). Undercorrection was observed in 3 eyelids (23.07%). Two eyelids covered 1 mm of the cornea, and 1 eyelid rested at the upper limbus. All patients (100%) were satisfied as regards the cosmetic results, with the degree of satisfaction ranging between very good for 3 patients and excellent for 4 patients. One patient had bilateral brick-shaped appearance. Gold weight implantation for treatment of thyroid-related upper eyelid retraction markedly improves the cosmetic appearance of the patient and, to a lesser extent, improves the manifestations of exposure with high patient satisfaction, and it is a relatively easy and safe procedure.

Treatment of extrinsic ectropion on burned face with facial suspension technique

The extrinsic ectropion is a condition with low prevalence characterized by an ectropion with normal eyelid and anatomy unchanged and the cause is found in tissues adjacent orbits. There are not many studies in the literature regarding their treatment, especially without addressing the eyelid respecting its anatomical integrity. PurposeTo evaluate the outcome of 8 extrinsic ectropions secondary to facial burns treated with facial suspension technique. Patients and methodsFive patients were evaluated with sequelae of facial burns and extrinsic unilateral or bilateral ectropion, a total of 8 ectropions. The technique used was the endoscopic facial suspension with or without release of the facial scar retraction. We evaluated the position of the lower lid over medium-pupillary line, symptoms, complications and patient satisfaction in a 24 months follow-up. Results6 Peri-orbital regions showed good results and two moderate results, all cases had clinical improvement of the ectropion, the symptoms and the esthetic aspect; there was not any complication or reoperation. There was a gain of 2.2–26.2% of the lower eyelid margin position in relation to the horizontal mid-pupillary line. ConclusionThe endoscopic facial suspension proved to be a surgical technique with low morbidity and efficient treatment in 8 facial extrinsic ectropion.

Aesthetic Considerations in Upper Eyelid Retraction Surgery

Classically, the aesthetic outcomes of eyelid retraction surgery in patients with thyroid-associated orbitopathy have been described in reference to eyelid margin position and marginal reflex distance. A critically important component of upper eyelid contour is the tarsal platform show (TPS). With this study, the authors aimed to assess the hypothesis that modification of the tarsal platform in posterior eyelid retraction surgery has a significant effect on the final aesthetic outcome. In a retrospective, observational, case-cohort study, the authors reviewed the medical records of 36 patients with thyroid-associated orbitopathy who underwent primary eyelid retraction surgery by 1 surgeon. Patients who underwent eyelid retraction surgery at the time of orbital decompression were excluded. The surgical technique consisted of posterior approach conjunctival release of Müeller muscle and graded recession of the levator aponeurosis. To address lateral flare, dissection was carried toward the lateral orbital rim with spreading of the lateral horn of the levator aponeurosis. Outcome measures were millimeters of TPS, millimeters of brow fat span, and symmetry of the eyelid margin position. Randomized preoperative and postoperative standardized photographs were evaluated in masked fashion by 4 surgeons to grade cosmetic outcomes. Fifteen patients (24 eyelids) met the inclusion criteria. Mean follow-up period was 6 months (range, 3-12). Mean TPS increased from 2.27 mm (standard deviation, 1.9 mm) to 4.77 mm (standard deviation, 1.7 mm; p < 0.05). Mean brow fat span remained unchanged, from 13.22 mm (standard deviation, 2.2 mm) to 13.25 mm (standard deviation, 1.9; p > 0.05). Evaluation of the aesthetic outcomes (eyelid contour, eyelid symmetry, and TPS) by 4 masked observers characterized the relevance of TPS in the postoperative aesthetics of eyelid contour and symmetry. In upper eyelid retraction surgery, the ability to control the TPS has a significant impact on the final aesthetic outcome. Posterior approach eyelid retraction surgery can control eyelid contour and can represent an ideal surgical approach in carefully selected patients. However, it has limited ability to control upper orbital volume and eyebrow and orbital fat (brow fat span). This can result in relative overelongation of the TPS. Factors such as ethnic characteristics, bony asymmetry, brow fat span, and premorbid TPS influence cosmetic outcomes achieved by the anterior or posterior approach. For optimal aesthetic results in eyelid retraction surgery, the decision for anterior versus posterior approach should be individualized.

Oral Medication With Diazepam or Midazolam Associated or Not With Clonidine for Oculoplastic Office Surgery Under Local Anesthesia

To compare the level of sedation of oral administration of diazepam or midazolam associated or not with clonidine and their effects on upper eyelid margin position, heart rate, arterial pressure, and oxygen saturation. Seventy consecutive healthy patients American Society of Anesthesiologists (ASA) grade I-II scheduled for lower eyelid blepharoplasty were randomized into 4 groups according to the oral sedative agent used (group 1, diazepam 10 mg; group 2, diazepam 10 mg plus clonidine 0.15 mg; group 3, midazolam 15 mg; group 4, midazolam plus clonidine 0.15 mg). For all patients, the midpupil-to-upper eyelid margin distance, the heart rate, systolic and diastolic blood pressure, and oxygen saturation were recorded before and 1 hour after the administration of oral medication. The level of sedation at the time of surgery was measured with the Michigan University scale. The depth of sedation was significantly more pronounced with midazolam (median score = 2) than with diazepam (median score = 1). Clonidine slightly increased the level of sedation of both diazepam and midazolam. The diastolic arterial blood pressure drop with midazolam associated or not with clonidine was significantly greater than with diazepam. The mean upper eyelid margin position shift (-1.42 mm) verified when clonidine was associated with midazolam was also significantly greater than with diazepam. Oral sedation with diazepam or midazolam associated or not with clonidine is safe for ASA grade I-II patients. The systemic effects of diazepam and midazolam were small and very similar. The sedation induced by midazolam was clearly greater than that induced by diazepam. However, this higher level of sedation was accompanied by a more important shift in upper eyelid margin position.

The Change of Eyebrow Position After Upper Lid Blepharoplasty in Patients With Dermatochalasis

Purpose: To evaluate whether upper eyelid blepharoplasty causes eyebrow position change in patients with or without brow ptosis. Methods: We analyzed the photographic records of 28 patients 53 eyes with dermatochalasis who had undergone upper eyelid blepharoplasty. Brow-pupil, brow-lid margin, lid margin-pupil, brow-lateral canthus, and brow-medial canthus distances were measured, and then the proportions of medial canthus-nasal alar were taken. Preoperative and postoperative measurements were compared. Results: After blepharoplasty, no one in the group without brow ptosis developed new brow ptosis. In the group with brow ptosis, only one patient felt a significant change in brow position after blepharoplasty. In both groups, the distance between the eyebrow and the lid margin decreased by similar amounts. There was no change in the upper eyelid margin position after blepharoplasty. Conclusions: In patients with dermatochalasis, upper eyelid blepharoplasty caused a lowering of the eyebrow without a change in the eyelid margin. It is important to evaluate the brow ptosis preoperatively and excise the correct amount of excess skin to avoid aggravation of brow ptosis.

The Transconjunctival Approach to the Orbital Floor and Orbital Fat A Prospective Study

The transconjunctival approach to the inferior orbit and orbital fat offers the potential advantage of avoidance of scar creation in the lower eyelid skin and anterior lamellae. Complications of this approach, including conjunctival fornix shortening and eyelid margin malposition, have been occasionally reported. We prospectively observed 25 patients undergoing transconjunctival blepharoplasty and orbital floor surgery. Fornix depth, eyelid margin position, and the presence or absence of eyelid retraction were measured preoperatively and at each postoperative visit. No significant permanent change in these parameters was observed. Temporary entropion was observed in two patients; this resolved with conservative treatment. On self-limited suture granuloma was observed. In a subgroup of six patients, the conjunctival incision was closed on one side and left unclosed on the other. No adverse healing was noted on the unclosed side. We conclude that the transconjunctival approach is associated with a low incidence of complications, and that it does not significantly alter the fornix depth or eyelid margin position. A skin incision is avoided. The inferior orbital septum is not violated, greatly reducing the risk of development of lower eyelid retraction.