Horizontal Lid Shortening Research Articles

Complicated lower lid ectropions presenting to tertiary care hospital in Sub-Himalayan Region of Himachal Pradesh and their management

Introduction: Ectropions of the lower lid area are of diverse etiology. They may be involutional, mechanical, paralytic, or cicatricial. The patients have lot of discomfort due to exposure and epiphora. Some of them also develop complications like infectious keratitis that are vision threatening as well. Cicatricial ectropions, severe ectropions with tissue laxity are sometimes difficult to manage. In this study, we intend to describe techniques we have used for the management of selected complicated cases of Ectropions. Aim and Objectives: The aim of the study is to describe the complicated cases of ectropions presenting to a tertiary care hospital in Sub-Himalayan region of Himachal Pradesh, India, and the various techniques used in their management. Materials and Methods: Cases of complicated ectropions fulfilling the inclusion and exclusion criterion which presented to the department of ophthalmology were included in the study. The patients were subjected to detailed history and clinical examination according to a predesigned pro forma. They were divided into four subtypes and managed surgically. Results: Horizontal lid shortening with or without blepharoplasty was performed in the cases of involutional ectropions and showed good outcome in all cases. There was no significant lid notching postoperatively. The cicatricial ectropion cases were managed surgically using Z plasty in all but one case of generalized cicatricial ectropion where skin grafting using postauricular graft was used. Postoperatively, the patients improved symptomatically, and cosmetic outcome was also acceptable. Conclusions: Horizontal shortening with or without blepharoplasty if performed meticulously is a good procedure providing excellent results; however, the site for pentagon excision and the amount of resection required needs to be decided, along with any medial or lateral canthal tendon stabilization. Cicatricial ectropions unless are generalized or very severe managed well with Z plasty, however, it is very important to understand the dynamics of the scar before deciding the site and dimensions of the Z plasty. Full-thickness skin graft is sometimes the only option for generalized cicatricial ectropions.

Management of periocular post burn scarring in the epileptics.

To assess the clinical presentation and management of patients with epilepsy presenting with periocular post burn scarring. Prospective and descriptive study. Department of Ophthalmology, Jinnah Postgraduate Medical Centre, Karachi from September 1999 to September 2002. This study included 23 patients who had epilepsy and presented with periocular post-burn scarring to the eye department for management. All patients had contractures of their lids with variable amounts of corneal scarring and damaged to the eye ball. The surgical procedure performed consisted of release of contracture, horizontal lid shortening and application of free skin graft. There were 18 (78.26%) female and 5 (21.73%) male patients. The age range was from 18 to 45 years with a mean of 28 years. In 17 (73.91%) patients, lid contracture was released to cover their eyeballs. In 6 (26.08%) patients the eyeball was lost due to late presentation. There should be a high index of suspicion in facial burns for ophthalmic damage and early referral to an ophthalmologist should be made to prevent complications. Early release of contracture with application of full or partial thickness skin grafts is advisable.

Orbicularis oculi muscle stripping and tarsal fixation for recurrent entropion

This prospective study highlights the result of a new technique for correction of recurrent lower lid entropion. The technique was designed to address the aetiological factors involved based on the pre- and per-operative findings. MATERIAL AND METHODS . 37 eyelids of 31 consecutive patients with recurrent entropion were enrolled. Under local anaesthesia, a horizontal incision was made at the lower border of the tarsus, involving the total width of the lower eyelid. Anterior lamellar (skin and orbicularis oculi muscle – OOM) inferior to the incision was dissected towards the orbital rim. An ellipse of the excess overriding OOM and overlying skin inferior to the incision was excised. The OOM was fixed to the lower border of the tarsus with three to four 6/0 Vicryl subcutaneous sutures. Skin was repaired with 6/0 silk sutures, which were removed five days post-operatively. Five cases underwent horizontal lid shortening and 15 had preaponeurosis fat sculpting in addition. RESULTS . 37 procedures were performed on 31 patients (23 M & 8 F). The mean age was 76.5 yrs. (range 63–90). The patients had had one to four (mean = 1.7) previous surgeries. All patients had OOM override. Fifteen had significant preaponeurosis fat prolapse. Lower lid laxity was not identified in all cases, in some due to previous lid surgery. There was no evidence of lower lid retractor laxity in the majority of cases. After a mean follow-up time of 18 months (5–36) there were three recurrences. One underwent further tarsal fixation and the other two had horizontal lid shortening with a favourable outcome. CONCLUSIONS . Excision of overriding OOM and tarsal fixation for recurrent entropion is simple and effective. Its success is due to direct tackling of the aetiological factors.

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.

Eyelid retractor surgery as an adjunct to cicatricial ectropion repair.

To evaluate the effectiveness of eyelid retractor repair in cicatricial ectropion of the lower eyelid. The study design was a prospective case series. One hundred and twenty eight eyelids were operated on in 100 consecutive patients with cicatricial ectropion. All patients underwent lower eyelid retractor repair via a conjunctival approach combined with skin replacement to the anterior lamella with or without a horizontal lid tightening procedure. When only medial ectropion was present, a medial-based transpositional skin flap was used to repair the anterior lamella (26 eyelids). The remaining eyelids with ectropion involving all or most of the eyelid underwent upper-to-lower eyelid lateral-based transpositional skin flap repair (92 eyelids), or full thickness free skin grafting (10 eyelids). Horizontal lid tightening was performed by lateral canthoplasty in 123 eyelids. Relief of cicatricial ectropion symptoms was reported in 90% of patients overall. A normal punctum position was achieved in 70% of eyelids, overall, and was highest (88%) with a medial-based transpositional skin flap. Eyelid retractor repair combined with skin replacement and horizontal lid shortening is an effective procedure for cicatricial ectropion.

A comparative study of two procedures for repair of involutional lower lid entropion

Objective The study compares the use of Jones’ retractor plication and the Wies procedure as a primary procedure for the repair of involutional lower lid entropion in the absence of horizontal lid shortening. Design Retrospective case series comparison. Participants One hundred two cases with at least 6 months follow-up after primary surgery for involutional lower lid entropion performed between 1993 and 1996. Interventions Two groups were compared: Jones’ retractor plication was performed in one group and the Wies procedure in the other; neither group had horizontal shortening of the lower eyelid. Main outcome measures The rates of cure, recurrence, and overcorrection of the lower lid entropion. Results Jones’ retractor plication was performed in 37 (36%) patients and the Wies procedure in 65 (64%). Two of the 37 (5%) Jones cases had recurrent entropion develop, both at 31 months after surgery, compared with 11 of 65 (17%) recurrences after the Wies procedure ( P = 0.81); recurrence after Wies procedure was earlier, at a median of 6 months after surgery. There were 20 of 65 (31%) overcorrections after the Wies procedure and 4 of 37 (11%) after the Jones procedure ( P < 0.02); one quarter of each group required secondary repair of the overcorrection (5 of 20 after failed Wies procedure; 25% after failed Jones procedure). Overall, there were 6 of 37 (16%) unsatisfactory results after the Jones procedure in contrast to 31 of 65 (48%) after the Wies procedure ( P < 0.001). Conclusions These data provide strong evidence ( P < 0.001) that, in the absence of horizontal shortening of the lower eyelid, a successful outcome is more likely after Jones retractor plication than after the Wies procedure.

Senile entropion - cure rate by retractor tightening and horizontal shortening.

In order to clarify the efficiency of two operations aimed at curing the principal causes of senile entropion, a consecutive series of patients were examined. In 19 lids, the lower lid retractors were tightened transcutaneously and in 45 a simultaneous horizontal lid shortening was performed. Surgery was uneventful in all cases. The patients were reexamined 7-53 months after surgery. In the group with mere retractor surgery were five recurrences; all lids that also had a horizontal shortening were satisfactorily cured. Lower eyelid retractor tightening with simultaneous horizontal shortening of the lid is recommended to correct senile operation with a lasting result.

Lid Imbrication Syndrome

Background: Lid imbrication syndrome is an abnormality of lid apposition in which the upper lid overlies the lower lid. Patients often complain of irritation, tearing, and foreign body sensation. The condition may be difficult to diagnose. Method: Twenty-one patients with suspected lid imbrication syndrome, were compared with 21 age-matched controls. All patients were given 0.5% topical rose bengal. Results: The diagnosis of lid imbrication syndrome was confirmed by the presence of rose bengal staining of the tarsal conjunctiva of the upper lid margin. The amount of rose bengal staining correlated with the severity of lid imbrication. Eighteen of 21 patients had received a diagnosis previously of dry eye syndrome. Four patients had persistent epithelial defects. Conclusions: Rose bengal staining of the superior lid margin tarsal conjunctiva offers an extremely reliable aid for diagnosing lid imbrication syndrome. The condition commonly presents as a dry eye or persistent epithelial defect. Treatment ranges from viscous tear substitutes to horizontal lid shortening of the upper lid.

Lid Imbrication Syndrome: Diagnosis with Rose Bengal Staining

Lid imbrication syndrome is an abnormality of lid apposition in which the upper lid overlies the lower lid. Patients often complain of irritation, tearing, and foreign body sensation. The condition may be difficult to diagnose. Twenty-one patients with suspected lid imbrication syndrome were compared with 21 age-matched controls. All patients were given 0.5% topical rose bengal. The diagnosis of lid imbrication syndrome was confirmed by the presence of rose bengal staining of the tarsal conjunctiva of the upper lid margin. The amount of rose bengal staining correlated with the severity of lid imbrication. Eighteen of 21 patients had received a diagnosis previously of dry eye syndrome. Four patients had persistent epithelial defects. Rose bengal staining of the superior lid margin tarsal conjunctiva offers an extremely reliable aid for diagnosing lid imbrication syndrome. The condition commonly presents as a dry eye or persistent epithelial defect. Treatment ranges from viscous tear substitutes to horizontal lid shortening of the upper lid.

Surgical Management of the Paralyzed Eyelid

The most devastating sequelae of the facial nerve paralysis is the loss of eyelid function. The inability to blink, lubricate and protect the globe can lead to exposure keratitis, corneal abrasion and even the loss of vision. Eyelid closure is approximately 85% upper eyelid and 15% lower eyelid. In order to ensure adequate protection of the globe, deficiencies of both eyelids must be addressed. We report our experience with 20 patients with eyelid paralysis. Upper lid reanimation was performed by the placement of gold lid weights on the tarsal plate. Lower lid reanimation procedures included lateral canthopexy and horizontal lid shortening. A discussion of the above-mentioned procedures, the timing of the procedures and a critical analysis of results will be included. A comprehensive approach to the management of the paralyzed eye will be presented.

Pressure Patch Treatment for Congenital Upper Eyelid Eversion

To the Editor. —Congenital upper eyelid eversion is a rare disorder of unknown etiology. The condition is typically bilateral, with a higher incidence observed in black newborns, infants with trisomy 21, and children of multiparous mothers.1-3Proposed pathophysiologic mechanisms of this anomaly include failure of the orbital septum and levator aponeurosis to fuse, orbicularis muscle hypotony, vertical shortening of eyelid skin, vertical elongation of posterior eyelid structures, and canthal abnormalities.2,3Although the condition is self-limited, complications of conjunctival desiccation, progressive chemosis, and secondary infection are relative contraindications to waiting several weeks for spontaneous resolution. Conservative treatment of lid eversion by applying moisture chambers or topical lubricants can take weeks to months for resolution; taping the eyelids closed is technically difficult and often unsuccessful. Instead, most recently published reports recommend early surgical treatment, such as suture tarsorrhaphy, skin grafting, horizontal lid shortening, and full-thickness sutures applied between the superior

Reconstruction of the horizontal palpebral aperture after failed ectropion surgery with temporal migration of punctum.

Involutional ectropion of the lower lid is the result of progressive stretching and elongation of the lid margin and medial and lateral canthal tendons. The relative laxities of the components of the lower lid-canthal tendon complex will determine the location and extent of the ectropion. Whereas inadequate canthal tightening or horizontal lid shortening will result in recurrent ectropion, overzealous lid shortening without tendon plication will result in a noticeably narrower horizontal palpebral fissure, a persistent ectropion, or temporal migration of the punctum. We used lateral cantholysis, medial canthal tendon plication, and punctal rotation to return the punctum to its normal position and temporalis muscle to support the lower lid in eight cases in which previous procedures had failed to correct the lid malposition. In all eight cases there was improvement of the lid position. In one case of severe medial ectropion, the punctal eversion was not completely corrected. This technique is not recommended as an initial procedure for ectropion repair. It is only used to manage previous surgical failures. It is a new application and combination of well-accepted techniques.