Lateral Canthal Tendon Laxity Research Articles

A small incision technique for repairing involutional lower eyelid entropion.

The objective of this paper is to describe and review our experience with Goldberg's small incision technique for use with involutional entropion. Retrospective consecutive interventional case series with validated late surgical outcomes were reported. All involutional entropion cases with horizontal laxity of less than 8mm were repaired with a small incision technique. Retractors were separated from the tarsus by blunt dissection made from three 4mm horizontal incisions. Three 6-0 double-armed polyglactin sutures were used to tighten retractors and the orbicularis oculi muscle. The sutures were removed 3weeks postoperatively or earlier if overcorrection continued during the first week of the postoperative period. Data were obtained for a postoperative follow-up period of at least 24months. A total of thirty-seven lower eyelids from thirty-one patients with involutional entropion were included in the study. Primary operations were performed on 31 eyelids and reoperations on six eyelids. The mean follow-up time was 40 ± 11months. Thirty-six (97.3%) of the eyelids had no recurrence. As overcorrection was seen postoperatively in ten eyelids (27%), a number of sutures had to be removed earlier than planned. The ectropion eventually resolved, and no recurrence was seen during follow-up in these patients. In our practice, the small incision technique has been highly effective in involutional entropion repair, with minimal complications. Although this approach does not directly address lateral canthal tendon laxity, the procedure has the advantages of being easy to learn and also that it can be combined with other procedures for tendon laxity.

Wedge resection of the tarsal plate combined with the modified Hotz procedure for correction of involutional lower eyelid entropion

ObjectivesTo investigate the outcomes for correction of involutional lower eyelid entropion by wedge resection of the tarsus combined with the modified Hotz procedure. DesignRetrospective study. ParticipantsPatients with lower eyelid involutional entropion that was surgically repaired by wedge resection of the tarsal plate combined with the modified Hotz procedure. MethodsIn a consecutive series of 43 patients with involutional lower eyelid entropion, wedge resection combined with the modified Hotz procedure was performed with an average follow-up period of 29.6 months (range, 6–62 months). ResultsAmong the patients, 93% had an excellent outcome within the follow-up period. For one patient, the outcome of both eyes was poor. For another patient, incision dehiscence of the eyelid margin in one eye occurred after the stitches were removed. The incision was sutured again, and it healed well. One patient complained of foreign body sensation in one eye after removal of the skin stitches. The complaint was resolved after wearing a corneal contact lens. No other significant complications occurred. ConclusionsIn our clinic, tarsal plate wedge resection combined with the modified Hotz procedure has been highly effective for correction of involutional lower eyelid entropion. Although this approach does not directly address lateral canthal tendon laxity, it does preserve the eyelid in case there is a future need for reconstruction due to ocular surface disease or trauma. Thus, wedge resection of the tarsal plate combined with modified Hotz procedure is a safe and effective method for involutional lower eyelid entropion.

Correction of lower eyelid retraction with hard palate graft in the anophthalmic socket

ObjectiveLower eyelid retraction is a common and challenging complication of the anophthalmic socket. The underlying pathophysiology includes contraction of the posterior lamellae of the eyelid, shortening of the inferior fornix, and lateral canthal tendon laxity. This study aimed to evaluate the surgical efficacy of hard palate mucosa as a posterior spacer graft in the lower eyelid retraction repair in the anophthalmic socket. MethodsThe surgical technique involved hard palate grafting combined with recession of inferior retractors and lateral tarsal strip suspension to lengthen the posterior lamellar and strengthen the support of the lower eyelid. The records of anophthalmic patients with lower eyelid retraction who underwent this technique from January 2009 through August 2014 were reviewed. Postoperative outcomes were determined by lower eyelid elevation, presence of lagophthalmos, complications, prosthesis fitting, and patient satisfaction. ResultsA total of 12 patients (12 eyelids) were included. The mean age at surgery was 36 years (range, 29–52 years) and the mean follow-up period was 53 months (range, 20–71 months). The lower eyelids of the operated eyes significantly elevated by 2.9 ± 0.8 mm, and mild residual lagophthalmos was observed in 3 patients. All patients were satisfied with the surgical outcomes. Minor complications occurred in 3 cases, including mild recurrent retraction, granuloma, and mucous discharge. There were no complications detected at the donor site. ConclusionHard palate grafting combined with recession of lower eyelid retractors achieves long-term stable outcomes in lower eyelid retraction repair in the anophthalmic socket.

Entropion and ectropion repair: a snapshot of surgical practice in the United Kingdom

ABSTRACTWe aim to provide a snapshot of the current surgical practice for correction of entropion and ectropion, the two most common oculoplastic procedures carried out in the UK, by surveying 135 consultant oculoplastic surgeons via the tool Survey Monkey. Forty-seven (35%) consultants responded. For entropion, 44% of surgeons opted for lateral tarsal strip (LTS) + everting sutures (ES). Other first-line choices included LTS + transcutaneous retractor plication (21%), Quickert’s procedure (14%), ES (7%), and Wies procedure (5%). Important patient-related factors to consider were horizontal lid laxity and retractor dehiscence.Regarding ectropion, LTS was most commonly practiced (35%), followed by LTS + transconjunctival retractor plication (28%), wedge excision (16%), and lateral canthoplasty (5%). The patient-related factors guiding choice were horizontal lid laxity, lateral canthal tendon laxity, and punctal position under traction. Responses found a wide range of preferred surgical techniques in practice. The factors guiding surgical choice were personal audit results (92% stated important/very important), familiarity with the technique (92%), and the technique being favoured by previous trainers (76%), suggesting current practice led by expert opinion, possibly due to a lack of evidence-based literature. This highlights the variety of core oculoplastic surgical techniques practiced and underlines the need for robust trials to guide surgical choice.

Orbicularis oculi muscle transposition for repairing involutional lower eyelid entropion.

To describe a simple technique for involutional entropion correction and to present the findings of a retrospective interventional case series study. We studied a consecutive series of 414 patients (609 eyelids). Patients presenting with involutional entropion in the absence of lateral canthal tendon laxity underwent orbicularis oculi muscle (OOM) transposition from pretarsal position to corresponding preseptum without horizontal shortening or resection of the orbicularis muscle. Immediate resolution of entropion and associated ocular symptoms was achieved in 607 eyelids (99.67%). An early postoperative complication was localized lid swelling that gradually subsided within one week. Over-correction occurred in six cases and resolved with pressure dressing, mostly one or two days post-operation. At final follow-up, a significant improvement in eyelid position was achieved in 579 eyelids (95.07% ). There was mild recurrence of entropion in 30 eyelids (4.93%). The mean follow-up was 6.84months (range, 6-12months). Orbicularis oculi muscle transposition is a reasonably successful procedure with a high success rate, and is particularly suitable for patients for whom there exits overriding of the preseptal OOM over the pretarsal OOM.

Congenital combined eyelid imbrication and floppy eyelid syndrome: Case report and review of literature

Congenital eyelid imbrication syndrome (CEIS) is an extremely rare, benign, transient, self-limiting eyelid malposition disorder. The classic triad of signs in patients with a CEIS consists of bilateral upper eyelids overriding the lower eyelids when child was in sleep, bilateral medial and lateral canthal tendon laxity and tarsal conjunctival hyperemia. We report a third case of congenital combined eyelid imbrication and floppy eyelid syndrome in healthy neonate that was resolved within a week with conservative treatment.

The Lower Lid Diamond

To describe a simple technique for involutional entropion correction and to present the findings of a pilot study. Consecutive case series of 42 procedures. Patients presenting with involutional entropion in the absence of lateral canthal tendon laxity (lateral canthus could be distracted 1 cm or more medially) underwent a modified full-thickness eyelid shortening combined with retractor plication. Main outcome measures were correction of entropion and cosmesis of the surgical site at final follow up. At final follow up, 92% of patients had a satisfactory eyelid position with no recurrence of entropion and a cosmetically satisfactory scar. This is a useful technique with a higher success rate than everting sutures and is particularly suitable for patients for whom rapid surgery is needed or a lateral canthotomy is best avoided.

Medial and Lateral Canthal Tendon Laxity: An Evaluation of Patients with Involutional Entropion and Epiphora

Medial and Lateral Canthal Tendon Laxity: An Evaluation of Patients with Involutional Entropion and Epiphora

The Lateral Tarsal Strip Mini-Tarsorrhaphy Procedure

The lateral canthus normally sits 1 to 2 mm higher than the medial canthus. With time, aging and gravity produce inferior displacement of the canthus. Numerous eyelid disorders can also result in lower eyelid or lateral canthal tendon laxity or malposition, requiring horizontal eyelid tightening or canthal repositioning. The lateral tarsal strip procedure has proven to be a useful technique in addressing these problems. Care must be taken when suspending the tarsal strip to the lateral orbital rim to preserve the almond shape of the lateral canthal angle. If mild to moderate upper eyelid laxity is present, suspension of the strip can result in upper eyelid overhang with lower eyelid and eyelash imbrication. We describe the lateral tarsal strip mini-tarsorrhaphy procedure that overcomes this problem. The technique provides excellent functional and aesthetic results and adds to the versatility of a time-tested procedure.

Effect of Eyelid Saccades on the Position of Lateral Canthus in Young and Older Subjects

Purpose: To measure the effect of down and upgaze on lateral canthus height. Methods: Observational study. The lateral canthus height of 125 eyes was quantified in the primary position, up, and downgaze. All measurements were monocular. The sample comprised 125 subjects divided into three age groups: 10 to 30, 31 to 50, and 51 to 70 years. All images were acquired with a digital camera and processed with the NIH image software. Results: The lateral canthus height was influenced by both age and position of gaze. Compared to the primary position of gaze, the mean lateral canthus height decreased significantly in downgaze for all age groups (1.51 mm for group 1, 1.72 mm for group 2, and 2.3 mm for group 3). Upgaze increased the height of the lateral canthus only for groups 2, and 3 (0.66 mm and 0.87 mm, respectively). Conclusions: The height of the lateral canthus is strongly influenced by upper and lower eyelid movements. The combined action of contraction of the lower eyelid retractors and relaxation of the levator muscle diminishes the height of the lateral canthus in all age groups. This effect is more pronounced in older subjects, probably reflecting the typical lateral canthal tendon laxity of the aging process.

The not-so-lazy-T: A modification of medial ectropion repair

Medial involutional ectropion without excessive lateral canthal tendon laxity is often corrected using the lazy-T procedure. This procedure however carries a potential risk of canalicular damage, and locating the lower lid retractors can be difficult. We have developed a modification. Replacing the tarso-conjunctival diamond with a subconjuctival pocket posterior and inferior to the punctum, into which the lower lid retractors are advanced from the base of the wedge excision, which effectively ensures plication of the lower lid retractors while maintaining a straightforward procedure. The follow-up data on five procedures showed surgical and symptomatic success in all patients, without complications. These results confirm the efficacy of this modification of the lazy-T procedure in the correction of medial lower lid ectropion.

Combined Hard Palate Spacer Graft, Midface Suspension, and Lateral Canthoplasty for Lower Eyelid Retraction: A Tripartite Approach

Eyelid retraction is an unfortunate consequence of cosmetic surgery, trauma, and disease states. It is frequently symptomatic and may be associated with dry eye syndrome and corneal compromise. The pathophysiology of lower eyelid retraction usually involves some degree of lateral canthal tendon laxity, middle lamella scarring, and malar descent. The authors describe for the first time a series of patients whose lid retraction was treated with a tripartite procedure that addresses all three pathophysiologic components simultaneously and rehabilitates the patients cosmetically and functionally. The authors retrospectively reviewed the records of 17 patients (24 eyelids) operated on between 1999 and 2003 by one senior surgeon. The age of the patients ranged from 26 to 77 years (mean, 50.3 years), and all presented with significant scleral show (average, 2.0 mm) and symptomatic corneal exposure from a variety of causes. Preoperatively, all patients were noted to have a combination of lower eyelid laxity, middle lamellar contracture, and malar descent. Preoperative and postoperative examinations included Shirmer's test, a measurement of scleral show, and a slit-lamp examination. Mean follow-up time was 13 months. All patients underwent a triad of hard palate spacer grafting, lateral canthal suspension, and midface elevation. All 17 patients (representing 24 retracted eyelids) had complete resolution of scleral show (2.5-mm average correction) and were uniformly satisfied with their cosmetic and functional outcome at last follow-up. Preoperative dry eye symptoms resolved in all patients in the series. There were no major complications and only two minor complications (corneal irritation from graft sutures in one patient and an oronasal palatal fistula in another), both of which resolved in the early follow-up period. The combination of hard palate spacer grafting, lateral canthoplasty, and midface suspension is an effective, aesthetic, and functional treatment for moderate to severe lower eyelid retraction resulting from multiple causes. This tripartite procedure is associated with predictable results, a low morbidity rate, and high patient satisfaction.

Reconstructive blepharoplasty

Neuromodulation, filling agents, non-ablative lasers and therma-lifting can non-invasively rejuvenate the peri-orbital tissues, but eyelid skin redundancy and loss of elasticity, fatty prolapse, levator aponeurotic disinsertion, lacrimal gland prolapse, lateral canthal tendon and lower lid margin laxity need to be addressed surgically. Carbon dioxide laser techniques allow us to perform skin and skin-muscle resections, levator aponeurotic repairs, lacrimal gland suspensions, lateral canthal plications, lipo-vaporization, fat ransposition and eyelid skin resurfacing efficiently, with great accuracy and minimal downtime, in a virtually bloodless field.

Transblepharoplasty Lower Eyelid and Midface Rejuvenation: Part I. Avoiding Complications by Utilizing Lessons Learned from the Treatment of Complications

Transblepharoplasty midface elevation has become a common aesthetic procedure in recent years. As new techniques have been utilized, complications have arisen. Management of these referred complications has resulted in the development of a technique that elevates the midface and restores the normal position and shape to the lower eyelid with minimal postoperative problems. Four principles must be followed to achieve satisfactory results. The orbicularis oculi/orbital septum bond must not be altered in midface surgery. The lateral canthus must be reattached to its normal anatomic location at the lateral orbital rim if there is lateral canthal tendon laxity. The orbital fat should be addressed via a transconjunctival approach, when necessary, to prevent middle lamella inflammation and orbital septum retraction. A suture at the inferior lateral orbital rim simulating the orbitomalar ligament, as well as orbicularis oculi muscle sutures, elevates the midface. Utilizing these steps, the midface and lower eyelid can be satisfactorily repositioned with minimal complications. This surgical approach can be utilized in all appropriate candidates but is especially useful in reoperative cosmetic surgery patients and the older patient population.

The Evaluation and Management of Lower Eyelid Retraction following Cosmetic Surgery

Lower eyelid retraction is a common complication after cosmetic surgery of the lower eyelids, midface, and the adjacent face. Lower eyelid retraction is defined as the inferior malposition of the lower eyelid margin without eyelid eversion. Lower eyelid retraction presents clinically with scleral show; round, sad-looking eyes; lateral canthal tendon laxity; and symptoms of ocular irritation, including photophobia, excessive tearing, and nocturnal lagophthalmos. These patients frequently require ocular lubricants, including artificial tears and ointments, which often provide only minimal alleviation of their symptoms. The author has observed that lower eyelid retraction is usually accompanied by midface descent. On the basis of surgical observations, the causes of lower eyelid retraction seem to be multifactorial and include scarring between the orbital septum and capsulopalpebral fascia (or lower eyelid retractors), lateral canthal tendon laxity, and midface descent. After describing the causes of lower eyelid retraction, the author presents a system for evaluating patients that can assist the surgeon in choosing the surgical procedure(s) required to correct the lower eyelid malposition. The surgeon must know how to tighten a lax lateral canthal tendon, be familiar with the anatomy of the lower eyelid from conjunctiva to skin side, and know how to surgically elevate the midface. The techniques for correcting lower eyelid retraction are also presented. Appropriate surgery, which is determined on the basis of the preoperative evaluation, has allowed for the correction of these previously difficult-to-treat lower eyelid malpositions with minimal complications.

Lateral canthal tendon suspension using the carbon dioxide laser. A modified technique.

The "tarsal strip" procedure was developed to correct lower eyelid ectropion caused by lateral canthal tendon laxity. The "tarsal strip" procedure is improved by using the carbon dioxide (CO2) laser. The CO2 laser was used to perform lateral canthotomy. Patients were evaluated postoperatively for subjective improvement in preoperative symptoms. Complications such as epithelial inclusion cysts were actively sought. Thirty-one patients (60 lids) were followed for an average of 12 months. Preoperative symptoms resolved in 86% (N = 27), improved in 7% (N = 2), and did not change in 7% (N = 2). Two patients required additional surgery. Complications were not observed in this study. The modified "tarsal strip" procedure using the CO2 laser provides many advantages compared with the original procedure. A clean dissection improves visibility and allows easy identification of the lateral tarsal plate. The lateral canthal angle is preserved and epithelial inclusions are prevented because the conjunctival mucosa is not violated.

Orbicularis Oculi Muscle Extirpation in a Combined Procedure for Involutional Entropion

Many factors are important in the pathophysiology of involutional entropion, including defects of the lower eyelid retractors, canthal tendon laxity, and acquired enophthalmos. The role of the overriding preseptal orbicularis oculi muscle is often ignored in modern techniques of entropion repair. The author describes a technique of extirpation of the preseptal orbicularis oculi muscle combined with repair of the lower eyelid retractors and a lateral tarsal strip procedure for the repair of primary and recurrent involutional entropion. Lateral canthal tendon laxity is recognized in most patients in this age group and must be corrected to avoid postoperative overcorrection and ectropion. Removal of the preseptal muscle had no clinical effect on the lacrimal pump and did not cause any significant cicatricial eyelid abnormalities. This combined procedure has been used in 50 eyelids of 40 patients with excellent functional and cosmetic results. Orbicularis extirpation is not advocated in combination with a marginal rotation procedure.

The Medial Tarsal Strip

Medial canthal malpositions and marked medial ectropion due to laxity, scarring, or trauma can be difficult to correct. Medial canthal tendon publications have been advocated but they do not achieve adequate posterior and medial placement of the medial canthal angle and they lack permanence. One of us (R.L.A.) has developed a surgical technique for correcting these problems that is a modification of the lateral tarsal strip procedure used to correct lateral canthal tendon laxity and malposition. The medial tarsal strip procedure repositions and tightens the medial lower or upper eyelid, establishing a normal anatomic appearance. Its use is indicated in cases of medial canthal malposition or marked medial ectropion associated with a nonfunctioning canalicular system or in those cases in which loss of function of a patent canaliculus is acceptable or desirable. The advantages of the medial tarsal strip are as follows: (1) surgery is directed at the site of the defect; (2) recurrence of canthal tendon laxity and elongation is avoided; (3) a more medial and posterior positioning of the medial eyelid can be obtained; (4) any amount of eyelid laxity can be corrected simultaneously; (5) the almond-shaped canthal angle is preserved or reestablished; and (6) the procedure is fast and easily performed.

The Tarsal Strip Procedure

We have developed a procedure that is particularly useful for (1) paralytic or senile upper and lower eyelid laxity, (2) lateral canthal tendon laxity or malposition, and (3) iatrogenic phimosis associated with recurrent entropion or ectropion after traditional lid-shortening procedures. Lateral canthal tendon laxity or elongation is the primary problem in the majority of these cases, and eyelid tightening with use of lateral tarsal strips corrects this deformity. The midtarsal portion of the eyelid, which is usually resected in traditional lid-shortening procedures, is seldom elongated, and recurrences of laxity are common secondary to further stretching of lax tendons. The technique involves a lateral canthotomy and transection of the appropriate crus of the lateral canthal tendon. The eyelid is then split into anterior and posterior lamellae, and tarsal strips are fashioned from the posterior lamella. The tarsal strips are sutured to periosteum at the lateral orbital wall, adjusting the height and tension of the lateral canthus. This technique gives a normal appearance to the lateral canthal angle and has yielded good results in 51 cases.