Lateral Canthal Tendon Research Articles

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.

Lower eyelid entropion repair with retractor mobilization and insertion onto the anterior surface of the tarsal plate

ABSTRACTPurpose: To evaluate a modified surgical technique for the correction of lower eyelid involutional entropion in terms of recurrence rate and relief of symptoms.Method: A prospective series of 67 consecutive eyelids in 55 patients who underwent lower eyelid entropion repair using a modified surgical approach not previously published in the literature to the authors’ knowledge. The surgical technique, via a skin crease incision, involves disinsertion of the lower eyelid retractors from the tarsus and conjunctiva and suturing the retractors onto the anterior surface of the tarsal plate. Standard excision of redundant lower lid skin and orbicularis muscle was also performed as well as lateral canthal tendon repair. All procedures were performed by a single surgeon (B. A. O’donnell). This study adhered to the principles of the Declaration of Helsinki.Results: There were 67 eyelids with a minimum of 12 months follow-up: of these only 1 patient (1%) required revision surgery (average follow-up 24 months). Four other eyelids had persistent or recurrent irritation (6%) not suggestive of, or secondary to, recurrence. Seven eyelids (10%) had undergone previous operative repair with no further recurrence following their most recent surgery.Conclusion: Disinsertion and reattachment of the retractors to the anterior tarsal plate in lower eyelid entropion repair is an effective surgical technique to improve lower eyelid stability. Although minimum follow-up is 12 months and average follow-up 24 months, longer follow-up would further evaluate this technique.

Lateral canthotomy orbitotomy: a rapid approach to the orbit.

PurposeThe lateral compartment of the orbit can readily be accessed through a horizontal lateral canthotomy without the need to swing the lid or remove bone. In this paper the technique, accessible orbital territory, and duration of surgery are presented.Patients and methodsRetrospective, non-interventional descriptive case series for patients who underwent a lateral canthotomy to access pathology within the lateral orbit.ResultsA series of 18 patients are included, all presenting with pathology lateral to, or within, the optic nerve. Pathologies included amyloidosis (1), lymphoma (4), metastatic adenocarcinoma within the optic nerve (1), idiopathic lateral rectus muscle mysositis (4), meningothelial meningioma of the optic nerve (1), intraconal orbital meningioma (1), reactive lymphoid hyperplasia (1), optic nerve glioma (3), optic nerve meningioma (1), and cavernous haemangioma (1). The median surgical time was 36 min (range 23-75 min). No patient required detachment of the lower lid, the technique leaving both upper and lower 'arms' of the lateral canthal tendon attached to Whitnall's tubercle.ConclusionsThe lateral canthotomy approach orbitotomy is a rapid, safe, and minimally disruptive approach for accessing pathology in the lateral orbit and optic nerve. The lateral canthal tendon is split along the horizontal raphe without detachment of either limb from Whitnall's tubercle, no bone is removed, and the post-operative recovery is rapid with minimal associated inflammation or chemosis. This approach is also flexible, permitting the clinician to increase exposure to the orbit peroperatively by swinging the lower lid if required.

English

INTRODUCTION: The eyelids are mobile tissue curtains protecting the eyes from injuries. The position of the eyelid against the globe is vital for maintaining the normal function and integrity of the underlying eyeball. Embryologically eyelids arises from two folds of ectoderm and mesoderm at about 8 weeks of gestational age. These two folds fuse by the age of tenth week. By seventh month of gestation they separate again to form eyelids. The lower lid position in relationship to the globe is due to various forces acting on the eyelid by its different anatomic attachments. Superior and posterior traction which keeps the eyelid margin in proper position are the medial and lateral canthal tendons. The lower lid retractors provides an inferior traction. An opposing force to the lower lids is provided in the anterior direction by the globe and various other orbital contents. In case of malfunction of one of the supporting structures or imbalance in the forces acting on the eyelid, the eyelid cannot properly maintain its position in relation to the globe. As a result, inversion or eversion of eyelid margin can occur. AIM OF THE STUDY: To evaluate the etiology and outcome of different surgical modalities applicable in the management of various types of ectropion. METHODS OF EVALUATION: It was a prospective interventional study conducted at Orbit and Oculoplasty department, RIOGOH, Egmore, Chennai for a period of 12 months.25 patients presented with ectropion were included in this study. RESULTS: Out of 25 patients, 19 patients (76%) had involutional ectropion. Among them lateral tarsal strip with medial canthoplasty was done in 10 patients (40%), 9 patients (39%) underwent lateral tarsal strip procedure. Two patients (8%) with mild cicatricial ectropion were subjected to Z Plasty. Of the remaining 4 patients (16%) who underwent scar excision with skin grafting for severe cicatricial ectropion, 1 patient (4%) had a unsatisfactory result with persistent eversion of the eyelid due to insufficient graft uptake. All other 24 patients (96%) had satisfactory surgical outcome outcome in the form of improvement of symptoms like watering, preservation of anatomy (opposition of eyelid to the globe) and better cosmesis. CONCLUSION: `Lateral tarsal strip procedure and medial canthoplasty procedure gives the successful surgical outcome in the form of alleviation of symptoms like watering,restoration of eyelid anatomy,corneal protection in the lateral aspect of the eye and better cosmesis in the management of involutional and paralytic ectropion. Both these procedures are simple with a short learning curve. Z Plasty and skin grafting is the procedure of choice in the management of cicatricial ectropion with local and generalized defect respectively. Thus planning appropriate surgical approach according to the type and pathogenesis of ectropion is the key for successful surgical outcome.

Pseudoexfoliation syndrome and ocular adnexa

Pseudoexfoliation syndrome (PEX) is a relatively widespread generalized age-related disease of the connective tissue. Therefore, it is reasonable to evaluate the condition of ocular adnexa in patients with PEX. The purpose of the study. To evaluate the state of ocular adnexal tissue in PEX. Methods. Both eyes of 66 patients with PEX and of 64 control individuals were examined in this prospective study. We evaluated the function of the upper eyelid levator muscles and the lower eyelid retractors, horizontal lid laxity (HLL), canthal integrity, degree of retractor disinsertion, and orbicularis muscle tone. Results. The HLL, degree of retractor disinsertion, and the laxity of the medial canthal tendon were statistically expressed in patients with PEX (p 0.05). However, the orbicularis muscle tone and the function of the lower eyelid retractors were statistically lower in these patients (p 0.05). The function of the upper eyelid levator muscles, tone of the lateral canthal tendon and degree of ptosis was found to be similar in both groups. Conclusion. Signs of atonic changes in ocular adnexa are relatively more common in patients with PEX (p 0.05).

Combined medial canthopexy and lateral tarsal strip for floppy eyelid syndrome

PurposeTo describe the eyelid condition known as “floppy eyelid syndrome” and to present the results of our experience treating patients with floppy eyelid syndrome. MethodsA retrospective analysis of 16 patients from 2009 to 2013 who underwent combined medial canthopexy and lateral tarsal strip by two surgeons (HBL and WRN) for the treatment of floppy eyelid syndrome (FES). Age, gender, presence of obstructive sleep apnea (OSA), papillary conjunctivitis, punctate keratopathy and lash ptosis were recorded pre-operatively. Outcomes assessed included improvement in upper eyelid laxity, operative complications, post-operative symptomatic relief and delayed recurrence of FES. ResultsA total of 18 procedures (on 36 eyelids) were performed on 16 patients over the 4-year period. All patients (18/18) had relief of symptoms and good functional results, defined as improvement in lid laxity and resolution of symptoms. Average follow up was 124days. 8 of 16 patients (50%) had a pre-existing diagnosis of OSA. The remaining 8 patients were referred for sleep study and 2 were subsequently diagnosed with OSA. Two patients experienced some degree of FES recurrence without return of symptoms. There was one complication reported in which a partial dehiscence of the lateral canthal tendon occurred which did not require operative revision. ConclusionsCombined medial canthopexy and lateral tarsal strip are a safe and effective technique for the treatment of floppy eyelid syndrome. There is a strong association of FES and OSA and it is important to have any patient diagnosed with FES evaluated for OSA.

Temporalis Muscle Transfer for the Treatment of Lagophthalmos in Patients With Leprosy: Refinement in Surgical Techniques to Prevent Postoperative Ptosis.

Facial paralysis resulting from leprosy has a serious impact on the entire face especially in the areas innervated by the facial nerves. In particular, lagophthalmos in patients with leprosy causes exposure keratitis, corneal, and conjunctival dryness, which can progress to blindness and disfigurement. Recently, we conducted 4 different temporalis muscle transfer (TMT) methods over the last 4 years to reduce ptosis. The methods used included Brown-McDowell, McCord-Codner, modified Gillies-Anderson, and modified Gillies. Seventy-five TMT operations in 60 patients were performed between 2011 and 2014. The mean age was 70.1. Fifteen patients had bilateral TMT procedures. As a result, ptosis appeared in 14(18.7%) of 75 TMT procedures for 4 years. To prevent or correct this complication, the following 4 technical refinements have simplified the surgery and yield better surgical outcomes. First, an increase in the length of the temporalis muscle flap to approximately 8 cm with a parallel course to the lateral canthus will reduce oblique pull. Second, the width of the fascia sling in the upper eyelid is narrowed (3-4 mm) to reduce weight on the eyelid. Third, the fascia sling in the upper lid should not be located along the full length of the upper lid but terminate 3.5 cm medial to lateral canthal tendon and in other words, should not be tied at the medial canthal tendon to reduce tension and weight. Lastly, the fascia sling in the eyelid should be located shallow (probably in subdermal layer) and as near as possible to the lid margin to prevent any functional disturbance in levator aponeurosis.

Lateral Canthal Position Following Lateral Orbitotomy and the Influence of Ocular Proptosis.

Anecdotal evidence suggests that detachment of the lateral canthal tendon during lateral orbitotomy results in shortening of the horizontal palpebral aperture (HPA) and rounding of the lateral canthal angle (LCA). This study investigated the change in HPA and LCA following lateral orbitotomy and the effect of proptosis on the HPA. Retrospective, single surgeon, review of all cases undergoing lateral orbitotomy, comprising of a canthotomy and cantholysis and reconstruction of the lateral canthus using a single suture. The HPA and lateral canthal height (LCH) were measured on pre- and postoperative photographs using ImageJ software. Changes in the LCA and degree of proptosis were also investigated. Exclusion criteria included previous eyelid surgery, acute trauma, and less than 6 months' follow up. There were 41 cases of lateral orbitotomy in 27 patients, 67% female, average age 51 years. Twenty patients had thyroid eye disease of which 14 underwent bilateral surgery; the other 7 patients had a variety of orbital pathologies. Thirteen patients underwent unilateral orbitotomy with the contralateral eye serving as a control. Average follow up was 23 months. Overall, the HPA and proptosis were reduced by 0.6 mm (p = 0.143) and 3.4 mm (p < 0.001), respectively. A 0.2-mm reduction in HPA was observed for every 1-mm reduction in proptosis. A difference in post-orbitotomy HPA was observed between cases and their matched controls (p = 0.016). No rounding of the LCA or significant change in LCH was observed following lateral orbitotomy. The described technique of lateral orbitotomy and simple reconstruction do not appear to cause lateral canthal drift or rounding. There was no significant change in HPA or LCH. The degree of change of proptosis does appear to influence the change of HPA.

The Locking Y Lateral Canthopexy With Osseous Integration: Clinical Experience and Surgical Technique.

To describe a surgical technique to correct lateral canthal tendon disinsertion with a strabismus surgery-inspired locking capture of the tendon complex and osseous integration via drill holes. Retrospective interventional case series including all patients with lateral canthal tendon disinsertion who underwent locking Y lateral canthopexy with drill hole reinforcement by 1 surgeon (D.T.T.) between 2006 and 2011. Outcome measures included resolution of presenting ocular symptoms, improved blink dynamics and lid closure, correction of lagophthalmos and exposure keratopathy, and need for further surgery. A total of 53 lateral canthopexies with osseous integration were performed in 42 patients who fulfilled clinical criteria for lateral canthal tendon disinsertion. The population was biased toward treatment failures; 81% of eyes (43/53) had a history of prior lateral canthal tightening, and of these 30.2% (16/53) had undergone 3 or more procedures. Postoperatively, all eyes demonstrated improved eyelid position and blink mechanics, and 83% (44/53) had subjective resolution of epiphora and ocular irritation. Lagophthalmos was fully corrected in 95% (19/20) of cases, and corneal staining resolved in 88% (14/16). With a mean follow-up period of 24 months, 3.7% of eyes (2/53) required additional lateral canthal tightening. The locking Y lateral canthopexy is an effective and durable method for repositioning the lateral canthal tendon complex to improve blink dynamics, eyelid closure, and cosmesis. Even in a population heavily biased toward treatment failure, clinical results are excellent and the reoperation rate is low.

Lateral Canthal Tendon Disinsertion: Clinical Characteristics and Anatomical Correlates.

To highlight features of lateral canthal tendon disinsertion (LCTD), provide an algorithm for systematic assessment, and describe the anatomic genesis of signs and symptoms. Retrospective case series of consecutive patients with lateral canthal tendon disinsertion, who underwent lateral canthal tendon fixation by a single surgeon (DTT) between 2004 and 2011. One hundred and seventeen eyes in 90 patients underwent lateral canthal tendon fixation. Average age was 69.3 ± 17.9 years. Twenty-three percentage of eyes had undergone lower eyelid blepharoplasty and 52% had undergone lateral canthal tightening; 35% had no previous periocular surgery. Patients with purely involutional lateral canthal tendon disinsertion were significantly older (76.1 ± 7.8 years of age; p < 0.03). Six key features associated with lateral canthal tendon disinsertion were identified. On static evaluation: 1) a blunted or vertically displaced lateral canthal angle; 2) a narrow horizontal fissure with reduced temporal scleral triangle; and 3) pseudo eyelid retraction. On dynamic evaluation with attempted closure: 4) medial and inferior movement of the lateral commissure; 5) incomplete apposition of the eyelid margins in the absence of anterior lamellar shortage; and 6) temporal eyelid imbrication. Improved blink dynamics with manual lateral canthal tendon complex repositioning ("the thumb test") predicted a favorable outcome with surgical tightening in 95.7% of cases. Lateral canthal tendon disinsertion results in altered eyelid fissure symmetry, blink dynamics, and lacrimal pump function. The authors recommend the mnemonic-A.B.C.: for Aperture configuration, Blink dynamics, and eyelid Closure-to structure the examination of all symptomatic patients. Manual restoration of the disinserted lateral canthal tendon with the "thumb test" predicts favorable outcomes with surgical fixation.

Double Lateral Flap: A New Technique for Lower Eyelid Reconstruction Alternative to the Tenzel Procedure.

The final esthetic result is a common concern of patients with eyelid tumors, especially young patients and those with tumors affecting the medial edge of the lower eyelid. The procedure herein described combines two lateral flaps: one tarsoconjunctival and the other from the periosteum. The first step is removal of the tumor lesion. Preseptal dissection is then performed through a subciliary incision on both the lateral and medial halves of the eyelid up to the orbital rim. Next, the lateral canthal tendon, lateral attachment of the orbital septum, capsulopalpebral fascia, and conjunctiva are cut. This allows the medial displacement of the tarsoconjunctival flap, which is sutured to the defect area. The second flap, a periosteal strip, is used to reconstruct the tarsus and lateral canthal tendon, providing firm support for the posterior lamella. The orbicularis muscle is anchored to the orbital rim, and the skin of the lower eyelid is directly sutured to the subciliary incision and periosteal strip. The author successfully carried out this procedure on nine patients. None of the patients developed ocular irritation or postoperative epiphora. The defects that can be repaired by this technique are equivalent in size to those repaired by the Tenzel procedure. Unlike the semicircular flap procedure, this technique allows eyelid reconstruction with no vertical scarring and a smaller lateral incision, and it ensures soft contact between the palpebral rim and surface of the eyeball. This procedure confers an attractive eyelid appearance that may be crucial for some patients. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Hypertelorism Correction With Facial Bipartition and Box Osteotomy

Hypertelorism may be corrected by either transcranial box osteotomy or facial bipartition. Despite radical bony resection, the associated soft tissue translation often seems disproportionate. The purpose of this study was to review bony and soft tissue movements in a series of 15 consecutive hypertelorism correction cases. Two surgical residents in training independently analyzed preoperative and postoperative axial and three-dimensional reconstructed computed tomography data from 15 consecutive patients undergoing facial bipartition (n = 7) or transcranial box osteotomy correction (n = 8) between 2001 and 2010. Anterior interorbital distance, lateral interorbital distance, midpoint globe distance, and globe protrusion were measured along with intercanthal distance and palpebral fissure width. The mean preoperative anterior interorbital distance was 35.5 mm; postoperatively, there was a mean reduction of 9.5 mm, to 26 mm. The mean preoperative intercanthal distance was 48.1 mm; there was a mean reduction of 10.3 mm, to 37.8 mm. The mean preoperative midpoint globe distance was 69.5 mm; there was a mean reduction of 9.6 mm, to 59.9 mm. The mean preoperative globe protrusion was 17.6 mm; there was a mean reduction of 5 mm, to 12.6 mm (28.5%). The mean interclass correlation (a measurement of interrater congruency with 1 being complete agreement) was 0.85 CONCLUSIONS: Transcranial box osteotomy and facial bipartition correct hypertelorism. The medial canthal tendons, lateral canthal tendons, and globes move in proportion to the bony attachments. We observed a reduction in globe protrusion an average of 29%, therefore risking enophthalmos.

A new method for forming the pretarsal fullness after lower blepharoplasty.

A new method for forming the pretarsal fullness after lower blepharoplasty.

The tarsal belt procedure for the correction of ectropion: description and outcome in 42 cases

Background/aimsEctropion correction is a challenge in plastic surgery. Correction of the lower lid area, including restoration of the shape and position of lid margin, is the surgical goal. In this...

Changing the Facial Features of Patients With Treacher Collins Syndrome

Treacher Collins syndrome is a disorder characterized by various congenital soft tissue anomalies involving hypoplasia of the zygoma, maxilla, and mandible. A variety of treatments have been reported to date. These treatments can be classified into 2 major types. The first type involves osteotomy for hard tissue such as the zygoma and mandible. The second type involves plastic surgery using bone grafting in the malar region and soft tissue repair of eyelid deformities. We devised a new treatment to comprehensively correct hard and soft tissue deformities in the upper half of the face of Treacher Collins patients. The aim was to "change facial features and make it difficult to tell that the patients have this disorder." This innovative treatment strategy consists of 3 stages: (1) placement of dermal fat graft from the lower eyelid to the malar subcutaneous area, (2) custom-made synthetic zygomatic bone grafting, and (3) Z-plasty flap transposition from the upper to the lower eyelid and superior repositioning and fixation of the lateral canthal tendon using a Mitek anchor system. This method was used on 4 patients with Treacher Collins syndrome who had moderate to severe hypoplasia of the zygomas and the lower eyelids. Facial features of these patients were markedly improved and very good results were obtained. There were no major complications intraoperatively or postoperatively in any of the patients during the series of treatments. In synthetic bone grafting in the second stage, the implant in some patients was in the way of the infraorbital nerve. Thus, the nerve was detached and then sutured under the microscope. Postoperatively, patients had almost full restoration of sensory nerve torpor within 5 to 6 months. We devised a 3-stage treatment to "change facial features" of patients with hypoplasia of the upper half of the face due to Treacher Collins syndrome. The treatment protocol provided a very effective way to treat deformities of the upper half of the face in patients with Treacher Collins syndrome.

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.

The “Leicester Lasso” Lateral Canthoplasty

To describe an innovative technique of lateral canthal tendon (LCT) anchoring to the lateral orbital rim on its inner aspect using a "lasso" technique, in order to provide the ideal vector. A retrospective case review of seven patients (n = 7), performed from 2009 to 2013 at our institution by the senior author (RGS). Excellent results in all cases with optimal restoration of form and function. The 'Leicester Lasso' technique is a safer technique of securing the LCT to the orbital rim.

Iatrogenic Cerebrospinal Fluid Oculorrhea

Cerebrospinal fluid leakage into the orbit (CSF orbitorrhea) or through the orbit to the exterior (CSF oculorrhea) occurs when there is a communication between orbit and subarachnoid space. It has rarely been described. We report a case of CSF oculorrhea following surgery for recurrent sphenoid wing meningioma. A 67-year-old patient who underwent craniotomy for a recurrent sphenoid wing meningioma complained of tearing from the ipsilateral eye. Fluid collection was observed in the right periorbital area contiguous with craniotomy wound. With wide retraction of eyelids, a 1-cm longitudinal full-thickness laceration through the conjunctiva toward the lateral orbital rim was visualized in the area of the lateral canthal tendon. Steady leakage of pink-tinged serous fluid through the forniceal laceration was observed. With a presumed diagnosis of iatrogenic CSF oculorrhea, the patient was treated conservatively with resolution by postoperative day 6.

Oculoplastic Approach to Congenital Cutis Laxa Syndrome

Cutis laxa is a rare congenital or acquired disorder of elastic tissue, characterized by loose skin with folds and multiple internal organ involvement, which may cause life-threatening complications. We present a patient with cutis laxa syndrome who had cross eyelids with esotropia. Bilateral lateral canthal tendon repositioning and bilateral medial rectus recession procedures were performed in a single session. The patient had acceptable eyelid and globe cosmesis after the procedure. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Lower eyelid suspension using polypropylene suture for the correction of punctal ectropion

ObjectiveTo evaluate the efficacy and complications of lower eyelid suspension with the modified Safdarjung hospital technique using 5:0 polypropylene suture for punctal ectropion. Study designProspective case series. MethodThirty one eyelids in 19 patients with mild and moderate ectropion and all types of laxity including involutional and paralytic were included. All patients underwent lower eyelid suspension with the modified Safdarjung hospital technique. A 5:0 polypropylene suture was passed in the pre-tarsal plane between the attachments of the lateral and medial canthal tendons near their insertion at the orbital rim. Successful outcome was judged by the anatomical restoration of the apposition of the punctum to the globe in the upward gaze and the physiological relief of epiphora. The recurrence of lid laxity, overall lid/globe apposition and complications were also noted. ResultsAt 1 year follow up anatomical success was achieved in 28 (90%) patients and functional success noted in 27 (87%) patients. Recurrence of lid laxity was noted in 2 patients. There was a suture exposure in one case and a suture granuloma in another case. The results did not correlate to the degree of ectropion and type of laxity. ConclusionLower eyelid suspension using 5:0 polypropylene suture is a useful procedure for the treatment of involutional and paralytic punctal ectropion. It is simple and effective with minimal complications. However, the effect on scleral show and the concern related to suture material biodegradation over years needs to be further evaluated.