Lateral Tarsal Strip Procedure Research Articles

Double Trouble: Entropion Repair Complicated by a Conjunctival Neurofibroma

While ocular involvement is well documented in association with neurofibromatosis type 1 (NF-1), conjunctival neurofibromas are very rare. We describe a challenging NF-1 case of a patient with a conjunctival neurofibroma in association with lower lid involutional entropion and severe conjunctival chemosis. A 65 year-old male presented with age-related left lower lid laxity, retractor dehiscence, inferior conjunctival chemosis and significant ocular discomfort. The patient underwent a left lower lid lateral tarsal strip procedure with retractor plication without much improvement in the chemosis and discomfort. However post-operatively it became evident that an injected mass was present in the left inferior fornix. Surgical debulking of this mass allowed for resolution of the patient’s signs and symptoms as well as proper lower lid alignment. Histopathologic diagnosis with S100 and CD34 positivity confirmed a conjunctival neurofibroma. Although uncommon, it is important to consider the possibility of a conjunctival mass in a patient with persistent chemosis and recurrent lower lid instability, particularly when confronted with a neurocutaneous syndrome.

The effectiveness of simultaneous medial spindle and/or lateral tarsal strip procedure in East Asian patients who need endonasal dacryocystorhinostomy

To evaluate the effectiveness of simultaneous medial spindle procedure (MS) and/or lateral tarsal strip procedure (TS) with an endonasal dacryocystorhinostomy (DCR) for treatment of involutional medial punctal ectropion, horizontal eyelid laxity, and nasolacrimal duct obstruction. We conducted a retrospective, interventional study of DCR performed from March 2009 to July 2011 by a single surgeon (Baek SH). Patient age, sex, results of medial and lateral distraction test, surgical procedure, time of tube removal, duration of follow-up, functional and anatomical success rate, and causes of failed surgeries were recorded. Lateral lower eyelid laxity was evaluated by a medial distraction test, and medial lid laxity was evaluated by a lateral distraction test. A total of 241 eyes in 175 patients were included in this study. The proportion of combined surgeries to total DCR was 24.5% (59 of 241 eyes). DCR and MS (D + M) were performed on 23 eyes in 17 patients (9.5%) and DCR and TS (D + T) on 29 eyes in 17 patients (12.0%). Concurrent DCR, MS and TS (D + M + T) were performed on seven eyes in four patients (2.9%). Mean age was significantly higher in the combined surgery groups (63.8 ± 10.0 years) than in the DCR group (56.2 ± 10.6 years; p = 0.01, by Mann-Whitney U test). The anatomical success rates were 84.2% in D, 86.9% in D + M, 89.5% in D + T, and 85.7% in D + M + T (p = 0.61 by Kruskal-Wallis test). Functional success rates were 82.4% in D, 86.9% in D + M, 86.2% in D + T, and 85.7% in D + M + T (p = 0.91 by Kruskal-Wallis test). MS and TS performed concurrently with a DCR may be an effective tool to deal with epiphora due to complex clinical situations such as nasolacrimal duct obstruction, lid laxity, and involutional medial ectropion. It is recommended to examine punctum and lid laxity carefully using slit-lamp biomicroscopy and lid distraction test in patients with epiphora, especially in elderly patients.

The Effectiveness of Simultaneous Lateral Tarsal Strip With Endonasal Dacryocystorhinostomy for the Treatment of Nasolacrimal Duct Obstruction and Lower Lid Laxity

The aim of this study was to evaluate the effectiveness of simultaneous lateral tarsal strip procedure (LTS) and endonasal dacryocystorhinostomy (DCR) for the treatment of nasolacrimal duct obstruction and lower lid laxity. We conducted a retrospective, interventional study of concurrent DCR with LTS for patients with nasolacrimal duct obstruction and lower lid laxity performed between March 2009 and July 2011 by a single surgeon (S.H.B.). Patient age, sex, the results of dacryoscintigraphy, time of tube removal, follow-up duration, and cause of failed surgery were recorded. Lower eyelid laxity was evaluated by a medial distraction test. A total of 29 eyes in 17 patients were included in the study. The mean age was 61.1 ± 11.8 years (range 41 to 81 years). The mean degree of lower lid laxity was 2.4 ± 0.5. Dacryoscintigraphy showed presac delay in 22 eyes (75.9%). The tube was removed after 11.3 ± 1.9 weeks. The primary anatomical success rate was 89.5% (27 eyes) and the functional success rate was 86.2% (25 eyes). Membranous obstructions were the cause of failed surgery in 2 patients, but both patients remained symptom free after revision surgery with a diode laser. Concurrently performed DCR with LTS can be an effective tool for the treatment of nasolacrimal duct obstruction and lower lid laxity. It is recommended for examining lid laxity carefully using lid distraction test in patients with epiphora.

Involutional Ectropion Repair with the Modified Medial Spindle and the Lateral Tarsal Strip Procedure

Involutional Ectropion Repair with the Modified Medial Spindle and the Lateral Tarsal Strip Procedure

Lateral Tarsal Strip Procedure Combined with Quickert Sutures in Correcting Involutional Entropion

Lateral Tarsal Strip Procedure Combined with Quickert Sutures in Correcting Involutional Entropion

Lateral Canthal Resuspension Sine Canthotomy

The purpose of this study is to describe a novel canthopexy technique-the lateral canthal resuspension sine canthotomy (LCR-SC)-performed via an upper-eyelid incision and to compare it with the lateral tarsal strip procedure (LTS). This is a retrospective study in which the pre- and postoperative photographs of 20 patients per group who had LCR-SC, LCR-SC + midface lift (LCR-SC+ML), or LTS were analyzed by using the Image-J 1.40 software. Parameters measured were as follows: the horizontal palpebral aperture margin-reflex distance 2 (MRD-2) and the height of lateral canthus. LCR-SC was performed through an upper-eyelid incision, by using a 4.0 Prolene suture. For the LCR-SC+ML, a large myocutaneous flap was created first and anchored to the orbital-rim periosteum. The surgical technique is described. Two-way ANOVA was used for analysis. The horizontal palpebral aperture was significantly increased by LCR-SC and LCR-SC+ML when compared with LTS (1.61 ± 0.22 mm and 1.56 ± 0.14 vs. 0.04 ± 0.12 mm; p < 0.01). LCR-SC and LCR-SC+ML decreased the MRD-2 more than the LTS (1.06 ± 0.26 and 1.50 ± 0.23 mm vs. 0.86 ± 0.1 mm; p < 0.01). All 3 procedures increased the lateral canthal height by less than 0.5 mm. LCR-SC is a safe and effective procedure for tightening the lower eyelids. It tightens both the upper and the lower cruri of the lateral canthal tendon, avoiding imbrication of the eyelids. LCR-SC obviates the need for a lateral canthal incision and widens the horizontal palpebral aperture. LCR-SC is more effective than LTS at decreasing the MRD-2. Concomitant midface elevation (LCR-SC+ML) further decreases MRD-2.

Fat repositioning via supraperiosteal dissection with internal fixation for tear trough deformity in an Asian population

To investigate the efficacy and complications of fat repositioning via supraperiosteal dissection with internal fat-flap fixation for tear trough deformity in an Asian population. This study is a retrospective chart review. From June 2005 to May 2010, 212 patients with lower eyelid fat prolapse and tear trough deformity underwent fat repositioning via supraperiosteal dissection with internal fat-flap fixation. Postoperative complications were recorded, and the degree of outcome satisfaction was obtained at the 6-month postoperative follow-up. In total, 142 patients underwent transconjunctival fat repositioning, and 70 received the transcutaneous approach for redundant lower lid skin and tear trough deformity. The level of satisfaction 6 months after the operation was high: 152 patients rated their experience as very satisfied (71.7%), 54 as satisfied (25.5%) and six as acceptable (2.8%). None reported being dissatisfied or unhappy. No diplopia or evidence of granuloma formation in the lower eyelid or check area was noted. Four patients who suffered from significant ecchymosis and conjunctival chemosis with corneal exposure were managed with lubricants and resolved spontaneously. Three patients who underwent the transcutaneous approach and excess skin excision had the complication of lower lid ectropion; they received lateral tarsal strip procedures with good results. Three patients required revision to remove the residual lateral fat pad because of inadequate lateral orbital fat excision during the initial procedure. Fat repositioning via supraperiosteal dissection with internal fat-flap fixation is a safe and effective method to create a youthful midface appearance for Asians with tear trough deformity.

Cicatricial upper and lower eyelid ectropion in an ichthyosis patient. Surgical correction.

Surgical correction of bilateral cicatricial upper and lower eyelid ectropion in an ichthyosis patient remains a challenge in clinical practice. A 24-year-old female patient presented to our clinic with bilateral upper and lower eyelid ectropion. Her skin over her entire body and face was dry and scaly. The diagnosis was cicatricial ectropion related in a patient with ichthyosis. The upper eyelids were treated by retroauricular full thickness skin grafts and upper eyelid lateral tarsal strip procedure. And lower eyelids were treated by cheek transposition grafts and lower eyelid lateral tarsal strip procedure. The upper and lower eyelids were corrected successfully with these surgical procedures. In patients with ichthyosis skin alterations in the eyelid cause shortening of the anterior lamella, subsequently resulting with ectropion. Successful surgical correction with skin grafts or transposition flaps can be performed to lenghten anterior lamella. Adding lateral tarsal strip procedure to skin grafting helps to maintain a beter lid margin apposition.

A 5-year Retrospective Review of Asian Ectropion: How Does It Compare to Ectropion Amongst Non-Asians?

This study reviews the differences in demographics and surgical outcomes between ectropion in Asian and non-Asian eyes. Medical records of surgically corrected ectropion cases from January 2002 to December 2006 were reviewed. Preand postoperative lid-globe apposition was graded: grade 0 with normal lid-globe apposition, grade 1 with punctal ectropion, grade 2 with partial lid eversion and scleral show, grade 3 with conjunctival hyperemia and thickening and grade 4 as for grade 3 with exposure keratitis. Sixty-nine eyes in 50 patients underwent surgical correction of lower lid ectropion, making up 3.3% of all lid procedures performed. Eighty-four percent of patients were above 50 years of age, 72% were males and 88% were Chinese. Involutional change was the commonest aetiology, accounting for the majority of bilateral cases. The mean duration to surgery was 10.0 ± 16.0 months. The most frequent preoperative severity grade was 2. Lateral tarsal strip (LTS) was the commonest procedure performed, comprising 91.3% of eyes. The mean duration of postoperative review was 19.4 ± 19.2 months (range, 1 to 74 months). Postoperative improvement of at least one grade was observed in 98% while normal lid-globe apposition was achieved in 76% of eyes. Involutional change is the most common cause of ectropion amongst both Asians and non-Asians. Ectropion is less prevalent amongst Asians as a result of anatomical differences and possibly reduced sun exposure. The LTS procedure is the most commonly performed surgical procedure for the successful correction of ectropion in both Asians and non-Asians.

Lateral Tarsal Strip Procedure and Silicone Tube Intubation on the Functional Nasolacrimal Duct Obstruction

Purpose: To compare the effects of the lateral tarsal strip procedure alone and the lateral tarsal strip procedure combined with silicone tube intubation in the treatment of functional lacrimal duct obstruction. Methods: The present study investigated 27 eyes of 20 patients underwent lateral tarsal strip procedure (LTS) alone and 29 eyes of 18 patients underwent combined lateral tarsal strip procedure and silicone tube intubation and who were diagnosed with functional lacrimal duct obstruction. The authors retrospectively reviewed patients' medical records for information including age, gender, history, follow-up period, tear meniscus height (TMH), and symptoms. Results: The average age of the LTS alone group was 60.3 years, and that of the combined groups was 65.9 years. The TMHs in the LTS only and combined operation groups were 0.62 0.23 mm and 0.62 0.19 mm before the operation and 0.43 0.20 mm and 0.26 0.09 mm after the operation, respectively. The postoperative improvement in epiphora was 74.1% after the LTS alone and 86.2% after combined LTS with silicone tube intubation. The postoperative improvement in epiphora and the operative technique of the lateral tarsal strip-canthus sparing or cantholysis were not relevant. Conclusions: Lateral tarsal strip combined with silicone tube intubation appeared useful in the treatment of epiphora patients without anatomic lacrimal duct obstruction. Determining which operative technique of lateral tarsal strip procedure should be chosen is difficult, and the preoperative syringing and snap back test may be helpful.

Herausforderungen der operativen Korrektur des komplizierten Ektropiums

Simple forms of involutional ectropion may be corrected by a horizontal shortening and a medial retractor-advancement procedure. In long-standing cases secondary changes of the skin and lid margin have to be corrected. This requires additional surgical steps. A complicated ectropion can develop to gross deformities of the lid margins so that resection and reconstruction of the margins become necessary. This study differentiates the indication of simple or complicated ectropion surgery and elucidates the surgical options for the complicated ectropion. We reviewed our corrected ectropion cases operated between January 2000 and December 2008. The cases were categorised according to the indicated surgical technique into simple (grade 1), simple combined (grade 2), complicated (grade 3) forms and complicated forms with major lid margin deformities (grade 4). Out of the 1101 corrected lids, we found 19 % to be simple ectropion cases (grade 1) that received a lateral tarsal strip procedure. An additional retractor advancement to correct the medial punctual eversion was necessary in 38 % of the cases of combined ectropion (grade 2). About the same number of the lids (41 %) was staged as complicated ectropion (grade 3) and required a subciliary skin graft and a lid margin reshaping. The remaining 2 % (grade 4) needed a lid margin reconstruction. In ectropion cases we find progressive pathological changes due to the duration of the everted lid position. Such changes vary from simple forms of ectropion to more complicated forms. In order to achieve good postoperative results and avoid recurrences, the surgical correction should be based on the degree of lid alteration. In the initial stage of simple ectropion (grade 1) it is sufficient to correct the lid laxity. More advanced stages of simple combined ectropion require a medial, inverting retractor correction in addition to the lid shortening procedure (grade 2). These two surgical steps are insufficient to manage the complicated ectropion stage (grade 3), where additional skin grafting and lid margin reshaping are required. Sometimes the lid margin cannot be reshaped if a major deformity is found (grade 4). The solution in such cases is to excise and reconstruct the lid margin.

The advantages of lateral tarsal strip procedure

The advantages of lateral tarsal strip procedure

Cicatricial ectropion correction in a patient with pyoderma gangrenosum: case report

A 19 year old female with pyoderma gangrenosum was referred to the oculoplastic clinic for evaluation of severe cicatricial ectropion of the right lower eyelid. Examination evidenced important scarring of lower eyelid and malar region with secondary ectropion. A full-thickness skin graft associated with a lateral tarsal strip procedure and scar tissue release was performed. The patient's corticosteroid dose was raised for the procedure, and after surgery there was no healing problem or ulcer formation in the eyelid or in the graft donor site. As pyoderma gangrenosum is associated with a pathergy phenomenon in up to 25% of the cases, the onset of new lesions is a relevant concern when performing surgery in these patients. In this case, the surgery was safely performed under corticosteroid immunosuppression.

Can Eyelid Taping Predict the Benefit of a Lateral Tarsal Strip Procedure in Patients With Eyelid Laxity and Functional Epiphora?

To determine whether taping of the lower eyelid laterally and upward onto the temple region (to mimic a lateral tarsal strip procedure) can effectively predict whether lateral tarsal strip surgery will lead to resolution or improvement in functional epiphora by correcting eyelid laxity. A case series of 28 eyes in 20 patients with symptomatic epiphora and equivocal lateral eyelid laxity were identified. The inclusion criteria included patent nasolacrimal systems on syringing with no other eyelid malposition or obvious cause for epiphora. Patients underwent taping of the lower eyelid using micropore tape to the temple region in the outpatient clinic for a period of 1 hour. The patients were asked to spend that time in conditions that would exacerbate their epiphora (e.g., outdoors). At the end of the hour the patients were recalled for subjective reassessment of epiphora. The mean age of the patients was 69 years. Eighteen patients (25 eyes) had subjective improvement in their epiphora when taped; this group was offered subsequent lateral tarsal strip surgery. Two patients (3 eyes) had no improvement in symptoms when taped. Postoperative follow-up showed decreased epiphora in 14 patients (20 eyes) of the 18 patients (25 eyes) operated. In 4 patients (5 eyes), although eyelid taping was beneficial, surgery did not resolve the epiphora. Temporary tightening of the lower eyelid with micropore tape to mimic the effect of lateral tarsal strip surgery can identify those patients who may benefit from an eyelid-tightening procedure. Patients who did not benefit from eyelid taping can avoid potentially unnecessary eyelid surgery.

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.

Adjunctive Transcanthotomy Lateral Suborbicularis Fat Lift and Orbitomalar Ligament Resuspension in Lower Eyelid Ectropion Repair

Severe or recurrent lower eyelid ectropion can be challenging to correct. Studies on the role of upper midface ptosis in lower eyelid malposition have been published. The authors describe their technique of supporting the lateral cheek by lifting and reestablishing support for the orbitomalar ligament through a 10-mm canthotomy incision as an adjunct to a lateral tarsal strip procedure. In many cases, this technique allows the eyelid to be properly repositioned without skin grafting. A retrospective chart review of patients with severe multifactorial or recurrent lower eyelid ectropion. A preperiosteal dissection over the malar eminence and resuspension of the lateral aspect of the suborbicularis oculi fat was performed through a 10-mm lateral canthotomy at the time of lateral tarsal strip procedure. The longest follow-up was 20 months, with an average of 7.8 months postoperatively. Postoperative eyelid position and patient symptoms were used as outcome measures. Twelve patients underwent repair of severe ectropion with a lateral tarsal strip procedure and adjunctive transcanthotomy lateral suborbicularis oculi fat lift with orbitomalar ligament resuspension. In 3 cases of severe paralytic ectropion and in 1 patient with poor healing, a small lateral tarsorrhaphy was also performed. The patients achieved excellent improvement in lower eyelid position, with resolution of symptoms and satisfactory aesthetic outcomes. Elevating the lateral suborbicularis oculi fat by resuspending the orbitomalar ligament was effective in supporting the lateral cheek. This resulted in recruitment of anterior lamella and allowed for good lower eyelid repositioning. The extent of dissection could be graded to achieve the desired surgical objectives. More invasive surgery such as full-thickness skin grafting was avoided. This technique can be a relatively noninvasive, yet powerful adjunct in the treatment of severe or recurrent lower eyelid ectropion.

Long-term Success Rate of Perforated Punctal Plugs in the Management of Acquired Punctal Stenosis

To give the long-term success rates of punctal dilatation with insertion of perforated punctal plugs (PPP) for the management of acquired punctal stenosis. A series of 44 eyes of 26 patients who underwent PPP implantation for the management of acquired punctal stenosis were retrospectively evaluated in terms of the severity of acquired punctal stenosis, associated eyelid disorders, implantation technique of PPP, and long-term success rate of PPP for the treatment of epiphora. In all patients, punctal dilation was performed prior to the insertion of plugs. Patients demonstrating moderate or severe horizontal eyelid laxity underwent a lateral tarsal strip procedure before PPP implantation. Complete stenosis of the punctum was treated with the radiofrequency unit before PPP implantation. The plugs were extracted at 2 months in every patient. The mean age of the patients was 63.6 +/- 10.5 years. The median interval between the onset of epiphora and PPP implantation was 15 months. There were 14 complete stenoses, 29 partial punctal stenoses, and 1 squamous papilloma involving the inferior punctum causing epiphora. Associated eyelid laxity was detected in 14 of 44 eyes (31.8%), and 8 eyes underwent a lateral tarsal strip procedure before PPP implantation. The mean follow-up time was 19.0 +/- 13.4 months. Success was achieved in 37 of 44 eyes (84.1%), with relief of epiphora. Of the 7 eyes with continued epiphora, 3 eyes demonstrated recurrent punctal stenosis and 4 eyes demonstrated mild horizontal eyelid laxity. The long-term success rate of PPP implantation for the treatment of acquired punctal stenosis is satisfactory. Associated eyelid pathologies should be evaluated for their contribution to epiphora and be treated before PPP implantation.

Clinical Results of Different Surgical Procedures in Correcting Involutional Entropion

Purpose: To evaluate the long-term effectiveness of different surgical procedures according to horizontal eyelid laxity in correcting involutional entropion. Methods: This retrospective study reviewed 104 eyes of 79 patients with involutional lower eyelid entropion who underwent surgical repair. The 62 eyes with horizontal eyelid laxity were classified as group I. In 17 eyes of group I, we performed the lateral tarsal strip procedure alone (group Ia), while in 45 eyes of group I, we performed the lateral tarsal procedure and Quickert suture (group Ib). The 42 eyes without horizontal eyelid laxity were classified as group II. In 13 eyes of group II, we performed a lower eyelid retractor reinsertion procedure only (group IIa), and in 29 eyes of group II, we performed combined lower eyelid retractor reinsertion and orbicularis resection (group IIb). Results: The recurrence rate in these four surgical subsets (group Ia , group Ib, group IIa, group IIb) was 11.7%, 0%, 15.4%, and 6.9%, respectively, with an average follow-up of 11 months. Six recurrent eyelids and two overcorrected eyelids successfully underwent procedures to correct recurrent entropion and ectropion, respectively. Conclusions: The lateral tarsal strip procedure is an effective approach for achieving long-lasting correction of involutional entropion with horizontal eyelid laxity, whereas the lower eyelid retractor reinsertion procedure is an effective approach for achieving long-lasting correction for involutional entropion without horizontal eyelid laxity. Use of the Quickert suture reduced the need to repeat the lateral tarsal strip procedure and additional orbicularis resection decreased the need to repeat the lower eyelid retractor reinsertion procedure.

Ophthalmic Plastic Surgical Skills Assessment Tool

To present a structured tool to assess ophthalmic plastic surgical skill and to determine its face and content validity. A 1-page structured subjective evaluation form was developed to evaluate a resident's oculoplastic surgical skill while performing lateral tarsal strip surgery. The tool consisted of generic task components and global indices evaluated using a 5-point Likert scale. A survey was conducted among a panel of highly experienced oculoplastic surgeons to establish face and content validity of the tool. All feedback was considered and, if feasible, was used to amend the tool. There was more than 90% agreement among the highly experienced oculoplastic surgeons regarding the content and weighting of each assessment component. The final format of the tool is divided in 9 task-specific indices, based on the lateral tarsal strip procedure, and 9 global indices which, after assessment, appraisal, and amendment by our expert panel, demonstrates face and content validity. The Ophthalmic Plastic Surgical Skills Assessment Tool is a structured, quantitative instrument designed to aid in the oculoplastic surgical evaluation and training of residents.

Lateral Cantholysis for Cataract Surgery

A patient with narrow palpebral aperture who required an elaborate lateral cantholysis prior to uncomplicated phacoemulsification surgery is described. Surgery was followed by a lateral tarsal strip procedure to reattach the lower lid.