Lower Eyelid Laxity Research Articles

Clinical Importance of the Lateral Tarsal Strip Procedure by a Single Experienced Oculoplastic Surgeon: 8 Years of Experience in a Tertiary Medical Center (Cross-Sectional Study).

Lateral tarsal strip (LTS) is a simple surgical technique that can correct eyelid malposition. Clinical indications vary from involutional entropion and ectropion, lower eyelid laxity, and lower eyelid retraction to punctal and paralytic ectropion. Lateral tarsal strip mainly treats eyelid malposition by correcting horizontal laxity. Herein, the authors report the clinical indications for and effects of LTS. The authors retrospectively reviewed medical records of patients who underwent LTS by a single oculoplastic surgeon with 8 years of experience performing the procedure at Korea University Guro Hospital. The authors included 247 patients with 325 treated eyelids. Involutional entropion was the most common indication, accounting for 69 patients (27.94%) and 88 eyelids (27.08%). The second most common indication was lower eyelid laxity [n=44 patients (17.81%) and 68 eyelids (20.92%)]. Simultaneous surgery in addition to LTS was performed in 167 patients (67.6%) and 219 eyelids (67.4%); the most common was endoscopic dacryocystorhinostomy (DCR), which was performed in 50 patients (29.94%) and 80 eyelids (36.53%). Lateral tarsal strip can be performed alone or simultaneously with oculoplastic procedures for various indications. Overcorrection with fixation above the canthal angle is useful to reduce recurrence. This study aims to explain the clinical importance of the LTS procedure.

The changes in lower lid position & laxity post cataract surgery

To evaluate the changes relating to lower lid position and laxity after cataract surgery.This is prospective study evaluating the lower eyelid position of patients who underwent cataract surgery from June to September 2019. Data collected includes duration of the cataract surgery, the duration of the speculum remaining insitu. Also we included measurements relating to the distraction test, distance of the lower lacrimal punctum from the inner canthus, and margin reflex distance 2 (MRD2) were performed 1 day, 2 weeks & 3 months post surgery. The data was analysed in Microsoft Excel & SPSS software. The study sample comprised 109 cataract patients, all of whom were of South Indian ethnicity, 68 (62.3%) were female with a median age of 74 years, and 67 (61.4%) had surgery in their left eye. The distraction test before surgery was 6.5 ± 0.2 mm, with mild increase after 1 day (7.3 ± 0.3 mm), sustained after 14 days (7.5 ± 0.2 mm), and decreasing after 3 months (7.0 ± 0.5 mm) to a level similar to the initial values (P = 0.02). The lower (lacrimal) lid punctum distance from the inner canthus preoperatively was 6.5 ± 0.3 mm and 7.4 ± 0.2 on day 1 post operatively, 7.2 ± 0.3 two weeks post operatively, 7.0 ± 0.4 mm at 3 months postoperatively (P = 0.04) [Table 1]. The MRD2 preoperatively was 5.0 ± 0.1 mm, 5.4 ± 0.1 mm at 1 days postoperatively, 5.2 ± 0.2 mm at 2 weeks, and 5.4 ± 0.3 mm at 3 months after surgery (P = 0.02). : An increase in lower lid laxity was noted on distraction test & lacrimal lower punctum distance post cataract surgery. Although such a change is expected in the common cataract surgery age group, there seems to be a definite increment noted in the post surgery group.

Lateral Tarsoplasty for Managing Ectropion and Laxity of the Lower Eyelid.

The most challenging complication associated with lower blepharoplasty is ectropion, and the traditional lateral canthopexy or canthoplasty procedure may carry the risk of eyelid malposition or subsequent chemosis. We propose lateral tarsoplasty with a detailed description of the techniques to treat and even prevent ectropion by not involving the medial or lateral canthal ligament so as to avoid complications. Lower eyelid laxity was analyzed with the snap-back test and distraction test before surgery. Approximately 5 mm medial to the lateral canthus, lateral tarsoplasty is performed through a full-thickness pentagonal tarsal-conjunctival resection according to the "overlapping test" for an accurate measurement of the amount of the tarsus to be resected. Seventy-two eyelids that received either ectropion correction or prevention with lateral tarsoplasty over an 8-year period at a single institution were collected and analyzed for this retrospective review. Lateral tarsoplasty was performed in 39 patients with a mean age of 63.8 years. Thirteen patients with 20 eyelids presented for ectropion correction, in whom 5 to 10 mm of tarsus was resected, 6.0 mm in average. The other 26 patients with 52 eyelids presented for ectropion prevention, in whom 3 to 7 mm of tarsus was resected, 4.1 mm in average. Apart from temporary mild chemosis, all patients experienced highly satisfactory results without any ectropion or malposition of the involved lower eyelids after a follow-up of 8.1 months in average. For patients with moderate and severe laxity of lower eyelids, lateral tarsoplasty without involvement of the lateral canthal ligament proves to be an effective way to treat and prevent lower eyelid ectropion.

Modified procedure of anterior orbital exenteration enables eye socket reconstruction: A retrospective cohort study.

The conventional procedure of anterior orbital exenteration is unfavorable for eye socket reconstruction, whereas a modified procedure enables socket reconstruction and prosthesis fitting. Our study aims to compare the cosmetic outcomes between these 2 surgical techniques.We retrospectively recruited patients treated with modified or conventional exenteration during January 2015 to May 2021 in our hospital. The conventional approach was performed along with dermis-fat graft transplantation. The modified approach was conducted followed by eye socket reconstruction and eyelid blepharoplasty. The clinical data were collected and analyzed, including demographics, tumor characteristics, postoperative complications, tumor-related events, and cosmetic outcomes.Forty-nine patients were consecutively recruited in this study, including 22 cases of modified exenteration and 27 cases of conventional exenteration. Forty-four subjects (89.8%) were diagnosed with ocular surface malignancies (conjunctival melanoma and squamous cell carcinoma) and 5 subjects (10.2%) were diagnosed with extraocular stage of uveal melanoma. After follow-up for 31.8 ± 17.1 months, the 1-, 2-, 5-year overall survival rate was calculated as 100%, 79.2%, and 59.2% in the Modified group, and 94.2%, 73.8%, and 51.5% in the Conventional group. Comparison of the survival curves showed no significant differences. In the Modified group, all patients received orbital implant placement and eye socket reconstruction. The implant motility was satisfactory in 12 cases (54.5%) with movements in 3 to 4 directions. The eyelid function was acceptable in 17 cases (77.3%) with no entropion, ectropion or lower lid laxity. Ocular prosthesis was delivered in 17 cases (77.3%) with successful fitting in 11 cases (64.7%). The self-rated cosmetic score was statistically (t test, P < .0001) higher in the Modified group (6.7 ± 0.9) than the Conventional group (2.2 ± 0.4).The modified approach to anterior orbital exenteration enables eye socket reconstruction and cosmetic rehabilitation while still preserves the curable chance for the treatment of advanced periocular/intraocular malignancies.

Modified impression tray and iris positioning ocular prosthesis of post enucleation socket syndrome: case report

The cosmetic disfigurements which arise due to loss of orbital volume after enucleation of an eye include enophthalmus, superior sulcus deformity, upper eyelid ptosis, and lower eyelid laxity. The treatment can be either conservative or surgical. For patients who does not want to undergo further surgical procedures, the conservative treatment is simple, non-invasive, and appropriate. This case report describes modified impression tray and iris positioning technique of post enucleation socket syndrome to achieve aesthetics and function. A 65-year-old male patient reported to the Dental Hospital Universitas Sumatera Utara with the chief complaint of facial disfigurement due to loss of the right eye. Patient had enucleation 6 months ago and using conformer after surgery. The diagnosis was post enucleation socket syndrome. Clear acrylic sclera as a tray without handgrip will precisely records of the palpebre con- vexity and specified socket. The use of eyebrow ruler helps accurately determine the symmetrical iris position com- pared to only visually determining which is subjective with the possibility of interobserver errors. It was concluded that clear acrylic sclera as a tray and eyebrow ruler to determine the position of iris resulting in patient satisfaction due to aesthetics and function.

Incidence of Primary Punctal Stenosis in Adult Patients with Epiphora

Abstract Background Punctal stenosis is one of the etiologies of epiphora, which is caused by an anatomical narrowing or occlusion of the external opening of the lacrimal canaliculi. Punctal stenosis is graded according to punctal sizes examined under slit-lamp biomicroscopy into grade 0 (could not find papilla and punctum), grade 1: Papilla is covered by a membrane (exudative or true membrane), grade 2: Smaller than normal size but recognizable, grade 3: normal, grade 4: Small slit (&amp;lt;2 mm) and grade 5: Large slit (&amp;gt;2 mm). Objective To assess the incidence of punctal stenosis in adult patients with epiphora attending outpatient’s ophthalmology clinic at Ain Shams University Hospital during the months of January and February 2020. Patients and Methods This is an observational study, conducted at the Ophthalmology Outpatient Clinic, Ophthalmology Department, Ain Shams University, using non-probability (convenience) sample. It included all patients above 18 years old who presented to the Ophthalmology Outpatient Clinic during the months of January and February 2020 with tearing, proved to be epiphora on clinical examination. Results Thirty one patients, out of 1800 patients attending the Outpatient Ophthalmology Clinic during the study period had epiphora with incidence of 1.6 %. Incidence of punctal stenosis was reported to be 68.4%. Other reported causes of epiphora were: Canaliculitis (3.5%), chronic dacrocystitis (5.3%), lacrimal sac mucocele (1.8%) and lower lid laxity (21.1%). Punctal stenosis was more common in females (61.5%) with mean age 58.55 years ± 11.67 SD. Punctal stenosis usually presented as bilateral (93.3%). Regarding ocular history 41% of cases were on topical anti glaucoma treatments. Most patients were medically free (54%). Conclusion Incidence of epiphora was 1.6% out of patients attending ASU Ophthalmology Outpatient Clinic. Punctal stenosis incidence was reported to be 68.4%. Most of the cases were females, above 63 years, grade one was the most common, with significant association with the long term use of topical anti-glaucoma medications.

Lateral Canthal Sling Procedure for Meibomian Gland Dysfunction? Results of a Pilot Study

ABSTRACT Background: Involutional changes of lid structures often induce horizontal lid laxity; this can result in a reduction of Meibomian gland expression, potentially leading to symptoms of dry eye. The aim of this study was to evaluate the effect of tightening the lower eyelid via a lateral canthal sling (LCS) procedure on dry eye parameters. Methods: Patients with Meibomian Gland Dysfunction (MGD), lower lid laxity (positive Snap-back Test and positive Pinch Test) and no previous lid surgery were evaluated before and 3 months after LCS procedure for symptoms by OSDI. The fellow eye without surgery functioned as a control group. MGD parameters included lipid layer thickness (LLT), non-invasive breakup time (NIBUT), tear meniscus height, loss of Meibomian glands, lid margin parallel conjunctival folds (LIPCOFs), Schirmer’s test, the number of expressible Meibomian glands as well as quality of Meibum. Results: Fourteen patients (8 men and 6 women; 79.2 ± 4.0 years) were enrolled in this prospective clinical study. After 3 months, the OSDI showed a significant reduction (preop 42.9 ± 24.7; postop 23.8 ± 21.6; p = .002); NIBUT (5.5 ± 2.6 s to 9.9 ± 6.8 s p = .08) and LLT (64.3 ± 30.4 to 74.1 ± 27.8; p = .025) improved, while Schirmer Test (15.3 ± 4.7 mm to 11.9 ± 2.9 mm; p = .03) and tear meniscus height were reduced (0.8 ± 0.3 to 0.6 ± 0.2; p = .05). Meibomian gland loss scored by the meiboscale slightly increased postoperatively (1.2 ± 0.9 to 1.4 ± 0.9; p = .18). The number of expressible Meibomian glands improved (4.4 ± 2.6 to 6.8 ± 2.1, p = .002) as well as the quality of Meibum (0.9 ± 1.0 to 0.5 ± 0.8, p = .04). Snap back test as well the pinch test were negative in all patients postoperatively. Conclusion: Addressing lower lid laxity with an LCS procedure simultaneously enhances tear drainage, reduces tear film volume parameters and increases tear film stability results with an improvement of dry eye symptoms. It is likely that increased lower eyelid tension and thus excretory pressure on the Meibomian glands is responsible for these alterations.

Evaluation of efficacy and safety of Botulinum toxin injection in treatment of epiphora

Purpose The aim of this study was to evaluate the efficacy and safety of Botulinum toxin injection in the palpebral lobe of the lacrimal gland for treatment of epiphora.Patients and methods A total of 20 patients with epiphora (crocodile tears syndrome, lower lid laxity, malposition of the lower lid, and obstruction of lacrimal drainage system in which lacrimal surgery was impossible) received intralacrimal gland injection of Botulinum toxin (2.5 IU/0.1 ml). Follow-up was performed on the first day, first week, first month, third month, and sixth month after injection to evaluate the efficacy, safety, and occurrence of any complications and to record the rate of recurrence.Results Cure was successfully achieved in 60% of the patients after the first injection and in 90% of patients after the second injection. There were 15% of recurrent cases after the first injection, and there were no recurrent cases after the second injection. Temporary ptosis occurred in 10% of this study group after the first injection and in 5% after the second injection. There was a highly significant decrease in Schirmer’s test and tear meniscus height among the study group regarding the pre-injection and follow-up values (P<0.01). In addition, there was a highly significant decrease in Munk scale and time of dye disappearance test among the study group regarding the pre-injection and follow-up values (P<0.01).Conclusion The injection of Botulinum toxin in the palpebral lobe of the lacrimal gland was effective and safe as a temporary measure to reduce excessive tearing until a more permanent measure can be taken.

Prosthesis-socket volume imbalance and dermofat graft rehabilitation in patients with an anophthalmic socket.

To identify problems caused by prosthesis-socket volume imbalances in anophthalmic sockets; and to evaluate rehabilitation with dermofat graft as a solution. We retrospectively reviewed medical records of patients operated in our clinic (between May 2011 and June 2016) with dermofat grafts to treat anophthalmic socket-related problems. During the preoperative examinations, ophthalmologists recorded the presence of eyelid problems due to the socket volume deficit, upper and lower fornix deficiency, deepening in the upper eyelid sulcus, epiphora and secretion, lower eyelid laxity, ptosis, entropion, and ectropion. Following the surgical repair, new prosthesis suitable for the resulting socket area were implemented for all the patients. The mean follow-up period was 27.42±16 months (ranging from 10-62 months). On the last control examinations, ophthalmologists recorded solved and unsolved socket problems that were present preoperatively. We included 16 men and 5 women in this study. The mean age was 38.3 ± 18.4 years (range, 5-75 years). The mean duration of preoperative prosthesis use was 9.4 ± 6.8 years (range, 1-30 years). Preoperatively, 7 patients had only orbital volume deficits, and 14 had socket volume displacements in addition to the volume deficits. After the dermofat graft implantations, the remaining deficits were corrected during another surgical session: 6 patients underwent ptosis corrections, 5 lateral canthal suspensions, 5 lower fornix with mucosal graft formations, and 2 upper fornix formations with mucosal grafts. All patients were able to use prosthesis postoperatively. The use of dermofat grafts to correct anophthalmic socket problems caused by orbital volume deficits or volume displacements is an effective, reliable, and reproducible surgical method.

Lateral Tarsal Strip, Can It Be One Solution for All Types of Lower Eyelid Malposition?

Background: Due to the exact nature and complex anatomy of the eyelid, corrective surgeries require a comprehensive understanding of the anatomy as well as comprehensive preoperative planning and surgical enforcement. Aim of the study: the present study was performed to evaluate the functional and cosmetic sequels of the lateral tarsal strip (LTS) in the correction of lower eyelid malposition Patients and Methods: this prospective single-arm interventional study was carried on 27 patients (27 eyelids) with lower eyelid malposition, executed from January 2015 to December 2017. Patients with lower eyelid malposition in the form of entropion, ectropion, or laxity as a sequence of facial palsy, involutional changes, spastic entropion and lid laxity with failure of opposition to the artificial shell were included. Results: Patients were 12 males and 15 females with a mean age of 59.37±10.27 years. Out of them, 17 (62.9%), 8 (29.6%), and 2 (7.4%) were suffered from ectropion, entropion, and lower eyelid laxity, respectively. As for the functional and aesthetic outcomes, 10 (90.9%) of patients with lower eyelid malposition, as a resultant effect of facial nerve palsy, have experienced complete healing of the epithelial defects; additionally, 4 (66.6%) of involutional ectropion candidates showed improvement of the tearing eye. Eventually, 6 (22.2%) participants developed postoperative complications. Conclusion: LTS is a simple procedure which proved its safety and efficacy in the surgical correction of lower eyelid malposition of different types and etiologies

Estimation of Eyelid Pressure Using a Blepharo-Tensiometer in Patients with Functional Nasolacrimal Duct Obstruction.

Purpose To compare the eyelid pressure between patients with functional nasolacrimal duct obstruction (FNLDO) and normal controls using blepharo-tensiometer, and to evaluate the relationship between eyelid pressure and the outcomes of silicone intubation (SI) in patients with FNLDO. Study design Prospective case-control study. Methods We enrolled 36 eyes of 36 patients with suspected FNLDO who underwent SI and 36 healthy eyes of age-matched controls. One eye of each patient with FNLDO was randomly selected for analysis. The eyelid pressure was estimated using a blepharo-tensiometer and compared between the control and FNLDO groups. The relationship between eyelid pressure and clinical variables was analyzed. The outcomes of SI were assessed at 6 months after surgery using subjective and objective criteria. Results The eyelid pressure was significantly lower in the FNLDO group than in the control group (P=0.008). In the control group, the eyelid pressure was correlated with age (P<0.001) and lower eyelid laxity (P=0.016). In the FNLDO group, the eyelid pressure was only correlated with age (P<0.001). The success rate of SI for FNLDO was 69.4% (25 of 36 eyes). The eyelid pressure was higher in the surgical success subgroup than in the failure subgroup, although the difference was not statistically significant (P=0.08). Conclusions Our results suggest that the eyelid pressure measured using a blepharo-tensiometer has a diagnostic value since it is decreased in patients with FNLDO. The role of eyelid pressure as a possible predictor of the outcomes of SI for FNLDO should be investigated in further studies. This trial is registered with KCT0002828.

Periorbital Phenol-Croton Oil Chemical Peel in Conjunction with Blepharoplasty

INTRODUCTION: Blepharoplasty can restore a youthful appearance to the periorbital region; however, surgery alone is often unable to address the issue of periorbital fine lines and hyperpigmentation. The literature is replete with publications regarding the efficacy of phenol-croton oil peel, yet, there is little specifically addressing peels of the periorbita. We present a series of patients who underwent a peel combined with blepharoplasty, or peel alone, in order to improve fine lines and/or hyperpigmentation. The authors describe their surgical methods and complications with this technique and how it fits into the plastic surgeon’s armamentarium for periorbital rejuvenation. METHODS: A retrospective chart review was done to identify patients who underwent periorbital phenol-croton oil peels performed by a single surgeon (J.E.Z) from 2003-2014. Treatment sequences included: 1) peel alone to treat hyperpigmentation, 2) peel alone to treat fine lines, 3) peel at the time of transconjunctival or pinch blepharoplasty, or 4) peel secondarily after cutaneous blepharoplasty. A standard concentration of 27.5% phenol and 0.105% croton oil was used for all peels. Patient age, Fitzpatrick type, history of prior facial surgery, blepharoplasty type, and ancillary procedures were obtained. Data was managed with RedCap database. RESULTS: We identified eighty-two patients (81 females, 1 male) who underwent a blepharoplasty and phenol-croton oil peel, or a peel alone. Average age was 58.66 ± 8.05 years. Indications for peel were periorbital hyperpigmentation (n=26) and/or fine rhytids (n=63). Fitzpatrick skin type was: I (n=30), II (n=36), and III (n=16). Twenty-five (30.4%) of these patients underwent a periorbital phenol-croton oil peel combined with a blepharoplasty. Blepharoplasty techniques included: upper lid blepharoplasty (n=20), lower lid pinch blepharoplasty (n=8), and/or transconjunctival lower lid blepharoplasty (n=6). Complications of peeling were few and included: residual hyperpigmentation (n=4), prolonged erythema (n=4), and telangectasias (n=2). Twelve patients (14.6%) underwent a second peel for residual rhytids. A typical result is demonstrated in Figure 1.Figure 1: Pre-operative photos of 54 year old female who underwent upper and lower lid blepharoplasty followed by periorbital phenol-croton oil peel.Figure 2: Post-operative photos of 54 year old female one month after phenol-croton oil peel and twelve months after bilateral upper and lower lid blepharoplasty.CONCLUSION: Judicious use of dilute concentrations of phenol-croton oil in the periorbital region can be successfully performed with minimal to no complications. It can be applied as a stand-alone procedure, or as a complement to blepharoplasty surgery. When these techniques are combined there is significant improvement in upper and lower lid laxity, hyperpigmentation, and reduction of fine rhytids. It is a cost effective treatment with long-lasting results.

Lower Lid Laxity is Negatively Correlated with Improvement of the Ocular Surface Disease Index in Dry Eye Treatment

ABSTRACTPurpose: To compare the responses to dry eye treatment of patients sorted by the degree of lower lid laxity.Methods: Sixty patients were grouped into three groups according to the degree of lower lid laxity. Tear break-up time (TBUT), Schirmer test (ST) scores, ocular surface disease index (OSDI) scores, and changes in OSDI score in each group were compared, before and at 3 months after treatment.Results: TBUT, ST, and OSDI scores were not different among the three groups at baseline. TBUT improved in each group at 3 months after treatment, and no differences between groups were found. ST scores were not increased after treatment, while OSDI were improved to 22.57 ± 5.243, 31.16 ± 11.353, and 37.85 ± 13.342 in the no, moderate, and high laxity groups, respectively; these improvements were statistically significant (p = 0.003, <0.001, <0.001, respectively). Patients with greater than moderate lower lid laxity saw the smallest improvement in response to dry eye treatment, as assessed by change in OSDI score (p = 0.005 versus moderate laxity group, p = 0.005 versus no laxity group).Conclusions: Lower lid laxity is one of the factors contributing to the responses to dry eye treatment assessed by change in OSDI score, independent of TBUT and ST scores.

Prevalence, risk factors, and morbidity of eye lid laxity in a veteran population.

The aim of this study was to study prevalence, risk factors, and morbidity of eyelid laxity in a veteran population. This prospective cross-sectional study with a retrospective chart review included 150 subjects evaluated from either an outpatient eye clinic or a geriatric clinic at the Miami Veterans Affairs Hospital from June through August 2013. Clinical data were gathered from a questionnaire and a computerized medical record system including demographics, medical history, and ocular irritation history. Upper and lower eyelid laxity was clinically graded. Main outcome measures were prevalence of eyelid laxity, risk factors for its presence, and its correlation to ocular surface symptoms. Fifty-four percent of participants (n = 81) had laxity (grade 1 or higher) in either upper and/or lower eyelids. Risk factors for eyelid laxity in our population included older age, higher body mass index, and a diagnosis of sleep apnea. Patients with any eyelid laxity (grade 1 or more in any eyelid) had a 2.23-fold risk of severe ocular surface symptoms (score of 12 or higher on the dry eye questionnaire 5) compared with those without laxity (95% confidence interval, 1.15-4.31; P = 0.017), and this was primarily driven by the presence of upper eyelid laxity. We found high prevalence of eyelid laxity in our population, and its presence was associated with significant ocular surface morbidity. This study reinforces the need to incorporate dynamic eyelid testing into ophthalmic examination in patients with ocular surface discomfort.

New Insights Into Physical Findings Associated With Postblepharoplasty Lower Eyelid Retraction

Postblepharoplasty lower eyelid retraction (PBLER) has been linked to anterior lamellar shortage, unaddressed eyelid laxity, and middle lamellar scarring. The authors believe there are other, less-appreciated physical findings (orbicularis weakness, negative-vector eyelid, and inferior eyelid/orbit volume deficit) that also influence the development and potentially the management of this complex type of eyelid malposition. To better understand PBLER, potentially prevent its development, and improve treatment options, the authors determined the incidence of various physical findings present on initial examination of patients referred for PBLER revision. The medical charts of patients referred for PBLER revision over a 21-month period were reviewed. The presence of anterior lamellar shortage, lower eyelid laxity, and a middle lamellar (internal eyelid) scar was documented. Orbicularis weakness, negative-vector eyelid topography, and volume deficiency of the lower eyelid/inferior orbit also were noted. The incidence of each finding was calculated. Forty-six patients (35 women, 11 men) were included. All patients had undergone primary transcutaneous surgery, which led to the eyelid retraction. Orbicularis weakness, anterior lamellar shortage, inferior eyelid/orbital volume deficit, negative-vector eyelid topography, and eyelid laxity were common. A middle lamellar scar of significance was found in only 17% of eyelids. The data suggest that the aforementioned underappreciated findings are common in patients with PBLER. Evaluating these factors when planning primary blepharoplasty may reduce the incidence of PBLER. Awareness of these findings when planning revisional procedures may improve surgical outcomes. 4.

Anophthalmic syndrome: a review of management.

To review and summarize current management of anophthalmic syndrome-enophthalmos, superior sulcus syndrome, lower eyelid laxity, and upper eyelid ptosis. The authors performed a PubMed search of all articles published in English on the management of anophthalmic socket syndrome. A review of 37 articles demonstrated that anophthalmic syndrome occurs in a significant proportion of this patient population. Primary prevention through careful selection of primary orbital implant is ideal. Residual mild deficits can then be corrected through prosthesis modification. When modification of the prosthesis is no longer sufficient, specifically targeted procedures become necessary. Ocularists and oculoplastic surgeons should work together closely to treat anophthalmic syndrome. Future studies should establish uniform measurement criteria as the next step in validating the benefit and limitation of each technique.

Commentary on: New insights into physical findings associated with postblepharoplasty lower eyelid retraction.

An analysis of the clinical findings in patients referred to a single surgeon with the problem of lower lid retraction following blepharoplasty is welcomed information. The reported series includes 46 patients over almost a 2-year recent period and should be of keen interest to surgeons who perform lower lid blepharoplasty.1 The series reported includes almost 2 patients per month, which is a good sampling of patients with this problem. Commonly recognized problems were present in the series: skin shortage (79%), unaddressed lower lid laxity (62%), and middle lamellae scarring (17%), as well as some not so commonly recognized. A preexisting negative vector (in many cases unrecognized global globe prominence) (65%) is a known pitfall when performing lower lid blepharoplasty. Not so common factors recognized by the author were inferior orbit/lower lid volume deficits (70%) and orbicularis weakness (87%). As indicated in the article, as from my own personal experience, many of these occur in combination, which makes surgical efforts at repair a difficult situation. The author includes descriptions of his methods of quantitation or certification of each problem, which is a worthwhile checklist for any surgeon facing restoration of these patients. They include the following:

The Looi Suture Technique for Anchoring the Lateral Tarsal Strip to the Lateral Orbital Wall

The lateral tarsal strip procedure (LTS) was first reported by Anderson and Gordy in 1979 for the management of paralytic or senile eyelid laxity. Since its description, the LTS procedure has been subject to several modifications by various authors. In this study, we described the Looi suture technique, a small modification in the technique of suturing the LTS to the lateral orbital wall periosteum. Using this technique, the surgeon achieves a larger area of contact between the anterior surface of the tarsal strip and the lateral orbital wall periosteum, promoting a stronger adhesion. With a double-armed suture, the technique also allows for adjustment of the lower lid tension to avoid over- or under-correction of horizontal lid laxity. This study aimed to evaluate the technique. This was a retrospective non-comparative case series of 39 eyelids of 31 patients who underwent LTS with Looi suturing technique for the correction of involutional lower lid laxity which had resulted in either entropion or ectropion. In this procedure, a novel technique utilising a double armed 5/0 Ethibond suture is used to secure the LTS to the lateral orbital rim, with the aim of increasing appositional contact between the LTS and periosteum. In 36 eyelids with entropion, the procedure was combined with lower lid retractor repair, and in 3 eyelids with ectropion, with medial tarsoconjunctivoplasty. Surgery was successful in 37 of 39 eyelids (94.87%) after one procedure. The remaining 2 eyelids required repeat procedures to achieve anatomical success. Both cases had been performed by trainee surgeons under supervision. Postoperative follow-up period ranged from 1 day (in a visiting overseas patient) to 2 years. This study described the Looi suturing technique in performing the LTS procedure and we found it a simple and effective modification when dealing with lower lid laxity.

Long-term surgical outcomes of Quickert sutures for involutional lower eyelid entropion

ObjectivesTo determine the long-term surgical outcomes associated with the use of Quickert sutures (Q-sutures) for involutional entropion and elucidate the risk factors for postoperative recurrences. MethodsThis is a retrospective, interventional case series. We recruited patients suffering from involutional entropion who were treated with Q-sutures during the period from January 2008 to August 2010. Preoperative clinical characteristics and surgical outcomes including recurrence at 1, 6, 12, and 24 months were investigated by reviewing the medical charts. ResultsOf 85 patients, 69 attended each follow-up visit and were included in the analysis. Thirty-four patients (49.3%) experienced recurrences within 2 years. The recurrence rate was 5 of 69 (7.2%) at 1 month, 15 of 64 (21.6%) at 6 months, 9 of 49 (13%) at 12 months, and 5 of 40 (7.2%) at 2 years. Multiple logistic regression analysis showed that men and patients with lower-lid laxity (OR = 2.852 [95% CI: 1.005–8.092] and OR = 3.780 [95% CI: 1.231–11.614], respectively) were susceptible to postoperative recurrences. ConclusionsThe recurrence rate among patients treated with Q-sutures was highest at the 6-month follow-up visit. Alternative surgical options should be considered in males and those with lower-lid laxity in order to prevent recurrences.

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.