Medial Canthal Tendon Plication Research Articles

CADS as a Decision-making Tool: Developing an Oculoplastic Management Algorithm for Facial Nerve Palsy.

The Cornea, Asymmetry, Dynamic, Synkinesis (CADS) score is a validated grading score for periocular involvement in facial nerve palsy (FNP). We conducted a retrospective review of FNP cases, including initial CADS scores and subsequent ophthalmic interventions. The results were used to inform the development of an oculoplastic management algorithm for FNP. Single-center retrospective cohort study of patients with FNP referred to a tertiary unit between 2016 and 2022. Data collected included demographic data, etiology of FNP, treatment initiated, and CADS grading at each visit. Adult patients with ≥6 months of follow-up were included, and cases were excluded if ocular surface or oculoplastic procedures were performed elsewhere prior to the initial review by the unit. Of 408 consecutive new patients with FNP, 80 fulfilled inclusion criteria (mean age 57 years, range 21-83 years). Presentations of FNP were unilateral in 98.8% (79/80), with an underlying preganglionic etiology in 75.0% (60/80). At the initial review, surgery was recommended for 61.3% (49/80) of cases. Subgroup analysis of surgical cases for each CADS domain showed 46.9% (23/49) had C-score ≥2, which was predictive of upper lid surgery requirement (e.g., upper lid platinum segment chain; levator recession). About 63.2% (31/49) had an A-score ≥1 which predicted for lower lid surgery requirement (e.g., retractor recession, lower lid sling, medial canthal tendon plication, and lower lid full thickness skin graft) as well as a brow lift. Almost 79.6% (39/49) had a D-score ≥2, which was associated with both upper lid and lower lid surgery requirements. Also, 59.2% (29/49) had an S-score of ≥1 however, this was not associated with the surgical requirement, highlighting a different approach compared with the other CADS domains. This study represents a large cohort of patients followed up with a validated ophthalmic-specific FNP grading scale. This was utilized to develop a CADS-based management algorithm to help guide decision-making for surgical intervention versus medical management in FNP.

Prise en charge du syndrome de blépharophimosis ptôsis épicanthus inversus (SBPE) dans un centre de référence en Tunisie

Blepharophimosis ptosis epicanthus inversus syndrome (BPES) is a rare congenital hereditary abnormality. It includes complex orbital-palpebral malformations, causing aesthetic and functional ramifications. Management of BPES requires two steps: diagnosis and treatment. We performed a retrospective descriptive study of 44 patients (88 eyelids) with blepharophimosis-ptosis-epicanthus inversus syndrome (BPES). In our series, we opted for two-stage surgery in 28 cases: epicanthus-telecanthus surgery followed by ptosis surgery. Simultaneous surgery was performed in 5 cases. The mean age at the first visit was 6 years (6.1±6.4). The mean age of our patients at the time of the first surgery was 6.6 years. Epicanthus surgery was performed in 35 cases. The two techniques used to correct epicanthus were Y-V plasty in 30 cases (85.7%, n=35) and Y-V+double Z plasty in 5 cases (14.3%, n=35). Correction of the telecanthus was performed at the same time by a medial canthal tendon plication in 31 cases (88.6%, n=35) or transnasal canthopexy in 4 cases (11.4%, n=35). The mean age at the time of ptosis surgery was 7.23 years (±6.25), ranging from 8 months to 27 years. Ptosis surgery was performed in 41 cases (79 eyelids), of which 3 patients underwent unilateral ptosis surgery due to asymmetrical ptosis. The techniques used were levator resection in 64 eyelids and frontal suspension in 15 eyelids. BPES is often clinically diagnosed. The difficulty in management lies in the complex surgery required. There is no established consensus regarding surgical techniques or the timing of the surgeries.

Clinical efficacy of improved method of inverted L-shaped incision combined with medial canthal tendon plication for moderate and severe epicanthus correction

Objective To explore the clinical effect of inverted L-shaped incision combined with medial canthal tendon plication for moderate and severe epicanthus correction. Methods Improved method of inverted L-shaped incision combined with medial canthal tendon plication were performed in 42 cases of moderate and severe epicanthus. The epicanthus covered more than 50% lacrimal caruncle with single-fold eyelids or unconspicuous double-fold eyelids. Among them, 40 cases received double-eyelid plasty simultaneously. Results The follow-up time of 38 cases ranged from 6 to 24 months. 37 cases received double-eyelid plasty simultaneously. All the patients obtained satisfactory results aesthetically, the contours of two eyelid fissures and the double-eyelid radian looked more natural postoperatively. There was no reoccurrence of epicanthus. Mild scar proliferation was observed in all of the patients in the early 1-2 months of postoperative period and then would fade within three months. Conclusions It is effective to correct epicanthus by improved method of inverted L-shaped incision combined with medial canthal tendon placation. Key words: Medial epicanthus; Double eyelid plasty

Outcome of Y to V Medial Canthoplasty With Medial Canthal Tendon Plication for the Correction of Blepharophimosis- Ptosis-Epicanthus Inversus Syndrome

AIM: Evaluation of the results of Y to V medial canthoplasty with medial canthal tendon (MCT) plication for the correction of blepharophimosis syndrome. MATERIALS AND METHODS: Prospective interventional case series which included 15 cases of blepahrophimosis syndrome. Two stages management was used in all cases. The first stage was Y to V medial canthoplasty with MCT plication. 3 months later, ptosis was corrected by bilateral frontalis suspension or maximum levator resection in the more ptotic eyelid in patients with asymmetric ptosis. Data regarding margin reflex distance 1 (MRD1), horizontal palpebral fissure length (HPFL), inner intercanthal distance (IICD), and the ratio of IICD to HPFL were recorded before and after surgery and were statistically analyzed. RESULTS: The mean age of patients was 3.7±0.8 years. According to the postoperative IICD/HPFL, 12 patients (80%) had successful outcome. The preoperative IICD had a mean of 37.6±1.5 mm, which was reduced post operative to a mean of 33.0±2.3 mm. The HPFL improved from preoperative mean 21±1.2 mm to postoperative mean 24.2±1.4 mm. The mean preoperative IICD/HPFL ratio was 1.8±0.2 which was reduced post operative to a mean of 1.37±0.2. The MRD1 improved from preoperative mean of 1±0.4 mm to 3.6±0.3 mm post operative. The main complication recorded was undercorrection which was observed in 3 patients (20%). CONCLUSION: The two stage management using simple procedures as Y to V medial canthoplasty with MCT plication followed by frontalis suspension or maximum levator resection yielded satisfactory results in the correction of complicated deformity as the blepharophimosis syndrome.

Transcaruncular Medial Canthal Tendon Plication with Lower Eyelid Suture Sling in Facial Nerve Palsy

Purpose: To report a technique for correcting lower eyelid punctal ectropion with an inferiorly displaced or retracted medial eyelid due to facial nerve palsy, by extending a suture sling along the pre-tarsal lower eyelid when performing transcaruncular medial canthal tendon plication.Methods: Single-centre retrospective, non-comparative review of patients with facial nerve palsy who underwent medial canthal tendon plication with lower eyelid suture sling (MCT suture sling). Outcome measures included: the presence of lower eyelid ectropion, medial eyelid height, punctal position, inferior marginal reflex distance (MRD) and inferior scleral show measured both pre-operatively and at the last follow-up visit.Results: Thirty-three patients with facial nerve palsy with a mean age of 59, underwent MCT suture sling for lagophthalmos and/or ectropion. Then, 66% (21/32) of cases had punctal ectropion pre-operatively and 9% (3/32) had punctal ectropion at the last follow-up. Medial eyelid height was deemed to improve in 66% (21/32) of cases at the last follow up visit. Follow-up was mean 13.5 months. Six (18%) patients were deemed failures due to inferior MRD and inferior scleral showing worse than pre-operative measurements.Discussion: We report a technique for incorporating a suture sling to transcaruncular-approach MCT plication when the medial canthus has retracted or descended thus requiring support and a posterior vector. It avoids rounding of the medial canthal angle that may occur with traditional medial canthoplasty. Transcaruncular MCT plication is well described. Incorporating a suture sling to potentially reduce single point-fixation cheese-wiring and early dehiscence is minimally invasive, non-excisional and repeatable.

Appraisal of a modified medial canthal plication for treating laxity of the medial lower eyelid

The purpose of this study was to evaluate the efficacy of modified medial canthal tendon plication technique for correcting laxity of the medial end of the lower eyelid. Eleven patients (9 males and 2 females, 21 eyes), with an age range of 31-80 years, having laxity of the medial end of the lower lid of varying degrees were enrolled in this study. These patients presented with complaints of watering, recurrent redness, photophobia and foreign body sensation. After grading the amount of lower lid laxity, plication was performed. In patients in whom laxity was associated with ectropion, the severity of lower lid ectropion was also graded. In patients with ectropion of Grade II or more, additional procedures for its correction were performed before undertaking plication. The patients were followed up 6 months post-operatively and re-assessed for laxity, recurrence of symptoms and complications of plication. All the lids were evaluated for the amount and extent of laxity of lower lid. Twelve (57%) eyes had Grade I, 9 (43%) had Grade II (and none Grade III) laxity of the lower lid. Twelve eyes had laxity restricted to the medial end and 9 eyes had laxity of the entire length of the lower lid. Some eyes also had an associated ectropion. Among the 21 eyes, 4 eyes (22%) had Grade 1, 11 (61%) had Grade 2, 6 (17%) Grade 3 and none Grade 4 ectropion. In the lids with associated ectropion, additional procedures had been performed. In 1 eye, the medial canthus was anchored to the tendon and this patient had poor apposition of the lower lid to the globe. Hence, in the remaining 20 eyes, the medial canthus was anchored to the orbital periosteum. The mean change in eyelid length was 2.6 mm (measured from medial to lateral canthus) from pre-operative status (33+/-3.4 mm) to the post-operative status (30+/-2.9 mm) this being statistically significant. An overriding of the lower lid was seen in 2 eyes (10%), and a residual gap between the lower lid and globe was noticed in 15 (71%) eyes. Some eyes had uncorrected symptoms including epiphora (3 eyes; 14%), redness (2 eyes; 10%), and photophobia (1 eye; 5%). All were those in which the lateral end was lax. None had a recurrence of foreign body sensation. Plication is easy, effective and quick for correcting laxity of the lower lid when restricted predominantly to the medial end. Correct identification of anatomical landmarks and appropriate tension of sutures is vital to achieve proper apposition of the lower lid to the globe.

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

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

Reconstructive and Plastic Surgery of the Eyelids

This book is intended as a guideline for established ophthalmologists and residents interested in ophthalmic plastic and reconstructive surgery of the eyelids. As such it is compromised by its length. In the book's 98 pages, 14 major areas of oculoplastic surgery are briefly considered. Inadequate technical detail is presented to prevent the pitfalls of these procedures. Little discussion regarding indications for various procedures and their postoperative management is given. I was disappointed that this collection of modern principles and techniques of eyelid restoration omitted what I regard as the most important recent advances in this field: (1) levator aponeurosis repairs for ptosis, (2) scleral grafting for lid retraction, (3) medial canthal tendon plication for ectropion, and (4) cryosurgery for trichiasis. This book suffers from the common plight of most other oculoplastic surgical texts. The numerous problems, principles, and procedures involved in this type of surgery cannot be encompassed in