Medial Ectropion Research Articles

Posterior medial canthal thermoplasty in facial palsy: A simplified technique

Abstract Purpose: The purpose of this study was to describe a new, simple, quick, reproducible, and minimally invasive surgical technique for medial canthal tendon (MCT) dehiscence and deformity in patients with facial palsy. Methods: A retrospective study of 10 patients having medial ectropion and MCT laxity in patients with facial palsy was included in the study. All patients underwent the simplified technique of posterior medial canthal thermoplasty and anchorage with 6/0 Vicryl. Ancillary procedures such as lateral tarsal strip, lower lid spacer, suborbicularis oculi fat lift, upper lid blepharotomy, and mullerectomy were also performed where warranted as a holistic treatment approach. Results: The study cohort included 10 patients. All patients had satisfactory outcomes concerning medial canthus position and lid-to-globe apposition. 9/10 patients had satisfactory punctum alignment. Conclusions: This technique is a safe alternate and reproducible procedure compared to the conventional open technique of anchoring the lid to the posterior lacrimal crest which is a challenging procedure even in experienced hands.

Mohs Surgery for Periocular Basal Cell Carcinoma Without a Mohs Surgeon: The First Series in Hong Kong.

Prospective non-comparative interventional case series. 20 consecutive Chinese patients (10 male, age 78.5+10.4 years, range 55-91 years) with primary periocular basal cell carcinoma (pBCC) referred to the university oculoplastic unit between October 2007 and August 2013. MMS were conducted according to a streamlined standard operating procedure emphasizing surgeon-driven mapping, specimen orientation, and on-site clinico-histological correlation with the dermatopathologist at the frozen-section laboratory. Clinical and histological characteristics of tumors, layers of Mohs procedures, complications, and biopsy-confirmed recurrence at the same location. Results All 20 patients received MMS as planned. Sixteen pBCCs (80%) were diffusely pigmented, and three (15%) were focally pigmented. Sixteen were also nodular. The average tumor diameter was 7+3 (3-15) mm.Seven (35%) were within 2 mm of the punctum. Histologically, 11 (55%) were nodules, and four (20%) were superficial. An average of 1.8+0.8 Mohs levels were performed. Apart from the initial two patients, who required four and three levels, respectively, seven (35%) patients were cleared after the first level of MMS using a 1mm clinical margin. The remaining 11 patients required two levels with an additional 1-2mm margin, but only focally as guided histologically.Defects in 16 patients (80%)were reconstructed by local flaps, two by direct closure, and two with pentagon closure. Among the seven patients with pericanalicular BCC, three patients had their remaining canaliculi successfully intubated, while two developed stenotic upper and two lower punctae postoperatively. One patient had prolonged wound healing. Three patients had lid margin notching, two had medial ectropion, one had medial canthal rounding, and two had lateral canthal dystopia.No recurrence was detected at a mean follow-up of 80+23 months (43 to 113 months) in all patients. Conclusions MMS was successfully introduced in Hong Kong without a Mohs surgeon. Providing complete microscopic margin control and preserving tissues, it was proven to be a valuable treatment option for pBCC.Our multidisciplinary protocol demonstrated that these merits are possible and warrant validation in other resource-limited healthcare settings.

The 'Invisible Lazy-T' Procedure for Correction of Medial Ectropion.

No accepted standard for the correction of medial ectropion has been established. The most critical part of the surgical treatment for medial ectropion is the tightening of both horizontal and vertical laxity. To correct this ectropion, we have applied a combination procedure which includes tightening of the conjunctiva and the eyelid retractors (posterior lamellae) and the lateral tarsal strip procedure. Our imitation of the 'Lazy-T', a surgical operation performed on the medial ectropion, is tentatively named 'Invisible Lazy-T'. It is a versatile technique with a less visible scar than alternative techniques because skin incision is made along the crease line of the 'the crow's feet'. Results suggest a satisfactory solution to this problem and with better outcomes than by other techniques. We propose this novel combination technique is the best strategy for the medial ectropion, and it does not require specialized surgical skill, so ectropion can be managed by craniofacial surgeons.

Correction of severe medial ectropion using a novel osseous fixation technique

ABSTRACT Purpose To study the feasibility of osseous medial canthal fixation for severe medial ectropion. Methods Retrospective analysis over a period of 3 years identified 10 patients who had undergone the modified medial canthoplasty. Outcome measures were based on the presence of complications and cosmetic/functional results. Results Post-operative evaluations of all patients were significant for excellent functionality and cosmetic results in the medial canthal area following the novel osseous fixation technique. No complications were reported intra-operatively or post-operatively. Conclusions For repair of severe medial ectropion, especially cicatricial and paralytic ectropion, the modified medial “puncture hole” canthoplasty is an effective alternative to traditional repair techniques and does not necessitate the use of anchoring systems such as wiring or microplates.

Lateral Tarsal Strip – A Method of Choice for Management in Variety of Lower Lid Malposition

Purpose: To determine the effectiveness of lateral tarsal strip procedure (LTS) in treating different types of lid malposition. Study Design: Interventional case series. Place and Duration of Study: Sindh Institute of Ophthalmology and visual sciences from January 2019 to December 2019. Method: There were 49 eyelids on which LTS procedure was performed. A complete ophthalmic examination was done and patients were assessed for horizontal lid laxity by pinch test. Patients with severe and moderate to severe medial canthal laxity were excluded. Patients with medial ectropion and minimal medial canthal laxity were included in the study where LTS was combined with medial spindle. Results: Twenty three patients had involutional ectropion. Spindle procedure was performed in addition to LTS in 3 of these 23 patients. Six patients had involutional entropion. One patient had recurrent ectropion and LTS was combined with everting sutures in 3 of them. Five patients had facial palsy and two of them had combined spindle procedure. One patient had traumatic avulsion of lateral canthal tendon which was not repaired primarily. Two patients had previous cantholysis. In one patient LTS was performed to support the prosthesis in a previously eviscerated eye. All the patients underwent LTS with variation in length of lateral tarsal strip which was adjusted to horizontal lid laxity and presumed post-operative position of lower lids in relation to lower limbus and canthal angle. Conclusion: .Lateral tarsal strip is a simple and effective procedure for correction of different types of lower lid laxity and malposition. Key Words: Lateral tarsal strip, lid malposition, horizontal lid laxity.

Augmented fascia temporalis sling for paralytic ectropion of the lower lid.

To report the effect of lower eyelid temporalis fascia sling combined with lateral canthoplasty and tarsorrhaphy for paralytic ectropion. Prospective case series of 10 patients with lower lid paralytic ectropion who were treated with lower eyelid fascia temporalis sling and lateral canthoplasty in addition to lateral tarsorrhaphy as a single-session procedure. Additional medial tarsorrhaphy was applied if the medial lower lid apposition was not adequate at the end of the procedures. Eyelid configuration and function were compared before and after surgery. The mean age of patients was 65.8 ± 10 years. Mean marginal reflex distance 1 (MRD1) and MRD2 changed from 3.5 ± 1.4 and 8.6 ± 2.4 mm to 2.2 ± 1.4 and 5.3 ± 1.2 mm respectively (p = 0.001 and 0.006). Mean pre-operative lagophthalmos improved from 9.2 ± 4.9 to 3.4 ± 1.3 mm (p = 0.001). The mean follow-up was 28.9 ± 12.1 months. Three patients required additional medial tarsorrhaphy to address residual medial ectropion in the same session. Combination of lower lid fascia temporalis sling, lateral canthoplasty and tarsorrhaphy as a single-session procedure can effectively improve the functional and aesthetic complications of paralytic ectropion.

A New Surgical Method for Medial Ectropion Repair: Fixing the Lower Eyelid Retractor to the Back of the Tarsal Plate.

Involutional ectropion is a disease in which the eyelids are everted outwards, and because the eyelids move away from the eyeballs, the ocular surface and conjunctiva are exposed causing inflammation, pain, photophobia, foreign body sensation, epiphora, and blurred vision. It is thought to be caused by horizontal and vertical laxity. Various surgical methods have reportedly been used to correct involutional ectropion. Shortening the lower eyelid retractor (LER) is an indispensable surgical operation for medial ectropion. When the LER is shortened, it is usually fixed to the lower edge of the tarsal plate. Herein we describe a new type of surgery that has now been performed on 6 eyes in 4 patients. The procedure involves separating the conjunctiva from the tarsal plate, inserting the LER between the conjunctiva and the tarsal plate, and then fixing it to the back of the tarsal plate. In all 6 eyes, the lower eyelid now contacts the eyeball, and morphological improvements were achieved. This new surgical method is a useful way to raise the tarsal plate.

Lower eyelid transconjunctival blepharoplasty with fat repositioning: outcomes and complications

The lower eyelid changes with aging include atrophy of the orbital septum with subsequent forward herniation of orbital fat, descent of the sub-orbicularis oculi muscle fat, ptosis of the orbicularis oculi muscle, weakening of the orbito-malar ligament and the development of laxity of the eyelid skin, the tarsus and the canthal tendons. In this article we aim at describing our experience of using a modified lower lid blepharoplasty with fat repositioning in patients with lower lid fat prolapse and tear trough deformity. A retrospective, non-randomised non-comparative interventional consecutive case series of patients seeking surgical treatment. Patients underwent surgery between April 2010 and October 2019 by a single surgeon (BL). Patient demographics, clinical examination, preoperative and postoperative clinical photography, outcomes and complications were recorded. Follow-up was initially at 2 weeks and finally at 16–20 weeks. Outcomes were recorded as subjective improvement and degree of patient satisfaction. A total of 150 patients were recruited in the study period. The mean age at the time of surgery was 49. One hundred forty-one (94%) patients were very satisfied with the final outcome of their surgery, 5 were satisfied and 4 were dissatisfied. One patient developed a bilateral lower lid infection requiring abscess drainage. Seventeen other patients experienced minor complications in the postoperative period, including 2 with a unilateral lower lid infection requiring oral antibiotics, 3 with a temporary inferior oblique palsy, 1 with temporary unilateral infraorbital nerve dysfunction, 3 with residual prolapses of the lateral fat pads, 1 with a medial lower lid lump, 2 with a conjunctival granuloma, 2 with a temporary medial ectropion, 1 with persistent unilateral lower lid oedema, 1 with persistent bilateral lower lid oedema and 1 with unilateral lower lid retraction. We report a high patient satisfaction with a low rate of significant complications following our modified lower lid transconjunctival blepharoplasty with fat repositioning. Level of evidence: Level III, therapeutic study

Cicatricial ectropion surgery: a prospective study of long‐term symptom control, patient satisfaction and anatomical success

Cicatricial ectropion repair is effective and has a low complication rate. To evaluate the effectiveness and long-term functional outcomes of surgical repair of lower lid cicatricial ectropion. Prospective consecutive case series. Forty-four consecutive operations for cicatricial ectropion repair. Consecutive cases of cicatricial ectropion repair completed during 2007-2011 in Waikato Hospital and Hamilton Eye Clinic, New Zealand, were enrolled in the study following formal ethics approval. Ectropion repair was completed using inferior retractor repositioning, horizontal lid tightening and full-thickness skin grafting. Patient-reported symptoms and satisfaction, ectropion recurrence and punctal ectropion. Forty-four eyes of 40 patients (30 males and 10 female) were included in the study. The average age at surgery was 75 years. Watering and poor appearance were the most common presenting symptoms. Postoperative follow-up was 1-6 years (mean = 4 years). There were no major perioperative complications, one patient developed trichiasis postoperatively. There were five reoperations (11%) during the study period. Two patients underwent medial spindle procedures for symptomatic medial ectropion and three patients required additional horizontal lid tightening. Seventy percent of patients reported satisfaction with their long-term results despite the partial recurrence of symptoms in 45%. Ectropion recurrence in <1 year occurred in three patients. In this series, satisfactory appearance and symptom control were reported by 68% of patients at long-term follow-up. Preoperative marked ectropion with marked lid laxity is associated with early treatment failure and may be regarded as a relative contraindication to surgical correction with this technique. Punctal ectropion is an unreliable indicator of functional success.

Transposed Corrugator Supercilii Muscle-Tendon Unit Flap for Contralateral Paralytic Medial Ectropion Repair.

Transposed Corrugator Supercilii Muscle-Tendon Unit Flap for Contralateral Paralytic Medial Ectropion Repair.

Z – Plasty for Medial Cicatricial Ectropion our Experience

Cicatricial ectropion of lower lid is a challenge to most ophthalmologists, as management requires complex procedures like skin grafts. However, Z plasty is a good alternative. Medial cicatricial ectropion is an even more complex problem to deal with, since not much tissue is available to work with, as opposed to lateral ectropion, where loose skin and soft tissue are available. We successfully managed two such cases with Z plasties using a technique which is quite simple and can be easily practiced by general ophthalmologist.

Punctal function in lacrimal drainage: the ‘pipette sign’ and functional ectropion

BackgroundThe aim was to assess the movements of the inferior punctum during blinking and discuss pertinent clinical applications.MethodsThis is a prospective, non‐comparative observational case‐series examining the function of inferior punctum during blinking using video recordings of the blinking action at the slitlamp with slow‐motion analysis and comparison.ResultsIn all 56 eyes of 28 patents, supero‐medial movement of the lower punctum toward the medial canthus, together with a medially directed protrusion of the inferior punctum was noted. It was also noted that the punctum blanched during this projectile movement compared to the rest of the lid margin.Simultaneous posterior rotation of the punctum was also observed in 48 eyes (85.7 per cent; 23 right eyes and 25 left eyes), resulting in apposition of the punctum to the lacus lacrimalis.In eight eyes (14.3 per cent; five right eyes and three left) from six patients, co‐existence of medial punctal ectropion led to failure of internal rotation of the punctum during blinking, even though punctal ‘pipette formation’ was preserved. These six patients all suffered from epiphora in the affected eyes. The presence of ‘pipette’ formation was calculated to have a sensitivity of 80 per cent and specificity of 100 per cent for punctal ectropion in our series. A two‐tailed Fisher exact test showed that based on our 56 eyes, these results were statistically significant (p < 0.0001).ConclusionsThe inferior punctum plays an active and important role in the drainage of tears by the mechanism of supero‐medial movement and medially directed protrusion (‘pipetting action’), failure of which contributes to epiphora. This is a highly specific sign and should be sought in the evaluation of epiphora, even in the absence of frank ectropion. In punctual stenosis where location of the punctal orifice is proving difficult, inducing the pipette sign will help in its identification.

Caruncular fixation in medial canthal tendon repair: the minimally invasive purse string suture for tendinous laxity and medial ectropion.

To describe a surgical technique for repair of medial ectropion that simply and reliably addresses tendinous laxity and punctal eversion. Prospective, single-blind, consecutive case study of 54 patients (79 eyes) by 3 surgeons. The subject population consisted of 33 males and 21 females, with a mean age of 81 years (SD = 9, range = 64-97). The presenting mechanisms of ectropion were as follows: cicatricial (n = 10), paralytic (n = 1), involutional (n = 62), mechanical (n = 3), and congenital (n = 3). Ectropion and punctal eversion was surgically addressed by use of a purse string suture that incorporated closure of a medial spindle incision and deep fixation to the base of the caruncle. The average postoperative follow-up period was 147 days (SD = 291, range 8-2,352). Sixty-four eyes had a presenting complaint of tearing (81%), with 50 eyes (78%) achieving complete resolution (p = 0.0001). Eyelid malposition was determined to be anatomically corrected in 34 of 35 eyes (97%, p = 0.0001). Four of the 79 operated eyelids had recurrence of ectropion (5%). All other reported complications were minor, resolved without sequalae. The technique demonstrated safety, efficacy, and reproducibility, regardless of ectropion mechanism. Incorporation of a purse string suture between the lower eyelid portion of the medial canthal tendon and the caruncle produces a reliable posterior-superior fixation parallel to the vectors of the posterior limb of the medial canthal tendon. This technique is equally effective as a primary correction method or when used in combination with other procedures.

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.

Reversible Severe Reaction to Imiquimod During Treatment of Eyelid Nodular Basal Cell Carcinomas.

Two patients affected by eyelid nodular basal cell carcinomas (BCC) were treated topically with 5% imiquimod. The first case experienced pain, extensive erythema and crusting, retractile medial ectropion and conjuctival mucous secretions during the second week of treatment. These effects improved progressively until the sixth week. Complete clearance of the BCC was also observed. The second case presented during the third week of treatment with pain and a wide crust similar to a third-degree burn. Two months later, complete clearance of the BCC was observed. The total absence of scars in the eyelid skin and absence of cicatricial ectropion were remarkable. Severe reactions may occur during treatment with topical imiquimod for nodular BCC of the eyelids. However, excellent cosmetic results remain after cessation of treatment.

Superiorly Based Bilobed Flap for Inferior Medial Canthal and Nasojugal Fold Defect Reconstruction

To evaluate the use of a superiorly based bilobed flap for reconstruction of nasojugal fold region defects. Retrospective review of all patients undergoing medial canthal, nasal sidewall, and nasojugal fold region reconstruction using a superiorly based bilobed flap from October 2000 through March 2008. Charts were reviewed for patient age and gender, indication, defect size and location, flap(s) used, and follow-up time. Outcome measures included ability to completely close the defect with minimal tension, cosmetic appearance, complications, and need for further surgery. Eighteen cases of medial canthal and nasojugal fold area reconstruction were performed using a superiorly based bilobed flap in 17 patients. There were 8 male and 9 female patients with an average age of 68.2 years (range, 11-88 years) and mean follow-up time of 17.8 months (range, 1-60 months). Mean defect size measured 2.0 x 1.4 cm (range, 0.7-4 cm). One patient underwent simultaneous glabellar flap repair, 2 patients underwent simultaneous lateral lower eyelid rotational flap repair, and 1 patient underwent simultaneous upper eyelid V-Y advancement flap. All defects closed completely with no wound tension. No cases of hemorrhage, infection, dehiscence, or necrosis developed during the follow-up period. Cosmetic satisfaction occurred in 16 of 17 patients. Complications included mild medial ectropion (2 patients) and canalicular stenosis (1 patient). None of these patients elected reoperation. Trapdoor deformity did not occur in any case. Two patients underwent reoperation for local tumor recurrence. A superiorly based bilobed flap adequately reconstructs inferior medial canthal, nasal sidewall, and nasojugal fold defects.

Laissez-Faire: How Far Can You Go?

Introduction: Lid defects created by removal of tumors are conventionally repaired by lid reconstruction. An alternative to surgical repair is wound healing by secondary intention. This technique, laissez-faire, as used in the periorbital region, was first described in 1957. Purpose: This report considers how effective this technique is for defects of various sizes and different locations in the periorbital region. Methods: Defects following excision of periocular tumors in 10 Caucasian patients were allowed to heal by laissez-faire. The locations of the defects were the medial canthus (n = 4), lower eyelid (n = 4), lateral canthus (n = 1), and upper lid (n = 1). The functional and cosmetic outcome of the healing process was noted. Results: A good functional and cosmetic outcome were obtained after healing by laissez-faire in 8 of the 10 patients. Of the 2 remaining patients one patient had a large medial canthal and lower lid defect which extended onto the cheek, which healed with residual scarring and medial ectropion. The second patient had a lower lid defect, which healed with a cicatricial ectropion. Of the 2 patients, only one required further surgery. Conclusions: This report shows the technique of healing by laissez-faire can be extended for relatively large defects with good results. The medial canthal region and full-thickness lower lid defects remain the favored locations for healing by secondary intention. In large defects particularly with extension onto the cheek, there is a significant risk of cicatrization, and the possibility of a second corrective operation should be discussed with the patient prior to tumor excision.

Direct Insertion of the Medial Rectus Capsulopalpebral Fascia to the Tarsus

To clarify the insertion of the medial rectus capsulopalpebral fascia to the tarsus in Asians. Specimens from 19 (11 right, 8 left) postmortem medial eyelids and orbits of 11 Asians (aged 45-96 years at death) were used. Samples had been fixed in 10% buffered formalin before their removal and microscopic examination. The tarsi were incised at 2 different heights in the upper and lower eyelids, as it was not disclosed which parts had the insertion of the medial rectus capsulopalpebral fascia. The first and second sections, parallel to the eyelid margin, were obtained, respectively, at 1 mm and 5 mm from the upper eyelid margin, and at 1 mm and 3 mm from the lower eyelid margin. Sections were stained with Masson trichrome. Both upper and lower eyelids demonstrated similar findings. The first sections, which showed the medial rectus capsulopalpebral fascia and included many smooth muscle fibers, did not insert in the tarsi. However, the deep part of Horner muscle directly inserted, whereas the superficial part went in the dense fibrous tissue closely attaching on the tarsi. Then, some of the muscle branched out in the tarsi. The second sections showed that the medial rectus capsulopalpebral fascia had a direct insertion to the tarsi. The tarsi are supported medially by the medial rectus capsulopalpebral fascia and Horner muscle. The "medial eyelid retractors, " comprising the medial rectus capsulopalpebral fascia and smooth muscles, were clearly defined, highlighting the relationship of the eyelid to the medial rectus muscle and offering a new pathogenesis and treatment for lateral tarsal shifts and lower medial ectropion.

Correction of Cicatricial Ectropion by Autologous Fat Graft

Over the past few years, treatment of burn scars with lipofilling has shown encouraging clinical results in terms of texture, color, softness, and quality of skin patterns. This clinical application has been widened to include treatment for scars resulting from surgical correction of cicatricial ectropion. In fact, although standard surgery with flaps and skin grafts can grant significant functional and cosmetic improvements, these often are not complete because of secondary surgical scars. The case of a 43-year-old man with cicatricial outcomes from chemical burns and subsequent surgical repair of medial ectropion in the lower eyelid is reported. The scar area was treated with injection of adipose tissue harvested from abdominal subcutaneous fat and processed according to Coleman's technique. At the 1-year follow-up assessment after lipostructure, the patient no longer reported xeroftalmia and epiphora. He had experienced complete functional recovery with excellent cosmetic results. Lipostructure of cicatricial ectropion seems to complete and improve the results of the standard surgical approach, and its long-lasting benefits are in keeping with the theoretical basis of this procedure.

An Alternative Procedure for Conjunctivodacryocystorhinostomy

Reconstruction of the total canalicular obstruction with destroyed medial canthal area is a challenging procedure for ophthalmic, plastic, and reconstructive surgeons. In the case presented, a supratrochlear artery--based island flap combined with a buccal mucosal graft was used for reconstruction of the medial canthal area. The medial canthal area was scarred significantly and demonstrated a medial ectropion and complete canalicular obstruction. To our knowledge, it is the first time for combined reconstruction of the medial canthal area and lacrimal drainage system in 1 stage, with island median forehead flap based on supratrochlear artery and buccal mucosal graft. During the 2-year follow-up period, no complication was encountered and the patient healed uneventfully.