Medial Ectropion Research Articles

SURGERY FOR LOWER LID SENILE ECTROPION

Objectives: To compare the results of lateral tarsal strip procedure with fullthickness pentagonal lid resection in the correction of involutional ectropion. Material and Method: A retrospectivestudy of 102 patients who underwent surgery for senile ectropion of lower lid. All the patients underwent either lateraltarsal strip operation or full thickness pentagonal resection. On the basis of signs and site of ectropion, the patientswere divided into three main groups; 1) Medial ectropion, 2) General ectropion and 3) ectropion with chronic lid marginchanges. Success was defined as relief of symptoms and good lid position. Results: 69% of patients had lateral tarsalstrip and 31% of patients had full thickness pentagon resection. Overall success was achieved in 90% patients whounderwent lateral strip operation and in 91% patients with full thickness pentagonal lid resection. In patients with medialectropion the success rate was 87% in lateral tarsal strip procedure compared to 96% with full thickness lid resection.In general ectropion group, the success rate was 92.5% with lateral tarsal strip and 80% with full thickness lid resection.In patients with secondary lid margin changes the success rate was 74% in lateral tarsal strip procedure compared to87% with full thickness pentagon resection. Conclusion: Both lateral tarsal strip and pentagon resection are effectivein the treatment of senile lower lid ectropion,

The not-so-lazy-T: A modification of medial ectropion repair

Medial involutional ectropion without excessive lateral canthal tendon laxity is often corrected using the lazy-T procedure. This procedure however carries a potential risk of canalicular damage, and locating the lower lid retractors can be difficult. We have developed a modification. Replacing the tarso-conjunctival diamond with a subconjuctival pocket posterior and inferior to the punctum, into which the lower lid retractors are advanced from the base of the wedge excision, which effectively ensures plication of the lower lid retractors while maintaining a straightforward procedure. The follow-up data on five procedures showed surgical and symptomatic success in all patients, without complications. These results confirm the efficacy of this modification of the lazy-T procedure in the correction of medial lower lid ectropion.

Correction of involutional lower eyelid medial ectropion with transconjunctival approach retractor plication and lateral tarsal strip

We describe the technique and our results in managing lower eyelid involutional medial ectropion using a combination of lateral tarsal strip to address horizontal eyelid laxity, and transconjunctival inferior retractor plication to address inferior retractor dehiscence. Patients with symptoms of epiphora or signs of medial ectropion were offered this procedure. All had the following characteristics: medial lower eyelid eversion, punctal eversion >3 mm, medial canthal tendon laxity <4 mm, significant horizontal eyelid laxity and lacrimal systems that were patent to syringing. A total of 24 eyelids of 17 patients underwent this procedure over a 12-month period. The mean age of the patients was 79.7 years; 11 were male and six were female. The mean follow-up time was 18 months. Two eyes had undergone previous surgery. All patients had restoration of the eyelid margin to the globe and relief of symptoms. No complications were noted. These results suggest that excision of posterior lamellar tissue is not necessary for correction of involutional medial ectropion. Transconjunctival plication or reattachment of retractors is easy to perform and allows for the repair of more than the medial portion of the retractors if required.

The E-Z(Easy) Clamp—A New Instrument to Facilitate Medial Ectropion Repair

The medial spindle/retropunctal diamond procedure is a useful technique to correct medial ectropion. Unfortunately, the procedure is difficult, due to the limited size of the surgical field, the bleeding that is seen when the marginal artery is encountered and because of the ever present risk of damaging the canaliculus. We have developed a clamp that overcomes the anatomical opposition outlined above and at the same time improves access to the surgical field.

Laser conjunctivoplasty: A new technique for correction of mild medial ectropion

Thirty patients with mild medial ectropion of the lower lid were treated by Argon green laser.A diamond-shaped area (6 × 4mm in size) on the medial part of the tarsal conjunctiva of the lower lid was burnt with overlapping spots until white blanching and visible contraction of tissue were seen. The apex of the diamond was kept 4mm below the punctal opening. After an average follow-up of 6 months, functional success was achieved in 22/30 eyes. Anatomical success in terms of repositioning of the punctum was attained in 24/30 eyes. The only side effect noted was a mild burning sensation of the eyes lasting for two hours after the procedure. This is the authors’ initial experience with a somewhat new and easy procedure to treat mild medial ectropion of the lower lid that can be performed on an outpatient basis.

Primary localized bilateral conjunctival amyloidosis and epiphora

BACKGROUND Conjunctival amyloidosis is a rare entity, which can present with epiphora. The management options, including the surgical treatment of this disease, are illustrated with a case study. METHODS A combination of retrospective and prospective review of a patient's clinical findings, course and treatment outcome. RESULTS A middle-aged patient with epiphora due to localized conjunctival amyloidosis is described. The clinical course of the epiphora during a 10-year period revealed a decrease on the initially symptomatic side and involvement of the opposite side despite bilateral progressive lacrimal drainage stenosis. The pathophysiology of this phenomenon is discussed. The progressive conjunctival deposits in this patient eventually required operative debulking through a conjunctival approach. Medial ectropion and punctal stenoses were also simultaneously corrected. The patient became symptom free one week after these operative interventions. CONCLUSIONS Localized conjunctival amyloidosis is a chronic, slowly progressive disease, which is frequently bilateral. Associated ocular involvement does not seem to be a part of this disease, even with long-term follow-up. The treatment of associated epiphora requires an organized approach to the underlying cause(s). The epiphora may be managed by a staged correction of its pathogenic mechanisms.

The maximal Hughes procedure.

To describe the use of oblique medial and lateral periosteal flaps with the Hughes tarsoconjunctival flap for the repair of maximal defects of the lower eyelid. A small prospective case series of eight patients requiring lower eyelid reconstruction following with maximal defect of the lower eyelid. The patients underwent a Hughes tarsoconjunctival advancement combined with oblique medial and lateral periosteal flaps, and were assessed for aesthetic outcome and surgical complications. All patients had uncomplicated surgery. Outcomes assessed included corneal protection, eye closure, lower eyelid retraction, complications, and patient satisfaction. Eyelid contour and protection was excellent in all patients. Postoperatively, one patient had mild lower eyelid retraction, and in a second patient, medial ectropion with mild lower eyelid retraction developed that required subsequent revision. The maximal Hughes procedure is a safe and effective procedure that may be performed with patients under local anesthesia and may avoid the need for more extensive techniques for surgical repair of maximal defects of the lower eyelid.

Reconstruction of the medial canthal eyelid. Methods, problems and outcome

Histologically controlled excision of medial canthal eyelid tumors often creates large skin defects, which may be closed by various reconstruction techniques. To obtain information about indications for surgery, complications, and esthetic and functional results we analyzed 39 of our patients who underwent surgery in this area between August of 1995 and January 1998. Four small defects were closed primarily. A free full-thickness skin graft was used in 15 patients with a medium-sized defect, and 18 patients with large defects were handled by a local rotation or transposition flap. Granulation was left to occur spontaneously in two patients in poor general health. No tumor recurrences were seen. The functional and esthetic results were good. After 3 months free transplants and rotational flaps had healed in well. Increased scarring with mild medial ectropion was seen in five patients with rotation flaps. Patients who were left to spontaneous granulation required a more intensive and longer local treatment. For the reconstruction of medial canthal defects after tumor excision, free skin transplants were used for small to medium, and rotation flaps for large defects. These are successful procedures with good functional and esthetic results. Spontaneous granulation is an acceptable therapeutic alternative for patients in poor general health.

Eyelid retractor surgery as an adjunct to cicatricial ectropion repair.

To evaluate the effectiveness of eyelid retractor repair in cicatricial ectropion of the lower eyelid. The study design was a prospective case series. One hundred and twenty eight eyelids were operated on in 100 consecutive patients with cicatricial ectropion. All patients underwent lower eyelid retractor repair via a conjunctival approach combined with skin replacement to the anterior lamella with or without a horizontal lid tightening procedure. When only medial ectropion was present, a medial-based transpositional skin flap was used to repair the anterior lamella (26 eyelids). The remaining eyelids with ectropion involving all or most of the eyelid underwent upper-to-lower eyelid lateral-based transpositional skin flap repair (92 eyelids), or full thickness free skin grafting (10 eyelids). Horizontal lid tightening was performed by lateral canthoplasty in 123 eyelids. Relief of cicatricial ectropion symptoms was reported in 90% of patients overall. A normal punctum position was achieved in 70% of eyelids, overall, and was highest (88%) with a medial-based transpositional skin flap. Eyelid retractor repair combined with skin replacement and horizontal lid shortening is an effective procedure for cicatricial ectropion.

Medial Canthoplasty for Optimum Support of the Lower Eyelid in 14 Patients

Medial canthoplasty surgically fuses the upper and lower lids medial to the puncta. The authors modified the procedure by inserting a temporary lacrimal stent in order to avoid kinking and scar contracture of the canaliculi. A medial canthoplasty successfully corrected lower eyelid laxity in 14 patients with the following conditions: (1) exposure and/or neurotrophic keratitis with medial ectropion and/or retraction of the lower eyelid (11 patients), and (2) inability to retain a prosthesis because of lower eyelid ectropion and contracture of the inferior conjunctival fornix (3 anophthalmic patients). All patients had a satisfactory cosmetic result despite minimal vertical and horizontal narrowing of the palpebral fissure. Complications included partial wound dehiscence and pyogenic granuloma. The modified medial canthoplasty described in this article corrects medial ectropion with minimal cosmetic deformity.

Surgical repair of medial ectropion.

Surgical repair of medial ectropion.

Age-related medial ectropion of the lower eyelid.

A simplified procedure is proposed for the repair of medial lower eyelid age-related ectropion. A posterior horizontal incision is made in the medial half of the lower eyelid at the inferior border of tarsus. The lower eyelid retractors are exposed and then plicated to the tarsus without excision of posterior lamellae or the use of everting sutures. The lid is then shortened horizontally with excision of a pentagonal section or lateral tarsal strip procedure. The procedure was performed in six patients successfully without complication. This is an effective method for repair of lower lid medial age-related ectropion.

Medial Canthotomy and Cantholysis in Eyelid Reconstruction

Combined medial canthotomy and cantholysis is a quick, technically simple, single-stage reconstructive technique for use in the reconstruction of the upper or lower eyelid. This technique, which transects one lacrimal canaliculus, provides up to 20% of the horizontal eyelid dimension for closure. Medial canthotomy and cantholysis is most frequently used in combination with other eyelid reconstructive techniques for difficult reconstructions, which would otherwise require more extensive surgical procedures. The surgical technique is readily performed with the patient under general anesthesia and entails the transection of one lacrimal canaliculus, lysis of one crus of the medial canthal tendon, and lateral advancement of the medial eyelid stump. We used medial canthotomy and cantholysis in the reconstruction of 29 eyelid defects (21 upper eyelids and eight lower eyelids) over a 12-year period with adequate reconstructive results in all cases. Eleven of the patients underwent simultaneous lateral canthotomy and cantholysis. Complications of the medial canthotomy and cantholysis technique include anterior displacement of the medial portion of the eyelid, epiphora, notching of the medial portion of the eyelid, medial ectropion, and blepharoptosis. If used with appropriate case selection, this technique allows an optimal reconstructive result to be achieved with a minimum of operative time and morbidity.

Medical canthal resection: an effective long-term cure for medial ectropion.

The results of 37 medial canthal resection procedures performed for the correction of severe paralytic or involutional medial ectropion are presented with an average follow-up of 5.4 years. Epiphora was improved in 33 out of the 37 cases and all but one patient had an anatomically improved lid-globe apposition, medial canthal angle, and posterofixation of the medial canthus. These results confirmed the long-term value of the operation.

Medial Palpebral Tendon Repair for Medial Ectropion of the Lower Eyelid

The primary functional support for the medial eyelid is from the deep attachments of the orbicularis muscle to the posterior lacrimal crest and lacrimal diaphragm. A dehiscence of the deep medial canthal attachments can alter the position of the lower eyelid with subsequent tearing, medial ectropion, and ocular exposure. In this study, medial palpebral tendon reconstruction was performed on seven lower eyelids with medial instability or ectropion and a dehiscence of the medial palpebral tendon. A periosteal flap left attached to the posterior lacrimal crest was used to replace the attenuated or absent medial palpebral tendon. After a mean follow-up of 7 months, 86% (6/7) of the eyelids had acceptable cosmetic and functional results. The use of a periosteal flap to replace a dehiscence of the medial palpebral tendon has several advantages. The periosteal flap is readily available, strong, and autogenous. The lower eyelid and punctum are pulled tightly against the globe. Lastly, the procedure may be repeated or combined with other ectropion procedures.

Carbon Dioxide Laser Repair of Medial Ectropion

Five patients with medial eyelid ectropion and punctal eversion due to senile changes, cicatrix, or vertical skin tightness were treated with a heretofore unreported method. Using a carbon dioxide laser, an ellipse of conjunctival-tarsal-inferior muscle tissue was excised from the inner surface of the ectropic lid inferior to the punctum. There was no bleeding, and each postoperative course was notable for minimal pain and edema. Lengthy follow-up revealed good anatomic results, with normal functioning of the inferior punctum. Patients taking warfarin sodium (Coumadin) have been treated without bleeding. Carbon dioxide laser ectropion repair may be tailored to each patient's specific condition, and is performed with ease in the office, thus offering diminished patient anxiety, discomfort, and expense.

The Medial Tarsal Strip

Medial canthal malpositions and marked medial ectropion due to laxity, scarring, or trauma can be difficult to correct. Medial canthal tendon publications have been advocated but they do not achieve adequate posterior and medial placement of the medial canthal angle and they lack permanence. One of us (R.L.A.) has developed a surgical technique for correcting these problems that is a modification of the lateral tarsal strip procedure used to correct lateral canthal tendon laxity and malposition. The medial tarsal strip procedure repositions and tightens the medial lower or upper eyelid, establishing a normal anatomic appearance. Its use is indicated in cases of medial canthal malposition or marked medial ectropion associated with a nonfunctioning canalicular system or in those cases in which loss of function of a patent canaliculus is acceptable or desirable. The advantages of the medial tarsal strip are as follows: (1) surgery is directed at the site of the defect; (2) recurrence of canthal tendon laxity and elongation is avoided; (3) a more medial and posterior positioning of the medial eyelid can be obtained; (4) any amount of eyelid laxity can be corrected simultaneously; (5) the almond-shaped canthal angle is preserved or reestablished; and (6) the procedure is fast and easily performed.

Medial Ectropion Repair A New Procedure

The lazy-T procedure described by Smith corrects medial ectropion of the lower lid by combining a horizontal full-thickness shortening of the lid with excision of conjunctiva and tarsus inferior to the punctum to invert the lid. However, some cases of senile medial ectropion involve an element of vertical traction on the skin as well as horizontal lid laxity. A new procedure is described that makes use of skin gained from horizontal lower lid shortening in the form of a medially based transposition flap to produce vertical skin lengthening. It is useful to treat medial ectropions that have horizontal laxity along with cicatricial components and has successfully relieved this condition in eight patients.

Carbon Dioxide Laser Repair of Medial Ectropion

Five patients with medial eyelid ectropion and punctal eversion due to senile changes, cicatrix, or vertical skin tightness were treated with a heretofore unreported method. Using a carbon dioxide laser, an ellipse of conjunctival-tarsal-inferior muscle tissue was excised from the inner surface of the ectropic lid inferior to the punctum. There was no bleeding, and each postoperative course was notable for minimal pain and edema. Lengthy follow-up revealed good anatomic results, with normal functioning of the inferior punctum. Patients taking warfarin sodium (Coumadin) have been treated without bleeding. Carbon dioxide laser ectropion repair may be tailored to each patient's specific condition, and is performed with ease in the office, thus offering diminished patient anxiety, discomfort, and expense.

Medial Ectropion: Association With Lower Lacrimal Obstruction and Combined Management

Nine consecutive patients who presented with a medial ectropion (12 eyelids) and epiphora were prospectively evaluated and surgically managed. Medial ectropion was successfully corrected in all 12 eyelids (mean follow-up 12.2 months). A lateral tarsal strip procedure (Anderson procedure) was used to correct the horizontal lid laxity. Resecting the retractors of the lower lid subjacent to the punctal area corrected the punctal eversion. Prior to medial ectropion repair, three of the 12 eyes demonstrated evidence of complete obstruction at or below the level of the lacrimal sac. These patients required concurrent dacryocystorhinostomy (DCR) in addition to repair of the medial ectropion. DCR with silicone intubation obviated the need for anastomosis of lacrimal sac and nasal mucosal flaps, and it corrected the punctal stenosis. Histopathologic examination of the sac specimens confirmed chronic inflammation. One of six patients without complete obstruction required DCR after medial ectropion repair and punctoplasty. Medial ectropion may predispose to lower lacrimal obstruction. In turn, the epiphora may lead to aggravation of the medial ectropion as a result of wiping of tears.