Management of Ec Trop i On

7/31/2019 Management of Ec Trop i On

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HE MANAGEMENT OF

NVOLUTIONAL LOWER LID

ECTROPION

BYRON C. SMITH, M .D. , STEPHEN L. BOSNIAK, M.D., MICHAEL E. SACHS, M.D.

New York Eye & Ear Infirmary, Manhattan Eye, Ear & Throat Hospital, New York

ABSTRACT

Lower lid ectropion is caused by the imbalance of the lower lid protractors and retractors. Laxi ty of the canthalt en ons wi a ect t e egree an oca ti on o t e ect ropion as we as t e surg ica eci sions or i ts repa ir.

sc ema or t e in iv i ua izat ion o surgi ca correct ion as we as a new app icat ion o tempora is musc e

trans er is presente .

Key Wor s: Invo utiona ec tropion; Me ia can t a ten on axity ; La ter a can t a t en on axi ty ; We ge r esect ion;

Dou e we ge r esec tion; La te ra tarsa s trip ; Me ia cant a ten on p i cati on ; Tempora is musc e tr ansfer.

Invo utiona ower i ectropion is t e manifestation of a com ination of factors. Laxity of t e suspensory cant a ten ons as

well as ischema and atrophy [1, 2] of the pretarsal and preseptal orbicularis muscles disturb the delicate balance between the lid

protractors an retractors resu ting in an ectropion. T e re ative contri ution of eac of t ese components wi etermine t e

nature an extent of t e eformity. Prominent me ia cant a ten on axity may yie a spectrum of me ia ectropion ranging

from minimal punctal eversion to frank ectropion. Lateral canthal tendon laxity may be responsible for a lateral or a generalized

ectropion. Comp ete eversion of t e entire i margin may e t e resu t of iffuse axity invo ving ot cant a ten ons an t e

or icu aris musc es. Correction of t ese eformities must e in ivi ua ize so t at t e re ative contri ution of eac component

can be corrected. Only in this manner can an adequate anatomic and cosmetic correction be achieved.

PREOPERATIVE EVALUATION

Lacrimal Excretory System

Palpebral conjunctiva that has been exposed and desiccated becomes keratinized with long-standing lower lid

ectropion. If t ere is me ia ectropion t e puncta may e o iterate : t erefore, t e puncta an ower cana icu ar system must e

eva uate preoperative y.

icatricia omponent

A lower lid that has been everted for many months or years may develop subcutaneous cicatrization and shortening of the

anterior ame a of t e i . T is cicatricia component must e etermine preoperative y. It must e correcte wit a free s in

graft or Z-p asty [3] at t e time of surgery.


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YRON C. SMITH, STEPHEN L. BOSNIAK and MICHAEL E. SACHS

Loca ization o Laxity

T e p nc test s an e ect ve means o eterm n ng ower ax ty ex sts. I t e can e pu e more t an mm away rom

t e g o e , t e s ax. rasp ng t e an p nc ng t w a so g ve n ormat on a out cant a ten on ax ty 5 . I t e punctum

is displaced laterally toward the nasal limbus, medial canthal tendon laxity exists (Figure 1). If the lid is shortened horizontally

w t out pr or me a cant a ten on p cat on, t e punctum w e permanent y sp ace . I t e or zonta pa pe ra ameter s

s ortene an t e stance etween t e tempora m us an t e atera cant a ang e s ecrease , t ere s ax ty o t e ateracant a ten on (F gure ). I t e atera cant a ten on s not t g tene e ore or zonta s orten ng o t e , a narrow ng o t e

or zonta pa pe ra aperture w resu t.

Inferior Scleral Show

In er or sc era s ow may e a unct on o cant a ten on ax ty, s orten ng o t e poster or ame a o t e , proptos s, s a ow

or ts, or g myop a w t arge g o es. Regar ess o ts et o ogy t can occur concom tant y w t ectrop on. s mp e ower

we ge resect on may correct t e contour, ut accentuate t e n er or sc era s ow. T e must a so e vert ca y engt ene w t

sclera or auricular cartilage and supported laterally with a lateral canthoplasty.

FIGURE 1. (A)( ) If the medial canthal tendon is lax, the punctum will be displased laterally when the lid is pinched

B


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SURGICAL TECHNIQUES

I me a cant a ten on (M T) ax ty s not apparent, we ave oun t e o ow ng tec n ques use u or t e correct on o

involutional ectropion (See Table 1).

1. Lower lid wedge resection for mild to moderate involutional ectropion

(F gure : e t ower ). T s proce ure s we nown y most op t a m c surgeons, an s a equate n t e ma or ty o cases.

n nverte pentagona we ge resect on s per orme at t e unct on o t e atera one t r an me a two t r s o t e ower .

vertical cut is made from lid margin to inferior fornix. The corneal protector is removed. And the wound edges are overlapped until

t e marg n approx mates t e g o e snug y (F gure ). T e nasa marg n s notc e at t e po nt t at t over aps t e tempora

e ge. T e pentagona resect on s comp ete .

The lid margin is reapproximated with three interrupted 6-0 black silk sutures placed first through the Meibomian orifices,

t en t roug t e as ne an fina y t roug t e grey ne. T e suture en s are e t ong so t at t ey can e anc ore un er t e

s n sutures an ept o t e cornea. T e tarsus an con unct va are c ose w t one or two m 5- c rom c sutures. T e s n s

closed d

. M to Mo erate We ge Resect on

. Mo erate Latera Tarsa tr p

. Mar e Dou e We ge Resect on

. Extreme Tempora s Musc e Trans er

TABLE 1. SURGICAL TECHNIQUES FOR CORRECTING LOWER LID

ECTROPION WITHOUT MCT LAXITY.

FIGURE 2. f the lateral canthal tendon is lax, the horizontal palpebralaperture is shortened as is the distance from the lateral limbus to the lateralcanthal angle.


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w t - nona sor a e sutures.

I t ere s not an o v ous excess o ower s n, t e resect on may e per orme t roug u t c ness eye . I t ere s

a mar e re un ancy o s n, t en t e resect on s est per orme un er a ep arop asty s n flap ; t e s n s tr mme

super or y an atera y as n a ep arop asty. Mar e ower asymmetry may occur t e s n s tr mme aggress ve y.2.

Lateral tarsal strip for moderate generalized or lateral involutional ectropion (Figure 5). The lateral canthal tendon (LCT) is

expose w t a or zonta nc s on exten ng atera y rom t e atera cant a ang e. T e n er or arm o t e L T s transecte w t

a vert ca nc s on t roug u t c ness ower at t e atera cant a ang e. T e severe e ge o t e marg n s over appe w t

the lateral canthal angle. The lid margin is pulled laterally and notched at the point where the lid is in tight apposition to the globe.

tr angu ar port on o t e tempora s resecte , spar ng t e tarsus (F gures , 7). mattress suture o - Mers ene, Pro ne, or

FIGURE 3. This 68-year-old man has a mild to moderate medial ectropion of his right lower lid(note the punctual eversion) and a moderate ectropion of his left lower lid with keratinization ofhis palpebral conjunctiva.

FIGURE 4. This lateral ectropion was the result of a medial canthal tendon plication with aninadequate horizontal lid shortening.


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upramy s use to anc or t e tarsa str p to t e per osteum atera y an super or y a ter pass ng t t roug t e super or arm o

the lateral canthal tendon (Figures 8, 9). A periosteal flap from the superior aspect of the lateral wall may be reflected for additional

support (F gure ).

I t ere s an o v ous excess o ower s n, t s proce ure may e per orme un er a ep arop asty s n ap. T e s n

is gently draped superiorly and trimmed where it overlaps the incision (Figure 11).

. Dou e we ge resection or mar e invo utiona ectropion (F gure ). W en t e ectrop on s severe an prom nent

ax ty o t e atera cant a ten on s apparent, a com nat on o proce ures s necessary to a equate y correct t e e orm ty.atera resect on w t tarsa str p com ne w t a pentagona resect on tempora to t e punctum w e ect ve y correct t e

ectrop on w t out stort ng t e cant a ang e or s gn ficant y narrow ng t e or zonta pa pe ra aperture (F gure ).

A subciliary lower lid skin incision is made. A lateral tarsal strip is developed and anchored to the periosteum. A pentagonal

we ge resect on s per orme mm tempora to punctum. T e s over appe an resecte appropr ate y. I t ere s res ua

punctua retrocana cu ar amon resect on o con unct va an su mucosa s per orme mm n er or to t e ower cana cu us an

closed with 6-0 plain catgut sutures. (Figure 13 insert)

4. For extreme, recurrent invo utiona ectropion tempora is musc e trans er T e prev ous y escr e proce ures are

re at ve y easy to per orm. t oug t s a stra g t orwar app cat on o as c pr nc p es, t s proce ure nvo ves t ssue not

often handled by the ophthalmic surgeon. It is reserved for the most severe cases of ectropion with marked generalized periocular

ax ty

ax ty t at as recurre a ter a prev ous surg ca correct on. Tempora s musc e trans er as een e ect ve y use to correct

para yt c ectrop on 7, . Invo ut ona an para yt c ectrop on s are one common et o og c actor-or cu ar s musc e

atrop y. Recent stu es mp y t at m cro n arct ons an sc em a a ect t e or cu ar s musc es n nvo ut ona ectrop on .

We have no follow-up longer than 6 months available on the use of this procedure for the correction of involutional ectropion,

ut t ere are severa potent a t eoret c a vantages to ts app cat on. It prov es a v a e ower s ng as we as a t ona

pretarsa musc e mass. s a secon ary enefit t may n t ate myo-neurot n zat on o t e atrop c or cu ar s musc e.

FIGURE 5. A relfected stip of periosteum may be used to reinforce the lateral tarsal strip.


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ere are some o v ous raw ac s. It s a s g t y more comp cate proce ure. t oug ts s ng e ect s very

predictable laterally, the length and availability of the temporalis muscle may limit its medial sling effect. Distortion of the lateral

cant a ang e as not een a pro em.

nce we are reserv ng t s tec n que or secon ary cases, t e oca zat on o t e res ua e orm ty w

determine which adjunctive techniques will precede the muscle transfer. But punctual rotations and wedge resections may easily be

accommo ate .

atera sca p nc s on over y ng t e m port on o t e tempora s musc e s ma e, ssect ng t e sca p n a p ane ust

superficial to the temporalis fascia so that the entire temporalis muscle may be identified and isolated. The length and bulk of

t e musc e mass s eva uate . n appropr ate amount o musc e s out ne n Met y ene B ue so t at t e arc o transpos t on

nee e to reac t e me a cant a ten on can e eva uate (F gure ). It s mportant to ssect t e ep cran um t at s a erent

to the temporalis muscle. The muscle is elevated off the cranial vault and a tunnel is made in a sub-muscular plane lateral to the

atera cant a reg on an exten ng ust eneat t e c a superfic a to t e tarsa p ate as ar as t e me a cant a reg on. It s

mperat ve to so ate an ent y t e ac a nerve ranc es t at are superfic a , over y ng t e zygomat c arc reg on. ac a

nerve stimulator is considered necessary for this portion of the procedure.

e musc e s t en appropr ate y transpose . I a t ona engt s necessary, t e superfic a tempora s as ca s ac cut an

re n orce w t - Mers ene sutures at t e sta e ge o t e musc e as n t e agram ( nsert, F gure ). T e me a cant a

ten on s expose . eep te n t e ten on anc ors t e asc a component o t e tempora s transpos t on an a or s a super or

an poster or pu . Tunne ng may e per orme w t out a s n nc s on. ternat ve y, a s n musc e flap as prepare n a ower

lid blepharoplasty can be used to expose the tarsus if an additional wedge resection is necessary. The transposed temporalis muscle

can t en e suture rect y to tarsus.

e e ect e t y t e transpose tempora s asc a s re at ve y unnot ce . ra n s p ace n t e area, pre era y a suct on

type apparatus, and the reconstructed area is then taped to stabilize the wound. No other precautions are necessary. Postoperative

ant ot cs are prescr e or ays.

e o ow ng tec n ques are e p u t ere s me a ectrop on (see Ta e ).

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IGURE 6. ouble wedge resection of the lower lid combining a lateral tarsal strip and Lazy T is used for severe involutionalectropion.


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. Retrocanu icu ar resection or mi puncta eversion. I t e punctum s v s e w t out grasp ng t e , t e punctum s

everte .

2. Lazy T for moderate medial ectropion [8] (Figure 3, right lower lid; Figure 13, insert). 4 mm lateral to the

ower punctum a pentagona resect on s per orme . Be ore t e marg n s reapprox mate , t e me a aspect o t e s

eas y everte an t e poster or ame a expose . Bowman pro e s nserte nto t e ower cana cu us. mm n er or to t e

canaliculus, a horizontal incision through conjunctiva and submucosa is made with a razor blade fragment. This incision is made

cont guous w t t e resect on. T e su mucosa s un erm ne nto t e n er or orn x. T e woun e ges are over appe an

an appropr ate amount resecte to return t e punctum to t e acr ma a e. T e con unct va an su mucosa are c ose w t

6-0 plain sutures. The lid margin is closed with 6-0 black silk sutures, tarsus with 5-0 chromic and the skin with 6-0 black silk.

. M T p acatio wer cana cu us.

. M Retrocana cu ar Resect on

. Mo erate Lazy T

. Mar e M T P cat on P us Lazy T

. Extreme empora s Musc e Trans er

BLE . UR I L TE HNI UE F R RRE TI N L WER LID

MEDI L E TR PI N.

ndson.If the muscle is not long eneough to reach the medial canthal tendon, it can be back cut (see insert A.)


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su c ary nc s on eg nn ng mm atera to t e n er or puncta s exten e me a y para e ng t e me a cant a ang e an

sweeping superiorly above the level of the MCT. The pretarsal MCT are exposed. A mattress suture of 4-0 Mersilene or

Pro ene s pu e t roug t e nasa e ge o t e tarsus an over y ng or cu ar s, an t en t roug t e per osteum un er t e

nsert on o t e superfic a arm o t e M T, ma nta n ng super or an poster or tens on. are must e ta en not to pass t e p cat on

suture through the lacrimal sac. A modified medial canthal sling [ 12] is fashioned by pulling the skin superiorly and trimming it

w ere t over aps t e nc s on. T e woun s c ose w t - ac s . ter t e M T s p cate , t e Lazy T s per orme .

4. For extreme recurrent me ia ectropion, a M T p ication wit Lazy T is rein orce wit a tempora is musc e trans er.

SUMMARY

Lo we r e ctr op o n ma y p re se nt as a co nt n uu m o e o rm t e s e pe n n g on t e re at ve ax t es o t e

me a or atera cant a ten ons. In v ua zat on o t e surg ca proce ures are necessary or a equate correct on.

REFERENCES

. TEF NY ZYN, M. ., Pat o ogy o ntrop on an Ectrop on, presente at t e Was ngton Hosp ta enter ver Ju ee

Oculoplastic Symposium, Washington D.C., March 25, 1983.

2. SISLER, H.A., LEBAY, G.R., and FINLAY, J.R., Senile ectropion and entropion: A comparative histopathological study.Ann. Op t a mo .

189:525 (1980)

. PUTTERMAN, A., Combined Z-Plasty and horizontal shortening procedure for ectropion. Amer. J. Ophthalmol. 189:525 (1980)

4. HILL, J.C., Analysis of senile changes in the palpebral fissure. Trans. Ophthalmol. Soc. UK. 95(pt 1):49 (1975)

5. SCHAEFER, A.J., Lateral canthal tendon tuck. Ophthalmol. 86:1879 (1979)

6. SMITH, B. and CHERUBINI, T.D., Modification of Kuhut Symanowski Ectropion Repair. In Oculoplastic Surgery: A Compendium of

Principles and Techniques, C.V. Mosby, St. Louis (1970) pp 92-94

7. ANDERSON, R.L. and GORDY, D.D., The tarsal strip procedure. ARCH. Ophthalmol. 97:2192 (1979)

8. SMITH, B., The Lazy-T correction of ectropion of the lower punctum. Arch. Ophthalmol. 94:1149 (1976)

9. GILLIES, H.D., Experiences with fascia lata grafts in operative treatment of facial paralysis. Proc. Roy. Sol. Med.: 1372 (1934).

10. MASTERS, F.W., ROBINSON, D.W., and SIMONK, J., Temporalis transfer for lagophthalmos due to seventh nerve palsy. Amer. J. Surg.

110:697 (1965)

11. JELKS, G.W., SMITH B., and BOSNIAK, S., The evalution and management of the eye in facial palsy. Clin Plast. Surg. 6:397 (1979)

12. LEE, O.S., Amer. J. Ophthalmol. 24:575 (1951)

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Management of Ec Trop i On

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