Lower eyelid ectropion repair with lateral tarsal strip and medial spindle procedure

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Author: Thidarat Tanking
Published:
Specialties: Ophthalmology
Schools: Harvard Medical School
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Basic Info

One of the most common causes of lower lid ectropion is horizontal lid laxity, the incidence of which increases with age. This condition induces poor ocular surface tear film coverage which leads to irritation, tearing, and keratopathy. Lateral tarsal strip fixation is the technique which is widely used to repair involutional ectropion due to horizontal lid laxity. Medial spindle procedure is the well-known technique for puntal ectropion correction. Both surgeries are minimally invasive, simple and effective.

Contributors
Suzanne K. Freitag, MD, Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School
Thidarat Tanking, MD, Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School

Advanced

Procedure

A lateral canthotomy is performed using a Westcott scissors, followed by an inferior cantholysis. The lateral tarsal strip is created by splitting the anterior and posterior lamella across the anterior surface of the tarsus and removing the epithelium from the lid margin in this area. The posterior surface of the conjunctiva is deepithelialized with a 15 blade. Then, a medial spindle procedure is performed by removing a small spindle-shaped piece of conjunctiva and lower lid retractors between the punctum and the inferior fornix. 6-0 double-armed polyglycolic acid suture is placed through retractors and conjunctiva at inferior edge of the spindle and these needles are everted and the upper edge of the conjunctiva and retractors are grazed with the suture as it is externalized full thickness in a slightly downward vector. Both ends were externalized and tied. Next, a double-armed 5-0 polypropylene suture is used to attach the tarsal strip to the lateral orbital rim periosteum in a mattress fashion. Recreation the lateral canthal skin angle is performed with a 6-0 polyglycolic acid suture. Skin is closed with absorbable sutures.

Indications

Lower eyelid ectropion from horizontal lid laxity and punctal ectropion leading to tearing and corneal damage.

Contraindications

Active local infection, bleeding disorder, advanced cicatricial ectropion, presence of skin lesion or tumor, ectropion that is not corrected when lateral distraction of the eyelid on clinical examination does not fix the lid malposition

Instrumentation

Setup

The procedure may be performed under IV sedation or with only local anesthetic either in a minor procedure setting or operating room.
Local injection with 2% lidocaine with epinephrine 1:100000 mixed 1:1 with 0.75% Marcaine at lateral canthus and medial aspect of each lower lid.
Surgical prep with diluted (5%) betadine. Sterile drapes exposing the eyelids as the surgical field.
Eye protection with scleral shell

Preoperative Workup

Full ophthalmic examination with testing of visual acuity, pupillary reaction, extraocular motility, slit lamp biomicroscopy, with specific attention to tear film, keratopathy, and to rule out other ocular surface pathology. Examination should include evaluation of the lacrimal system including irrigation in a patient complaining of epiphora. Eyelid external evaluation should include position and patency of lacrimal puncta. The causative factors of eyelid ectropion should be evaluated including degree of horizontal eyelid laxity, presence of cutaneous cicatricial changes or lesions, midface/malar descent, disinsertion of lower lid retractors, and globe position with regard to orbital rim.

Anatomy and Landmarks

Advantages/Disadvantages

This is minimally invasive technique which can be performed in 15 minutes in the hands of an experienced surgeon. The success rate for surgery is at least 95%. There is minimal post-op discomfort. There is little disadvantage to this procedure if patient selection is appropriate.

Complications/Risks

wound infection, retrobulbar hemorrhage, loss of vision, failure to correct problem, damage to globe including corneal abrasion or rupture of globe, conjunctival scarring, recurrence of ectropion, persistence of tearing

Disclosure of Conflicts

None

Acknowledgements

References

Ghafouri RH,Allard FD,Migliori ME,Freitag SK. Lower eyelid involutional ectropion repair with lateral tarsal strip and internal retractor reattachment with full-thickness eyelid sutures. Ophthal Plast Reconstr Surg. Sep-Oct 2014 ;30(5):424-6.

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