|Year : 2014 | Volume
| Issue : 4 | Page : 263-267
Classification and management of ectropion with medial canthal tendon laxity
Hesham A Ibrahim, Heba N Sabry
Department of Ophthalmology, Alexandria University, Alexandria, Egypt
|Date of Submission||05-Sep-2014|
|Date of Acceptance||07-Nov-2014|
|Date of Web Publication||24-Feb-2015|
Hesham A Ibrahim
MD, FRCS-Ed, 19 Sorya Street, Roushdy, Alexandria
Source of Support: None, Conflict of Interest: None
Lower eyelid ectropion is usually accompanied by a variable degree of medial and lateral eyelid laxity. This work investigates a clinical evaluation scheme and a surgical plan to repair ectropion associated with different stages of such associated laxity.
Patients and methods
Forty-two procedures on 30 patients with lower eyelid ectropion associated with variable degree of medial palpebral ligament laxity were performed on the basis of the ectropion classification and management protocol described in this work. Patients were followed up for at least 6 months postoperatively.
Firm medial eyelid fixation against lateral traction and correction of ectropion were achieved in all cases. Epiphora was cured in 26 eyes. The planned cosmetic outcome was achieved in 28 cases.
Individualizing the surgical repair for involutional ectropion on the basis of the clinical findings is cosmetically and functionally rewarding.
Keywords: Ectropion, lid tightening, lower lid, medial canthus
|How to cite this article:|
Ibrahim HA, Sabry HN. Classification and management of ectropion with medial canthal tendon laxity. J Egypt Ophthalmol Soc 2014;107:263-7
| Introduction|| |
The development of horizontal eyelid shortening, especially after the lateral tarsal strip procedure (LTS), has rendered lower eyelid ectropion repair straightforward, reliable, and cosmetically rewarding ,. In the presence of medial palpebral ligament (MPL) laxity, LTS on its own is likely to induce lateral displacement of the medial eyelid. MPL plication/stabilization provides a counterforce against lateral traction in cases of moderate MPL laxity . MPL plication is not an option with severe MPL laxity. The redundant eyelid tissues become crowded medially, and the lacrimal canaliculus becomes kinked or tortuous, which would impair both the cosmetic and the functional outcome. Medial eyelid resection and reconstruction of MPL is recommended for such cases. The complex arrangement of the MPL and orbicularis muscle fibers around the lacrimal drainage system limits functional and cosmetic success following medial eyelid resection procedures .
In this report, the author presents a clinical evaluation scheme and a surgical plan to tackle different stages of MPL laxity associated with ectropion.
| Patients and methods|| |
Lower eyelid medial laxity was classified on the basis of its lateral distraction, lateral displacement, and the presence of punctal ectropion [Table 1].
The surgical strategies used to correct lower eyelid ectropion associated with medial and lateral lower eyelid laxity are summarized in [Table 2].
In this work the authors described two surgical modifications in detail: MPL reconstruction and MPL plication through a medial spindle defect. The medial spindle and LTS procedures are well described in the literature ,,,,.
The modified MPL reconstruction technique [Figure 1] is used for stage III or severe MPL laxity. The lower canaliculus is marsupialized upward by means of a single-snip procedure through a dilated punctum. The eyelid is split medially into anterior and posterior lamellae. Lateral to the lacrimal punctum, the eyelid is split at the gray line for 10 mm. Medial to the punctum; the split lid is carried medially along the floor of a marsupialized canaliculus. Medial and lateral anterior eyelid flaps are fashioned from the anterior eyelid lamella by incising the fashioned anterior lid lamella vertically at the site of the lacrimal punctum. The posterior dehiscence underneath the anterior flap is repaired by excising the redundant tissues from the posterior eyelid lamella and by tightening the medial horn of the lower lid retractors to the inferomedial edge of the tarsus with a 5/0 vicryl suture the medial horn of the lower eyelid retractors sutured to a firm attachment to the posterior lacrimal crest. The anterior eyelid lamella is repaired and the orbicularis tarsus embracement mechanism is retightened. The medial and lateral anterior flaps are overlapped and excess tissues are excised. The medial anterior flap is sutured to the anterior lateral flap onto the front surface of the tarsal plate. The tightened anterior and posterior lamellae are reapproximated at the eyelid margin with a 6/0 vicryl suture. The tarsal plate becomes supported with such repair by the orbicularis oculi muscle fibers anteriorly. With orbicularis contraction the tarsus is pushed backward against the globe (the tarsus embracement mechanism). The lower canaliculus can preferably be intubated to ensure a patent new punctum.
|Figure 1: Severe MPL Laxity. (a) The lacrimal part of the lid is deformed everted and keratinized (b) the lacrimal punctum displaceable across the pupil in straight gaze.|
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Posterior MPL plication through a medial spindle incision used for stage IIb or moderate MPL laxity [Figure 2],[Figure 3]a and b.
|Figure 2: MPL reconstruction. (a) The lower canaliculus is split open upward. (b) The eyelid margin lateral to the punctum is split into anterior and posterior layers. (c, d) The anterior layer is cut vertically into medial and lateral flaps. (e, f) The posterior layer is resected and tightened. (g) The lacrimal probe indicates the new site for the punctum. (h) The anterior flaps are overlapped, resected, and tightened. (i) The anterior and posterior lamellae are approximated at the lid margin with firm MPL fixation. MPL, medial palpebral ligament.|
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|Figure 3: (a) A triangular defect underneath the punctum is created. (b) The lower eyelid retractors are plicated through the medial spindle defect before its closure.|
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A 4 × 4 mm posterior eyelid lamella elliptical defect is created with a pair of spring scissors. The medial horn of lower eyelid retractors is identified and anchored to the inferomedial angle of the tarsal plate through the undermined wound edges. The orbicularis fibers medial and lateral to the defect edges are tightened. The medial and lateral slanting upper lips of the defect are sutured to the corresponding lower wound lips with a double-armed 5/0 vicryl suture. The two ends are brought out to the skin surface at a level lower than that of the created defect and tied together to exert an additional inverting effect.
| Results|| |
Forty-two lower eyelid involutional ectropion repair procedures on 30 patients with variable degree of MPL laxity were performed following the protocol in [Table 2]. MPL reconstruction was performed on 12 eyes of nine patients with severe medial ectropion. Three of them were referred following two previously failed lower eyelid shortening procedures. One patient had a history of facial trauma with lower canaliculus involvement and previous maxillofacial repair. Three patients had bilateral simultaneous surgery. Lacrimal intubation was performed in two eyes. Eight of 12 required LTS; however, two of them did not undergo this procedure simultaneously [Table 3].
After MPL plication was performed through a medial spindle incision in 30 eyes of 21 patients, LTS was required in 17 of these eyes. Simultaneous manipulation of punctal keratinization or stenosis was performed in 14 eyes with a three-snip procedure. Skin grafting was performed in two eyes. Patients were followed up for at least 6 months postoperatively. Firm medial eyelid fixation against lateral traction and correction of ectropion were achieved in all cases. Epiphora was cured in 26 eyes. The planned cosmetic outcome was achieved in 28 cases [Figure 4].
|Figure 4: Firm MPL fixation 6 months following bilateral MPL plication through a medial spindle wound. MPL, medial palpebral ligament.|
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| Discussion|| |
Medial ectropion of the lower eyelid with mild to moderate degree of MPL laxity is managed successfully with various horizontal eyelid shortening procedures combined with vertical shortening of the posterior lamella underneath the lacrimal punctum ,. Retropunctal cautery, medial spindle, lazy-T procedure, or resection of posterior lamellar flap are all well-established procedures that shorten the eyelid posterior lamella ,,,.
Posterior MPL plication through a medial spindle incision should not differ significantly on short term from these traditional procedures. However, it would provide effective medial fixation against lateral displacement of the medial canthus when a lateral eyelid shortening procedure is required. Posterior MPL plication or stabilization was described for moderate MPL laxity. It entailed using a nonabsorbable suture to attach the periosteum behind the caruncle to the medial edge of the tarsus ,. Placing such a suture is not an easy task. This technique bridged the MPL and ignored the repair of eyelid natural mechanics. It can disrupt the medial canthus and can induce symblepharon with consequent double vision on abduction. Lower eyelid ectropion associated with severe MPL laxity presents a surgical challenge. Jordan in 2003 described current techniques for severe MPL laxity repair as unsatisfactory . In a questionnaire in the same article, most coauthors avoided MPL repair, and the threshold to interfere surgically was relatively high. A lateral displacement of the medial punctum of up to 5 mm was considered acceptable when performing a LTS. Nonresection plication procedures were described to treat severe MPL laxity. Plication of an already elongated distorted medial canthus would lead to medial crowding of tissues, medial canthal deformity, and loss of lacrimal drainage function. The use of a periosteal flap was suggested by Edelstein and Dryden . Franzco et al.  described a transcaruncular medial orbitotomy approach for stabilization after MPL with a nonabsorbable suture. These procedures can work well in mild to moderate cases where a simpler procedure can be at least as efficient.
The authors share in the opinion of Jordan, Crawford, and Collin in that medial eyelid shortening or excision is the surgical intervention of choice in cases with severe MPL laxity . The most popular medial eyelid resection procedure for severe MPL laxity entails a full thickness resection of the medial part of the eyelid with the replacement of the medial attachment of the tarsus to the posterior lacrimal crest by a nonabsorbable suture ,,. This technique requires incision behind the caruncle to expose the posterior lacrimal crest and to directly anchor the periosteum with a nonabsorbable suture to the medial edge of a resected tarsus. This technique does not address properly the rebuild of the lower eyelid stabilization mechanisms. Patients who undergo this technique can develop adhesions between the globe and the medial edge of the tarsus. The cosmetic outcome was poor, and restriction of abduction was not infrequently encountered. The nonabsorbable sutures can produce residual tenderness granuloma or residual deformity. Jordan and colleagues in 1990 developed the medial tarsal strip, a technique similar to the LTS procedure, to reconstruct the MPL. This technique failed to address the fine details of the medial canthal area. Because of the difficulty of posterior fixation, medial tarsal strip was sutured to the undersurface of the anterior MPL. They reported the occurrence of a gap between the globe and the eyelid. This technique also could not maintain a patent lower canaliculus. They have recommended it to patients in whom the loss of the function of a patent canaliculus is acceptable .
Current options for medial ectropion repair with severe medial canthal tendon laxity are technically difficult and do not always achieve a satisfactory outcome. They merely aim at the restoration of firm medial fixation with little consideration to fine anatomical and physiological details of the medial canthus . MPL reconstruction in cases of ectropion associated with severe MPL laxity, as described in this work, exposes tissue planes through which layers of the MPL are surgically accessible. This approach improves the tone of the superficial and the deep elements of the orbicularis, which keeps the lid in apposition to the globe (restores the tarsal embracement mechanism). It provides a patent access for tears to reach the lower canaliculus. It maintains natural-looking almond-shaped medial canthal angle; it makes use of the patient's own local tissues, which would consistently achieve a reliable natural healing with a better anatomical and cosmetic outcome. The disadvantages of MPL reconstruction: it is a time-consuming technique, it requires a vertical incision not coinciding with the natural eyelid crease; tightening after MPL may pull the caruncle anteriorly and cause rounding of the medial angle; and the lacrimal canaliculus can become obliterated and so may require simultaneous lacrimal intubation, especially when intact canalicular mucosa is questionable. The correction of the medial eyelid position against the globe, even with a blocked lower punctum, improves epiphora by preventing the formation of a medial lacrimal pool. MPL reconstruction as described in this article is mainly a medial eyelid fixation procedure to restore the normal medial canthus function and cosmesis. Any residual eyelid laxity following MPL reconstruction should be addressed with a lateral lid tightening procedure. Lateral eyelid shortening procedures were used very often in this series of patients. LTS procedure is the authors' choice for the treatment of lower eyelid ectropion because it is directed to the correction of the anatomical defect, it avoids lid notching, it preserves the lid skeleton represented in the tarsal plate, and it avoids iatrogenic phimosis ,.
| Conclusion|| |
MPL reconstruction and MPL tightening through a medial spindle defect are efficient approaches to achieve good cosmetic and functional repair for lower eyelid ectropion associated with moderate and severe MPL laxity.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]