This article will summarize my talk from the Oculoplastics Symposium at Hawaiian Eye 2017. I spoke about the two most common eyelid malpositions — ectropion and entropion.
When patients are faced with these eyelid issues, their ocular surface decompensates because the lids no longer function properly to protect the cornea. Both are due to horizontal eyelid laxity and dehiscence to some degree of the lower eyelid retractors.
In both conditions, the eyelid must be tightened. The most traditional way to do this is through a lateral tarsal strip procedure. A lateral canthotomy is performed, dissection is carried down to the lateral orbital rim, the anterior lamella is split from the posterior lamella laterally to create a clean tarsal strip. A double armed 5-0 merselene suture is used to plicate the lateral tarsal strip to the periosteum inside of the lateral orbital rim.
Another lid tightening procedure is the lateral canthal tendon plication, which addresses the entire body of the tendon, including the superior crus and the inferior crus. This is the procedure of choice if the patient shows evidence of tendon dehiscence with rounding of the lateral canthal angle and/or shifting of the angle medially when the patient blinks. A small horizontal incision is made just lateral to the lateral canthus, extending about 1 – 1.5 cm. Dissection is carried down to the lateral canthal tendon. A double armed 5-0 merselene suture is passed first through the body of the tendon, then, in a double locking fashion, through the superior and inferior crux. Each arm of the suture is then thrown through the periosteum inside the lateral orbital rim, thereby restoring the natural anatomy of the tendon attachment. The skin wound is closed with two to three interrupted sutures.
If the patient has coexisting retractor disinsertion, a retractor reinsertion must be performed. The can be done through a subciliary or transconjunctival incision. The disinserted retractors are identified in front of the conjunctiva and reattached to the inferior tarsal plate.
If the patient has coexisting entropion, the lid must be rotated before the horizontal tightening. This can be achieved using fornix sutures back-handed through the inferior fornix and brought up just beneath the tarsal plate, essentially bringing up the disinserted retractors and inserting them at the inferior border of the tarsus.
This talk was a brief introduction to entropion and ectropion. Of course there are many versions of horizontal lid tightening, many of which can be combined with other procedures such as blepharoplasties. But this gives some basic techniques that hold tried and true.
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