Introduction

Intact eyelids cover the eye completely while closed and the lid margins stay in direct contact with the globe while opened¹. The lid margin’s contact line to the ocular surface is of vital importance to the integrity of the ocular surface. Dysfunction of lid motility and position can lead to symptoms varying from mild discomfort and dry eye to severe corneal ulceration and sight-threatening ocular surface disease. It is therefore most important to address lid malposition with the appropriate surgical therapy^2–4. (Further suggested reading).

Entropion is a condition in which the lid margin is turned inward onto the ocular surface, while ectropion by definition is the contrary, describing a lid margin that turns outward, leading to exposure of tarsal conjunctiva (Figs 46.1 and 46.2).

Fig. 46.1 Involutional ‘spastic’ entropion.

Fig. 46.2 Involutional ectropion with horizontal laxity.

Epidemiologic consideration and terminology

Congenital eyelid malpositions are rare in Caucasians, but can be potentially sight threatening if lash abrasion of the corneal surface leads to ulceration and infection (e.g. tarsal kink). Continuous and profuse secretion, pain, photophobia, and blepharospasm in a baby should always raise the suspicion and lead to immediate investigation under general anesthesia. In the Asian population, congenital epiblepharon – an inward positioning of the lashes in the medial part of the lid due to a fold of orbicularis muscle and skin – is a common diagnosis. If it is more severe, all of the lid margin is turned towards the eye, causing a true entropion. True and chronic congenital ectropion is also rare and most often an associated condition of a genetic disorder, e.g. trisomy 21.

Lid malposition can be the result of cicatrizing changes of either conjunctiva or skin after trauma or surgery, or in destructive skin and mucous membrane diseases (e.g. scleroderma, ocular pemphigoid). Ectropion might also be the result of paralysis of the orbicularis muscle, as in facial palsy.

The majority of cases of entropion and ectropion, however, are caused by involutional changes that alter the homeostasis of skin tension, muscle action, and stabilizing forces of the lid retractors.

Anatomical considerations

Anatomically, both upper and lower eyelids can be separated into an anterior and a posterior lamella. The anterior lamella consists of skin and orbicularis muscle. The posterior lamella consists of the tarsal plate, containing the meibomian glands and the conjunctiva covering the posterior surface. Medially and laterally, the canthal tendons fixate the lids to the medial and lateral orbital wall.

It is essential for any surgical procedure at the canthal region to understand that, in order to hold the lids correctly against the ocular surface, the vector of the deep canthal fixation has to be as posterior into the orbit as possible, at least as posterior as the equator of the globe.

Lid posture and vertical movement are dependent on the levator and tarsal muscle in the upper eyelid and on the complex system of lid retractors in the lower lid. This distinct difference makes it impossible to transfer surgical principles from lower to upper lid one to one.

Medially, the lacrimal punctum and canaliculi are embedded in the lid margin and canthal fixation system. Any surgical procedure aiming to reconstruct or tighten the canthal tendon has to address this delicate anatomical situation.

Fundamental principles and goals for surgery

In repairing ectropion and entropion, all the general principles of oculoplastic surgery need to be applied. With the exception of tumor removal, incisions around the lids should follow the relaxed tension lines in order to avoid visible scars. It is necessary to understand the complex anatomy, especially of the medial canthal area. All procedures addressing eyelid malpositions aim to restore the lid function while maintaining or restoring an adequate esthetic result: complete closure, blinking, tear distribution, tear pump, position of lashes, and texture of lid skin.

Indications for surgery

In principle, surgical correction of eyelid malposition is indicated whenever patient discomfort can be repaired with sufficient safety and predictability.

While minor entropion or ectropion may be mainly disturbing for esthetic reasons and the indication for repair considered only optional, malpositions causing ocular surface infection and ulceration should lead to immediate repair.

Preoperative assessment

In addressing the patient with lid margin malposition, it is most important to first decide whether the condition is disturbing normal lid function and surgery is needed to prevent further damage to the ocular surface or if it is mainly an esthetic problem for which surgery can be delayed.

The choice of procedure depends on the clinical assessment of the anatomical changes, which follows a catalog of questions:

Anesthesia

The majority of surgical procedures can be done under local anesthesia. Claustrophobic or psychologically unstable patients can also usually be operated on with intravenous or preoperative peroral sedation. It is much more comfortable for the patients if the whole face is surgically cleaned and then left open. Critically ill and cardiovascular unstable adults should always be supervised by an anesthetist during surgery and children under the age of 16 should always be considered for general anesthesia.

As local anesthetic 2% Xylocaine (lidocaine, lignocaine) with 1 : 200 000 epinephrine (adrenaline) is a very good choice for local infiltration. If prolonged anesthesia is required, bubivacaine can be added in equal volume. Some surgeons add hyaluronidase to the solution to obtain a faster effect.

Operation techniques

Both entropion and ectropion are more common in the lower eyelid; upper and lower eyelids are addressed separately in this section.

Lower lid ectropion

Ectropion occurs either as a result of aging changes to skin, muscle, or connective fibers, loss of muscle tone due to the lack of innervation as in seventh nerve palsy, or as a result of scar formation in the anterior lamella of the lid. Surgical repair aims either at restoring horizontal tightness at the medial or lateral canthal tendon and the lid margin itself or at reconstructing the anterior lamella. If the underlying cause of a neurological deficit cannot be addressed, the lid must be either elevated or horizontally tightened or both.

Tarsoconjunctival excision

If the canthal tendon is tight and ectropion of the medial third of the lid has led to eversion of the lower punctum, an excision of the posterior lamella with or without plication of the lower lid retractors is sufficient to correct the problem⁵.

Technique

The conjunctiva is grasped with a forceps and a diamond-shaped excision of the tarsoconjunctiva is made below the punctum using straight scissors held parallel to the lid margin (a scalpel can be used if preferred by the surgeon), leaving enough conjunctiva below the punctum to place a needle. The canaliculus is protected by a probe. The horizontal extent of the excision is about 7 mm. A double armed 6-0 absorbable suture is passed through the upper edge of the wound just below the punctum; the other arm of the suture is passed through the lower edge of the wound, picking up the lower lid retractors. The knot is tied and buried in the wound and the suture left for spontaneous absorption.

Alternatively – if the eversion is more extensive – a non-absorbable suture can be used, passed through the skin and tied over a bolster. This will produce a stronger inverting effect. (See ‘lazy-T’ procedure below). The suture can be removed after 10–14 days.

(Tarso)conjunctival excision, inverting sutures, and horizontal lid shortening (lazy T procedure)

If the canthal tendons are tight and the eversion is mainly in the medial third of the lid, inverting the lid margin by excising a part of the conjunctiva and shortening the lid horizontally will correct the malposition. The resulting incision lines after closure forms a T that lies lazily on its side, hence the name⁶.

Technique (Fig. 46.3 A,B)

A diamond-shaped excision is made with a one third longer horizontal axis at about 2–3 mm exactly below the lower punctum. A probe is entered into the canaliculus and the excision is tarso-conjunctival but care is taken not to damage the tearway. A double armed 6-0 silk suture is introduced at the upper border, picking up the conjunctiva and just the border of the tarsus. Both arms are then passed through the lower edge of the conjunctival wound, picking up the lid retractors and then brought out through the skin at about 1 cm below the punctum. The needles are passed through a silicone bolster and kept loose for later tightening. A full thickness vertical cut through the lid margin is made at about 3 mm lateral to the punctum. The amount of lid that needs to be resected is defined by pulling the lid medially. The lid is then shortened by a standard pentagonal excision and the wound closed by interrupted 6-0 silk sutures: two intermarginal sutures and three to four sutures through skin and tarsus are used to close the wound just like in any tarsal wedge resection. The ends of each suture are tied into the knot below in order to prevent the sutures irritating the cornea.

Fig. 46.3 (A&B) Lazy-T procedure. A diamond-shaped tarsconjunctival excision, pentagonal full-thickness lid resection.

The inverting suture is tied to just invert the lid margin to the globe. A little overcorrection is acceptable. Sutures can be removed at 10 days, the inverting suture at 14 days.

Horizontal lid shortening and skin excision (Kuhnt–Szimanowski)

If horizontal lower lid laxity and an abundance of skin is present while the medial and lateral canthal tendons are firm, the lid can be tightened by a pentagonal excision and the skin excess reduced via a subciliary incision.

Technique (Fig. 46.4 A–D)

A skin incision is made just below the lash line, but the lashes are not cut and a narrow strip of skin is left for later suture placement. The incision is extended over the lateral canthal region in the lateral skin crease. The skin is raised above the muscle and a skin flap elevated laterally and superiorly.

Fig. 46.4 (A–D) Horizontal lid shortening and skin excision. (A) Incision. (B) Everted skin flap and excised lid. (C) Skin resection. (D) Wound closure.

A full-thickness pentagonal excision of the lid is performed with straight scissors or a number 11 blade scalpel. The pentagonal wound is closed in the same fashion as after a tumor resection: two marginal sutures (6-0 silk) are placed to adjust the gray line. The end of these sutures are left long to be later buried under the skin suture. Two to three 6-0 Vicryl sutures that pick up the tarsus are used to close the wound.

With the patient opening his or her mouth and looking upwards, the amount of resectable skin is assessed and cut. The skin is then closed with an intracutaneous or regular continuous 6-0 nylon suture.

Lateral canthal plication through upper lid crease incision

A lateral canthal tendon laxity can be repaired without shortening the lateral canthal tendon by plicating it with a suture⁷.

Technique

A lateral upper lid crease incision is made and the orbicularis muscle divided to allow access to the lateral orbital rim. The lateral canthal tendon is identified and bluntly and partially separated from the orbital rim. A double armed 5-0 long-acting absorbable suture is introduced through the tendon from inside the wound, passed through the skin at exactly the lid angle and back through the same pass. This picks up the tendon, which will then be tightened by passing the suture through the periosteum at a deeper level within the orbit. The knot can be tied, which will tighten the tendon. The skin is closed by a running suture.

Lateral canthal sling

Laxity of the lateral canthal tendon leads to lower lid ectropion as the orbicularis muscle fibers weaken and become unable to overcome the horizontal tendinous laxity. The ‘snap test’ shows that the lid doesn’t move back to the globe adequately when pulled away. Tightening the inferior limb of the canthal tendon will correct this laxity⁸.

Technique (Fig. 46.5 A–D)

A horizontal subciliary skin incision is made in the lateral third of the lower lid and extended over the lateral canthus. With careful cautery, the incision is deepened to the lateral orbital rim. The lower limb of the lateral canthal tendon is cut and a tarsal strip created⁹: the lid margin is freed from lash roots, conjunctiva and skin. A double armed 5-0 long-acting absorbable suture is passed through the strip. A slit incision is made through the upper arm of the lateral canthal tendon and each arm of the suture is then passed through the slit, behind the lateral orbital rim, through the periosteum, pulled through anteriorly, tied, and buried under the musculature.

Fig. 46.5 (A–D) Lateral tarsal sling with skin graft and inverting suture. (A) A strip of tarsus is prepared for fixation to the lateral orbital rim. (B) The open wound is prepared for full-thickness transplantation. (C) Lid prepared for skin transplantation. (D) Lid (i) after wound closure and (ii) after removal of sutures.

The size of the tarsal strip is approximately 5–7 mm in length. Any excess of skin can be excised before closing the wound. Care is taken to not excise too much skin to avoid postoperative.

The skin incision can be closed by interrupted 6-0 silk sutures or by a intracutaneous running suture.

Medial canthal tightening – posterior limb suture

Tightening the medial canthal tendon will correct a predominantly medial ectropion caused by medial canthal laxity. Laxity of the anterior limb of the medial canthal tendon is easily corrected but frequently leads to malposition of the punctum and doesn’t address the problem at its main cause. There are several possibilities to tighten the posterior limb by an open or closed approach. The following technique allows a deep posterior fixation and direct suture.

Technique (Fig. 46.6)

An incision is made directly at the lower border of and through the caruncle. The tissue dissection is extended to the medial border of the tarsus and to the medial orbital wall behind the tear ways, which are protected by a probe in the inferior canaliculus. The periosteum can be exposed by blunt dissection.

Fig. 46.6 Medial canthal tightening. Posterior limb suture through open caruncular approach.

A double armed 5-0 non-absorbable suture with a half-circle needle is passed through the exposed tarsus. Alternatively, if there is enough identifiable strong tissue of the posterior limb, a strip of tissue can be formed and picked up with a long-acting absorbable suture.

Both arms of the suture are then passed through the periosteum above the level of the posterior lacrimal crest. If the exposure of the medial orbital wall is good and wide enough, the knot can be directly tied and buried. If not, both arms can be brought out through the skin above the medial canthal tendon and buried under a skin incision.

Medial canthopexy

Medial lower lid ectropion can be repaired with a small procedure if the medial canthal tendon is firm and the ectropion is minor. The principle is to correct the ectropion and the malposition of the lower punctum by lifting the lower medially with the help of the upper lid.

Technique

Probes are introduced into the canaliculi and an incision just medial to the puncti is made and extended medially over the anterior limb of the canthal tendon. Three to four 6-0 absorbable or silk sutures are placed to bring the wound edges (orbicularis and skin) of lower and upper lid together. This inverts the punctum and supports the lower lid.

The sutures can be removed after 10 days or left for spontaneous loss.

Skin replacement for cicatricial ectropion

Lower lid ectropion requiring skin replacement is caused by either previous surgical procedures (esthetic or reconstructive) or extensive ageing changes. A skin replacement should be considered only if a generalized weakness of the cheek tissues with cheek ptosis cannot be corrected by a cheek- or SOOF-lift.

Technique (see Fig. 46.5 C,D)

Two traction sutures are placed in the lid margin to pull the lid superiorly. A subciliary incision is made and the wound widened. Any scar tissue is resected and the defect made as large as necessary to correct the ectropion. The wound bed is prepared according to the individual situation. Sometimes it is necessary to reposition or resect orbicularis musculature and to redress orbital fat in order to obtain an even surface.

A full-thickness skin graft is harvested and placed into the defect. It is trimmed to fit tightly and sutured by a running 7-0 absorbable suture. The traction sutures are left in place and fixed to the forehead. Antibiotic ointment and a firm pressure patch are placed over the graft and left for 2 days.

Traction sutures are left for 5 days, graft sutures are removed after 6 days.

Lower lid entropion

In principle, the decision to correct a lower lid entropion with a certain procedure depends on several key questions¹⁰:

Is the cause of entropion involutional or cicatricial? Is there excessive horizontal lid laxity? What is the status of the lower lid retractors (tight or weak?) What is the relative position of the lid lamellae against each other? Is there additional trichiasis? Is it a recurrence?

If there is a relative dissociation between anterior and posterior lamella that allows the orbicularis muscle to move upwards and turn the lid margin inwards, a horizontal lid split (and everting sutures) will correct and further prevent it. If involutional changes have weakened the lid retractors, they will have to be shortened or plicated. If involutional changes have weakened the horizontal tension, the lid has to be shortened horizontally. If the tarsal plate is thickened or irregular due to scar formation, the lid margin has to be everted and possibly split vertically. In the presence of trichiasis, the lid margin has to be split vertically, the posterior lamella advanced, or the lashes have to be sacrificed by either cryotherapy or electrocoagulation.

Direct skin excision and retractor fixation for congenital entropion

In children with recurrent ocular surface problems due to congenital entropion and irritation by the inverted lid margin, a skin excision with direct closure and connection of the skin to the lid retractors at the lower tarsal border can correct the malposition.

Technique

The skin below the everted lid margin and punctum is excised in an ellipsoid fashion. The amount of skin excised depends on the amount that can be picked up to just turn the lid margin into the correct position. If too much skin is excised, an ectropion will result with the scarring process. A strip of orbicularis is excised with the skin.

Several – usually three to four – 6-0 absorbable sutures are passed through the skin, picking up the lower lid retractors just at the lower border of the tarsal plate. They can be left in place until they are spontaneously resorbed and fall off, but they can also be removed after 10–14 days if necessary.

Everting sutures

Everting sutures can be placed to correct a lower lid entropion, when a quick and easy procedure is needed (e.g. bedside treatment). They have, however, only a temporary effect (i.e. as long as they are in place and only a little longer) and should be avoided or replaced when definite surgery is possible.

Technique

A double armed non-absorbable suture such as 4-0 silk is passed through the conjunctiva just below the tarsal plate and pulled out either side at the same height (when entropion only occurs on tight lid closure). If a stronger everting effect is necessary, the sutures can be placed deeper in the fornix, picking up the lid retractors and pulled through not just transversely but at a higher pretarsal level, but at least 2 mm below the lashes. Placement of the sutures depends on the location and amount of entropion; a centrally placed suture can be enough, but up to three sutures might be necessary.

Horizontal (transverse) lid split and everting sutures

This is probably the most commonly used and versatile procedure to correct an involutional entropion with a ‘spastic’ component, where long-term cure is required and no horizontal laxity is present. It can also work satisfactorily, when only mild laxity is present. The technique was first described by Wies¹¹ and produces a transverse fibrous scar to prevent the preseptal orbicularis muscle from moving upward towards the lid margin and pushing it inward. The everting sutures additionally pull the margin outward through the force of the lid retractors.

Technique (Fig. 46.7 A–C)

A horizontal skin incision is made: its central point is 4 mm below the lashes, its lateral and medial end slightly more distant, therefore ensuring that it is truly horizontal and not parallel to the lid margin. The length of the incision depends on the involved area. Nasally, it should not exceed a point 2 mm lateral to the punctum.

Fig. 46.7 (A–C) Horizontal lid split and everting sutures. (A) Full-thickness lid incision. (B) Position of everting sutures. (C) Tied knots.

The incision is deepened through the muscle and then completed through the lid by opening the conjunctiva. The globe can be protected by a globe guard.

A double armed resorbable polyglactin 5-0 suture is passed through the conjunctiva at the lower edge of the wound, picking up the lid retractors, then entering the upper part of the wound and exiting the skin anterior to the tarsus. Three sutures are placed to secure the effect. The knots are tied after the last suture has been placed. The closer the sutures are to the lashes, the greater is the everting effect. Care is taken to tie the knots just to the desired effect.

The skin incision can be closed by a separate running suture, single knots, or just with a Steri-strip according to the surgeon’s preference.

Everting sutures are left in place for 10 to 14 days. If gross overcorrection is noted, they can be removed earlier.

DIrect lower lid retractor plication (Jones)

If the lower lid retractors are loose, a simple everting suture will not sufficiently correct an entropion. In this case, they can be plicated by a direct approach. In contrast to a horizontal lid split, the conjunctiva is not opened.

The procedure must be combined with a tightening procedure if horizontal laxity is present.

Technique (Fig. 46.8)

A horizontal skin incision is made just below the tarsal plate. The incision is deepened through the muscle and then completed through the lid just to, but not through, the conjunctiva.

Fig. 46.8 Direct lower lid retractor placation.

In order to reach the lower lid retractors, the orbital septum has to be opened, which will expose orbital fat. Holding back the fat, the retractors can be identified. It is easier to identify the retractors with movements of the globe, but the movement of the retractors will be somewhat reduced due to their laxity.

A double armed resorbable polyglactin 5-0 suture is put through the retractors and passed out through the lower border of the tarsus and with a new bite through the skin at the upper border of the wound. The other needle is passed directly through the muscle and skin at the lower border of the wound. Three such sutures can be placed in each third of the lower lid.

The sutures will tighten the retractors, but not evert the lid as much as everting sutures that are placed closer to the lid margin.

The sutures will plicate the retractors depending on their position. At the end of the operation, the lid should be in an normal position and move with gaze. Over- or undercorrection should be corrected by replacing the sutures either closer to the tarsus or deeper into the retractor plane.

Excess skin and muscle can be excised at the lower part of the wound.

The skin incision can be closed by single knots that are removed at 7 days.

Everting sutures are left in place for 10 to 14 days.

Horizontal lid shortening

If horizontal lid laxity is present, the lid or the canthal tendons have to be shortened. This has to be decided by pulling the lid away from the globe and assessing its spontaneous repositioning (’snap’ test), as well as pulling sideways to assess the position to which either the lacrimal punctum or the lateral canthus can be displaced, respectively. Pulling the lid sideways over the temporal orbital rim will give an estimate of lid laxity and the possible effect of shortening (lateral ‘thumb’ test)¹².

Transverse lid split with everting sutures and horizontal lid shortening (Quickert)

This procedure combines the correction of the upward movement of orbicularis muscle, as in a ‘Wies’-type procedure with the correction of a horizontal lid laxity.

Technique (Fig. 46.9)

A horizontal incision line is marked with ink below the lower border of the tarsus, just like in a ‘Wies’-type procedure.

Fig. 46.9 Transverse lid split with everting sutures and horizontal lid shortening (Quickert).

An almost vertical full-thickness lid incision, angled at 90° from the lid margin, is carried out in the lateral third of the lid.

Two or three 5-0 absorbable sutures are passed from the conjunctival side, through the conjunctiva at the lower edge of the wound, picking up the lid retractors. The sutures are exiting the wound and left for later placement.

The lid is pulled laterally and the necessary amount is resected by carrying out a parallel vertical incision with straight scissors.

The vertical wound is closed with interrupted 6-0 silk sutures as in a regular lid repair.

The everting sutures are now completed, entering the upper part of the wound between the tarsal plate and the pretarsal orbicularis muscle and exiting the skin anterior to the tarsus at about 2 mm below the lashes. The knots are tied and the wound closed with a 7-0 running suture.

Skin sutures are removed at 7 days, everting and lid margin sutures at 10 days.

Transverse lid split with everting sutures and horizontal lid shortening by lateral tarsal sling

Instead of a horizontal lid shortening by a vertical resection in the lateral third of the lid, the lid can also be shortened at the level of the lateral canthal tendon by a lateral tarsal sling procedure.

Technique

A horizontal incision is made at the lateral canthus. The lower part of the lateral canthal tendon is cut and the incision advanced through the conjunctiva and orbicularis muscle, until the lid can be pulled laterally. A full-thickness horizontal lid split is then made using straight scissors, below the tarsus and just up to the medial third of the lid.

Two or three 5-0 absorbable sutures are passed from the conjunctival side, through the conjunctiva at the lower edge of the wound, picking up the lid retractors. The sutures are exiting the wound and left for later placement.

A new lower limb of the lateral canthal tendon is created by excising the lid margin skin and preseptal muscle over about 5–7 mm, depending on the amount of laxity (in the case of an entropion, the laxity will be not as extensive, otherwise, ectropion would be the more likely situation). The tarsal conjunctiva is scraped away from the inner aspect of the tarsal strip. The strip of tarsus is freed of all remaining tissue and both arms of a 4-0 double armed long-acting absorbable suture are passed through the tarsal strip.

An incision is made in the upper part of the lateral canthal tendon and extended to the lateral orbital rim. The two arms of the double armed suture are passed through the incision and as far posterior to the orbital rim as possible and then passed through the skin incision lateral–superiorly. The strip of tarsus should be pulled to the posterior part of the orbital rim.

Excess skin and orbicularis muscle are now removed and the everting sutures are completed by passing the needles between the pretarsal orbicularis and the tarsus and through the skin at 2 mm below the lash line. The skin incision is closed by a 7-0 running suture.

Skin sutures are removed a 7 days, everting sutures at 10 days.

Posterior lamellar graft

When the posterior lamella is shortened due to cicatricial changes, the resulting entropion must be corrected by lengthening of the posterior lamella with a graft.

Technique

Traction sutures are placed through the lid margin to hold the lid everted while making a horizontal incision into the full thickness of the cicatrized tarsal plate, thus allowing the lid to be positioned in the correct position, correcting the inversion.

The bed for the implant must be prepared superiorly and inferiorly by freeing the remaining parts of tarsus, allowing the lower part to retract and the upper part to evert. The graft is then placed into the resulting space.

There are several choices for grafts, either autogenous or artificial: buccal mucosa, hard palate mucosa, tarsal plate with conjunctiva (from the upper lid of either the same or contralateral side), ear cartilage, Alloderm or similar products. The choice of graft is dependent on the surgeon’s experience and preferences, but if the lid needs firm stabilization it should include firm tissue and either a hard palate mucosal or Alloderm graft will be the best choice.

The graft is sutured into its bed with 6-0 vicryl Sutures. It is firmly secured by several 4-0 sutures that enter the graft at the mucosal side and are passed through the skin below the lashes to hold the graft in place.

Antibiotic ointment is put into the conjunctival sac and the lid closed with the traction sutures that can be left in place and secured on the forehead with an adhesive plaster for 3 days.

Sutures can be removed at 5–10 days.

Upper lid ectropion

Euryblepharon repair

Euryblepharon is a rare condition in which there is a vertical shortage of skin of the anterior lamella and a horizontal excess of lid tissue that leads to eversion when the orbicularis muscle contracts. It typically occurs in patients with Down syndrome and can lead to severe chronic inflammatory changes and keratinization of the conjunctival epithelium and corneal ulceration due to lagophthalmus. In mild cases, an inverting suture can be sufficient to re-invert the lid. This is limited to cases in which the lid still closes sufficiently to cover the corneal surface. If this is not the case, horizontal lid shortening and vertical replacement of skin are necessary.

Inverting suture

Technique

A double armed non-absorbable suture is passed through a bolster, into the lid above the upper fornix, then out through the conjunctiva at the upper border of the tarsus. The same needle is then passed through the same hole and back out through the skin at distance of about 3 mm. The suture is tied over the bolster and left in place for 10 days.

If this procedure fails to correct the condition permanently, a skin replacement will be necessary.

Full-thickness skin replacement and horizontal lid shortening

If an euryblepharon cannot be corrected with an inverting suture alone, the horizontal laxity and anterior lamella deficiency must be corrected by shortening the lid and a full-thickness graft.

Technique (Fig 46.10 A–C)

A traction suture is placed in the lid margin to hold the lid. The lid is inverted and the lid held in place by pulling on the suture. A supraciliary incision is made along the lash line, leaving at least 1.5 mm above the lashes and not exposing the lash roots. The skin is separated from the orbicularis muscle and the necessary defect created to allow complete and easy lid closure.

Fig. 46.10 (A–C) Euryblepharon repair. (A) Euryblepharon. (B) Pentagonal resection. (C) Full-thickness skin graft.

A full-thickness pentagonal excision is carried out in the lateral third of the lid and the wound closed by absorbable sutures through the tarsal plate.

A thin but full-thickness skin graft is harvested from the retroauricular area (or from any other suitable site like the inner aspect of the upper arm or the groin). The graft is adjusted to the defect and secured with a running 7-0 absorbable suture.

A firm pressure patch is applied over Vaseline gauze and kept for at least 3 days.

Graft sutures can be removed after 1 week and the scar can be treated locally with anti-scar formation ointment or aids after that. The lid margin sutures can be removed after 10 days.

Floppy eyelid repair

Floppy eyelid syndrome occurs typically in middle-aged (and obese) men who present with marked horizontal laxity and lash ptosis and a history of mucous discharge not associated with infectious conjunctivitis. The floppy lid may evert spontaneously and with forced closure of the lid in some cases, but can be massively displaced by the pulling it laterally in all. The disorder is most commonly associated with obstructive sleep apnea, which should always be looked for if the lid abnormality is present.

The tarsal tissue is soft and the lid foldable and lax. Surgery must aim to correct the horizontal laxity and surplus of tissue and prevent the lid from spontaneous eversion. Shortening the lid can be done by just resecting a full-thickness lateral pentagon, but since this might lead to loss of a large portion of the tarsus it is better to reduce the lid medially, as described below¹³.

Technique (Fig. 46.11 A–C)

The amount of excisable skin and the amount of resection to correct the horizontal surplus are determined by pulling the lid and skin and the incision marked with ink. The skin incision follows a blepharoplasty incision line. The skin is excised with a strip of orbicularis. A pentagonal full-thickness lid excision is made in the previously marked area of the medial third of the eyelid, at a safe distance to the upper punctum. The lid defect is closed by deep absorbable 6-0 sutures through the tarsus and intermarginal 6-0 silk sutures. The skin is closed by an intracutaneous or regular running suture. Skin sutures can be removed after 1 week, the intermarginal sutures after 10 days.

Fig. 46.11 (A–C) Floppy eyelid. (A) An example of a floppy eyelid. (B) Skin incision lines. (C) Wound closure.

Upper lid entropion

Upper lid entropion usually occurs as the result of an inflammatory and finally cicatrizing process of the posterior lamella. The choice of procedure to correct the inward malposition of the lid margin depends on the severity of rotation, the extent of scarring and the changes of the tarsus.

Shortening of the anterior lamella with or without vertical marginal split

In mild to moderate upper lid entropion, the anterior lamella is shortened and the margin rotated by everting sutures; the rotation can be augmented by a vertical lid margin split at the gray line.

Technique (Fig. 46.12 A–D)

The skin incision is made in the lid crease or slightly inferior at approximately 1 mm below the upper border of the tarsal plate. The incision is deepened through the orbicularis muscle and extended inferiorly to just above the lash roots. A 6-0 long-acting absorbable or silk suture is passed into the skin at 1–2 mm above the lashes, then through the tarsus at a 2 mm higher level parallel to the lid margin and out through the skin at the same height as entered. Four of these sutures are placed and tied, which will rotate the lid margin. The skin is closed by single knots that pick up the aponeurosis.

Fig. 46.12 (A–D) Anterior lamella repositioning with marginal lid split. (A) Upper lid entropion. (B) Placement of everting sutures. (C) A knot is preliminarily tied to test the everting effect. (D) Marginal lid split.

If the rotation of the lid margin pulls it from the cornea, a vertical split is made in the gray line, just anteriorly to the orifices of the meibomian gland, to allow the anterior lamella to retract. This wound can be left to heal by spontaneous epithelialization.

In order to ensure lid closure, it is advisable to weaken Muller’s muscle and to incise it over the length of the lid incision.

Sutures can be removed at 6 days (skin closure), everting sutures should be left at least 14 days.

Tarsal wedge resection

If the tarsal plate is thick, the effect of everting an upper lid entropion by everting sutures and a marginal lid split will be better stabilized by excising a wedge from the anterior portion of the tarsal plate.

Technique

A horizontal incision is made in the upper lid crease and the tarsal plate exposed by blunt dissection. The lash roots should not be exposed. Two incisions at a 90° angle to each other are made along the tarsal surface, in the area of maximal thickening and the resulting wedge of tarsus is removed. It will be necessary in most cases to incise the insertion of Muller’s muscle fibers at the upper border of the tarsal plate in order to advance the posterior lamella of the lid sufficiently. Three to four double armed 6-0 silk sutures are passed through the inferior part of the tarsus, onto the superior part and then out through the skin above the lash roots. A marginal split is done as in an anterior lamella repositioning procedure. The knots are tied and the lid will evert when the wound edges of the tarsal wedge resection are brought together (the marginal split will open and the anterior lamella will be repositioned). Any excess lid skin can now be removed and the wound closed with interrupted sutures or a running suture.

Skin sutures are removed after one week. Everting sutures should be left longer, i.e. 3–4 weeks. Long-acting absorbable sutures can be left until they disintegrate spontaneously.

Lid split and mucous membrane graft

Severe upper lid entropion with a thin tarsus is not suitable for a tarsal wedge resection. If the tarsoconjunctiva is intact and there is no or only minimal keratinization of the lid margin, the posterior lamella can be advanced by a lid split and the resulting anterior tarsal wound can be covered by a mucous membrane graft.

Technique

The lid is split with a knife into an anterior lamella and posterior lamella. The cut is made anterior to the meibomian glands and the posterior lamella is freed upwards to the fornix; Muller’s muscle will have to be horizontally dissected to allow vertical stretching of the posterior lamella. It can then be advanced until the lids close easily. In order to hold the posterior lamella advanced in relation to the anterior lamella, several double armed 5-0 long-acting absorbable sutures are placed at the upper border of the tarsal plate and passed through the skin crease. The sutures should be passed through the skin somewhat lower than the upper tarsal border in order to hold the lashes everted. The lower border of the anterior lamella is fixed to the tarsus with interrupted 6-0 absorbable sutures. A mucous membrane graft – preferably a split-thickness graft harvested from the mouth with a mucutome – is fixated with a 7-0 absorbable running suture. A thin full-thickness mucous membrane graft or an amniotic membrane graft can be used as well.

The sutures can be removed after 10–14 days.

Summary, suture material, key points, and complications

• Summary: If the entropion is severe, lid closure is incomplete, and an anterior lamella repositioning does not sufficiently correct the condition, an advancement of the posterior lamella with a mucous membrane graft is a very good way to obtain a vertically long enough upper lid with everted lashes.

• Sutures: 5-0 and 6-0 long-acting absorbable and 7-0 absorbable sutures are used.

• Key points: It is important to advance the posterior lamella sufficiently, i.e. at least 4 mm over the anterior lamella. Muller’s muscle needs to be incised in most cases to achieve this amount of advancement. Only if no mucous membrane graft is available should the exposed tarsus be left to spontaneous epithelialization.

• Complications: Retraction (possibly due to insufficient advancement) of the posterior lamella will lead to recurrence.