The natural history is for the laxity to worsen and for the ocular surface irritation to persist and worsen.
Corneal erosion can result from chronic mechanical abrasion and can lead to scarring.
Ocular lubrication at night can protect the eye from exposure.
Meibomian gland dysfunction can be treated with tetracycline and other measures.
Blepharitis can be treated with steroid/antibiotic ointment.
Eyelids can be taped and eye shield can be worn while asleep.
Sleep apnea can be treated with positive pressure ventilation.
There are important differences between horizontal tightening of the upper versus the lower eyelid.
- The lower lid is static, whereas the upper lid is dynamic.
- Raising the upper lid accentuates lid margin irregularities and notching after wedge excision on the upper lid.
- In lower lid wedge excision, palpebral conjunctival disruption is mostly away from the cornea, whereas upper lid wedge excision disrupts the palpebral conjunctiva in direct contact with the cornea.
- The lower lid tarsus has a constant height of 4 mm across the horizontal span, whereas the upper lid tarsus has a variable height of 3–10 mm.
- The most vulnerable area of the lower lid is medial at the tear drainage system, whereas the vulnerable area of the upper lid is lateral where the lacrimal gland ductules emerge.
- The "dog ear" created by a large wedge excision in the lower lid will extend below the lid margin and can be blended into the skin tension lines, whereas the same excision in the upper lid creates a vertically oriented scar that runs perpendicular to and in the direction of the lid crease (Figure 2).
- A lid crease incision can be made to redistribute skin after an upper lid wedge excision.
- Horizontally tightening the lower lid does not significantly change its position because it is a straight line, whereas horizontally tightening the upper lid can induce a ptosis because it is an arc.
- Shortening the circumference reduces the radius.
- The arc length of excised tissue in tightening the upper lid for FES is commonly greater than the length of excised tissue in tightening the lower lid for ectropion.
Lower lid laxity is frequently repaired at the same time as upper lid laxity in FES.
- The two incision sites should ideally be adequately separated, for example, by performing a wedge excision in the upper lid and lateral tarsal strip procedure in the lower lid.
Pentagonal wedge resection (Figure 3) at the lateral third of the upper eyelid is a reasonable approach to tightening the upper lid.
The wedge excision can be performed in the medial third of the lid.
Lateral tarsal strip repair of the upper lid can be performed, but care must be taken to avoid trauma to lacrimal gland ductules.
A temporally placed back-tapered wedge resection and advancement flap can be performed to create a wound that is more nearly parallel to the eyelid crease, potentially camouflaging it (Perlman, OPRS 2002).
Figure 2. 2–3-mm incisions perpendicular to the lateral canthal angle and curvilinear lid crease incision.
Figure 3. Pentagonal excision of posterior lamella.
Other management considerations
There might be a need for concurrent repair of ptosis, dermatochalasis, or lacrimal gland prolapse.
Common treatment responses, follow-up strategies
Once the mechanical laxity has been adequately corrected, the inflammation should improve.
Further tightening might be needed until the problem is adequately corrected.