Restore normal anatomic eyelid position

• Correction of involutional lower lid ectropion, entropion, and/or retraction

Maintain anatomic apposition of lid to globe

• Lid laxity causes poor lid-to-globe apposition leading to tear film instability and exposure keratopathy

Restore normal lid tension

• Tear pump failure can result from excessive lid laxity or facial nerve palsy (Vick, OPRS 2004)
• Floppy eyelid syndrome, eyelid imbrication (see below)

Improve aesthetic appearance of eyelid

• Eyelid contour can be affected by laxity of lateral or medial canthal tendons
• Rounding of lateral commissure
• Contour abnormality can result from performing lower lid blepharoplasty without addressing lid laxity.
• Lateral canthal dystopia can be involutional, traumatic, or developmental
• Normal position of lateral commissure slightly higher than medial commissure
• Medial canthal deformities (e.g., telecanthus, dystopia, epicanthal folds) are usually traumatic or congenital

Indications

Lid malposition due to horizontal laxity

• Involutional ectropion (Bedran, Semin Ophthal 2010) (Figure 1)
• Poor lid-to-globe apposition causing exposure keratopathy
• Punctal ectropion causing epiphora
• Involutional entropion (Pereira, Semin Ophthal 2010)
• Significant ocular discomfort caused by lashes and keratinized skin rubbing directly on cornea
• Pathophysiology
• Lower-lid laxity
• Dehiscence of lower lid retractors
• Overriding orbicularis — often exacerbated by irritative symptoms causing blepharospasm ("spastic" entropion)
• Enophthalmos
• Lower-lid retraction (Chang OPRS 2011)
• Involutional — lid laxity
• Cicatricial — infection, inflammation, trauma, burns, postsurgical (e.g., lower-lid blepharoplasty, laser skin resurfacing)
• Mechanical — midface ptosis, craniofacial anomalies, tumor
• Paralytic — facial nerve palsy

Figure 1. Involutional right lower lid ectropion.

Tear pump failure

(Meyer, Curr Opin Ophthal 1993)

• Involutional and/or paralytic

Medial canthal tendon (MCT) laxity

• Severe laxity, especially in setting of facial nerve paralysis, can cause punctal ectropion, medial lower lid retraction, lagophthalmos/exposure keratopathy, and epiphora.
• Performing lateral canthal tendon (LCT) tightening in presence of MCT laxity can lateralize punctum and cause lacrimal outflow deficiency.

Canthal malposition

• Involutional, developmental, postsurgical, or traumatic

Floppy eyelid syndrome

(Culbertson, AJO 1981; Moscato, Compr Ophthal Update 2007)

• Marked lid laxity associated with softening of tarsus
• Multiple possible factors implicated in pathogenesis:
• Prone or side sleeping position causes mechanical pressure on lids
• Ischemia and reperfusion injury
• Upregulation of matrix metalloproteinases (MMP) implicated in elastin degeneration
• Lids can spontaneously evert during sleep, causing exposure keratopathy and chronic papillary conjunctivitis
• Associated with obstructive sleep apnea and obesity
• Surgical treatment involves upper-eyelid tightening

Eyelid imbrication

(Karesh, Ophthalmology 1993)

• Lid laxity causes upper-lid margin to overlap lower lid
• Upper palpebral conjunctiva rubs across lower lashes, leading to chronic irritation
• Sometimes associated with floppy eyelid syndrome
• Can be addressed with lower- and/or upper-lid tightening

Reconstruction following trauma or surgery

• Traumatic LCT/MCT avulsion
• Must rule out canalicular injury with MCT avulsion
• LCT resuspension following emergent lateral canthotomy and cantholysis for orbital compartment syndrome
• Tumor resection

Mild lower-lid laxity or lateral canthal deformity

• Open or closed lateral canthoplasty often performed in conjunction with various facial rejuvenation procedures (Taban, OPRS 2010) (e.g., upper- or lower-lid blepharoplasty, midface lift)

Contraindications

Relative

• Significant medial canthal tendon laxity (see above)
• Proptosis: surgical tightening of lids in presence of proptosis can lead to lid retraction
• Options for amelioration:
• Supraplacement of LCT on orbital rim (McCord 2008)
• Midface lift with possible malar augmentation to improve negative vector between cheek and orbit (Steinsapir, PRS 2003)
• Correction of proptosis (orbital decompression) or lateral rim repositioning (Kikkawa, Ophthalmology 2002)

Absolute

• Presence of malignancy, infection, or other pathology that would compromise surgical result

Patient history

HPI

• Inquire about complaints of tearing, ocular discomfort, exposure symptoms.
• Tearing often multifactorial: excessive reflex tearing and deficient lacrimal outflow

Conditions that can cause or exacerbate involutional changes

• Facial nerve paralysis
• Bell's palsy
• Facial trauma
• Surgery (e.g., vestibular schwannoma resection)
• CNS tumor
• Blepharospasm
• Obstructive sleep apnea (OSA)
• Risk factor for floppy eyelid syndrome (Moscato, Compr Ophthal Update 2007)
• Should be referred for sleep study if OSA suspected due to risk of systemic complications

Conditions that can cause or exacerbate cicatricial abnormalities

• Infection
• Trachoma
• HSV/HZV
• Necrotizing fasciitis
• Inflammation
• Stevens-Johnson syndrome
• Ocular cicatricial pemphigoid (OCP)
• Sarcoidosis
• Sezary syndrome, mycosis fungoides
• Tumors (primary or following resection/reconstruction)
• Basal cell carcinoma
• Squamous cell carcinoma
• Sebaceous carcinoma
• Melanoma
• Trauma
• Periorbital lacerations
• Burns (thermal or chemical)
• Surgery
• Lower-lid blepharoplasty
• Laser skin resurfacing
• Facial/orbital fracture repair

Conditions associated with medial or lateral canthal deformities

• Congenital anomalies (Jones 2013; Fries, Surv Ophthalm 1990)
• Down syndrome
• Craniosynostoses (Crouzon, Apert syndrome etc.)
• Euryblepharon
• Mandibulofacial dysostosis (Treacher-Collins syndrome)
• Oculoariculovertebral dysplasia (Goldenhar syndrome)
• Blepharophimosis syndrome
• Narrowed horizontal palpebral fissure
• Ptosis
• Epicanthus inversus

Trauma

• Naso-orbito-ethmoid (NOE) fractures (Markowitz, PRS 1991)
• Zygomaticomaxillary complex (ZMC) fractures
• Under-reduced frontozygomatic fracture (Converse, Clin Plast Surg 1975)
• Failure to resuspend midface following subperiosteal dissection, resulting in midface ptosis and lateral canthal dystopia (Lee 2008)
• Periocular lacerations

Clinical examination

Lid laxity

• Snap-back test, lid distraction
• MCT laxity: Distract lid laterally and observe punctal position
• Laxity significant if punctum moves close to or beyond nasal limbus
• Floppy eyelids
• Easily evertable upper lids
• Papillary conjunctivitis
• Eyelid imbrication: upper lid overlaps lower with lid closure

Lid malposition

• Ectropion, entropion, or retraction
• Punctal ectropion or override ("kissing puncta")

Lagophthalmos

Retractor disinsertion

• Associated with involutional entropion and severe involutional ectropion
• With lower lid eversion, edge of disinserted retractor can be visualized subconjunctivally as a transition from white to pink below the inferior border of the tarsus.

Lamellar shortening

• Scarring or shortening of anterior or posterior lamella can cause ectropion or entropion, respectively.
• Scarring of the orbital septum (middle lamella) can cause tethering of the lid to the orbital rim.

Midface ptosis and/or hypoplasia

• Downward traction exerted by cheek on lower lid can exacerbate retraction and ectropion
• Malar hypoplasia (developmental or age-related) can create negative vector of forces apposing lid to globe.

Signs of corneal exposure

• Epithelial erosions/defects, scarring, etc.

Lacrimal outflow evaluation as indicated

• Primary dye test or dye disappearance test
• Canalicular probing and irrigation

Proptosis or enophthalmos

Preoperative assessment

Treatment must be individualized to each patient.

Involutional ectropion

• Distract lid laterally to estimate effect of tightening on lid position.
• Consider medial spindle in addition to lower lid tightening if punctal ectropion persists (Nowinski, Arch Ophthalmol 1985).
• Evaluate for possible retractor dehiscence.

Involutional entropion

• Repair typically involves lower lid tightening, retractor reinsertion, and excision of overriding orbicularis (if external approach used).
• Retractors can be approached transconjunctivally (Erb, Ophthalmology 2006) or externally through subciliary incision.

Lower-lid retraction

• Critical to distinguish involutional from cicatricial, mechanical, and paralytic causes
• Depending on underlying pathology, might need to consider adjunctive procedures in addition to lid repositioning
• Midface ptosis — midface lift
• Midface hypoplasia — malar augmentation
• Cicatricial entropion or thyroid orbitopathy — posterior lamellar spacer graft
• Anterior lamellar scarring — full thickness skin graft
• Scarring of orbital septum — dermis fat graft spacer Chang

Medial canthal tendon laxity

• MCT plication can be performed alone or concurrently with lateral canthoplasty
• Anterior crus can be plicated transcutaneously (Sodhi, J Cranio-Maxillofacial Surg 2005).
• Might not improve globe apposition
• Posterior plication can be performed through transcaruncular approach (Fante, OPRS 2001).
• Theoretical advantage in correcting globe apposition due to posterior vector

Lateral canthal dystopia

• Usually correctable with standard LCT suspension from lateral orbital wall, with or without lower lid tightening
• In recurrent or complex cases (e.g., cicatricial retraction, midface reconstruction), lateral canthopexy may be considered by securing with sutures or wires to:
• Drill holes in lateral rim
• Titanium screws
• Bone anchors (e.g., Mitek, Lactosorb syndrome, etc.)

Medial canthal dystopia

• Usually post-traumatic or developmental
• Can be addressed with medial canthopexy or Z-plasty reconstruction

Telecanthus

• Usually traumatic or congenital
• Normal intercanthal distance approximately equal to horizontal palpebral fissure length
• Must determine whether abnormality is purely soft tissue, or if underlying bony deformity is present (i.e., telorbitism or hypertelorism)
• Repair technique largely depends upon this anatomic distinction

Epicanthal folds

• Numerous options involving advancement or transposition flaps
• Must determine whether attachment of MCT is in proper anatomic position; medial canthopexy may be required if not

Nonsurgical

Observation

Ocular lubrication

Corneal protection

• Burns (Malhotra Surv Ophth 2009), severe cicatrization
• Moisture chambers
• PROSE lens (Kalwerisky, Ophthalmology 2012)
• Amniotic membrane (ProKera) (Pachigolia, Eye Contact Lens 2009)

Horizontal lid taping

• Involutional entropion

Surgical

Lagophthalmos

• Tarsorrhaphy (McInnes, AJO 2006) (suture or permanent)
• Lid weight implantation (Mavrikakis OPRS 2006)
• Upper-lid recession (Ben Simon, AJO 2005)
• Full-thickness blepharotomy (Demirci OPRS 2007)

Involutional entropion

• Quickert sutures (Quickert, Arch Ophth 1971)

Lid tightening

• Full-thickness wedge resection (Callahan 1956) (largely historical)

Horizontal lower lid tightening

Lateral tarsal strip procedure

(Anderson Arch Ophth 1979) (Figure 2)

• Infiltrate local anesthetic.
• Perform lateral canthotomy and inferior cantholysis.
• Determine amount of horizontal laxity.
• Place lateral traction on lid and mark point where lid crosses lateral rim and commissure.
• Create tarsal strip
• Dissect anterior lamella and excise to point where lid crosses lateral commissure.
• Excise marginal epithelium.
• Detach retractors/conjunctiva from inferior edge.
• Remove palpebral conjunctiva with blade, low energy cautery, or radiofrequency ablation.
• Trim tarsal strip to point where lid crosses orbital rim
• Suspend strip from periosteum over inner aspect of rim
• 4-0 or 5-0 absorbable or nonabsorbable suture (e.g., polyglactin, polydiaxanone, or polypropylene) on a small half-circle needle (P‑2 or OPS‑5)
• Horizontal mattress or half-horizontal mattress pattern, ensuring positioning of strim posterior to lateral rim
• Slight overcorrection advisable: about 2–3 mm superior to intended final position of lateral commissure
• Reform lateral canthal angle (Weber, Ophth Surg 1991)
• Trim redundant skin
• Close skin

Figure 2. Lateral tarsal strip procedure. From Nerad JA, Techniques in Ophthalmic Plastic Surgery, 2010.

Modified Bick procedure

(Barrett, OPRS 2012)

• Lateral canthotomy/inferior cantholysis
• Distract lid laterally and mark point where lid crosses lateral rim.
• Excise triangular wedge of lateral canthal tendon and tarsus.
• Suspend end of tarsus to periosteum as above.
• Reform lateral canthal angle.
• Close skin.

Closed lateral canthoplasty

(Taban, Georgescu, Rizvi, Lessa)

• Carry dissection to lateral orbital rim through lateral upper lid crease incision.
• Pass suture internal to external through lateral commissure, then back internally at same point.
• Pass suture through periosteum behind lateral orbital rim and tie.
• Suture can also be passed through drill holes in lateral rim using "Leicester lasso" technique (Kannan OPRS 2014).
• 4-0 silk suture twisted into lasso and passed external to internal through drill holes x2
• LCT suture ends passed through lasso, pulled through drill holes with lasso, and tied

Reinforcement lateral canthoplasty

(Dailey OPRS 2011)

• For complex or recurrent LCT laxity/dehiscence
• Superior and inferior crus of LCT approached through supraciliary/subciliary incisions
• LCT plicated and suspended from periosteum behind lateral orbital rim
• Y-shaped graft (e.g., autogenous fascia lata, acellular dermal matix, porcine dermal collagen) sutured to limbs of LCT and periosteum over lateral rim

Adjunctive procedures

• Medial spindle procedure (Nowinski, Arch Ophthalmol 1985)
• Excision of diamond-shaped wedge of conjunctiva/retractors inferior to lower punctum
• Double-armed absorbable suture (e.g., 6-0 polyglactin or chromic gut) passed from inferior to superior wound edges, then through inferior fornix and externalized, tied over skin
• Orbitomalar ligament suspension (Korn PRS 2010)
• Dissection carried from lateral canthotomy through orbitomalar ligament under lateral midface, suture passed through deep aspect of SOOF and suspended from lateral orbital rim periosteum
• Alternative fixation technique: LCT suture passed through single drill hole in lateral rim and tied externally to SOOF suture (Oh, OPRS 2013)
• Midface lift
• Preperiosteal (Marshak OPRS 2010) or subperiosteal (Elner, Arch Fac Plast Surg 2003) dissection
• Consider malar augmentation for midface hypoplasia (Steinsapir, PRS 2003; Binder, Fac Plast Surg 2011)
• Midface tissues suspended and fixated with sutures to drill holes, screws, malar implants, or elevated with fixation devices (e.g., Endotine™ midface (Berkowitz, Aesth Surg J 2005)

Upper-lid tightening

• Full-thickness wedge resection (traditional)
• Lateral tarsal strip procedure or modified Bick procedure can be performed on upper lid in similar manner as lower lid (Dutton, AJO 1985; Perlman, OPRS 2002)
• 4-lid lateral tarsal strip-periosteal flap technique (Burkat, OPRS 2005)
• 5-mm lateral canthus incision to expose lateral rim
• 6-mm periosteal flap created and reflected medially
• Lateral tarsal strips fashioned in standard fashion and fixated to periosteal flaps with 5-0 polyglactin suture

Medial canthoplasty

Anterior medial canthal tendon plication

(Sodhi 2005)

• Create skin incisions (single horizontal or double vertical) over anterior crus of MCT and medial end of tarsus
• Pass suture sequentially through MCT near bony insertion, subcutaneous tunnel, and medial end of tarsus, taking care to avoid canaliculus (placement of lacrimal probe helpful)
• Tie under appropriate tension
• Close skin incisions(s)

Transcaruncular (posterior) medial canthal tendon plication

(Fante OPRS 2001)

• Incise conjunctiva below medial end of lower tarsus
• Create transcaruncular incision between caruncle and plica semilunaris, dissect bluntly to medial orbital wall
• Engage medial end of tarsus with suture (4-0 polypropylene on P-2 needle), avoiding canaliculus, and pass suture subconjunctivally to transcaruncular incision
• Pass same suture through periosteum at or above posterior lacrimal crest, then back through subconjunctival space to exit incision beneath tarsus
• If medial lower lid retraction is present, suture can be fixated more superiorly on medial rim Moe
• Adjust suture tension and tie
• Rotate knot to bury it in medial orbit

Medial tarsal suspension for medial lower lid retraction

(Frueh OPRS 2002)

• Create horizontal skin incisions from medial commissure to within 2 mm medial to each punctum.
• Dissect pockets in suborbicularis plane medial to lower punctum (avoiding canaliculi) and in superomedial upper lid.
• Pass suture (5-0 or 4-0 nonabsorbable) through periosteum over superomedial rim.
• Pass same suture through medial end of lower tarsus and tie under appropriate tension.
• Rotate knot to bury next to superomedial rim.
• Sew edges of upper and lower lid skin incisions together (medial tarsorrhaphy).

Repair of epicanthal folds

• Create canthoplasty incisions.
• Mustarde "stick man" (Anderson, Arch Ophth 1989)
• 5-flap technique
• Skin redraping method (Sa, Ophthalmology 2012)
• Undermine and transpose myocutaneous flaps.
• Excise excess soft tissue.
• Close skin and soft tissues.

Medial canthal z-plasty for MC dystopia

(Fox 1976)

• Create z-plasty incision incorporating anterior crus of MCT into lower limb of Z.
• Dissect MCT from lacrimal sac, undermine flaps.
• Transpose flaps and resuspend MCT in higher position with suture to periosteum over frontal process of maxilla.
• Close incisions.

Medial canthopexy

Congenital hypertelorism

• Bony reconstruction required
• Multidisciplinary craniofacial team approach recommended

Primary repair of NOE fracture

(See Orbital Fractures)

Transnasal wiring

(Smith 1992; Dutton, AJO 1985)

• Bilateral telecanthus, e.g., blepharophimosis (Sebastia, Aesth Plast Surg 2011) bilateral NOE fractures
• MCTs are wired to each other through drill holes across the nasal cavity.
• Wire can aid in reduction/fixation of bony abnormalities, or in setting of normal bony anatomy, can be passed through drill holes to engage MCTs and reduce telecanthus.
• Surgical approaches include bicoronal, Lynch incision, or incision directly over MCT (Nunery incision) (Timoney, OPRS 2012).
• Unilateral telecanthus (traumatic)
• MCT is wired across the nasal cavity to stable bone (frontal process of maxilla or frontal bone) on the opposite side (Kelly, OPRS 2004; Markowitz, PRS 1991).
• Titanium wire with barb and needle (Synthes®) can be used transnasally or anchored directly to frontal process (Engelstad Int J Oral Maxillofac Surg 2012).

Fixation of MCT to bone anchors

• Titanium microplates/screws (Shore, Ophthalmology 1992; Howard, Arch Ophth 1992)
• Mitek bone anchor (Antonyshyn, PRS 1996; Goldenberg, Ann Plast Surg 2008)
• Lactosorb anchor (Sharma, Arch Ophth 2006)

• Postoperative instructions
• Appropriate activity limitations
• Keep wounds clean and dry.
• Monitor for signs of infection.
• Medications
• Antibiotic ointment to incisions
• Pain medications as needed
• Counsel patient that lids will be initially tight and will slowly relax over time.
• If nonabsorbable skin sutures used, remove 5–7 days postoperatively.
• Monitor for appropriate anatomic changes and functional/aesthetic response to treatment.

• Failure to correct underlying pathology
• Suture failure with canthal dehiscence
• Multiple sutures can be placed primarily to prevent
• Suture granulomas
• Treatment: excision, steroid injection
• Lateralization of punctum caused by unrecognized/unaddressed medial canthal tendon laxity
• Lid retraction can occur in setting of proptosis or aggressive lower lid blepharoplasty.
• Diplopia due to scarring of conjunctiva or lateral rectus tendon sheath

Disease-related complications

• Uncommon, usually associated with involutional changes
• Facial nerve palsy: exposure keratopathy, epiphora, brow ptosis
• Floppy eyelid syndrome: associated with obstructive sleep apnea

Repair of involutional lower lid ectropion

• Traditional surgery involved full-thickness wedge resection.
• Kuhnt-Szymanowski procedure (Callahan 1966) (Figure 3)
• Bick procedure (Bick, AJO 1963)
• Lateral tarsal strip procedure described by Anderson in 1979 (Anderson, Arch Ophth 1979)
• Many modifications of tarsal strip now used

Repair of involutional lower lid entropion

• Most early repair techniques focused on retractors and/or orbicularis.
• Jones, Reeh, and Tsukimura (Jones 2013)
• Quickert sutures
• Full-thickness wedge resection advocated by Hill, Quickert
• Lateral tarsal strip introduced and has become standard component of entropion repair

Figure 3. Kuhnt-Szymanowski procedure. From Callahan A. Reconstructive Surgery of the Eyelids and Ocular Adnexa, 1966.

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