Rotation mattress suture: a powerful adjunct for ectropion correction

We describe an effective adjunctive suture technique for severe forms of both tarsal and marginal ectropion in a case series of 28 patients undergoing the rotation mattress suture technique for ectropion repair. Forty eyelids, followed for 1 to 5 years (average, 2.5 years), underwent tarsal or marginal ectropion repair, using the rotation mattress suture technique. Transient notching was noted in 31 eyelids (78%) but persisted in only 1 case (3%). Twenty-five eyelids (63%) had 0.5 to 1.0 mm of eyelid retraction. There were only 2 cases (5%) of recurrent ectropion. We found that excluding transient changes and predictable, mild lower eyelid retraction, the rotation mattress suture provides a powerful adjunctive reparative option for difficult cases of ectropion with low complication and failure rates.     

Sliding tarsal flap for reconstruction of large, shallow lower eyelid tarsal defects

PURPOSE: To describe a novel technique for reconstructing shallow, full-thickness defects of the lower eyelid. METHODS: Twelve patients with shallow, full-thickness lower eyelid defects after Mohs excision of eyelid malignancies were treated with this technique. The posterior lamella was reconstructed by obliquely incising the residual tarsus to create medial and lateral tarsal flaps. These flaps were obliquely overlapped to tighten the eyelid and reconstruct a tarsus approximating normal height. The anterior lamella defect was then reconstructed by using local flaps or free grafts in a conventional manner. RESULTS: Eyelid defects ranged from 25 to 40 mm horizontally and 20 to 35 mm vertically, with tarsal defects ranging from 18 to 27 mm horizontally and 2 to 3.5 mm vertically. A stable eyelid margin with good aesthetic appearance was achieved in all patients. Two patients had mild eyelid retraction not requiring intervention, and one had lower eyelid entropion 9 months after surgery. CONCLUSIONS: Sliding tarsal flaps are an effective technique for reconstruction of this type of defect. The advantages of this approach are its simplicity, utilization of preserved tissue, and avoidance of the morbidity associated with more complex procedures.     

Spontaneous eyelid expansion after full thickness eyelid resection and direct closure

BACKGROUND/AIMS: Direct closure of eyelid defects gives excellent functional results but is usually restricted to defects measuring less than a quarter of the eyelid length for fear of distorting the palpebral aperture and compromising lid function. The authors have used direct closure in larger defects. The aim of this study was to establish the effects of direct closure of full thickness eyelid margin defects under tension on the palpebral aperture dimensions. METHODS: A consecutive series of patients who had undergone one eyelid, full thickness lid resection repaired by direct closure were identified and invited to have both eyes photographed. The palpebral apertures of both eyes were measured from the photographs by a masked observer. The amount of eyelid resected was recorded from the operation notes. The unoperated palpebral aperture was used as the control. The result were analysed using a paired samples t test. RESULTS: The photographs of 18 patients were included in the analysis. The mean width of excised full thickness lid tissue was 15 mm (range 7-26 mm). The mean vertical palpebral aperture height was 9.2 (SD 1.4) mm in the operated eye as opposed to 9.3 (SD 1.2) mm in the non-operated eye. The mean horizontal palpebral aperture width was 26.1 (SD 1.9) mm in the operated eye as opposed to 26.4 (SD 1.8) mm in the non-operated eye. There was no statistically significant difference between the operated and unoperated horizontal and vertical palpebral measurements. CONCLUSIONS: Direct closure of large full thickness eyelid defects is possible in selected patients with excellent functional and cosmetic results. Eyelid tissue expansion occurs spontaneously following direct eyelid defect closure under tension, restoring the palpebral aperture dimensions.     

Double-bridged flap procedure for nonmarginal, full-thickness, upper eyelid reconstruction

PURPOSE: To describe the technique and results of double-bridged flap reconstruction of full-thickness upper eyelid defects that spares the upper eyelid margin. METHODS: The surgical technique is described and illustrated in 2 patients who underwent this procedure. RESULTS: The 2 patients presented in this study achieved excellent functional and cosmetic results following the procedure. One patient subsequently underwent a frontalis sling procedure to correct residual ptosis. CONCLUSIONS: Double-bridged flap reconstruction of the upper eyelid that spares the eyelid margin can provide excellent functional and cosmetic results, particularly in cases of nonmarginal eyelid tumor excision, severe upper eyelid scarring, and severe cicatricial retraction.     

Internal cantholysis for full thickness eyelid defects

Eyelid reconstruction requires an understanding of normal eyelid anatomy and function. A thorough understanding of the basic anatomy, contour, and mobility of the eyelids is essential in restoring the tissue to its presurgical level. There are many different surgical options to assist in the repair of full thickness eyelid defects involving the margin. Direct wound closure depends on eyelid laxity and is often possible with smaller defects. Moderate to larger sized defects are often under undue wound tension if direct closure is attempted. We have developed a new technique for closure of eyelid defects using a transconjunctival cantholysis to release the lateral canthal tendon cruces, thereby avoiding the external incision while still allowing for eyelid mobility. Using this technique for defects 15 mm in horizontal eyelid margin length or greater, we have found positive results. Direct closure of eyelid defects represents the most straightforward technique to repair any full-thickness eyelid defect and provides maximal functional and cosmetic results. Internal cantholysis represents an excellent option for repairing smaller and even larger full thickness eyelid defects. Eyelid mobility increases by 4–10 mm, sometimes more, and allows for closure of defects larger than even 20 mm.     

皮肤眼轮匝肌切除联合睫毛外翻褥式缝合矫正儿童下睑倒睫的疗效观察

目的 观察下睑皮肤眼轮匝肌切除联合睫毛外翻褥式缝合矫正术治疗儿童下睑倒睫的远期疗效。设计 回顾性病例系列。研究对象 2013年6月至2016年2月北京同仁医院眼科下睑倒睫患儿200例（400眼）,年龄3~10岁,平均5.56±2.30岁。方法 对200例（400眼）下睑倒睫者适量切除下睑皮肤及眼轮匝肌,睫毛外翻褥式缝合,皮肤连续缝合,部分患者联合灰线切开。术后随访观察6~12个月。主要指标 睫毛位置、畏光、流泪、角膜损伤、眼睑位置形态、有无下睑泪小点外翻、下睑皮肤凹陷性瘢痕、有无明显的下双眼皮。结果 术后患者倒睫全部矫正。200例患者术后随访观察6个月,倒睫无复发。170例患儿随访观察12个月,1例（1眼）倒睫部分复发。术后200例患儿畏光、流泪均消失,200例（380眼）角膜上皮损伤愈合,无下睑内、外翻,无下睑泪小点外翻,无下睑切口处皮肤凹陷性瘢痕,无明显下双眼皮,外观良好。结论 通过对下睑倒睫手术方案的精准设计,皮肤以及眼轮匝肌切除联合睫毛外翻褥式缝合,远期观察倒睫手术效果确切,且外观恢复良好。     

“Sandwich Block” for Eyelid Reconstruction

Purpose: To report on a one-stage technique for eyelid reconstruction with preservation of the eyelid margin.

Design: Prospective study.

Methods: Five patients with small-to-intermediate full-thickness lower eyelid defects (n?=?3) and upper eyelid defects (n?=?2) after tumor excision. Defect size ranged from 5 to 7?mm vertically and from 7 to 12?mm horizontally. For eyelid reconstruction, a full-thickness pentagonal graft from the opposite lid was sutured into the full-thickness defect after removal of the orbicularis oculi muscle from the graft. The orbicularis muscle flap from the recipient eyelid was mobilized and brought in for vascular supply between tarsus and skin of the graft. The outcome after surgery was assessed using a subjective scoring system with 4 subsequent grades.

Results: At 1 week postoperatively, adequate viability of the grafts was noted in all patients. After a mean follow-up of 13 months (range 3–33 months) the cosmetic and functional outcome was adequate in 1 case, good in 2 cases, and excellent in 2 cases.

Conclusion: Reconstruction of small to intermediate full-thickness defects of both lower and upper eyelid with the “sandwich block”-technique is associated with a good functional and cosmetic outcome.     

Congenital upper lid colobomas: management and visual outcome

PURPOSE: Congenital upper lid colobomas may be associated with ocular and systemic anomalies. The ophthalmologist's role involves both the diagnosis and management of their various ocular structural defects and management of the visual development. METHODS: All cases of congenital eyelid colobomas referred to the Singapore National Eye Centre between July 1992 and July 1995 were assessed for the extent of the eyelid defect, associated ocular anomalies, status of the cornea, and any systemic anomalies. RESULTS: Four infants were tested during this period. The mean follow-up was 25 months (range, 16 to 30 months). All required surgical correction of their eyelid defects before 2 years of age. The patients also had refractive errors requiring amblyopia management. Three of the babies also needed other surgical procedures. CONCLUSIONS: Congenital upper eyelid colobomas are a potential threat to vision at an early age and a significant cosmetic blemish later in life. Early surgical intervention is usually required when the defect is larger than one third of the eyelid margin. Close monitoring of the visual development of patients with congenital upper eyelid colobomas is also essential since the risk of amblyopia in these patients is high.     

60例眼睑全层裂伤的临床特征和急诊手术方法

目的探讨急诊眼睑全层裂伤的病因、临床特点、手术方法及效果。设计回顾性病例系列。研究对象北京同仁医院眼科急诊的60例（60眼）眼睑全层裂伤患者。方法询问病史，详细眼科检查。应用垂直褥式、水平褥式和三缝线缝合法修复眼睑全层裂伤。对伴有泪小管断裂、内外眦韧带离断、眼睑皮肤缺损、眼睑全层缺损、提上睑肌断裂者，还需行泪小管断裂吻合、内外眦韧带复位、提上睑肌断裂缝合复位、皮肤缺损及眼睑缺损修复术。主要指标眼睑形态，日艮睑位置，眼睑运动功能，吻合后的泪小管是否通畅。结果眼睑全层裂伤病因主要是车祸伤、外物击伤、坠落伤、动物咬伤。眼睑裂伤多伴有泪小管断裂、内外眦韧带离断、眼睑皮肤及全层缺损、提上睑肌断裂。急诊手术后随访6～12个月，绝大部分患者术后眼睑外观形态、眼睑闭合以及运动恢复良好，38例（95％）泪小管吻合术后保持通畅。结论车祸伤和外物击伤是急诊眼睑全层裂伤的主要原因，及时、正确、细致地手术处理可使大部分眼睑裂伤在Ⅰ期得到良好的修复，同时也为少部分患者Ⅱ期整复做好准备。     

Direct Frontalis Flap with and without Levator Pulley for Correction of Severe Ptosis with Poor Levator Function in the Same Patient

Purpose: To compare two techniques of frontalis muscle flap suspension in different eyelids of the same patient for correction of severe ptosis with minimal levator function.

Material and methods: A prospective study of four patients with severe bilateral ptosis and poor levator function, who underwent direct frontalis muscle flap on the right eyelid and frontalis muscle flap with levator pulley on the left eyelid was conducted. Eyelid studies measurements were taken at baseline, 2 months, one year and 5 years after surgery. The presence of complications, flap function and palpebral contour were evaluated.

Results: Despite the surgical technique performed, good results in terms of functionality, contour and aesthetics were observed. In the eyes that underwent frontalis muscle flap (FMF)-direct, there were 2 cases with moderate anteriorization of eyelid margin in extreme upgaze and all patients showed eyelash ptosis that persisted one year after surgery, but improved after 5 years. In the eyes that underwent FMF-pulley, no upgaze anteriorization of eyelid margin was observed and three patients had eyelash ptosis of lesser extent than the fellow eye, improving after 1 year follow-up. FMF-pulley showed more long-term stability in eyelid height, compared with FMF-direct.

Conclusions: Frontalis muscle flap with a pulley in the levator aponeurosis prevents some complications caused by the excessive vertical component of the direct frontalis muscle flap, especially in deep-set eye patients, with better stability of the eyelid height and contour over time.     

A new method for eyelid elevation in glaucoma patients with ptosis during automated perimetry testing

PURPOSE: Ptosis is a well-recognized confounding factor when interpreting superior visual field defects. As the current technique for eyelid elevation during automated perimetry is cumbersome and inconsistent, we developed a new technique. To evaluate its efficacy and feasibility, we studied a group of glaucoma patients with ptosis and superior visual field defects that had been attributed to nerve fiber layer defects. PATIENTS AND METHODS: A 24-2 SITA-fast visual field was performed without eyelid elevation. Then, it was repeated either with elevation (group A, 14 eyes, 7 patients) or without (group B, 9 eyes, 5 patients). Elevation was achieved by the following method: a 4-0 silk suture (needle removed) was wrapped around a micropore strip, attached to the upper eyelid margin. Suture edges were pulled and attached to the forehead creating a slinglike elevation. Mean thresholds of upper and lower hemifields were calculated. Mean deviation and pattern standard deviation were recorded for each visual field. Results of the first and second tests were compared. RESULTS: Eyelid elevation resulted in significant improvement in mean thresholds for upper hemifield in group A: values increased by 28% in OD and 22% in OS. Lower hemifield values did not change. Significant improvement also was observed in mean deviation and pattern standard deviation. In group B, there were no significant differences between the 2 sets of tests. CONCLUSIONS: This new method of eyelid elevation significantly improves visual field testing by reducing the confounding effect of ptosis on interpretation of visual field defects in glaucoma patients.     

Dry Eye Symptoms in Patients after Eyelid Reconstruction with Full-Thickness Eyelid Defects: Using the Tomey TG-1000 Thermographer

Background: Large full-thickness eyelid defects are conventionally reconstructed by either a Hughes flap or Cutler-Beard bridge flap. Since the structure of the eyelid and its components are necessary for the tear film production and stability, we investigated the outcome after eyelid reconstruction focusing on dry eye symptoms using a new thermographic device, the TG-1000. Methods: Seventeen eyes of patients formerly treated with Hughes flaps (n = 16) and a Cutler-Beard bridge flap (n = 1) were compared to untreated healthy eyes (n = 17) regarding the functional and aesthetic outcome. The follow-up ranged from 3 to 63 months (mean 24.88 ± 17.86). Results: There was no significant difference in Schirmer's test, break-up time and ocular surface temperature (p > 0.05) between patients after full-thickness eyelid reconstruction and a control group. Eleven patients had minor postoperative complications such as notching of the lid margin (11/17), epiphora (1/17), superficial punctate keratitis (6/17), trichiasis (2/17) and a mild tendency to eversion of the lid margin (6/17). More than 75% of the patients rated their postoperative aesthetic outcome as good or even excellent. Conclusion: The new TG-1000 device is a simple and quick tool for screening of dry eye. This study shows that tarsoconjunctival grafts offer good aesthetic and functional outcome with sufficient tear film composition and stability.     

采用180°旋转皮瓣修复眼睑肿物切除术后眼睑皮肤缺损的临床研究

目的　探讨采用180°旋转皮瓣修复眼睑肿物切除术后眼睑皮肤缺损的安全性和有效性。方法　回顾性分析29例38眼采用180°旋转皮瓣修复眼睑肿物切除术后造成的眼睑皮肤缺损患者。术中按照标记线切除肿物后,在肿物一侧或两侧标记松弛的上睑或下睑皮肤量,按照重睑或眼袋延长线切开皮肤,在靠近皮肤缺损区的上方或下方留5 mm左右宽的蒂,分离皮瓣,并带有少量的眼轮匝肌,然后将皮瓣旋转180°,修剪皮瓣后间断缝合,再连续缝合供皮区皮肤切口。术后加压包扎48 h。对术后外观和皮瓣的存活情况进行连续性观察。结果　所有180°旋转皮瓣均在眼睑缺损区良好存活,不需要打包加压,而且皮瓣收缩量低,术后手术瘢痕相对隐蔽。2眼皮瓣在术后早期出现皮瓣尖端发黑;多数皮瓣蒂部早期存在轻度猫耳现象,术后3个月猫耳逐渐平复,除1眼术后6个月因上睑皮肤松弛和猫耳现象而行上睑成形术外,其余患者均无需二次手术。结论　180°旋转皮瓣手术操作相对简单,可避免发生眼睑外翻、变形等并发症,是眼睑前层缺损修复的备选方法。     

Correction of involutional lower eyelid medial ectropion with transconjunctival approach retractor plication and lateral tarsal strip

AIM: We describe the technique and our results in managing lower eyelid involutional medial ectropion using a combination of lateral tarsal strip to address horizontal eyelid laxity, and transconjunctival inferior retractor plication to address inferior retractor dehiscence. METHODS: Patients with symptoms of epiphora or signs of medial ectropion were offered this procedure. All had the following characteristics: medial lower eyelid eversion, punctal eversion >3 mm, medial canthal tendon laxity <4 mm, significant horizontal eyelid laxity and lacrimal systems that were patent to syringing. RESULTS: A total of 24 eyelids of 17 patients underwent this procedure over a 12-month period. The mean age of the patients was 79.7 years; 11 were male and six were female. The mean follow-up time was 18 months. Two eyes had undergone previous surgery. All patients had restoration of the eyelid margin to the globe and relief of symptoms. No complications were noted. DISCUSSION: These results suggest that excision of posterior lamellar tissue is not necessary for correction of involutional medial ectropion. Transconjunctival plication or reattachment of retractors is easy to perform and allows for the repair of more than the medial portion of the retractors if required.     

Medial tarsal suspension: a method of elevating the medial lower eyelid

PURPOSE: When attempting to elevate the lower eyelid for any reason, medial elevation is the most difficult to attain. Medial canthal tendon tightening creates mostly horizontal tension and contributes little vertical vector. We present a technique for applying a lifting force to the medial end of the eyelid: medial tarsal suspension. METHODS: The technique to suspend the medial lower eyelid tarsal plate to the superior orbital rim periosteum is described. The procedure, medial tarsal suspension (MTS), was performed on 38 lower lids of 24 patients. Adjunctive procedures, most commonly lateral canthal sling, were performed on 66% of the lids at the time of the initial medial tarsal suspension. The patients ranged in age from 29 years to 84 years. All had medial lower eyelid retraction, with facial nerve palsy, Graves eye disease, involutional lower eyelid retraction, and forms of muscular dystrophy the commonest etiologies. RESULTS: Thirty-one (82%) of the 38 MTS procedures were successful. There was no unifying factor among the seven failed procedures in five lids of five patients. Three of the five patients, including two who were operated on twice, ultimately had a successful MTS. This procedure was not repeated on the other two failed patients. Range of follow-up was 9 months to 5.6 years, with a mean of 3.7 years. The mean elevation of the central lower eyelid was 1.6 mm in the successful cases. CONCLUSIONS: Medial tarsal suspension is an effective way to elevate the medial end of the lower eyelid.     

Modifications to the semicircular flap technique in eyelid reconstruction.

The most common reconstructive procedure in the upper and lower eyelid is direct closure of the lid margin. When additional mobilization of tissue is needed to close a defect, lateral canthotomy and cantholysis is suggested. Mobilization of tissue beyond the lateral orbital rim is occasionally required. We have found that in the lower eyelid the mobilized tissue is much better supported if the initial incision is made vertically toward the eyebrow rather than temporally, as is suggested with the semicircular flap technique. We describe modifications to this technique, which we refer to as the vertical-temporal advancement flap, and present the results in 28 consecutive patients followed for 8 months to 3 years.     

Lower eyelid reverse ptosis repair

PURPOSE: To report the results of the surgical repair of lower eyelid reverse ptosis. METHODS: Retrospective case series. Eight patients ranging in age from 31 to 77 years underwent surgical repair of lower eyelid reverse ptosis. The pupillary axis of the affected eye(s) in each patient was obscured in downgaze, interfering with reading. The lower eyelid reverse ptosis resulted from involutional changes in 3 patients, previous orbital decompression in 3 patients, multiple prior retinal and extraocular muscle operations in 1 patient, and previous orbital floor fracture and repair in 1 patient. Transcutaneous advancement of the lower eyelid retractors was performed in 12 eyelids of the 8 patients. RESULTS: The mean preoperative vertical eyelid fissure was 6.2 mm (median, 6 mm; range, 3-9 mm), increasing after surgery to a mean of 7.7 mm (median, 8 mm; range, 5-11 mm). The mean preoperative distance between the central light reflex and the lower eyelid margin was 1.7 mm (median, 1.25 mm; range, 1-4 mm); this distance increased to a mean of 3.3 mm (median, 3.25 mm; range, 2.5-4.5 mm) after surgery. Symptoms improved in all patients, and there were no perioperative complications. Follow-up intervals ranged from 2 months to 24 months (mean, 9 months; median, 13 months). CONCLUSIONS: Analogous to upper eyelid ptosis repair by advancement of the levator aponeurosis, lower eyelid reverse ptosis may be corrected effectively and safely by advancing the lower eyelid retractors.     

Reconstruction Following Subtotal Full-Thickness Upper Eyelid Resection with Preservation of the Lid Margin

Purpose: To describe a modification of a technique for upper eyelid reconstruction previously described by Patrinely et al. Methods: Radical excision of a large adenoid cystic carcinoma of the upper eyelid resulted in a subtotal full-thickness eyelid defect with preservation of 2 mm of eyelid margin. Reconstruction was performed with a free transconjunctival graft of maximum size from the contralateral upper eyelid, an overlying bipedicled skin-orbicularis oculi muscle flap and a free skin graft. Results: With this one-step technique, a good cosmetic and functional result could be obtained. Conclusion: If the eyelid margin can be spared, reconstruction of even very large upper eyelid defects with a modification of the technique reported by Patrinely et al. may yield a good result.     

Medpor下睑插片植入治疗下睑退缩

目的评价Medpor下睑插片作为下睑植入物治疗先天性及后天性下睑退缩的效果。设计回顾性病例系列研究。研究对象33例患者36眼，其中先天性下睑退缩4例6眼，后天性者29例30眼。方法术前测量在第一眼位下睑相对角膜下缘的位置及距下眶缘的位置。手术采用下睑袋皮肤切口，打开眶隔，视患者下睑退缩程度修剪Medpor下睑插片的形状及大小，将植入物置于下睑板下缘及眶下缘骨缘之间。术后观察植入物是否移位或脱出。术后2周及3个月时测量下睑位置，观察其变化情况。主要指标第一眼位下睑位置。结果对33例36眼行Medpor下睑插片植入者随访6～24个月，无植入物脱出及移位。34眼在第一眼位下睑位于角膜缘或角膜下缘上0．5mm，2眼仍残存≥1mm的下睑退缩。结论Medpor下睑插片作为植入物可提供下睑长期的支撑，可达到良好的功能及美容效果。Medpor下睑插片可作为治疗下睑退缩的较理想植入物。     

Free tarsus autogenous graft struts for lower eyelid elevation

PURPOSE: Free tarsus autogenous graft (FTG) has emerged as a useful biological spacer in lower eyelid elevation. However, it has limited use where a spacer of greater than 4 mm height is required, because at least 4 mm of upper tarsal height must be preserved to maintain upper eyelid rigidity. We describe an augmentation of FTG in its use as a spacer, by way of creating 2 parallel-placed vertical FTG struts, in contrast to interpositioning the FTG horizontally. METHODS: This case series describes the technique of harvesting and interpositioning FTG struts. Nine eyelids in 6 patients in whom FTG struts were used for lower eyelid elevation are reported. The patients ranged in age from 41 to 80 years. Underlying diagnoses included thyroid orbitopathy, previous blepharoplasty, and previous facial and eyelid thermal burns. RESULTS: FTG struts achieved an effective spacer height of up to 7 mm, and follow-up of 9 to 20 months revealed a good outcome in all 3 cases, with no complications. CONCLUSIONS: FTG struts provide an effective and lasting lower eyelid elevation when used as a spacer. A spacer graft of up to 7 mm in vertical height may be harvested from a long strip of upper eyelid tarsus that is 4 mm in vertical height. This technique would allow autogenous upper eyelid tarsus to be harvested with maximum conservation of tissue.