Lateral canthal dynamics, correlation with periorbital anthropometric measurements, and effect of age and sleep preference side on eyelid metrics and lateral canthal tendon

PURPOSE: To evaluate dynamic and static properties of lateral canthal tendon and involutional periorbital anthropometric and lateral canthal changes with any possible effect of sleep reference side on these changes. METHODS: Ninety-two healthy adult subjects with a mean age of 43.5 years were enrolled in the study. Lateral canthal tendon lengths (LCT), canthal movement amplitudes, and other periorbital anthropometric parameters were measured. Any effects of age and sleep preference side on anthropometric and particularly lateral canthal tendon measurements were evaluated. Pearson correlation analysis, one-way analysis of variance, and t-test for paired samples were used for statistical evaluation. RESULTS: LCT length was weakly correlated with age, lower lid tractability, horizontal palpebral fissure length, and interpupillary distance and also inversely correlated with margin reflex distance, but not with other measurements. Age was also correlated with lower lid tractability, and with the ratio of LCT to the horizontal palpebral fissure length (LCT-HPFL). No correlation between age and horizontal palpebral fissure length was detected. Age was weakly and inversely correlated with canthal height but not with canthal movement amplitudes. No effect of sleep preference side on LCT length, canthal height, or lower lid tractability was detected. CONCLUSIONS: Lateral canthus has a dynamic structure that is not correlated with any other periorbital anthropometric measurements. LCT length is correlated with lower lid tractability, and increases with age, unlike horizontal palpebral fissure that stays constant with increasing LCT-HPFL ratio. Sleep preference side has no effect on the eyelid metrics and LCT.     

Medial canthal tendon repair for moderate to severe tendon laxity

Background: Medial canthal tendon laxity is a common cause of epiphora and ocular irritation. It is difficult to treat due to the proximity of the lower canaliculus and punctum to the tendon. Methods: The results of a prospective series of patients with involutional medial canthal tendon laxity between 1997 and 2002 were reviewed. Symptoms and measured laxity were recorded before and after medial canthal tendon repair. The medial canthal tendon was routinely repaired through a cut along the lid margin extending from the punctum medially. This avoids a vertical cut onto the anterior lamella of the eyelid, which is useful if a skin graft is required. Results: Twenty lower eyelid medial canthal tendon repairs were performed on 17 patients. Preoperatively, the lower punctum in all patients was able to be distracted to the medial limbus or further and in 50% of cases, the lower lid punctum was able to be distracted to the pupil midline or further. Postoperatively all patients had reduction of their medial canthal tendon laxity. Postoperatively in 85% of cases the lower punctum was not able to be distracted beyond the medial limbus; however, 15% of cases still had significant residual laxity. Eighty‐five per cent of patients reported improvement in symptoms. Conclusions: This is an effective procedure in the majority of patients with moderate to severe medial canthal tendon laxity; however, residual lower lid laxity persisted in some patients.     

External (subciliary) vs internal (transconjunctival) involutional entropion repair

PURPOSE: To compare surgical outcomes of internal (transconjunctival) vs external (subciliary) involutional entropion repair. DESIGN: Retrospective, consecutive case series. METHODS: Electronic medical record review of all patients who underwent involutional entropion repair at the Jules Stein Eye Institute over a 4-year period was performed. MAIN OUTCOME MEASURES: Anatomic and functional success, recurrence rate, and complications. RESULTS: Forty-nine eyes (39 patients) were operated. Twenty-nine eyes underwent subciliary incision repair; 20 eyes underwent transconjunctival repair, both with lower lid retractors reinsertion. Good correlation was found between two masked observers in grading surgical outcome (on a scale of 1 to 4) (r = .76, P < .001). Forty-two cases (84%) achieved good surgical repair and improvement in symptoms. Recurrence was noticed in 4 eyes (8.2%). Recurrence was higher with the internal approach (15% vs 3% with subciliary incision), but this was not statistically significant (P = .14). Complications included: three cases (8.2%) with mild eyelid retraction that were treated conservatively, three cases with postoperative ectropion (all in the external approach, two of which lateral canthal resuspension was not performed), and two cases (4.1%, one case in each group) with pyogenic granuloma. CONCLUSIONS: Surgical correction of involutional entropion by reinsertion of lower eyelid retractors has similar outcome with internal (transconjunctival) and external (subcilliary) approaches. Although not statistically significant, internal repair may result in a higher recurrence rate, whereas external repair may show more postoperative ectropion, most probably attributable to scarring of the anterior lamella. Lateral canthal resuspension, when needed, may reduce the rate of postoperative ectropion.     

Repair of telecanthus by anterior fixation of cantilevered miniplates.

BACKGROUND: The accepted surgical method for telecanthus repair is transnasal wiring. This procedure requires a stable posterior lacrimal crest on the affected side and surgical manipulation of the wires as they exit the contralateral side. A method for repairing telecanthus that obviates these prerequisites is presented. Indications for use of this technique and comparison to transnasal wiring is discussed. METHODS: A Y-shaped titanium rigid orbital plating system ("miniplate") was used to surgically correct traumatic telecanthus in five patients, two in the acute setting and three in late reconstruction. The miniplate was cantilevered from the lateral aspect of the nose and directed posteriorly into the orbit. This provided a stable fixation point for the medial canthal tendon. RESULTS: Marked resolution of the telecanthus was noted in four patients. No post-operative complications have been encountered to date. CONCLUSIONS: Miniplate fixation was used successfully to repair unilateral traumatic telecanthus. Miniplate fixation of the medial canthal tendon should be considered in unilateral cases of traumatic telecanthus and in cases where poor bony support for transnasal wires is evident.     

Infraglabellar transnasal bilobed flap in the reconstruction of medial canthal defects

We investigated the effectiveness of reconstruction using an infraglabellar bilobed flap of transnasal skin and subcutaneous tissue for patients with medial canthal defects. Our noncomparative interventional case series involved 11 consecutive patients with medial canthal defects following Mohs micrographic excision of basal cell carcinoma. The medial canthal area was divided into 3 zones: zone 1, just above the medial canthal tendon; zone 2, centered on the medial canthal tendon; and zone 3, just below the medial canthal tendon. Primary closure was achieved easily with a good cosmetic result for all 3 zones. There were no complications or further procedures required. The outcome measures documented clinically and photographically included complete closure of the defect, cosmetic appearance, complications, and further surgery.     

Modified retractor plication technique in lower lid entropion repair: a 4-year follow-up study

BACKGROUND: Lower eyelid entropion is an eyelid malposition characterized by inward rotation of the eyelid margin associated with potentially significant discomfort and, occasionally, keratopathy. In this study we evaluated and compared the efficacy of two surgical techniques of retractor plication for involutional lower lid entropion repair. METHODS: Sixty-two consecutive patients (62 eyes) with involutional lower lid entropion were included. Of the 62, 34 underwent the Jones retractor plication technique, and 28 underwent a modification of this technique that simplifies the procedure. We evaluated horizontal lid laxity, medial canthal tendon laxity and lower lid excursion before and after surgery, and determined the rate of entropion recurrence in the two groups. All measures were obtained before and 1 month, 6 months, 1 year, 2 years, 3 years and 4 years after surgery. RESULTS: Preoperatively, there was no statistically significant difference between the two groups in any of the measures studied. Postoperatively, the mean amount of horizontal lid laxity was significantly less in the modified technique group than in the Jones technique group (6.86 mm [standard deviation (SD) 0.41 mm] vs. 7.30 mm [SD 0.64 mm]) (p < 0.05). Similarly, the mean amount of medial canthal tendon laxity in the resting position was significantly less in the modified technique group than in the Jones technique group (1.90 mm [SD 0.56 mm] vs. 1.25 mm [SD 0.43 mm]) (p < 0.05). The rate of entropion recurrence was significantly lower in the modified technique group (7.1%) than in the Jones technique group (14.7%) (p < 0.05). INTERPRETATION: The modified retractor plication technique showed encouraging results in terms of successful and long-lasting lower lid entropion repair.     

Centurion Syndrome: Clinical Presentation and Surgical Outcome

ABSTRACT

Purpose: To describe the clinical signs and outcome of surgery in cases with Centurion syndrome and highlight the clinical presentation of this syndrome. Methods: A retrospective review of records of patients with Centurion syndrome who underwent surgery between January 2002 and July 2007. The position of the punctum, nasal bridge prominence, Hertel exophthalmometry and the presence of inferiorly directed sharp angulation of the medial canthus was noted. The patients underwent anterior canthal tendon release, punctoplasty or medial conjunctivoplasty or a combination of these. Results: Of the 13 cases, 10 had been treated medically elsewhere. The mean age of onset was 20.7 years. Most of the patients were male 10 (76.9%). A prominent nasal bridge was demonstrable in 9 (69.2%) patients and sharp inferior angulation of the medial canthus, the ‘beak’ sign was present in 9 (69.2%) cases. Anterior canthal tendon release alone was performed in 4 patients, in combination with punctoplasty in 5 and with conjunctivoplasty in 4. Watering resolved in 10 patients. 3 patients who had a combination of anterior canthal tendon release and punctoplasty had persistent but asymptomatic epiphora. Discussion: Centurion syndrome is characterised by the abnormal anterior insertion of the medial canthal tendon with displacement of the punctum out of the lacrimal lake. Most cases present with unexplained watering. Surgical management by anterior canthal tendon release with or without conjunctivoplasty or lower lid retractor plication is usually successful.     

Anterior canthal tendon release for correction of the centurion syndrome

PURPOSE: To investigate the effectiveness of anterior canthal tendon release in the management of centurion syndrome. METHODS: Four patients diagnosed as having the centurion syndrome were treated over a period of 3 years. They all underwent bilateral anterior canthal tendon release under local anesthesia. RESULTS: None of these patients had adequate apposition of the lower puncta after surgery. One patient had partial relief of epiphora on one side. CONCLUSIONS: Our results indicate that anterior canthal tendon release is insufficient as a sole treatment for patients with centurion syndrome.     

Transcaruncular approach to medial canthal tendon plication for lower eyelid laxity

PURPOSE: A new operation to correct lower eyelid laxity was evaluated. METHODS: A new transcaruncular, orbital approach to posterior medial canthal tendon plication was performed on eight orbits of four cadavers, which were then analyzed with computed tomography or histologic techniques. The procedure was also performed on 23 eyelids of 15 patients with lower eyelid medial canthal tendon laxity, alone or in conjunction with other procedures. These patients were followed up for a mean of 12 months. RESULTS: Improved postoperative eyelid position, epiphora, and superficial punctate keratopathy were found. Radiographic and histologic analysis demonstrated consistency of suture placement without involvement of contiguous anatomical structures. CONCLUSIONS: This procedure appears to be a safe, reproducible, and effective corrective procedure for medial canthal tendon laxity and lagophthalmos. When combined with lateral lower eyelid tightening, it is also an effective treatment for lower eyelid retraction and superficial punctate keratopathy. Other potential advantages and complications of this procedure are described in comparison to other reported surgical methods used to address medial canthal tendon laxity and malpositions of the medial lower eyelid.     

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.     

Anatomical risk margins in dacryocystorhinostomy

The relationship of medial canthal tendon, an important landmark for lacrimal sac localization with intracranial fossa, which reveal the risk of entering the cranium during dacryocystorhinostomy, was evaluated in 28 cadaver eyes. Distances from the medial canthal tendon to the frontal sinus floor and to the anterior border of the cribriform plate were measured. We conclude that there is a very small, if any, possibility of entering the cranium directly during dacryocystorhinostomy.     

Functional and anatomic outcome of retinal detachment surgery in pseudophakic eyes

PURPOSE: To determine the long-term anatomic and functional visual outcome of retinal detachment (RD) surgery in pseudophakic eyes after uncomplicated cataract surgery. DESIGN: An interventional, retrospective noncomparative case series PARTICIPANTS: One hundred thirty-eight consecutive patients who had undergone uncomplicated extracapsular cataract extraction and intraocular lens implantation followed by rhegmatogenous RD between 1990 and 1995. METHODS: One hundred one eligible patients were examined (inclusion ratio, 73%) a median of 4.3 years after last RD surgery. The best-corrected visual acuity (BCVA), visual fields, retinal status, and patient-rated visual outcome were recorded, the latter by a questionnaire that included self-reported satisfaction, trouble with vision, a modified Cataract Symptom Score, and the VF-14 Visual Functioning Index. MAIN OUTCOME MEASURES: BCVA, retinal attachment, diameter of visual field, modified Cataract Symptom Score, VF-14 score. RESULTS: Baseline characteristics of enrolled and nonenrolled patients were comparable, except that nonenrolled patients were older. When RD developed, 55 eyes had an intact posterior capsule, and 46 had a laser posterior capsulotomy (LCT). The BCVAs before (median, logarithm of the minimum angle of resolution [-logMAR] 1.2 versus 1.1, Snellen equivalent 0.063 versus 0.08) and after retinal surgery (median, -logMAR 0.46 versus 0.4, Snellen equivalent 0.35 versus 0.4) were comparable for eyes with and without LCT (P = 0.86). The retina was reattached with one procedure in 75 eyes (74%), with two procedures in 98 eyes (97%), and with three to five procedures in all eyes. The retina remained attached long term in 92 eyes (91%). Redetachment rate (9% versus 9%, P = 1.0) and visual field diameters were comparable for eyes with and without LCT. Overall, 80% of patients were satisfied or very satisfied with their binocular vision, and 62% had no or only a little trouble with binocular vision. Visual performance was similar regardless of presence or absence of LCT (median Cataract Symptom Score, 3.0 versus 3.0, P = 0.76; and median VF-14 score, 87.5 versus 87.5, P = 0.81). CONCLUSIONS: Nine in 10 pseudophakic retinal detachments remain attached long term, and 8 in 10 patients are satisfied with their binocular vision after surgery. Even though secondary cataract and posterior capsulotomy can cause problems for the retinal surgeon, the anatomic and functional outcomes of pseudophakic RD are not influenced by capsulotomy.     

Microscopic findings of lateral tarsal fixation in Asians

PURPOSE: To identify microscopically lateral tarsal fixation in Asians. METHODS: Specimens from 19 postmortem lateral eyelids and orbits of 11 Asians (11 right, 8 left; aged 45-96 years at death) were used. Samples damaged on sectioning and samples without tarsal plates were excluded. The samples were fixed in 10% buffered formalin and examined under a microscope. Two levels of tarsus were observed in the upper and lower eyelids, suggesting the possibility of different means of fixation. The first and second sections, which were incised parallel to the eyelid margin, were obtained at 1 mm and 5 mm from the upper eyelid margin, and at 1 mm and 3 mm from the lower eyelid margin. The sections were stained with Masson trichrome. RESULTS: The first sections of all upper eyelids and those of the lower eyelids except one showed tarsal fixation by both the lateral rectus capsulopalpebral fascia (lr-CPF) and the tendon-ligament complex of the lateral canthal tendon (LCT), which in several cases received the muscle of Riolan. The second sections of all upper eyelids showed fixation by the lr-CPF and the ligamentous part of the LCT. The second sections of the lower eyelids were mostly similar to the second sections of upper eyelids, though some showed only ligamentous fixation. The lr-CPF in all cases included a small amount of smooth muscle fibers. CONCLUSIONS: The lateral aspect of the tarsus is supported by the lr-CPF and the LCT, which in some cases includes the muscle of Riolan.     

Orbicularis oculi muscle extirpation in a combined procedure for involutional entropion

Many factors are important in the pathophysiology of involutional entropion, including defects of the lower eyelid retractors, canthal tendon laxity, and acquired enophthalmos. The role of the overriding preseptal orbicularis oculi muscle is often ignored in modern techniques of entropion repair. The author describes a technique of extirpation of the preseptal orbicularis oculi muscle combined with repair of the lower eyelid retractors and a lateral tarsal strip procedure for the repair of primary and recurrent involutional entropion. Lateral canthal tendon laxity is recognized in most patients in this age group and must be corrected to avoid postoperative overcorrection and ectropion. Removal of the preseptal muscle had no clinical effect on the lacrimal pump and did not cause any significant cicatricial eyelid abnormalities. This combined procedure has been used in 50 eyelids of 40 patients with excellent functional and cosmetic results. Orbicularis extirpation is not advocated in combination with a marginal rotation procedure.     

Stabilization of the posterior limb of the medial canthal tendon using biodegradable tag anchors: a cadaveric model

PURPOSE: This study describes and tests in a cadaveric model a new method of fixation designed for potential stabilization of the posterior limb of the medial canthal tendon, using biodegradable Tag anchors. METHODS: Study of the possibility of performing surgery to repair medial ectropion using biodegradable polyglyconate Tag anchors was commenced in the sheep cadaveric head model, and in the whole dry human skull model. This was then performed using five preserved human cadaveric whole heads, and pullout tensions were estimated in four of these. Computed tomography and magnetic resonance imaging were obtained for this model in the fifth head, and computed tomography was performed on the whole dry human skull. Dissections were carried out to establish the site of the bony defect in each of the heads. RESULTS: It was possible to obtain good Tag anchor fixation in bone overlying the maxillary and ethmoidal sinuses of the sheep, and in a young human skull. It was also possible to place adequately the anchor in the medial wall of the orbit close to the posterior lacrimal crest in all cases in the human cadaveric model. Pullout strengths were evaluated and found to range from 3.5 N to 12.4 N (mean, 7.5 N). Computed tomography and magnetic resonance imaging failed to demonstrate the biodegradable anchors in both the dry human whole skull and in the fifth cadaveric head, but did demonstrate the bony defects in the medial orbital walls through which the anchor passed. CONCLUSIONS: We have shown, for the first time, the stability of biodegradable Tag anchor fixation in a human cadaveric head model using pullout tensions and dissection studies. This method would allow adequate strength and stability to provide for control of fixation of the medial end of the lower eyelid in patients with medial ectropion and medial canthal tendon laxity.     

Recurrent retinal detachment more than 1 year after reattachment

PURPOSE: Little information exists regarding recurrent retinal detachment after 1 or more years of complete retinal reattachment. To better understand this uncommon problem, we evaluated late recurrent retinal detachments in relation to the contemporary classification of proliferative vitreoretinopathy (PVR). DESIGN: Retrospective consecutive noncomparative case series. PARTICIPANTS: Nine patients (10 eyes) with late recurrent retinal detachment after 1 or more years of complete reattachment. METHODS: We retrospectively analyzed the clinical and operative records of one surgeon over a 9-year period to identify late recurrent retinal detachments that occurred 1 or more years after complete retinal reattachment. The study group was derived from a total of 453 consecutive cases of rhegmatogenous retinal detachment repair not associated with proliferative diabetic retinopathy, uveitis, or penetrating ocular trauma. MAIN OUTCOME MEASURES: Late recurrent retinal detachments after 1 or more years of complete retinal reattachment. RESULTS: The study group consisted of 10 eyes (2.2% of total) in nine patients. Redetachment occurred from 12 to 126 months (average, 46.8 months) after the initial detachment surgery. Late recurrent retinal detachments were associated with new retinal breaks (five eyes), reopening of old breaks (three eyes), or both (two eyes). In all, 13 open breaks were identified, nine of which were on or anterior to the scleral buckle. Eight eyes had grade C PVR, including four eyes with anterior PVR, three eyes with posterior PVR, and one eye with both anterior and posterior PVR. The retina was reattached after additional vitreoretinal surgery in eight eyes of seven patients; two patients (two eyes) declined reoperation. Visual acuity improved in seven of eight eyes after repair of the late recurrent retinal detachment. Postoperative follow-up after late recurrent detachment repair ranged from 69 to 140 months (average, 101.7 months, or 8.5 years). CONCLUSIONS: Vitreous base traction seems to be an important factor in late recurrent retinal detachments occurring 1 or more years after complete retinal reattachment, and the associated PVR was probably a secondary phenomenon and not a causative factor in most cases. Reoperation for such late recurrent retinal detachments can successfully reattach the retina and improve visual acuity in most cases.     

Photodynamic therapy with verteporfin for peripapillary choroidal neovascularization

PURPOSE: To evaluate the efficacy of photodynamic therapy with verteporfin in the management of symptomatic extrafoveal peripapillary choroidal neovascularization (CNV). METHODS: Seven eyes of seven patients with symptomatic peripapillary CNV underwent visual acuity testing, ophthalmic examination, color photography, and fluorescein angiography to evaluate the results of photodynamic therapy with verteporfin. Patients were offered treatment following the development of hemorrhage, subretinal fluid, or lipid if it was associated with visual symptoms. A standard nomogram was used to dose Visudyne, application was performed in three separate 30-second zones confluent over the extent of the lesion. The light dose per unit area applied to the retina was approximately 18 J/cm. RESULTS: Five of the seven had CNV limited to the peripapillary area associated with age-related macular degeneration; the remaining two eyes had presumed ocular histoplasmosis syndrome. In five of the seven eyes, two treatments were needed and in two eyes only one treatment was necessary to elicit resolution of active leakage. Retreatment was performed at an average of 76 days after initial treatment. Baseline best-corrected visual acuity (BCVA) ranged from 20/20 to 20/150. Final BCVA ranged from 20/20 to 20/80. In all eyes except for one, which had a pretreatment vision of 20/20, at least two lines of Snellen visual acuity improvement were achieved. Resolution of submacular fluid, hemorrhage, or exudates was noted in six eyes; in the remaining eye there was persistence of subretinal lipid. There were no complications including optic neuropathy in any of the treated eyes. Follow-up ranged from 6 to 13.5 months following last treatment (mean, 10 months). CONCLUSION: Photodynamic therapy with verteporfin for extrafoveal symptomatic peripapillary CNV appears to be effective in improving vision and promoting the resolution of subfoveal exudates, hemorrhage, or fluid. A randomized controlled study with longer follow-up is justified.     

Vitrectomy for stage 1 macular holes identified by optical coherence tomography.

BACKGROUND AND OBJECTIVE: To describe a series of patients with decreased vision secondary to stage 1 macular hole confirmed by optical coherence tomography (OCT) that failed to spontaneously resolve with observation. To determine whether current surgical techniques can prevent progression to a full-thickness macular hole and lead to improved visual acuity. PATIENTS AND METHODS: Retrospective, comparative case series presenting patient demographics, duration of symptoms, timing of surgery, preoperative and postoperative vision, and clinical outcome based on examination and OCT. RESULTS: Five eyes of five patients with stage 1 macular holes identified on OCT required surgical repair. All eyes showed anatomic closure and lack of progression to a full-thickness hole confirmed by OCT after one procedure. Mean preoperative visual acuity was 20/102 (range, 20/50 to 20/200) and mean postoperative visual acuity was 20/52 (range, 20/25 to 20/200). Average improvement for all five eyes was 3 Snellen lines, with four of the five (80%) improving 5 lines each. CONCLUSION: In symptomatic eyes with stage 1 macular holes that fail to spontaneously resolve with observation, vitrectomy with intraocular gas tamponade may prevent progression to a full-thickness hole and lead to improved visual acuity.     

Canthus-sparing ectropion repair

PURPOSE: To describe a novel surgical technique for lower eyelid ectropion repair that avoids canthotomy and cantholysis and can be used in combination with external levator repair and/or in combination with blepharoplasty. METHODS: A retrospective analysis of lower eyelid procedures with the use of the canthus-sparing technique between January 1, 1998, and December 31, 1999, was performed. The canthus-sparing approach was used in 198 eyelid procedures for the correction of lower eyelid ectropion. Seventy-four (37.4%) procedures involved the correction of lower eyelid ectropion alone and 25 (12.6%) procedures involved the correction of lower eyelid ectropion during upper eyelid small-incision external levator repair. In these cases, an incision was made lateral to the lateral canthus and a periosteal flap was created at the lateral orbital rim. The inferior crus of the lateral canthal tendon was then attached to this full-thickness elevated periosteum. Twenty (10.1%) procedures involved the correction of ectropion during upper blepharoplasty and 79 (39.9%) procedures involved the correction of ectropion during combined upper eyelid ptosis repair and blepharoplasty. In these cases, the inferior crus of the lateral canthal tendon was attached to a periosteal flap created through the lateral portion of the blepharoplasty incision. RESULTS: The mean age of patients undergoing ectropion repair was 74.3+/-9.3 years (range, 42-93 years). The average duration of symptoms (most commonly tearing and/or ocular irritation) was 20+/-14 months (range, 3-84 months). Recurrences of lower eyelid ectropion or symptoms occurred in 4 (2%) eyelids. The average follow-up interval was 54+/-65 days (range, 3-330 days). CONCLUSIONS: The canthus-sparing approach to ectropion repair promotes a secure adhesion to the lateral orbital wall with minimal violation of normal anatomic structures and relations. It is time-efficient and reduces postoperative morbidity.     

Ultrasonic visualization of the effect of blinking on the lacrimal pump mechanism

Background The role of the lacrimal sac (LS) and the medial canthal tendon in the lacrimal pump mechanism is controversial. This study used ultrasonic visualization to analyze this phenomenon.Methods Movements of the LS and the medial canthal tendon during blinking were visualized with sonography. In addition, the maximal profile area of the LS was measured before and after blinking using 15-MHz sonography in 14 individuals with a normal lacrimal drainage system and in six patients with lacrimal duct obstruction.Results The upper part of the LS could be located as an echolucent structure between the lacrimal bone and the medial canthal tendon. The medial canthal tendon appeared to compress the LS during lid closure and release the LS during lid opening. The measured profile area of the visible normal LS at the compression time decreased by 50%. The dilated LS of patients with obstruction could also be compressed by the orbital muscle on blinking, but the maximum area decrease was only 15.5%.Conclusion The findings imply that the lacrimal part of the orbicularis muscle contracts during blinking, with the medial canthal tendon compressing the LS in a cranial direction. Completion of lid closure then compresses both canaliculi and LS, forcing the intrasacral fluid through the drainage system. The expansion of the LS during the opening phase of the blink causes suction, and after opening of the punctal areas the canaliculi and LS vacuum breaks to reload with tear fluid. These findings demonstrate the importance of the orbicularis muscle and the medial canthal tendon for the lacrimal pump mechanism during blinking.