Botulinumtoxin bei Überfunktion der Tränendrüse, spastischem Entropium und Oberlidretraktion bei endokriner Orbitopathie

After proximal facial nerve lesions, misrouting of nerve fibres may cause the phenomenon of crocodile tears. Transconjunctival injections of botulinum toxin in the palpebral part of the lacrimal gland are the treatment of choice. An initial dose of 2.5 U of toxin is recommended, and injections may be repeated after 6 months if symptoms reoccur.Botulinum toxin A is also a highly effective temporary treatment for involutional (spasmodic) entropion until surgery is performed. A dose of 10 U of botulinum toxin is injected in the pretarsal part of the lower lid near the eyelashes.Botulinum toxin treatment is also effective for dysthyroid upper eye lid retraction, especially in instable thyroid disease or mild retraction. Slight transient ptosis may occur in some cases. Depending on the amount of retraction, a dose of 5 or 7.5 U of toxin is injected into the subconjunctival space at the superior margin of the tarsal plate.     

Lid retractors desinsertion in acquired ptosis and involutional lower lid entropion: surgical implications.

BACKGROUND: An association exists between upper and/or lower lid retractors' desinsertion and acquired ptosis and/or involutional lower lid entropion. METHOD: By highlighting the similarities that exist in the anatomy of the upper and lower lid retractors a possible pathophysiological mechanism leading to acquired ptosis and involutional lower lid entropion is suggested. As a logical consequence, in case of desinsertion, it is proposed to reattach the lid retractors to the tarsus. RESULTS: With this simple "physiological" surgical approach it is possible to treat with success a great majority of acquired ptosis and/or involutional lower lid entropion. CONCLUSION: Repairing upper and/or lower lid retractors' desinsertion can cure acquired ptosis and/or involutional lower lid entropion.     

Avoidance of complications in lower lid blepharoplasty

The most common complication of lower lid blepharoplasty is lower lid malposition either lower lid retraction or frank ectropion. This is caused by the vertical pull of skin shortage or shrinkage on a lax tarso-ligamentous sling. A method of tightening the tarso-ligamentous sling combined with a lower lid blepharoplasty is presented. An alternate method of lower lid fat removal through the fornix without skin incision is presented to be used in patients with taut lower lid skin.     

Treatment of dysthyroid lower lid retraction with autogenous tarsus transplants.

Lower lid retraction is commonly seen in dysthyroid orbitopathy. We have treated 55 lower lids in 38 patients with lower lid retraction by a tarsal transplant from the upper lid to the lower lid. An overall effect of 2-mm improvement +/- 0.7 mm occurred. Eighty-nine percent of the lids achieved the position of the lower lid within 1 mm of the limbus. We think that the upper to lower tarsal transplant offers a technically easy and reasonable solution to moderate lower lid retraction associated with dysthyroid orbitopathy.     

Involutional entropion of the upper lid

Involutional entropion is an inturning of the eyelid margin caused by changes of lid tissues due to aging. Two patients with the uncommon finding of involutional entropion of the upper lid were treated with surgery based on the principles used to treat common lower lid entropion. The causes of lower lid entropion include increased horizontal and vertical lid laxity, and correcting these same factors in the upper lid resulted in a satisfactory repair of the entropion. Treatment of involutional entropion in the upper lid is compared and contrasted with that of the lower lid.     

Cosmetic Lower Lid Blepharoplasty

This article will review the topic of cosmetic lower lid blepharoplasty including: preoperative patient evaluation and selection; blepharoplasty surgery; postoperative patient care; and complications of surgery. The emphasis of this article is surgical techniques, including standard lower lid blepharoplasty via a subciliary skin incision, lower lid blepharoplasty combined with lateral canthal lower lid tightening procedures, and the transconjunctival lower lid blepharoplasty procedure. Preoperative and postoperative surgical results are presented.     

Everting suture correction of lower lid involutional entropion

AIMS: To assess the long term efficacy of everting sutures in the correction of lower lid involutional entropion and to quantify the effect upon lower lid retractor function. METHODS: A prospective single armed clinical trial of 62 eyelids in 57 patients undergoing everting suture correction of involutional entropion. Patients were assessed preoperatively and at 6, 12, 24, and 48 months postoperatively. The main outcome variables were lower lid position and the change in lower lid retractor function. RESULTS: When compared with the non-entropic side, the entropic lid had a greater degree of horizontal laxity and poorer lower lid retractor function. These differences however, were not significant. At the conclusion of the study and after a mean follow up period of 31 months, the entropion had recurred in 15% of the patients. There were no treatment failures in the group of five patients with recurrent entropion. The improvement in lower lid retractor function after the insertion of lower lid everting sutures did not reach statistical significance. There was no significant difference between the treatment failure group and the group with a successful outcome with regard to: the degree of horizontal lid laxity or lower lid retractor function present preoperatively; patient age or sex; an earlier history of surgery for entropion. There was neither a demonstrable learning effect nor a significant intersurgeon difference in outcome. The overall 4 year mortality rate was 30%. CONCLUSIONS: The use of everting sutures in the correction of primary or recurrent lower lid involutional entropion is a simple, successful, long lasting, and cost effective procedure.     

Partial and Total Reconstruction of the Lower Eyelid

Our techniques for reconstruction of the lower lid are based on the maintenance of tarsal support in the reconstructed lid. The surgical approach is dictated by the position and extent of the defect produced by tumor excision. Lysis of the extension of the lateral canthal ligament to the lower lid allows closure of small, full-thickness defects. Mobilization of tarsal remnants by temporal advancement flaps provides for closure of larger defects. An advancement flap of split-thickness upper lid tarsus is combined with a pedicle flap of skin from the upper lid for total lower lid reconstruction.     

Clinical,biochemical and histological results of a levator muscle transposition for ptosis in Cynomolgus monkeys

The transposition of the levator muscle of the upper lid on the frontal muscle was studied on four Macaque cynomolgus monkeys. The results indicate a re-innervation of the transposed levator muscle from nerve fibres of the frontal muscle. This operation introduces a new alternative to the treatment of ptosis with synkinesia of Marcus Gunn.     

Lower lid retraction in thyroid orbitopathy: lamellar shortening or proptosis?

To investigate any correlation between lower lid retraction and proptosis and also between lower lid retraction and lamellar length, as measured by fornix depth, in patients with thyroid eye disease (TED). One hundred and sixty-six eyes of 83 patients with TED were enrolled. The inferior fornix depth, Hertel exophthalmometry measurement, clinical activity score, and lower lid position were the main outcome variables. The correlation between lower lid position measurement and Hertel measurements and also between the lower lid position measurement and inferior fornix depth were evaluated using ANOVA and Pearson’s tests. The mean age of subjects in patients with and without lid retraction was 42.8 ± 1.5 and 47.7 ± 1.6 years, respectively (P = 0.4). The inferior fornix depth in patients with and without lower lid retraction was 11.8 ± 1.5 and 11.8 ± 1.3 mm, respectively (P = 0.960). Pearson’s analysis showed a significant correlation between the degree of proptosis and lower lid retraction in TED patients (P = 0.01). However, no significant correlation was found between the level of lower lid retraction and the fornix depth (P = 0.87). The main cause of lower lid retraction in TED is proptosis. The beneficial effect of orbital decompression on improvement of lower lid retraction must be considered during a stepwise surgical approach in TED patients.     

Reconstruction of the horizontal palpebral aperture after failed ectropion surgery with temporal migration of punctum

Involutional ectropion of the lower lid is the result of progressive stretching and elongation of the lid margin and medial and lateral canthal tendons. The relative laxities of the components of the lower lid-canthal tendon complex will determine the location and extent of the ectropion. Whereas inadequate canthal tightening or horizontal lid shortening will result in recurrent ectropion, overzealous lid shortening without tendon plication will result in a noticeably narrower horizontal palpebral fissure, a persistent ectropion, or temporal migration of the punctum. We used lateral cantholysis, medial canthal tendon plication, and punctal rotation to return the punctum to its normal position and temporalis muscle to support the lower lid in eight cases in which previous procedures had failed to correct the lid malposition. In all eight cases there was improvement of the lid position. In one case of severe medial ectropion, the punctal eversion was not completely corrected. This technique is not recommended as an initial procedure for ectropion repair. It is only used to manage previous surgical failures. It is a new application and combination of well-accepted techniques.     

A new lid sign in seventh nerve palsy

This paper describes a new lid sign in two patients with facial nerve paralysis. The facial nerve palsy was secondary to a pontine abscess in the first case and a complication of acoustic neuroma resection in the second patient. Both patients were found to have absence of the normal nasal twist of the lower lid during eyelid closure. The nasal twist is felt to help pump tears into the lacrimal drainage system. This paper will describe the absence of an important eyelid function in a patient with facial nerve paralysis. By way of background, Doane's slow motion movies have shown that during a normal blink, the upper lid moves both down and nasally, while the lower lid moves from 2 to 5 mm nasally. As the upper lid descends, the lower lid normally moves 2 to 5 mm in a horizontal and nasal direction. This motion of the lower lid helps produce a partial vacuum in the lacrimal system and is responsible for moving the fluid and debris in the tear mentiscus across the eye and into the lacrimal drainage system. The two cases of facial nerve paralysis to be presented demonstrate absence of tear drainage on the side of the lesion and a build-up and overflow of the tears on that side.     

Total lid replacement by an autologous and homologous combination graft in emergencies

Report on 3 cases with total loss of a lid which required an "emergency lid" in order to protect the cornea. In all cases the tarsus was replaced by a strip of dura mater, the eye-lid skin by a free retroauricular graft. In all 3 cases the attempt was made to mobilize the levator and other adjacent tissue and fix them to the tarsus replacement. In one case the upper palpebral and bulbar conjunctiva was also replaced by 2 flaps of lip mucosa. In this case the lower half of the tarsal zone was rejected; however, the situation was mastered by tarsoconjunctival shifting of the lower lid with a free lid skin graft from the other eye. All "emergency lids" resulted in lid closure which protected the cornea sufficiently. The 2 patients in whom the upper lid was replaced had active lid movement of 3 to 4 mm.     

Role of the lower lid retractors in involutional ectropion repair

AIM. To outline the role of the lower lid retractors in correction of involutional ectropion. METHODS. Eight eyelids with a tarsal ectropion were included in the study. Clinical clues to help identify weakness of the lower lid retractors were documented. A transconjunctival lower lid retractor reattachment with concommitant correction of horizontal lid laxity and lamellar dissociation was performed. RESULTS. Stable eyelid position was obtained in 7 of the 8 cases. One case had a lateral ectropion due to a wound dehiscence. CONCLUSIONS. This small study helps better define the clinical presentations of retractor weakness and provides evidence of a systematic approach in correcting involutional ectropion.     

Eyelid reconstruction with tarsomarginal grafts

Summary In the past 3 years, 85 basal cell carcinomas were treated in our clinic using eyelid reconstruction. During the same period, 54 lids were reconstructed after other diseases, mostly after chemical burns. In one of the 54 patients, the upper lid was reconstructed using a tarso-marginal graft after congenital coloboma. Method: In 31 of the 85 patients with basal-well carcinoma (36 %), so much tarsus was lost that a transplantation of tarsus was necessary. Fifteen of the 31 patients were treated with a Hughes-plasty and 16 using a tarsomarginal graft, two in the upper lid. Results: In eight of the remaining 16 cases, the defect was less than one half of length, so that the graft was taken from the second lower lid. In the remaining eight patients, the defect was two thirds of length or longer. In six cases, a 7 mm-graft was taken from the upper lid. As the tarsus from the upper lid measures 10 mm and is thus twice as big as the lower lid tarsus, it was divided into two grafts, resulting in two grafts measuring 7 × 5 mm. They were placed in the lower lid (“double tarsomarginal graft”). The former lower part with lashes was placed in the middle of the lower lid, the former upper part peripherally. In two patients, the defect was healed with three tarsomarginal grafts. A pedicle skin flap was transposed to cover the posterior grafts. Remaining defects were closed with free skin transplants. Conclusion: The tarsomarginal graft permits a short operation time and early rehabilitation of the patients. The disadvantage of the double tarsomarginal graft is that the more valuable upper lid tarsus is used to reconstruct the less valuable lower lid tarsus.      

Medical ectropion repair. A new procedure

The lazy-T procedure described by Smith corrects medial ectropion of the lower lid by combining a horizontal full-thickness shortening of the lid with excision of conjunctiva and tarsus inferior to the punctum to invert the lid. However, some cases of senile medial ectropion involve an element of vertical traction on the skin as well as horizontal lid laxity. A new procedure is described that makes use of skin gained from horizontal lower lid shortening in the form of a medially based transposition flap to produce vertical skin lengthening. It is useful to treat medial ectropions that have horizontal laxity along with cicatricial components and has successfully relieved this condition in eight patients.     

Senile entropion: the importance of eyelid laxity

In senile entropion preoperative assessment of eyelid laxity will determine whether the condition is primarily due to increased horizontal lid laxity or to disinsertion of the retractors of the lower lid, with subsequent superior migration of the orbicularis. With increased horizontal lid laxity the lid must be surgically tightened. If such laxity is not present, an operation directed at the orbicularis or at the retractors of the lower lid is advisable. This approach had an initial success rate of 97% in a series of 75 new cases and 15 cases referred for reoperation; a second operation was successful in two of the three instances of primary failure.     

The association of unilateral congenital glaucoma and congenital lower lid entropion: causal or casual?

This case documents unilateral congenital glaucoma associated with congenital lower lid entropion. A 2-year-old female infant was referred for evaluation and treatment of right-side buphthalmos caused by congenital glaucoma associated with bilateral congenital lower lid entropion that was prominent on the right side and present at birth. Examination disclosed a lower eyelid entropion of the right side that was treated surgically by reinserting the disinserted retractor aponeurosis to anterior inferior tarsal border. After three weeks, the patient was successfully treated with primary combined trabeculotomy-trabeculectomy for congenital glaucoma. The entropion of the left lower lid was asymptomatic and did not require any surgery. Buphthalmos caused by congenital glaucoma may be associated with congenital lower lid entropion and the association may be causal or coincidental.     

Lower eyelid CO(2) laser rejuvenation: a randomized, prospective clinical study

PURPOSE: The effect of transconjunctival blepharoplasty alone compared with transconjunctival blepharoplasty and CO(2) laser skin resurfacing on lower lid bulging and wrinkles was examined. DESIGN: Randomized clinical trial. PARTICIPANTS: Forty-four subjects, including 13 men and 31 women. METHODS: Subjects were prospectively randomly assigned into two groups: (1) transconjunctival blepharoplasty with immediate CO(2) laser resurfacing or (2) transconjunctival blepharoplasty with CO(2) laser resurfacing 2 months later. Standardized photographs were taken before and 2 months after each procedure. A trained, masked observer graded the photographs. MAIN OUTCOME MEASURES: Bulging and wrinkles of the medial, central, and lateral portions of the lower lid were scored and compared at specified end points. RESULTS: Transconjunctival blepharoplasty alone resulted in an improvement in lower lid bulging in 92% of subjects, whereas lower lid wrinkling worsened in 46%. When transconjunctival blepharoplasty was performed with simultaneous CO(2) laser resurfacing, or with CO(2) laser resurfacing 2 months later, a statistically significant improvement in wrinkles occurred (chi square = 20.625; P < 0.0005). The timing of the procedures had no statistically significant effect on final outcome. No subject had lower lid retraction develop. CONCLUSIONS: Transconjunctival blepharoplasty and adjunctive CO(2) laser resurfacing represents an excellent alternative to transcutaneous lower blepharoplasty. The procedure addresses lower lid wrinkles, skin redundancy, and fat herniation without a scar and with little risk of lower lid retraction.     

The Aponeurotic Approach to Eyelid Retraction

A technique for the upper lid retraction that involves an anterior approach similar to aponeurotic ptosis surgery is presented. Instead of advancing the aponeurosis, it is recessed and Moller's muscle is completely extirpated. The lateral horn of the levator must be cut to relieve the marked temporal elevation of the eyelid. Lid height and contour are adjusted intraoperatively with patient cooperation. In the lower lid, the retractors are recessed via a conjunctival approach unless simultaneously performed with orbital decompression. Any amount of lid retraction may be corrected by this technique in the upper lid and up to 3 mm of lower lid retraction can be corrected. Lid height in both the upper and lower lid is lasting and predictable. Thirty-one patients (63 eyelids) have been operated on using this technique with good results. Results in 17 patients (35 eyelids) with follow-up ranging from 8 to 42 months are presented.