Monday, March 5, 2012
Mark R. Levine, MD
Involutional lower eyelid ectropion occurs with aging, consisting of laxity of the medial and lateral tendons and atrophy and laxity of the orbicularis muscle. This may start medially with medial canthal laxity, resulting in medial ectropion, punctal eversion and stenosis. Predominant lateral canthal laxity results in medial canthal migration and lateral ectropion. A complete eversion of the entire lid margin is the result of medial and lateral canthal tendon laxity with atrophy of the orbicularis muscle.
Conjunctival exposure leads to inflammation and keratinization of the conjunctiva. Inferior keratopathy may occur secondary to exposure or infection. With poor tear drainage due to punctal stenosis or orbicularis pump dysfunction, recurrent conjunctivitis occurs with epiphora and secondary eczematous skin changes.
Horizontal lid laxity is most likely due to the stretching of the medial and lateral canthal tendons rather than elongation of the tarsal plate. Horizontal lid laxity may be corrected by a full-thickness lid resection and closure. However, this may lead to a lateral canthal deformity and blunting of the canthal angle. Therefore, a better procedure with emphasis on correcting lateral canthal laxity is the lateral tarsal strip procedure popularized by Drs. Anderson and Gordy. This procedure is performed simply and quickly by shortening the lid at the lateral canthal angle, avoiding lid margin sutures or notching. Simply put, the lateral canthal tendon is sutured to the periosteum on the inner aspect of the frontal process of the zygoma. This may be combined with a one-snip punctoplasty for punctal stenosis. If punctal stenosis is severe, an inferior retractor advancement is necessary, as described by Dr. Tse in my Manual of Oculoplastic Surgery, published by SLACK Incorporated.
Prior to surgical correction, lower eyelid eczematoid skin changes are treated with cortisone cream lid massages followed by hydrating moisture creams. Frequent instillation of artificial tears protects the cornea and reduces keratinization of the conjunctiva. The keratinization resolves, however, following normal lid position. In severe keratinization, the use of a hand-held cautery to the conjunctival surface nicely thins out the conjunctiva. Don't forget to remove the char.
An important caveat is hydrodissecting the skin from the subcutaneous tissue with the anesthetic. This remarkably balloons the tissues and stretches the skin, improving the lid margin position prior to the lateral tarsal strip. Watch this video by Drs. Black, Nesi and Servat to see how it is done.
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