Implants and spacers for paralytic ectropion: Literature review and assessment of a thin-profile porous polyethylene implant

Purpose: There is no ideal treatment paradigm for paralytic ectropion. This study evaluated lower eyelid spacers and the efficacy of a novel lower eyelid thin profile, bio?integratable, porous polyethylene. Methods: A retrospective review of 15 consecutive patients who underwent thin?profile porous polyethylene implantation and canthoplasty for paralytic ectropion was carried out. A comprehensive literature review of spacers for paralytic ectropion and retraction using the Pubmed database with search terms “[implant or graft or spacer] and [paralytic ectropion or paralytic retraction],” “graft and paralysis and ectropion,” “implant and paralysis and ectropion,” “graft and paralysis and retraction,” and “implant and paralysis and retraction” was carried out. Results: The mean patient age was 69 years (range: 50–88). Lagophthalmos improved from a mean of 5.7 mm (SD = 3.3, range 3–14 mm) to 1.4 mm (SD = 1.1, range 0–3.5 mm), P < 0.0001. MRD 2 improved from a mean of 6.7 mm (SD = 2.3, range 2–12 mm) to 4.2 mm (SD = 0.9, range 3–6 mm), P = 0.0005. No patients needed additional lower eyelid surgery. There were no implant exposures at a mean follow?up of 7.6 months (SD = 7.9, range 0.7–21.6 months). Detailed literature review revealed that hard palate and ear cartilage are the most reported spacers, each with unique disadvantages. Conclusion: The thin?profile porous polyethylene implant is a useful addition to the management of symptomatic paralytic ectropion. Meaningful comparison of lower eyelid spacers is difficult because of variations in surgical technique, spacer size, and poorly reported outcome data. No spacer proves superior

Encephalocele presenting as lower lid swelling: A rare case report

Encephalocele is a rare congenital abnormality characterized by abnormal protrusion of brain and meninges through an opening in the skull. We report an 8-year-old girl who presented with a swelling in the right lower lid for the last 6 years. In her infancy, she had undergone surgery for a very small swelling located in the right nasolacrimal area. On further clinicoradiological evaluation, anterior encephalocele was diagnosed. This case highlights the uncommon site of anterior encephalocele; misdiagnosis and mismanagement of which could result in dreaded complications such as meningitis and cerebrospinal fluid leaking fistula formation.

The effect of anterior transposition of the inferior oblique muscle on eyelid configuration and function.

Purpose: To evaluate the alteration of lower lid configuration and function with anterior transposition surgery of the inferior oblique (IO) muscle. Patients and Methods: A prospective clinical trial was conducted on a consecutive series of patients underwent anterior transposition of the IO as a sole operation. All patients received a thorough ophthalmic examination 1 day before and 3 months after surgery. Output parameters were consisted of palpebral fissure, margin reflex distance 1–2, lower lid function, hertel value, and lower lid crease. The differences of the collected data were calculated for statistical significance by using the Wilcoxon test. Results: A total of 19 eyes of 16 consecutive patients were included. The median preoperative grade of IO overaction was 3.5 (ranging from 3 to 4), which decreased to 0 (ranging from 0 to 2) postoperatively (P < 0.05). No significant change was observed in all parameters 3 months postoperatively (P > 0.05). Conclusion: In this study, no significant effect on lower lid configuration and function was observed following IO anterior transposition in which the disinserted muscle was placed posterior to inferior rectus insertion.

The Effects of Lower Lid Laxity to the Response of Dry Eye Treatments

PURPOSE: To compare the response of dry eye treatment in patients divided by the degree of lower lid laxity. METHODS: Thirty patients were classified into three groups - normal, moderate and severe, according to the degree of lower lid laxity. Tear break-up time (TBUT), Schirmer test (ST), ocular surface disease index (OSDI) scores and changes in OSDI score in each group were compared before and at 3 months after the treatment. RESULTS: TBUT, ST and OSDI scores were not different among the three groups at baseline. TBUT improved to 6.60 +/- 1.43, 6.0 +/- 2.54 and 6.0 +/- 1.45 sec in normal, moderate and severe lower lid laxity group, respectively at 3 months after the treatment and no difference among the groups was found. ST scores did not increase after the treatment, while OSDI scores improved to 12.20 +/- 1.40, 16.10 +/- 4.63 and 20.80 +/- 4.52 in each group, respectively and they were significantly different (p = 0.029, 0.029, <0.001, respectively). The response to the dry eye treatment as assessed by changes in OSDI scores was poorer in patients in the severe lower lid laxity group (p = 0.019 vs. moderate laxity group, <0.01 vs. normal group). CONCLUSIONS: As the degree of lower lid laxity increases, the response to dry eye treatment becomes poorer even when TBUT increases.

Orbital Sarcoidosis Presenting as Diffuse Swelling of the Lower Eyelid

The author reports a case of orbital Sarcoidosis in a 70-year-old female that initially presented as diffuse swelling of the lower eyelid. The patient complained of painless swelling of the left lower lid without palpable mass, and a computerized tomography (CT) scan of the orbit was unremarkable. A serum angiotensin converting enzyme level was elevated, and hilar lymphadenopathy was noted on the chest CT. The patient underwent surgical debulking for histologic confirmation, which led to a final diagnosis of sarcoidosis involving the orbital fat. Unexplained chronic eyelid swelling without a mass should be considered a possible ophthalmic manifestation of orbital sarcoidosis.

A Case of Acute Idiopathic Bilateral Lower lid Ectropion

Introduction: Ectropion is an eversion of the eyelid due to various causes, and it mainly develops in the lower lid. Usually it shows a slow progression, and it is classified as involutional, cicatricial, paralytic and congenital. Acute idiopathic bilateral lower lid ectropion is very rare; few cases have been reported worldwide, and none have been seen in Korea. CASE SUMMARY: A 79-year-old male patient visited our department with a six-day history of epiphora and lower lid eversion in both eyes. On slit-lamp examination, lower lid ectropion was present in both eyes, and mild corneal punctate epithelial erosion was also observed. Two weeks after conservative treatment, the lower lid eversion disappeared and the lower lid returned to its original position. No changes were observed three months after treatment. We report a case of acute idiopathic bilateral lower lid ectropion with a literature review.

Analysis of Age-related Changes in the Lower Lid and Soft Tissue Using Computed Tomography

PURPOSE: The anatomic relationships of the lower lid and soft tissue between younger and older groups were compared using CT scans for confirming the negative vector relationship in the Korean population. METHODS: The study sample was composed of 100 patients with no history of previous surgery and no ocular disease. Two groups of 100 patients, younger (less than 30 years of age) versus older (above 50 years of age), were studied using CT scans. The distances from the anterior cornea to the lower lid fat, inferior orbital rim and anterior cheek mass were measured at the midpupillary plane. RESULTS: The mean age of the younger group was 22.0 years (ages 14 through 29), compared with 60.6 years (ages 53 thru 73) for the older group. Comparison of mean linear measurements revealed an anterior movement of the lower lid fat between younger and older groups (-5.09 mm vs. -3.50 mm, respectively, P < 0.01). A regression of the inferior orbital rim (-6.93 mm vs. -8.98 mm, P < 0.01) and anterior cheek mass (3.07 mm vs. 0.43 mm, P < 0.01) was observed with age in the sagittal cross section view. CONCLUSIONS: The present study demonstrates the orbital remodeling according to age in the Korean population. Because the negative vector is more common in the elderly and portends a greater risk for lower lid complications after surgery, surgeons need to consider the orbital remodeling according to age before surgery.

Lateral Tarsal Strip Procedure and Silicone Tube Intubation on the Functional Nasolacrimal Duct Obstruction

PURPOSE: To compare the effects of the lateral tarsal strip procedure alone and the lateral tarsal strip procedure combined with silicone tube intubation in the treatment of functional lacrimal duct obstruction. METHODS: The present study investigated 27 eyes of 20 patients underwent lateral tarsal strip procedure (LTS) alone and 29 eyes of 18 patients underwent combined lateral tarsal strip procedure and silicone tube intubation and who were diagnosed with functional lacrimal duct obstruction. The authors retrospectively reviewed patients' medical records for information including age, gender, history, follow-up period, tear meniscus height (TMH), and symptoms. RESULTS: The average age of the LTS alone group was 60.3 years, and that of the combined groups was 65.9 years. The TMHs in the LTS only and combined operation groups were 0.62 +/- 0.23 mm and 0.62 +/- 0.19 mm before the operation and 0.43 +/- 0.20 mm and 0.26 +/- 0.09 mm after the operation, respectively. The postoperative improvement in epiphora was 74.1% after the LTS alone and 86.2% after combined LTS with silicone tube intubation. The postoperative improvement in epiphora and the operative technique of the lateral tarsal strip-canthus sparing or cantholysis were not relevant. CONCLUSIONS: Lateral tarsal strip combined with silicone tube intubation appeared useful in the treatment of epiphora patients without anatomic lacrimal duct obstruction. Determining which operative technique of lateral tarsal strip procedure should be chosen is difficult, and the preoperative syringing and snap back test may be helpful.

An Anatomic Study of the Infraorbital Fat Compartments in Adult Cadavers

PURPOSE: This study investigated the anatomy of infraorbital fat and the relationship between surrounding structures and infraorbital fat. METHODS: Forty-one orbits from adult Korean cadavers were dissected. Among them 20 orbits were male and 21 orbits were female. The cadavers were perfused and embalmed in formalin solution. The skin and orbicularis oculi muscle were dissected to expose the arrangement and compartments of infraorbital fat. A punctal probe was used to find a deeper fat compartment lying under the another compartment. The width of each compartment and the distances from the inferior orbital rim and from the lower lid margin to the topmost point of each compartment were measured using a digital caliper. The distance from the top of the medial compartment and lower lid margin to the first appearance of the inferior oblique muscle, located between the medial and the central fat compartments, were measured, respectively. RESULTS: The width of the medial compartment was 11.49+/-2.54 mm, the central compartment was 21.78+/-5.69 mm, and the lateral compartment was 17.94+/-4.99 mm. The distance from the inferior orbital rim to the medial compartment was 8.13+/-2.72 mm, to the central compartment was 9.91+/-3.44 mm, to the lateral compartment was 9.58+/-3.76 mm. The distance from the lower lid margin to the medial compartment was 5.55+/-1.22 mm, to the central compartment was 7.09+/-3.22 mm, and to the lateral compartment was 5.41+/-3.07 mm. The distance from the inferior oblique muscle to the medial compartment was 9.09+/-2.63 mm, and to the lower lid margin was 13.60+/-2.27 mm. CONCLUSIONS: Our study evaluates the normal anatomy of the infraorbital fat compartments in Korean patients and suggests a useful index for lower blepharoplasty and lower orbital surgery.

A Polypropylene Sheet as a Spacer Graft for the Correction of Lower Eyelid Retraction

PURPOSE: To evaluate the usefulness of a polypropylene non-woven sheet as a spacer graft for the correction of lower lid retraction METHODS: Fifteen New Zealand white rabbits were randomized into three groups. Polypropylene non-woven sheets were implanted between the tarsus and lower lid retractor via a transcutaneous approach (Group 1), a transconjunctival approach (Group 2), or a transconjunctival approach with amniotic membrane transplantation (Group 3). Numerous large pores were made in the sheet with a 21-gauge needle before implantation. Rabbits were sacrificed serially after 1, 2, 4, 6, and 8 weeks in each group. Gross and histologic examinations were performed. RESULTS: In Group 1, the polypropylene sheets stayed in place well, without any exposure on gross observation except at 2 weeks. In Group 2, the conjunctival wound was not healed on the polypropylene sheet, and the sheet was exposed to the ocular surface and extruded gradually. In Group 3, the conjunctival wound was well healed on the surface of polypropylene sheet, and the sheet remained stationary at 4, 6, and 8 weeks on gross examination. Histologic examinations showed gradual fibrovascular ingrowth into the polypropylene sheets in Groups 1 and 3, but not in Group 2, in which only severe inflammatory infiltrations were observed. CONCLUSIONS: The polypropylene non-woven sheet is a good candidate for a spacer material in lower lid retraction operation, and either the transcutaneous approach or the use of an amniotic membrane is necessary for best postoperative outcome.

The Effects of Lateral Tarsal Strip Procedure on the Functional Nasolacrimal Duct Obstruction

PURPOSE: To evaluate the effects of the lateral tarsal strip procedure in the treatment of lacrimal pump dysfunction related to lower lid laxity. METHODS: This study investigated 46 eyes of 35 patients diagnosed with dysfunction of the lacrimal pump on which the lateral tarsal strip procedure was performed between June 2001 and February 2004. We retrospectively reviewed patients' medical records for information including age, gender, history, follow-up period, change of fluorescein dye disappearance test (DDT), tear meniscus height (TMH), symptoms, and complications. RESULTS: Improvement of tearing was noted in 26 patients (78.8%). Thirty-seven eyes (80.5%) were improved by more than 1 grade on DDT. Significant improvement above 2 grades was observed in 16 eyes (34.7%). With respect to age, 62.5% of 3rd-decade patients improved most effectively by more than 2 grades on DDT. Postoperative TMH compared with preoperative TMH measures were significantly lower according to statistics. The most common complication was discomfort or tenderness over the orbital rim (13.0%). CONCLUSIONS: Performance of the lateral tarsal strip procedure for tearing caused by dysfunction of the lacrimal pump and related to lower lid laxity improved patients' tearing, DDT and TMH status. We therefore expect the lateral tarsal strip procedure to be effective in the surgical treatment of lacrimal pump dysfunction secondary to lower eyelid laxity.

Correction of Lower Eyelid Retraction with Autogenous Hard Palate Mucosa : 2 Case Report

PURPOSE: Grave's disease is an autoimmune disease with chronic and systemic features. It affects the orbital fat and muscle bringing about defect in extrinsic eye motility, diplopia, optic nerve defect and lid retraction. In patients with lagopthalmos and resulting facial deformity, treatment can be done by rectus muscle recession or filling with various material. Autogenous auricular cartilage graft is often used and synthetic material such as synthetic acellular dermis, polyethylene meshs are also used for filling of the depressed area. Nevertheless, autogenous auricular cartilage grafts are difficult to utilize and synthetic materials sometimes result in protrusion or infection. Therefore, hard palate mucosa was considered as an alternative. We report two cases of patients with lower eyelid retraction corrected with autogenous hard palate mucosa. METHODS: We performed this operation in two patients of Graves' ophthalmopathy. The capsulopalpebral fascia was incised and elevated through an incision on the conjunctiva. Then, the harvested hard palate mucosa was sutured to the inferior border of the tarsus and covered with the conjunctiva. RESULTS: The lower eyelid retraction was corrected successfully. No hypertrophy or deformation of the transplanted hard palate mucosa was noted 6 months after the surgery. CONCLUSIONS: From the results above, we may conclude that the hard palate mucosa serves as an ideal spacer for the curvature and the inner lining in lower lid retraction. Hard palate mucosa is as sturdy as the autogenous cartilage but is much easier to utilize. It can be also used for lid retraction after lower lid aesthetic surgeries or traumas.

Polytetrafluoroethylene as a Spacer Graft for the Correction of Lower Eyelid Retraction

PURPOSE: To evaluate the efficacy of porous expanded polytetrafluoroethylene (e-PTFE, Goretex (R) ) containing large pores made with a 21-gauge needle as a graft for the correction of lower lid retraction. METHODS: e-PTFE grafts were implanted between the tarsus and lower lid retractor via a transconjunctival approach with/without amniotic membrane transplantation, or via a transcutaneous approach. Rabbits were examined and assessed for corneal and conjunctival complications and for e-PTFE graft status. Rabbits were sacrificed for a histological study at 8 weeks postoperatively. RESULTS: e-PTFE grafts were uniformly extruded 3 weeks postoperatively in eyelids operated on via the transconjunctival approach. However, rabbits operated on via the transcutaneous approach demonstrated e-PTFE graft retention; in addition, dense fibrovascular ingrowths into the large pores of e-PTFE were observed histologically. CONCLUSIONS: e-PTFE is a good substitute for other graft materials as a spacer in lower lid retraction operations, especially as an interpositional graft using a transcutaneous approach.

Correction of Lower Lid Retraction Combined with Entropion using an Ear Cartilage Graft in the Anophthalmic Socket

PURPOSE: To investigate the surgical results of an ear cartilage graft and supplemental procedures for correcting lower lid retraction combined with entropion in anophthalmic patients. METHODS: We reviewed retrospectively the medical records of 7 anophthalmic patients with lower lid retraction and entropion, who received a posterior lamellar ear cartilage graft and one or both of lateral tarsal strip or eyelash-everting procedure between March 1998 and March 2003. Preoperative and postoperative lid and socket statuses were also investigated. RESULTS: Ear cartilage grafts were performed in all 7 patients, lateral tarsal strips in 6, and eyelash-everting procedures in 5. Postoperative follow-up durations ranged from 4 to 28 months (average 12.6 months). Retractions were corrected during follow-up in all patients. There were no cases of entropion immediately after surgery. However, the eyelashes of the lower lid returned to an upright position in 4 patients, but not so severe as to touch the ocular prosthesis, and thus did not require surgical correction during follow up. CONCLUSIONS: Lower lid retraction combined with entropion in anophthalmic patients can be corrected effectively using an ear cartilage graft with selective, supplemental procedures.

Hard Palate Mucosa Grafts for Lower Lid Retraction

Lower eyelid retraction is usually managed by recession of the lower lid retractors and interposition of a spacer graft including ear cartilage, nasal septal cartilage, donor sclera or autogenous tarsoconjunctiva.We have used hard palate mucosa as a spacer in 10 patients (11 eyelids)with lower lid retraction.Average age at operation was 36 years with the range of 10 years to 59 years.Causes of the lower lid retraction were thyroid ophthal-mopathy (4 eyelids), strabismus surgery (2 eyelids), entropion repair (2 eye-lids), eyelid infection (2 eyelids), and trauma (1 eyelid).Of 11 eyelids, 7 eye-lids were combined with entropion due to the shortage of posterior lamella. The follow-up period ranged from 3 to 45 months (mean 17 months).Surgi-cal results in all 11 eyelids were satisfactory.There was no complication in donor site.Hard palate closely approximates lower lid tarsus in terms of contour, thickness, and stiffness, provides a mucosal surface and shows only minimal shrinkage. We suggest hard palate mucosal grafts as one of the best available spacer material for the treatment of lower lid retraction.

Surgical Treatment of Sensile Entropion

Senile entropion is caused by following pathophysiologic changes ; disinsertion or weakness of lower lid retractor, upward migration and overriding of the preseptal orbicularis oculi muscle over pretarsal orbicularis muscle, horizontal lid laxity, and relative enophthalmos from absorption of orbital fat. There have been numerous procedures to correct senile entropion, but the difficulty of adequate and concurrent correction of all of the underlying defect result in high recurrence rate. Therefore, authors performed a combined procedure including reattachment of disinserted lower lid retractor or tucking of weakened lower tarsus, and the extirpation of overriding preseptal orbicularis oculi muscle. At the same time we performed the correction of the lower lid laxity using lateral tarsal strip procedure of full-thickness wedge resection. Authors performed this method in 21 cases of 17 patients and the cosmetic and functional result were satisfactory.

Surgical Correction of Lower Lid Retraction Using The Scleral Spacer

Lower lid retraction can be caused by many etiologies but few require surgical intervention except for cosmetic reasons and exposure deratitis due to lagophthalmos. We report three lower lid retraction patients who underwent lower lid reconstruction was due to congenital etiology or was secondary to excessive inferior rectus muscle recession or lower lid blepharoplasty due to orbital neurofibroma. All three patients found their results satisfactory and showed no severe side effects during the follow-up period. It is suggested that the use of scleral spacer combined with lateral canthoplasty be an effective surgical procedure for correction of lower lid retraction.