Combining early lower eyelid surgery with neuromuscular retraining for synkinesis prevention after facial palsy: the role of the eye in aberrant facial nerve regeneration.

Background: Facial synkinesis (FS) is a distressing sequela of facial palsy (FP) characterized by involuntary, simultaneous movements of facial muscles occurring during voluntary facial expressions. Treatment of synkinesis is challenging, and preventive methods are needed. Aim: This study evaluated the efficacy of physical facial nerve rehabilitation (PFNR) therapy alone vs. PNFR with eyelid surgery to correct lagophthalmos and prevent the onset of synkinesis. Methods: Twenty five outpatients were randomized to receive either PFNR alone (neuromuscular retraining and Kabat proprioceptive neuromuscular facilitation) or PNFR and early (90 days after FP onset) eyelid surgery (involving a conservative oculoplastic correction for lagophthalmos with epiphora or ectropion). Comprehensive otolaryngological assessments and Magnetic Resonance Imaging (MRI) were conducted. Synkinesis progression was measured using Another Disease Scale (ADS) at baseline, 3-, 6-, 12-, and 24-months post-treatment. The data were analyzed with ANOVA, τ-test, Chi-Square analyses. Results: Patients undergoing eyelid surgery with PFNR showed faster (p < 0.001) and better recovery of facial movements (p < 0.05) than patients receiving PFNR alone comparing T0 and T12 (p < 0.0001). No synkinesis were observed in the PFNR plus surgery group while 37% of patients in PFNR alone had synkinesis (p = 0.03). At 24 months, none of the patients in the surgery group presented synkinesis. Conclusion: Combining early surgical treatment of paralytic lagophthalmos or epiphora with PFNR accelerated functional recovery and reduced synkinesis in patients with FP compared to facial rehabilitation alone. Further investigations in larger populations with long-term follow-up are needed. Clinical trial registration: https://clinicaltrials.gov/study/NCT06538103, NCT06538103.

Enhancing Lower Eyelid Suspension Outcomes Through Pre-surgical Facial Nerve Reanimation: A Comparative Study.

BACKGROUND: Lower eyelid suspension, a common therapeutic procedure for facial paralysis-induced eyelid retraction, faces challenges due to high recurrence in patients lacking facial muscle function and impedes wider adoption. This research aims to explore the potential effects of restoring orbicularis oculi muscle tension through facial nerve reanimation prior to lower eyelid suspension and to define the indications for lower eyelid suspension. METHODS: The study encompassed 32 individuals with complete facial paralysis, segmented into group A (reanimation group) and group B (non-reanimation group), based on whether the orbicularis oculi muscle's tension was restored through facial nerve reconstruction prior to lower eyelid suspension. Subjective assessments of eyelid closure (the inter-eyelid gap upon gentle closure) and objective methods measures of scleral show (the distance from the pupil's center to the lower eyelid margin, MRD2) were used to provide a comprehensive analysis of long-term effectiveness. RESULTS: The group A exhibited significantly greater long-term improvement in lagophthalmos and lower eyelid ectropion. The alterations in MRD2 measured 2.66 ± 0.27 mm in the group A versus 2.08 ± 0.53 mm in the group B, denoting a statistically significant variance (p < 0.001). Moreover, while the ratio of MRD2 preoperative 6 months postoperative revealed no significant difference between groups, a significant difference emerged in 12 months postoperative (group A: 1.02 ± 0.21; group B: 1.18 ± 0.24; p < 0.05), with the values in group A closer to 1, indicative of enhanced symmetry. CONCLUSIONS: Restoring the tension in the orbicularis oculi muscle through facial nerve reconstruction prior to palmaris longus tendon sling could effectively sustain long-term outcomes of lower eyelid retraction correction and reduce the recurrence rate. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Optimizing topical drop efficacy with proper eyelid positioning.

Purpose: To report the observation that the efficacy of topical glaucoma treatment improved after surgical correction of ectropion in a 71-year-old male with a known history of glaucoma. Observations: The patient initially presented for tearing and lid malposition and was found to have bilateral elevated intraocular pressures (IOP) in addition to bilateral lower eyelid ectropion. IOP control was initially prioritized over ectropion repair, with IOP remaining elevated despite topical glaucoma treatment and selective laser trabeculoplasty. Sequential unilateral ectropion repair was then carried out, with topical glaucoma treatment resumed after the first repair. It was observed that the IOP improved with topical glaucoma treatment on each side after ectropion repair, despite no changes to medications nor dosing. Conclusions and importance: The efficacy of topical glaucoma treatment is dependent on drop availability and absorption. While recent efforts to increase drop efficacy have been focused on engineering formulations that increase retention or corneal penetration, our case highlights that in selected glaucoma patients, correction of lid malposition may serve as an effective way to improve drop efficacy.

Gender-Related Differences in Dry Eye Symptoms Following Involutional Ectropion and Entropion Surgery.

This prospective case-control study investigated gender-related differences in dry eye symptoms following surgery for involutional ectropion and entropion. A total of 109 patients, aged between 65 and 89, were categorized by eyelid condition and gender. Postoperative assessments included the Tear Film Break-Up Time (TBUT) test, Schirmer I test results, corneal and conjunctival staining, eyelid margin characteristics, and scores from the Ocular Surface Disease Index (OSDI) questionnaire. The analysis revealed notable gender-related differences in dry eye manifestations. Initially, men exhibited lower TBUT scores but higher Schirmer test readings compared to women; however, these disparities diminished over time. No significant gender differences were detected in corneal and conjunctival staining, indicating similar levels of ocular surface damage across genders. Males showed significantly higher values in several eyelid margin characteristics (LMI, LMT) at various postoperative time points. According to the OSDI questionnaire, women experienced more severe symptoms of dry eye both pre- and post-operatively, suggesting a greater subjective symptom burden. When comparing surgical outcomes for ectropion and entropion, both conditions showed improvement in eyelid positioning and dry eye symptoms post-surgery. Despite these improvements, women with either condition reported more severe dry eye symptoms compared to men throughout the postoperative period. This study highlights the gender-specific variations in dry eye symptoms following eyelid malformation surgery and emphasizes the importance of adopting gender-sensitive approaches in postoperative care to improve outcomes and ocular health.

Lateral canthal reconstruction for the treatment of macroblepharon/diamond eye conformation in dogs.

PURPOSE: To introduce a novel surgical technique for treatment of macroblepharon and diamond eye conformation in dogs. METHODS: Lateral canthal reconstruction was used in dogs with prominent eyelid malformations resulting in ocular surface disease. Lateral canthus was resected and new lateral canthus was created using a two-layer closure. This technique was performed either alone or in combination with additional procedure(s). Additionally, this technique was used to resect lateral canthal dermoid. RESULTS: One hundred and fifty-three eyes of 85 dogs were included in the study. Procedure was done for macroblepharon and/or lateral canthal entropion (149 eyes of 81 dogs) or for lateral canthal dermoid (four eyes of four dogs). Procedure was done either alone (n = 68 eyes) or in combination with additional procedure (n = 85 eyes). Favorable cosmetic outcome and client satisfaction was achieved in all dogs. Good to excellent functional outcome was recorded in all but 6 eyes of 4 dogs, which required additional surgery. Most common complications included slight undercorrection or overcorrection. CONCLUSIONS: Lateral canthal reconstruction is a simple yet effective surgical procedure for macroblepharon and/or lateral canthal entropion. If done early, it prevents development of secondary eyelid malformation ("pagoda defect") in giant breed dogs. If done after severe eyelid malformation has developed, combining this technique with concurrent pagoda resection is recommended to achieve ideal eyelid conformation. None.

Ectropión congénito en síndrome de Noonan / Congenital ectropion in Noonan syndrome

Caso clínico: Niña de 10 años con dismorfia facial, escoliosis, baja talla, hipotonía muscular, foramen oval permeable y retraso madurativo, acude a consulta para corrección de ectropión congénito bilateral. Al examen oftalmológico se constató ectropión palpebral inferior, euribléfaron y lagoftalmos bilaterales, con fenómeno de Bell positivo. Se realizaron injertos cutáneos autólogos de espesor completo en párpados inferiores con cantoplastia lateral bilateral, resolviendo el ectropión y mejorando la oclusión palpebral. Posteriormente, se hizo un estudio genético que reveló una mutación en el gen PTPN11 y permitió, junto a la clínica, hacer el diagnóstico de síndrome de Noonan (SN).DiscusiónEl SN es un trastorno genético multisistémico con una gran variedad de fenotipos, que suele cursar con alteraciones oculares y perioculares. El ectropión palpebral, característica distintiva de la paciente, es una manifestación oftalmológica infrecuente de este síndrome que puede corregirse con injerto cutáneo de espesor completo y cantoplastia lateral. (AU)

Case report: Ten-year-old female patient, with facial dysmorphia, scoliosis, short stature, muscular hypotonia, patent foramen ovale and maturational delay, presented for correction of bilateral congenital ectropion. Ophthalmological examination revealed bilateral lower eyelid ectropion, euryblepharon and lagophthalmos, with a positive Bell's phenomenon. She was treated with full-thickness autologous skin grafts on the lower eyelids with bilateral lateral canthoplasty, resolving the ectropion and improving eyelid occlusion. Subsequently, a genetic study was performed that revealed a mutation in the PTPN11 gene and allowed, together with the clinical picture, to make the diagnosis of Noonan syndrome.DiscussionNoonan syndrome is a multisystem genetic disorder with a wide variety of phenotypes, which usually presents with ocular and periocular disorders. Eyelid ectropion, a distinctive feature of this patient, is a rare ophthalmological manifestation of this syndrome that can be corrected with full-thickness skin graft and lateral canthoplasty. (AU)

Recalcitrant postoperative bleeding after ectropion repair in the setting of undiagnosed chronic disseminated intravascular coagulation.

Disseminated intravascular coagulation (DIC) is characterized by abnormal activation of the coagulation cascade, which leads to simultaneous hypercoagulation and excessive bleeding. While it typically occurs in systemic diseases, such as infection, inflammation, obstetric complications, and malignancy, it can rarely manifest postoperatively. This case report describes a patient who presented with prolonged, refractory bleeding after ectropion repair via a lateral tarsal strip procedure. Due to the inability to control the patient's bleeding with conservative measures followed by surgical exploration and electrocautery, the patient underwent a hematologic work-up. Laboratory studies were consistent with DIC, attributed to his large burden of endovascular stents. He was treated with anticoagulation using apixaban in addition to tranexamic acid to achieve lasting hemostasis. This case highlights the importance of thorough preoperative assessments, even for minor surgical procedures, and systemic workup for atypical postoperative bleeding.

Burn-Induced Cicatricial Eyelid Retraction: A Challenging Case and Review of Management Principles.

Thermal and chemical burns can result in cicatricial eyelid retraction, characterized by an abnormal resting position of the eyelid margin and increased palpebral fissure height. Eyelid retraction often leads to exposure keratopathy, which can cause complications ranging from mild dry eye to globe-threatening ulceration and perforation. Prompt intervention includes aggressive lubrication, moisture chambers, eyelid tarsorrhaphy, and retraction repair surgery. Discussed here is a burn patient that developed severe cicatricial eyelid retraction and ectropion, leading to severe exposure keratopathy and infectious corneal ulceration with perforation. The patient required aggressive medical intervention, as well as 2 surgeries to restore the normal eyelid anatomy to protect the globe.

Scleral Contact Lens to Preserve a Corneal Graft in Chronic Lagophthalmos.

Facial burns involving the periorbital region may lead to cicatricial ectropion and lagophthalmos, causing severe exposure keratopathy and eventually blindness if uncorrected. In these patients, it is critical to provide aesthetic and functional surgical correction to protect the ocular surface from chronic desiccation in addition to visual rehabilitation. Conventional methods may not be sufficient to provide visual rehabilitation in complex cases. Scleral lenses can be a multipurpose alternative for these patients. Herein, we present the challenging case of a patient who developed cicatricial lagophthalmos and exposure keratopathy after facial transplantation due to gasoline burns and received a scleral contact lens for visual rehabilitation.

Lateral Tarsoplasty Combined with a Full-Thickness Skin Graft for Managing Severe Lower Eyelid Ectropion Following the Subciliary Approach for Infra-Orbital Rim Fracture: A Retrospective Observational Study.

Subciliary incision is a common approach for facial fracture surgery; however, it has a higher incidence of lower lid ectropion, which can be particularly challenging for beginning surgeons to manage. This study reports the usage of lateral tarsoplasty combined with a full-thickness skin graft (FTSG) to correct severe ectropion following the subciliary approach for infra-orbital rim fractures. We retrospectively reviewed all facial fracture cases involving infra-orbital rim fractures through a subciliary approach treated in our department between March 2021 and May 2023. Electronic medical records and clinical digital photographs of patients who met the inclusion criteria were reviewed. After reviewing 196 cases that used the subciliary approach, we found 6 patients (3.06%; 4 males and 2 females; mean age, 68.5 ± 4.89 years) with postoperative severe ectropion managed using lateral tarsoplasty and FTSG. The mean ectropion development and correction times after facial fracture surgery were 0.78 ± 0.24 and 0.91 ± 0.37 months, respectively. At the 12-month follow-up, all patients showed favorable outcomes, and the position of their lower eyelids was well maintained without ectropion recurrence. Based on these successful outcomes, lateral tarsoplasty combined with FTSG is proposed to be an effective and straightforward method for managing lower eyelid ectropion caused by facial fracture surgery.

Resolution of Pityriasis rubra pilaris induced ectropion with oral dexamethasone. A case report.

An 82-year-old male presented with generalised Pityriasis rubra pilaris (PRP) managed initially by dermatology team. The patient did not respond to first- and second-line treatment, including oral acitretin, steroid creams, and methotrexate, and developed bilateral cicatricial ectropion, for which he was referred to oculoplastic team for surgical management. A head injury resulting in subacute subdural haematoma, managed with a week course of low dose oral dexamethasone, resulted in the improvement of his skin condition and complete resolution of the cicatricial ectropion within a few weeks. Thus, systemic treatment of PRP with oral dexamethasone may be considered sooner in the treatment of cicatricial ectropion in similar cases.

Congenital ectropion in Noonan syndrome.

Ten-year-old female patient, with facial dysmorphia, scoliosis, short stature, muscular hypotonia, patent foramen ovale and maturational delay, presented for correction of bilateral congenital ectropion. Ophthalmological examination revealed bilateral lower eyelid ectropion, euryblepharon and lagophthalmos, with a positive Bell's phenomenon. She was treated with full-thickness autologous skin grafts on the lower eyelids with bilateral lateral canthoplasty, resolving the ectropion and improving eyelid occlusion. Subsequently, a genetic study was performed that revealed a mutation in the PTPN11 gene and allowed, together with the clinical picture, to make the diagnosis of Noonan syndrome. Noonan syndrome is a multisystem genetic disorder with a wide variety of phenotypes, which usually presents with ocular and periocular disorders. Eyelid ectropion, a distinctive feature of this patient, is a rare ophthalmological manifestation of this syndrome that can be corrected with full-thickness skin graft and lateral canthoplasty.

Evaluation of dry eye disease and corneal epithelial mapping in patients with lower eyelid ectropion.

PURPOSE: To evaluate the corneal epithelial mapping, ocular surface parameters and their relationship with each other in lower eyelid ectropion patients according to severity. METHODS: This retrospective study included 48 lower eyelid ectropion patients and 63 healthy individuals as control group. Ocular surface and tear functions were evaluated with ocular surface staining score, tear film break-up time (BUT), non-invasive tear break-up time (NIBUT) and ocular surface disease index (OSDI). Meibography scores and corneal epithelial thickness (CET) mapping were evaluated. The lower eyelid ectropion was classified and divided into subgroups as follows: mild, moderate and severe. RESULTS: There was no significant differences between the groups for age and gender. Compared to controls, CET was significantly thinner at inferior (p = 0.047) and inferior nasal quadrants (p = 0.023) in the ectropion patients. Lower BUT and NIBUT, higher OSDI scores and higher ocular surface staining were observed in the ectropion patients. In the subgroups determined according to the severity of ectropion, ocular surface damage was found to be significantly higher as the severity of ectropion increased (p < 0.05). CONCLUSION: Patients with lower eyelid ectropion had worse ocular surface findings and more ocular complaints. Furthermore, the inferior and inferior nasal CETs were thinner in patients with lower ectropion.

Management of Ectropion Associated With a Malunited Zygomaticomaxillary Complex Fracture: A Case Report.

We report the case of a 35-year-old male patient who presented with a right zygomaticomaxillary complex fracture, which was five months old. It was associated with ectropion over the right eye. Diagnosis was made by clinical examination and confirmed by computed tomography, which included a three-dimensional reconstruction view. The patient was concerned about a projecting deformity over the right side of his face and blurring of vision. Surgical rationale of treatment was to easily access the surgical site for the correction of deformity and to achieve the desired facial contour and ectropion correction with uneventful postoperative healing. Deformity at the right zygomatic arch was exposed by a hemicoronal incision. Ectropion over the lower eyelid was addressed by performing Z-plasty. Outcomes were esthetically pleasing with no loss of motor and sensory functions loss. The patient was followed up for six months.

Short-term qualitative and quantitative analyses of preseptal injection of hyaluronic acid on the treatment of acquired lower eyelid cicatricial ectropion / Análise preliminar qualitativa e quantitativa da injeção pré-septal de ácido hialurônico para tratamento do ectrópio cicatricial adquirido da pálpebra inferior

ABSTRACT Purpose: Recently, hyaluronic acid (HA) was proposed as a promising option for the treatment of acquired lower eyelid cicatricial ectropion. However, this effect was not confirmed by quantitative assessments. This study aimed to assess the effect of hyaluronic acid on the treatment of acquired lower eyelid cicatricial ectropion. Methods: Eight patients with acquired lower eyelid cicatricial ectropion (13 eyelids) were treated with a single 1 mL injection of hyaluronic acid in the preseptal area of the lower eyelid. Evaluation of symptoms and biomicroscopic exam was performed before and 30 days after hyaluronic acid injection. Quantitative analysis of the lower eyelid position (with and without lid traction) was determined before and 30 days after hyaluronic acid injection through standard photographs analyzed using the ImageJ. Results: All patients experienced partial improvement of symptoms. The lower eyelid position was significantly lifted after hyaluronic acid injection with a significant reduction of medial and lateral angles, reduction of the margin reflex distance, and total and medial ocular fissure area. However, signs of lid margin inflammation and corneal punctate keratitis persisted. Conclusions: Hyaluronic acid injected in the pre-septal area of the lower eyelid improved acquired lower eyelid cicatricial ectropion symptoms and significantly lifted the position of the lower eyelid. Further studies, with a large number of participants and a long-term follow-up period, are needed to better determine the permanency of the effects of hyaluronic acid injections on the treatment of acquired lower eyelid cicatricial ectropion.

RESUMO Objetivo: Recentemente, o ácido hialurônico foi proposto como promissor no tratamento do ectrópio cicatricial adquirido da pálpebra inferior. No entanto, não foram feitas avaliações quantitativas para confirmar este efeito, motivo que levou a realização do presente estudo que visou avaliar o efeito do ácido hialurônico no tratamento do ectrópio cicatricial adquirido da pálpebra inferior. Métodos: Oito portadores de ectrópio cicatricial adquirido da pálpebra inferior (13 pálpebras) foram tratados com uma única dose de 1 mL de ácido hialurônico, injetada na área pré-septal da pálpebra inferior. Os sintomas e o exame biomicroscópico foram realizados antes e 30 dias após a injeção do ácido hialurônico. A análise quantitativa da posição palpebral inferior (com e sem tração palpebral) foi determinada antes e 30 dias após a injeção do ácido hialurônico por meio de fotografias que foram analisadas usando o programa ImageJ. Resultados: Todos os pacientes apresentaram melhora parcial dos sintomas. A posição da pálpebra inferior foi elevada significativamente após a injeção do ácido hialurônico, com redução significativa dos ângulos medial e lateral, da distância entre o reflexo pupilar e a margem da pálpebra inferior, da área de fissura palpebral total e da área medial. No entanto, sinais de inflamação da margem palpebral e ceratite puntata da córnea persistiram. Conclusões: O ácido hialurônico injetado na área pré-septal da pálpebra inferior, melhorou os sintomas do ectrópio cicatricial adquirido da pálpebra inferior e elevou significativamente a posição da pálpebra inferior. Estudos com maior número de participantes e período de acompanhamento mais longo são necessários para melhor determinar os efeitos das injeções de ácido hialurônico a longo prazo no tratamento do ectrópio cicatricial adquirido da pálpebra inferior.

Prenatal ultrasound detection of collodion membrane in association with an autosomal recessive congenital ichthyosis due to transglutaminase 1 deficiency.

We describe a case of collodion baby diagnosed prenatally by ultrasound. Classic signs (ectropion, flattened nose, and eclabion) were detected on routine ultrasound at 21 weeks of gestation. At birth, the presence of collodion membrane was confirmed and subsequently, the diagnosis of an autosomal recessive congenital ichthyosis due to compound heterozygosity of the TGM1 gene was made.

Clinical features, evaluation, and management of ophthalmic complications of facial paralysis: A review.

The purpose of this review was to study the evaluation, diagnosis, and management of ophthalmic complications associated with facial nerve palsy and to discuss the current and future interventions. The ophthalmic complications of facial paralysis include lagophthalmos, ectropion, exposure keratopathy, ocular synkinesis, and crocodile tears. Evaluation by an ophthalmologist skilled in recognizing and managing complications of facial paralysis shortly after its initial diagnosis can help identify and prevent long-term complications. Several types of grading scales are used to evaluate, measure the severity, and track surgical and patient-reported treatment outcomes. Lagophthalmos or ectropion are managed using temporary measures aimed at lubricating and covering the eye, including scleral lenses; however, these measures can be expensive and challenging to acquire and maintain. Temporary surgical interventions include lateral tarsorrhaphy, weighted eyelid implants, lateral canthoplasty, and other procedures that tighten or lift the eyelid or surrounding tissues. Management of flaccid facial paralysis due to iatrogenic injury or neoplasm requires neurorrhaphy or graft repair. The most common techniques for dynamic reconstruction in chronic facial paralysis are regional and free muscle flap transfer. Future directions for the management of ophthalmic complications aim to induce blinking and eye closure by developing systems that can detect blinking in the normal eye and transmit the signal to the paralyzed eye using mechanisms that would stimulate the muscles to induce eyelid closure. Blink detection technology has been developed, and a study demonstrated that blinking can be stimulated using electrodes on the zygomatic branch of the facial nerve. Further studies are needed to develop a system that will automate blinking and synchronize it with that of the normal eye.

Ophthalmic findings in patients with autosomal recessive lamellar ichthyosis due to TGM1 mutations in an isolated population.

PURPOSE: To describe the ocular clinical characteristics of a group of Mexican patients with lamellar ichthyosis (LI) arising from TGM1 pathogenic variants. METHODS: Ophthalmological exploration, pedigree analysis and genetic screening were performed in patients with an established clinical diagnosis of lamellar ichthyosis from families located in a small community in the Southeast of Mexico. RESULTS: Nine patients with LI in five families were identified. There were six affected females. All patients (9/9) demonstrated eye lid abnormalities with eight patients showing lid margin abnormalities. Madarosis was present in only three individuals and corneal scarring was documented in two. All nine individuals carried biallelic TGM1 variants, either homozygously or as compound heterozygous. CONCLUSION: Ocular anomalies are common in individuals with TGM1-related LI. The occurrence of a variety of private or rare mutations hampers the identification of a genotype-phenotype correlation for ocular anomalies in this disorder.