Lateral Tarsal Strip Procedure for Left Lower Eyelid Entropion
Main Text
Table of Contents
Lower lid entropion or inversion is a common involutional inward rotation of the tarsus and eyelid margin. It is caused by a combination of horizontal laxity of the eyelid, attenuation or disinsertion of eyelid retractors, and overriding of preseptal over pretarsal orbicularis muscle fibers. These changes result in the instability of the eyelid with age. The inverted eyelid leads to constant rubbing of eyelashes against the cornea and the globe, causing irritation, foreign body sensation, and in severe cases, corneal erosion, pannus formation, and ulceration. The lateral tarsal strip procedure is aimed at addressing the causes of entropion, thus correcting the eyelid position and improving its function. Upon successful surgical intervention, normal eyelid position and function are restored. Cosmesis of the eyelid also improves. This article will discuss the preoperative assessment of the patient, the preparation, the surgical procedure, and possible complications.
The main complaints of patients with entropion are irritation, discomfort, foreign body sensation, tearing, redness, as well as cosmetic concerns. If corneal erosion is present, complaints such as photophobia, pain, and blurred vision may also be present.1, 2 Entropion is typically managed through surgical correction to restore the normal position of the eyelid and alleviate the associated symptoms.
The patient in this case is a 67-year-old male with persistent ocular irritation and dry eye syndrome with foreign body sensation that has worsened over the course of 8 months. Symptoms were described worse in the left eye. The cause of his symptoms was determined to be the entropion of the left lower lid, which was causing poor eyelid apposition to the globe as well as rubbing of eyelashes against the cornea. Attempts with epilation were previously unsuccessful. Both Dr. Lee and the patient agreed the best course of action was to surgically repair the eyelid entropion via the lateral tarsal strip procedure.
Slit-lamp examination: Evaluation of eyelid and eyelash position to evaluate the malposition of the eyelid margin. Evaluation of the anterior surface of the eye for signs of chronic irritation, inflammation and possible corneal lesions.
Lower lid distraction test: The lower lid is pulled from the globe and distance is measured to evaluate the laxity.1, 3
Snapback test: Involves gently pulling the eyelid to assess its mobility and how well it returns to its normal position.1, 3
Assessment of orbital fat prolapse.1
A complete ocular examination: Including visual acuity testing and dry eye testing, as well as fundus examination.
Medical history and systemic medications: Should be noted and taken into account when planning the procedure.
The natural course of entropion is often progressive. Early signs and symptoms may be insignificant and intermittent.1 In some cases, entropion may remain stable or progress slowly over time, while in others, it may worsen more rapidly. Without treatment, the symptoms associated with entropion can persist and potentially lead to worsening complications.
- Surgical intervention, such as a lateral tarsal strip procedure or other corrective procedures, is commonly recommended to reposition the eyelid and alleviate the associated symptoms.
- Artificial tears or lubricating ointments and bandage contact lenses are used for symptomatic relief.
- Temporary eyelid eversion with tape. Repositioning the anterior lamella away from the eyelid margin with tape can sometimes be effective in relieving symptoms.1
- Lid-everting sutures are a quick and easy temporary solution. They last several months and can be used in cases when definitive surgical intervention is contraindicated or should be postponed.2
- The Wies procedure is a viable alternative to the lateral tarsal strip procedure and has been shown to have satisfying results.4, 5 It is, however, less effective if not combined with the lateral tarsal strip procedure to address both horizontal and vertical components of the entropion.6
- Lower lid retractor reinsertion is another alternative to the lateral tarsal strip procedure; however, it has a significantly lower success rate.7
In this case the lateral tarsal strip procedure was performed to correct an involutional entropion. The aim of the surgery is to correct the malposition of the eyelid, improve eyelid function, and alleviate associated symptoms.
Contraindications to this procedure include:
- In patients with uncontrolled systemic disease, which could lead to intra- and postoperative complications.
- If an active infection is present. In such cases it is advised to postpone the intervention.
- If the patient is on antiplatelet or anticoagulation medications. These medications raise the risk of retrobulbar hemorrhage.
- If there is insufficient eyelid tissue. The lateral tarsal strip procedure requires adequate eyelid tissue to perform the repositioning and anchoring. In cases where there is insufficient eyelid tissue, such as after trauma or previous surgery, alternative surgical techniques may be more suitable.8, 9
Potential postoperative complications include the following conditions:1–3
- Overcorrection
- Retrobulbar hematoma
- Eyelid retraction or malposition
- Exposure keratopathy
- Granuloma formation
- Inclusion cyst
- Persistent rim tenderness
- Infection
- Wound dehiscence
- Ocular surface irritation
The lateral canthal area is anesthetized with a local injection of 2% lidocaine and epinephrine. The lateral canthal tendon is cut with Westcott scissors to create a lateral canthotomy. Inferior cantholysis is performed by cutting the inferior crus of the lateral tarsal tendon. The mobilized lower eyelid is pulled laterally, and the new position of the lateral canthal angle is determined and marked. The anterior and posterior lamella of the marked portion are separated beginning at the greyline and extending across the anterior surface of the tarsus. The eyelash follicles are removed and the lid margin is deepithelialized. Redundant tissue of the tarsal strip is determined by drawing the strip to the lateral orbital tubercule. The excess tissue is excised, and the new lateral border of the tarsus is reattached to the periosteum of the lateral orbital rim with Mersilene double-armed suture, which effectively acts as the new lateral canthal tendon. After hemostasis is achieved, the lateral canthal angle and the skin are closed. A small cutaneous triangle can be excised from the inferior wound margin lateral to the tarsal angle, in order to enhance aesthetics.1 In some cases, Quickert-type lid sutures may be placed to enhance the marginal rotation.1,10
- Forceps
- Westcott scissors
- Needle driver
- No. 15 blade
- 4-0 Mersilene double-armed non-absorbable suture
- 6-0 Plain gut suture
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Rumelt S. Ophthalmology. 4th Edition. (in print and online) Yanoff M, Duker JS. (2013) ISBN 978-1455-7398-44, Elsevier. Graefe’s Arch Clin Exp Ophthalmol. 2017;255(2). doi:10.1007/s00417-015-3050-y.
- Salmon J, Kanski JJ. Kanski’s Clinical Ophthalmology E-Book: A Systematic Approach. Elsevier. Published online 2020.
- Korn BS. 2021-2022 Basic and Clinical Science Course, Section 7: Oculofacial Plastic and Orbital Surgery. Am Acad Ophthalmol Sect 7. Published online 2021.
- Shahid E, Fasih U, Shaikh A. Wies procedure for correcting involutional entropion of the lower lid in geriatrics. Malaysian J Ophthalmol. 2021;3(1). doi:10.35119/myjo.v3i1.170.
- Bleyen I, Dolman PJ. The Wies procedure for management of trichiasis or cicatricial entropion of either upper or lower eyelids. Br J Ophthalmol. 2009;93(12). doi:10.1136/bjo.2008.142505.
- Emesz M, Wohlfart C, Grabner G. Combination Wies procedure and lateral tarsal strip in the therapy of involutional entropion. Spektrum der Augenheilkd. 2004;18(3). doi:10.1007/bf03163157.
- Ezzeldin ER. Lateral tarsal strip vs. lower lid retractors reinsertion for treatment of involutional entropion. Delta J Ophthalmol. 2022;23(2). doi:10.4103/djo.djo_65_21.
- Bergstrom R, Czyz CN. Eyelid Reconstruction, Entropion.; 2018.
- Vahdani K, Siapno D Lou, Lee JH, Woo KI, Kim YD. Long-term outcomes of acellular dermal allograft as a tarsal substitute in the reconstruction of extensive eyelid defects. J Craniofac Surg. 2018;29(5). doi:10.1097/SCS.0000000000004464.
- Ho SF, Pherwani A, Elsherbiny SM, Reuser T. Lateral tarsal strip and quickert sutures for lower eyelid entropion. Ophthal Plast Reconstr Surg. 2005;21(5). doi:10.1097/01.iop.0000179370.96976.ee.
Cite this article
Arzumanian L, Martin A, Lee J. Lateral tarsal strip procedure for left lower eyelid entropion. J Med Insight. 2023;2023(402). doi:10.24296/jomi/402.
Procedure Outline
Table of Contents
- Anesthesia of the lateral canthal angle with a local injection of 2% lidocaine and epinephrine.
- Prepping and draping.
- Creation of a lateral canthotomy by cutting through the lateral canthal tendon with Westcott scissors.
- Inferior cantholysis is performed by cutting the inferior crus of the lateral tarsal tendon using Westcott scissors.
- The new position of the mobilized lower lid is approximated and marked.
- The anterior and posterior lamella of the marked portion are separated using Westcott scissors.
- The strip containing the eyelash follicles is removed.
- The lid margin and posterior tarsal strip is deepithelialized with scissors and #15 blade.
- The excess portion of the tarsal strip is removed.
- The tarsal strip is reattached to the periosteum of the lateral orbital rim with a 4-0 Mersilene double-armed non-absorbable suture.
- The lateral canthal angle and the skin are closed with 6-0 plain gut running suture.
- Cold compresses or ice packs for the first 4–5 days after surgery.
- Topical and oral antibiotics.
- Artificial tears for lubrication as needed.
- Follow-up in 1 week for postoperative evaluation.
Transcription
CHAPTER 1
Hello, my name is Dr. John Lee.I'm the Oculoplastic and Reconstructive Surgeonfor Boston Vision.I want to introduce a videoof a surgery we're about to perform,it is a lateral tarsal strip procedure,and in this case, it's for an entropic lower eyelid.The surgery is first performedby anesthetizing the lateral canthal angle.This is done with 2% lidocaine and epinephrineon a very thin, 32-gauge needle.The initial step is to create a lateral canthotomywith Westcott scissors,and this is reflected inferiorlyto complete an inferior cantholysis.Once the lower lid is fully mobile,it is draped laterally to approximate its new position.This position is marked on the lower eyelid margin.That portion of the lower eyelidis then separated from the anterior and posterior lamella,using Westcott scissors.The posterior tarsal strip is then preparedby deepithelializing it with the scissors and a 15 blade.Next, a 4-0 Mersilene suture,which is a non-absorbable suture,is used to reattach the tarsal strip to the periosteumof the lateral orbital rim.Once that's secured,the lateral canthal angle and skin are closedwith a 6-0 plain gut suture in a running fashion.
CHAPTER 2
So, do a little testing to see if he's numb.He suffers from an involutional entropion,where his lower eyelid rolls inward on him,causing persistent irritation,so we're gonna do a procedure called a lateral tarsal strip.We've already injected some lidocaine with epinephrinethrough the lateral canthus,all the way down to the lateral orbital rim,across the anterior and posterior partof the lateral lower lid,and the upper portion of the lateral canthal angle there.Just ensuring that he's numb. Excellent.
CHAPTER 3
First step is we're gonna free the lower lid,make it more mobile.We'll start with the lateral canthotomy,so a pair of Westcott scissorsincising through the lateral canthal angle,through the lateral canthal tendon.And I'm aiming for that lateral orbital rim.I can feel it just underneath that pair of scissors there.So that's the lateral canthotomy.
CHAPTER 4
And we're gonna proceed with the inferior cantholysis.So if I pass my scissors here,it strums tight like a guitar string,and that's the lateral -sorry, the inferior crest of the lateral canthal tendon.So we're gonna incise through there.And you can see that the lower lid is freeing up.And now we have a very mobile lower lid.
CHAPTER 5
So if we look where the upper lid ends, laterally -this is where the lower lid initially ended.We are gonna change that position,and make that there.So, mark it.
CHAPTER 6
And then I'm gonna separate the posteriorand the anterior lamella of the lower lid.On the forceps side will be the skin and orbicularis.On the globe side will just be the tarsusand the palpebral conjunctiva.I'm gonna go all the way to my previous mark.I'm gonna remove this strip that contains the follicles.And that gives me a freely mobile tarsal strip here.
CHAPTER 7
The epithelium is still on the margin,so that's gonna be removed with the scissors.And there's still epithelium on the posterior surfaceof that tarsal strip, so that will be scraped off.And this is more strip than we need,so we will remove the excess portion.Can you load the Mersilene for me?
CHAPTER 8
So our suture for this portionis a 4-0 Mersilene double-armed suture.It is a non-absorbable suture, so it will remain there.So what I do is I take my tarsal strip -I'm gonna pass the suturethrough the superior portion of it.And then I take the second halfof that double-armed suture,grab the strip again,and pass it through the inferior portion of it.Now these two arms of the same suturewill now recreate that lateral canthal tendonwhen we attach it to the orbital rim.So I can palpate down to the lateral orbital rim here,and I'm gonna pass that suture right through the periosteumof that orbital bone.So as I pass it, I can feel that I have a good purchase.A very solid connection.I take the second arm of the Mersilene suture,and I'm gonna aim a little more superiorlythan the first pass.Again, I can feel the bone right underneath the suture.I'm grabbing periosteum.And this will function as a new lateral canthal tendon,and you can see how the lower lid is much more taut.So, scissors to you.Cut.Cut.And plain gut, please.Now before we secure these,we're gonna recreate the lateral canthal angle.We remove the lateral portion of the lower lid,so now this is gonna be the lateral aspect of the lower lid,and you still have the original lateral aspectof the upper lid,so these two parts are gonna be connected.
CHAPTER 9
So this is a 6-0 plain gut suture.I'm just gonna grab a portionof what I want to be the new lateral canthal angle.And this is the original upper lid portionof the lateral canthal angle.And that should come togetherto form the new lateral canthal angle.
I'm gonna set aside this plain gutbecause I still have to secure the Mersilene sutures here.So typically I'll do a double-knotbecause this is under quite a bit of tension.And the knot will be buried just above the periosteum.Scissors to me.Dab.You can dab.Now all that remains is closure of the lateral canthotomywith the same 6-0 plain gut suture.That's gonna go from the newly created lateral canthal angle.And secure the suture to itself.The procedure is complete.