Lateral Tarsal Strip Procedure for Right Lower Eyelid Entropion
Main Text
Table of Contents
Eyelid entropion is a condition characterized by the inward turning of the eyelid margin, causing the eyelashes to rub against the cornea and conjunctiva.1 This condition predominantly affects the lower eyelids and may lead to ocular discomfort, corneal abrasions, ulcerations, and potentially vision-threatening complications if left untreated.2,3 Involutional entropion is the most common form in elderly patients due to horizontal eyelid laxity and dehiscence of the lower lid retractors.4 The condition is often bilateral, though asymmetrical in presentation.
The management of entropion ranges from conservative approaches, such as lubricating eye drops and temporary eyelid taping, to definitive surgical correction.5,6 Among the various surgical techniques, the lateral tarsal strip procedure has emerged as one of the most effective and widely employed methods for addressing involutional entropion associated with horizontal eyelid laxity.7,8
The lateral tarsal strip procedure for lower eyelid entropion is contraindicated in cases of active ocular or periocular infection, significant cicatricial changes without horizontal laxity, severe dry eye syndrome, uncontrolled coagulopathy, or in patients unable to tolerate local anesthesia.9 This procedure offers several advantages, including addressing the fundamental underlying cause of involutional entropion, providing long-lasting correction, causing minimal postoperative discomfort, and having a low recurrence rate compared to other procedures. Additionally, it can be combined with other procedures when indicated.
The accompanying video provides a detailed, comprehensive description of this surgical technique with visual demonstration of each step.
The surgical technique begins with a lateral canthotomy, creating a horizontal incision at the lateral commissure until the orbital rim is palpated. The inferior crus of the lateral canthal tendon is then severed, mobilizing the lower eyelid completely. After assessing the position, the lateral edge of the lower eyelid is dissected into its anterior and posterior components, facilitating creation of the tarsal strip.
The lid margin epithelium is excised, and the palpebral conjunctiva on the posterior aspect is deepithelialized to create a raw surface for reattachment. Any excess tissue is trimmed to achieve appropriate length before securing the tarsal strip to the periosteum of the lateral orbital rim using a 4-0 Mersilene double-armed suture. The lateral canthal angle is then reconstructed with a suture capturing both the upper and lower lids, and the skin wound is closed with a running 6-0 plain gut suture.
The lateral tarsal strip procedure effectively addresses the underlying problem of lower eyelid laxity by tightening the eyelid in a new, vertically oriented position. The procedure can be challenging due to bleeding, which may obscure the surgical field; however, the use of small needles allows the surgeon to rely on tactile feedback to engage the periosteum and secure the tarsal strip. This procedure is well-tolerated by patients, requiring only local infiltration of anesthetic, typically lidocaine with bicarbonate. The simplicity of the technique, combined with its lasting and effective relief for patients, makes the lateral tarsal strip procedure a preferred choice for the correction of involutional entropion associated with horizontal eyelid laxity. This video will be particularly beneficial for ophthalmologists, oculoplastic surgeons, and trainees seeking to refine their understanding and surgical skills in the management of entropion.
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
- Karpecki PM. Kanski’s Clinical Ophthalmology. Opt Vis Sci. 2015;92(10). doi:10.1097/opx.0000000000000737.
- Maman DY, Taub PJ. Congenital entropion. Ann Plast Surg. 2011;66(4). doi:10.1097/SAP.0b013e3181e56e69.
- Piskiniene R. Eyelid malposition: lower lid entropion and ectropion. Medicina (Kaunas). 2006;42(11).
- Lo C, Glavas I. Diagnosis and management of involutional entropion. Am Acad Ophthalmol. 2016;25(April).
- Lin P, Kitaguchi Y, Mupas-Uy J, Sabundayo MS, Takahashi Y, Kakizaki H. Involutional lower eyelid entropion: causative factors and therapeutic management. Int Ophthalmol. 2019;39(8). doi:10.1007/s10792-018-1004-1.
- Lebedeva P, Sitnik H. Features of surgical treatment of lower eyelid entropion. Oftalmologija Vostochnaja Evropa. 2022;12(4). doi:10.34883/PI.2022.12.4.015.
- Kopecký A, Rokohl AC, Heindl LM. The role of the lateral tarsal strip procedure in modern ophthalmic plastic surgery—a review. Front Ophthalmol. 2022;2. doi:10.3389/fopht.2022.871964.
- Rougraff PM, Tse DT, Johnson TE, Feuer W. Involutional entropion repair with fornix sutures and lateral tarsal strip procedure. Ophthalmic Plast Reconstr Surg. 2001;17(4). doi:10.1097/00002341-200107000-00008.
- Bergstrom R, Czyz CN. Entropion Eyelid Reconstruction. [Updated 2023 May 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470540/.
Cite this article
Lee J. Lateral tarsal strip procedure for right lower eyelid entropion. J Med Insight. 2025;2025(512). doi:10.24296/jomi/512.
Procedure Outline
Table of Contents
- 1. Introduction
- 2. Lateral Canthotomy and Inferior Cantholysis to Disinsert Lower Eyelid at Lateral Orbital Rim
- 3. Determining New Eyelid Position
- 4. Separation of the Posterior and Anterior Lamella of the Lower Eyelid
- 5. Excision of Lid Margin Epithelium
- 6. Deepithelialization of Palpebral Conjunctiva Along Posterior Aspect of Tarsal Strip
- 7. Trimming Tarsal Strip to Appropriate Length
- 8. Reattachment of the Tarsal Strip to the Periosteum of the Lateral Orbital Rim with 4-0 Mersilene Double-Armed Suture
- 9. Closure of the Lateral Canthal Angle and Skin with Running 6-0 Plain Gut Suture
- 10. Post-op Remarks
Transcription
CHAPTER 1
My name is John Lee, I'm the Oculoplastic Surgeon at Boston Vision. We're gonna show you a video, where I perform a lateral tarsal strip procedure to fix a lower eyelid ectropion. First, we're gonna free the lower eyelid from the lateral orbital rim, isolate the tarsal strip, and re-secure the lower eyelid in a tighter position to fix the ectropion.
CHAPTER 2
So, we're gonna start a right lower lid ectropion repair. We're gonna start by doing a lateral canthotomy, where we go to the lateral commissure of the eyelids and we sharply dissect down, until we hit the lateral orbital rim, which I can feel right through that cut there. And then I'm gonna reflect the incision inferiorly by grabbing the lateral aspect of the lower lid. I can still feel it tethered by the inferior crus of the lateral canthal tendon. And I will continue to cut that lateral canthal tendon at the inferior aspect until that eyelid is very mobile. And I will strum this area to see if I can feel any more residual tendon fibers, and I feel a couple. And if you can see, as I incise that, I get an even more mobile eyelid. So, we have a completely disinserted lower eyelid at the lateral orbital rim.
CHAPTER 3
Next thing I'm gonna do is drape the lower eyelid into the position that I want it to end up in. So I'll take a peek at the... Upper aspect of that lateral commissure. And I'll mark it on the lower lid. There, and that's about where the new position of the lower aspect of the lateral commissure will be.
CHAPTER 4
Then we're gonna dissect the lower eyelid along the lateral tarsal edge here into its two anterior versus posterior components. The anterior component is skin and orbicularis muscle, and the posterior component is tarsus and palpebral conjunctiva.
CHAPTER 5
We will discard... The lid margin epithelium. 15 blade next.
CHAPTER 6
And then we'll depithelialize the palpebral conjunctiva along the posterior aspect of the tarsal strip. This is a 15 blade, and we're just gonna scrape away this tissue.
CHAPTER 7
So this is the aspect of the lateral tarsal strip that we reattach to the periosteum of the lateral orbital rim. This is more than we need, so we will amputate the most lateral aspect of it and discard it.
CHAPTER 8
And then we need a non-absorbable suture. We're gonna use Mersilene. Cut it? Nope, I need double-armed. So, this is 4-0 Mersilene, double-armed. With small spatulated needles. So I'm gonna grab that stump of the lateral tarsal strip. You feeling any of that? I'm gonna pass from anterior to posterior, save that. And pass similar suture inferior to the first. And this will get secured to the periosteum of the lateral orbital rim. If you can keep that out of my way there. So I'm palpating down to the lateral orbital rim, add some pressure to get some temporary hemostasis. And then I will pass the suture through that periosteum. I wanna make sure I have a good purchase on it, so I'm tugging on it. And with these small needles, it is hard to see the tip, but the small needle allows us a little bit more mobility with the neighboring globe. Okay. We'll go back to the superior arm of the Mersilene, and pass a similar periosteal stitch. Okay, and these sutures can now be cut.
CHAPTER 9
I will not tie them yet, because we need to recreate the lateral canthal angle. Plain gut, please. But this shows how that stump of the lateral tarsus is now reconnected to the periosteum, and a significantly tighter lower eyelid, which should resolve the ectropion. I'll take a short one. Initial incision, we lost the lateral canthal angle, so we're gonna recreate it. With a bite on the lower lid and the upper lid and we'll secure that. Okay, suture cut. And I'll leave that aside. And now I can secure the Mersilene sutures. And that should be buried underneath that stump of the lateral tarsus. Scissors to me. Needle driver to me. And that same plain gut stitch we'll use to close the remaining skin wound. So we've disinserted the lateral aspect of the lower lid, reattached it to the periosteum with a much tighter and now vertically-oriented lower eyelid. That's it.
CHAPTER 10
The underlying problem with lower eyelid ectropion is laxity. So, the surgery is used to tighten the lower eyelid in a new position. In this case, we had some difficulty with bleeding, which obscured the view. But when you use small needles, a lot of it is done by feel, and you can feel the small needles engage the periosteum and re-tighten that position. This procedure is pretty well tolerated. All it requires is local infiltration of an anesthetic where we use lidocaine with bicarb. It's a very simple procedure to perform and gives patients lasting and effective relief.