Preseptal transconjunctival approach in orbital floor fracture repairs to prevent postoperative lower eyelid malposition.

PURPOSE: Lower eyelid malposition can be a complication following orbital floor fracture surgeries. We present our incidence of lower eyelid malposition from a large case series of orbital floor fracture repairs using the 'swinging eyelid' approach and 'hang back' technique. METHODS: A retrospective review of all orbital fracture surgeries at our institution from November 2011 to March 2021 was performed. Primary outcomes included the incidence of lower eyelid malposition by category, the average time to presentation after primary surgery, and reoperation rates among cases with lower eyelid complications. RESULTS: A total of 438 cases that involved repair of the fractured orbital floor were identified. Six patients (1.37 %) developed lower eyelid malposition following primary orbital floor repair. Two patients (0.46 %) developed reverse ptosis of the lower eyelid. Two patients (0.46 %) returned with lower lid cicatricial ectropion. One patient (0.23 %) had postoperative lower eyelid retraction. One patient (0.23 %) had postoperative lower eyelid cicatricial entropion. No cases of lower lid flattening, lower eyelid fat flattening, or eyelid notch was noted. All patients with lower eyelid malposition underwent additional surgeries except one patient with reverse ptosis (83.3 %). The average time to the presentation of postoperative complications from the surgery date was 292.8 days (range = 49 days to 3.5 years). CONCLUSION: Lower eyelid malposition after orbital floor repair is a known complication that can be decreased by employing the 'swinging eyelid' with a preseptal approach and closure by the 'hang back' technique.

Evaluation of outcomes of lower eyelid entropion and ectropion surgical repair.

<b><br>Introduction:</b> The imbalance of external and internal forces acting on the lower eyelid can result in entropion and ectropion, both of which cause ocular irritation and loss of proper eye protection. Potential complications of untreated cases include recurrent inflammation of the conjunctiva and cornea, conjunctival neovascularization, corneal abrasion or perforation, and ultimately even loss of vision. Although various surgical techniques are used to address this problem, their long-term outcome and effectiveness are still under discussion. </br> <b><br>Aim:</b> To evaluate outcomes of surgery for entropion and ectropion, including a modified Wheeler's method for entropion correction.</br> <b><br>Methods:</b> A non-comparative study (prospective and retrospective groups) included 100 patients operated on in two university hospitals' plastic surgery departments for lower eyelid entropion or ectropion, following formal ethics approval. The prospective group included 50 patients assessed preoperatively and at 3 and 12 months postoperatively. The retrospective group was comprised of 50 patients (2012-2018), whose preoperative documentation and clinical examinations were analyzed. The main outcome measures were change between pre- and postoperative patient-reported symptoms (VAS scale), ectropion/entropion grading scale (EGS/EnGS), quality of life (WHOQOL-BREF), and occurrence of complications.</br> <b><br>Results:</b> The differences in the severity of all symptoms before and after surgery evaluated with the VAS scale were statistically significant in both groups (p <0.05). We observed 6 recurrences (12%) in the prospective group and 9 (18%) in the retrospective group, with minor complications. Very good functional and esthetic postoperative results were confirmed in 70% (79) of the whole group and in 13 patients (81.3%) treated with the modified Wheeler's method. In the prospective group, the Mann- Whitney U test for dependent variables revealed significant improvement in the somatic, psychological, and environmental domains, with no significant change in the social relationships domain.</br> <b><br>Conclusions:</b> The results following entropion/ectropion surgery prove the effectiveness of the methods used. Complementing them with the modified Wheeler's method brought an increase in the number of very good outcomes. Surgery of lower eyelid malposition contributed to reduced symptoms and improved quality of life. The rates of postoperative sequelae were low.</br>.

Ageing increases risk of lower eyelid malposition after primary orbital fracture reconstruction.

Lower eyelid malposition (LEM) is a common sequela after orbital fracture reconstruction. This study aimed to analyse the development of LEM, specifically ectropion and entropion, following primary orbital fracture reconstruction, to identify predictive factors for LEM, and to assess the effect of the eyelid complication on patients' daily lives. The retrospective cohort comprised patients who had undergone orbital floor and/or medial wall fracture reconstruction for recent trauma. Demographics, fracture type and site, surgery and implant-related variables, follow-up time and number of visits, type and severity of LEM, subsequent surgical correction, and patient satisfaction, were analysed. The overall occurrence of LEM was 8%, with ectropion in 6% and entropion in 2% of patients. Older age, complex fractures, transcutaneous approaches, preoperative traumatic lower lid wounds, and implant material were associated with the development of LEM. Of all patients, 3% needed surgical correction of LEM. Six of the 13 patients (46%) who developed LEM required surgical correction. The transconjunctival approach and patient-specific implants should be preferred, especially in elderly patients and those with more complex fractures. LEM often requires subsequent surgical correction, and the treatment period is substantially prolonged, with multiple extra visits to the clinic.

Bilateral Enophthalmos as an Unusual Presenting Feature of Non-Hodgkin's Orbital Lymphoma.

Lymphoma is the commonest orbital malignancy. The typical presentation is proptosis or swelling, which warrants imaging and confirmation by tissue biopsy. Enophthalmos is a much rarer clinical sign and if bilateral and symmetrical can often present late. We describe a patient who presented with bilateral enophthalmos and symptomatic, secondary entropion due to bilateral non-Hodgkin's lymphoma in which orbital fat was replaced by a monoclonal proliferation of small B cells. Low-dose orbital radiotherapy and entropion surgery relieved the patient's symptoms.

Experience of orbital floor fractures in a UK level one trauma centre: a focus on the surgical approach and lid-related complications.

The two surgical approaches to access orbital fractures are transconjunctival and transcutaneous. The aim of this study was to assess the outcomes of orbital repairs with a focus on lid-related complications and their management. A retrospective analysis was carried out over a five-year period (January 2015 to January 2020) to assess all consecutive orbital repairs in our unit. Data were collected for variables including demographics, fracture pattern, surgical approach, and details of postoperative complications. A total of 111 patients were included in the study, 94 were male (85%), the majority being between 16 and 45 years of age. A total of 46 (41%) had isolated orbital floor fractures, 31 (28%) zygomaticomaxillary complex, and 18 (16%) Le Fort pattern fractures. Eighty per cent (n = 91) received a transconjunctival approach as first choice. In the transconjunctival group, six (6.6%) had entropion and increased scleral show, four (4.4%) had ectropion, and none had canthal malposition. In the transcutaneous group (n = 20) there was a higher rate of ectropion (25%, n = 5), a lower rate of entropion (n = 1, 5%) and higher rate of increased scleral show (n = 2, 10%). Factors associated with a higher rate of complications included complex fractures, use of conjunctival sutures, and increased length of time to surgery. Seventy-two per cent of patients who suffered entropion required further surgical treatment. The most common complication of the transconjunctival approach was entropion, and clinicians should have a low threshold for early surgical management. We feel that this should be part of the consenting process, especially in high-risk cases.

Surgical Management of Ocular Cicatricial Pemphigoid in a Pediatric Patient.

PURPOSE: The purpose of the report was to describe the first successful tarsal fracture surgery in a 1-year-old boy diagnosed with cicatricial ocular pemphigoid whose visual and psychomotor development were notably limited. METHODS: We present the case of a 1-year-old boy diagnosed with mucous membrane pemphigoid by biopsy who was treated with rituximab (375 mg/m 2 intravenous infusion at 2-week interval administered twice) and stable with oral dapsone (2 mg·kg -1 ·d -1 ). His eyelid cicatricial entropion and trichiasis in both eyes prevented him from opening his eyes, impeding visual development. After 1 year of clinical stability, we performed a tarsal fracture procedure in both eyes to restore eyelid anatomy and functionality, with the aim to prevent an inflammatory reaction, administrating intravenous dexamethasone before and after surgery. RESULTS: The intervention was successfully performed without postoperative complications. Excellent anatomic and functional results allowed him to develop normally in his daily life the first week after surgery. He is currently taking oral dapsone (2 mg·kg -1 ·d -1 ) as a maintenance treatment to stop the progression of the disease. CONCLUSIONS: Tarsal fracture surgery may be considered part of the treatment in pediatric patients with stable ocular cicatricial pemphigoid presenting with severe entropion and trichiasis.

Postoperative changes in status of meibomian gland dysfunction in patients with involutional entropion.

PURPOSE: To examine postoperative changes in the status of meibomian gland dysfunction in patients with involutional entropion. METHODS: This prospective, interventional study included 10 eyelids of 8 patients with involutional entropion who underwent posterior layer advancement of the lower eyelid retractors and either a lateral tarsal strip or transcanthal canthopexy procedure. The following features were examined for evaluation of meibomian gland dysfunction and dry eye: the presence or absence of eyelid abnormalities (irregular eyelid margin, vascular engorgement, and plugged meibomian gland orifices), Marx line score, meibum expression score, loss of the meibomian glands, A (area) and D (density) scores for corneal fluorescein staining, and tear breakup time. All the measurements were performed before and 6 months after surgical correction of involutional entropion. RESULTS: Regarding the findings of meibomian gland dysfunction, irregular eyelid margin, vascular engorgement, and plugged meibomian gland orifices improved only in 1 eyelid of 1 patient (P = 0.317, P = 1.000, and P = 1.000, respectively) postoperatively. The scores of Marx line, meibum expression, and loss of meibomian glands did not statistically change after surgery (P = 0.157, P = 0.705, and P = 0.317, respectively). The D score was statistically improved after surgery (P = 0.046), although the difference between the pre- and postoperative A score was not statistically significant (P = 0.083). Tear breakup time did not change after surgery (P = 0.705). CONCLUSIONS: Our study indicates that meibomian gland dysfunction does not resolve after surgical correction of involutional entropion.

Correction of Recalcitrant Cicatricial Lower Lid Retraction and Entropion With Transverse Tarsotomy and Tarsoconjunctival Flap.

PURPOSE: To describe a novel technique to correct cicatricial lower lid entropion and retraction using a transverse lower lid tarsotomy with an interposed tarsoconjunctival flap posterior lamellar spacer. METHODS: Technique description and retrospective interventional case series. RESULTS: Four patients underwent the procedure-two with complications following treatment of sinonasal carcinoma and two with complications following orbital fracture repair. All patients had failed prior posterior lamellar spacer grafts, including donor sclera, dermis-fat graft, and hard palate mucosa. Average time to flap takedown was 20 (11-28) days, with an average follow-up interval of 8.4 (6.2-11.5) months. All patients had resolution of lower lid entropion and significant improvement of lower lid retraction with an average of 2.8 mm (2.0-4.3) of elevation. There were no serious complications, and all patients reported significant improvement in ocular surface symptoms. CONCLUSIONS: Transverse tarsotomy combined with a tarsoconjunctival flap is effective for the correction of cicatricial lower lid retraction and entropion in eyelids that have failed surgery with traditional posterior lamellar spacer grafts.

[Anterior lamellar resection with lid margin split of the upper eyelid in the treatment of trachomatous entropion]. / Marginoplastie par recul de la lamelle antérieure dans le traitement de l'entropion trichiasis trachomateux de la paupière supérieure.

INTRODUCTION: The goal of this study is to assess functional and aesthetic results of anterior lamellar resection with lid margin splitting of the upper lid in the treatment of cicatricial trachomatous entropion. PATIENTS AND METHODS: Descriptive cross-sectional study of a series of 26 consecutive patients treated between January 2014 and December 2015. All patients were operated for cicatricial trachomatous entropion in our tertiary center using the technique of the anterior lamellar resection with lid margin splitting of the upper eyelid. All patients were followed for 6 to 12 months after surgery. The anatomical, functional and aesthetic results were evaluated six months after surgery. They were considered good if there was no recurrence of the entropion, no lashes in contact with the cornea and no associated eyelid complications. RESULTS: The mean age of the patients was 68.5±10 years with a male predominance (sex ratio=1.8). The average initial corrected visual acuity was 0.65±0.35 LogMAR, ranging from counting fingers at 1m to 6/10. Involvement was bilateral in 34.6% of cases. Correction of the cicatricial entropion was achieved in 24 patients (92.3% of cases) and full correction of misdirected lashes without any contact with the ocular surface was obtained in 23 patients (88.4% of cases). The lid margin was regular in 88.4% of cases. A significant improvement of the tear film and corneal surface was observed in 84.6% of patients. During the follow-up period, no cases of recurrent entropion were reported. DISCUSSION: Among the various surgical techniques, anterior lamellar resection with lid margin splitting is one that most respects the anatomy of the upper eyelid and allows precise intraoperative control of eyelid rotation and eversion of the misdirected lashes. Therefore, it reduces significantly the risk of recurrence and significantly enhances the aesthetic results of surgery. CONCLUSION: Anterior lamellar resection with lid margin splitting of the upper eyelid is a simple and effective technique that significantly improves the aesthetic result of cicatricial trachomatous entropion.

A Simple New Technique for Treatment of Tarsal Kink Syndrome.

Congenital tarsal kink syndrome is a rare type of upper eyelid entropion associated with keratitis due to trichiasis. The authors describe a new technique for treatment of congenital horizontal tarsal kink syndrome by means of absorbable everting sutures via a posterior approach. A neonate was referred to eye clinic with right eye redness and corneal opacity since birth. Clinical examination revealed inversion of the eyelid margin with a horizontal kink in the tarsal plate and corneal ulcer. Surgical treatment resulted in successful correction of upper eyelid malpositioning, rapid resolution of the corneal ulcer with excellent anatomical outcome, visual development and cosmesis, with no evidence of recurrence after 6 years. Absorbable everting sutures via a posterior approach is a simple, minimally invasive, and effective surgical technique for treatment of congenital horizontal tarsal kink syndrome.

Etiopathogenetic patterns of blepharoptosis in Western Nepal : an Overview.

BACKGROUND: The clinical picture of blepharoptosis varies from a cosmetic problem to severe visual dysfunction depending on the pathogenesis and the degree of ptosis. OBJECTIVE: To study the type, pattern and causes of ptosis in patients seeking oculopastic care in western Terai of Nepal Patients and methods: A retrospective descriptive hospital based was carried out over a period of 2 years in oculoplastic clinic in Lumbini Eye Institute, Bhairahawa. Demographic variables including the age of the patient, gender, laterality of the eye(s), visual acuity, presence of refractive error and or amblyopia, type of ptosis and previous ptosis surgery were recorded. RESULTS: There were altogether 326 patients of ptosis during the 2 year-period. Congenital ptosis presented early the mean age being 23(SD ±9.91) years. Acquired ptosis presented late with the mean age of 35(SD± 14.98) years. Congenital ptosis was more common (52%) compared to acquired ptosis (48%). 4.7% of congenital ptosis had amblyopia. Among all ptosis patients, myogenic cause of ptosis was the commonest followed by mechanical, aponeurotic, traumatic and neurogenic. Simple congenital ptosis was the commonest, and among acquired ptosis, mechanical ptosis was the commonest. Most of the ptosis was unilateral (87.7%) regardless of its onset either congenital or acquired. Regarding the severity of ptosis, mild ptosis was the commonest. CONCLUSION: Ptosis was the 3rd most common lid condition in oculoplastic clinic presentation after entropion and chalazion. Simple congenital ptosis was the commonest form of ptosis.

[Migration increases aspects of ocular pathology]. / Migratia îmbogateste arsenalul patologiei oftalmologice.

The authors present a case abundant in general and specific pathology, which makes up take a closer look to the pathology specific to Eastern doctors.

[Eyelid surgery for refractory filamentary keratitis].

PURPOSE: Cases of filamentary keratitis that are unresponsive to conventional medical treatment methods are often encountered in the clinical setting. Here we report on cases of filamentary keratitis that showed no recurrence for long periods after performing eyelid surgery. SUBJECTS AND METHODS: Enrolled were 17 eyes of 13 patients with filamentary keratitis who had eyelid surgery (4 men and 9 women ranging in age from 54-89 years; mean age: 73.6 years). Ptosis operations were performed with blepharoptosis (14 eyes of 11 patients) and entropion operations were performed on cases with filamentary keratitis but without entropion (3 eyes of 2 patients). RESULTS: Following blepharoptosis, the filamentary keratitis disappeared in all cases except in one which experienced a recurrence of filamentary keratitis probably due to the recurrence of ptosis. However, the filamentary keratitis in that case also disappeared following reoperation for the blepharoptosis. After entropion surgery, the keratitis disappeared in all cases with eye drops. CONCLUSION: The satisfactory, long-term postoperative results obtained in this study suggest that eyelid surgery is an effective treatment for filamentary keratitis unresponsive to conventional medical treatment methods.

Early onset childhood cicatricial pemphigoid: a case report and review of the literature.

Cicatricial pemphigoid is an extremely rare condition in children, since only 17 cases have been reported in the English literature, so far. We describe a new case in a 20-month-old boy, who is to our knowledge the youngest patient reported yet. The disorder had begun 10 months before he was referred to our department by mucosal crusted erosions of the oral and nasal cavities and conjunctivae. Cutaneous examination showed buccal erosions with limited mouth opening, entropion of the lower eyelids, trichiasis, cicatricial cornea, synechia of the nasal cavities and hypopigmented lesions of the abdomen. There were no anal or genital lesions. Cicatricial pemphigoid was confirmed by positive direct and indirect immunofluorescence on mucous biopsy. Systemic corticosteroids (2 mg/kg/day), maintained for 12 months, had led to complete healing of lesions. But due to cicatrization, synechia of the nasal cavities and corneal opacities, leading to a dramatic visual loss, have occurred. Dapsone 25 mg/day and topical ocular cyclosporine are now maintained to avoid relapse. Our review of the literature of all cases of CP showed that ocular and to a less degree, vulvar lesions are the most severe ones, due to the serious complications with scar formation.

Entrópio senil da pálpebra inferior: cirurgia baseada na etiopatogenia / Senile entropion of the lower lid: surgery performed by the etiopathogeny

Introdução: O entrópio é uma rotação interna da pálpebra, em que o epitélio e os cílios raspam o olho, ocasionando irritação. Este trabalho tem o objetivo de apresentar, detalhadamente, um tratamento cirúrgico baseado na associação de três técnicas, cada uma direcionada a tratar uma das três principais causas do entrópio senil e sua evolução. Método: Quatorze pálpebras com entrópio senil foram submetidas ao procedimento cirúrgico, que consistiu de encurtamento tarsal horizontal, plicatura dos retratores ao tarso com pontos em “U” e ressecção de uma fita muscular da pálpebra inferior. Em todos os retornos, foram avaliadas intercorrências, recidivas, complicações e resolução dos sintomas. Resultados: De julho de 2006 até abril de 2008, foram operadas 10 pacientes com entrópio senil. As queixas eram irritação ocular (100%) e lacrimejamento (80%). Ao exame físico, todos os pacientes apresentavam hiperemia. Cinco arrancavam os cílios e 3 usavam fitas adesivas para tracionar a pálpebra inferiormente. As cirurgias levaram, em média, 26 minutos e transcorreram bem, sem intercorrências. Todos receberam alta bem, com equimose que regrediu em 2 semanas. Nove pacientes tiveram melhora dos sintomas e um apresentou recidiva parcial do entrópio. Conclusão: Foi demonstrada uma modalidade de tratamento para o entrópio senil baseada nas suas três principais causas, com bons resultados. Tivemos recidiva parcial em um paciente, que foi tratada, repetindo-se o procedimento.

Background: The entropion is an inward rotation of the eyelid margins as the epithelium and the eyelashes rub against the eye resulting irritation. The purpose of this study is present a surgical treatment with the association of three techniques that resolves the main causes of senile entropion and the follow up. Methods: Fourteen eyelids with senile entropion under went surgical repair with wedge tarsal shortening, plication of the lid retractors with “U” sutures and a segmental resection of pre septal orbicular. In follow up was available any problems, recurrence, complications and complain resolution. Results: From 2006 July to 2008 April, ten patients with senile entropion were operated. Complain was ocular irritation (100%) and excessive tearing (80%). In physical examination, all patients had hyperemia. Five take out the lashes, and 3 used tapes to take the lid down. The surgery time was 26 minutes, without problems. All patients discharged with chemosis that resolved in the first 2 weeks post operatively. Nine were completely treated and one had partial recurrence. Conclusions: The study demonstrated, with details, a model of treatment for senile entropion based in three main causes. All patients didn’t have immediate complications, but one patient had partial recurrence, that was treated with the same procedure.

Paciente con manos y pies en «tenaza de langosta»: síndrome ectrodactilia-displasia ectodérmica-fisura facial / Patient with 'Lobster Claw' Hands and Feet: Ectrodactyly-Ectodermal Dysplasia-Clefting Syndrome

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