Lateral Tarsal Strip Procedure for Left Lower Eyelid Entropion

Abstract

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.

Case overview

Focused History

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. 

Physical Examination

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.

Natural History

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.

Options for Treatment

• 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

Rationale for Treatment

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.

Special Considerations 

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 complications

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

Discussion

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

Equipment 

• Forceps
• Westcott scissors
• Needle driver
• No. 15 blade
• 4-0 Mersilene double-armed non-absorbable suture
• 6-0 Plain gut suture
  

Disclosures

Nothing to disclose.

Statement of Consent

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.