Efficacy of allogenous fascia lata grafts in the management of lower eyelid retraction

PURPOSE

To report on the use of allogenous fascia lata (FL) grafts in patients with lower eyelid retraction (LER).

METHODS

In this retrospective study, a consecutive series of 27 patients (39 eyes) with LER who underwent lower eyelid elevation with FL was included. Examinations including measurement of the palpebral fissure vertical height (PFVH), the inferior scleral show distance, the margin reflex distance 2 (MRD 2), and the evaluation of conjunctival hyperemia were conducted at baseline and after a mean postoperative time of 25.9 ± 25.5 (5.0-81.0, median 13.0, last follow-up) months in all patients.

RESULTS

At the last follow-up, a significant reduction of the PFVH (11.3 ± 1.7 versus 12.8 ± 2.1 at baseline, p < 0.001), the inferior scleral show distance (0.7 ± 1.0 mm versus 2.1 ± 1.1 at baseline, p < 0.001), and the MRD 2 (6.4 ± 0.9 versus 7.8 ± 1.3 at baseline, p < 0.001) occurred. The conjunctival hyperemia grading score (McMonnies) was significantly reduced (1.8 ± 0.7) at the last follow-up compared to baseline (2.6 ± 0.6, p < 0.001). No case of ectropion or entropion was observed at the last follow-up visit.

CONCLUSION

In this case series, lower eyelid elevation with FL grafts as a spacer led to a significant reduction of the PFVH, MRD 2, inferior scleral show distance, and conjunctival hyperemia. No severe surgery-related complications occurred.

Axenfeld-Rieger syndrome combined with ectropion uveae and pigment dispersion syndrome: A case report

BACKGROUND

In January 2021, we found one case of Axenfeld-Rieger syndrome combined with pigment dispersion syndrome (PDS), and this patient additionally manifested a symptom of ectropion uveae. The co-existence of both 2 syndromes is very rare and has not been reported in any literature yet.

CASE PRESENTATION

A 34-year-old female truck driver presented to our institution with a dimness of vision in her right eye. The patient had obvious posterior embryotoxons at bitamporal, and peripheral anterior synechia could be visualized by the slit lamp. The dispersion of pigment granules was observed behind the cornea. The pupil was slightly shifted upwards the nose, with 360° ectropion uveae. Gonioscopy revealed pigment accumulation on the trabecular meshwork. The patient underwent cataract surgery on her right eye, during which, flaky pigmentation around the posterior capsule was observed. These signs were consistent with Axenfeld-Rieger syndrome and PDS.

CONCLUSIONS

We report a rare case of Axenfeld-Rieger syndrome with PDS and uveal eversion. Although the patient did not present with glaucoma, follow-up should be noted. Besides, the correlation between these 2 syndromes needs to be demonstrated by more cases or further evidence.

Outcomes of two surgical techniques for major trichiasis treatment

The purpose of this article is to analyze the outcomes of two surgical techniques to treat major trichiasis. A retrospective chart review of 67 patients (89 eyelids) with major trichiasis was performed who underwent surgical treatment using one of two techniques: intermarginal split lamella with graft (ISLG group) or lid lamella resection (LLR group). There were 30 lids in the ISLG group with mean patient age of 71.8 years and 63.3% were females. There were 59 lids in the LLR group with mean patient age of 72.5 years and 52.5% were female. The minimum postoperative follow up was six months. Statistical analysis included descriptive measures, Goodman association test for contrasts between and within multinomial populations and nonparametric Mann-Whitney test for comparison between groups. P < 0.05 was considered statistically significant. The underlying causes of trichiasis were blepharitis (37.07%), chronic meibomitis (21.3%), multiple causes (20.2%), ectropion (11.2%), actinic keratosis (6.7%), or prior ocular surgery (3.3%). Postoperatively, in the ISLG group, there were 20% lids with complete success, 50% underwent laser or electrolysis, 16.7% required further surgery, and 13.3% were unsuccessful. Postoperatively, in the LLR group, there were 47.5% eyelids with complete success, 46.7% underwent laser or electrolysis, 6.8% required further surgery, and 5.1% were unsuccessful. There was a higher statistical chance of complete success with LLR (P < 0.05). LLR is superior to ISLG surgery for the treatment of major trichiasis. There is a greater chance of success with LLR and it is technically simpler.

[Keratopathy versus allergic eye disease: misdiagnosis leading to keratitis]

A case report of involutional ectropion associated with exposure keratopathy - which complicated to exposure keratitis due to incorrect management is presented. Upon consulting the local pharmacy the patient was wrongly given anti-allergic eye drops. Patients with involutional ectropion have high risk of dry eye disease and may rarely be complicated with keratitis. Distinguishing between exposure keratopathy and allergic eye disease is pivotal as management differs and wrong therapy may lead to serious eye disease.

[Clinical investigation on AC/A ratio in intermittent exotropia coexisting with ametropia]

OBJECTIVE

To investigate AC/A ratio and coexisting ametropia in intermittent exotropia. To discuss the relation between AC/A ratio and the development of intermittent exotropia.

METHODS

The medical records of 135 patients who had an exotropia were retrospectively reviewed. Patients were divided into 3 groups based on the type of ametropia: exotropia without ametropia (-0.50-+3.00 D between the age of 3-6 years old, -0.50-+2.00 D between the age of 7-40 years old) , exotropia coexisting with myopia (-0.50-7.75 D) and exotropia coexisting with hypermetropia ( ≥ + 3.00 D of 3-6 years old , ≥ + 2.00 D of 7 ∼ 40 years old). AC/A ratios of all patients were assessed using synoptophore method. Distance and near deviations were assessed using prism cover test. AC/A ratios and deviation angles of 3 groups were compared. The relationship between AC/A ratios and ametropia/age were investigated.

RESULTS

There were obvious differences in AC/A ratios(2.686 ± 1.372, 1.773 ± 1.110, 4.581 ± 1.552, F = 36.323, P < 0.001) and in near deviation angles (44.473(Δ) ± 19.008(Δ), 53.621(Δ) ± 20.749(Δ), 34.455(Δ) ± 13.292(Δ), F = 8.762, P = < 0.001) between 3 groups of patients, no obvious differences were seen in distance deviation angles (40.333(Δ) ± 19.474(Δ), 44.052(Δ) ± 23.722(Δ), 35.590(Δ) ± 11.143(Δ), F = 1.444, P = 0.24). AC/A ratios were negative linear correlated with refractive powers for patients of intermittent extropia coexisting with myopia or with hypermetropia (r = 0.320, P = -0.469 and r = -0.046, P = 0.036, respectively) . A trend of decline with age was found for AC/A ratios only in patients of intermittent extropia without ametropia (r = -0.320, P = 0.019; r = -0.023, P = 0.865; r = 0.246, P = 0.296 for the other 2 groups, respectively).

CONCLUSIONS

Myopia and hypermetropia, when coexisting with abnormally low or high AC/A ratio, can destroy the balance between extraocular muscles and induce exophoria to be manifest.

[Congenital ectropion uvea and secondary glaucoma]

OBJECTIVE

To investigate the clinical features of congenital ectropion uvea (CEU) and the relationship between CEU and secondary glaucoma.

METHODS

This is a retrospective case series. Clinical features and treatments of 11 patients with CEU were summarized. Combined with the literatures review of CEU, the pathogenesis and therapeutic results of secondary glaucoma were analyzed.

RESULTS

Among these 11 patients, there were 10 patients with secondary glaucoma and one patient with ocular hypertension. There were 4 patients complicated with congenital ptosis, 2 patients with ocular proptosis, 1 patient with congenital cataract, 1 patient with lens subluxation, 3 patients with ankylodactylia and 1 patient with Rieger's syndrome. The intraocular pressure of 9 patients was controlled after the trabeculectomy.

CONCLUSIONS

CEU is a rare, nonprogressive anomaly accompanied other ocular abnormalities and various systemic disorders. The pathogenesis of secondary glaucoma is related to iridotrabecular dysgenesis. It is essential to detect and to treat the secondary glaucoma as early as possible.

[Eyelid ectropion in Down's syndrome related to allergic conjunctivitis: case report]

This is a case report of a patient with Down's syndrome with an important mechanical ectropion and elongation of the lower lid related to chronic allergic conjunctivitis, besides cataract and keratoconus. The tarsal strip technique and resection of redundant and thick conjunctiva was the surgical approach chosen for this case. Functional and cosmetic outcomes were considered satisfactory.

[Eyelid alterations associated with palpebral ectropion]

PURPOSE

To evaluate eyelid margin alterations in ectropion carriers.

METHODS

An observational study was done involving 53 eyelid ectropion patients and 25 individuals with dermochalasis (control group). Eyelash position and margin inflammation were observed using digital images. The data were submitted to statistical analysis.

RESULTS

Patients with ectropion showed a decreased number of eyelashes, loose convexity, trichiasis and distichiasis as compared with the control group.

CONCLUSION

Patients with eyelid ectropion have eyelid margin alterations probably due to the chronic inflammatory process in this region.

Utilisation de la N-acétylcystéine en application topique cutanée dans le traitement d’un ectropion bilatéral chez un enfant atteint d’ichthyose lamellaire

PURPOSE

To report for the first time bilateral ectropion treatment in an infant with severe lamellar ichthyosis associating N-acetylcysteine applied directly to the skin and oral acitretin.

METHODS

An 8-week-old male child with major bilateral ectropion due to lamellar ichthyosis was given treatment associating oral acitretin (Soriatane) and topical N-acetylcysteine. Though the precorneal tear film quality could be maintained, after 1 month of initial treatment with acitretin only, bilateral upper eyelid ectropion remained threatening for the child's cornea. The adjunction of topical N-acetylcysteine enabled a complete regression of ectropion. No complementary surgery was needed and the eyelids remained well positioned.

CONCLUSION

Topical N-acetylcysteine has been proved to have an antiproliferative effect on keratinocytes in vitro and in vivo. It may be useful in the treatment of major forms of ectropion in children with lamellar ichthyosis. Its association with conventional acitretin treatment may prevent unnecessary surgery.

Acquired external punctal stenosis: etiology and associated findings

PURPOSE; To investigate the underlying causes of acquired external punctal stenosis (AEPS) and assess the associated tear drainage problems.

DESIGN

Prospective, noncomparative observational case series.

METHODS

Seventy-eight eyes of 52 patients with symptomatic AEPS were prospectively assessed by or under supervision of a consultant oculoplastic surgeon from June 1999 to October 2002. The severity of the stenosis was graded on clinical examination. Associated findings from ophthalmic examination, diagnostic probing, and irrigation were recorded. The chi(2) test with 95% confidence interval (CI) and the Fisher exact test were used for statistical analysis.

RESULTS

The age range was 39 to 90 years (mean, 69.4 years). Acquired external punctal stenosis was due to chronic blepharitis in 35 eyes (45%), unknown etiology in 21 eyes (27%), ectropion in 18 eyes (23%), and related to drugs in 4 eyes (5%). Associated canalicular stenosis and common canalicular stenosis with obstruction (at the level of the internal punctum) was found in 36 eyes (46%) with AEPS. Nasolacrimal duct stenosis (5 eyes) or obstruction (2 eyes) was found in 8.5%. The number of patients with associated canalicular and common canalicular stenosis increased with increasing age (95% Confidence Interval [CI] = 0.03-0.04, P =.03) and duration of symptoms (95% CI = 0.02-0.03, P =.02). The number of patients with associated nasolacrimal duct stenosis and obstruction increased with increasing age (95% CI = 0.000- 0.001, P =.001) and in AEPS with unknown etiology (95% CI = 0.004-0.006, P =.003).

CONCLUSIONS

Chronic blepharitis is a common cause of AEPS even after treating the blepharitis, but in a significant number of patients there is no apparent etiology. Associated upper and lower tear drainage stenosis should be considered in the preoperative evaluation and surgical plan for AEPS.

Primary congenital ectropion uveae associated with vitreoretinal degeneration

Primary congenital ectropion uveae is an extremely rare ocular malformation frequently associated with unilateral glaucoma. We report on a 15-year-old boy with unilateral congenital ectropion uveae, glaucoma and transvitreal strands in an optically empty vitreous. Dark adaptation was normal, but scotopic ERG showed subnormal b-wave amplitudes in the affected eye, which is a typical finding in hereditary vitreoretinal degenerations. The coincidence of primary congenital ectropion uveae and unilateral vitreoretinal degeneration without a family history seems to be sporadic and very extraordinary but could be due to a common defect of maturation.

[Operation of the floppy eyelid. Symptomatic cases require surgical eyelid stabilization]

BACKGROUND

Floppy Eyelid is a rare condition causing chronic papillary conjunctivitis and chronic corneal disorders (superficial punctate keratitis, epithelial and stromal ulcers). It is characterized by an extremely enlarged and "floppy" upper eyelid which can be easily everted by slight elevation. Usually obese men are affected who use to sleep face down either on the right or on the left side. Pushing the eyelid against the pillow, the lid is intermittently everted at sleep. This lagophthalmus with rubbing of the exposed eye and lid structures causes all pathologic disorders. Shielding the eye at night may help temporarily.

PATIENTS

We performed surgery on 7 men with symptomatic floppy eyelid in the age of 42 to 61 years. The patients had been symptomatic between 1 month and 4 years prior to the definite diagnosis. Follow-up time has been 7 months to 4.5 years.

RESULTS

In all cases surgery achieved improvement.

CONCLUSIONS

Cases of unclear conjunctival or corneal damage and inflammation should led consider Floppy Eyelid as a possible cause. The typical clinical findings make diagnosis easy. As complete stopping of eyelid-rubbing by changing the patient's sleeping habits is mostly not easily possible, for acute therapy of threatening damages to cornea and conjunctiva a surgical shortening of the lid is necessary which stabilizes the lid in order to avoid nightly spontaneous eversion for a long time.

Floppy eyelid syndrome in a child with chronic unilateral conjunctivitis

PURPOSE

To report a 2-year-old child who had chronic unilateral conjunctivitis and spontaneous left upper eyelid eversion during sleep consistent with the floppy eyelid syndrome.

METHODS

The patient's parents used a video camera to document nocturnal ectropion of the left upper eyelid. Examination demonstrated left upper eyelid swelling and left palpebral conjunctival hyperemia with papillary hypertrophy.

RESULTS

All signs and symptoms of the floppy eyelid syndrome resolved with taping of the left upper and lower eyelids to close the palpebral fissure and to prevent ectropion during sleep, and with application of ocular lubricants.

CONCLUSIONS

Floppy eyelid syndrome may manifest in childhood without other contributing conditions and should be considered in the differential diagnosis of chronic papillary conjunctivitis in patients at any age.

Age-related medial ectropion of the lower eyelid

BACKGROUND

A simplified procedure is proposed for the repair of medial lower eyelid age-related ectropion.

METHODS

A posterior horizontal incision is made in the medial half of the lower eyelid at the inferior border of tarsus. The lower eyelid retractors are exposed and then plicated to the tarsus without excision of posterior lamellae or the use of everting sutures. The lid is then shortened horizontally with excision of a pentagonal section or lateral tarsal strip procedure.

RESULTS

The procedure was performed in six patients successfully without complication.

CONCLUSIONS

This is an effective method for repair of lower lid medial age-related ectropion.

Congenital ectropion uveae with glaucoma

Congenital ectropion uveae (CEU) is a rare, non progressive anomaly characterised by the presence of iris pigment epithelium on the anterior surface, an anterior iris insertion, dysgenesis of the drainage angle and glaucoma. The condition is characteristically unilateral and rarely hereditary. The current theory of development arrest is discussed. We report three cases with CEU of which two already developed glaucoma. All patients with CEU should be carefully examined periodically to detect glaucoma.

Treatment of the paradoxic inversion of the lashes in ectropion

Ectropion leads to chronic inflammation of the exposed conjunctiva. This inflammation can lead to shrinkage and to a cicatricial paradoxic inversion of the lashes. When the lid margin is surgically brought into its correct position, these lashes may become trichiatic. The surgical eversion of the lid margin at the time of the ectropion operation can prevent this complication.

Late presentation of congenital ectropion of the eyelids in a child with Down syndrome: a case report and review of the literature

Congenital eversion or ectropion of the upper eyelids is rare. Only 50 cases have been reported since the condition was first described in 1896. We encountered an additional case of congenital ectropion of the eyelids, which is also unusual because of its late presentation for treatment. This case demonstrates the unfavorable outcome of failure to treat this condition at birth and illustrates the association with Down syndrome. Our case is compared with the others reported in the literature.

Medical canthal resection: an effective long-term cure for medial ectropion

The results of 37 medial canthal resection procedures performed for the correction of severe paralytic or involutional medial ectropion are presented with an average follow-up of 5.4 years. Epiphora was improved in 33 out of the 37 cases and all but one patient had an anatomically improved lid-globe apposition, medial canthal angle, and posterofixation of the medial canthus. These results confirmed the long-term value of the operation.

Cicatricial ectropion in lamellar ichthyosis

A 35-year-old woman presented with bilateral lower lid ectropion associated with lamellar ichthyosis. She was successfully treated with postauricular skin grafts and horizontal lid shortenings. This report reviews the literature on the surgical management of this condition and suggests several modifications to prevent recurrence.

Epiblepharon with inverted eyelashes in Japanese children. II. Surgical repairs

We used lid bracing sutures, buried sutures, and skin resection operations to correct epiblepharon in Japanese children. Epiblepharon and ocular irritation in 103 children (254 eyelids) were treated first with lid bracing sutures. Postoperatively the inversion of eyelashes resolved in 73 patients (196 eyelids). Of these 103 patients 30 (58 eyelids) developed recurrences, which included 11 who also complained of foreign body sensation and ocular pain. These 11 patients (22 eyelids) underwent a second surgical procedure (buried sutures or skin resection) before they became free of symptoms. No severe complications were noted in any of the 103 patients. We believe that lid bracing sutures correct most cases of mild epiblepharon in children and that buried sutures or skin resection are valuable for more severe conditions.

Carbon dioxide laser repair of medial ectropion

Five patients with medial eyelid ectropion and punctal eversion due to senile changes, cicatrix, or vertical skin tightness were treated with a heretofore unreported method. Using a carbon dioxide laser, an ellipse of conjunctival-tarsal-inferior muscle tissue was excised from the inner surface of the ectropic lid inferior to the punctum. There was no bleeding, and each postoperative course was notable for minimal pain and edema. Lengthy follow-up revealed good anatomic results, with normal functioning of the inferior punctum. Patients taking warfarin sodium (Coumadin) have been treated without bleeding. Carbon dioxide laser ectropion repair may be tailored to each patient's specific condition, and is performed with ease in the office, thus offering diminished patient anxiety, discomfort, and expense.

Surgical correction of entropion and ectropion in the same lid

A patient with medial ectropion and lateral entropion of the same lower lid is presented, and the surgical management of this unusual condition utilizing a horizontal lid-shortening, orbicularis sling procedure, fixation of the posterior and anterior lamellae of the lid, and resection of the tarsal conjunctival layer is described. We believe that the key to the successful management of this condition lies in treating each component surgically as if it were a separate entity, and by using a combination of surgical techniques, both eyelid malpositions can be corrected.

Medial ectropion: association with lower lacrimal obstruction and combined management

Nine consecutive patients who presented with a medial ectropion (12 eyelids) and epiphora were prospectively evaluated and surgically managed. Medial ectropion was successfully corrected in all 12 eyelids (mean follow-up 12.2 months). A lateral tarsal strip procedure (Anderson procedure) was used to correct the horizontal lid laxity. Resecting the retractors of the lower lid subjacent to the punctal area corrected the punctal eversion. Prior to medial ectropion repair, three of the 12 eyes demonstrated evidence of complete obstruction at or below the level of the lacrimal sac. These patients required concurrent dacryocystorhinostomy (DCR) in addition to repair of the medial ectropion. DCR with silicone intubation obviated the need for anastomosis of lacrimal sac and nasal mucosal flaps, and it corrected the punctal stenosis. Histopathologic examination of the sac specimens confirmed chronic inflammation. One of six patients without complete obstruction required DCR after medial ectropion repair and punctoplasty. Medial ectropion may predispose to lower lacrimal obstruction. In turn, the epiphora may lead to aggravation of the medial ectropion as a result of wiping of tears.

Congenital ectropion uveae and glaucoma

Congenital ectropion uveae is a rare condition which may be present in one or both eyes. If the patient is followed glaucoma will always be found to be present. Associated features which have been described are ptosis, Rieger's anomaly, Prader Willi syndrome, facial hemiatrophy and neurofibromatosis. This paper describes a patient followed for 18 years who had bilateral congenital ectropion uveae, bilateral ptosis, asthma and late onset of a dental defect.

Ectropion and epiphora in McArdle's syndrome

Ectropion is unusual in young individuals. Recently, we treated a 19-year-old male college student for epiphora due to bilateral ectropion associated with McArdle's syndrome, a myophosphorylase deficiency. To our knowledge, there have been no previous reports of ectropion and epiphora as a result of this rare glycogen-storage disease.

Surgical treatment of the denervated or sagging lower lid

Paralytic ectropion of the lower eyelid and increased curvature of the lower eyelid associated with anophthalmos both cn be optimally treated by use of an autogenous fascia lata sling. Some patients also have problems with prosthesis retention due to lower eyelid deformity with a shortened inferior fornix. In some instances, it is also necessary to perform a horizontal shortening operation on the lower eyelid. In anophthalmic patients, the relationship between prosthesis size and weight and a sagging lower lid is discussed. In some patients when the lower eyelid is elevated, the patient then has an upper lid ptosis for which it is necessary to perform an appropriate levator shortening operation. Surgical technique and illustrative pre- and post-operative photographs are shown.

[Bilateral congenital microblepharon with ectropion and microphthalmus (author's transl)]

A very rare combination of congenital malformations of the eyelids and eyes in a 6-month-old boy is reported. The main symptoms are a bilateral microblepharon associated with ectropion and bilateral aphakic microphthalmus. The pathogenesis of these changes is discussed.

Euryblepharon: a case report with photographs documenting the condition from infancy to adulthood

A case of euryblepharon with lateral ectropion is reported, with photographs from infancy to adult life. The value of obtaining photographs, if available, in cases such as this is stressed, to avoid unnecessary clinical studies being done. The photographs indicate the stability of the condition. They also indicate that, at least in some cases, the ectropion will become less apparent with body growth and may need no therapy.

Peters' anomaly: dominant inheritance in one pedigree and dextrocardia in another

Two case reports are described to illustrate the unusual occurrence of dominant inheritance of Peters' anomaly and the concomitant occurrence of Peters' anomaly with colobomatous microphthalmos and dextrocardia. Studies of additional families are necessary to determine conclusively the pathogenesis, genetic mode of inheritance, ocular and systemic associated malformations, and proper management of this complex entity.

[Bilateral retro- and subauricular fistulae with eversion of the epithelial lining (author's transl)]

An infant with multiple congenital anomalies was observed: bilateral cleft lip and palate, left cystic kidney, bilateral retroauricular fistulae with ectropion of the epithelial lining. These fistulae ended in tissue of thymus. They are derived from the ductus thymopharyngicus. In this case a large ectropion was constated on both sides, which was in this form not described before. The early case history, the therapy and the rare histological findings are described and the up to date unknown abnormality with figures represented.