Surgical Technique
Transconjunctival Epiblepharon Repair Edward J. Wladis, M.D., F.A.C.S. Department of Ophthalmology, Ophthalmic Plastic Surgery, Lions Eye Institute, Albany Medical College, Slingerlands, New York, U.S.A.
Purpose: To document the use of a transconjunctival approach to lower eyelid epiblepharon repair. Materials and Methods: Retrospective chart review of all patients who underwent transconjunctival lower eyelid epiblepharon repair. Results: Nine patients underwent repair via this approach. All patients experienced the resolution of their keratitis and cilia-cornea touch by a 3-month postoperative interval, and no patient developed a postoperative complication. Furthermore, no patient developed cutaneous scarring. Conclusions: Conventional approaches to lower eyelid epiblepharon repair have necessitated the creation of a skin and muscle flap, thus risking the development of scarring and a cosmetically unacceptable eyelid crease. This report documents the use of a transconjunctival approach for the management of this condition that avoids external incisions and provides excellent outcomes without scarring of the anterior lamella of the eyelid. (Ophthal Plast Reconstr Surg 2014;30:271–272)
C
ongenital epiblepharon is a common lower eyelid condition in which excess skin and orbicularis oculi muscle override the eyelid margin, resulting in inward rotation of the cilia toward the globe and keratitis.1 Multiple surgical approaches have been used to address this problem, and conventional techniques have classically focused on resection of lower eyelid skin and muscle to alleviate the protracting force of the orbicularis muscle.1–5 Although these procedures are generally quite successful in alleviating this eyelid malposition and keratitis, the need for an external incision may result in cosmetically unacceptable scarring and the development of an unsightly eyelid crease.1,2 In addition, resection of skin places patients at risk of lower eyelid retraction, ectropion, and ocular surface disease. To avoid the potential complications associated with skin resection, this report documents a transconjunctival approach to epiblepharon repair. Given that this approach resects the orbicularis oculi muscle, it addresses the fundamental problem of the overriding muscle in a durable, cosmetically acceptable manner.
MATERIALS AND METHODS This study was approved by the Institutional Review Board of Albany Medical College and adhered to the tenets of the Declaration of Helsinki. Accepted for publication February 28, 2014. The authors disclose no financial or conflict of interest. Address correspondence and reprint requests to Edward J. Wladis, M.D., F.A.C.S., Department of Ophthalmology, Ophthalmic Plastic Surgery, Lions Eye Institute, Albany Medical College, 1220 New Scotland Rd., Suite 302, Slingerlands, NY 12159. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000167
Ophthal Plast Reconstr Surg, Vol. 30, No. 3, 2014
The surgical logs of one surgeon were reviewed to identify all patients who underwent transconjunctival congenital epiblepharon repair. In addition, a retrospective review of those patients with a diagnosis of epiblepharon was performed to ensure that all cases were captured. Clinical data (age, gender, presence of pre- and postoperative keratitis, duration of follow up, and complications) were then extracted from a review of these patients’ charts. Surgical Technique. All repairs were performed under general anesthesia. The lower eyelid was infiltrated with 2% lidocaine with epinephrine 1:100,000. The 4-0 silk sutures were passed through the gray line of the lower eyelid and were used to elevate and retract the eyelid. Cutting cautery was used to incise the conjunctiva along the inferior aspect of the tarsus (Fig. A). The conjunctiva was gently retracted, and dissection was carried out through the eyelid retractors, revealing the orbicularis oculi muscle (Fig. B). A strip of orbicularis that was immediately inferior to the tarsal plate was grasped with a 0.5 forceps and excised with Westcott scissors (Fig. C). Double-armed 5-0 chromic catgut sutures were passed through the inferior aspect of the lower eyelid fornix and exited the eyelid 1 mm below the eyelash bed along the central, medial, and lateral aspects of the lower eyelid. The sutures were tied in position, and the tension of the sutures was titrated to avoid overcorrection. At that point, the conjunctiva was redraped to its original position and the silk sutures were removed from the gray line.
RESULTS Transconjunctival epiblepharon repair was performed on 18 lower eyelids of 9 patients (5 males, 4 females). All patients reported East Asian ancestry. The mean age was 5.22 years (standard deviation = 1.99 years). By historical report, the patients had been managed conservatively with topical lubrication and taping of the lower eyelid by referring physicians for a mean of 7.61 months (standard deviation = 4.62 months). All patients had significant cilia-cornea touch and keratopathy preoperatively. The mean duration of follow up was 9.44 months (standard deviation = 4.03 months). The keratitis had completely resolved in 7 of 9 patients (77%) at 1 week postoperatively. All patients (100%) experienced a resolution of their keratitis and cilia-cornea touch by a 3-month postoperative interval. No patient developed an infection, undercorrection, overcorrection, hematoma, cutaneous scar, or recurrence, and no patient required a reoperation. The families of all patients were pleased with the cosmetic outcomes.
DISCUSSION The keratitis associated with congenital epiblepharon is a bothersome and potentially vision-threatening problem. Multiple surgical interventions have been devised to address this problem, and the reported postoperative success rates are generally quite high for the procedures. Nonetheless, conventional modalities necessitate the creation of a skin and muscle flap to repair the overlying orbicularis, thereby risking overcorrection
271
Ophthal Plast Reconstr Surg, Vol. 30, No. 3, 2014
E. J. Wladis
A, Transconjunctival dissection along the base of the tarsus is performed to isolate the orbicularis. B, The conjunctiva is retracted to expose the orbicularis. C, A strip of the orbicularis is excised with Westcott scissors.
and ectropion, retraction, and cosmetically unacceptable scarring of the eyelid. To address these concerns, this report documents the use of a transconjunctival approach that avoids a cutaneous incision. This intervention is technically simple and was universally effective in this cohort of patients. Furthermore, this technique proved durable and quite favorable cosmetically. In addition, although previous descriptions have indicated that the passage of chromic sutures alone may provide relief from epiblepharon, the approach described in the current report resects orbicularis muscle, with the intent of ensuring the success of the rotation of the eyelid. Several limitations apply to this study. First, given that this review attempted to characterize this approach, the transconjunctival approach was not directly compared with existing, standard transcutaneous interventions for the management of epiblepharon. Nonetheless, the results of this surgical modality compared favorably with existing historical data1–5 and avoided the visible cutaneous scars that have traditionally been reported with epiblepharon repair.1,2 Furthermore, while this study did not identify any cases of recurrence with this technique, longer follow-up intervals should be used in future analyses to ensure the robustness of these successful outcomes. In addition, while this approach does not offer the theoretical advantage of
272
cutaneous resection to address the redundant skin that patients with this problem often face, all patients were happy with their cosmetic outcome, no patient reported a redundant skin crease, and the technique affords the opportunity to repair the keratopathy without external scarring. Despite these issues, transconjunctival epiblepharon repair is a technically simple, durable approach that offers excellent outcomes and avoids cutaneous scarring.
REFERENCES 1. Kim MS, Sa HS, Lee JY. Surgical correction of epiblepharon using an epicanthal weakening procedure with lash rotating sutures. Br J Ophthalmol 2014;98:120–3. 2. Jung JH, Kim HK, Choi HY. Epiblepharon correction combined with skin redraping epicanthoplasty in children. J Craniofac Surg 2011;22:1024–6. 3. Hwang SW, Khwarg SI, Kim JH, et al. Lid margin split in the surgical correction of epiblepharon. Acta Ophthalmol 2008; 86:87–90. 4. Chang M, Lee TS, Yoo E, et al. Surgical correction for lower lid epiblepharon using thermal contraction of the tarsus and lower lid retractor without lash rotating sutures. Br J Ophthalmol 2011;95:1675–8. 5. Woo KI, Yi K, Kim YD. Surgical correction for lower lid epiblepharon in Asians. Br J Ophthalmol 2000;84:1407–10.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Transconjunctival Epiblepharon Repair Edward J. Wladis, M.D., F.A.C.S. Department of Ophthalmology, Ophthalmic Plastic Surgery, Lions Eye Institute, Albany Medical College, Slingerlands, New York, U.S.A.
Purpose: To document the use of a transconjunctival approach to lower eyelid epiblepharon repair. Materials and Methods: Retrospective chart review of all patients who underwent transconjunctival lower eyelid epiblepharon repair. Results: Nine patients underwent repair via this approach. All patients experienced the resolution of their keratitis and cilia-cornea touch by a 3-month postoperative interval, and no patient developed a postoperative complication. Furthermore, no patient developed cutaneous scarring. Conclusions: Conventional approaches to lower eyelid epiblepharon repair have necessitated the creation of a skin and muscle flap, thus risking the development of scarring and a cosmetically unacceptable eyelid crease. This report documents the use of a transconjunctival approach for the management of this condition that avoids external incisions and provides excellent outcomes without scarring of the anterior lamella of the eyelid. (Ophthal Plast Reconstr Surg 2014;30:271–272)
C
ongenital epiblepharon is a common lower eyelid condition in which excess skin and orbicularis oculi muscle override the eyelid margin, resulting in inward rotation of the cilia toward the globe and keratitis.1 Multiple surgical approaches have been used to address this problem, and conventional techniques have classically focused on resection of lower eyelid skin and muscle to alleviate the protracting force of the orbicularis muscle.1–5 Although these procedures are generally quite successful in alleviating this eyelid malposition and keratitis, the need for an external incision may result in cosmetically unacceptable scarring and the development of an unsightly eyelid crease.1,2 In addition, resection of skin places patients at risk of lower eyelid retraction, ectropion, and ocular surface disease. To avoid the potential complications associated with skin resection, this report documents a transconjunctival approach to epiblepharon repair. Given that this approach resects the orbicularis oculi muscle, it addresses the fundamental problem of the overriding muscle in a durable, cosmetically acceptable manner.
MATERIALS AND METHODS This study was approved by the Institutional Review Board of Albany Medical College and adhered to the tenets of the Declaration of Helsinki. Accepted for publication February 28, 2014. The authors disclose no financial or conflict of interest. Address correspondence and reprint requests to Edward J. Wladis, M.D., F.A.C.S., Department of Ophthalmology, Ophthalmic Plastic Surgery, Lions Eye Institute, Albany Medical College, 1220 New Scotland Rd., Suite 302, Slingerlands, NY 12159. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000167
Ophthal Plast Reconstr Surg, Vol. 30, No. 3, 2014
The surgical logs of one surgeon were reviewed to identify all patients who underwent transconjunctival congenital epiblepharon repair. In addition, a retrospective review of those patients with a diagnosis of epiblepharon was performed to ensure that all cases were captured. Clinical data (age, gender, presence of pre- and postoperative keratitis, duration of follow up, and complications) were then extracted from a review of these patients’ charts. Surgical Technique. All repairs were performed under general anesthesia. The lower eyelid was infiltrated with 2% lidocaine with epinephrine 1:100,000. The 4-0 silk sutures were passed through the gray line of the lower eyelid and were used to elevate and retract the eyelid. Cutting cautery was used to incise the conjunctiva along the inferior aspect of the tarsus (Fig. A). The conjunctiva was gently retracted, and dissection was carried out through the eyelid retractors, revealing the orbicularis oculi muscle (Fig. B). A strip of orbicularis that was immediately inferior to the tarsal plate was grasped with a 0.5 forceps and excised with Westcott scissors (Fig. C). Double-armed 5-0 chromic catgut sutures were passed through the inferior aspect of the lower eyelid fornix and exited the eyelid 1 mm below the eyelash bed along the central, medial, and lateral aspects of the lower eyelid. The sutures were tied in position, and the tension of the sutures was titrated to avoid overcorrection. At that point, the conjunctiva was redraped to its original position and the silk sutures were removed from the gray line.
RESULTS Transconjunctival epiblepharon repair was performed on 18 lower eyelids of 9 patients (5 males, 4 females). All patients reported East Asian ancestry. The mean age was 5.22 years (standard deviation = 1.99 years). By historical report, the patients had been managed conservatively with topical lubrication and taping of the lower eyelid by referring physicians for a mean of 7.61 months (standard deviation = 4.62 months). All patients had significant cilia-cornea touch and keratopathy preoperatively. The mean duration of follow up was 9.44 months (standard deviation = 4.03 months). The keratitis had completely resolved in 7 of 9 patients (77%) at 1 week postoperatively. All patients (100%) experienced a resolution of their keratitis and cilia-cornea touch by a 3-month postoperative interval. No patient developed an infection, undercorrection, overcorrection, hematoma, cutaneous scar, or recurrence, and no patient required a reoperation. The families of all patients were pleased with the cosmetic outcomes.
DISCUSSION The keratitis associated with congenital epiblepharon is a bothersome and potentially vision-threatening problem. Multiple surgical interventions have been devised to address this problem, and the reported postoperative success rates are generally quite high for the procedures. Nonetheless, conventional modalities necessitate the creation of a skin and muscle flap to repair the overlying orbicularis, thereby risking overcorrection
271
Ophthal Plast Reconstr Surg, Vol. 30, No. 3, 2014
E. J. Wladis
A, Transconjunctival dissection along the base of the tarsus is performed to isolate the orbicularis. B, The conjunctiva is retracted to expose the orbicularis. C, A strip of the orbicularis is excised with Westcott scissors.
and ectropion, retraction, and cosmetically unacceptable scarring of the eyelid. To address these concerns, this report documents the use of a transconjunctival approach that avoids a cutaneous incision. This intervention is technically simple and was universally effective in this cohort of patients. Furthermore, this technique proved durable and quite favorable cosmetically. In addition, although previous descriptions have indicated that the passage of chromic sutures alone may provide relief from epiblepharon, the approach described in the current report resects orbicularis muscle, with the intent of ensuring the success of the rotation of the eyelid. Several limitations apply to this study. First, given that this review attempted to characterize this approach, the transconjunctival approach was not directly compared with existing, standard transcutaneous interventions for the management of epiblepharon. Nonetheless, the results of this surgical modality compared favorably with existing historical data1–5 and avoided the visible cutaneous scars that have traditionally been reported with epiblepharon repair.1,2 Furthermore, while this study did not identify any cases of recurrence with this technique, longer follow-up intervals should be used in future analyses to ensure the robustness of these successful outcomes. In addition, while this approach does not offer the theoretical advantage of
272
cutaneous resection to address the redundant skin that patients with this problem often face, all patients were happy with their cosmetic outcome, no patient reported a redundant skin crease, and the technique affords the opportunity to repair the keratopathy without external scarring. Despite these issues, transconjunctival epiblepharon repair is a technically simple, durable approach that offers excellent outcomes and avoids cutaneous scarring.
REFERENCES 1. Kim MS, Sa HS, Lee JY. Surgical correction of epiblepharon using an epicanthal weakening procedure with lash rotating sutures. Br J Ophthalmol 2014;98:120–3. 2. Jung JH, Kim HK, Choi HY. Epiblepharon correction combined with skin redraping epicanthoplasty in children. J Craniofac Surg 2011;22:1024–6. 3. Hwang SW, Khwarg SI, Kim JH, et al. Lid margin split in the surgical correction of epiblepharon. Acta Ophthalmol 2008; 86:87–90. 4. Chang M, Lee TS, Yoo E, et al. Surgical correction for lower lid epiblepharon using thermal contraction of the tarsus and lower lid retractor without lash rotating sutures. Br J Ophthalmol 2011;95:1675–8. 5. Woo KI, Yi K, Kim YD. Surgical correction for lower lid epiblepharon in Asians. Br J Ophthalmol 2000;84:1407–10.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
