Indications
- lower lid senile ectropion
- improvement of epiphora and eye irritation
Differential diagnosis
Preoperative
- diagnosis (including assessment of the lacrimal duct and lateral canthal tendon laxity, good quality frontal, side and up-gaze pictures)
- consent form: always mention risk of recurrence, persisting epiphora and scarring
- anaesthesia: local anaesthesia plus sedation
- anticoagulation: adjust antiplatelet or anticoagulant medication if possible (stop Aspirin® 10 days before surgery; Marcoumar® INR >= 1.2 on the day of surgery; new anticoagulants (Eliquis®, Lixiana®, Xarelto® etc.): stop 2 days before, on the day of surgery and 2 days after surgery)
Preparation
- preoperatively: check that anticoagulation has been stopped, clean skin, no creams, no make-up
- 3x Tetracaine SDU® 1% eye drops (every 5 minutes)
- cleanse skin with alcohol wipes
Surgical setup
- operating table: supine position, elevate head if needed to reduce bleeding
- surgical loupes if needed, bipolar cautery
- Nettleship punctum dilator, anatomical Adson forceps for skin marking, surgical Adson forceps, Paufique forceps, fine toothed forceps, straight sharp-pointed scissors
- Westcott scissors, Stevens scissors, Castroviejo needle holder, surgical basin
Disposables
- Hibidil® disinfecting solution, ice-cold NaCl solution
- anaesthetic solution (7.2 ml Rapidocain® 2% with epinephrine + 0.9 ml sodium bicarbonate 8.4% + 0.9 ml tranexamic acid 500mg) in 2x 5 ml syringes with a 30G needle
- sterile drape, marking pen, no.15 blade, disposable lacrimal cannula, gloves, dental rolls for haemostasis, compresses for haemostasis, round gauze swabs
Sutures
- 5-0 Vicryl® or 5-0 Prolene® for tarsal suture
- 6-0 Vicryl® for medial spindle
- 6-0 Prolene® or 7-0 Vicryl® for skin closure
Surgical technique
There are numerous surgical techniques based on the surgeon's preference. The aim is to invert the punctum (medial spindle) and to shorten the eyelid horizontally (lateral canthal strip).
Tetracaine eye drops. Disinfect. Cover with a sterile drape exposing both eyes and the malar region. Injection of local anaesthetic.
Medial spindle: subciliary incision medially. Probe with a Nettleship dilator or Bowman probe to protect the canaliculus. Excise a diamond of conjunctiva posterior to the punctum. Pass a 6-0 double-armed Vicryl® suture through the retractors to fix them to the tarsus.
Lateral canthal strip: lateral canthotomy with a no.15 blade, cantholysis with scissors. Haemostasis. Dissect the tarsal strip and remove the anterior lamella and lid margin. Reinsert the strip on the posterior lateral orbital rim with 5-0 Vicryl® or 6-0 Prolene®. Canthopexy. Close orbicularis with 6-0 Vicryl®. Skin closure with 6-0 and 7-0 Vicryl® or 6-0 Prolene®.
Tobradex® ointment. Eye pad. If bilateral surgery, pad the more bruised eye or the eye with worse visual acuity.
Postoperative
- elevate head, reduce physical activity
- leave the pad on until the following day
- Paracetamol 1g every 6-8 hours if needed (max 4g/day)
Follow-up
- 1 day postop: check visual acuity, pupillary reaction, IOP and signs of bleeding
- 7 days postop: remove sutures; start scar gel if needed (Strataderm® Gel once a day on the scar for at least 3 months); avoid sun exposure for 2 months (SPF 50)
- after 4-6 weeks: assess eyelid position, symmetry, oedema, patient satisfaction
