Indications
- lower lid senile entropion
- improvement of corneal irritation due to abrading eyelashes
Differential diagnosis
- distichiasis/trichiasis/cicatricial entropion
Alternative therapy
lower lid tape/lower lid botulinum toxin
Preoperative
- diagnosis (including assessment of lateral canthal tendon laxity, retractor overriding, good quality frontal, side and up-gaze pictures)
- consent form: always mention risk of recurrence 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
- 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, gloves, dental rolls for haemostasis, compresses for haemostasis, round gauze swabs
Sutures
- 5-0 Vicryl® for eyelid retractors and tarsus
- 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 stabilise the retractors vertically and to shorten the eyelid horizontally.
Tetracaine eye drops. Disinfect. Cover with a sterile drape exposing both eyes and the malar region. Injection of local anaesthetic. Subciliary incision. Dissection superficial to the orbital septum. Shorten the posterior lamella (wedge removal or lateral tarsal strip). Haemostasis. Stabilise/plicate the lower lid retractors with 5-0 Vicryl®. Readapt the tarsus with 5-0 Vicryl®. Remove excess skin. Skin closure with 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
