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Retraction of the lower eyelid.

Retraction of the lower eyelid is a useful sign of disease. It is an early manifestation of weakness of the facial muscles, occurring with myopathies, myasthenia, and upper and lower motor neuron facial paresis. Rarely, lower and upper lid retraction occur without proptosis in patients with Graves disease. Lower lid retraction occurs in proptosis and varies directly with the degree of proptosis. It is also seen with senile entropion or ectropion, after eye muscle or orbital surgery, and with contraction of lid tissues. Apparent retraction results when the contralateral lower lid is pathologically elevated, as in Horner syndrome, in enophthalmos, or with vertical deviations of the eye.

Exophthalmos↗

Xanthelasma palpebrarum.

The management of xanthelasma can be challenging, as evidenced by our own experiences as well as that of other physicians. Appreciating the difficulties is important, so as to inform the patient of the risks of recurrences after surgical excision and to plan the surgical procedure to prevent ocular complications such as ectropion. The patient with xanthelasma who desires a blepharoplasty is an especially interesting topic. A conservative approach, at times using staged excisions, as discussed in this article, will help achieve the desired result and assure patient satisfaction.

Adult↗

Harlequin ichthyosis in two greater kudu (Tragelaphus strepsiceros).

Two greater kudu calves (Tragelaphus strepsiceros) born 7 years apart were found with fissures and thickened, scaly, cutaneous plates covering over 80% of their bodies. One was dead at presentation, and the other was euthanized shortly after birth. Both animals shared a common sire. On necropsy, chemosis, ectropion, eclabium, and bilateral valgus deformities of the tarsal joints were observed in one calf, presumed to be secondary to the plates restricting normal fetal development. The principal microscopic lesion was severe lamellar orthokeratosis, with focal mild parakeratosis. Ultrastructural epidermal lesions included the absence of normal lamellar granules, large dilated endoplasmic reticulum, and abnormal retention of organelles and vesicles. Gross, histopathologic, and electron microscopic findings in both kudu calves were consistent with those of harlequin ichthyosis, a rare dermatosis of humans believed to have an autosomal recessive inheritance pattern. The underlying genetic and molecular abnormality and heritability of this condition in this greater kudu herd were not determined.

Animals↗

Refractory ulcerative lupus vulgaris associated with CD4 lymphocytopenia, inversion of chromosome 14, primary amenorrhoea and mental retardation.

A case of ulcerative lupus vulgaris, confirmed by polymerase chain reaction (PCR) is reported. The initial lesion of our case was a papule on the nose, which progressed during antituberculous treatment and caused cartilage destruction and ectropion. Immunological analysis revealed CD4 lymphocytopenia, and the possibility of idiopathic CD4 lymphocyte deficiency was considered. In addition, the patient had primary amenorrhoea, mental retardation and inversion of chromosome 14. CD4 lymphocytopenia and chromosomal abnormality are the possible causes of antituberculous treatment failure.

Adolescent↗

Vulvar reconstruction with an abdominal flap.

There are many procedures for vulvar reconstruction after excision for cancer. The aim of which is to provide cosmetic and functional results with minimal secondary deformity. A patient presented with gross fibrous contracture and vaginal ectropion after radical vulvectomy and groin dissection for cancer. We used the pendulous lower abdominal tissue to reconstruct the vulva and mons pubis. There was no secondary deformity.

Adult↗

Neu-Laxova syndrome: pathological evaluation of a fetus and review of the literature.

Neu-Laxova syndrome is a rare autosomal recessive disorder characterized by ichthyosis, intrauterine growth retardation, microcephaly, short neck, central nervous system abnormalities, hypoplastic or atelectatic lungs, limb deformities, edema, polyhydramnios, and short umbilical cord. Abnormal facial features include sloping forehead, hypertelorism, severe ectropion, proptosis, malformed ears, flat nose, and micrognathia. A necropsy study of a male infant with Neu-Laxova syndrome is described. Cleft palate and ambiguous external genitalia were present in addition to anomalies characteristic of Neu-Laxova syndrome. The clinical manifestations are compared with those of the 40 previously reported cases.

Abnormalities, Multiple↗

Congenital primary upper eyelid entropion.

A case of primary congenital upper eyelid entropion ( PCUEE ) is reviewed. The author proposes a congenital shortness of the levator muscle with anomalous insertion onto the tarsal plate as the etiology, and a new simplified surgical correction is described. The classification of PCUEE as a syndrome with multiple congenital anomalies is supported, and the need for a complete systemic evaluation is stressed. Congenital primary upper eyelid entropion is an exceedingly rare condition. In 1969, Hiles and Wilder reviewed the 13 known cases in the ophthalmic literature, and presented a new case. They suggested the possibility that congenital upper eyelid entropion was part of a syndrome involving multiple systemic anomalies. Surgical correction of the ectropion is usually necessitated by corneal erosion secondary to trichiasis, and a multifarious assortment of surgical procedures has been described. The following is a case report of primary congenital upper eyelid entropion which corroborates the categorization as a syndrome, suggests a pathophysiologic abnormality of the eyelid as the etiology, and describes a new, simplified technique of surgical repair.

Abnormalities, Multiple↗

Congenital eyelid eversion with orbicularis spasm.

Eversion of the lids at birth is a rare condition of debated etiology. It has been attributed most frequently to birth trauma or to congenital lid hypotonia. Most reported cases have been treated by immediate taping of the lids or by surgery (tarsorraphy, intermarginal sutures, and/or plastic procedures). A prominent association with Down's syndrome has been noted. We report a normal infant, born by Caesarean section, with bilateral upper eyelid eversion which subsided spontaneously after treatment only with lubricants. A prominent spastic ectropion component was observed. Lid laxity appeared to be an effect rather than a cause of the eversion, and disappeared as the condition improved. Management should take into account the duration of total occlusion caused by this abnormality.

Eyelid Diseases↗

Temporalis muscle transfer in the correction of lagophthalmos due to leprosy.

In the correction of lagophthalmos due to leprosy neuritis temporalis muscle transfer (TMT) is used to provide a motor to assist in lid closure. This study of TMT in 51 eyes was carried out to assess the effectiveness of TMT in achieving lid closure and corneal protection. The average lid gap preoperatively on light closure was 7.3 mm which was reduced to 3.2 mm on final follow-up. The average lid gap pre-operatively on tight closure was 5.3 mm which was reduced to 0.4 mm at final follow-up. It is possible to train patients with partial or total anesthesia of the cornea in a visual THINK-BLINK reflex. The common complications encountered were ectropion in 6 eyes (12%) and ptosis in 3 eyes (6%).

Adolescent↗

Subperiosteal rejuvenation of the midface and periorbital area: a simplified approach.

A simplified approach to subperiosteal midface rejuvenation is presented. The technique was developed through experience with 60 subperiosteal face lifts over an 8-year period. Because it does not involve a lower eyelid incision, there is no risk of ectropion, yet the midfacial structures and orbicularis oculi muscle can be elevated easily and precisely. The procedure can be performed alone but is more commonly performed in conjunction with brow lift and traditional SMAS dissection of the lower face and neck. The benefits of this subperiosteal approach to the midface are powerful elevation of the midfacial structures, improvement of the nasolabial folds, enhancement of the cheek prominences, smoothing of the nasojugal folds, and tightening of the orbicularis oculi. The procedure is performed through small incisions in the temple and gingival sulcus. The operation is technically straightforward and poses little risk to neurovascular structures. Concerns over prolonged swelling have not materialized. There have been no instances of lower lid or canthal abnormalities.

Female↗

Reanimation of the lagophthalmos using stainless steel weight implantation; a new approach and prospective evaluation.

Weight implants have been used for over 30 years in surgical rehabilitation following lagophthalmos. However, there has been a renewed interest among ophthalmologists in recent years. The weight implant technique combined with lateral canthus resuspension was performed on 22 eyes in Thai patients. It is a reliable method for correcting lagophthalmos and ectropion. In previous studies almost pure gold was used in 99.99% of eyelid implants. However, we wanted to use other materials which are not expensive and are readily available. A stainless steel plate was selected. The majority of our surgeries were done with a stainless steel weight implant of 1.368 g. Patients were followed for 7 to 55 months, and no rejections of the implants were observed. This study achieved a > or = 90% success rate, and showed that a stainless steel plate is an alternative to gold for the weight implant technique.

Adult↗

Congenital ichthyosiform erythroderma: particulate staining pattern of TGK.

A case of late onset non-bullous congenital ichthyosiform erythroderma (CIE) was studied. This patient was not born as a collodion baby and did not have skin abnormalities until 9-10 years of age. She gradually developed erythroderma and fine scales, callosities of her feet, and a mild ectropion. Since recent work has revealed that in the majority of CIE patients, transglutaminase (TGK) is distributed in the cytoplasm of granular cells and horny cells (11), TGK was studied in our case. It was found that TGK was distributed along the cell periphery of horny cells and also in the cytoplasm of granular cells. In the control skins, TGK was stained along the cell periphery of horny cells and granular cells. The marginal band formation was normal. Involucrine and loricrin, the building materials of the marginal band whose-cross-linking is mediated by TGK, were normally stained in the upper epidermis. Cytoplasmic TGK of granular cells and normal development of the marginal band may serve as a helpful diagnostic marker of CIE, particularly because the often confusing collodion baby of lamellar ichthyosis may lack TGK staining and the marginal band altogether.

Age of Onset↗

Iridocorneal adhesions in posterior polymorphous dystrophy.

The variability of clinical expression in posterior polymorphous dystrophy is illustrated with emphasis on the occurrence of iridocorneal adhesions. These are believed to be synechiae and not Rieger's anomaly. The occurrence of glass-membrane-like material extending onto the iris from the cornea, causing synechiae and pupillary ectropion, is documented.

Adult↗

The correction of oriental lower lid involutional entropion using the combined procedure.

INTRODUCTION: Involutional entropion is a common lid malposition problem in the Chinese geriatric population. The major contributing factors of involutional entropion include disinsertion of the lower lid retractors and horizontal lid laxity. The combined procedure (lower lid retractor repair and lateral tarsal strip procedure) is a useful technique that tackles both the horizontal and vertical aetiologic components of this condition. The surgical technique of this procedure is described and the results and complications presented. MATERIALS AND METHODS: A retrospective non-randomised study on 41 lower eyelids of 38 Chinese patients. The combined procedure was performed by a single surgeon over a 2 years 11 months period. Nine patients had bilateral lid surgeries. The clinical charts and operative notes were reviewed by an observer. RESULTS: The mean age of the patients was 74.7 years (range 51 to 92 years). There were 14 males (36.8%) and 24 females (63.2%). The cases were followed up postoperatively for a mean duration of 13 months (range 3 to 48 months). Twelve lids had early postoperative overcorrection but the majority (8 lids) resolved spontaneously with good lid-globe apposition. Of the remaining 4 eyelids, 3 lids had persistent mild asymptomatic ectropion that did not require surgical treatment and only one required re-operation. CONCLUSION: The combined procedure is an effective means of repair for oriental lower lid entropion with low complication rates.

Age Factors↗

[Iridocorneal endothelial syndrome. Series of 7 cases].

The ICE syndrome includes 3 variants of the same disease, previously believed to be independent entities. All 3 share clinical and histopathological features such as endothelial abnormalities, iris damage, and progressive closure of the iridocorneal angle. Seven cases of ICE syndrome are reported, affecting 6 women and 1 man, with a mean age of 40 years. Corectopia was found in 5 eyes, a uveal ectropion in 2 cases, and other iris changes in 3 cases. The endothelial changes of the cornea were confirmed by a speculum microscopy in 5 cases. There were 5 cases of Chandler syndrome, 1 of Cogan-Reese syndrome, and 1 case of iris essential atrophy in our series. Ocular hypertony was observed in 3 cases, 2 of which needed to be operated. In one patient, a corneal edema was observed.

Adult↗

Esthetic blepharoplasty.

Esthetic blepharoplasty is the operation designed to correct excess skin and/or pseudoherniation of fat in the eyelids. These eyelid changes give the pateint a tired look and make him or her look (prematurely) old. The indications and contraindications for the procedure are reviewed. The possibilites and the limitations of the operation must be thoroughly discussed with the patient preoperatively. A psychological evaluation of the patient must be carried out by the surgeon in order to discard unsuitable candidates for the operation. The esthetic blepharoplasty is performed under local anesthesia, completed by intravenous sedation. The operative technique is outlined and consists of judicious skin excisions and resection of fat from the differenct orbital compartments. Atraumatic technique is of utmost importance. Complications are rare in experienced hands but are almost unavoidable in inexperienced hands. Ectropion of the lower eyelid is the most common complication. The cause, prevention and treatment of possible complications are discussed. If carried out properly in a well selected patient by a competent plastic surgeon, the esthetic blepharoplasty gives very satisfying results.

Anesthesia, Local↗

[Orbital fat preservation and orbicularis muscle flap suspension for lower eyelid pouches].

OBJECTIVE: This is to introduce the experience in the treatment of lower eyelid pouches by orbital fat preservation and orbicularis oculi muscle flap suspension techniques. METHODS: From Sept. 1996 to May 1997, thirty patients with lower eyelid pouches were treated using Hamra's procedure. During the operation, the arcus marginalis was incised. The orbital fat was released and advanced beyond the infraorbital rim and sutured. A lateral-based orbicularis oculi muscle flap was created, and its pedicle was repositioned to the periosteum of the upper lateral orbital rim in a superiomedial direction. RESULTS: A total of 26 patients were available for postoperative follow-up for 3 to 8 months (mean 5.6 months). Of them one patient developed unilateral lower eyelid ectropion due to flabby reposition of the orbicularis oculi muscle flap. The rest obtained excellent cosmetic results without complications. CONCLUSION: This new method has following advantages: 1. The lower eyelid pouches and the infraorbital rim show that may be corrected simultaneously: 2. Sunken eyelids and scleral show that may follow fat removal in conventional lower blepharoplasty can be effectively avoided. 3. "Cheek lift" and a youthful eyelid-cheek complex contour can be obtained.

Adult↗

[Lower lid blepharoplasty by using the principles of plastic surgery and the technique of orbital fat release].

OBJECTIVE: To create a new method for lower lid blepharoplasty in order to prevent the complication of lower lid ectropion after the operation. METHODS: Eight patients with 16 eyelids were undergoing the lower lid blepharoplasty with the use of plastic surgery principles and the technique of orbital fat release. The following-ups were carried out in each patient. RESULTS: Eight patients with 16 eyelids were treated with the above-mentioned technique. The satisfactory results were achieved with good appearance. CONCLUSION: The above-mentioned technique is a safe, simple and effective method for the lower lid blepharoplasty.

Adult↗