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Method of Correction of Tarsal Ectropion
M E T H O D O F CORRECTION O F TARSAL ECTROPION J. H. W H I T E ,
M.D.
Newark, New Jersey
The term tarsal ectropion is used by Fox 1 to describe lower eyelid eversion that is lim ited to the tarsal-containing portion only. It has sometimes been described as spastic ec tropion, a term which, according to DukeElder,2 erroneously relates its development to spasm of the marginal fibers of the orbicularis muscle and which should be reserved for those cases of ectropion occurring in young people and characterized by a facile reduction. Tarsal ectropion (Fig. 1) cannot be reinverted by manual reduction. In tarsal ectropion, Fox further observes that there is no relaxation of the tissues of the eyelid below the tarsus as in senile ectro pion. Further, an actual shortage of skin ap pears to develop (Fig. 2 ) . The following technique uses the skin to reinvert the tarsus.
Fig. 1 (White). Preoperative appearance of tarsal ectropion.
TECHNIQUE
Two traction sutures are first placed through the margin of the lower eyelid and traction is exerted in an upward direction. A horizontal incision is then made through the skin about 4 mm below and parallel to the margin of the lower eyelid, preferably in the line of a skin fold. The incision should extend over the middle two-fourths of the eyelid. The skin above and below the incision is carefully freed from the underlying orbicularis muscle (Fig. 3). It is important that adequate mobil ization of the skin below the incision be ob tained. Dissection is then carried upward between the folded layers of the orbicularis until the inferior border of the tarsus is reached (Fig. 4). The orbicularis is incised at this point and the inferior border of the From the Division of Ophthalmology, New Jer sey College of Medicine and Dentistry, Newark, New Jersey. Reprint requests to J. H. White, M.D., The Divi sion of Ophthalmology, New Jersey College of Medicine and Dentistry, 100 Bergen Street, New ark, New Jersey.
CONJUNCTIVA SEPTUM TARSUS ORBICULARIS
Fig. 2 (White). Diagramatic cross-section of tarsal ectropion.
tarsus is exposed for its entire length (Fig. 5). Three double-armed sutures of 5-0 silk are inserted horizontally in the inferior border of the tarsus, one in the midline and one to each side. The sutures are then brought out through the skin below the incision line. The distance 615
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AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 3 (White). Skin freed from orbicularis muscle.
Fig. 4 (White). Incision of orbicularis to reach lower border of tarsus.
SEPTEMBER, 1971
Fig. 5 (White). Lower border of tarsus dissected free.
of the suture from the incision is usually about 2 mm, but this distance may be varied according to the need for inversion. Overcorrection, with consequent dragging down of the lower eyelid margin, should be avoided. Each suture is passed through a peg of rubber tubing and pulled tight (Fig. 6). Overcorrection and undercorrection can be adjusted, if necessary, by replacement of the sutures. Finally, the sutures are tied over the rubber pegs. They should be left in place for approximately 10 days. The skin incision is closed with interrupted silk sutures which may be removed after five days. The postop erative appearance after removal of all su tures is shown in Figure 7. The result of this procedure is that the lower border of the tarsus becomes firmly at tached through the opening in the orbicularis to the skin beneath the incision, thus correct ing the ectropion. Eight such procedures have now been per formed, with satisfactory reinversion of the
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tarsus in all. In one case residual horizontal eyelid laxity required bilateral correction by the Kuhnt-Szymanowski procedure. In an other case residual eyelid laxity was cor rected at the time of the original surgery by a modified Szymanowski procedure. This was achieved by extending the horizontal skin incision 2 cm in an upward and lateral direction and then making a downward ver tical incision in the usual manner. DISCUSSION
Procedures such as the Kuhnt-Szyma nowski operation which exert their effect by horizontal shortening of the eyelid do not correct advanced cases of tarsal ectropion where the defect is in a vertical direction. They may even make the ectropion worse by fixing the tarsus more tightly in its everted position. Shortening of the orbital septum would
Fig. 7 (White). Postoperative appearance 10 days after surgery.
appear to be one logical approach to the problem. Jones and associates3 describe a method of tucking the orbital septum for the correction of senile entropion. In one case of tarsal ectropion, satisfactory inversion was obtained by this method, but the lower eyelid was drawn down well below the normal posi tion. This result appears to be the result of failure to resolve the problem of lack of skin in the lower eyelid. The technique described earlier is an ex tension of the Snellen suture technique.4 It transfers the pull of the skin from the upper margin of the tarsus to the anterior lower border. This reinverts the tarsus around its horizontal axis through the medial and lat eral palpebral tendons. Any further down ward pull of the skin holds the tarsus in its vertical position. SUMMARY
To correct tarsal ectropion, the lower edge of the tarsus is exposed through a horizontal skin incision. This edge is sutured to the skin below the incision. Subsequent down ward pull of the skin reinverts the tarsus. REFERENCES
Fig. 6 (White). Insertion of sutures through tarsus and skin.
1. Fox, S. A.: Marginal (tarsal) ectropion. Arch. Ophth. 63:660, 1960. 2. Duke-Elder, S.: Textbook of Ophthalmology, vol. S. The Ocular Adnexa, St. Louis, C. V. Mosby, 1952, p. 5188. 3. Jones, L. T., Reeh, M. J., and Tsujimura, J. K.: Senile entropion. Am. J. Ophth. 55:463, 1963. 4. Fuchs, H. E.: Textbook of Ophthalmology, 5th ed. London, Lippincott, 1917, p. 957.
M.D.
Newark, New Jersey
The term tarsal ectropion is used by Fox 1 to describe lower eyelid eversion that is lim ited to the tarsal-containing portion only. It has sometimes been described as spastic ec tropion, a term which, according to DukeElder,2 erroneously relates its development to spasm of the marginal fibers of the orbicularis muscle and which should be reserved for those cases of ectropion occurring in young people and characterized by a facile reduction. Tarsal ectropion (Fig. 1) cannot be reinverted by manual reduction. In tarsal ectropion, Fox further observes that there is no relaxation of the tissues of the eyelid below the tarsus as in senile ectro pion. Further, an actual shortage of skin ap pears to develop (Fig. 2 ) . The following technique uses the skin to reinvert the tarsus.
Fig. 1 (White). Preoperative appearance of tarsal ectropion.
TECHNIQUE
Two traction sutures are first placed through the margin of the lower eyelid and traction is exerted in an upward direction. A horizontal incision is then made through the skin about 4 mm below and parallel to the margin of the lower eyelid, preferably in the line of a skin fold. The incision should extend over the middle two-fourths of the eyelid. The skin above and below the incision is carefully freed from the underlying orbicularis muscle (Fig. 3). It is important that adequate mobil ization of the skin below the incision be ob tained. Dissection is then carried upward between the folded layers of the orbicularis until the inferior border of the tarsus is reached (Fig. 4). The orbicularis is incised at this point and the inferior border of the From the Division of Ophthalmology, New Jer sey College of Medicine and Dentistry, Newark, New Jersey. Reprint requests to J. H. White, M.D., The Divi sion of Ophthalmology, New Jersey College of Medicine and Dentistry, 100 Bergen Street, New ark, New Jersey.
CONJUNCTIVA SEPTUM TARSUS ORBICULARIS
Fig. 2 (White). Diagramatic cross-section of tarsal ectropion.
tarsus is exposed for its entire length (Fig. 5). Three double-armed sutures of 5-0 silk are inserted horizontally in the inferior border of the tarsus, one in the midline and one to each side. The sutures are then brought out through the skin below the incision line. The distance 615
616
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 3 (White). Skin freed from orbicularis muscle.
Fig. 4 (White). Incision of orbicularis to reach lower border of tarsus.
SEPTEMBER, 1971
Fig. 5 (White). Lower border of tarsus dissected free.
of the suture from the incision is usually about 2 mm, but this distance may be varied according to the need for inversion. Overcorrection, with consequent dragging down of the lower eyelid margin, should be avoided. Each suture is passed through a peg of rubber tubing and pulled tight (Fig. 6). Overcorrection and undercorrection can be adjusted, if necessary, by replacement of the sutures. Finally, the sutures are tied over the rubber pegs. They should be left in place for approximately 10 days. The skin incision is closed with interrupted silk sutures which may be removed after five days. The postop erative appearance after removal of all su tures is shown in Figure 7. The result of this procedure is that the lower border of the tarsus becomes firmly at tached through the opening in the orbicularis to the skin beneath the incision, thus correct ing the ectropion. Eight such procedures have now been per formed, with satisfactory reinversion of the
TARSAL ECTROPION
VOL. 72, NO. 3
617
tarsus in all. In one case residual horizontal eyelid laxity required bilateral correction by the Kuhnt-Szymanowski procedure. In an other case residual eyelid laxity was cor rected at the time of the original surgery by a modified Szymanowski procedure. This was achieved by extending the horizontal skin incision 2 cm in an upward and lateral direction and then making a downward ver tical incision in the usual manner. DISCUSSION
Procedures such as the Kuhnt-Szyma nowski operation which exert their effect by horizontal shortening of the eyelid do not correct advanced cases of tarsal ectropion where the defect is in a vertical direction. They may even make the ectropion worse by fixing the tarsus more tightly in its everted position. Shortening of the orbital septum would
Fig. 7 (White). Postoperative appearance 10 days after surgery.
appear to be one logical approach to the problem. Jones and associates3 describe a method of tucking the orbital septum for the correction of senile entropion. In one case of tarsal ectropion, satisfactory inversion was obtained by this method, but the lower eyelid was drawn down well below the normal posi tion. This result appears to be the result of failure to resolve the problem of lack of skin in the lower eyelid. The technique described earlier is an ex tension of the Snellen suture technique.4 It transfers the pull of the skin from the upper margin of the tarsus to the anterior lower border. This reinverts the tarsus around its horizontal axis through the medial and lat eral palpebral tendons. Any further down ward pull of the skin holds the tarsus in its vertical position. SUMMARY
To correct tarsal ectropion, the lower edge of the tarsus is exposed through a horizontal skin incision. This edge is sutured to the skin below the incision. Subsequent down ward pull of the skin reinverts the tarsus. REFERENCES
Fig. 6 (White). Insertion of sutures through tarsus and skin.
1. Fox, S. A.: Marginal (tarsal) ectropion. Arch. Ophth. 63:660, 1960. 2. Duke-Elder, S.: Textbook of Ophthalmology, vol. S. The Ocular Adnexa, St. Louis, C. V. Mosby, 1952, p. 5188. 3. Jones, L. T., Reeh, M. J., and Tsujimura, J. K.: Senile entropion. Am. J. Ophth. 55:463, 1963. 4. Fuchs, H. E.: Textbook of Ophthalmology, 5th ed. London, Lippincott, 1917, p. 957.