- Email: [email protected]
Nonsurgical correction of epiblepharon using hyaluronic acid gel
Accepted Manuscript Nonsurgical correction of epiblepharon using hyaluronic acid gel Milind N. Naik, MD, Aditi Pujari, MD, Mohammad Javed Ali, MD, FRCS, Swathi Kaliki, MD, Tarjani Vivek Dave, MD PII:
S1091-8531(17)30440-8
DOI:
10.1016/j.jaapos.2017.12.018
Reference:
YMPA 2834
To appear in:
Journal of AAPOS
Received Date: 1 June 2017 Revised Date:
13 December 2017
Accepted Date: 27 December 2017
Please cite this article as: Naik MN, Pujari A, Ali MJ, Kaliki S, Dave TV, Nonsurgical correction of epiblepharon using hyaluronic acid gel, Journal of AAPOS (2018), doi: 10.1016/j.jaapos.2017.12.018. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Nonsurgical correction of epiblepharon using hyaluronic acid gel Milind N Naik, MD, Aditi Pujari, MD, Mohammad Javed Ali, MD, FRCS, Swathi Kaliki, MD, and Tarjani Vivek Dave, MD
RI PT
Author affiliation: Department of Ophthalmic Plastic Surgery, LV Prasad Eye Institute, Hyderabad, India Submitted June 3, 2017. Revision accepted December 26, 2017.
SC
Correspondence: Milind N Naik, MD, LV Prasad Eye Institute, LV Prasad Marg, Banjara Hills, Hyderabad 500034, India (email: [email protected]).
AC C
EP
TE D
M AN U
Word count: 1,867 Abstract only: 229
ACCEPTED MANUSCRIPT
Abstract Purpose To report a single-center experience with nonsurgical correction of epiblepharon using
RI PT
hyaluronic acid gel. Methods
The medical records of consecutive patients with symptomatic epiblepharon treated over a 3-year
SC
period with hyaluronic acid gel injection were reviewed retrospectively. Hyaluronic acid gel was injected transcutaneously into the suborbicularis plane to obliterate the abnormal skin fold or
assessed by lash-corneal touch. Results
M AN U
evert the eyelid margin. Successful treatment was defined as eversion of the eyelid margin as
Ten eyelids of 8 patients (7 girls [88%]) underwent transcutaneous hyaluronic acid gel injection
TE D
for correction of epiblepharon. Average age at presentation was 16.5 months (range, 1-72 months). Two patients had bilateral involvement. Of 10 eyelids, 8 had a distinct skin fold with a “valley” above it. Nine of 10 eyelids (9 eyelids had lash-corneal touch in the primary gaze; 1 in
EP
downgaze). All 10 eyelids had punctate corneal epitheliopathy on fluorescein staining. An average of 0.19 ml (range, 0.1–0.3 ml) of hyaluronic acid gel was injected per eyelid. After
AC C
injection, 9 of 10 eyelids showed no lash-corneal touch in downgaze, and all 10 eyelids showed resolution of symptoms and epitheliopathy. Patients remained symptom-free for an average final follow-up of 19.1 months (range, 5-42 months). No procedure-related complications were noted. Conclusions
In our small case series, transcutaneous hyaluronic acid gel injection into the lower eyelid effectively corrected symptomatic epiblepharon; the effect was long lasting.
ACCEPTED MANUSCRIPT
In the congenital eyelid disorder epiblepharon, an abnormal eyelid fold leads to the eyelashes turning in and irritating the ocular surface.1,2 Corneal epithelial erosions and induced astigmatism due to squeezing have been reported in epiblepharon.2 Hypertrophy of the orbicularis and failure
RI PT
of retractor attachment to the eyelid skin are proposed causal mechanisms of epiblepharon.1 A mild degree of epiblepharon is almost universal in an Asian eyelid. Epiblepharon is rare in the Indian subcontinent and is believed to be self-correcting.
SC
Surgical correction of epiblepharon is only indicated in symptomatic and severe cases; several surgical techniques have been described.3,4 Nonsurgical treatment of epiblepharon with
M AN U
hyaluronic acid gel injection via a transconjunctival approach was first described by Taban and colleagues.5 At about the same time we reported correction of epiblepharon using hyaluronic acid gel via a transcutaneous approach.6 Nonsurgical treatment of epiblepharon using hyaluronic acid gel injection can be suitable for moderately symptomatic epiblepharon in anticipation of
TE D
natural resolution. The current case series reports our experience with nonsurgical correction of epiblepharon using hyaluronic acid injection. Subjects and Methods
EP
The clinical records of all patients with epiblepharon who were treated with hyaluronic acid gel injection from 2009 to 2012 at the LV Prasad Eye Institute, Hyderabad, were retrospectively
AC C
reviewed. The study was approved by the Institutional Review Board of LV Prasad Eye Institute. The following data were collected: demographic profile, extent of epiblepharon, and outcomes following hyaluronic acid gel injection. Only symptomatic patients with epiphora or reflex spasm and corneal epitheliopathy due to the inwardly turned lashes were considered for treatment. Preinjection evaluation included a note of lash-corneal touch in primary gaze and downgaze, presence or absence of a definite lower eyelid fold, and corneal epithelial changes as
ACCEPTED MANUSCRIPT
noted by fluorescein staining. The hyaluronic acid gel used for correction included either Juvederm (Juvederm Ultra, Allergan, Irvine, CA) or Restylane (Medicis Aesthetics Inc, Scottsdale, AZ). All procedures
RI PT
were performed under laryngeal mask airway anesthesia. Hyaluronic acid gel was injected
transcutaneously in the suborbicularis plane at the lower edge of the tarsus using the needle provided. When a definite skin fold was noted, the valley between the eyelid margin and the skin
SC
fold was filled to obliterate it completely (Figure 1). Filler was delivered by inserting the needle medially and injecting in a retrograde manner as it was withdrawn. When the skin fold was
M AN U
absent, the gel was injected along the lower border of tarsus in the suborbicularis plane to achieve eversion of the eyelid margin (Figure 1). All patients were counseled about the possibility of conversion to a surgery (traditional skin-muscle excision) in the same sitting if the filler did not adequately evert the eyelid margin by the end of the procedure. All patients
TE D
underwent a complete eye evaluation under anesthesia, including irrigation of the lacrimal apparatus to rule out nasolacrimal duct obstruction. Postoperative evaluation included improvement in symptoms, a note of lash-corneal
EP
touch in primary and downgaze, fluorescein staining of cornea, and complications related to the injection procedure. Each of these parameters was evaluated at subsequent follow-up at 2 weeks,
AC C
6 weeks, and at 3- to 6-month intervals thereafter as deemed necessary. Results
A total of 10 eyelids of 8 patients with epiblepharon underwent hyaluronic acid gel injection during the study period. Patient demographics, relevant clinical findings, treatment outcome, and final follow-up of all 8 patients are provided Table 1. The average age at presentation was 16.5 months (range, 1-74). Six patients had
ACCEPTED MANUSCRIPT
unilateral epiblepharon; 2 cases had bilateral involvement. Seven of the 10 eyelids showed a distinct skin fold in the lower eyelid. Nine eyelids had lash-corneal touch in the primary gaze, and 1 eyelid had lash-corneal touch only in downgaze. All 10 eyes had punctate corneal
RI PT
epitheliopathy. Of the 6 unilateral cases, the other eye of the patient showed mild asymptomatic epiblepharon in 3 cases, microphthalmos with orbitopalpebral cyst in 1 case, retinitis pigmentosa in 1 case, and 1 was normal.
SC
An average of 0.19 ml (range, 0.1–0.3 ml) of hyaluronic acid gel was required for adequate eversion of the eyelid margin. Seven eyelids required an injection to achieve
M AN U
obliteration of the valley above the eyelid fold (Figure 2), and 3 eyelids required an injection to achieve eversion of eyelid margin in the absence of distinct eyelid fold (eFigure 1). At an average final follow-up of 19.1 months (range, 5-42 months), all patients continued to remain symptom-free, with no lash-corneal touch in primary or downgaze. Corneal epitheliopathy and
TE D
symptoms improved in all cases. Procedure-related complications were limited to minimal bruising lasting up to 1 week. Discussion
EP
Epiblepharon is believed to be a self-limiting condition, which corrects itself as the patient ages. In mild, asymptomatic cases, simple observation with conservative management is sufficient.
AC C
Severe cases, with corneal epithelial keratopathy, may require surgical management. The nonsurgical treatment we report here can be a good alternative to surgery in moderate cases.5,6 Transcutaneous injection allows easy visualization of the plane of filler delivery and makes it easy to fill the eyelid fold just below the epiblepharon. Linear threading type of filler injections are easier to perform with a transcutaneous approach as opposed to a transconjunctival approach. Khwarg and Lee1 proposed a useful clinical classification of epiblepharon based on the
ACCEPTED MANUSCRIPT
height of eyelid skin fold, area of lash-corneal touch, and the area of corneal erosion. Most cases in their series of Korean patients required skin muscle excision, and the amount of excision correlated with the severity of eyelid fold height.1 The authors noted 10% of patients where
RI PT
eyelid fold height was mild despite severe lash-corneal touch and suggested that this subgroup probably needs retractor reattachment rather than simple skin muscle excision.1 The eyelid
anatomy of epiblepharon patients in our series differs from that of the Korean patients detailed
SC
by Kwarg and Lee1; nevertheless, a definite skin fold was also found in 7 of 10 eyelids of symptomatic epiblepharon in our series.
M AN U
All but one patient in our series was symptomatic and had clinically significant epiblepharon. Nine of 10 cases had lash-corneal touch in primary gaze, and all had corneal epitheliopathy on fluorescein staining. Only case 2 (Table 1) had no symptoms, and the lashcorneal touch was present only in downgaze. We decided, however, to treat because of her visual
TE D
status.
The endpoint of the injection procedure was clear in all cases. For the 7 eyelids with a distinct eyelid fold, the filler was injected in the suborbicularis plane with an intention to
EP
obliterate the valley above the skin fold. In the 3 eyelids where a fold was absent, filler gel was injected at the lower border of tarsus until the eyelid margin showed eversion and lashes moved
AC C
away from the cornea. In all 10 cases, definite eversion of the eyelid margin with correction of lash-corneal touch was noted and this persisted during the follow-up period. We thus used two types of filler injection techniques based on the presence or absence of the eyelid fold described by Khwarg and colleagues.1
In cases where there is a definite skin fold, obliteration of the valley with a filler provides a splinting effect that prevents the abnormal skin fold to push the lashes inward. In cases without
ACCEPTED MANUSCRIPT
a definite skin fold, the filler gel probably rearranges the position of the tarsal plate, thereby inducing an everting effect. It is also possible that the filler stretches the orbicularis oculi such that it more effectively pulls the anterior lamella inferiorly, leads to better eyelash position.
RI PT
We noted several advantages of treating epiblepharon with a filler injection. The
technique is minimally invasive and avoids surgical incisions and dissection and the attendant risk of overcorrection, ectropion, lower eyelid retraction, and a visible scar. Injection of the gel is
SC
completely reversible. The endpoint of correction is definite, and its success can be predicted at the time of treatment. Although we did not have any cases where we had to resort to corrective
M AN U
surgery, having a definite endpoint allows us to keep that option open. The procedure allows a temporary turning out of the lashes for a period of 8-15 months during which the condition may be observed while awaiting spontaneous resolution. This observation period could probably be prolonged by choosing a higher cross-linked filler gel for a long-lasting effect.
TE D
With respect to duration of effect, 7 eyelids in our series had more than 12 months of follow-up—the presumed period of expected resorption of the filler. All these patients continued to remain asymptomatic and demonstrate a normal eyelid with no lash-corneal touch even in
EP
downgaze. On palpation, filler gel could not be identified in these cases. It is possible that the filler corrected the epiblepharon during the stipulated period, and thereafter the epiblepharon
AC C
resolved due to development of the nasal bridge. Of the 2 patients with a long follow-up (40 months), 1 showed noteworthy findings (eFigure 2). This patient was injected at the age of 4 months and the epiblepharon resolved. At 12 months after injection the epiblepharon did recur, but it was not clinically significant. The epiblepharon continued to remain corrected even at 40 months’ follow-up. This case highlights the importance of close follow-up to note recurrence of epiblepharon at the expected time of filler resorption.
ACCEPTED MANUSCRIPT
It is possible that this proposed mechanism of action may not be effective in all cases, especially in the subgroup described by Khwarg and Lee, where there is minimal eyelid fold height despite severe inturning. None of our patients had any untoward side effects from
RI PT
treatment. Postinjection bruising was limited to 1 week and resolved spontaneously. Due to a deep filling, we did not notice lumpiness of the filler or any other cosmetic disfigurement. We did not have any intraoperative failure with the filler gel, but in each case we were prepared to
SC
shift to a surgical option at the same sitting. In all 10 eyelids, a desirable outcome was obtained
AC C
EP
TE D
M AN U
after filler injection.
ACCEPTED MANUSCRIPT
References 1.
Khwarg SI, Lee YJ. Epiblepharon of the lower eyelid: classification and association with astigmatism. Korean J Ophthalmol 1997;11:111-17. Kim C, Shin YJ, Kim NJ, Khwarg SI, Hwang JM, Wee WR. Conjunctival epithelial
RI PT
2.
changes induced by cilia in patients with epiblepharon or entropion. Am J Ophthalmol 2007;144:564-9.
Hwang SW, Khwarg SI, Kim JH, Kim NJ, Choung HK. Lid margin split in the surgical
SC
3.
correction of epiblepharon. Acta Ophthalmol 2008;86:87-90.
Khwarg SI, Choung HK. Epiblepharon of the lower eyelid: technique of surgical repair
M AN U
4.
and quantification of excision according to the skin fold height. Ophthalmic Surg Lasers 2002;33:280-87. 5.
Taban M, Mancini R, Nakra T, et al. Nonsurgical management of congenital eyelid
Naik MN, Ali MJ, Das S, Honavar SG. Nonsurgical management of epiblepharon using
EP
hyaluronic acid gel. Ophthal Plast Reconstr Surg 2010;26:215-17.
AC C
6.
TE D
malpositions using hyaluronic acid gel. Ophthal Plast Reconstr Surg 2009;25:259-63.
ACCEPTED MANUSCRIPT
Legends FIG 1. Technique of injecting hyaluronic acid gel for epiblepharon: For an epiblepharon with distinct eyelid fold (A, arrowheads), filler gel is injected to achieve obliteration of the ‘valley’
to achieve out-turning of lashes intraoperatively (D).
RI PT
above the skin fold (B, asterisk). When no distinct eyelid fold is present (C), filler gel is injected
FIG 2. A 4-year-old boy with left lower eyelid epiblepharon (A, arrowheads), showing the
SC
distinct skin fold with a “valley” above it (B). Two weeks following injection of 0.2 ml of
hyaluronic acid gel to obliterate the left lower eyelid “valley” (C). Nine months following initial
M AN U
injection with no lash-corneal touch, and well-corrected epiblepharon (D).
eFIG 1. A 6-month-old boy with right lower eyelid epiblepharon (A, arrowhead), showing absence of the distinct skin fold (A-B, arrowhead). Five months following injection of 0.3ml of hyaluronic acid gel to evert the right lower eyelid margin (C) showing no lash-corneal touch
TE D
even in downgaze (D). The left epiblepharon was mild and functionally insignificant. eFIG 2. A 4-month-old infant with right symptomatic epiblepharon resulting in lash-corneal touch in primary gaze (A, arrowhead). Note the skin fold in downgaze prior to filler injection
EP
(B), the successful out-turning of eyelid margin 1 week following filler gel injection (C, arrow), and 1-month postinjection clinical photograph (D). Same child showing adequate eversion of
AC C
eyelid margin 12 months (E), and 40 months after filler injection showing complete resolution of epiblepharon (F).
ACCEPTED MANUSCRIPT
Table 1. Patient demographics, pre-treatment findings, and post-injection findings in 10 eyelids of 8 patients with epiblepharon
SC
M AN U TE D EP AC C
1 (R) 2 (R) 3 (L) 4 (L) 5 (R) 5 (L) 6 (R) 6 (L) 7 (R) 8 (R)
Age, Sex Pre-treatment Epiblepharon Hyaluronic Post-injection Final months lash-corneal skin fold acid gel lash-corneal follow-up, touch per eye, ml touch months 4 F Yes Yes 0.2 No 42 72 F Downgaze only Yes 0.2 No 11 48 M Yes Yes 0.2 No 9 24 F Yes Yes 0.3 No 24 7 F Yes No 0.1 Downgaze only 13 7 Yes No 0.1 No 13 31 F Yes Yes 0.15 No 15 31 Yes Yes 0.15 No 15 1 F Yes Yes 0.2 No 40 6 F Yes No 0.3 No 9
RI PT
Case (eye)
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S1091-8531(17)30440-8
DOI:
10.1016/j.jaapos.2017.12.018
Reference:
YMPA 2834
To appear in:
Journal of AAPOS
Received Date: 1 June 2017 Revised Date:
13 December 2017
Accepted Date: 27 December 2017
Please cite this article as: Naik MN, Pujari A, Ali MJ, Kaliki S, Dave TV, Nonsurgical correction of epiblepharon using hyaluronic acid gel, Journal of AAPOS (2018), doi: 10.1016/j.jaapos.2017.12.018. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Nonsurgical correction of epiblepharon using hyaluronic acid gel Milind N Naik, MD, Aditi Pujari, MD, Mohammad Javed Ali, MD, FRCS, Swathi Kaliki, MD, and Tarjani Vivek Dave, MD
RI PT
Author affiliation: Department of Ophthalmic Plastic Surgery, LV Prasad Eye Institute, Hyderabad, India Submitted June 3, 2017. Revision accepted December 26, 2017.
SC
Correspondence: Milind N Naik, MD, LV Prasad Eye Institute, LV Prasad Marg, Banjara Hills, Hyderabad 500034, India (email: [email protected]).
AC C
EP
TE D
M AN U
Word count: 1,867 Abstract only: 229
ACCEPTED MANUSCRIPT
Abstract Purpose To report a single-center experience with nonsurgical correction of epiblepharon using
RI PT
hyaluronic acid gel. Methods
The medical records of consecutive patients with symptomatic epiblepharon treated over a 3-year
SC
period with hyaluronic acid gel injection were reviewed retrospectively. Hyaluronic acid gel was injected transcutaneously into the suborbicularis plane to obliterate the abnormal skin fold or
assessed by lash-corneal touch. Results
M AN U
evert the eyelid margin. Successful treatment was defined as eversion of the eyelid margin as
Ten eyelids of 8 patients (7 girls [88%]) underwent transcutaneous hyaluronic acid gel injection
TE D
for correction of epiblepharon. Average age at presentation was 16.5 months (range, 1-72 months). Two patients had bilateral involvement. Of 10 eyelids, 8 had a distinct skin fold with a “valley” above it. Nine of 10 eyelids (9 eyelids had lash-corneal touch in the primary gaze; 1 in
EP
downgaze). All 10 eyelids had punctate corneal epitheliopathy on fluorescein staining. An average of 0.19 ml (range, 0.1–0.3 ml) of hyaluronic acid gel was injected per eyelid. After
AC C
injection, 9 of 10 eyelids showed no lash-corneal touch in downgaze, and all 10 eyelids showed resolution of symptoms and epitheliopathy. Patients remained symptom-free for an average final follow-up of 19.1 months (range, 5-42 months). No procedure-related complications were noted. Conclusions
In our small case series, transcutaneous hyaluronic acid gel injection into the lower eyelid effectively corrected symptomatic epiblepharon; the effect was long lasting.
ACCEPTED MANUSCRIPT
In the congenital eyelid disorder epiblepharon, an abnormal eyelid fold leads to the eyelashes turning in and irritating the ocular surface.1,2 Corneal epithelial erosions and induced astigmatism due to squeezing have been reported in epiblepharon.2 Hypertrophy of the orbicularis and failure
RI PT
of retractor attachment to the eyelid skin are proposed causal mechanisms of epiblepharon.1 A mild degree of epiblepharon is almost universal in an Asian eyelid. Epiblepharon is rare in the Indian subcontinent and is believed to be self-correcting.
SC
Surgical correction of epiblepharon is only indicated in symptomatic and severe cases; several surgical techniques have been described.3,4 Nonsurgical treatment of epiblepharon with
M AN U
hyaluronic acid gel injection via a transconjunctival approach was first described by Taban and colleagues.5 At about the same time we reported correction of epiblepharon using hyaluronic acid gel via a transcutaneous approach.6 Nonsurgical treatment of epiblepharon using hyaluronic acid gel injection can be suitable for moderately symptomatic epiblepharon in anticipation of
TE D
natural resolution. The current case series reports our experience with nonsurgical correction of epiblepharon using hyaluronic acid injection. Subjects and Methods
EP
The clinical records of all patients with epiblepharon who were treated with hyaluronic acid gel injection from 2009 to 2012 at the LV Prasad Eye Institute, Hyderabad, were retrospectively
AC C
reviewed. The study was approved by the Institutional Review Board of LV Prasad Eye Institute. The following data were collected: demographic profile, extent of epiblepharon, and outcomes following hyaluronic acid gel injection. Only symptomatic patients with epiphora or reflex spasm and corneal epitheliopathy due to the inwardly turned lashes were considered for treatment. Preinjection evaluation included a note of lash-corneal touch in primary gaze and downgaze, presence or absence of a definite lower eyelid fold, and corneal epithelial changes as
ACCEPTED MANUSCRIPT
noted by fluorescein staining. The hyaluronic acid gel used for correction included either Juvederm (Juvederm Ultra, Allergan, Irvine, CA) or Restylane (Medicis Aesthetics Inc, Scottsdale, AZ). All procedures
RI PT
were performed under laryngeal mask airway anesthesia. Hyaluronic acid gel was injected
transcutaneously in the suborbicularis plane at the lower edge of the tarsus using the needle provided. When a definite skin fold was noted, the valley between the eyelid margin and the skin
SC
fold was filled to obliterate it completely (Figure 1). Filler was delivered by inserting the needle medially and injecting in a retrograde manner as it was withdrawn. When the skin fold was
M AN U
absent, the gel was injected along the lower border of tarsus in the suborbicularis plane to achieve eversion of the eyelid margin (Figure 1). All patients were counseled about the possibility of conversion to a surgery (traditional skin-muscle excision) in the same sitting if the filler did not adequately evert the eyelid margin by the end of the procedure. All patients
TE D
underwent a complete eye evaluation under anesthesia, including irrigation of the lacrimal apparatus to rule out nasolacrimal duct obstruction. Postoperative evaluation included improvement in symptoms, a note of lash-corneal
EP
touch in primary and downgaze, fluorescein staining of cornea, and complications related to the injection procedure. Each of these parameters was evaluated at subsequent follow-up at 2 weeks,
AC C
6 weeks, and at 3- to 6-month intervals thereafter as deemed necessary. Results
A total of 10 eyelids of 8 patients with epiblepharon underwent hyaluronic acid gel injection during the study period. Patient demographics, relevant clinical findings, treatment outcome, and final follow-up of all 8 patients are provided Table 1. The average age at presentation was 16.5 months (range, 1-74). Six patients had
ACCEPTED MANUSCRIPT
unilateral epiblepharon; 2 cases had bilateral involvement. Seven of the 10 eyelids showed a distinct skin fold in the lower eyelid. Nine eyelids had lash-corneal touch in the primary gaze, and 1 eyelid had lash-corneal touch only in downgaze. All 10 eyes had punctate corneal
RI PT
epitheliopathy. Of the 6 unilateral cases, the other eye of the patient showed mild asymptomatic epiblepharon in 3 cases, microphthalmos with orbitopalpebral cyst in 1 case, retinitis pigmentosa in 1 case, and 1 was normal.
SC
An average of 0.19 ml (range, 0.1–0.3 ml) of hyaluronic acid gel was required for adequate eversion of the eyelid margin. Seven eyelids required an injection to achieve
M AN U
obliteration of the valley above the eyelid fold (Figure 2), and 3 eyelids required an injection to achieve eversion of eyelid margin in the absence of distinct eyelid fold (eFigure 1). At an average final follow-up of 19.1 months (range, 5-42 months), all patients continued to remain symptom-free, with no lash-corneal touch in primary or downgaze. Corneal epitheliopathy and
TE D
symptoms improved in all cases. Procedure-related complications were limited to minimal bruising lasting up to 1 week. Discussion
EP
Epiblepharon is believed to be a self-limiting condition, which corrects itself as the patient ages. In mild, asymptomatic cases, simple observation with conservative management is sufficient.
AC C
Severe cases, with corneal epithelial keratopathy, may require surgical management. The nonsurgical treatment we report here can be a good alternative to surgery in moderate cases.5,6 Transcutaneous injection allows easy visualization of the plane of filler delivery and makes it easy to fill the eyelid fold just below the epiblepharon. Linear threading type of filler injections are easier to perform with a transcutaneous approach as opposed to a transconjunctival approach. Khwarg and Lee1 proposed a useful clinical classification of epiblepharon based on the
ACCEPTED MANUSCRIPT
height of eyelid skin fold, area of lash-corneal touch, and the area of corneal erosion. Most cases in their series of Korean patients required skin muscle excision, and the amount of excision correlated with the severity of eyelid fold height.1 The authors noted 10% of patients where
RI PT
eyelid fold height was mild despite severe lash-corneal touch and suggested that this subgroup probably needs retractor reattachment rather than simple skin muscle excision.1 The eyelid
anatomy of epiblepharon patients in our series differs from that of the Korean patients detailed
SC
by Kwarg and Lee1; nevertheless, a definite skin fold was also found in 7 of 10 eyelids of symptomatic epiblepharon in our series.
M AN U
All but one patient in our series was symptomatic and had clinically significant epiblepharon. Nine of 10 cases had lash-corneal touch in primary gaze, and all had corneal epitheliopathy on fluorescein staining. Only case 2 (Table 1) had no symptoms, and the lashcorneal touch was present only in downgaze. We decided, however, to treat because of her visual
TE D
status.
The endpoint of the injection procedure was clear in all cases. For the 7 eyelids with a distinct eyelid fold, the filler was injected in the suborbicularis plane with an intention to
EP
obliterate the valley above the skin fold. In the 3 eyelids where a fold was absent, filler gel was injected at the lower border of tarsus until the eyelid margin showed eversion and lashes moved
AC C
away from the cornea. In all 10 cases, definite eversion of the eyelid margin with correction of lash-corneal touch was noted and this persisted during the follow-up period. We thus used two types of filler injection techniques based on the presence or absence of the eyelid fold described by Khwarg and colleagues.1
In cases where there is a definite skin fold, obliteration of the valley with a filler provides a splinting effect that prevents the abnormal skin fold to push the lashes inward. In cases without
ACCEPTED MANUSCRIPT
a definite skin fold, the filler gel probably rearranges the position of the tarsal plate, thereby inducing an everting effect. It is also possible that the filler stretches the orbicularis oculi such that it more effectively pulls the anterior lamella inferiorly, leads to better eyelash position.
RI PT
We noted several advantages of treating epiblepharon with a filler injection. The
technique is minimally invasive and avoids surgical incisions and dissection and the attendant risk of overcorrection, ectropion, lower eyelid retraction, and a visible scar. Injection of the gel is
SC
completely reversible. The endpoint of correction is definite, and its success can be predicted at the time of treatment. Although we did not have any cases where we had to resort to corrective
M AN U
surgery, having a definite endpoint allows us to keep that option open. The procedure allows a temporary turning out of the lashes for a period of 8-15 months during which the condition may be observed while awaiting spontaneous resolution. This observation period could probably be prolonged by choosing a higher cross-linked filler gel for a long-lasting effect.
TE D
With respect to duration of effect, 7 eyelids in our series had more than 12 months of follow-up—the presumed period of expected resorption of the filler. All these patients continued to remain asymptomatic and demonstrate a normal eyelid with no lash-corneal touch even in
EP
downgaze. On palpation, filler gel could not be identified in these cases. It is possible that the filler corrected the epiblepharon during the stipulated period, and thereafter the epiblepharon
AC C
resolved due to development of the nasal bridge. Of the 2 patients with a long follow-up (40 months), 1 showed noteworthy findings (eFigure 2). This patient was injected at the age of 4 months and the epiblepharon resolved. At 12 months after injection the epiblepharon did recur, but it was not clinically significant. The epiblepharon continued to remain corrected even at 40 months’ follow-up. This case highlights the importance of close follow-up to note recurrence of epiblepharon at the expected time of filler resorption.
ACCEPTED MANUSCRIPT
It is possible that this proposed mechanism of action may not be effective in all cases, especially in the subgroup described by Khwarg and Lee, where there is minimal eyelid fold height despite severe inturning. None of our patients had any untoward side effects from
RI PT
treatment. Postinjection bruising was limited to 1 week and resolved spontaneously. Due to a deep filling, we did not notice lumpiness of the filler or any other cosmetic disfigurement. We did not have any intraoperative failure with the filler gel, but in each case we were prepared to
SC
shift to a surgical option at the same sitting. In all 10 eyelids, a desirable outcome was obtained
AC C
EP
TE D
M AN U
after filler injection.
ACCEPTED MANUSCRIPT
References 1.
Khwarg SI, Lee YJ. Epiblepharon of the lower eyelid: classification and association with astigmatism. Korean J Ophthalmol 1997;11:111-17. Kim C, Shin YJ, Kim NJ, Khwarg SI, Hwang JM, Wee WR. Conjunctival epithelial
RI PT
2.
changes induced by cilia in patients with epiblepharon or entropion. Am J Ophthalmol 2007;144:564-9.
Hwang SW, Khwarg SI, Kim JH, Kim NJ, Choung HK. Lid margin split in the surgical
SC
3.
correction of epiblepharon. Acta Ophthalmol 2008;86:87-90.
Khwarg SI, Choung HK. Epiblepharon of the lower eyelid: technique of surgical repair
M AN U
4.
and quantification of excision according to the skin fold height. Ophthalmic Surg Lasers 2002;33:280-87. 5.
Taban M, Mancini R, Nakra T, et al. Nonsurgical management of congenital eyelid
Naik MN, Ali MJ, Das S, Honavar SG. Nonsurgical management of epiblepharon using
EP
hyaluronic acid gel. Ophthal Plast Reconstr Surg 2010;26:215-17.
AC C
6.
TE D
malpositions using hyaluronic acid gel. Ophthal Plast Reconstr Surg 2009;25:259-63.
ACCEPTED MANUSCRIPT
Legends FIG 1. Technique of injecting hyaluronic acid gel for epiblepharon: For an epiblepharon with distinct eyelid fold (A, arrowheads), filler gel is injected to achieve obliteration of the ‘valley’
to achieve out-turning of lashes intraoperatively (D).
RI PT
above the skin fold (B, asterisk). When no distinct eyelid fold is present (C), filler gel is injected
FIG 2. A 4-year-old boy with left lower eyelid epiblepharon (A, arrowheads), showing the
SC
distinct skin fold with a “valley” above it (B). Two weeks following injection of 0.2 ml of
hyaluronic acid gel to obliterate the left lower eyelid “valley” (C). Nine months following initial
M AN U
injection with no lash-corneal touch, and well-corrected epiblepharon (D).
eFIG 1. A 6-month-old boy with right lower eyelid epiblepharon (A, arrowhead), showing absence of the distinct skin fold (A-B, arrowhead). Five months following injection of 0.3ml of hyaluronic acid gel to evert the right lower eyelid margin (C) showing no lash-corneal touch
TE D
even in downgaze (D). The left epiblepharon was mild and functionally insignificant. eFIG 2. A 4-month-old infant with right symptomatic epiblepharon resulting in lash-corneal touch in primary gaze (A, arrowhead). Note the skin fold in downgaze prior to filler injection
EP
(B), the successful out-turning of eyelid margin 1 week following filler gel injection (C, arrow), and 1-month postinjection clinical photograph (D). Same child showing adequate eversion of
AC C
eyelid margin 12 months (E), and 40 months after filler injection showing complete resolution of epiblepharon (F).
ACCEPTED MANUSCRIPT
Table 1. Patient demographics, pre-treatment findings, and post-injection findings in 10 eyelids of 8 patients with epiblepharon
SC
M AN U TE D EP AC C
1 (R) 2 (R) 3 (L) 4 (L) 5 (R) 5 (L) 6 (R) 6 (L) 7 (R) 8 (R)
Age, Sex Pre-treatment Epiblepharon Hyaluronic Post-injection Final months lash-corneal skin fold acid gel lash-corneal follow-up, touch per eye, ml touch months 4 F Yes Yes 0.2 No 42 72 F Downgaze only Yes 0.2 No 11 48 M Yes Yes 0.2 No 9 24 F Yes Yes 0.3 No 24 7 F Yes No 0.1 Downgaze only 13 7 Yes No 0.1 No 13 31 F Yes Yes 0.15 No 15 31 Yes Yes 0.15 No 15 1 F Yes Yes 0.2 No 40 6 F Yes No 0.3 No 9
RI PT
Case (eye)
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT