Floppy eyelid syndrome repair
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This is Richard Allen at the University of Iowa.
This video demonstrates an upper and lower lateral tarsal strip in a patient with floppy eyelid syndrome.
The significant laxity of the patient's eyelids are demonstrated. This patient has a history of sleep apnea and is now treated with CPAP. It is mandatory for any patient with floppy eyelids to have a sleep evaluation. A lateral canthotomy is performed with the 15 blade. An upper cantholysis is then performed with the needle tip cautery. A lower cantholysis is performed with the needle tip cautery. A lower lateral tarsal strip is then developed by dissecting between the anterior and posterior lamella. In floppy eyelids, the dissection is performed for approximately one third to one half of the eyelid. The mucocutaneous junction is excised. The amount of shortening is determined and Westcott scissors are used to shorten the strip. As is demonstrated, almost 2 cm of tarsus is excised. The posterior surface of the strip is scraped with a 15 blade. A double armed 4-0 Mersilene suture on a half circle need is used to engage the strip, posterior to anterior. The suture then engages the periosteum of the lateral orbital rim at the level of Whitnall's tubercle. Both sutures are then placed and left untied.
Attention is then directed to the upper eyelid where a lateral tarsal strip is developed. I do not perform wedge resections of the upper eyelid any more for floppy eyelid syndrome. One should limit dissection only to the superior border of the tarsus to prevent damaging the lacrimal gland ductules. The mucocutaneous junction is excised. The posterior surface of the strip is scraped and the amount of shortening needed is determined. Westcott scissors are then used to shorten the strip; again, this is significant in these cases of floppy lids. The double armed 4-0 Mersilene suture is then used to engage the strip posterior to anterior. The sutures are then placed adjacent to the lower lid sutures inside the lateral orbital rim through the periosteum. Again, this is a periosteal bite inside the lateral orbital rim. The lashes are excised laterally to prevent burying them into the closure. The upper lid sutures are tied. This results in adequate tightening of the upper eyelid.
The lower sutures are then tied. The lashes are excised laterally. The canthotomy incision is then repaired by suturing the lower anterior lamella to the periosteum of the lateral orbital rim. The anterior lamella of the upper and lower lid can then be sutured together lateral to the lateral orbital rim. I prefer 5-0 fast absorbing suture in this area.
At the conclusion of the case, the patient will use antibiotic ointment three times per day and return in one week for reevaluation.