Repair of lower lid cicatricial entropion with an anterior lamellar recession and retractor reinsertion
Richard C. Allen, MD, PhD, FACS
Additional Notes: Length 03:49
This video demonstrates repair of cicatricial entropion in a patient with a history of mucous membrane pemphigoid. The patient has significant disease in his left eye. The right eye is demonstrated which shows evidence of lower lid laxity as well as tarsal instability. A 15 blade is used to make an incision along the eyelid margin between the anterior and posterior lamella. In this case, an anterior lamellar recession will be performed along with a retractor reinsertion. Dissection is then carried along the posterior surface of the orbicularis muscle inferiorly to the inferior orbital rim. The orbital septum is then opened and the central fat pad is dissected from the underlying lower lid retractors. The lower lid retractors are then disinserted from the inferior border the tarsus and dissected from the underlying conjunctiva. I believe it is important in these patients with active cicatricial processes to not disturb the underlying conjunctiva which may result in more inflammation. The lower lid retractors are then advanced to the inferior border the tarsus with interrupted 5–0 Vicryl sutures. Approximately 3-4 sutures are placed. This will result in stabilization of the inferior border the tarsus. A lateral tarsal strip will be performed in order to tighten the lid horizontally. An inferior cantholysis is performed. The strip is then engaged with a double-armed 4-0 Mersilene suture on an S2 needle. The suture then engages the lateral orbital rim at the level of Whitnall's tubercle. The sutures are left untied. A superior strip of the anterior lamella is then excised. This contains some aberrant lashes. This will also result in recession of the anterior lamella. A 5–0 Vicryl sutures is used to engage the anterior lamella. The suture then engages the anterior surface of the tarsus making a mattress suture. The sutures are placed in order to recess the anterior lamella. This will result in approximately 2 millimeters of exposed anterior surface of the tarsus. Approximate 3-4 sutures are placed along the length of the eyelid. The exposed anterior surface of posterior lamella will be allowed to granulate postoperatively. The lateral tarsal strip suture is then tied in order to tighten the lid horizontally. The eyelid appears be in good position. The lateral canthotomy incision is then closed with interrupted 5-0 fast-absorbing sutures. At the conclusion of the case, the eyelid appears to be in good position. Erythromycin ophthalmic ointment will be placed over the repair and the patient will follow-up in approximate 1-2 weeks for removal of the 5–0 Vicryl sutures.
