Ptosis repair, malposition and eyelid tumours

Surgical Selection for Blepharoptosis

Ptosis surgery depends on cause, severity, levator and frontalis function, corneal protection, Bell response, age, visual-development risk and patient goals. Phenylephrine response can help selected planning, but no two-variable algorithm fits every case.

1. Posterior Müller's Muscle-Conjunctival Resection (MMCR / Putterman Technique):
   • Indications: Mild ptosis ($1.0-2.0\text{ mm}$), excellent levator excursion ($\ge 12-15\text{ mm}$), and a positive phenylephrine test (eyelid elevates to normal contour). Commonly selected for Horner syndrome, minor involutional ptosis, or contour touch-ups.
   • Mechanism: Eyelid is everted; a measured strip of conjunctiva and underlying Müller's muscle ($8-9\text{ mm}$ of tissue for $2\text{ mm}$ of lift) is clamped, resected, and sutured. Leaves no visible cutaneous scar.
2. Fasanella-Servat Procedure:
   • Resection of the superior border of the tarsus, Müller's muscle, and conjunctiva. Similar indications to MMCR; contraindicated if tarsal height is depleted.
3. Levator Aponeurosis Advancement / Repair (Anterior Approach):
   • Indications: Aponeurotic involutional ptosis with good to normal levator function ($\ge 10-12\text{ mm}$).
   • Mechanism: Skin crease incision; dissection through orbicularis; preaponeurotic fat reflected; disinserted or thinned levator aponeurosis identified, advanced, and securely anchored to the anterior mid-tarsus with non-absorbable or long-acting absorbable sutures.
4. Levator Muscle Resection (External Levator Resection):
   • Indications: Moderate congenital or myogenic ptosis with fair levator function ($5-11\text{ mm}$).
   • Mechanism: The levator muscle is shortened by dissecting it free from Whitnall's ligament, resecting a measured segment of muscle belly, and re-attaching the shortened muscle to the tarsus.
5. Frontalis Suspension (Frontalis Sling):
   • Indications: Severe ptosis with poor levator function ($<4\text{ mm}$) (severe congenital ptosis, Marcus Gunn jaw-winking, blepharophimosis-ptosis-epicanthus inversus syndrome [BPES], third nerve palsy, or severe myopathies).
   • Mechanism: The eyelid margin is mechanically coupled to the frontalis muscle using a sling material routed in a pentagonal or double-triangle (Fox) configuration, enabling the patient to elevate the eyelid by raising their eyebrow.
   • Materials:
     • Autologous Fascia Lata: A durable sling material in suitable patients. Harvest feasibility depends on age, size and available tissue; alternatives may be preferable in a small child or particular anatomy. Recurrence and infection depend on technique and population, so no material has a universally lowest rate.
     • Silicone Rods: Preferred in infants under age 3, progressive myopathies (CPEO, where adjustability and reversibility prevent corneal exposure), or third nerve palsies.

Entropion & Ectropion: Biomechanics & Management

Entropion (Inward Rotation of the Eyelid Margin)

Inversion of the eyelid margin causes eyelashes and keratinized skin to rub against the cornea, producing trichiasis, punctate keratopathy, corneal ulceration, and scarring.

1. Involutional Entropion (Lower Eyelid):
   • Pathophysiological Triad:
     1. Horizontal Eyelid Laxity: Attenuation and stretching of the medial and lateral canthal tendons.
     2. Disinsertion / Attenuation of Lower Eyelid Retractors: The capsulopalpebral fascia detaches from the inferior tarsal border, allowing the tarsus to rotate inward.
     3. Overriding of Preseptal Orbicularis: The preseptal orbicularis muscle slips superiorly over the pretarsal orbicularis during blinking, tilting the tarsal margin inward. (Secondary factor: enophthalmos from age-related orbital fat atrophy).
   • Surgical Repair: A combined anatomical correction addressing horizontal laxity and retractor disinsertion: Lateral Tarsal Strip (LTS) combined with Lower Eyelid Retractor Reinsertion (Jones procedure) or transverse full-thickness blepharotomy with everting sutures (Wies procedure).
2. Cicatricial Entropion:
   • Shortening and cicatricial contracture of the posterior lamella (tarsoconjunctiva) resulting from trachoma, ocular cicatricial pemphigoid (OCP), Stevens-Johnson syndrome (SJS), chemical burns, or trauma.
   • Surgical Repair: Posterior lamellar lengthening using mucosal autografts (hard palate mucosa, buccal mucosa) or amniotic membrane, combined with anterior lamellar repositioning.

Ectropion (Outward Eversion of the Eyelid Margin)

Eversion of the eyelid margin exposes the palpebral conjunctiva, predisposing to epiphora, chronic conjunctival hyperaemia, keratinization, and exposure keratitis.

1. Involutional Ectropion:
   • Caused by severe horizontal eyelid laxity and canthal tendon stretching. Tarsal plate sags away from the globe.
   • Repair: Lateral Tarsal Strip (LTS) or full-thickness wedge resection (Bick procedure) to tighten the lower eyelid horizontally. If medial punctal ectropion predominates, a medial spindle excision (conjunctival-retractor diamond excision beneath the punctum) is added.
2. Paralytic Ectropion:
   • Caused by facial nerve (CN VII) palsy (Bell's palsy, acoustic neuroma resection, trauma) resulting in denervation flaccidity of the orbicularis oculi muscle.
   • Features: Lagophthalmos (inability to close the eyelid), lower lid sagging, severe exposure keratitis.
   • Management:
     • Conservative / Temporary: Intensive unpreserved lubricants, moisture chambers, botulinum toxin injection into the levator (inducing temporary protective ptosis).
     • Permanent Surgical Rehabilitation: Upper eyelid gold or platinum weight implantation (gravity-assisted eyelid closure), combined with lower eyelid lateral tarsal strip / lateral canthoplasty $\pm$ midface suborbicularis oculi fat (SOOF) lift.
3. Cicatricial Ectropion:
   • Vertical shortage of the anterior lamella (skin scarring, thermal burns, solar elastosis, excessive skin resection during blepharoplasty).
   • Repair: Lengthening the anterior lamella using Z-plasty, transposition flaps, or full-thickness skin grafting (retroauricular or preauricular donor skin).

Malignant Eyelid Neoplasms

An enlarging ulcerated lesion, lash loss, distortion, recurrent chalazion or persistent unilateral blepharoconjunctivitis needs assessment for malignancy. Basal-cell carcinoma is common, especially on the lower lid/medial canthus, and usually invades locally. Squamous carcinoma has metastatic potential; assess regional nodes and risk factors. Sebaceous carcinoma can masquerade as recurrent chalazion or diffuse inflammation and spread within conjunctival epithelium. Melanoma needs appropriate staging and tissue interpretation rather than diagnosis from colour alone.

Document location, margin involvement, conjunctiva, nodes and orbital signs. Arrange biopsy suited to the lesion and suspected diagnosis, with orientation and clinical information for pathology. Conjunctival map biopsies are considered for suspected pagetoid spread, particularly diffuse sebaceous disease; they are not mandatory for every isolated lesion. Modern immunohistochemistry, including adipophilin on paraffin material, can support sebaceous differentiation; fresh-tissue Oil Red O is not the only diagnostic route.

Treatment uses histological margin control and tumour-specific risk assessment. A single fixed millimetre margin does not suit every histology, size and location. Mohs or other controlled excision may be appropriate; advanced disease needs an oncology team. Plan reconstruction after clearance, retaining lid closure, blink, corneal protection and lacrimal function. Large defects require restoration of anterior and posterior lamellae with at least one vascularised component; two unsupported free grafts have poor survival. Discuss recurrence surveillance and tissue results.

Infectious and benign lid lesions

An external hordeolum is an acute tender infection near a lash follicle; an internal hordeolum involves a meibomian gland. A chalazion is a lipogranulomatous reaction to retained gland secretions and is usually a less tender persistent nodule. Warm compresses and lid care may suffice initially. Antibiotics treat associated bacterial infection/cellulitis rather than dissolve every sterile chalazion. Persistent symptomatic lesions can need incision/curettage or selected intralesional treatment after assessment. Recurrent, atypical or same-site lesions, lash loss, margin distortion and unilateral chronic conjunctivitis require consideration of biopsy for sebaceous or other malignancy.

Molluscum contagiosum produces umbilicated lid papules; a small margin lesion can sustain follicular conjunctivitis. Inspect the complete lid margin before calling unilateral follicles an idiopathic conjunctivitis. Treat or remove the responsible lesion with appropriate ocular protection, and consider immunosuppression when lesions are extensive or atypical. Herpetic vesicles need corneal examination and appropriate antiviral assessment; indiscriminate topical steroid use can aggravate an unrecognised infection.

Benign papillomas, inclusion/retention cysts and xanthelasma can be differentiated by surface, contents, distribution and history, but an appearance-based label does not replace histology when the lesion grows, ulcerates or destroys architecture. Xanthelasma warrants assessment of relevant metabolic risks without implying that every patient has hyperlipidaemia. Document size and a photograph when observing; send excised suspicious tissue for histology and orient margins where relevant.

In a swollen lid, assess acuity, pupils, motility, proptosis and systemic illness. A local gland nodule and orbital cellulitis have different urgency. Fever, painful restricted movement or optic-nerve dysfunction require an orbital pathway, not merely another course of chalazion treatment.