Lower Eyelid Ectropion
Lower eyelid ectropion is an eyelid malposition in which the lower eyelid margin is turned away from its normal position in contact with the eye. The condition is commonly age-related but can also occur in patients with skin problems e.g. severe eczema, following an injury/burn, or in patients with a facial palsy. The ectropion leads to overflow tearing of the eye (epiphora) and discomfort. This can lead to a vicious cycle of secondary events and needs to be addressed early. Epiphora may lead to irritation and contraction of the skin of the lower eyelid that further worsens the ectropion. In addition, the patient tends to continually wipe the lower eyelid, which in turn results in eyelid stretching that further worsens the lower eyelid ectropion. If the condition is neglected, the conjunctiva on the inside surface of the eyelid becomes exposed and eventually thickened. The patient’s eye may show associated dryness.
Lower Eyelid Entropion
Lower eyelid entropion is an eyelid malposition in which the lower eyelid margin is turned inwards against the globe causing discomfort from contact between the eyelashes and the surface of the eye. An entropion is usually involutional (age-related) and the majority of these are therefore seen in older patients.
The treatment of the ectropion depends on the underlying cause. Most patients undergo surgery to tighten the eyelid at the outer aspect of the eyelids (a lateral tarsal strip procedure). Some patients with shortening of the skin of the eyelids require a skin graft. This can be taken from the upper eyelid, from behind the ear or from the upper inner arm. Some patients develop a lower lid ectropion due to the development of an allergic dermatitis which requires medical treatment with a steroid cream after identifying and removing the causative factor e.g. glaucoma drops/antibiotics drops to which some patients develop an allergy.
In the case of acute spastic entropion, the treatment is directed to the provoking stimulus e.g. in growing eyelashes, blepharitis, dry eye. Although a bandage contact lens or botulinum toxin injections may improve symptoms temporarily, these are rarely justified. The use of lower lid tape can be advised for use in primary care while the patient is waiting to be seen by an ophthalmologist.
These procedures are commonly used to manage this eyelid problem:
- Everting sutures (see photo below)
- Lower lid retractor advancement with lateral tarsal strip
These procedures are usually performed under local anaesthesia with or without mild sedation “twilight anaesthesia”.
Everting sutures are offered to all older patients at the initial consultation and are used exclusively for the following patients:
- Elderly patients with concomitant medical problems for whom surgery is contraindicated
- Patients with a severe bleeding tendency e.g. patients taking warfarin
- Patients unable to co-operate with surgery
- Patients who are unable to lie in a semi-recumbent position e.g. due to breathing difficulties
Everting sutures have been commonly regarded as a temporary form of treatment but many patients achieve a permanent result with the sutures alone. If the entropion recurs they are offered a repeat procedure or a more definitive surgical procedure. The sutures are very quick and simple to insert in a clinic setting and provide instant relief for the patient.For all other patients, a lower eyelid retractor advancement combined with a lateral tarsal strip procedure is performed in the operating theatre. This is a very convenient operation for the patient as no sutures need to be removed. It does, however, leave a sore tender lumpy area at the outer corner of the lower eyelid for a few weeks before this settles.
You will visit the clinic to have a preoperative consultation with your surgeon. This usually lasts 30-45 minutes. You will be asked to complete a healthcare questionnaire, providing information about:
- Your specific concerns
- Your current and past general health
- Any previous eye, eyelid or facial surgery or treatments including refractive surgery or laser eye surgery
- Any past dermatology history e.g. cold sores, eczema, rosacea, skin cancer
- Any history of a dry eye problem
- Any contact lens wear
- Any allergies
- Any medications you take (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements)
- Any history of smoking
- You will have your blood pressure checked by the nurses.
- The nurses are also happy to answer any further questions and to show you the facilities at Face & Eye, including the operating theatre if it is not in use.
- Please answer all questions completely and honestly as they are asked only for your own wellbeing, so that your cosmetic surgery can be planned as carefully as possible. The information is treated confidentially. If you are unsure of the names of any medications, bring them with you.
- You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure as long as these are not medically essential. You might need to check this with your GP. Any anti-inflammatory medicines e.g. Ibuprofen, Nurofen must be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. You will be given a leaflet advising you on what medications, foods, and vitamin supplements to avoid prior to surgery. Your blood pressure should also be under good control if you take medications for hypertension. This is very important.
- Your vision in each eye is measured. Your eyes are examined carefully using a slit lamp (a special ophthalmic microscope). Your tear film status is determined and the back of the eyes (called the retina) are examined as well as the eyelids themselves.
- The rest of your face is then examined. Photographs of your face and eyelids are taken before surgery so that the results of surgery can be compared with the original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.
- All our patients are provided with a detailed report following a consultation. This summarizes the consultation, the recommendations and also the preoperative and postoperative requirements.
What are the possible complications of this surgery?
Complications in the hands of a trained and experienced oculoplastic surgeon are very rare and all precautions are taken to minimize any risks.
Most complications of eyelid surgery are amenable to successful treatment.
Complications from cosmetic eyelid surgery include:
- Blurred or double vision, lasting mainly for a few hours, and sometimes up to a day or two after surgery. This may occur for several reasons – ointment put in the eyes immediately after the operation, local anesthetic used in the operation, swelling of the muscles that control eye movement or swelling of the normally clear covering around the eye (the conjunctiva). Swelling of the conjunctiva (this may mimic a severe hay fever reaction) is referred to as “chemosis” and in some patients can take a few weeks to resolve. If blurring persists for longer than 48 hours, it is important to inform your surgeon.
- Watery eyes – this is quite common for the first few days after the operation due to some irritation of the eyes and a temporary weakness of reflex blinking of the eyelids.
- Injury to the surface of the eyeball (a corneal abrasion) that causes persistent pain. If the pain lasts longer than a few hours after the operation, the surgeon must be informed. Such a problem is extremely rare in the hands of an oculoplastic surgeon. Such a problem is treated with antibiotic ointment. Sometimes a bandage contact lens needs to be used.
- Bleeding. A collection of blood around the eyelids or behind the eyeball, is called a hematoma. A sudden hematoma behind the eyeball can cause loss of eyesight if not managed appropriately and without delay. This is the most serious potential complication of this surgery but is extremely rare. An oculoplastic surgeon is trained to prevent and to manage such a problem. A hematoma usually needs to be drained in the operating theatre.
- Acute glaucoma – this is raised pressure within the eye, which results in pain in the eye, haloes around lights or severe blurring of vision, a headache above the eye, and vomiting. A patient at risk of such a postoperative problem would be identified by an oculoplastic surgeon. An oculoplastic surgeon is trained to diagnose and treat such a problem.
- Infection. An infection following this surgery is extremely rare but it is important to follow postoperative wound care instructions to help to prevent such a problem. These should be given to you in writing for you to take home following surgery.
- Asymmetry. It is impossible for any surgeon to achieve perfect symmetry although an oculoplastic surgeon strives to achieve this. Further surgery may be required to address this.
- Scarring. Most eyelid wounds heal with scars that are barely perceptible although full maturation of the wounds can take some months. Poor scarring can follow infection or wound disruption but this is very rare. Poor scars can be treated with steroid injections or with the application of silicone gels e.g. Kelocote. Rarely, scars need to be revised surgically.
- Eyelid lumps. Lumps can very occasionally occur as a reaction to sutures used to close the wounds. These usually resolve with time but occasionally steroid injections are required. Rarely, lumpiness can occur in fat that is repositioned over the inferior orbital margin. This usually responds to postoperative massage.
- Reoperation. Further surgery within the first few weeks to address any asymmetries may be required. This should be borne in mind. There are a number of factors beyond a surgeon’s control, which can have an impact on postoperative progress e.g. postoperative swelling affecting one side more than the other, which in turn can necessitate re-intervention.
What happens after this surgery?
After this surgery, the eyes are initially covered with pressure dressings for approximately half an hour to reduce postoperative swelling and the wounds are treated with antibiotic ointment. The dressings are then removed and replaced with cool packs. For some patients the dressings may be left in place for a longer period of time e.g. if a skin graft has been required to manage a lower lid ectropion which has been caused by tightness of the skin. Activity is restricted for 2 weeks to prevent bleeding.
You will be asked to clean the eyelids very gently using clean cotton wool and Normasol (sterile saline) or cooled boiled water and repeat the application of antibiotic ointment (usually Chloramphenicol or Soframycin) to the wounds 3 times a day for 2 weeks. The sutures used for this surgery are usually dissolvable but are often removed in clinic after 2 weeks.
It is important to devote a lot of time to your aftercare for the first 2 weeks and some patients find this somewhat labour intensive.
A realistic period of recovery must be expected. Postoperative bruising usually takes at least 2-3 weeks to subside completely. Swelling takes much longer. Most of the swelling disappears after 3-4 weeks but this can vary considerably from patient to patient as does the extent of the swelling. The final result is not seen for at least 3-4 months. This should be taken into consideration when scheduling the operation. You should arrange this surgery after holiday periods or important professional or social events and not before so that you are available for postoperative review and just in case any surgical adjustments are required.
Contact lenses should not be worn for a few weeks following this type of surgery.
Conscious sedation, also known as “twilight anaesthesia”, is a type of anaesthesia which is preferred by many patients for most of our surgical procedures. It is a very comfortable and gentle type of anaesthesia which is safer and far less invasive than general anaesthesia but at the same time highly effective. It is also of advantage for very nervous or anxious patients undergoing quite minor surgical procedures. Typically patients sleep most of the way through their procedure and have no or very little recollection of it at all. You are looked after throughout the procedure by a specialist consultant anaesthetist who has many years of experience of this type of anaesthesia, so that your surgeon can concentrate fully on your operation.
Shortly before moving to the operating room, a small tube (cannula) is placed into a vein in the back of your hand by the consultant anaesthetist and the anaesthetic drug is given through that. This is Propofol, a drug which is also used for general anaesthesia but, for conscious sedation, much lower doses are used. With conscious sedation there is no breathing tube or breathing machine, just a gentle flow of oxygen given through a plastic tube within a soft sponge protector inserted into one of your nostrils. Once the sedation has been commenced a local anaesthetic solution (a mixture of Marcaine and Lignocaine) is injected into the operative area to ensure a painless procedure. Typical side effects of general anaesthesia including a sore throat and nausea are avoided. Waking up takes only a few minutes at the completion of the surgery and is usually free of any “grogginess.” This type of anaesthesia has been used safely and successfully for our surgical procedures for over 20 years.