Paralytic ectropion treatment with lateral periosteal flap canthoplasty and introduction of the ectropion severity score

Abstract

Background: Paralytic ectropion patients suffer from impairment of function and appearance of the lower eyelid and are at high risk of developing an exposure keratitis. A canthoplasty procedure can reduce the horizontal eyelid laxity and elevate the lower eyelid. We used a periosteal flap from the outer orbit to create a new canthal ligament. This study investigates the long-term outcomes of this technique.

Methods: Cross-sectional outcome study in which 30 cases of paralytic ectropion are treated with a lateral periosteal flap canthoplasty after adequate eyelid shortening. At the desired canthal height, a periosteal flap from the outer temporal orbital rim is mobilized around the rim and sutured in a double-breasted fashion to a tarsal strip. Effect of the operation is measured by comparing preoperative and postoperative photographs for signs of ectropion. For this purpose, a new photograph-based scoring method [the Ectropion Severity Score (ESS)] was developed and evaluated.

Results: The ESS proved to be reliable and sensitive to the presence of ectropion. Significant improvement of the ectropion sequelae was measured after a mean follow-up period of 2 years. In 3 cases (13%), a revision procedure was necessary because of relapse of lower eyelid sagging after a mean time of 1.9 years. In these cases, the periosteal flap could be reused.

Conclusions: The ESS is a useful instrument to score the severity of paralytic ectropion. The periosteal flap canthoplasty is an effective procedure, with durable results in paralytic ectropion patients. The same periosteal flap can be used in a revision procedure.

Fig.1.

Schematic representation showing the technique for the lateral periosteal flap canthoplasty. A, Frontal view. A 2-mm skin flap is left on the lateral canthal region. Partially denuded tarsus after cantholysis and horizontal shortening. Periosteal flap from the outer side of the lateral orbita is mobilized around the orbital rim. The periosteal flap and the lateral end of the denuded tarsus are sutured in a double-breasted fashion. B, Transversal view. The periosteal flap is mobilized around the orbital rim to the level of Whitnall’s tubercle.

Fig. 2.

Intraoperative photographs showing the technique for the lateral periosteal flap canthoplasty. A, Planning of a subciliary incision extended laterally in Borges’s lines. B, Planning of the periosteal flap on the outer lateral orbital rim. C, Elevation of the periosteal flap around the orbital rim to a point 3 mm into the orbit. D, Mild tensioning of the lower eyelid against the periosteal flap to determine the redundant length. E, The periosteal flap and the lateral end of the denuded tarsus are sutured in a double-breasted fashion. F, Direct postoperative result.

Fig. 3.

A, Preoperative photograph of a patient suffering facial paralysis after resection of a large squamous cell carcinoma. A gold weight is already implanted in the upper eyelid and a static correction of the mouth is performed with fascia lata strips. An ESS of 6 was scored (lateral apposition, medial apposition, scleral show, excess tear film, round canthus, and visible punctum). B, Two years later, the lateral periosteal flap canthoplasty was performed. A good apposition of the lower eyelid was obtained (ESS, 0). C, Close-up view of A. D, Close-up view of B.

Fig. 4.

A, Preoperative photograph of a patient suffering facial paralysis due to a trauma. An ESS of 8 was scored (maximal score). A gold weight is implanted in the upper eyelid at the same time the lateral periosteal flap canthoplasty was performed. B, One year and three months later, the lateral periosteal flap canthoplasty was performed. A moderate apposition of the lower eyelid was obtained. ESS is 2 because of a visible punctum and a slightly decreased lateral apposition. C, Close-up view of A. D, Close-up view of B.