Eyelid Surgery

Eyelid
Surgery
A Fresh Perspective
on Correcting Common
Conditions
Vladimir Thaller
123
Eyelid Surgery
Vladimir Thaller FRCOphth, FRCS
Vladimir Thaller
Eyelid Surgery
A Fresh Perspective on Correcting
Common Conditions
Vladimir Thaller
Royal Eye Infirmary
Plymouth, UK
ISBN 978-3-031-31526-8 ISBN 978-3-031-31527-5 (eBook)

https://doi.org/10.1007/978-3-031-31527-5
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
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does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or
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The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To my teacher, mentor, and friend, Richard
Collin, in gratitude for showing me the way.
Foreword: Keeping Eyelid Surgery
Simple—A Surgical Manual
Many medical texts attempt to cover all issues and repeat concepts prevalent at
the time of writing—including those ideas that are ill-conceived or, in some cases,
clearly wrong. As thoughts change slowly with time, this leads to most textbooks
becoming out-of-date fairly soon and requiring frequent revision if to remain of
value.
It therefore is particularly refreshing to have a manual of eyelid surgery using
a frank and logical teaching of principles and practice, this arising through the
author’s evolution as a surgeon and based on decades of practical experience. A
lesson is usually best remembered where teaching is presented with a touch of
humour, and in a well-explained fashion: To do the latter requires an enquiring
and objective mind (as mathematician Alfred North Whitehead said, “It requires
a very unusual mind to undertake the analysis of the obvious”), and to provide
the former requires a slight sense of mischief and humour. For the 40 years we
have been acquainted, Ok Thaller has certainly shown both the analytical and a
humorous mindset!
The author is not afraid to discuss experience learnt through both good and
bad results, and many of his ideas were ahead of their time, challenging the com-
mon attitude of “that is the way it has always been done”? Einstein said, “the
only source of knowledge is experience”, and this condensation of the author’s
life experience provides an invaluable—and enjoyable—resource for both trainee
and more experienced surgeons. We must congratulate and thank Ok Thaller for
condensing the broad spectrum of eyelid surgery into a practical and highly read-
able manual, and remember that “a person who never made a mistake never tried
anything new” (Einstein). It is very clear that the author has tried many new things,
very wisely learnt from any such misjudgements, and has had the courage to pass
on this knowledge to the next generation. We “all build on the shoulders of giants”,
and this book is not only a delight to read, but also a particularly thoughtful foun-
dation on which we can continue to build a better future for those trusting in our
care.
January 2023 Geoffrey E. Rose, D.Sc., FRCOphth
vii
Preface
Why?
Experience is simply the name we give our mistakes.

—Oscar Wilde
I admit to not being an avid reader of textbooks, probably because I still read in
the way I was taught to as a child. In mitigation, it may be that most textbooks
were not written to be read, merely consulted. Either way, what follows is a basic
surgical manual, not a textbook!
Similarly, I have yet to outgrow the annoying childhood habit of always asking
“Why?”. Often, I am surprised by the lack of clear answers. Now, at the end of a
career’s worth of surgical “experience”, I feel honour bound to attempt at least to
pass on my few, hard gained, answers. Although we are each destined make our
own mistakes, all must start from somewhere. I consider this manual to be as good
a starting point as any. May it set you on the right path.
Plymouth, UK Vladimir Thaller, FRCS, FRCOphth

[email protected]
Acknowledgements I thank my many teachers for all they have taught me and for their kind
forbearance at my endless questions. I include patients among my teachers. I have learnt much from
them. The National Health service, for all its imperfections, is a wonderful altruistic organisation
whose dedicated staff have supported me throughout my career and made me look forward to each
working day. And last but not least I thank my dear wife Linda for her unwavering support and
understanding.
ix
Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Congratulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.3 The Target (Fig. 1.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.4 “Common Things are Common…Save Common Sense” . . . . . . 2
1.5 Less is More . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.6 The Truth, NOT the Whole Truth, and Nothing
But the Truth! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.7 A Matter of Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.8 Heresy, Not Hearsay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.9 Concept or Cookbook? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.10 10,000 hour Expert? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.11 Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.12 The Good Outcomes Secret . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.13 Style and Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.14 Exceptions Prove the Rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.15 Warning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2 The Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.2 Do Least Harm! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.3 Surgery is Directed Scarring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.4 The Healing Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.4.1 Primary Intention Healing . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.4.2 Secondary Intention Healing . . . . . . . . . . . . . . . . . . . . . . . 8
2.5 Stages of Wound Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.6 Thermal Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.7 Tension, Expansion, Migration, and Contraction . . . . . . . . . . . . . . 9
2.7.1 Tissue Expansion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.7.2 Suture Migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.7.3 Contraction (Hydrocortisone Ointment
and Massage) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.8 The Dog Ear Dilemma (Waste Not, Want Not!) (Fig. 2.3) . . . . 12
2.9 Active v Passive Surgical Mechanisms (Fig. 2.5) . . . . . . . . . . . . . 14
xi
xii Contents
2.10 The Kit (Instruments) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

2.11 Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.12 Haemostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.12.1 Vasoconstriction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.12.2 Positioning (Fig. 2.6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.12.3 Diathermy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.12.4 Cut Uphill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.13 Plication v Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.14 Post-operative Antibiotics and Padding . . . . . . . . . . . . . . . . . . . . . . . 17
2.14.1 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.15 Fail-Safe Redundancy (Fig. 2.7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.16 Take Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3 Sutures and Suturing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.2 Suture Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3.2.1 Absorbable v Non-absorbable . . . . . . . . . . . . . . . . . . . . . . 22
3.2.2 Suture Tension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3.2.3 Suture Gauge (Table 3.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3.2.4 Knotting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.2.5 Monofilament v Braided . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.2.6 Suture Needles (Fig. 3.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.2.7 Needle Shape (Fig. 3.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
3.3 Suturing Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.3.1 Interrupted v Continuous (Fig. 3.3) . . . . . . . . . . . . . . . . . 25
3.3.2 Suture Bite Spacing (Fig. 3.4) . . . . . . . . . . . . . . . . . . . . . . 26
3.3.3 Suture Spaghetti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.3.4 Simple v Mattress (Fig. 3.5) . . . . . . . . . . . . . . . . . . . . . . . . 27
3.3.5 Horizontal v Vertical Mattress (Fig. 3.7) . . . . . . . . . . . . 28
3.3.6 The Humble Horizontal Mattress (Fig. 3.8) . . . . . . . . . 30
3.3.7 The ‘Magic Suture’ (Fig. 3.9) . . . . . . . . . . . . . . . . . . . . . . 30
3.4 The Cotton Bud: An Aid to Suturing . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.4.1 Steps (Fig. 3.11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4 Pertinent Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.2 The Lid Skeleton (Fig. 4.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.2.1 Canthal Tendons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.2.2 Orbital Septum (7 Veils) . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4.3 Lid Layers (or Lamellae) (Fig. 4.2) . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4.3.1 Anterior Lamella (Fig. 4.2a) . . . . . . . . . . . . . . . . . . . . . . . . 36
4.3.2 Posterior Lamella (Fig. 4.2b) . . . . . . . . . . . . . . . . . . . . . . . 37
4.3.3 In-Between . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Contents xiii
4.4 Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
4.4.1 Skin Tension Lines (Langer’s Lines) (Fig. 4.3) . . . . . . 38
4.5 Don’t Get Lost (Surgical Landmarks) (Fig. 4.4) . . . . . . . . . . . . . . 39
4.6 Tarsal Plate (Fig. 4.6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.7 The Meibomian Orifice Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.8 The Grey Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.9 Pre-aponeurotic Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.10 Lacrimal Ductules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.11 Blood Supply (Fig. 4.7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.12 Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4.13 The Rest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
5 Fundamental Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.1 Overview (Fig. 5.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.2 Lid Margin Repair (Fig. 5.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
5.2.1 Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.2.2 Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
5.2.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
5.2.4 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.3 Lateral Canthal Repair (Fig. 5.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.3.1 Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.3.2 Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.3.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.4 The Magic Suture (Fig. 5.4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
5.4.1 Principle and Considerations . . . . . . . . . . . . . . . . . . . . . . . 56
5.4.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
5.4.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
5.4.4 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
5.5 Tarsal Traction Suture (Fig. 5.6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
5.5.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5.5.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5.5.4 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
5.6 Emergency Cantholysis (Fig. 5.7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
5.6.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.6.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.6.4 Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
6 Eyelid Malposition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
6.1 Overview (Fig. 6.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
6.2 Lid Stability (Fig. 6.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
6.2.1 Tarsal Plate Width . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
6.2.2 Orbicularis Tone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
xiv Contents
6.2.3 Lid/Globe Apposition and Volume Deflation . . . . . . . . 64

6.2.4 Gravity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
6.2.5 Retractor Tethering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
6.3 The Palpebral Aperture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
6.4 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
6.5 Significance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
6.6 Causation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
6.7 Don’t Strip! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
7 Ingrowing Eyelashes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
7.1 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
7.2 Treatment Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
7.2.1 Epilation (Fig. 7.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
7.2.2 Electrolysis to the Lash Root . . . . . . . . . . . . . . . . . . . . . . . 70
7.2.3 Localized Full Thickness Lid Margin Resection . . . . . 70
7.2.4 Localized ‘en bloc’ Lash Resection . . . . . . . . . . . . . . . . . 71
7.2.5 Lash Cryotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
7.2.6 Anterior Lamellar Repositioning . . . . . . . . . . . . . . . . . . . . 71
8 Entropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
8.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
8.2 Types of Entropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
8.2.1 Congenital Entropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
8.2.2 Involutional (Age Related) Entropion . . . . . . . . . . . . . . . 74
8.2.3 Cicatricial Entropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
8.3 Entropion Assessment/Examination . . . . . . . . . . . . . . . . . . . . . . . . . . 76
8.3.1 Lid Tone and Laxity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
8.3.2 Medial Canthal Tendon and Lateral Canthal
Tendon Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
8.3.3 Conjunctival Scarring/Symblepharon . . . . . . . . . . . . . . . 76
8.3.4 Orbicularis Over-Riding . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
8.4 Temporary Lower Lid Involutional Entropion
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
8.4.1 Taping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
8.4.2 Botulinum Toxin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
8.4.3 Everting (Quickert) Sutures . . . . . . . . . . . . . . . . . . . . . . . . 78
8.5 ‘Permanent’ Surgical Correction of Involutional
Entropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
8.5.1 Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
8.5.2 The Lid Shortening Rule . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
8.6 Lateral Lid Margin Resection and Modified Bick Repair
(Fig. 8.7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
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8.6.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

8.6.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
8.6.4 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
8.7 Lower Lid Retractor Plication (Fig. 8.8) . . . . . . . . . . . . . . . . . . . . . . 84
8.7.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
8.7.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
8.8 Posterior Medial Canthal Thermoplasty . . . . . . . . . . . . . . . . . . . . . . 87
8.8.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
8.8.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
8.8.4 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
8.9 ‘Permanent’ Surgical Correction of Moderate Cicatricial
Entropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
8.9.1 Anterior Lamellar Repositioning . . . . . . . . . . . . . . . . . . . . 89
8.9.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
8.9.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
8.10 Mucosal Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
9 Ectropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
9.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
9.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
9.3 Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
9.3.1 Congenital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
9.3.2 Involutional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
9.3.3 Eye Rubbing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
9.3.4 Cicatricial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
9.3.5 Paralytic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
9.4 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
9.4.1 Relative Lid/Globe Laxity (Invariably Present) . . . . . . 97
9.4.2 Medial Canthal Tendon and Lateral Canthal
Tendon Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
9.4.3 Anterior Lamellar Insufficiency . . . . . . . . . . . . . . . . . . . . . 98
9.4.4 Orbicularis Tone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
9.5 Temporary Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
9.6 Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
9.7 Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
9.7.1 Lid Margin Wedge Resection and Bick Repair . . . . . . 100
9.7.2 Medial Lower Lid Retractor Plication (Fig. 9.6) . . . . . 104
9.7.3 Central Lower Lid Retractor Posterior Plication
(Fig. 9.7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
9.7.4 Free Skin Graft (Fig. 9.8) . . . . . . . . . . . . . . . . . . . . . . . . . . 108
9.7.5 Upper to Lower Lid Skin Pedicle Flap (Fig. 9.9) . . . . 111
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9.7.6 Permanent (Overlap) Lateral Tarsorrhaphy

(Fig. 9.10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
9.7.7 Medial Canthoplasty (Fig. 9.11) . . . . . . . . . . . . . . . . . . . . 115
10 Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
10.1 Overview (Fig. 10.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
10.2 Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
10.2.1 Vertical Palpebral Aperture (PA) . . . . . . . . . . . . . . . . . . . . 120
10.2.2 Levator Function (LF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
10.2.3 Skin Crease (SC) and Skin Fold (SF) (Fig. 10.5) . . . . 122
10.2.4 ‘Hang-Up’ in Downgaze (Fig. 10.6) . . . . . . . . . . . . . . . . 124
10.3 Types of Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
10.3.1 Congenital Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
10.3.2 Acquired Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
10.4 Choice of Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
10.5 Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
10.5.1 White Line Advancement (Anterior Approach)
Fig. 10.8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
10.5.2 Conversion to an Anterior Levator Aponeurosis
Reinsertion/Resection Fig. 10.9 . . . . . . . . . . . . . . . . . . . . . 131
10.5.3 Levator Resection Fig. 10.10 . . . . . . . . . . . . . . . . . . . . . . . 133
10.5.4 Addition of a Skin and Muscle Blepharoplasty
Fig. 10.11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
10.5.5 Müller’s Muscle Resection Fig. 10.12 . . . . . . . . . . . . . . 137
10.5.6 Frontalis Suspension (Fox’s Pentagon)
Fig. 10.13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
10.6 General Observations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
10.6.1 Lower Lid Traction Suture Fig. 10.14 (See
Chap. 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
10.6.2 ‘On Table’ Lid Height . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
10.6.3 Post-operative Adjustment—Early Suture
Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
10.6.4 Hering’s See-Saw (Fig. 10.15) . . . . . . . . . . . . . . . . . . . . . . 144
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
11 Dermatochalasis and Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
11.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
11.2 Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
11.3 Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
11.4 Upper Lid Skin and Muscle Blepharoplasty (Fig. 11.1) . . . . . . . 148
11.4.1 Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
11.4.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
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11.5 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148

11.6 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
12 Lid Lumps and Bumps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
12.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
12.2 Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
12.2.1 Meibomian Cyst Incision and Curettage (I & C) . . . . 154
12.3 Tumour Excision (Fig. 12.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
12.3.1 First is Best . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
12.3.2 Clear Cutaneous Margins . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
12.3.3 Stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
12.3.4 Deep Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
12.3.5 Waste Not, Want Not . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
12.3.6 Beware the Canthi (Fig. 12.3) . . . . . . . . . . . . . . . . . . . . . . 158
12.3.7 Biopsy: Excision V Incision . . . . . . . . . . . . . . . . . . . . . . . . 158
12.3.8 Histology First! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
12.3.9 One Stop Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
12.4 Full Thickness Lid Margin Tumour Resection (Fig. 12.4) . . . . . 159
12.4.1 Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
12.4.2 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
12.5 Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
13 Eye Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
13.1 Overview (Fig. 13.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
13.2 Occlusive Dressing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
13.3 Manual Blink (Fig. 13.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
13.4 ‘Cling Film’ Occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
13.5 Closing the Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
13.5.1 Not the ‘Grey Line’! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
13.5.2 Avoid Toxin Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
13.5.3 The ‘Tarsal Traction Suture’ (see Chap. 5) . . . . . . . . . . 164
13.5.4 Non-tarsal Traction (Fig. 13.5) . . . . . . . . . . . . . . . . . . . . . 166
13.5.5 Temporary Central Suture Tarsorrhaphy
(Fig. 13.6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
13.5.6 Temporary Lateral Suture Tarsorrhaphy
(Fig. 13.6e) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
13.5.7 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
13.6 Permanent Surgical Tarsorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
13.6.1 Permanent (Overlap) Lateral Tarsorrhaphy
(Fig. 13.7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
13.6.2 Permanent Medial Canthoplasty (Fig. 13.8) . . . . . . . . . 172
13.6.3 Lower Lid Lifting (Fig. 13.9) . . . . . . . . . . . . . . . . . . . . . . . 173
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14 Lid Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

14.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
14.2 The Reconstruction Ladder (Fig. 14.2) . . . . . . . . . . . . . . . . . . . . . . . 176
14.3 Upper Lid Essential, Lower Lid Optional! . . . . . . . . . . . . . . . . . . . . 177
14.4 Proof of Cure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
14.5 Eyelid Tension: Normal and Necessary . . . . . . . . . . . . . . . . . . . . . . . 178
14.6 Don’t Undermine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
14.7 Direct Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
14.7.1 Tissue Expansion (Fig. 14.6) . . . . . . . . . . . . . . . . . . . . . . . 180
14.7.2 No Cantholysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
14.7.3 Closure Scar Lengthening . . . . . . . . . . . . . . . . . . . . . . . . . . 182
14.8 Direct Closure of Lid Margin Defect (Fig. 14.8) . . . . . . . . . . . . . . 183
14.8.1 Principles and Considerations . . . . . . . . . . . . . . . . . . . . . . 183
14.8.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
14.8.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
14.9 The Trans Incisional Tarsal Traction Suture (Fig. 14.9) . . . . . . . 187
14.9.2 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
14.10 Direct Closure of a Skin Defect (Fig. 14.10) . . . . . . . . . . . . . . . . . 188
14.10.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
14.10.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
14.11 Directed Laissez-Faire (Incomplete Direct Closure) . . . . . . . . . . . 190
14.11.2 Directed Laissez-Faire of a Lid Margin Defect
(Fig. 14.11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
14.11.3 Directed Laissez-Faire of Skin Defect
(Fig. 14.12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
14.12 Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
14.12.1 Paper Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
14.12.2 Upper to Lower Lid Skin Flap (Fig. 14.16) . . . . . . . . . 196
14.12.3 Cheek Pedicle Flap (Fig. 14.17) . . . . . . . . . . . . . . . . . . . . 198
14.12.4 Mustardé Lower Lid Switch Flap . . . . . . . . . . . . . . . . . . . 199
14.13 Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
14.13.1 Skin Graft Donor Sites (Fig. 14.20) . . . . . . . . . . . . . . . . . 204
14.13.2 Alternative Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
14.13.3 Skin Graft Harvesting (Fig. 14.21) . . . . . . . . . . . . . . . . . . 205
14.13.4 Split Skin Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
14.13.5 Mucous Membrane Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . 207
14.14 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Contents xix
15 Revision Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

15.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
15.2 Avoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
15.3 Healing Shrinks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
15.3.1 Pout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
15.3.2 Planes Contract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
15.4 Faces Are Mobile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
15.5 Delay (Fig. 15.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
15.6 Analyse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
15.7 Lengthen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
15.8 Transverse Release-Plasty (Fig. 15.5) . . . . . . . . . . . . . . . . . . . . . . . . 213
15.8.1 Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
15.8.2 Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
15.8.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
15.8.4 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
16 Watering Eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
16.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
16.2 Causes (Fig. 16.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
16.3 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
16.3.1 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
16.3.2 Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
16.3.3 Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
16.3.4 Lacrimal Syringing (Fig. 16.2) . . . . . . . . . . . . . . . . . . . . . 220
16.3.5 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
16.4 Treatment Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
16.4.1 Lacrimal Mucocoele Expression (Fig. 16.3) . . . . . . . . . 222
16.4.2 Lacrimal Probing (± Silicone Intubation) . . . . . . . . . . . 223
16.4.3 Punctal Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
16.4.4 Punctal Inversion Surgery (Fig. 16.8) . . . . . . . . . . . . . . . 228
16.4.5 Lid Margin Tightening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
16.4.6 Lacrimal Drainage Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 230
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
17 Eye Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
17.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
17.2 Specific Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
17.3 Evisceration V Enucleation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
17.4 Evisceration (Fig. 17.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
17.4.1 Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
17.4.2 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
17.5 Enucleation (Fig. 17.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
17.5.1 Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
17.5.2 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
xx Contents
17.5.3 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

18 Socket Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
18.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
18.2 Socket Lining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
18.3 Orbital Implantation (Fig. 18.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
18.3.1 Implant Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
18.3.2 Implant Material and Shape . . . . . . . . . . . . . . . . . . . . . . . . 244
18.3.3 Implantation Following Evisceration (Fig. 18.4) . . . . . 244
18.3.4 Implantation Following Enucleation (Fig. 18.5) . . . . . 246
18.4 Orbital Implant Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
18.4.1 Conjunctival Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
18.4.2 Early or Late Wound Dehiscence . . . . . . . . . . . . . . . . . . . 249
18.4.3 Implant Migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
18.4.4 Late Implant Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
18.4.5 Post Enucleation Socket Syndrome (Fig. 18.7) . . . . . . 251
18.4.6 Lower Lid Laxity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
18.4.7 Upper Lid Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
19 Thyroid Eye Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
19.1 Overview (Fig. 19.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
19.2 Wet or Dry? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
19.3 Immunosuppression of Active TED . . . . . . . . . . . . . . . . . . . . . . . . . . 255
19.3.1 Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
19.4 Orbital Triamcinolone Injection [2] . . . . . . . . . . . . . . . . . . . . . . . . . . 256
19.4.1 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
19.4.2 Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
19.4.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
19.4.4 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
19.5 Surgical Management of Inactive (Dry) Thyroid Eye
Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
19.5.1 Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
19.5.2 Inferior Rectus Recession with Lid Retractor
Recession (Fig. 19.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
19.5.3 Eyelid Recession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
19.6 Upper Lid Blepharotomy [3] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
19.6.1 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
19.6.2 Steps (Fig. 19.7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
19.6.3 Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
19.7 No Spacers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
19.8 Lower Lid Retractor Recession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
19.8.1 Considerations and Principle . . . . . . . . . . . . . . . . . . . . . . . 267
19.8.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Contents xxi
19.8.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268

19.8.4 Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
20 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Introduction
1
1.1 Overview
• Is this book for you?
• This book’s philosophy and style.
1.2 Congratulations
Congratulations on choosing the eyelids as your surgical field! Being functional as

well as aesthetic units, you should find them an absorbing challenge. In terms of
healing, there is no better or more forgiving part of the body, unlike for example
an elderly shin. Consequently, your repairs and grafts should invariably heal well.
However, the outcomes of your endeavours will be very visible (‘in your face’
as they say), so you’d better get them right the first time! I hope that the tips
contained in the following pages help you in this respect.
1.3 The Target (Fig. 1.1)
This book is a practical manual for anyone performing eyelid surgery. It is partic-
ularly aimed at those in training, including non-oculoplastic surgeons who venture
into this field. Experienced colleagues may find some of the content unconven-
tional (to put it kindly). Please indulge me by not dismissing my novel ideas
and assertions out of hand. Instead, give them your critical consideration, perhaps
even try them out? You might be pleasantly surprised. Dear reader, if you have an
interest in eyelid surgery and an open mind, please read on!
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 1

V. Thaller, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_1
2 1 Introduction
Fig. 1.1 Target audience
1.4 “Common Things are Common…Save Common Sense”
Lid surgery, like many other things, follows the 80–20 rule (known as the Pareto
principle). Eighty percent of your surgery is for the mere 20% of conditions that
are common. This book aims to help you get that 80% of common operations right
the first time by promoting simple, safe, and above all, effective techniques. It is
not comprehensive making no attempt to cover less usual conditions or critique
the myriad of alternative operations. Established texts already do this admirably.
However, in my humble opinion some popular operations fail the common-
sense test, so here I only describe techniques which make sense to me.
1.5 Less is More
You will discover that I favour a minimalist approach to surgery to do “the least
harm”. As an enthusiastic novice I had a naïve faith in the benefits of surgery.
Experience tempered that enthusiasm with the realization that surgery is always a
trade-off, and the risk of complications is ever present.
1.6 The Truth, NOT the Whole Truth, and Nothing

But the Truth!
This book builds on sound foundations handed down by generations of innovative

surgeons. Everything I have included is based on my personal experience and I
currently believe it to be true. But learning continues and beliefs change. So, ‘my
current truth’ cannot be the whole truth and will, in time, be superseded by new
knowledge. I challenge you to add to that knowledge base, as I have tried to do.
1.9 Concept or Cookbook 3
1.7 A Matter of Principle
Look for the principles behind each operation. Your chosen procedure should
address all the factors you believe to be causing a particular problem. Analyse
your current and future surgical repertoire on this basis, to help you discern the
best of several options. Doing so may even stimulate you to develop your own
improvements.
1.8 Heresy, Not Hearsay
Some of what I describe is unorthodox and does not appear in or even contradicts
existing textbooks. I challenge some popular practices e.g., use of the lateral tarsal
strip procedure, or employing complex reconstructions when direct closure would
suffice. Some regard this as heresy. The following heresies are currently unique to
this manual:
• Meibomian orifice line superiority over the grey line

• Suture tarsorrhaphy as a replacement for temporary surgical tarsorrhaphy
• Maximizing the use of direct closure, directed laissez-faire, and tissue expansion
in eyelid reconstruction
• The magic suture subcutaneous closure
• Medial canthal thermoplasty
• Control of active thyroid eye disease with depot orbital steroid injections
• Full orbital volume replacement of after eye removal
• Modified Bick lid margin resection in preference to the lateral tarsal strip for
lid tightening
• Transverse release-plasty of radial traction bands.
1.9 Concept or Cookbook?
Individual learning styles vary. Some of us will always practise ‘painting by num-
bers’ surgery. The step-by-step instructions in this manual should cater to your
taste. Like a recipe, these ‘cook-book’ instructions generally give good outcomes.
They are the best way for a novice to learn.
Those of an artistic or inquisitive nature will gain more from understanding the
principles outlined and adapt the procedures described to suit specific situations.
4 1 Introduction
1.10 10,000 hour Expert?
No book can take the place of ‘hands on’, supervised, surgical experience. How-
ever, the saying “practice makes perfect” only holds true if you practise the right
things. This manual guides you in that ‘right direction’.
1.11 Challenge
In this book I sometimes question accepted treatments. I challenge you to do the

same and analyse alternative operations critically, particularly when you try new
techniques. You can only do this by auditing your own outcomes.
1.12 The Good Outcomes Secret
Good outcomes are more likely when you operate on patients who by the nature of
their condition should do well. For example, a ptosis patient with normal levator
function should do better than one with poor levator function. Case selection may
be a luxury for a veteran but is essential for the less experienced surgeon who
needs positive outcomes in order to acquire the confidence needed to progress.
This book aims to build that confidence by promoting simple and safe procedures
for appropriately selected patients.
1.13 Style and Structure
I have chosen a didactic, first-person style for this manual. Most chapters loosely
follow the structure below:
• Overview
• Introduction
• Principle and considerations
• Case selection (indications)
• Steps (technique, method)
• Notes (variations / discussion / surgical pitfalls / what can go wrong /
complications)
• Take home message
You will notice much repetition for which I make no apologies. Firstly, should
you delve in mid-way I would not want you to miss important points mentioned
previously. Secondly, the repetition helps to reinforce the message.
I have included few references because references are not the authority behind
this volume. My personal experience is. The selected references which are included
are there to support some of my more contentious assertions.
1.15 Warning 5
1.14 Exceptions Prove the Rule
Occasionally I have broken my own rule by including uncommon procedures

because they are so important, e.g., Emergency lateral canthotomy and upper lid
reconstruction using the Mustardé lid switch flap.
1.15 Warning
As a single author work this book is necessarily biased. It is neither comprehensive,

nor a typical surgical textbook. Beware, you may find some of the unorthodox
concepts and techniques which I promote useful and possibly infectious. My not
so hidden agenda is to help you to improve your surgical outcomes.
The Basics
2
2.1 Overview
• Surgery = directed scarring

• Primary v secondary intention healing
• Tension, expansion, migration and contraction
• Active v passive operations
• Surgical instruments
• Anaesthesia
• Haemostasis
• Plication v resection
2.2 Do Least Harm!
The famous exhortation to physicians to “First do no harm”, sounds laudable but is

impossible for a surgeon. Fundamentally, all surgery involves judicious wounding,
albeit with altruistic intent. So, while we cannot avoid harm, we should strive to
limit our wounding to the minimum required to achieve our goal, for example by
not undermining unnecessarily the naturally mobile skin around the eye. Similarly,
do not use a flap or graft to repair a lid defect that you can close directly. Virgin
tissue is always better than an additional avoidable scar.

8 2 The Basics
2.3 Surgery is Directed Scarring
Having first wounded the patient, the benefits of surgery derive from ensuring that
the tissues heal in the desired way. To achieve this, we direct the healing with
sutures. In lid surgery the direction of the suture induced tension is all important.
2.4 The Healing Response
Millennia of evolution have equipped us with amazing powers of healing. All

wounds heal in one of two ways, referred to as primary intention and secondary
intention healing.
2.4.1 Primary Intention Healing
Primary intention healing occurs when a wound’s edges are brought together and
held, usually with sutures, long enough for healing to take place. On the face such
wounds heal very quickly and are usually secure within 5 to 7 days. However, it
may take 6–8 weeks for them to attain maximum strength. Align wound edges
‘anatomically’ (layer by layer) to restore the best function and appearance.
2.4.2 Secondary Intention Healing
Evolution has ensured that gaping wounds still heal even when their edges are not
brought together. Such healing takes longer, the length of time depending on the
degree of wound edge separation. The process by which this occurs is known as
healing by secondary intention. It results in larger scars, and therefore we use it
less. But, in many cases, the ultimate result is acceptable. It is a viable alternative
to a graft or flap repair which are both more complex and create additional donor
site scars. Note that secondary intention scars contract radially in all directions
creating forces that a free lid margin is unable to resist. This results in lid margin
retraction.
2.5 Stages of Wound Healing
The stages of wound healing are similar for both types of healing. They are:
1. Haemostasis. Fibrin clot formation occurs within seconds to minutes of wound-

ing and, apart from assisting haemostasis, provides the scaffold for stage 3. As
surgeons we are often impatient and assist haemostasis by coagulating vessels
that continue to bleed with heat in the form of diathermy or cautery. Keep this
to a minimum as burns cause further tissue damage and incite fibrosis. Simply
applying local pressure and waiting a few minutes can be as effective.
2.7 Tension, Expansion, Migration, and Contraction 9
2. Inflammatory. Starting immediately, this phase continues for several days. It

involves leakage of intravascular fluid into the tissues causing swelling, pain,
and redness. The relevance of this phase for the reconstructive surgeon is that
the suture holding strength of inflamed tissues is significantly reduced and they
are more prone to bleed at operation. This makes early delayed wound repair
more difficult. Therefore, if wound repair must be delayed it is better to delay
it by several days until the acute inflammatory phase has subsided.
3. Proliferative. This phase starts at about three days and continues for sev-
eral weeks. Myofibroblast invade the clot and contract to pull the edges
together and make the wound smaller. Type III collagen is laid down. Surface
epithelialisation occurs during this phase.
4. Maturation/remodelling. Scar remodelling begins at 3–4 weeks and continues
for 1–2 years. The type III collagen is converted to type I and the scars soften
and thin. When possible, delay any revision surgery you plan until this phase
is well under way. The surgery will be easier to perform and its outcome more
predictable.
2.6 Thermal Burns
Thermal burns sometimes incite an ongoing scarring (cicatricial) process which

can be difficult to manage. Use diathermy and cautery sparingly and avoid them
on the skin to minimize visible scarring.
2.7 Tension, Expansion, Migration, and Contraction
2.7.1 Tissue Expansion
Tissues subjected to sustained tension relieve that tension by elongating. You see
an example of this in cicatricial ectropion. In this condition the sustained pull of
a tight skin scar causes the lid margin to lengthen and sag so that it no longer sits
against the eye. The expanded lid margin does not return to its original position
after the traction has been surgically released. The phenomenon of tissue expansion
is underused in lid reconstruction.
2.7.2 Suture Migration
We use sutures to pull and hold tissues together during healing. If you tighten a
suture too much it will either exceed its own tensile strength and break or tear
through the tissue. What few people realise is that all sutures migrate. This is a
process that allows a suture to move through tissues until all its tension is lost
(Fig. 2.1). Individual cells in front of a tight suture temporarily divide and then
10 2 The Basics
Fig. 2.1 Suture migration. Sutures dissipate tension by migrating through tissues
reunite behind it. This allows the suture to pass through tissues without visible
inflammation or scarring.
The fact of suture migration calls into question the rationale behind using so
called ‘permanent’ non-absorbable sutures. They may last permanently but their
tension is most definitely transient, lasting only a matter of weeks. Consequently,
the only two reasons for choosing non-absorbable sutures are their relative inert-
ness (e.g., polypropelene v polygalactin) and their higher tensile strength. For
eyelid surgery these differences are rarely relevant.
2.7.3 Contraction (Hydrocortisone Ointment and Massage)
Linear scars shorten, wounds and grafts shrink concentrically. Because the lid mar-
gin is unattached it is unable to resist the pull of scar contraction and becomes
distorted (Fig. 2.2a and b). These are facts of life. Can anything be done to reduce
this? Yes, massage! Tissues under strain grow by ‘tissue expansion’ and ‘biological
creep’. Therefore, repeatedly stressing tissues in a desired direction will lengthen
them in that direction. Firmly massaging a scar can, to some extent, mitigate the
inevitable contraction that is an integral part of the healing process. This contrac-
tion takes place within the first 6–8 weeks of healing. Massage is most helpful
during this critical period. Thereafter tissue remodelling softens the scar naturally.
2.7 Tension, Expansion, Migration, and Contraction 11
Fig. 2.2 Scar contraction. a Linear lid margin scars contract along their length to cause a lid
margin notch. b Tissue defects and scar planes contract radially, distorting the free lid margin
The same phenomenon takes place in scar planes which contract in two dimen-
sions. The interface between a graft or skin flap and its recipient bed is such a
scar plane. Scarring is the reason that the linear dimensions of full thickness skin
grafts and flaps contract by about one third of their linear dimensions. Regular
firm massage reduces this shrinkage. Start massage a week or so after surgery,
to allow time for revascularization to occur. Use oils or ointments to protect the
skin during massage. Whether the type of lubricant plays a role in the process is
unclear. I recommend the sparing application of 1% hydrocortisone ointment as
the lubricant for scar massage. The additional benefit of using a steroid ointment
remains to be proven. However, this weak steroid does not carry significant risk
during prolonged topical use. Hydrocortisone does help to reduce healing asso-
ciated inflammation and can work wonders on the eczematous component of an
ectropion prior to surgery. Very occasionally, massage with hydrocortisone alone
can cure the ectropion, avoiding surgery altogether.
12 2 The Basics
2.8 The Dog Ear Dilemma (Waste Not, Want Not!) (Fig. 2.3)
You create tension across a wound whenever you close it. This tension is maxi-
mal at the widest point of the original wound, progressively decreasing towards its
end(s) (Fig. 2.4a). As you pull the wound edges together the tension at the ends
becomes negative compared to that at the centre. This pushes the slack tissue for-
ward to form so called ‘dog ears’ (Fig. 2.4b). It is customary to extend defects into
ellipses by removing additional skin at the ends, to smooth the tension transition
and minimize dog ears (Fig. 2.4c and d). However, this extends the scar length and
discards healthy skin. This is counterintuitive in periocular reconstruction where
lid skin is in short supply. Fortunately, tissue tension acts to remodel scars and
periocular dog ears usually disappear within a matter of months. So, I recommend
ignoring dog ears and reassuring the patient that they are likely to vanish.
Fig. 2.3 Dog-ears

2.8 The Dog Ear Dilemma (Waste Not, Want Not!) (Fig. 2.3) 13
b
a
c d
Fig. 2.4 Dog-ears. Direct wound closure a results in closure scar tension b that is maximal cen-
trally and reverses at each end to create dog ears of loose tissue. Converting a circular excision into
an ellipse by excising extra tissue c lengthens the scar but smooths the tension transition d reducing
dog ear formation
14 2 The Basics
2.9 Active v Passive Surgical Mechanisms (Fig. 2.5)
The mechanism by which any given operation achieves its purpose is active, pas-
sive, or a combination of both. By active we mean a procedure which reattaches
a muscle or its tendon/aponeurosis or one that modifies the direction (vector) of a
muscle’s action. Every time the muscle contracts it actively exerts its effect e.g., the
levator muscle in ptosis correction. Such operations continue to work indefinitely.
Passive operations on the other hand work by transferring or tightening non
muscle connected tissues and do not involve altering muscle function e.g., lid
margin resection and skin blepharoplasty (although both may involve functionally
insignificant orbicularis muscle resection). Such passive operations fail in time
as the tissues involved stretch under load (exceptions being bone, ligaments, and
tendons).
It is instructive to analyse the mechanism by which an operation achieves its
effect.
Fig. 2.5 Active v passive mechanisms active operations rely on muscle action to achieve their
effects
15
2.10 The Kit (Instruments)
Few surgical instruments are required in a basic lid set. The following list includes
the essentials:
1. Large-toothed tissue holding forceps e.g., Toothed Adsons

2. Fine toothed tissue holding forceps e.g., Jayles forceps (long handled) and St
Martins forceps (short handled)
3. Moorfields (non-toothed) tissue forceps. Used for holding conjunctiva, tenons
fascia and silicone tubes
4. Fine Needle holders e.g., Castroviejo, locking
5. Scissors:
a. Spring scissors e.g., Curved Westcott tenotomy, –for dissection
b. Straight tenotomy, –for cutting tougher tissues
c. Straight pointed, –for suture cutting and blunt dissection
6. Retractors e.g., 3 Desmarres (small, medium, and large)
7. Squint hooks e.g., 2 Squint hooks & 1 Chavasse hook. Can double as retractors
8. Eye protecting plate e.g., Berke-Jaeger lid plate
9. Straight bipolar diathermy forceps
10. Cotton buds (used as a surgical instrument for blunt dissection and counter
pressure during suturing)
11. Artery clips (haemostats). Curved and straight
12. Bulldog (aneurysm) clips for holding pairs of suture ends together prior to
tying.
Additional specialist instruments are required for specific tasks e.g., Wright’s fas-
cia needle for ptosis sling insertion or Thaller tarsal forceps (A6360 Altomed) for
easy lid margin traction suture placement (see Chap. 13).
2.11 Anaesthesia
Most eyelid surgery can be performed under direct infiltration local anaesthesia.
Lacrimal surgery is easier under general anaesthesia for both the patient and the
surgeon.
For lid surgery use local anaesthetic combined with adrenaline. The adrenaline
induced vasoconstriction prolongs the duration of anaesthesia by slowing anaes-
thetic absorption. This doubles the total safe dose that may be administered,
although toxicity is rarely a concern with the small volumes used for lid surgery.
The true reason we use adrenaline is the vasoconstriction it causes which
reduces bleeding and improves surgical field visibility. Unfortunately, adrenaline
containing local anaesthetics sting more on injection as they are acidic.
16 2 The Basics
2.12 Haemostasis
Surgery relies on accurate anatomical orientation and dissection. Visualization is

facilitated by good haemostasis.
2.12.1 Vasoconstriction
Full vasoconstriction, following local adrenaline injection, takes longer to manifest

than one might expect (about 15 min).
2.12.2 Positioning (Fig. 2.6)
Position your patient with their upper body slightly raised on the operating table
to reduce venous congestion and reduce bleeding. The head should be at least as
high as the highest point on the patient’s chest or abdomen. This posture both
aids venous return and reduces abdominal content pressure on the diaphragm, so
improving breathing. This is important as hypercapnia causes vasodilation and
bleeding.
Fig. 2.6 Patient posturing. Ensure the patient’s head is higher than the chest and abdomen to
reduce bleeding
2.14 Post-operative Antibiotics and Padding 17
2.12.3 Diathermy
Use bipolar diathermy for the eyelid (in preference to monopolar) and set it to
the minimum power that works. To control coagulation further adjust the spacing
between the bipolar forceps tips. The closer they are together, the stronger the
current. Remember that once the tips meet, they short-circuit and cease to work.
2.12.4 Cut Uphill
Cutting causes bleeding. Cutting in an ‘uphill’ direction causes the blood to flow
away from the skin markings that you are trying to cut along. This makes life
easier for you and less stressful for your assistant.
2.13 Plication v Resection
‘Plication’ means to tuck or pleat a tissue. The dissection and suturing involved
produce relatively mild wounding and therefore little stimulus for the scarring
(healing) needed to permanently hold the tissues in their new configuration.
Resection means cutting and removing tissue (excision). This creates raw edges
which are more likely to heal together strongly and permanently.
2.14 Post-operative Antibiotics and Padding
The applications of postoperative antibiotic ointment (usually Chloramphenicol)

and a pressure dressing are deeply ingrained in oculoplastic practice. As neither
has a strong evidence base, it is only right that we should now question their
use. Despite this I strongly recommend postoperative pressure dressing following
periocular surgery. The laxity of periocular tissues gives them a great propensity
to swell. I believe that applying pressure to the surgical site reduces haematoma
formation, bruising, and inflammatory phase exudation, leading to less strain on
suture lines and faster rehabilitation. Furthermore, the dressing hides the surgical
site from the patient’s view, reducing their immediate postoperative anxiety, and
providing protection from interfering fingers.
I find it harder to argue in favour of antibiotic ointment over an aseptic lubricant
even though the traditional use of chloramphenicol ointment at the end of surgery
has stood me in good stead over many years. More evidence is needed.
18 2 The Basics
2.14.1 Steps
1. Wash and dry the surgical site to remove any residual antiseptic skin-prep and
blood.
2. Apply a thin coating of tincture of benzoin solution (Friar’s Balsam) to the
surrounding skin and allow it to dry. This improves surgical tape to skin
adherence.
3. Place a non-stick paraffin gauze or non-adherent film such at Tegapore® (3 M
Health Care Ltd) over the surgical site. Fold the latter if it is too large as cutting
it to size impairs its non-stick properties.
4. Apply Chloramphenicol ointment freely over the film.
5. Place one folded eye-pad over the orbital area followed by two more unfolded
pads.
6. Tape this dressing in place with several overlapping strips of 1 (2.5 cm) elastic
adhesive surgical tape to apply pressure. Press on the tape for a few seconds
until it adheres fully. If your patient has a history of allergy to elastic surgical
tape use a hypoallergenic stretchy alternative tape such as Blenderm® (3 M
Health Care Ltd).
2.15 Fail-Safe Redundancy (Fig. 2.7)
Many of the operations described in this manual use more sutures than are strictly
necessary to achieve the desired result, thus adding to the cost and duration of the
procedure. While this goes against my ‘minimalist’ philosophy, the extra sutures
are deliberately redundant to provide a degree of safety. Two sutures in a lateral
canthal repair mitigate against a critical suture failure. Three levator aponeurosis
sutures in ptosis correction are not only a fail-safe but also add a degree of control
over the lid curve. Additional skin suturing after the wound is effectively closed by
the retractor sutures allows for selective early retractor suture removal to resolve
an overcorrection without fear of the wound opening. After all, would you go
skydiving without a reserve parachute?
2.16 Take Home Message 19
Fig. 2.7 Fail-safe redundancy. Back-ups can avert disaster
2.16 Take Home Message

• Surgery is judicious wounding followed by suture directed healing.
• Even permanent sutures have only a temporary effect.
Sutures and Suturing
3
3.1 Overview
• Suture characteristics
• Suturing techniques
• Mattress sutures
• The magic suture.
Although a plethora of surgical sutures exist, you can carry out most eyelid surgery
using only four types of suture:
• 6/0 Polygalactin 910 (Vicryl®) on an 8 mm ½ circle, spatulate cutting needle,

(Ethicon W9756)
• 7/0 Polygalactin 910 (Vicryl®) on an 8 mm 3/8 circle, spatulate cutting needle,
(Ethicon W9561)
• 4/0 Polygalactin 910 (Vicryl®) on a 20 mm ½ circle, spatulate cutting needle,
(Ethicon W9113)
• 4/0 Polypropelene (Prolene®) on a 17 mm ½ circle round-bodied taper-point
needle (Ethicon W8557).
Choose your suture according to the properties you require for the particular task.

22 3 Sutures and Suturing
3.2 Suture Characteristics
3.2.1 Absorbable v Non-absorbable
Much is made of the differences between non-absorbable (permanent) and

absorbable sutures. Modern absorbable sutures usually take about two months
to absorb fully. This is more than enough to allow satisfactory wound healing.
Suture longevity is consequently an irrelevant characteristic except for the fact
that non-absorbable sutures may require removal.
The only significant difference between absorbable and non-absorbable sutures
is the degree of inflammation that they incite. Absorbable sutures stimulate more
inflammation due to enzymatic hydrolysis. In practice, for eyelid surgery, this dif-
ference is rarely important and polygalactin sutures may safely be used in the
skin.
3.2.2 Suture Tension
Sutures must be tied under sufficient tension to hold the tissues together. This
tension dissipates within a matter of weeks as the suture migrates through the tis-
sues. So, although non-absorbable sutures persist as foreign bodies and retain their
strength, after a few weeks they no longer fulfil any useful function. Consequently,
they are no more effective than absorbable sutures.
3.2.3 Suture Gauge (Table 3.1)
Suture gauge refers to the cross-sectional area of the suture which correlates posi-
tively with the suture’s tensile strength. When you need more strength use a thicker
suture. The suture diameter also correlates positively with its tissue holding ability.
A thin suture cheese-wires through tissues more easily.
Table 3.1 Commonly used

USPa Ø mm
suture gauges in relation to
their metric diameters 7–0 0.05
6–0 0.07
4–0 0.15
a USP = United States Pharmacopeia
3.2 Suture Characteristics 23
3.2.4 Knotting
Silk is a naturally occurring polymer and braided silk sutures hold knots extremely
well. A silk surgical knot will hold securely with only two successive single
throws.
Most other sutures are synthetic and prone to knot slippage and unravelling.
Tie synthetic suture knots with a minimum of three single throws. I often add an
‘hysterical 4th’ throw to help me sleep better.
Cut the knot suture ends no shorter than 2 mm to avoid spontaneous unravelling.
3.2.5 Monofilament v Braided
Braided multifilament sutures are more compliant (bendy) and have less memory
(springiness). The cut ends of monofilament sutures are sharp and can cause prick-
ing under the skin. On the other hand, monofilament sutures are less likely to wick
in bacteria and secretions that can cause a suture abscess.
3.2.6 Suture Needles (Fig. 3.1)
Most surgical sutures are now supplied swaged to ‘atraumatic’ needles. In this
context an ‘atraumatic needle’ is defined as an eyeless surgical needle with the
suture attached to a hollow end. The needles however are far from ‘atraumatic’
to the tissues that they penetrate. They are in effect tiny knives with a point and
Fig. 3.1 Suture needle tip profiles. a Triangular cutting, b Spatulate cutting, c Taper point non-
cutting
two or three cutting edges. Hence, they are referred to as cutting needles. They
cut tissue to ease their entry and passage. Cutting needles have either a triangular
or a spatulate (flat) cutting profile. The former, as its name suggests, has three
cutting surfaces, one always cutting inwards or outwards. The spatulate needle
only has only two, cutting to either side. Spatulate needles are the more useful
in oculoplastic surgery as the needle is less likely to inadvertently cut into or out
of the delicate lid tissues. The one non-cutting needle is the ‘round bodied’ or
‘taper point’ needle which has only a sharp point and lacks a cutting edge. Its
sharp point enables tissue penetration, and the tapered body stretches the opening
to allow the needle and suture to pass. Its passage causes minimal tissue damage.
It is the least likely to cut out of delicate tissues. The downside is that taper point
needles require more force to penetrate tissues. This is not an issue in lid surgery.
3.2.7 Needle Shape (Fig. 3.2)
Curved needles are the more useful for lid surgery. They allow shorter tissue bites
to be taken. They come in different radii of curvature and arc of curve (1/4, 3/8 or
½ circle). The 8 mm, tightly curved ½ circle needles are especially suited to tarsal
plate suturing.
1/2 3/8 1/4
a b c
Fig. 3.2 Curved suture needle arc. a Half circle needles are best for eyelid suturing. c Quarter
circle needles are suited to suturing extraocular muscle to sclera
3.3 Suturing Techniques 25
3.3 Suturing Techniques
3.3.1 Interrupted v Continuous (Fig. 3.3)
Interrupted sutures are knotted individually and are independent of each other
(Fig. 3.3a and b). They take slightly longer to place but if one fails this does
not affect the remaining sutures. Individual sutures can be removed selectively
as necessary e.g., for a suture abscess, without weakening the remainder of the
wound.
Continuous sutures only have a knot at either end. Fewer knots make them
faster to insert. However, when one bite cuts out the suture loosens along the
whole length of the suture line. Figure 3.3c, d and e illustrate how to bury the
knots of a continuous suture (only useful for absorbable sutures).
a b
c d
Fig. 3.3 Interrupted versus continuous suturing. a Place the first interrupted suture centrally to
align the closure. b Add sufficient additional sutures to close the defect. c Start a continuous
absorbable suture with a buried knot. d To finish, externalize a deep loop to tie a self-burying knot.
e Only bury absorbable suture knots
3.3.2 Suture Bite Spacing (Fig. 3.4)
As a rule of thumb, sutures (or suture bites for a continuous suture) should be
spaced the same distance apart as span of the suture (Fig. 3.4a). The longer the
suture span the fewer sutures are needed to close the wound (Fig. 3.4b). This is
because their closing force is spread over a wider segment of the wound edge. In
thin skin use a short suture span by placing the bites close to the wound edges
to prevent the edges from rolling (in or out) and space the bites closely to reduce
gaping between them (Fig. 3.4c).
3.3.3 Suture Spaghetti
In a restricted space, such as the eyelid, pre-place all adjacent sutures before tying
any. Doing so allows you see the wound edges clearly before they are obscured
by the first stitch tied. You can evert the edges for clear visualization without fear
of loosening or of pulling out a previously tied suture. Clip each pair of suture
ends together with an aneurysm clip before placing the next one. This simplifies
the subsequent tying of the correct pairs of ends together and avoids a suture
spaghetti.
Fig. 3.4 Suture bite spacing. a x

x
a Inter suture spacing should
equal the suture span X. b In X/2
thick skin place the sutures
further from the edge and
spaced further apart than in
thin skin. The longer the bite,
the more widely the suture’s
force is spread along the b
wound (shaded sector). c Too
long a span encourages in
rolling of thin skin edges
c
3.3.4 Simple v Mattress (Fig. 3.5)
Mattress suturing is designed to evert epithelial surfaces to improve wound adhe-

sion (as epithelial surfaces do not heal together when apposed). It also discourages
inclusion cyst formation (caused when surface epithelium gets buried). An addi-
tional benefit is to cause the wound edges to pout, making allowance for inward
scar contraction during healing (Fig. 3.6a). This discourages unsightly, depressed
scars from forming (Fig. 3.6b).
Fig. 3.5 Simple versus mattress suture. a A simple suture causes flat edge approximation. b A
horizontal mattress suture causes wound edge eversion (pouting)
Fig. 3.6 Scar depression. Because of healing scar contraction, a vertical mattress pouting closure
(a) results in a flat scar (b). Simple suture flat closure (c) results in a depressed scar (d)
3.3.5 Horizontal v Vertical Mattress (Fig. 3.7)
In terms of suture line eversion there is little to choose between horizontal

(Fig. 3.7a) and vertical mattress (Fig. 3.7b) configurations. Use horizontal mat-
tress sutures in thin skin and vertical in thick skin (such as in the forehead). Do
not insert the suture bites too far from the skin edges or the edges will separate as
you tighten the suture (Fig. 3.7c).
Fig. 3.7 Mattress sutures. a Horizontal mattress suture. b Vertical mattress sutures. c Horizontal
mattress suture induced wound edge separation as the bites are too far from the edge
3.3.6 The Humble Horizontal Mattress (Fig. 3.8)
The horizontal mattress has three additional advantages over a simple suture:
1. The long surface loop pulls down against the skin, rather than towards the
wound edge. This makes a mattress suture less prone to cut out than a simple
suture (Fig. 3.8a).
2. The two bites act as a double pully during suture tightening, halving the suture
tension required to bring the wound edges together (Fig. 3.8b).
3. The downward pull of the first throw against the skin during knot tightening
significantly enhances friction. This prevents the first throw from slipping while
you tie the second knot throw (Fig. 3.8c).
These properties make the horizontal mattress suture particularly useful for directly
closing wounds under tension, as recommended in Chap. 14.
A buried horizontal mattress suture is very useful for suturing tarsal plate to
canthal tendon.
3.3.7 The ‘Magic Suture’ (Fig. 3.9)
The exotically named magic suture is nothing more than a strategically placed,
buried, subcutaneous, absorbable suture (Fig. 3.10). It should run subcutaneously
for 10 mm on either side of a facial wound. Within thin eyelid orbicularis a 5 mm
long bite is sufficient. Insert the suture from within the wound so that the knot
becomes deeply buried.
The magic in these sutures is twofold. Placing a single suture in this fash-
ion magically transforms a defect’s geometry. The first stitch simulates the final
effect that the specific wound closure direction will have on the lid position. If
you judge the effect to be sub-optimal, remove and replace the suture in a more
favourable orientation. Secondly, because the muscle layer carries the overlying
skin, the suture almost closes the skin defect. This makes skin suturing easier by
reducing skin closure suture tension which, in turn, makes the resulting scar less
likely to stretch. For magic suture placement steps see Chap. 5.
Fig. 3.8 Horizontal mattress suture advantages. a Mattress closure force is spread along the length
of the suture bite (low skin pressure) making it less likely to cut out than a simple suture whose
force is concentrated on a small area of skin the width of the suture gauge (high pressure). b The
horizontal mattress double pulley action makes pulling the wound edges together easy. c The knot
first double throw locks against the skin and doesn’t slip
Fig. 3.9 Suture magic
a b
c d
Fig. 3.10 The magic suture. a Take a long muscle bite (5−10 mm) starting deep in the wound.
b Take a similar bite on the far side starting close to the skin. c Lift and tighten the knot’s first
double throw until the wound closes. d Complete the knot ensuring it retracts deep into the wound
3.4 The Cotton Bud: An Aid to Suturing 33
3.4 The Cotton Bud: An Aid to Suturing
Cotton buds (cotton tip applicators) are commonly used in eyelid surgery to swab
blood and to help localize bleeding points. When doing this, roll the cotton bud
over the surface to be cleaned rather than wiping as wiping may restart bleeding by
rubbing off clots that have already formed. Forwards and backward rolling across
a bleeding point helps to visualize the leaking vessel for accurate diathermy.
The friction between cotton bud and tissue is useful for tissue retraction, either
by gently pressing and pulling or by rolling the cotton bud between one’s fingers.
The friction is also useful for blunt dissection of tissue planes.
A novel use of the cotton bud is as an aid to suturing in which role it has five
functions:
1. To unroll thin skin to reveal the true wound edge before suture placement.
2. To aid needle penetration of lax skin by applying counter pressure under the
needle tip.
3. To pull the needle and suture through the tissues once the needle tip is
embedded in the bud.
4. To hold the needle for re-grasping with a needle holder in preparation for the
next suture bite.
5. As a needle tip protector to reduce the likelihood of tip damage or needle stick
injury.
The technique of using a cotton bud for suturing is easy to learn but requires a
little practice. Tightly wound cotton buds are better for use in suturing. Remember
that buds have a hard central core which you need to avoid with your needle tip
by entering the bud at a glancing angle.
3.4.1 Steps (Fig. 3.11)
1. Hold the bud against the surface or underneath the skin and slowly rotate it to
retract and unroll any in-turned skin revealing the true wound edges.
2. Use the bud to apply tissue counter pressure under the needle tip (Fig. 3.11a).
3. During needle penetration adjust the angle between the needle tip and the bud
so that the needle penetrates the soft cotton covering without hitting the hard
central core (Fig. 3.11b).
4. When the needle tip is embedded, rotate the bud to pull the remainder of the
curved needle through the tissues (Fig. 3.11c). Avoid doing this too vigorously
so as not to disengage the needle from the bud.
5. As soon as the whole needle is clear of the tissue apply slight counter rotation to
the bud and lift it up to pull the suture through (Fig. 3.11d). The counter rotation
prevents the suture drag from pulling the needle out of the bud prematurely.
6. Re-grasp the needle with the needle holder ready for the next suture bite and
disengage it from the bud.
Fig. 3.11 Cotton bud as an aid to suturing. a Apply skin counterpressure over the suture needle tip
until it penetrates. b Engage the needle tip in the cotton bud. c Pull the needle completely through
by rotating the bud. d Apply 180° counterrotation to the bud and pull the suture through by lifting
the bud
Note: Although the technique has been broken down into individual steps, in
practice they blend into one smooth movement [1].
• The horizontal mattress and the magic suture techniques are powerful and
underused.
• A cotton bud can be used as a surgical instrument when suturing thin skin.
Reference
1. Cotton Bud: An Aid to Suturing. YouTube video: https://youtu.be/K2-_QzJhW5U

Pertinent Anatomy
4
4.1 Overview
• Lid Layers
• Surgical landmarks.
An understanding of functional lid anatomy is essential if you are to avoid

getting lost and have successful surgical outcomes. The upper and lower lids are
analogous in structure save for a few important differences which I shall highlight.
4.2 The Lid Skeleton (Fig. 4.1)
The eyelids are attached to orbital rim by the medial and lateral canthal tendons
(known by some as canthal ligaments) and by the orbital septum. The tarsal plates
and canthal tendons together make up the eyelid skeleton. Repair any disruption
to their integrity as a priority.
4.2.1 Canthal Tendons
The canthal tendons are inelastic. The tarsal plate, on the other hand, stretches
slowly under sustained load. The medial lid margin is pulled posteriorly towards
the posterior lacrimal crest by Horner’s muscle (formerly thought to be a posterior
limb of the medial canthal tendon). The medial canthal tendon arises from the
periosteum of the anterior lacrimal crest, and the lateral canthal tendon from the
lateral orbital tubercule situated just inside the orbital rim.

36 4 Pertinent Anatomy
Orbital Septum
Upper Tarsal Plate
Horner’s Muscle
Lateral Canthal Tendon
Medial Canthal Tendon

Arcus Marginalis
Lower Tarsal Plate
Orbital Septum
Fig. 4.1 Eyelid skeleton. The tarsal plates and canthal tendons together make up the eyelid
skeleton
4.2.2 Orbital Septum (7 Veils)
The orbital septum arises from the arcus marginalis of the orbital rim and sepa-
rates the orbital from the pre-orbital compartments. Though spoken of as a single
layer and contrary to common belief, the orbital septum is made up of seven lay-
ers. This can be a cause of confusion during surgery for the uninitiated when, after
having divided one or more septal layers further ones are found. The septum is rel-
atively inelastic. This is the reason orbital pressure can rise dangerously high with
a retrobulbar haemorrhage. The septum also restricts medial and lateral movement
of the lid margin and may need to be divided if you are trying to move a section
of lid margin to a new position. Scarring and contraction of the septum cause lid
margin retraction.
4.3 Lid Layers (or Lamellae) (Fig. 4.2)
Think of the lid as a two-layer sandwich. We call the layers ‘lamellae’.
4.3.1 Anterior Lamella (Fig. 4.2a)
The outer lid layer (anterior lamella) is made up of skin and orbicularis muscle.
These are closely bound together by the orbicularis fascia, though this attachment
weakens with age. So, dissection is easier in the sub-orbicularis plane than in the
4.3 Lid Layers (or Lamellae) (Fig. 4.2) 37
a Orbicularis b
Skin Conjunctiva
Tarsal Plate
Fig. 4.2 Eyelid layers. a Anterior lamella = Skin and Orbicularis. b Posterior lamella = Tarsal
plate and Conjunctiva
subcutaneous plane. This is of practical significance when performing blepharo-

plasty. Removing excess skin together with its attached orbicularis is quicker and
easier than separating the two. External to the orbital rim always dissect in the
subcutaneous plane to avoid damaging facial nerve branches which run on the
muscular layer. Remember this when raising periocular flaps.
Confusingly some surgeons have recently begun to refer to the orbicularis as a
separate ‘middle lamella’ because it can be used as a vascular flap to support both
an anterior and a posterior free graft.
4.3.2 Posterior Lamella (Fig. 4.2b)
The inner lid layer (posterior lamella) is made up of tarsal plate and conjunc-
tiva. The conjunctiva is inseparably bound to tarsal plate. Proximal to the tarsal
plate border the conjunctiva is bound progressively less tightly to the overlying
Muller’s muscle. Lower lid Muller’s muscle is not surgically visible and can only
be discerned microscopically.
4.3.3 In-Between
The sandwich filling, between the anterior and posterior lamellae, contains the
orbital septum, the insertions of the retractor muscles via their aponeuroses, and the
palpebral arteries and veins. The pre-aponeurotic fat pads lie between the orbital
septum anteriorly and the retractor aponeurosis posteriorly.
There is no distinct levator muscle in the lower lid. Instead, inferior rectus
movement is transmitted to the lower lid by a fibrous aponeurosis known as the
capsulo-palpaebral head. As in the upper lid, this lies immediately posterior to the
preaponeurotic fat pad.
4.4 Skin
Eyelid skin is very thin, mobile, and elastic. It has no underlying fat (unlike
other skin). With aging the skin usually thins (except in patients with severe sun
damage), stretches and loses elasticity.
4.4.1 Skin Tension Lines (Langer’s Lines) (Fig. 4.3)
Karl Langer, a Viennese anatomist, plotted the direction in which skin punctures
made in fresh cadavers elongated due to inherent skin tension. By joining the
puncture axes, he drew lines that are named after him. More recently skin tension
has been measured in living subjects resulting in slightly different line orientations.
Siting surgical incisions along such tension lines minimizes the tension across the
healing scars, making them stretch less and consequently less visible. However,
when there is significant skin loss do not align the closure scar with the tension
lines or you will cause ectropion and/or interfere with eyelid movement. Instead,
close the wound to align the closure tension tangentially to the lid margin. The
resulting scar orientation is usually perpendicular or oblique to the skin tension
lines.
Fig. 4.3 Skin tension lines.

These indicate the direction
of maximal tension within the
skin
4.5 Don’t Get Lost (Surgical Landmarks) (Fig. 4.4) 39
4.5 Don’t Get Lost (Surgical Landmarks) (Fig. 4.4)
It is easy to get lost in the lid layers, especially during re-operations. Apart from
the skin anteriorly, and the conjunctiva posteriorly, only two landmarks are con-
stant within the eyelid. They are the tarsal plate and the pre-aponeurotic fat pad
(Fig. 4.5). Use them to orientate yourself during surgery. When re-operating on a
scarred lid start dissecting in a previously uninvolved area where the tissue planes
are still clear and develop your surgical plane from there.
Fig. 4.4 Don’t get lost
Pre-aponeurotic
fat fad
Tarsal Plate
Fig. 4.5 Surgical landmarks. The two constant landmarks are tarsal plate and preaponeurotic fat
Fig. 4.6 Tarsal plate and meibomian glands. Alignment of the meibomian glands that make up
70% of the tarsal plate and open onto the lid margin
4.6 Tarsal Plate (Fig. 4.6)
Tarsal plate is a distinctive, firm, pale tissue that extends away from the eyelid
margins. Meibomian glands (approx. 30 per lid) make up 70% of it. They are
aligned side by side and held together by collagen and elastin (Fig. 4.6). Tarsal
plate is the strongest layer of the eyelid margin and must be repaired following
lid margin lacerations or incisions. Note that unlike tendon, tarsal plate stretches
progressively under tension. This makes a tarsal strip a poor substitute for a lateral
canthal tendon. Respect tarsal plate as there are no good substitutes to replace it
with (cartilage being much stiffer).
4.7 The Meibomian Orifice Line
The meibomian orifice line marks the mid tarsal plate plane at the lid margin. You
can make it more visible by squeezing the lid margin and looking for the egress of
Meibomian secretions. Sutures placed in the Meibomian orifice line will engage
tarsal plate and thus gain firm lid margin purchase (which can be used for lid
traction).
4.8 The Grey Line
The grey line marks the junction of the anterior and posterior lamellas. Though
frequently referred to in textbooks it is a poor anatomical landmark as it becomes
increasingly difficult to discern with age. Its only surgical significance is when
splitting the lid margin into its two lamellae.
The grey line derives its colour from the underlying muscle of Riolan (modified
terminal orbicularis) as seen through the extremely thin lid margin skin. Because
4.11 Blood Supply (Fig. 4.7) 41
of this, and contrary to common practice, sutures placed in the grey line have
almost no holding strength and serve no useful function.
4.9 Pre-aponeurotic Fat
Pre-aponeurotic fat, unlike other fat, is extremely fine without visible globules.
Deep yellow in colour, it flows at body temperature. You can encourage pre-
aponeurotic fat to prolapse through a septal incision by pressing on the eye or
on the opposing lid. Anteriorly the fat pad is contained by the orbital septum. The
structure immediately posterior (deep) to the pre-aponeurotic fat is, by definition,
the levator aponeurosis in the upper lid and the retractor aponeurosis in the lower
lid.
4.10 Lacrimal Ductules
The lacrimal gland, which sits superotemporally between the upper lid lamellae,
secretes tears into the upper conjunctival fornix via one or several lacrimal duc-
tules. Take care to avoid damaging them during surgery. As they are not easily
visible you should identify and mark the ductules before you operate. Do this
by first doubly everting the upper lid over a large Desmarres retractor, and then
instilling a drop of Fluoresceine 2% onto the conjunctiva laterally. Wait and watch
until you see tears from the ductule opening dilute the orange fluoresceine to make
it fluoresce green. This reveals the ductule openings which you should mark with
ink for easy identification when you operate.
4.11 Blood Supply (Fig. 4.7)
Eyelids possess an excellent anastomosed blood supply. This enables them to heal
quickly and protects wounds from infection. It also makes lids bleed a lot during
surgery. There are two main bleeding points in the eyelid margin – the marginal
and the peripheral vascular arcades (Fig. 4.7). The marginal arcade lies on the
anterior surface of the tarsal plate, deep to orbicularis, just proximal to the lash
roots. The peripheral arcade lies on Muller’s muscle in the upper lid, close to the
proximal border of the tarsal plate. [Note: Most textbooks only show a single arcade
in the lower lid, but surgical experience tells a different story]. Knowing the vessel
location makes accurate diathermy easier. To perform diathermy, first squeeze the
full thickness of the cut lid sandwich with forceps and clean away any blood with a
cotton bud (Fig. 4.8a). Then identify the bleeding points as you slowly release the
pressure and bleeding restarts (Fig. 4.8b). Diathermy the cut vessels (Fig. 4.8c).
The two arcades unite into a single palpebral artery and vein at either end of
the lid.
Peripheral Vascular
Arcade
Marginal Vascular
Arcade
Palpaebral Arteries
Fig. 4.7 Eyelid vascular arcades. The marginal arcade is on the anterior tarsal plate surface close
to the margin. The peripheral arcade lies on Müller’s muscle, just proximal to the tarsal plate. They
join at either end to form the palpaebral arteries
a b
Marginal Vascular Arcade
Peripheral Vascular Arcade
Fig. 4.8 Eyelid bleeding points. a Grasp and squeeze the lid margin and remove the blood. b Gen-
tly ease the forceps pressure until bleeding restarts to reveal the cut vessels. c Apply diathermy to
the bleeding vessels
4.12 Muscles 43
4.12 Muscles
The eyelid closing muscle (protractor) is the orbicularis oculi. This is a thin sheet
of concentrically arranged muscle fibres extending from the lid margin to well
outside the orbital rim. It is customary to consider it in three functional parts:
the pretarsal, the pre-septal and the orbital, even though they are a continuum
(Fig. 4.9). The pretarsal orbicularis is responsible for blinking, whereas the orbital
part performs strong lid squeezing. The pre-septal orbicularis takes part in both
but also serves a lid stabilizing function that is lost if it is allow migrate to a
pretarsal position through weakening of the orbicular fascia. Loss of orbicularis
function may result in incomplete eye closure. Bell’s reflex (involuntary upward
rolling of the eyes on attempted eye closure) mitigates the consequent corneal
exposure. Loss of orbicularis function may also give rise to lower lid paralytic
ectropion. Occasional involuntary contraction of the orbicularis is called a tick,
when persistent and unilateral, hemi facial spasm, and when persistently bilateral,
the idiopathic blepharospasm syndrome.
The eye-opening muscle (retractor) of the upper lid is the levator palpebrae
superioris (Fig. 4.10a & b). It shares the same innervation as the superior rectus
muscle (upper division of the oculomotor nerve). It inserts into the orbicular fascia
at the level of the skin crease and into the anterior surface of the mid and lower
tarsal plate. Its function is modulated by Muller’s muscle by up to 2 mm. Muller’s
muscle is a thin sheet of sympathetically innervated muscle that originates from
the under surface of the levator and inserts into the upper border of the tarsal
plate. At its insertion it is closely bound to the conjunctiva but becomes easier
to separate surgically higher up. Paralysis of the sympathetic nerve supply, as in
Horner’s syndrome, causes no more than 2 mm of ptosis.
Unlike the upper lid, the lower lid does not have a separate retractor. This func-
tion is performed by the capsulo-palpebral head of the inferior rectus. Likewise,
the lower lid does not have a surgically visible Muller’s equivalent.
Orbital
Pre-septal
Pre-tarsal
Fig. 4.9 The orbicularis oculi. Artificial subdivision of the continuous orbicularis sheet into func-
tional parts: pretarsal for blinking, pre-septal for stabilization, and the orbital for squeezing
a
Levator aponeurosis
Müller’s muscle
Capsulo-palpaebral
aponeurosis
b Levator aponeurosis
Levator Palpaebri
Superioris
Müller’s
muscle
Inferior Rectus
Capsulo-palpaebral aponeurosis
Fig. 4.10 Lid retractors. a Anterior view of the retractor aponeuroses. b Lateral view showing the
relationships of Müller’s muscle to levator, and the capsulo-palpaebral aponeurosis to the inferior
rectus
The shared oculomotor innervation of the eyelid and eye is important for lifting
the upper lid in up-gaze and retracting the lower lid in downgaze.
4.13 The Rest
This simplified account of the anatomy misses out a lot. The lacrimal gland and
drainage apparatus are mentioned in Chap. 16. Whitnall’s ligament is of note. It is a
strong fibrous band that runs from the trochlea, where it is narrow, over the surface
of the levator aponeurosis, widening as it inserts into the peri-lacrimal fascia. The
novice is only likely to encounter it when converting a white line advancement
ptosis correction to a levator resection (see Chap. 10).

• The tarsal plate and the pre-aponeurotic fat pads are constant anatomical
landmarks.
• The orbital septum is a multi-layered structure.
Fundamental Procedures
5
Fig. 5.1 Fundamentals
5.1 Overview (Fig. 5.1)

• Lid margin repair
• Lateral canthal repair
• The magic suture
• The tarsal traction suture
• Emergency canthotomy
Most lid operations are made up of a combination of basic surgical blocks. The
first four techniques listed are integral to many procedures; hence I consider them
to be fundamental. The last, emergency canthotomy, though rarely needed can be
sight saving.

48 5 Fundamental Procedures
5.2 Lid Margin Repair (Fig. 5.2)
Lid margin repair forms part of entropion and ectropion correction, tumour resec-
tion and laceration repair. This technique uses absorbable sutures which only
require removal should they loosen and irritate. It works equally well for sur-
gical resections as for traumatic lid lacerations. The same technique, with minor
modification, works at the lateral canthus.
a b
c d
e f
Fig. 5.2 Eyelid margin repair. a Turn the wound edge out. b View the cut surface end on to place
the suture. c Push the skin and orbicularis back with the flat of the needle to enters the anterior tarsal
plate surface. d Advance the needle to emerge on the cut surface of the tarsal plate. e Place 3 tarsal
sutures. f Clip the paired suture ends together. g Enter the wound edge through the orbicularis with
a 7/0 suture and rotate the needle to emerge from the lash line. h Re-enter the lid margin through
the meibomian orifice line on the same side to exit the cut tarsal plate surface close to the margin.
i With the same needle re-enter the far side similarly. j Put a loose single throw on this suture and
clip the untied suture ends together. k Tie and cut the preplaced tarsal sutures in reverse order of
placement. l Tighten and tie the pre-placed lid margin mattress suture. m Confirm that it causes the
lid margin join to pout. n Repair the remainder of the skin wound
5.2 Lid Margin Repair (Fig. 5.2) 49
g h
i j
k l
m n
Fig. 5.2 (continued)
5.2.1 Considerations
As the tarsal plate forms the skeleton of the lid it is the most important lid margin
structure needing repair.
Ensure that the lid margin union pouts by the end of the repair or a notch will
later form through scar contraction.
5.2.2 Principle
• Accurately align the two sides.

• Pre-place all the tarsal plate and lid margin sutures before tying any.
• Place them so that they are unable to irritate the cornea once tied and cut.
• Always tie the tarsal suture furthest from the margin first to take the tension.
This makes it easier to subsequently tie the more important marginal sutures
tightly without slippage.
• Use a buried lid margin mattress suture to make the lid margin pout.
5.2.3 Steps
1. Insert a 6/0 absorbable suture, mounted on an 8 mm spatula, ½ circle needle,

through the tarsal plate on either side to span the wound. Place it as close to
the lid margin as possible. Take particular care to align the suture bites on each
side to avoid creating a step in the margin.
a. Grasp the full thickness of the lid ‘sandwich’ perpendicularly to the mar-
gin, about 2–3 mm from the cut edge, with toothed forceps. Turn this edge
outwards to improve visibility and access (Fig. 5.2a and b).
b. Use the flat surface of the suture needle to push the skin and orbicularis
to the side, so that the needle tip enters the anterior tarsal plate surface
perpendicularly, about 1–1½ mm from the tarsal plate edge (Fig. 5.2c).
c. As soon as the needle tip engages the tarsal plate rotate and advance the
needle so that it emerges close to the conjunctival surface on the cut surface
of the tarsal plate, i.e., after engaging almost the full tarsal plate thickness.
Do not penetrate the conjunctiva. This is particularly important for upper lid
repairs.
d. Retrieve and remount the needle from this first bite and grasp the far side of
the lid margin with tissue forceps, as in step 1a.
e. Insert the needle into the cut surface of the tarsal plate close to its conjunc-
tival surface. Take special care to place this bite at the same distance from
the lid margin as the first bite (Fig. 5.2d).
f. As soon as the needle tip engages tarsal plate rotate and advance the needle
so that it emerges on the anterior surface of the tarsal plate 1–1½ mm from
the wound edge. Avoid engaging the orbicularis and skin. If you do, lift
them off your needle tip.
g. Clip the two untied suture ends together with a bulldog clip and retract them.
2. In the lower lid, place 2 further sutures below the first one in a similar fashion,
spacing them about 1 mm apart (Fig. 5.2e). In the upper lid, which has a wider
tarsal plate, 3 or 4 additional sutures may be required. Again, clip each pair of
untied suture ends together to aid later identification when tying (Fig. 5.2f).
51
3. Preplace a lid margin horizontal mattress 7/0 absorbable suture so that its knot
will become buried in the lash line. This configuration will cause the lid margin
repair to pout as intended when you eventually tie this suture.
a. With the needle enter the wound edge through the orbicularis, just anterior
to the tarsal plate surface. Rotate the needle so that it emerges from the
skin within the lash line, 1½ mm from the wound edge, having engaged the
orbicularis and skin (Fig. 5.2g).
b. With the same needle re-enter the lid margin perpendicularly through the
meibomian orifice line on the same side (Fig. 5.2h). Rotate and advance the
needle to exit the cut tarsal plate surface close to the margin. Take special
care not to engage accidentally the first preplaced tarsal plate suture from
step 1, as this would prevent it from being tightened when tying.
c. With the same needle enter the far tarsal cut edge perpendicularly and bring
the needle tip out through the meibomian orifice line. Take special care not
to engage accidentally the first preplaced tarsal plate suture from step 1.
d. With the same needle re-enter the lid margin perpendicularly through the
lash line and bring it out through the cut edge of orbicularis (Fig. 5.2i).
e. Put a loose single throw on this suture and clip the untied suture ends
together out of the way (Fig. 5.2j).
4. Now tie firmly and cut the preplaced tarsal sutures in reverse order of place-
ment, i.e., starting with the one furthest from the lid margin (Fig. 5.2k). Once
tied, this first suture takes up most of the wound tension. This makes tying the
remaining tarsal plate sutures easy and their first throws unlikely to slip. By the
end of this step the lid margin wound should be accurately and securely closed.
5. Tighten and tie the pre-placed lid margin mattress suture (Fig. 5.2l). Confirm
that it causes the lid margin join to pout (Fig. 5.2m). Cut its ends short enough
for them to retract into the wound anterior to the tarsal plate (away from the
cornea).
6. Repair the remainder of the skin wound with interrupted 6/0 or 7/0 absorbable
sutures which incorporate the underlying orbicularis into each bite, (Fig. 5.2n)
or suture the orbicularis first, as a separate layer with a ‘magic suture’ (see
below).
5.2.4 Notes
An accurately repaired lid margin will not leave a noticeable scar, notch, or lash
line gap.
a b
c d
e f
g h
Fig. 5.3 Lateral canthal repair. a Grasp the lateral canthal tendon with toothed forceps performing
the ‘tug test’. b Place a 6/0 absorbable suture, through the tendon. c Place a second, double armed
suture in a similar fashion slightly below the first. d Insert the first pair of needles into the tarsal
plate. e Place the second pair of sutures similarly, 1 mm below the first pair. f Preplace a lid margin
horizontal mattress 7/0 absorbable suture so that its knot will become buried in the lash line at the
lateral canthus. g With the same needle enter the canthal tendon/tarsal junction of the opposing lid.
h Put a loose single throw on this suture. i Tie and cut the two preplaced tarsal mattress sutures in
reverse order of placement. j Tighten and tie the pre-placed lateral canthal margin mattress suture.
k Repair the remainder of the skin wound with interrupted 6/0 or 7/0 absorbable sutures
5.3 Lateral Canthal Repair (Fig. 5.3) 53
i j
5.3 Lateral Canthal Repair (Fig. 5.3)
The lateral canthal angle is formed by the pull of the lateral canthal tendon (LCT).
If the LCT is damaged, repair it. Should that not be possible use an alternative
lateral fixation point such as the orbital rim periosteum or insert a self-tapping bone
screw from which to anchor your suture. Eyelid incisions at the lateral canthus heal
aesthetically without a visible notch.
5.3.2 Principle
This is a modification of the lid margin repair described above. As there is no

lateral tarsal plate, strong fixation relies on suturing to the canthal tendon. A single
horizontal mattress suture is sufficient, but I recommend using two, as a failsafe.
5.3.3 Steps
1. Grasp the presumed lateral canthal tendon with toothed forceps in the lateral
wound edge (Fig. 5.3a). The tendon can be difficult to see, especially if the
lateral palpaebral artery is bleeding. Ask an assistant to pull the lateral canthal
tissues apart to improve visualization. Positively identify that what you are
holding is tendon by performing the ‘tug test’. Tug firmly on the tissue you
are holding. A tendon resists such tugs without any ‘give’, what we might call
‘a hard stop’. If the resistance to your tug is ‘softer’ you are not holding the
tendon. Re-grip presumed canthal tendon and repeat the tug test until you are
certain that you are holding the tendon.
2. Without releasing your grip, place a double armed 6/0 absorbable suture,
mounted on an 8 mm spatula, ½ circle needle, through the tendon. Follow
this with a second, locking, pass, and clip the suture ends together (Fig. 5.3b).
3. Place a second, double armed suture in a similar fashion slightly below the first
(Fig. 5.3c).
4. Insert the first pair of needles into the tarsal plate (Fig. 5.3d), either transcon-
junctivally or through its cut edge, the former being easier.
Note: Normally we avoid breaching the conjunctiva with an abrasive suture, but
at the lateral canthus the chance of the suture irritating the cornea is remote and
it quickly migrates subconjunctivally.
Place the first bite close to the lid margin so that it emerges on the anterior
surface of the tarsal plate 1½ mm from the wound edge. Avoid engaging the
orbicularis and skin. Place the second needle similarly but 1 mm below the
first. Clip the two untied suture ends together with a bulldog clip and retract
them.
5. Place the second pair of sutures similarly, 1 mm below the first pair (Fig. 5.3e).
Clip the untied suture ends together.
will become buried in the lash line at the lateral canthus. This configuration
will cause the lateral canthal margin to pout when this suture is eventually tied.
a. With the needle enter the wound edge through the orbicularis, just anterior
to the tarsal plate surface and rotate the needle so that it emerges from the
skin within the lash line, 1½ mm from the wound edge after engaging the
orbicularis and skin.
b. With the same needle re-enter the lid margin perpendicularly through the
meibomian orifice line on the same side (Fig. 5.3f). emerging on the cut
tarsal plate surface close to the margin.
Note: Take special care not to accidentally engage the first preplaced tarsal
plate suture from step 4, as this would prevent it from being tightened.
c. With the same needle enter the canthal tendon/tarsal junction of the opposing
lid (Fig. 5.3g). Bring the needle tip out through the meibomian orifice line.
d. With the same needle re-enter the lid margin perpendicularly through the
lash line and bring it out through the cut edge of the orbicularis at the lateral
canthus.
e. Put a loose single throw on this suture and clip the untied suture ends
together out of the way (Fig. 5.3h).
5.4 The Magic Suture (Fig. 5.4) 55
7. Now, tighten, tie firmly and cut the two preplaced tarsal mattress sutures in
reverse order of placement, i.e., starting with the one furthest from the lid mar-
gin. Lift and pull each pair of suture ends laterally, to close the wound using the
pulley effect, before snugging down the first throw. Once tied, the first suture
takes up most of the wound tension. This makes it easy to tie the second suture
tightly (Fig. 5.3i). By the end of this step the lid margin wound should be
accurately and securely closed.
8. Tighten and tie the pre-placed lateral canthal margin mattress suture (Fig. 5.3j).
Cut its ends short enough for them to retract into the wound. The canthus is
now reformed.
9. Repair the remainder of the skin wound with interrupted 6/0 or 7/0 absorbable
sutures which incorporate the underlying orbicularis into each bite (Fig. 5.3k),
or suture the orbicularis first, as a separate layer with a magic suture.
5.4 The Magic Suture (Fig. 5.4)
A long reach, subcutaneous, suture, placed across the centre of a tissue defect can
transform a gaping wound into a narrow slit “as if by magic”, hence its name. It
is an extremely useful technique for two reasons:
• Temporarily tying this first stitch simulates the ultimate effect that your cho-
sen closure direction will have on the eyelid margin position. Should it cause
ectropion or retraction, the suture is quick and easy to replace in a better
orientation.
• Secondly, by aligning and approximating the skin edges this suture speeds up
the remainder of the wound closure.
a b
Fig. 5.4 Magic suture direction. a In the right lower lid, the suture is placed at an oblique wound
axis. In the left brow along the long wound axis. b When tightened the suture tension is parallel to
the respective lid margin tangent and transforms the wound’s geometry
5.4.1 Principle and Considerations
Bringing the subcutaneous tissue layer together carries the overlying skin with it.
The salient properties of any suture bite are its direction, length and depth, and
the tissue it engages. With the magic suture all three properties differ from those of
conventional subcutaneous sutures. The most critical factor is the suture direction.
In conventional wound closure the sutures are placed across the short axis of a
defect. For a magic suture, by contrast, the direction of the closure tension must
be parallel to the tangent at the nearest point on the lid margin, irrespective of the
short axis of the actual defect (Fig. 5.4a). This ensures that the repair does not
pull on the lid margin to cause retraction. Consequently, the resulting closure scar
tends to lie more perpendicularly to the lid margin though not necessarily at right
angles. Place the Magic suture very roughly centrally on each side of the wound,
as this is the point at which maximum closure tension develops. However, Fig. 5.4
illustrates that with oblique and irregular wounds this is not necessarily the case.
Therefore, align the suture parallel to the lid margin, irrespective of the wound’s
orientation. Do not worry if you don’t get it right the first time. The suture is quick
to replace. The suture bites should start and end in the depth of the wound to bury
the suture knot when tied.
The suture material used for this technique is not critical. However, as suture
tension invariably dissipates by suture migration, I recommend an absorbable
suture on a half-circle needle. You gain no advantage by using non-absorbable
sutures. 6/0-gauge sutures work well within the eyelid area. Stronger 4/0-sutures
are preferable more peripherally.
5.4.2 Case Selection
Widely applicable to most wounds.
5.4.3 Steps
1. From the depth of the wound engage the subcutaneous tissue roughly at the
midpoint with a suture on a ½ circle needle (Fig. 5.5a). Within the periocular
area the subcutaneous tissue is mostly orbicularis muscle.
Note: Do not to engage immobile structures, such as the orbital septum inad-
vertently, as this would limit wound edge movement. Occasionally one may
deliberately choose to engage a canthal tendon in the knowledge that this side
of the repair will remain fixed, and all the mobility must come from the opposite
bite.
2. The bite length on each side of the wound should be no less than 5 mm within
the pre-tarsal area and no less than 10 mm in the surrounding tissue. Make
this bite deep enough to strongly engage the subcutaneous layer (usually the
orbicularis).
5.4 The Magic Suture (Fig. 5.4) 57
a b
Skin
Skin
Orbicularis
Orbicularis
Periocular 10 mm
Periocular 10 mm
Eyelid 5 mm
Eyelid 5 mm
c d
Fig. 5.5 The magic suture. a From the depth of the wound engage the subcutaneous orbicularis
muscle. b Bring the needle tip up until it is just visible through the skin, rotate by 90° and advance
subcutaneously to the wound edge. Traverse the wound and take a similar bite on the far side.
c Place the first double throw of the knot and tighten. d Complete the knot with three additional
single throws
3. At the required distance, bring the suture needle tip up until it is just visible
through the skin. At this point rotate the needle by 90° towards the wound
edge.
4. Advance the needle within the subcutaneous plane close to the skin until it
exits at the wound edge.
5. Traverse the wound and enter the subcutaneous plane on its far side.
6. Advance the needle within this plane for 5 or 10 mm, as for the first bite, and
then rotate the tip down to penetrate the muscle layer.
7. Rotate the needle out through the deep wound edge (Fig. 5.5b).
8. Place the first double throw of the knot (Fig. 5.5c).
Note: When tying the suture, it is helpful to have an assistant push the two sides
of the wound towards each other, temporarily reducing the wound tension. Lift
this first double suture throw clear of the tissues by lifting and pulling on both
the suture ends. Rock the knot side to side during this step to encourage the
suture to slide through the tissues as you pull them together.
9. While maintaining the suture tension, snug the knot down. Repeat this
sequence of lifting, rocking, and tightening several times until the wound
edges stop coming closer. The phenomenon of ‘tissue creep’ is gradually
occurring as you do this so do not rush this step.
10. Complete the knot with three additional single throws (Fig. 5.4d). Ask an
assistant to hold the first throw with the very tips of Moorfields forceps to
stop it slipping while you lock it with the second throw.
5.4.4 Notes
• Occasionally more than one magic suture is required. If you need even stronger
tissue holding use a buried horizontal mattress suture configuration instead.
However, the placement steps essentially remain the same.
• A ‘magic suture’ enables the direct closure of larger defects than at first appears
possible. Use it as a first step to minimize any defect, even if you are planning
a flap or graft repair. Once it is in place reconsider your options. You may find
that direct closure has now magically become possible.
5.5 Tarsal Traction Suture (Fig. 5.6)
You will often need to pull on a lid with a suture either during an operation or
during the early healing phase. Traditionally you would do this by placing your
traction suture into the grey line and out through the skin, tarsorrhaphy tubing or
over a bolster to spread the load over a larger area, and back into the skin to exit
the grey line. The following method is a surer, longer lasting and more comfortable
alternative.
a Grey Line
b
Meibomian Orifice Line
900
Meibomian Gland
c d
Fig. 5.6 The tarsal traction suture. a Lid margin landmarks. b Perpendicular needle entry into the
Meibomian Orifice Line. c Needle advanced within the tarsal plate. d Taping the lid margin suture
on traction
5.5 Tarsal Traction Suture (Fig. 5.6) 59
The tarsal plate is the strongest part of the eyelid despite 70% of it being mei-
bomian gland tissue. Consequently, it is the best structure into which to anchor
a traction suture. Although the tarsal plate is only 1–2 mm thick the meibo-
mian gland orifices provide a convenient surface landmark for the mid-tarsal plane
(Fig. 5.6a).
Tarsal plate has few nerve endings so a suture pulling on it causes no pain.
Eyelid skin, by contrast, is sensitive to suture pressure, even if you pass your
traction suture over a bolster or through tubing.
A tapered, non-cutting needle causes minimal tarsal damage because it sepa-
rates, rather than cuts as it passes. Do not use a cutting needle for fear of shredding
the relatively thin tarsal plate, weakening it with each pass.
A 4/0 monofilament polypropylene suture on a 17 mm half circle, non-cutting
taper-point needle (Ethicon Prolene W8557) makes an excellent traction suture. It
is both strong and inert.
This way of applying lid traction is applicable to either lid, anywhere along its
margin. It is the basis of the ‘bolster-less suture tarsorrhaphy’ (see Chap. 13).
Any lid requiring sustained traction per operatively or postoperatively up to several

weeks e.g., to immobilize a graft bed or protect an eye.
5.5.3 Steps
(1) Grasp the full thickness of the lid as parallel to the margin as possible with
large forceps (e.g., Toothed Adson’s or the specifically designed Thaller Tarsal
forceps [Altomed A6360]) and evert the margin. As you squeeze the lid the
egress of meibomian secretions identifies the meibomian orifice line.
(2) Enter the meibomian orifice line with the round bodied needle tip held
perpendicularly to the lid margin (Fig. 5.6b).
(3) Slowly advance the needle within the plane of the tarsal plate, allowing it to
follow its own curve to exit once more through the meibomian orifice line
some 10 to 12 mm from its point of entry (Fig. 5.6c). If the needle exits
prematurely, too anteriorly through the lash line or too posteriorly through the
conjunctival surface of the tarsal plate, partially withdraw the needle, alter the
angle at which you are holding the lid margin and re-advance the needle until
the tip exits the meibomian orifice line as intended. Even if you have to repeat
this a few times the non-cutting needle does minimal damage.
(4) Finally inspect the lid to ensure that the suture has not breached the conjunctiva
or skin during its long passage.
(5) Apply traction as required (Fig. 5.6d).
5.5.4 Notes
• Premature failure results through cutting out if you engage an insufficient length
of tarsal plate or inadvertently miss it. This is caused by not entering the
meibomian gland orifice line perpendicularly.
• Eventual failure by suture migration out of the lid is inevitable but takes sev-
eral weeks. It occurs gradually and is only an issue with long-term suture
tarsorrhaphy. If this occurs, simply replace the suture.
• A correctly placed tarsal traction suture causes no pain or inflammation while
in place, nor scarring after removal.
5.6 Emergency Cantholysis (Fig. 5.7)
Emergency lateral cantholysis is rarely required but I include it here because it

is a sight saving procedure when raised intra-orbital pressure threatens vision. It
heals spontaneously and seldom needs to be repaired. It can be performed in any
setting.
a b
Fig. 5.7 Emergency cantholysis. a At the lateral canthus crush the lid downward and laterally at
45°. b Cut downward and laterally at 45° through the crush mark dividing the full thickness of the
lid. c Extend the incision until the lower lid is completely detached
Release the lid from its attachment to the lateral orbital rim by making a diagonal
full thickness cut at the lateral canthus. Cutting at an oblique angle, rather than
horizontally, avoids damaging the lateral canthal tendon.
Emergency decompression of a tense orbit following trauma, haemorrhage or

infection.
5.6.3 Steps
(1) Grasp and hold the lower lid close to the lateral canthus with strong toothed
forceps (Adson’s).
(2) Insert one blade of a pair of straight artery forceps under the lower lid mar-
gin at the lateral canthus and crush the lid downward and laterally at 45°
(Fig. 5.7a).
(3) Remove the artery forceps and insert one blade of a pair of strong scissors
(e.g., Steven’s tenotomy scissors) under the lower lid margin at the lateral
canthus and cut downward and laterally at 45° through the crush mark dividing
the full thickness of the lid (Fig. 5.7b).
(4) If the lower lid is not completely detached from the canthus, extend the
incision further until it is (Fig. 5.7c).
5.6.4 Note
• Cantholysis may be performed on either the upper or the lower lid, or even on
both.

• Accurately align a lid margin repair.
• A single, correctly aligned, subcutaneous suture can positively transform a lid
defect.
• Place sutures in the meibomian orifice line, not the grey line.
• Emergency cantholysis saves sight.
Eyelid Malposition
6
Fig. 6.1 Lid malposition

• Factors affecting eyelid position and stability.
The palpebral aperture, being the gap between the upper and lower lid margins,
is affected by both vertical and rotational lid margin malposition. Vertical eye-
lid malpositions comprise blepharoptosis (usually abbreviated ‘ptosis’) and eyelid
retraction. The rotational malpositions are entropion (inward turning of the margin)
and ectropion (outward turning of the margin).

64 6 Eyelid Malposition
6.2 Lid Stability (Fig. 6.2)
6.2.1 Tarsal Plate Width
The lower lid is prone to rotational malposition as its tarsal plate is narrow (4 mm
wide) making it inherently less stable about its long axis than the upper lid (tarsal
plate width 8–10 mm).
6.2.2 Orbicularis Tone
The lids gain stability by being held flat against the globe. The active force doing
this is the orbicularis muscle tone. Usually this is spread evenly thanks to the
orbicular attachments to skin. With aging these attachments weaken allowing the
pre-septal orbicularis to move to a pre-tarsal position during contraction. This
creates net inward pressure on the lid margin which can cause entropion.
6.2.3 Lid/Globe Apposition and Volume Deflation
Passive stability stems from the geometry of the bony attachments of the lids (via
the canthal tendons) relative to the pupillary plane. For the lid to gain support it
must be bowed forwards by the eye.
Aging leads to facial and orbital volume loss (deflation). The resulting enoph-
thalmos gives less lid support and the lid becomes lax relative to the eyeball
(‘eyelid/globe disparity’). In severe enophthalmos a space can develop between
the lower lid margin and the sunken eye.
Fig. 6.2 Lower lid stability

Factors contributing to lower Centre of rotation
lid margin instability
8-10 mm
Enophthalmos
4 mm Narrow Tarsus
Retractor Laxity
Gravity
6.3 The Palpebral Aperture 65
6.2.4 Gravity
Gravity presses the upper lid down against the eye improving stability. By contrast,
in the upright posture gravity pulls the lower lid downwards, away from the eye,
reducing stability.
6.2.5 Retractor Tethering
The above factors allow the lower eyelid to rotate more easily about its long axis
(length) and flip inwards under the pressure of orbicularis contraction during blink-
ing and eye squeezing, or outwards if the orbicularis is atonic, as in facial palsy.
The lower lid retractors help to resist such rotation by tethering the inferior edge
of the tarsal plate. This stabilizing effect is lost if the retractors dehisce or become
relatively lax through volume deflation.
Visible lower fornix fat prolapse is a sign of retractor dehiscence. Pull the lower
lid down to the orbital rim and look for a fat bulge between the eye and the tarsal
plate [1].
6.3 The Palpebral Aperture
The horizontal palpebral aperture length depends on the integrity of the medial
and lateral canthal tendons.
The vertical aperture (degree of lid opening) is determined by:
(1) The dynamic balance between the opening muscles (retractors), the levator and
Müller’s muscle, and the closing muscle (protractor), the orbicularis oculi. The
tone in the levator is controlled by the upper division of the oculomotor (III)
nerve, that of Müller’s muscle by the sympathetic nervous system, and the
orbicularis by the facial (VII) nerve.
(2) Static factors acting on the lid:
a. Normally, gravity and posture have relatively little effect on eyelid position.
b. Lid mass and volume does affect the palpebral aperture. Increase in volume,
such as by oedema, retention cysts or tumour infiltration can push the lid
margin towards closing. In the upper lid the increased weight causes posture
dependent ptosis, an effect that is occasionally exploited by implanting gold
or platinum lid weights in facial palsy.
c. Tissue elasticity is reduced by aging, frequent eye rubbing, recurrent
inflammation, and scarring,
d. Anterior lamellar tissue loss or relative shortage due to scarring or mid face
descent causes retraction and/or ectropion. Posterior lamellar (conjunctival)
scarring leads to lid margin retraction and cicatricial entropion.
6.4 Assessment
Note the following:
1. The lid margin appearance, contour, lash and meibomian orifice orientation,
and the symmetry between the two eyes.
2. The eyelid movement in various gaze positions.
3. The strength of forced eyelid closure.
4. The presence of masses or tethering.
5. Internal or external scarring.
6.5 Significance
Eyelid malpositions affect function and appearance. With upper lid ptosis the lid
margin can occlude the visual axis and impair vision. With lesser degrees of pto-
sis, the affected eye appears smaller, attracting unwelcome attention. Conversely,
eyelid retraction increases corneal exposure, giving rise to discomfort and a staring
look. Always ask yourself whether you are observing true ptosis or contralateral
lid retraction. The latter can cause a pseudo ptosis thanks to Hering’s law of equal
innervation.
Entropion allows lash and skin keratin contact with the cornea causing irrita-
tion and potentially corneal ulceration and scarring. Ectropion, on the other hand,
causes little discomfort or risk to vision. Instead, increased watering, and redness
and crusting of the exposed conjunctival lid surface are the commonest complaints.
6.6 Causation
Aging is by far the commonest cause of eyelid malposition in temperate climates.

It leads to weakening of connective tissues and deflation of the mid face and orbit
resulting in relative eyelid laxity against the now enophthalmic eye as already
mentioned.
The exact mechanism of individual malpositions is still debated. Why for
example are the signs of involutional ptosis, contact lens wear related ptosis,
and Horner’s ptosis identical (normal levator function, raised skin crease and no
‘hang-up in downgaze)? Might Müller’s muscle failure be a common denomina-
tor? Apparent medial canthal tendon laxity could be a consequence of deflation,
dehiscence, or weakening of the posterior pull of Horner’s muscle.
6.7 Don’t Strip! 67
6.7 Don’t Strip!
Eyelid tightening is an integral part of most entropion and ectropion correction.

If the canthal tendons are intact, it involves resection of part of the lid margin.
This may be carried out anywhere along the lid margin. Performing the resection
at the lateral canthus gives the best functional and aesthetic outcomes. There are
two ways of performing this: the lateral tarsal strip (LTS) (Fig. 6.3b) and the Bick
resection (BR) (Fig. 6.3c). They both achieve a similar initial outcome (Fig. 6.3d),
but the more complex LTS risks damaging the lateral canthal tendon and has a
higher complication rate [2], so avoid it.
Lateral canthopexy involves using a suture to suspend the lid from the lateral
orbital rim periosteum. It is used by some to temporarily tighten a lid e.g., after a
lower lid blepharoplasty. However, as minimal permanent scarring is induced, this
procedure soon fails through suture migration.
Note: Originally, the ‘lateral canthal sling’ operation was developed to correct
lateral canthal tendon weakness. Since being rebranded as the LTS it has become
the most popular lateral lid shortening procedure. This is unfortunate because the
LTS relies on burying a strip of the tarsal plate. The tarsal plate stretches, losing
effectiveness, and burying the meibomian glands it contains may cause granulomas.
a b
c d
Fig. 6.3 Lateral lid shortening options. a Full thickness, oblique, lateral canthal incision. b Lateral
tarsal strip (fashioned from the excess lid margin). c Lateral lid margin resection. d Result of both
looks similar. However, the LTS stretches with time
• Eyelid position is determined by the sum of all the active and passive forces
acting on it.
References
1. Beigi B, Kashkouli MB, Shaw A, Murthy R (2008) Fornix fat prolapse as a sign for involutional
entropion. Ophthalmology 115(9):1608–1612
2. Vahdani K, Rebecca F, Garrott H, Thaller V (2018) Lateral tarsal strip versus Bick’s procedure
in correction of eyelid malposition. Eye 32. https://doi.org/10.1038/s41433-018-0048-9
Ingrowing Eyelashes
7
Fig. 7.1 Epilation
Inwardly growing eyelashes are not only uncomfortable but can cause corneal
ulcers. The commonest cause is lid margin or conjunctival scarring which misdi-
rects lash growth. We call this trichiasis (normal lashes growing in an abnormal
direction).
Rarely, individuals are born with an extra row of lashes growing from an
abnormal position such as from the meibomian glands. This is termed distichiasis.
Metaplastic lashes are abnormal lashes growing from an abnormal position as
a result of chronic inflammation.
7.1 Assessment
1. Is there a recognised reason for the lash line distortion, such as previous
trauma?
2. Establish whether the lid margin is correctly orientated by noting the position
of the meibomian orifice line. An entropion of the lid margin causes symptoms
similar to trichiasis but is treated differently.

70 7 Ingrowing Eyelashes
3. Look for conjunctival scarring as the cause (cicatricial lash entropion). Unex-
plained symblepharon (abnormal connection between the palpaebral and bulbar
conjunctiva) is a red flag for cicatricial pemphigoid. It is best seen by pulling
the lid away from the eye and looking for conjunctival tethering.
4. Look for rounding of the posterior lid margin (seen in chronic staphylococcal
lid margin disease).
5. Check whether the lashes are being pushed inwards by an overhanging skin
fold. This might require a blepharoplasty.
6. Note the position and number of lashes involved.
7.2 Treatment Options
7.2.1 Epilation (Fig. 7.1)
Pulling the lashes out is worth trying on the first occasion if only a few lashes
are involved. Review the patient after 8 weeks to check whether the lashes have
regrown. Do not use epilation as a long-term treatment.
Note: If you fail to epilate the eyelash bulb the broken lash will regrow as sharp
stubble which is more dangerous for the cornea than a long bendy lash.
7.2.2 Electrolysis to the Lash Root
Passing a small electric current through the root can permanently destroy individ-
ual lashes if administered correctly. Because the lash roots are not visible it can be
difficult to be certain that you have positioned the electrolysis needle tip correctly
alongside the root. Overtreatment risks causing lid margin scarring and distortion
which can lead to further trichiasis of adjacent lashes. Therefore, use the lowest
current that causes bubbling for the shortest time that allows you to lift the lash out
without pulling. There is approximately a 50% treatment failure per lash treated
so warn the patient that the treatment may have to be repeated. For this reason,
reserve electrolysis for the treatment of isolated lashes.
7.2.3 Localized Full Thickness Lid Margin Resection
This is the most effective way of treating a clump of in turning lashes. It does
not leave a visible gap in the lash line but carries the risk of causing a lid margin
notch if not performed well.
7.2.4 Localized ‘en bloc’ Lash Resection
Resecting only the lash bearing anterior lamella is an effective and less invasive
alternative to full thickness resection but leaves a denuded lash free section on the
lid margin which patients may find less acceptable.
7.2.5 Lash Cryotherapy
This is very effective and avoids surgery. Use only a proprietary, calibrated, trichia-
sis cryoprobe, applying a double freeze/thaw cycle. The freeze timing is cryoprobe
dependent e.g., for the Cryo II Collins Trichiasis Pencil (Keeler) use two freeze
cycles each lasting for 25 s in the upper lid and for 20 s in the lower lid. Protect
the eye with an insulating shield as you do so. Cryotherapy destroys all the lash
roots treated. However, it also causes skin depigmentation, lid margin atrophy, and
occasionally full thickness lid margin necrosis (especially if the lid vascularity has
been compromised by previous surgery).
7.2.6 Anterior Lamellar Repositioning
This is the most effective and aesthetically acceptable treatment for trichiasis
involving 1/3 or more of the lid margin. (See Chap. 8).
• Repeated epilation is not a good long-term trichiasis treatment strategy.

Entropion
8
8.1 Overview
• Types of entropion
• Entropion assessment
• Lower lid involutional entropion:
temporary management and
permanent correction.
The lower lid is inherently less stable about its long axis than the upper lid, as
explained in Chap. 6. It flips inwards on minimal provocation giving rise to entro-
pion. By contrast, upper lid margin entropion requires a sustained strong force,
such as that caused by conjunctival scarring, to cause margin entropion.
8.2 Types of Entropion
8.2.1 Congenital Entropion
Entropion present at birth is uncommon.

Lower lid entropion often resolves spontaneously as the mid-face develops.
Therefore, monitor a child who is happy and does not have a red eye or photopho-
bia. By contrast, prompt surgical entropion correction is necessary for an unhappy,
photophobic child with a red eye watery eye. Excise a narrow horizontal strip
of skin and orbicularis from below the lash line, avoiding the lash roots. Form a
skin crease by including a bite of the inferior tarsal plate edge in the skin closing
sutures (Hotz repair Fig. 8.1).
Rarely, congenital entropion may be part of the ocular fibrosis syndrome
(associated with strabismus due to extraocular muscle fibrosis).
The tarsal kink syndrome is a rare form of upper lid entropion occurring when
the lid becomes folded in on itself in utero. Unnecessarily complex procedures have
74 8 Entropion
a b
c d
Fig. 8.1 Hotz repair for congenital lower lid entropion. a Lower lid congenital entropion. b Evert
the lower lid margin by pulling down and mark a narrow skin ellipse that avoids the lash roots (3–
4 mm below the lashes). Excise the marked ellipse of skin with the underlying orbicularis. c Place
3 or 4 absorbable 6/0 sutures across the defect ensuring that each includes a bite of the lower tarsal
plate edge. d Tie the sutures to close the wound and create a skin crease to prevent future orbicularis
overriding
a b
Fig. 8.2 Tarsal kink everting sutures. a Congenital tarsal kink is a rare condition in which the
upper tarsal plate is folded on itself at birth. b Place three absorbable everting sutures to perma-
nently cure the problem
been described to treat it. Simply inserting temporary absorbable transcutaneous

lid everting sutures between the superior and inferior edges of the tarsal plate
effects a permanent cure (Fig. 8.2).
8.2.2 Involutional (Age Related) Entropion
Age is the commonest cause of lower lid entropion in temperate climates, conse-
quently the focus of this chapter. A similar type of entropion can occur in younger
patients as the result of persistent eye rubbing.
8.2 Types of Entropion 75
The factors requiring surgical correction are:
1. the relative laxity of the eyelid against the eye (lid-globe disparity),
2. lower lid retractor laxity or imbalance, and
3. the overriding of the pre-septal orbicularis to a pre-tarsal position.
Spastic entropion is a subset of involutional entropion. Corneal irritation provokes

reflex orbicularis contraction, which leads to in-turning of an unstable lid margin.
The irritation caused by the entropion perpetuates the squeezing and hence also
the entropion.
8.2.3 Cicatricial Entropion
The term ‘cicatricial’ implies scarring related. Any condition that causes conjunc-
tival or sub-conjunctival shrinkage will pull the lid margin inwards. Either one or
both lids may be affected. The following are the most common causes.
8.2.3.1 Trachoma
Trachoma is a chronic infectious conjunctivitis caused by chlamydia trachomatis.
It causes progressive conjunctival scarring which leads to cicatricial entropion. The
entropion, in turn, leads to secondary corneal scarring and eventually to blindness.
It is endemic in parts of Africa, South America, Asia, and Australia, and is the
commonest cause of preventable blindness worldwide.
8.2.3.2 Chronic Staphylococcal Lid Margin Disease

This is the most common cause of cicatricial entropion in temperate climates. It
causes initial rounding of the normally angled posterior lid margin followed by
in turning of the meibomian orifice openings and then progressive lash/corneal
contact (Trichiasis).
8.2.3.3 Ocular Cicatricial Pemphigoid

Ocular cicatricial pemphigoid is a rare auto-immune condition giving rise to
recurrent conjunctival inflammation which results in scarring and shrinkage. It is
ultimately a blinding condition if not managed by effective immunosuppression.
The onset is insidious, and sadly it is often diagnosed too late. Unless you specif-
ically look for it you will miss the diagnosis. Regard unexplained symblepharon
(abnormal attachment between the bulbar and tarsal conjunctiva) as cicatricial
pemphigoid until proved otherwise. Diagnostic conjunctival biopsy is advocated,
but it only has a 50% sensitivity. Conjunctiva breaching surgery accelerates the
condition, and any surgery, including biopsy, should be delayed until the patient
is effectively immunosuppressed. In my opinion the diagnosis remains a clinical
one.
76 8 Entropion
8.3 Entropion Assessment/Examination
8.3.1 Lid Tone and Laxity
Grasp the lower lid skin, close to the lashes, between your thumb and forefinger
and pull it away from the eye. Note how far away from the cornea the margin
moves. Then let go and note how quickly and completely it returns to a normal
position (the ‘snap back’ test). Alternatively perform the ‘snap back’ test by pulling
the lower lid down to the orbital rim with your thumb or finger and observe the
speed of its return when released.
Apparent lid laxity may result from age associated enophthalmos. The back-
ward displacement of the globe through loss of orbital fat means that the eye is no
longer pressing as firmly against the lid from behind.
Actual lid lengthening occurs through a combination of aging and chronic eye
rubbing.
Finally, the canthal tendons, which anchor the lid to the orbital rim, may have
weakened or dehisced (see below).
8.3.2 Medial Canthal Tendon and Lateral Canthal Tendon

Integrity
Grasp the lower lid close to the lashes, between your thumb and forefinger and pull
it laterally, away from the medial canthus while observing the movement of the
lower lid punctum relative to the corneo-scleral limbus. Any movement past the
medial limbus (in straight ahead gaze) suggests significant medial canthal tendon
laxity.
Repeat this manoeuvre again but this time pulling the lid medially while observ-
ing the movement of the lateral canthus. A significant drift of the lateral canthus
medially towards the lateral limbus suggests lateral canthal tendon dehiscence.
8.3.3 Conjunctival Scarring/Symblepharon
Evert the lids to examine the conjunctival surface with a slit lamp. Note any sub-
conjunctival scarring. This is best seen using green illumination. Scarring may be
a sign of previous surgery, trauma, trachoma, or of an on-going process such as
cicatricial pemphigoid. Check particularly for any conjunctival fornix shrinkage or
localized bands (symblepharon) between the lid and the globe. Do this by pulling
the lid away from the eye and asking the patient to look in the opposite direction.
8.3.4 Orbicularis Over-Riding
Correct the lower lid entropion by pulling downward on the skin to restore the lid
margin to its correct orientation. Observe whether the entropion returns when the
8.4 Temporary Lower Lid Involutional Entropion Management 77
patient blinks. If it does not, ask the patient to squeeze their eyes tightly shut to
see whether this triggers entropion recurrence.
8.4 Temporary Lower Lid Involutional Entropion

Management
8.4.1 Taping
Teach the patient to apply a strip of adhesive tape to the lower lid skin, just below
the lashes, to pull the skin downwards towards the cheek. This additional pull
on the lid margin may temporarily control the entropion while the patient awaits
surgery.
8.4.2 Botulinum Toxin
A single subcutaneous injection of botulinum toxin (10 units of Dysport® or 2.5

units of Botox® ) to the pre-tarsal orbicularis at the junction of the lateral 1/3
and medial 2/3 of the lid temporarily paralyses the lower lid orbicularis and may
control a spastic entropion for several weeks (Fig. 8.3). It is not a permanent
solution but a useful temporising treatment of the spastic component while surgical
correction is being arranged. Paradoxically, it can make it harder to persuade a
patient of the need for surgical correction once their symptoms have temporarily
abated.
Dysport®10 units or
Botox® 2.5 units
1/3 2/3
Fig. 8.3 Botulinum toxin entropion relief. Paralyse the pretarsal orbicularis with a subcutaneous
injection of botulinum toxin
78 8 Entropion
8.4.3 Everting (Quickert) Sutures
Absorbable 6/0 sutures placed obliquely through the lid, from the conjunctival
surface just below the tarsal plate to emerge on the skin just below the lashes
(Fig. 8.4), will temporarily stop the orbicularis from overriding and may tighten
the lower lid retractors and so prevent the entropion from occurring. In my hands
the effectiveness of everting sutures is short lived, lasting only as long as the
sutures themselves. I consider them to be a temporizing manoeuvre. However,
some authors have reported longer lasting success (78% at 18 months) [1].
Fig. 8.4 Quickert everting sutures. a. Insert three double armed absorbable sutures transconjuncti-
vally from the lower fornix to exit the skin 3–4 mm below the lash line. b. The tied sutures transfer
the lower lid retractor pull to the anterior lamella and create a barrier to orbicularis overriding
8.6 Lateral Lid Margin Resection and Modified Bick Repair (Fig. 8.7) 79
8.5 ‘Permanent’ Surgical Correction of Involutional

Entropion
8.5.1 Principle
Surgical correction of lower lid involutional entropion requires:
1. tightening of a lax lid margin,

2. reinsertion of dehisced lower lid retractors into the anterior lamella, and
3. preventing the pre-septal orbicularis from overriding pre-tarsally.
‘Permanent’ is used loosely in this context as the aging that caused the involutional
entropion is not stopped by surgery. In my experience, effective surgery prevents
entropion recurrence for a minimum of 5 years and usually much longer. If your
corrections fail sooner review your surgical technique.
The above three factors are all corrected by the well described Quickert ‘four
snip’ entropion correction procedure [2] (Fig. 8.5). The shortening of the lid mar-
gin can be performed more elegantly at the lateral canthus using a Bick resection/
repair, and the retractor plication under direct vision can be performed without
breaching the conjunctiva as described below (Fig. 8.6). I describe these two com-
ponents separately although you will perform both together for most entropion
corrections.
8.5.2 The Lid Shortening Rule
As a rule of thumb, shortening a lid margin by less than 5 mm verges on homeopa-

thy. In contrast, never shorten by more than 15 mm because you will have missed
a canthal tendon dehiscence which must be corrected first.
8.6 Lateral Lid Margin Resection and Modified Bick Repair

(Fig. 8.7)
Relative lid/globe laxity is a usual pre-requisite for involutional entropion to occur.

The simplest surgical remedy is to shorten the lid margin. Only undertake short-
ening once you have confirmed the integrity of the medial and lateral canthal
attachments. Address any dehiscence of these before attempting to shorten the lid.
Combine lid shortening with a retractor plication.
Involutional entropion without canthal tendon laxity.

80 8 Entropion
a b
c d
e f
Fig. 8.5 Quickert entropion correction. a. Pull the lid down to correct the entropion. b. Mark and
incise a horizontal incision 4–5 mm below the lash line and a vertical incision from the lid margin to
meet it. c. Overlap the resulting lid margin flaps and mark and excise the excess. d Insert 3 double
armed sutures transconjunctivally to pick up the lower lid retractors. Then repair the lid margin.
e Bring the retractor sutures out through the orbicularis and skin 2 mm below the lash line. f Tie
the retractor sutures tightly and close the horizontal skin wound
8.6.3 Steps
1. Load two double ended 6/0 absorbable sutures onto locking needle holders and
prepare them for instant use.
2. Grab the full-thickness lid margin laterally with Adson’s forceps and place
the lateral canthus on stretch by pulling the lid medially. Detach the lower lid
margin from the lateral canthus by cutting infero-laterally at 45° from the lateral
canthus for approximately 5–8 mm with Steven’s tenotomy scissors (Fig. 8.7b).
a b
5 mm
c d
e f
Fig. 8.6 Entropion correction. a Incise the skin and orbicularis. b Find and tag the lower lid retrac-
tors with 3 double armed absorbable sutures. c Shorten the lid margin laterally. d Repair the lateral
defect to tighten the lid margin. e Bring the retractor sutures out through the skin edges. f Tie the
sutures to simultaneously close the skin, plicate the retractors and create a barrier to orbicularis
overriding. Consider adding a continuous skin suture between the retractor suture knots
Note: Cut slowly to crush the vessels and reduce bleeding.
3. Without delay (before the bleeding starts) grab the exposed cut lateral canthal
tendon with toothed forceps (St Martins) and insert the first of the two pre-
mounted double armed 6/0 sutures as close to the canthus as possible. Before
letting go, insert the second arm of the suture 1 mm below the first. Confirm
a strong purchase by tugging the suture ends firmly. There should be no give.
Clip the pair of suture ends together with a bulldog clipboard (Fig. 8.7c).
82 8 Entropion
a b
c d
e f
g h
i j
Fig. 8.7 Bick resection. a Pull the lid down to correct entropion and mark incision at the lateral
canthus. b Cut the full thickness of the lid infero-laterally to detach it from the canthus. c Pre-
place two lateral canthal tendon absorbable sutures. d Overlap the cut edges to mark the excess
lid margin. e Excise the excess lid margin. f Reattach the tarsal plate with the preplaced sutures.
g Insert a margin closing 7/0 absorbable horizontal mattress suture. h Tighten and tie the tarsal
plate sutures. i Tighten and tie the lid margin suture to bury the knot. j Close the orbicularis and
skin
Note: An assistant is required to spread the canthal tissues apart to improve

visualization.
4. Place the second 6/0 suture 2 mm below the first in a similar fashion and again
confirm strong fixation. If there is any ‘give’ replace the suture more deeply.
Clip both ends together.
5. Ask an assistant to pull the upper of the two lateral canthal tendon sutures
medially to put the lateral canthus on medial stretch. Grasping the cut lateral
edge of the lid margin with toothed Adson’s forceps, pull it laterally to overlap
the taut lateral canthus until the lid margin is straight and mark the extent of
the overlap with a surgical marking pen (Fig. 8.7d). Measure this overlap. It is
normally between 7 to 15 mm. In the unlikely event that it is less, there was
either no lid margin laxity or the lid was not being pulled firmly enough. If
greater than 15 mm, undiagnosed medial canthal laxity is present and needs
to be treated before continuing.
6. Excise the excess lid margin as a triangle or pentagon, with tenotomy scissors
(Fig. 8.7e).
7. Insert the two pairs of pre-placed LCT 6/0 sutures in sequence through the
cut edge of the tarsal plate, starting with the uppermost (Fig. 8.7f). Insert
them from behind, trans-conjunctively, through the full thickness of the tarsal
plate, exiting through its anterior surface and bring them out of the wound
edge. Avoid engaging the orbicularis or skin. Place each subsequent suture
about 1 mm below the previous one. Clip the corresponding pairs of sutures
together again, temporarily. This results in the shortened lid being reattached
by the two horizontal mattress sutures.
8. Before tying the above sutures, place a single ended 7/0 absorbable suture in
the lid margin as a horizontal mattress (Fig. 8.7g). This time insert the suture
through the orbicularis to exit the skin through the lash line, 1–2 mm from the
wound edge.
9. Then, with the same needle, re-enter the lid through the meibomian orifice line
and exit through the cut tarsal plate edge just above the top, already placed,
6/0 suture bite (taking care not to inadvertently engage it with your needle).
10. Now enter the lateral canthal wound with the same needle, engage the upper
lid tarsal plate, and bring the needle out through the meibomian orifice line
1–2 mm from the lateral canthus.
11. Re-enter the upper lid lash line and exit the wound through orbicularis to
complete this lid margin mattress suture. Clip its two ends together.
12. Now that you have placed the sutures under direct vision, pull the ends of the
lower of the two 6/0 sutures laterally (Fig. 8.7h). Use their pulley action to
pull the lid margin laterally towards the LCT to close the posterior lamella.
Tie the suture with no less than three throws and cut the ends no shorter that
2 mm (to prevent spontaneous unravelling).
13. Tighten, tie and cut the upper 6/0 suture similarly.
84 8 Entropion
14. Tie the 7/0 pre-placed margin suture (Fig. 8.7i). This will align the lid margin
at the lateral canthus. Cut the ends flush with the skin so that the knot becomes
buried and does not irritate.
15. Close the remaining anterior lamellar defect with two or three horizontal
mattress 7/0 absorbable sutures through the skin and orbicularis (Fig. 8.7j).
8.6.4 Notes
• The tightened lid margin may slip below the globe appearing retracted. This is
usually only temporary and resolves within a couple of weeks.
• In Bick’s original procedure the lid margin is crushed before cutting to reduce
bleeding. This advantage is gained at the expense of clear visualization of the
epithelial surfaces and makes an accurate two lamellar repair more difficult.
• For entropion repair, the lid margin shortening is usually combined with a
retractor plication (Fig. 8.8). Pre-place the retractor sutures before perform-
ing the lid margin resection but do not bring them through the skin until the lid
shortening is complete to avoid horizontal misalignment.
8.7 Lower Lid Retractor Plication (Fig. 8.8)
In humans lower lid retraction in down gaze is achieved by a fibrous connection

between the inferior rectus muscle and the eyelid. It is known as the capsulo-
palpebral head or aponeurosis of the inferior rectus (the lower lid has no distinct
retractor muscle analogue to the upper lid levator palpaebri superioris). A sec-
ondary effect of the retractor is to stabilize the lower edge of the tarsal plate.
Laxity of this retractor, through stretching, dehiscence, or relative laxity from
enophthalmos, may render the eyelid margin unstable. Dehiscence of only the
anterior lamellar attachment allows the pull of the posterior lamellar attachment
to pull the lid margin inwards. Surgically re-attaching the retractor to the anterior
lamella works dynamically pulling the lid margin outwards each time the retractors
pull.
Additionally, anterior approach retractor plication prevents orbicularis over-
riding by creating a surgical barrier scar that separates the pre-tarsal from the
pre-septal orbicularis (a passive mechanism). Always combine plication with a
concurrent lid margin tightening unless you have a strong reason not to [3].
8.7 Lower Lid Retractor Plication (Fig. 8.8) 85
a b
5 mm
c d
White line
Retractor aponeurosis
Septum & Pre-apo fat
e f
g h
Fig. 8.8 Lower lid retractor plication. a Pull the lid down to unroll any margin entropion. b Keep-
ing the skin on a downward stretch, incise the skin and orbicularis horizontally 5 mm below the
lash line. c Bluntly dissect the septum and fat pad infero-posteriorly to reveal the retractor aponeu-
rosis. d Grab the aponeurosis fold (‘white line’) and insert a suture centrally. e Place two more
white line sutures. f For each suture bring one end out through the upper and the other through the
lower edge orbicularis and skin. g Tie the white line sutures tightly. h Close the skin between the
retractor sutures and cut them flush with the lid margin
86 8 Entropion
Involutional entropion if combined with a lid tightening.
8.7.3 Steps
1. Place the lower lid skin on a gentle downward stretch (Fig. 8.8a) and make
a horizontal incision through the lower lid skin and orbicularis approximately
5 mm below the lash line (Fig. 8.8b).
2. Bluntly separate the deeper tissues downwards, retracting and pushing the
orbital septum and underlying fat pad posteriorly with a cotton bud while
stretching the lid margin upwards. This reveals a whitish sheet of tissue and
often a ‘white line’ where the aponeurosis reflects on itself (Fig. 8.8c).
3. Grab the ‘white line’ with toothed forceps centrally (in the mid-pupillary
line) and tag it with a double armed 6/0 absorbable suture (e.g., polygalactin)
(Fig. 8.8d).
4. While asking the patient to look up with both eyes open, take up any slack in
the suture and hold it under gentle tension between the thumb and forefinger.
Then ask the patient to look downward as far as possible. You should feel a
tug on the suture, positively confirming that it is anchored in the retractors. If
you do not feel a tug, try again, but this time instruct the patient to follow your
other hand in a downward arc, to ensure that you elicit full down gaze. If there
is still no pull, then the suture is not anchored in the retractors, and you need
to replace it following further dissection.
5. Place two similar sutures, one on either side at about 5 mm from the central
suture. Keep each pair of suture ends together with a bulldog clip until all three
are placed (Fig. 8.8e).
6. At this point perform full thickness lid margin shortening if necessary (see Bick
repair above).
7. At the end of the operation (after any lid margin resection) pass one end of
each pair of retractor placation sutures through the superior and inferior skin
edges respectively (Fig. 8.8f).
8. Tie them across the wound. They both close the wound and create a skin crease
which deepens when the patient looks downward. Do not cut the suture ends at
this stage but clip them together again (Fig. 8.8g).
9. Finally, close the skin incision further with a continuous absorbable 7/0 suture,
placing a bite between each of the retractor sutures and a knot at either end
(Fig. 8.8h). Cut the retractor sutures flush with the lid margin. This leaves their
ends long enough to grasp easily should a suture need early removal.
Note: In the unlikely event that you discover an overcorrection the next day (a lid
margin ectropion) remove the retractor suture(s) which appears to be responsible.
You may do this safely as the continuous skin suture will prevent the wound from
re-opening.
8.8 Posterior Medial Canthal Thermoplasty 87
8.8 Posterior Medial Canthal Thermoplasty
Laxity of the medial canthal tendon (MCT) is common. Whether it is due to failure
of the tendon itself or merely a dehiscence of its attachment to the tarsal plate
is unclear. Several techniques have been described to address the problem, but
none are straightforward, and most are not long lasting. Most use non-absorbable
sutures. Although the sutures remain permanently, any useful tension they provide
is soon lost through suture migration. The technique I describe here is what I call
a “cheat operation”. It involves no dissection and works by creating a directed,
posterior lamellar, thermal scar. This simple procedure is surprisingly effective in
about 3/4 of cases.
Significant medial canthal tendon laxity (the punctum can be pulled laterally past
the medial corneal limbus).
8.8.3 Steps
1. Check whether there is significant MCT laxity by observing punctal movement

as you pull the lid laterally (Fig. 8.9a). If it moves as far as the medial limbus
or further the laxity is clinically significant.
2. Before embarking on a thermoplasty check for the presence of a strong medial
canthal fixation point. Do this by grabbing the tissue between the medial
canthus and the caruncle, through the conjunctiva, with toothed forceps and
pulling (Fig. 8.9b). This tissue probably represents the lateral extent of the
medial canthal tendon. If there is firm resistance (no give), then a thermoplasty
can be used.
3. Insert a 6/0 double armed, absorbable suture transconjunctivally behind your
forceps through this firm tissue with a double pass (Fig. 8.9c). Clip the two
ends of the suture together. Confirm firm placement by tugging on the suture.
There should be no give.
4. Place a second suture similarly to the first just below it as a failsafe (optional).
Clip this pair of ends together. If you are unable to obtain strong suture fixation
abandon the procedure.
5. Insert a Bowman’s lacrimal probe into the lower canaliculus until it stops
against the nose and use this probe as a lever to evert the medial lower lid
over a cotton bud held by an assistant (Fig. 8.9d).
6. Mark an inverted triangle of conjunctiva with its base extending from the
caruncle medially to the lacrimal punctum laterally and just avoiding the lower
canaliculus (made visible by the probe). The apex of the triangle is in the
conjunctival fornix, 5 mm proximal to the lid margin (Fig. 8.9e).
88 8 Entropion
a
b
d
c
e f
g h
Fig. 8.9 Posterior medial canthal thermoplasty. a Assess medial canthal laxity by observing punc-
tum movement as you pull the lid laterally. b Check for a strong medial canthal fixation point. Grab
the tissue between the medial canthus and the caruncle with toothed forceps and pull. You should
feel firm resistance (no give). c Pre-place two absorbable sutures into firm tissue. d Evert the medial
lid with a lacrimal probe and cotton bud. e Mark a medial triangle, based below the canaliculus
and the apex in the fornix. f Apply strong diathermy to burn the marked conjunctiva. g Insert the
pre-placed sutures into the tarsal plate transconjunctivally, bringing them out through a skin stab
incision. h Tie the sutures firmly and encourage the knots to retract under the skin
8.9 ‘Permanent’ Surgical Correction of Moderate Cicatricial Entropion 89
7. Burn the whole of this triangle with bipolar diathermy forceps, keeping their
tips slightly apart, until it is white (Fig. 8.9f). Avoid the canalicular area.
8. Rub off any loose necrotic conjunctiva with a cotton bud. Then withdraw the
lacrimal probe.
9. Make a small skin stab incision 4 mm below the lacrimal punctum.
10. Now pass the first of the pre-placed sutures into the tarsal plate, just lateral
to the punctum, from the conjunctival surface, as close to the lid margin as
possible, and bring the needle out through the skin stab incision. If this bite is
too far from the margin a punctal ectropion may result.
11. Pass the second end of the first suture similarly but enter the tarsal plate a
millimetre below the first. Bring the needle out through the same skin stab
incision.
12. Pass the second pair of preplaced sutures similarly, each a millimetre below
the previous one (Fig. 8.9g).
13. Tie each of the two pairs of sutures tightly, allowing their knots to retract into
the skin stab incision and bury themselves (Fig. 8.9h).
8.8.4 Notes
• This procedure causes temporary distortion and kinking of the canalicular por-
tion of the lid margin medial to the punctum. This will resolve once the sutures
absorb. The purpose of the sutures is to direct the conjunctival scar formation
and contraction medially rather than inferiorly.
• The sutures may occasionally cut through and cause some discharge and
irritation. Remove any loose sutures.
• The efficacy of this procedure does not distinguish between the possible aeti-
ologies of the original medial laxity. The thermal scar created could equally
well address a Horner’s muscle failure as a MCT dehiscence.
8.9 ‘Permanent’ Surgical Correction of Moderate Cicatricial

Entropion
8.9.1 Anterior Lamellar Repositioning
8.9.1.1 Principle and Considerations

Anterior lamellar repositioning corrects mild to moderate lash entropion. It works
by first separating the anterior from the posterior lid lamella as far as the lash roots
and then suturing the lamellae together again with the anterior lamella pulled away
from the margin. This everts the lid margin and lashes and provides a static compo-
nent to the correction. Suturing the lid retractors to the skin incision during wound
closure adds a long-acting dynamic component to the operation. The procedure is
equally applicable to the upper or the lower lid.
90 8 Entropion
Cicatricial lid margin entropion with sufficient conjunctival fornix not to require a
mucous membrane graft.
8.9.3 Steps
1. Make a skin crease incision, through the skin and the orbicularis, the length of
the lid. In the upper lid make this at the level of the desired post-operative skin
crease (usually about 7–8 mm from the lid margin in Caucasians). In the lower
lid 4–5 mm from the margin is usually satisfactory (Fig. 8.10a).
2. Dissect down, perpendicularly to the surface, to reach the tarsal plate. If you
cut at an oblique angle, you confuse your orientation.
3. Starting in the middle of the incision, dissect towards the lid margin taking care
to remain on the surface of the tarsal plate throughout (Fig. 8.10b).
4. Continue the dissection towards the lid margin until the lash roots become vis-
ible from behind (Fig. 8.10c). At this point the scissors usually enter a narrow,
channel like, space. Extend the dissection medially and laterally by keeping one
blade of the Westcott scissors within this channel and the other outside it on
the surface of the tarsal plate. This makes extending the dissection very easy.
This dissection separates the anterior lamella from the posterior lamella, but they
remain hinged at the margin.
5. Place five 6/0 absorbable interrupted, everting sutures (Fig. 8.10d). Penetrate
the anterior lamella just proximal to the lash line. Then take a partial thickness,
horizontal, 2 mm long bite of tarsal plate about 2 mm proximal to the skin
entry site i.e., higher up the tarsal plate. Finally exit the anterior lamella just
proximal to the lash line (but distal to the tarsal bite) to complete the ‘box’
type suture. Do not tie this suture but clip its ends together. Now insert and clip
the next suture similarly before tying the first. This delayed tying allows clear
access and visualization for the accurate placement of the subsequent suture
and avoids stressing the previously placed suture. Repeat this sequence for all
the sutures.
Note: As each suture is tied the lashes are seen to evert. Very slight lid margin
eversion may also be seen. If there is significant eversion of the margin, then the
tarsal bite has been placed too proximally. That suture should either be tied less
tightly or replaced.
8.9 ‘Permanent’ Surgical Correction of Moderate Cicatricial Entropion 91
a b
c d
e f
i ii
iii iv
Fig. 8.10 Anterior lamellar repositioning (ALR). a Mark and make a skin crease incision. b Dis-
sect down to the tarsal plate. c Dissect on the tarsal plate surface to expose the lash roots. d Insert 5
box type everting sutures from low down on the anterior lamella to higher on the posterior lamella.
e Plicate the levator aponeurosis to the skin incision to reform a skin crease. f Use the plication
sutures to close the skin incision. g i & ii Cross-sectional view of simple ALR. iii & iv ALR
augmented by grey line split
92 8 Entropion
If more lash eversion is needed, make a 1–1.5 mm deep grey line incision along
the length of the lid margin (Fig. 8.10g iii and iv). Take care not to detach the whole
anterior lamella from the margin by joining this incision to the deep dissection plane.
6. Bluntly dissect beneath the upper wound edge, proximally upwards (on the
surface of Müller’s muscle in the upper lid) to reveal the ‘white line’ of the
reflected retractor aponeurosis. In patients with strong connective tissue West-
cott spring scissors may need to be used for this dissection. Pull Muller’s muscle
downwards to make the white line appear.
7. Suture the white line to the skin with three absorbable 6/0 sutures (Fig. 8.10e).
Note: In this way the retractor pulls on the anterior lamella imparting a lasting
‘dynamic’ component to the operation.
8. When applying the dressing ensure that the lashes are padded in an everted
direction.
Note: Warn the patient that the lashes will initially point unnaturally upwards but
that they will gradually return to a more normal position.
8.10 Mucosal Grafting
If conjunctival scarring has caused significant shrinkage of the fornix, additional

labial or buccal mucosal grafting will be required to deepen the fornices. Details
of this fall outside the scope of this book.
• Aging is the commonest cause of entropion.

• Cicatricial pemphigoid, though rare, is easily missed if not specifically looked
for.
• Lasting correction of involutional entropion requires lid margin shortening,
retractor reinsertion and orbicularis stabilization.
References 93
References
1. Meadows AE, Reck AC, Gaston H, Tyers AG (1999) Everting sutures in involutional entropion.
Orbit 18(3):177–181. https://doi.org/10.1078/orbi.18.3.177.2708.PMID:12045982.
2. Quickert MH. In: Sorsby A (ed) Modern ophthalmology, vol 4, 2nd edn. Butterworth, London,
p 940
3. Danks JJ, Rose GE (1998) Involutional lower lid entropion: to shorten or not to shorten? Oph-
thalmology 105(11):2085–2087. ISSN 0181–8420. https://doi.org/10.1018/S0181-8420(98)911
28-5
Ectropion
9
9.1 Overview
• Types
• Assessment
• Surgical management:
– Lid margin wedge resection & Bick repair
– Medial lower lid retractor plication
– Central lower lid retractor posterior plication
– Free skin graft
– Upper to lower lid skin pedicle flap
– Permanent (overlap) lateral tarsorrhaphy
– Medial canthoplasty.
Lid margin ectropion (outward turning) can affect both the upper and the lower
lids. The commonest cause of lower lid ectropion is aging (involutional ectropion).
Upper lid ectropion is the result of anterior lamellar scarring (cicatricial ectropion).
Iatrogenic upper and lower lid cicatricial ectropion sometimes follow periocular or
mid face surgery. They can be avoided by following simple rules (see Chap.14).
9.2 Symptoms
Watering is the commonest symptom of ectropion. It occurs with as little as a mil-

limetre of punctal ectropion. An ectropic punctum dries and closes spontaneously.
Lower lid margin ectropion allows tears to collect in the trough formed between the
everted lid and the eye. They overflow when the patient leans forwards, particularly
when reading.
Constant wetting from tear overflow causes an eczematous skin reaction which
adds a cicatricial component to the ectropion. Manage this by waterproofing the

96 9 Ectropion
skin with a thin smear of hydrocortisone 1% skin ointment. This also settles the
inflammation. Instruct the patient to massage the ointment gently towards the lid
margin two or three times a day.
The second commonest complaint is of redness and crusting of the of the
exposed lower lid conjunctiva. Even when the patient is not bothered about these,
it bothers those who see them.
Ectropion may cause minimal symptoms in the elderly whose tear production
is naturally reduced. It is not a threat to vision and is safe to leave untreated if the
patient prefers.
9.3 Types
9.3.1 Congenital
Congenital ectropion is rare, associated with anterior lamellar shortage and it may
be part of a syndrome such as Down’s.
9.3.2 Involutional
Aging is the commonest cause of lower lid ectropion. Enophthalmos caused by

orbital fat atrophy results in a relative laxity of the lid (lid-globe disparity) making
it unstable. ‘Facial deflation’ through fat atrophy, together with stretching of the
facial suspensory ligaments by relentless gravity, leads to mid face descent, which
in turn pulls downward on the lower lid, stretching it. A lifetime of eye rubbing,
and relative loss of orbicularis tone are further causative factors.
The posterior attachment of the lower lid retractors to the inferior edge of the
tarsal plate stabilizes it. Laxity of the retractors permits an unstable lid to flip
outwards by 180o (tarsal ectropion).
Gravity prevents upper lid involutional ectropion by holding the lid against the
eye.
9.3.3 Eye Rubbing
Constant eye rubbing stretches the lid margin and weakens the canthal tendons.
Nocturnal stretching of the lids by head movement against the bedclothes is a
possible explanation for the floppy eyelid syndrome.
9.4 Assessment 97
a b
Fig. 9.1 Paralytic ectropion. a Paralytic ectropion tends to recur. b Combine lid shortening (pas-
sive) with medial canthoplasty and lateral tarsorrhaphy to transfer active lift from the upper to the
lower lid
9.3.4 Cicatricial
Any condition that causes skin shrinkage will pull the lid margin outwards.
Chronic eczema, and the eczematous reaction caused by constant skin wetting
through tearing, cause ectropion. Rare conditions such as Icthyosis have a simi-
lar effect. However, the commonest cause is sun damage related skin shrinkage.
Iatrogenic skin deficit can occur following periocular tumour surgery, cosmetic
blepharoplasty and chemical or laser ‘skin resurfacing’.
9.3.5 Paralytic
Loss of orbicularis muscle tone, whether age related or due to denervation, as

in facial palsy or botulinum toxin treatment, can give rise to a paralytic lower
lid ectropion. This type of ectropion has a strong tendency to recur following
simple lid margin tightening unless an additional active ‘lift’ from the upper lid
is introduced by performing a small lateral tarsorrhaphy and medial canthoplasty
(Fig. 9.1).
9.4 Assessment
9.4.1 Relative Lid/Globe Laxity (Invariably Present)
Geometry dictates that for a lid margin to hang away from the eye it must have
become lax relative to the eye. It is irrelevant whether this is due to enophthalmos
or actual lid margin lengthening through a combination of aging, frequent eye
rubbing and/or the chronic pull from tight skin.
98 9 Ectropion
9.4.2 Medial Canthal Tendon and Lateral Canthal Tendon

Integrity
Grasp the lower lid close to the lashes, between your thumb and forefinger and pull
it laterally, away from the medial canthus, while observing the movement of the
lower lid punctum relative to the corneo-scleral limbus. Any movement past the
medial limbus (in straight ahead gaze) suggests significant medial canthal tendon
laxity.
Repeat this manoeuvre again but this time pulling the lid medially while observ-
ing the movement of the lateral canthus. A significant drift of the lateral canthus
medially towards the lateral limbus suggests lateral canthal tendon dehiscence.
Correct canthal tendon dehiscence before contemplating lid margin resection.
If you do not, you will erroneously excise excessive lid margin to the detriment of
lid stability.
9.4.3 Anterior Lamellar Insufficiency
Attempt to correct (reduce) the lower lid ectropion by pulling the lid margin later-
ally and upwards with your finger. Observe whether tightness of the skin prevents
return of the lid margin to its normal position. Alternatively, while the patient is
looking upwards, gently pull the mid cheek slightly up and down and look for cou-
pled movement of the lid margin. Such movement confirms a significant anterior
lamellar deficit. Normally the cheek and lid move independently.
9.4.4 Orbicularis Tone
Place your forefingers on gently closed upper lids and your thumbs on the lower
lids and ask the patient to squeeze their eyes tightly shut. Try to open the eyes
with your fingers. This should only be possible with strong effort. Compare the
two sides. A weak orbicularis suggests a paralytic component.
9.5 Temporary Management
The management of ectropion is surgical. While awaiting surgery ask the patient
to massage their lower lid upwards, towards the lid margin with a thin smear
of Hydrocortisone 1% skin ointment (for three minutes, three times a day). This
softens the skin, treats tear overflow eczema, and prevents further skin shrinkage,
optimizing conditions for surgery. On rare occasions it can even cure the ectropion.
You can temporarily correct a tarsal ectropion by placing inverting sutures, but
this is seldom justified (Fig. 9.2).
9.6 Surgical Management 99
a b
Fig. 9.2 Inverting sutures. a Insert 3 double armed absorbable sutures transconjunctivally at the
lower edge of the tarsal plate, bringing them out through the skin 5 mm below the lash line.
b Tightening the sutures inverts the lid margin
9.6 Surgical Management
Factors requiring potential surgical correction are:
1. The relative laxity of the eyelid against the eye (invariably present),
2. Any apparent anterior lamellar shortage (caused by mid face descent, skin
shrinkage or scarring).
3. Significant lower lid retractor laxity ( for tarsal ectropion).
4. Lack of muscle tone.
They are present in various combinations and to various degrees. The decision
chart Fig. 9.3 may help you plan the appropriate combination of techniques during
surgery.
The mainstay of ectropion correction is lid margin tightening. This may require
canthal tendon repair and/or lid margin shortening.
In the presence of an anterior lamellar deficit first decouple the lid margin from
the mid face with a horizontal skin and orbicularis incision about 5 mm below the
lash line, extending it medially and laterally past the canthi. Once released, carry
out the necessary lid margin tightening to restore the lid to its correct position.
This reveals the true amount of anterior lamellar deficit.
If the lid is flipped completely inside out (‘tarsal ectropion’) with the proximal
tarsal plate edge forming the new margin, plicate the lower lid retractors to the
bottom of the tarsal plate to pull it downwards.
If an anterior lamellar defect remains after margin tightening, fill it with a skin
graft or flap, sized to allow for post-operative contraction. Use a temporary tarsal
traction suture to pull the lid margin upwards to expand the graft bed when sizing.
Tape this suture on tension to immobilize the graft during healing.
Finally, where there is significant orbicularis weakness consider performing a
small medial canthoplasty and lateral tarsorrhaphy to transfer active upper lid lift
to the lower lid.
100 9 Ectropion
Yes
Tight Anterior lamella? Subciliary anterior
release
No
Yes
Canthal tendon laxity? Canthal tendon repair
No
Yes
Lid margin lax? Shorten lid margin
No
Yes
Tarsal ectropion? Retractor plication
No
Yes
Anterior lamellar deficit? Skin graft/flap
No
Yes
Orbicularis weakness Medial canthoplasty &
Lateral tarsorrhaphy
No
End of operation
Fig. 9.3 Ectropion decision chart. Use this to determine the appropriate combination of proce-
dures for a particular case
9.7 Operations
9.7.1 Lid Margin Wedge Resection and Bick Repair

‘Tightening’ the lid margin by partial resection or canthal tendon plication sta-
bilizes a lid until it stretches again. Being a static repair, it fails in time. Full
thickness lid margin shortening may be carried out anywhere along the lid margin
(Fig. 9.4). Some argue that for a medial ectropion the resection should be carried
out medially, the merit being that the hypertrophied and inflamed section of the
lid is excised. However, this need not be an important consideration as the hyper-
trophy quickly settles once you restore the lid margin to its normal orientation.
9.7 Operations 101
Medial resection may be combined with medial lower lid retractor plication, as
in the Lazy T repair, or the medial plication can be separate from say a lateral
resection. I believe the lateral Bick resection to be the most elegant lid margin
shortening and the least likely to lead to margin notching or a noticeable scar.
Fig. 9.4 Shorten anywhere. a Lateral canthal lid margin resection. b Lateral lid margin resection.
c Medial lid margin resection
102 9 Ectropion
9.7.1.2 Steps
1. Load two double ended 6/0 absorbable sutures and prepare them for instant
use.
2. Grab the full-thickness lid margin laterally with Adson’s forceps and place
the lateral canthus on stretch by pulling the lid medially. Detach the lower lid
margin from the lateral canthus by cutting infero-laterally at 45° from the lateral
canthus for approximately 5–6 mm with Steven’s tenotomy scissors (Fig. 9.5a).
Note: Cut slowly to crush the vessels and reduce bleeding.
3. Without delay (before the bleeding starts) grab the cut lateral canthal tendon
(LCT) with toothed forceps and insert the first of the two prepared double
armed 6/0 sutures as close to the canthus as possible with a double pass
(Fig. 9.5b). Confirm correct placement by tugging on the suture firmly. There
should be no give. Apply a bulldog clip to the pair of suture ends.
Note: Get an assistant to stretch the canthal tissues apart to improve visualization.
4. Place the second 6/0 suture 2 mm below the first in a similar fashion and again
confirm strong fixation in the tendon. If there is any ‘give’ replace the suture
more deeply. Clip both ends together.
5. Ask your assistant to pull the upper of the two lateral canthal tendon sutures
medially to put the lateral canthus on medial stretch. Grasping the cut edge
of the lid margin with toothed Adson’s forceps pull it laterally to overlap the
lateral canthus until the lid margin is straight. Mark the extent of the overlap
with a marking pen (Fig. 9.5c). Measure this overlap. It should be between 7
to 15 mm. In the unlikely event that it is less, there was either no lid margin
laxity or the lid was not being pulled firmly enough. If greater than 15 mm,
undiagnosed canthal tendon laxity is present and needs to be treated before
continuing.
6. Excise the excess lid margin with tenotomy scissors as a wedge or pentagon
(Fig. 9.5d).
7. Insert the two pairs of pre-placed LCT 6/0 sutures in sequence through the
cut edge of the tarsal plate, starting with the uppermost (Fig. 9.5e). Insert
them from behind, trans-conjunctivally, through the full thickness of the tarsal
plate, exiting through its anterior surface and bring them out of the wound
edge before engaging the orbicularis or skin. Place each suture 1 mm below
the previous one. Clip the corresponding pairs of suture ends together again,
temporarily. This results in two horizontal mattress sutures reattaching the lid.
8. Before tying the above sutures, place a single ended 7/0 absorbable suture in
the lid margin as a horizontal mattress (Fig. 9.5f). This time insert the suture
through the orbicularis to exit the skin through the lash line, 1-2 mm from the
wound edge.
9.7 Operations 103
a b
c d
e f
g h
Fig. 9.5 Bick resection ectropion. a Divide the lower lid from the lateral canthus. b Pre-place 2
double armed absorbable sutures into the lateral canthal tendon (LCT) stump. c Overlap the wound
edges and mark the excess lid margin. d Excise the excess lid margin. e Insert the LCT pre-placed
sutures into the cut edge of the tarsal plate. f Insert a lid margin horizontal mattress 7/0 absorbable
suture. g Tighten and tie the LCT sutures. h Tighten and tie the lid margin mattress to bury the
knot. i Close the orbicularis and skin
104 9 Ectropion
9. Then, with the same needle, re-enter the lid through the meibomian orifice
line and exit through the tarsal plate just above the top, already placed, 6/0
suture bite (taking care not to inadvertently engage it with your needle).
10. Now enter the lateral canthal wound with the same needle, engage the upper
lid tarsal plate, and bring the needle out through the meibomian orifice line
1–2 mm from the lateral canthus.
11. Re-enter the upper lid lash line and exit the wound through the orbicularis to
complete this lid margin mattress suture. Clip its two ends together.
12. Now that you have placed the sutures under direct vision, pull the ends of the
lower of the two 6/0 sutures laterally (Fig. 9.5g). Use their pulley action to
pull the lid margin laterally towards the LCT to close the posterior lamella.
Tie the suture with no less than three throws and cut the ends no shorter that
2 mm (to prevent spontaneous unravelling).
13. Tie and cut the upper 6/0 suture similarly.
14. Tie the 7/0 pre-placed margin suture (Fig. 9.5h). This aligns the lid margin at
the lateral canthus. Cut the ends flush with the skin so that the knot becomes
buried and does not irritate.
15. Close the anterior lamella with two or three horizontal mattress 7/0 absorbable
sutures passed through the skin and orbicularis (Fig. 9.5i).
9.7.1.3 Notes
• The tightened lid margin will slip below the globe and appear retracted. This is
usually only temporary and resolves within a couple of weeks.
• For tarsal ectropion correction combine the lid margin shortening with lower lid
retractor plication. It is easier to identify the retractor aponeurosis and preplace
the sutures before performing the Bick repair.
9.7.2 Medial Lower Lid Retractor Plication (Fig. 9.6)

Punctal ectropion is a common occurrence. Even an ectropion of as little as 1 mm
can give rise to disproportionally symptomatic watering. Traditionally a ‘tarsocon-
junctival diamond’ excision is performed below the lower punctum. Such diamond
excision is pointless for two reasons. Firstly, there is next to no tarsal plate to
excise in that area, so what is excised is conjunctiva. Secondly, excision of con-
junctiva achieves nothing, as conjunctiva stretches. A better alternative is to make
a horizontal conjunctival incision through which the lower lid retractors are identi-
fied and plicated to the inferior edge of the tarsal plate below the punctum to pull
it inwards as an active repair.
9.7 Operations 105
9.7.2.2 Case Selection
• Punctal ectropion
• Medial ectropion if you combine the plication with a lid margin tightening
9.7.2.3 Steps
1. Evert the lower lid and make a 5 mm long, horizontal, conjunctival incision
below the lacrimal punctum and the inferior edge of the tarsal plate (Fig. 9.6a).
a b
c d
Fig. 9.6 Medial lower lid retractor plication. a Evert the lower lid and make a 5 mm long, hori-
zontal, conjunctival incision below the lacrimal punctum and the inferior edge of the tarsal plate.
b Bluntly dissect infero-laterally between the conjunctiva and the lower lid retractors. c With-
draw the retractor aponeurosis from the pocket with toothed Jayles forceps and tag it with a 6/
0 absorbable suture before letting go. d Bring the suture needle out through the inferior edge of
the tarsal plate and upper conjunctival edge, below the punctum and take the needle back into the
wound through the inferior conjunctival edge. e Tie the suture tightly and cut the ends to 2 mm. so
that the knot becomes fully buried
106 9 Ectropion
2. Hold the inferior conjunctival edge on upward stretch with Moorfields forceps
while bluntly dissecting infero-laterally between the conjunctiva and the lower
lid retractors with Westcott spring scissors (Fig. 9.6b).
3. Keeping the conjunctiva on stretch insert toothed Jayles forceps into the pocket,
aimed infero-laterally, and grab and withdraw the retractor aponeurosis. Tag it
with a 6/0 absorbable suture before letting go (Fig. 9.6c).
4. Check the retractor pull by putting the suture on gentle upward traction while
the patient is looking up, and then asking the patient to look maximally down-
wards. You should feel a tug on the suture. If it is not felt, repeat the manoeuvre
but this time asking the patient to follow your hand into downgaze. If there is
still no pull on the suture, remove and replace it.
5. Bring the suture needle out through the inferior edge of the tarsal plate and
conjunctiva, below the punctum.
6. Take the needle back into the wound through the inferior conjunctival edge
(Fig. 9.6d). Ensure that both ends are on the same side of the suture loop (to
allow the knot to retract once tied). Tie the suture tightly and cut the ends to
2 mm. Encourage them to retract into the wound so that the knot becomes fully
buried (Fig. 9.6e). This single suture both plicates the retractors to the tarsal
plate and closes the conjunctival incision. Whenever the patient looks down the
retractors pull the punctum inwards.
9.7.2.4 Note
• Tightening the lid margin laterally (Bick repair) can also resolve a mild punctal
ectropion without a retractor plication.
9.7.3 Central Lower Lid Retractor Posterior Plication (Fig. 9.7)

When the lower lid tarsal plate flips out completely (by 180°) a ‘tarsal ectropion’
is said to exist. Reattaching the lower lid retractors to the inferior tarsal edge
anchors it downwards stabilizing the lid. However, it is still advisable to tighten
the lid margin as well as addressing any anterior lamellar shortage.

Lower lid tarsal ectropion.
9.7 Operations 107
9.7.3.3 Steps
1. Evert the lower lid over a Desmarres retractor and make a 10 mm long hori-
zontal conjunctival incision centrally, just below the proximal tarsal plate edge
(Fig. 9.7a).
a b
c d
Fig. 9.7 Central lower lid retractor plication. a Evert the lower lid over a Desmarres retractor and
make a 10 mm long horizontal conjunctival incision centrally, just below the tarsal plate edge.
b Bluntly dissect on the under surface of the conjunctiva. c Grab and withdraw the retractor fascia
using toothed Jayles forceps and tag it with a 6/0 absorbable suture. d Bring the suture needle out
through the edge of the tarsal plate and conjunctiva, and then back into the wound through the infe-
rior conjunctival edge. e Tie the suture tightly and cut the ends to 2 mm to retract into the wound.
Perform a lid margin shortening
108 9 Ectropion
2. Bluntly dissect proximally on the under surface of the conjunctiva while holding
the inferior conjunctival edge on upward stretch (Fig. 9.7b).
3. Insert toothed Jayles forceps into the dissected pocket and grab and with-
draw the retractor fascia. Tag it with a 6/0 absorbable suture before letting
go (Fig. 9.7c).
4. Check the retractor pull by putting the suture on gentle upward traction while
the patient is looking up, and then asking the patient to look maximally down-
wards. You should feel a tug on the suture. If it is not felt, repeat the manoeuvre
but this time asking the patient to follow your hand into downgaze. If there is
still no pull on the suture, remove and replace it.
5. Bring the suture needle out through the edge of the tarsal plate and conjunctiva,
and then back into the wound through the inferior conjunctival edge (Fig. 9.7d).
The tarsal bite should be placed 5 mm medially of centre in anticipation of a
subsequent lateral lid margin shortening.
6. Tie the suture tightly and cut the ends to 2 mm. Encourage them to retract
into the wound so that the knot becomes fully buried. This single suture both
plicates the retractors to the tarsal plate and closes the conjunctival incision.
7. Proceed to perform a lid margin shortening (lateral wedge resection and Bick
repair) (Fig. 9.7e).
9.7.3.4 Note
• Retractor plication alone is only of marginal benefit if performed without lid

shortening.
• Alternatively, the retractors may be plicated via an anterior approach (see
Fig. 8.8b–d). Use this approach when you need to perform anterior lamellar
augmentation.
9.7.4 Free Skin Graft (Fig. 9.8)

Take a full thickness patch of colour and texture matched donor skin from an
available donor site and suture it into the anterior lamellar deficit. Stabilize the
graft bed with a lid margin traction suture and the graft with a pressure dressing.

Anterior lamellar deficit (actual or secondary to mid face drop).
9.7 Operations 109
9.7.4.3 Steps
1. Incise the lower lid skin and orbicularis 5 mm below the lid margin and
perform lid margin tightening if one is required (Fig. 9.8a). It usually is!
2. Put the recipient bed on stretch and dry it. Blot the area with a piece of paper
to obtain a blood-stained imprint of the defect. Remove the paper and cut
a b
c d
x
x + y ≥ 20 mm
Fig. 9.8 Anterior lamellar graft. a Incise the lower lid skin and orbicularis 5 mm below the lid
margin and perform lid margin tightening if required. b Blot the recipient bed with a piece of paper
to obtain a blood-stained imprint of the defect to create a paper template. c Use the template to mark
the area of skin to be harvested. d Transfer the skin graft to the donor bed anchoring it at either end.
e Use the anchoring sutures to suture the graft in place with a continuous suture. Suture the donor
site
110 9 Ectropion
around the imprint to create a paper template of the defect. Check this against
the wound and refine it as necessary (Fig. 9.8b).
3. Place the paper template on the gently stretched donor site and mark the area
of skin to be harvested. If you choose the upper lid as the donor site, ensure
that you leave sufficient skin behind to allow full eyelid closure. As a rule of
thumb, leave at least 20 mm of skin between the lid margin and the lower
edge of the eyebrow (Fig. 9.8c).
4. Intumesce the donor site with a sub-dermal injection of local anaesthetic with
adrenaline. This assists haemostasis and makes it easier to harvest a thin graft.
5. Incise the full thickness of the skin along the marked line with a scalpel.
6. Grasp one edge of the donor skin with toothed forceps to keep the skin on
traction and carry out a sharp dissection in the superficial subcutaneous plane
with the tip of the scalpel blade or with scissors. Check frequently that you
are not perforating the graft.
7. Wrap the harvested skin graft around your index finger, subcutaneous side
out, and trim off any excess subcutaneous tissue remaining on the graft with
Westcott scissors.
8. Anchor the skin graft to the donor bed at either end with a 6/0 absorbable
suture but do not cut the suture ends (Fig. 9.8d).
9. Use the anchoring sutures to suture the graft in place with a continuous suture.
Do this in two stages using one of the anchoring sutures for one half and the
other for the second half. Tie each suture to the free end of the other one to
complete (Fig. 9.8e).
10. Suture the donor site.
11. Tape the lid margin traction suture securely to the forehead (for the lower lid)
or cheek (for the upper lid) to keep it on traction and so immobilize the graft
bed.
12. Apply a non-stick film, copious antibiotic ointment, and a firm pressure dress-
ing to the closed eye. Leave this undisturbed for 5–7 days to keep the graft
immobile while it revascularizes.
9.7.4.4 Notes
• Take care when removing the pressure dressing not to pull on the graft as not all
dressings marketed as ‘non-stick’ live up to their name. Remove the lid margin
traction suture.
• Apply twice daily antibiotic ointment to the graft for a further week to keep it
soft and moist.
• Thereafter the patient should massage the graft gently towards the lid margin,
twice daily, with a thin smear of hydrocortisone 1% skin ointment. This helps
to reduce postoperative graft shrinkage.
9.7 Operations 111
9.7.5 Upper to Lower Lid Skin Pedicle Flap (Fig. 9.9)

Skin may be transferred to the donor site on its own vascular pedicle. This has the
theoretical advantage of ensuring flap survival. In practice, there is little additional
benefit over a free graft because the periocular region is so well vascularized.
When possible ‘set in’ the flap pedicle to avoid the need for a second operation.
a b
x
x + y ≥ 20 mm
c d
a
b c
a c
Fig. 9.9 Anterior lamellar pedicle flap. a Create a paper template of the defect. b Use the template
to mark the pedicle flap. c Raise the flap and transfer it to the recipient site. d Anchor the tip of the
flap in its new position with a 6/0 absorbable suture and anchor the lateral corner of the recipient
skin (point c) into the lateral end of the donor incision (point a). e Suture the flap into place with
a continuous suture and close the upper lid donor bed
112 9 Ectropion

Anterior lamellar deficit (actual or secondary to mid face drop) when sufficient
upper lid donor skin is present.
9.7.5.3 Steps
1. Put the recipient bed on stretch, using a 4/0 monofilament lid margin traction
suture, and dry it. Blot the area with a piece of paper to obtain an imprint of
the defect. Remove the paper and cut around the blood stain to create a paper
template. Check this against the wound and refine it, as necessary (Fig. 9.9a).
2. Place the paper template on the chosen skin donor site. Ensure that the skin is
gently stretched before marking the area to be harvested (Fig. 9.9b). Mark also
the pedicle on which this donor skin will be transferred. This should not be
narrower than the flap. Take particular care to align the upper and lower ends
of the pedicle base (points a and b) vertically, one above the other (Fig. 9.9c).
This ensures that when transferred the pedicle beds in aesthetically.
3. Intumesce the donor site with a superficial injection of local anaesthetic with
adrenaline. This helps with haemostasis.
4. Incise the full thickness of the skin along the marked line with a scalpel.
5. Grasp the tip of the flap and dissect the flap free of its bed with Westcott
scissors. The dissection plane can either be between the skin and the orbicu-
laris, or the orbicularis can be included as part of the flap. The latter results
in an easier dissection, better vascularity and slightly more ‘support’ from the
pedicle.
6. Anchor the tip of the flap in its new position with a 6/0 absorbable suture (do
not cut the ends) (Fig. 9.9d).
7. Anchor the lateral corner of the recipient skin (point c) into the lateral end of
the donor incision (point a) with a second suture to complete the alignment.
8. Suture the flap into place with a continuous suturing technique, using the uncut
anchoring sutures (Fig. 9.9e).
9. Finally, close the upper lid donor bed with a continuous absorbable suture.
10. Tape the lid margin traction suture securely to the forehead to immobilize the
flap bed and keep it on traction.
11. Apply a non-stick film, copious antibiotic ointment, and a firm pressure dress-
ing to the closed eye and leave this undisturbed for 1–7 days. It is not strictly
necessary to keep a flap padded for as long as a graft. However, a pad does
protect the surgical site from the patient’s wandering hands during the early
healing phase.
9.7 Operations 113
9.7.6 Permanent (Overlap) Lateral Tarsorrhaphy (Fig. 9.10)

Adding a short (4 mm) permanent lateral tarsorrhaphy transfers some of the upper
lid levator pull to lift the lower lid laterally. This imparts an active component to
an otherwise passive ectropion repair. This is especially important when correcting
paralytic ectropion.

Atonic lower lid ectropion. Usually combined with lid margin shortening and with
medial canthoplasty.
9.7.6.3 Steps
1. Make a 4 mm long incision in the lower lid grey line up to the lateral canthus
(Fig. 9.10a).
2. Based on the grey line incision, excise a semicircle of anterior lamella below
it, including skin, lashes, and orbicularis, to expose the underlying tarsal plate
(Fig. 9.10b). Ensure that the exposed tarsal plate surface is free of connective
tissue. Gentle diathermy may be applied if required to enhance adhesion.
3. Evert the upper lid margin and mark out a corresponding semicircle on the
sub-tarsal conjunctiva ensuring that it also starts at the lateral canthus. Apply
gentle diathermy to this area to destroy the conjunctiva without significantly
damaging the tarsal plate (Fig. 9.10c). Wipe off any loose necrotic conjunctiva.
4. Insert a 6/0 absorbable suture through the middle of the exposed lower lid
tarsal plate margin.
5. With the same suture take a bite of the upper edge of the adjacent diathermied
area of the everted upper lid tarsal plate (Fig. 9.10d).
6. Tie this suture and cut its ends short, so that they do not irritate the eye.
7. Insert a 4/0 monofilament suture on a round bodied needle through the upper
lid skin, just above the lashes so that it exits the denuded tarsal plate close to
the lateral canthus.
8. With the same suture now take a strong, partial thickness, bite to span the
exposed lower lid tarsal plate.
9. Complete this suture by taking it through the upper lid tarsal plate at the
medial end of the denuded tarsal crescent, so that it exits through the skin just
above the lashes (Fig. 9.10e).
10. Cut a piece of silicone tubing the length of the distance between the suture
entry and exit points and thread it onto the suture. It will act as a bolster. Clip
the untied suture ends together.
11. Place one or two 6/0 absorbable sutures to bring together the upper lid mei-
bomian orifice line and the cut edge of the lower lid orbicularis and skin. Tie
the suture(s) (Fig. 9.10f).
114 9 Ectropion
a b
c d
e f
Fig. 9.10 Permanent lateral tarsorrhaphy. a Make a 4 mm long incision in the lower lid grey line
up to the lateral canthus. b Excise a semicircle of anterior lamella to expose bare tarsal plate.
c Evert the upper lid and diathermy a corresponding area without significantly damaging the tarsal
plate. d Insert a 6/0 absorbable suture between the middle of the exposed lower lid tarsal plate
margin and the upper edge of the adjacent diathermied area of the everted upper lid tarsal plate
and tie it. e Insert a 4/0 monofilament suture on a round bodied needle through the upper lid skin,
just above the lashes so that it exits the denuded tarsal plate close to the lateral canthus and take
a strong, partial thickness, bite of exposed lower lid tarsal plate. Complete this suture by taking it
through the upper lid tarsal plate to exit the skin just above the lashes. Thread it through a piece
of silicone tubing. f Place two 6/0 absorbable sutures to bring together the upper lid meibomian
orifice line and the cut edge of the lower lid orbicularis and skin together
9.7 Operations 115
12. Tighten and tie the preplaced 4/0 monofilament suture to hold the raw tarsal
plate surfaces in firm apposition, so that they unite during healing.
13. Before cutting the 4/0 suture ends, thread one end back through the tubing,
using the blunt end of its needle. By pulling on this suture the knot can be
pulled to lie inside the tubing for the patient’s comfort. Cut both suture ends
close to the tubing.
14. No dressing is required. Remove the non-absorbable suture and bolster at two
weeks. The remaining sutures are allowed to dissolve spontaneously.
9.7.6.4 Notes
• Such tarsorrhaphies are well camouflaged by the upper lid lashes.

• They are permanent and cannot be reversed without causing distortion of the
lid margin.
• They are often combined with a medial canthoplasty which provides medial lift
to the lower lid.
9.7.7 Medial Canthoplasty (Fig. 9.11)

Medial canthoplasty is a tarsorrhaphy carried out medially to the lacrimal puncta. It
transfers upper lid levator pull to a paralytic lower lid adding an active component
to a paralytic ectropion correction. Take great care not to damage, or suture closed
the lacrimal canaliculi during this procedure as they lie close to the tendon.

Atonic lower lid ectropion. Usually combined with lid margin shortening and with
lateral tarsorrhaphy.
9.7.7.3 Steps
1. Insert ‘0’ gauge Bowman lacrimal probes into the upper and the lower canali-
culi and ask an assistant to keep them in the lacrimal sac by pressing them
gently against the side of the nose (Fig. 9.11a).
2. Carefully make a ‘U’ shape skin incision around the medial canthus from
punctum to punctum and 1–2 mm outside the probes (hence also the canaliculi).
3. Separate the orbicularis under the incision by blunt dissection using pointed
scissors.
4. Using a 6/0 absorbable suture on a curved needle take a strong horizontal bite
of the firm medial canthal tendon tissue adjacent to the canaliculus (Fig. 9.11b).
116 9 Ectropion
a b
c d
Fig. 9.11 Medial canthoplasty. a Insert ‘0’ gauge Bowman lacrimal probes into the upper and
the lower canaliculi and make a ‘U’ shape skin incision around the medial canthus from punc-
tum to punctum and 1–2 mm outside the probes. b Using a 6/0 absorbable suture on a curved
needle place 2 ‘box’ sutures. c Withdraw the Bowman probes and tie both sutures firmly. Place
two 6/0 absorbable horizontal mattress sutures across the wound, engaging both the skin and the
orbicularis. d Tie the skin sutures to evert the skin edges
The tendon is identified by its resistance to distraction rather than by its vis-
ibility. Start at the medial canthus. If you touch metal with your needle tip it
has penetrated the canaliculus and should be withdrawn.
5. Take a similar bite of tendon with the same suture through the opposing lid in
the opposite direction to make a ‘box’ suture. Clip the two suture ends together.
6. Place a second suture adjacent to the first so that the bites extend to the lateral
ends of the incisions, close to the lacrimal puncta.
7. Withdraw the Bowman probes and tie both sutures firmly. In doing so the lid
margins become inverted so that there is no epithelium between the raw surfaces
of the upper and lower limbs of the medial canthal tendon.
8. Place two 6/0 absorbable horizontal mattress sutures across the wound, engag-
ing both the skin and the orbicularis. As you tie them, they will evert the skin
edges (Fig. 9.11c, d).
9. No dressing is required. Leave the sutures to dissolve spontaneously.
9.7.7.4 Notes
A medial canthoplasty hides the caruncle. Usually this is not a major aesthetic
issue particularly as in paralytic ectropion the pre-operative medial canthus is
excessively widened.
9.7.7.5 Problems
Lid margin tightening and anterior lamellar flaps and grafts rely on static mech-
anisms of action and are therefore prone to ectropion recurrence. Recurrence
is particularly likely if a small anterior lamellar deficit has gone unnoticed and
uncorrected.
• Surgical correction of involutional ectropion requires substantial lid margin

shortening ± anterior lamellar supplementation with a skin graft or flap.
• Ectropion recurrence is common because the surgery mostly relies on passive
mechanisms.
Ptosis
10
Fig. 10.1 Ptosis. When assessing ptosis note the brow position, head posture and facial expression
in addition to the lid movement
• Clinical evaluation
• Types of ptosis
• Levator function-based choice of correction
• Surgical techniques:
– White line advancement, anterior approach,
– Müller’s resection,
– Anterior approach levator aponeurosis reinsertion,
– Silicone frontalis suspension.
120 10 Ptosis
The word ptosis comes from Greek, meaning the act of falling. Ophthalmologists
use the term as shorthand for ‘Blepharoptosis’, namely a dropping upper lid. There
are many different causes of ptosis. Age related ptosis is by far the most common
and is therefore the focus of this chapter. As always, the history of onset is helpful
in diagnosing the type of ptosis, followed by the examination.
10.2 Examination
The following measurements are helpful in choosing the most appropriate ptosis
operation.
10.2.1 Vertical Palpebral Aperture (PA)
This is the distance between the central upper and lower lid margins in primary
gaze (looking straight ahead). It depends on the position of both lids. For greater
accuracy therefore the lid margin to corneal light reflex distances (MRD) are mea-
sured for both the upper and the lower lid margins (MRD1 & MRD2 respectively)
(Fig. 10.2). Added together they should equal the PA.
Pseudo ptosis can arise from an overhanging skin fold (Fig. 10.3a) which masks
the true palpaebral aperture.
Vertical ocular misalignment will also cause ‘pseudo ptosis’ of the hypotropic
eye as the lid follows the eye’s position. The pseudoptosis vanishes when the eye
is forced to look straight ahead (Fig. 10.3b). Hypotropia should be addressed by
squint correction before ptosis correction is contemplated. Ten percent of congen-
ital ptosis has an associated superior rectus weakness (as the superior rectus and
levator muscles develop together and share a common innervation).
MRD1
PA
MRD2
Fig. 10.2 Palpebral aperture (PA) and margin reflex distance (MRD). The PA should equal the
sum of the upper and lower lid MRD
10.2 Examination 121
Fig. 10.3 Pseudoptosis. a An overhanging skin fold masks the true PA. b The pseudoptosis of a
hypotropic eye disappears when the eye takes up fixation
10.2.2 Levator Function (LF)
This is the distance that the central upper lid margin moves from full downgaze
to full up-gaze while you neutralize any frontalis muscle contribution by pressing
on the brow (Fig. 10.4). Levator function cannot be improved by surgery. There-
fore, the LF dictates the choice of operation most likely to work for that patient.
The LF also dictates the degree of post-surgical improvement possible. A patient
with normal levator function is likely to get an excellent (near normal) surgical
outcome. By contrast a patient with poor LF who is successfully corrected for
straight ahead (primary) gaze will still have a degree of ptosis in up-gaze and
‘hang-up’ in downgaze. Levator function is a clinical surrogate measure of muscle
strength.
Normal levator function is an excursion of between 12 and 17 mm. Poor levator
function is 0–4 mm.
122 10 Ptosis
LF
Fig. 10.4 Levator Function (LF). LF is the full excursion of the central upper lid margin expressed
in millimetres
10.2.3 Skin Crease (SC) and Skin Fold (SF) (Fig. 10.5)
Most occidental eyelids have a skin crease about 5–10 mm from the lid margin. It
is thought to be caused by the pull of the anterior insertion of the levator aponeuro-
sis into the orbicular fascia. Absence of a skin crease may imply very poor levator
function i.e., no pull on the skin. Oriental lids have a much lower skin crease due
to a lower aponeurosis insertion.
Lax skin above the crease may hang over as a skin fold and hide the true crease.
The skin crease is usually raised in age related, contact lens induced, and post-
surgical ptosis, as well as in Horner’s syndrome. Why should this be and what
SC
SF
Fig. 10.5 Skin Crease (SC) and Skin Fold (SF). A SF may overhang and mask the true SC
10.2 Examination 123
Fig. 10.6 Hang-up in downgaze. a Left upper lid ptosis in primary gaze. b In downgaze the left
ptosis disappears because the lid is prevented from moving down by the dystrophic levator. c In
upgaze the left ptosis worsens because the dystrophic levator cannot lift it as well as the right
124 10 Ptosis
is the common denominator? Perhaps they are all caused by a failure of Müller’s
muscle rather than of the levator aponeurosis?
10.2.4 ‘Hang-Up’ in Downgaze (Fig. 10.6)
A ptosis may seem to reduce, disappear, or even reverse in downgaze. This is

because as well as not contracting normally, an abnormally formed levator muscle
does not relax or stretch as well as the normal contralateral muscle. Such downgaze
‘hang-up’ strongly suggests a congenital ptosis (or previous levator resection).
10.3 Types of Ptosis
10.3.1 Congenital Ptosis
• Present from birth

• Reduced levator function (lid margin excursion from full downgaze to full up
gaze).
• ‘Hang-up’ in downgaze (the affected lid does not move as far down as the normal
lid).
• Sometimes part of a syndrome (e.g., Marcus Gunn jaw wink).
10.3.2 Acquired Ptosis
10.3.2.1 Age Related Ptosis

(synonyms: Involutional, Senile, Aponeurosis disinsertion, Levator dehiscence).
• The most common.

• Gradual onset.
• Normal levator function.
• Often a raised skin crease.
Note: The term Aponeurotic disinsertion ptosis (above), although frequently used, is
not indicative of the underlying pathology. Rather it derives from the type of surgery
used to correct it i.e., aponeurosis repair or reinsertion.
10.3.2.2 Traumatic Ptosis (Including Post Eye Surgery, Contact Lens

Wear and Birth Trauma)
• History of causative trauma.

• Levator function normal unless direct muscle trauma or complete dehiscence.
10.4 Choice of Operation 125
10.3.2.3 Myopathic Ptosis (Myaesthenia, Progressive External

Ophthalmoplegia)
• Gradually deteriorating levator function.

• Fatiguability.
• Normal skin crease.
10.3.2.4 Neurological Ptosis (Associated Neurological Signs)

Horner’s Syndrome
• 2 mm of ptosis or less.
• Normal levator function.
• Smaller pupil.
• Ipsilateral anhidrosis and/or skin hyperaemia
Third Cranial Nerve Palsy (Partial or Complete).
• Poor levator function.

• Impaired eye movements.
10.4 Choice of Operation
The levator function (range of upper lid movement) dictates the choice of
operation, according to the Table 10.1. But there can be exceptions. An other-
wise healthy but severely ‘dehisced’ levator may have reduced levator function
without being weak. A few patients with congenital ptosis have an unusual
levator-extraocular muscle synkinesis that gives them a good levator function mea-
surement, but which does not reflect levator innervation in primary gaze [1]. If this
synkinesis is not spotted the standard surgery will result in an under-correction.
The better the levator function, the better the likely outcome of ptosis surgery.
Near normal levator function should give near normal outcomes. The best that
Table 10.1 Choice of ptosis

Levator function Degree of Preferred
correction procedure based
(mm) ptosis (mm) operation
on levator function
Normal 12–17 =<2 Muller’s
resection
>2 Aponeurosis
re-insertion
Moderate 5–11 Levator
resection
Poor 0–4 Frontalis
suspension
126 10 Ptosis
Fig. 10.7 Post successful ptosis correction with poor levator function (LF). a Left ptosis cor-
rection successful in primary gaze. b In downgaze hang-up is visible (the left upper lid appears
retracted). c In upgaze the ptosis becomes visible
10.5 Operations 127
can be hoped for with poor levator function is an acceptable lid level in primary
gaze, but under-correction in up-gaze and over correction (hang-up) in downgaze
(Fig. 10.7). The cause of the ptosis must also be considered. A patient with pro-
gressive external ophthalmoplegia and a LF of 7 may ultimately do better with
a frontalis suspension than a levator resection as the LF will continue to decline.
Counsel the patients to have realistic expectations regarding what surgery can and
can’t achieve.
10.5 Operations
10.5.1 White Line Advancement (Anterior Approach) Fig. 10.8
Age related ptosis is the commonest ptosis. The easiest and most commonly appli-
cable levator re-insertion operation is the ‘white line advancement’. I strongly
recommend it for all involutional, contact lens related and post periocular surgery
a b
c d
Fig. 10.8 White line advancement ptosis correction. a Mark and incise the desired postoperative
skin crease. b Cut through the orbicularis and posterior levator aponeurosis to expose the upper
1/3 of the tarsal plate. c Extend the incision medially and laterally to the full extent of the skin
incision. d Clean the exposed anterior surface of the upper 1/3 of the tarsal plate of any remaining
connective tissue, to ensure firm healing. e Bluntly dissect upwards with a cotton bud to expose the
anterior surface of Müller’s muscle. f Pull the Müller’s muscle downwards and continue the blunt
dissection superiorly until the so called ‘white line’ (folded levator aponeurosis) appears. g Insert a
double armed 6/0 absorbable suture through the white line centrally. h Insert two further white line
sutures similarly and insert both ends of the sutures into the upper 2–3 mm of the exposed tarsal
plate as partial thickness bites. Then pass one of each pair of suture ends out through the upper and
the other through the lower skin edge. i Tie sutures on the skin and complete skin closure with a
suture
128 10 Ptosis
e f
g
h
ptosis, provided that levator function is normal (which it should be in those cases).
White line advancement has two selling points:
1. The first is that mostly it is easy to perform, requiring minimal dissection.

2. The second is that it seems to set the lid at the correct height, as if by magic,
without any per-operative measurement.
It can be performed either via an anterior (skin) or a posterior (conjunctival)

approach. The skin approach is easier to learn and is described below. If required,
it can also be combined with excess skin removal (blepharoplasty) and it causes
no ocular irritation. I acknowledge that many prefer the posterior, conjunctival
approach which avoids a skin incision and works equally well.
Should the white line advancement prove difficult or insufficient it is easy
to convert it to a more formal aponeurosis insertion or levator resection. The
conversion is also described below.
10.5 Operations 129

Draw the levator aponeurosis down by pulling on Müller’s muscle to create a fold.
The aponeurosis fold appears as a ‘white line’. Suture the white line to the upper
edge of the tarsal plate. This effectively shortens the aponeurosis.

Ptosis with good levator function (LF ≤ 12 mm). This includes age related, contact
lens induced and post-surgical ptosis.
10.5.1.3 Steps
1. Mark the new skin crease position on the surgical side while holding the skin
on gentle upward stretch (Fig. 10.8a). Match its height with the crease on the
contralateral lid. In bilateral ptosis set it at about 7–8 mm (for occidental lids).
2. Incise the skin along the marked line with a no. 15 scalpel while protecting the
eye with a guard held under the lid.
3. Deepen the incision centrally with Westcott scissors (Fig. 10.8b). Dissect per-
pendicularly through the orbicularis and posterior levator aponeurosis until the
upper 1/3 of the tarsal plate is reached.
Note: Angling the dissection can cause you to dissect too proximally, missing the
tarsal plate, or too low, where the aponeurosis inserts into the tarsal plate.
4. Bluntly dissect the pretarsal space medially and laterally with closed Westcott
scissors. Then extend the incision to the full extent of the skin incision. Do this
with one blade of the scissors inside the tunnel and the other on the orbicularis
surface (Fig. 10.8c).
5. Clean the exposed anterior surface of the upper 1/3 of the tarsal plate of any
remaining connective tissue, to ensure firm healing (Fig. 10.8d).
Note: Not cleaning thoroughly can lead to poor union and late surgical failure when
the sutures absorb.
6. Pull the lid downwards with toothed forceps and bluntly dissect upwards with
a cotton bud, beyond the upper edge of the tarsal plate to expose the anterior
surface of Müller’s muscle (Fig. 10.8e).
Note: This is usually an easy manoeuvre, but occasionally firmer connective tissue
is encountered and a little sharp dissection with Westcott scissors is required. In a
few patients some yellow fat may be encountered in this plane.
7. Now pull the upper extent of Müller’s muscle firmly downwards with toothed
forceps (e.g., Jayles) and continue the blunt dissection superiorly with a cotton
bud until a white fold of connective tissue appears—the so called ‘white line’
(folded levator aponeurosis) (Fig. 10.8f).
130 10 Ptosis
8. Grasp the white line firmly and gently stretch it downwards. Instruct the
patient to look upwards. You should feel a strong tug. This confirms that the
structure is indeed the levator aponeurosis.
9. Insert a double armed suture 6/0 absorbable (Vicryl) suture through the white
line centrally with a double bite.
10. Insert both ends of this central suture into the upper 2–3 mm of the exposed
tarsal plate as partial thickness bites. Before completing each needle bite, evert
the lid to check that the needle pass has not penetrated the conjunctival surface.
If it has, withdraw the needle, and replace it more superficially to avoid corneal
irritation by the suture (Fig. 10.8g).
11. Tighten this suture and tie it as a bow. Check the lid height, curve, and move-
ment by asking the patient to look first straight ahead and then up and down.
The lid margin height should be 1–2 mm higher than the contralateral side to
compensate for the local anaesthetic induced orbicularis paralysis.
12. Undo the bow and insert two further white line sutures similarly, one on either
side and each about 3 mm away from the central one. To do this ask an
assistant to pull downwards on the previously placed central suture to keep
the white line exposed.
13. Undo the temporary bows and pass one of each pair of suture ends out through
the upper and the other through the lower skin edge (Fig. 10.8h).
14. Tie the sutures on the skin. This advances the white line to the tarsal plate,
closes the incision, and reforms the skin crease. Do not cut the suture ends at
this stage but clip them out of the way.
15. Complete skin closure with a continuous 6/0 or 7/0 absorbable suture taking
a bite between each of the knots and tie it at each end (Fig. 10.8i).
Note: Although this suture is usually superfluous, it keeps the incision closed if you
need to remove an aponeurosis suture early because of an overcorrection.
16. Now pull the white line suture ends down and cut them at the level of the
lid margin. This ensures that the ends remain exposed and long enough to
identify and grasp easily should you need to remove them.
17. Instruct the patient to keep the eye closed and apply antibiotic ointment and a
pressure dressing overnight.
18. Review the lid height the next day. If there is an overcorrection remove one
or more of the levator aponeurosis sutures by lifting the knot and cutting one
side of the suture below it. Pull the whole suture out.
10.5.1.4 Notes
Some surgeons advocate using only a single aponeurosis suture to save time. While
this can work it does risk creating an unattractive ‘cathedral arch’ upper lid con-
tour if you insert the suture too low on the tarsal plate. Furthermore, there is no
redundancy for the eventuality of suture failure. Using three sutures gives more
control over the lid contour and the extra time they take to place is a worthwhile
investment for the novice.
10.5 Operations 131
10.5.2 Conversion to an Anterior Levator Aponeurosis

Reinsertion/Resection Fig. 10.9
Steps 1–5 are as above. If step 7 is problematic (the white line cannot be found)
or the lid height is too low at the end of surgery proceed as follows:
a b
c d
Fig. 10.9 Conversion to an anterior levator aponeurosis reinsertion. a While retracting the upper
skin and orbicularis edge upwards, grasp the anterior layer of the levator aponeurosis (immedi-
ately posterior to the orbicularis) and incise it. b Pull the aponeurosis and bluntly dissect upwards
to expose the orbital septum and pre-aponeurotic fat pad. c Insert a double armed 6/0 absorbable
suture into healthy aponeurosis. d Place 2 more sutures similarly and insert them into the upper
tarsal plate, bringing all three pairs out through the skin edges. e Tie the sutures while observ-
ing the lid margin position and curve. Insert a continuous skin suture taking a bite between each
aponeurosis suture
132 10 Ptosis
7. While pulling the upper lid skin incision edge upwards, grasp the layer imme-
diately posterior to the orbicularis muscle layer. This is the anterior layer of
the levator aponeurosis (and not the orbital septum as many mistakenly think).
Incise this layer along the whole length of the wound (Fig. 10.9a)
8. Pull down the proximal cut edge of the aponeurosis and bluntly dissect upwards
on its anterior surface to expose the actual orbital septum. Pressing on the
lower lid causes the pre-aponeurotic fat pad to flow forwards under the septum,
positively identifying it.
9. The orbital septum is not a single layer but made up of seven thin layers.
Divide the several thin layers of orbital septum to expose the pre-aponeurotic
fat (Fig. 10.9b)
Note: This fat is very fine and has a characteristic deep yellow colour. It is a constant
landmark in the lid and helpful for orientation.
10. Retract the pre-aponeurotic fat to expose the full extent of the levator aponeu-
rosis, up to the transversely running Whitnall’s ligament and the aponeurosis
levator muscle junction.
11. Insert a double armed 6/0 absorbable suture into healthy aponeurosis, close to
its lower edge (Fig. 10.9c)
12. Insert this same suture into the upper tarsal plate centrally and tie it with a
bow.
13. Assess the lid height by asking the patient to follow your finger. The operated
lid should be set 1–2 mm higher than the other side to compensate for the
anaesthetised orbicularis. If the lid is not at the correct height replace the
suture higher or lower in the aponeurosis and recheck the lid height.
14. Place two further sutures similarly, one on either side of the first.
15. Now bring all three pairs of aponeurosis/tarsal plate sutures out through the
skin edges, one of each pair on either side of the skin incision (Fig. 10.9d)
16. Tie the sutures while observing the lid margin position and curve. If a suture
is lifting the lid too much you can loosen it before placing the locking throw.
17. Before cutting the suture ends run a continuous suture along the length
of the wound taking a bite between each aponeurosis suture. This suture
keeps the wound closed should the aponeurosis sutures require early removal
(Fig. 10.9e)
18. Cut the aponeurosis sutures about 4 mm long so that they are easy to find and
grasp, should early removal be required.
10.5 Operations 133
10.5.3 Levator Resection Fig. 10.10

The approach to levator resection is identical to the anterior levator aponeurosis
reinsertion/resection described above. It differs in that the ‘horns’ (the medial and
lateral extent) of the levator aponeurosis are cut and the aponeurosis dissected free
from the overlying Whitnall’s ligament. Müller’s muscle is also separated from
its insertion into the upper border of the tarsal plate and dissected free from the
underlying conjunctiva. This enables the levator/Müller’s complex to be pulled
down as one to enable sutures to be placed higher up within the levator muscle
belly. Check the lid height as previously. The desired ‘on table’ lid height depends
on the pre-operative levator function.

Ptosis with levator function of 5–11 mm.
Because levator resection is reserved for patients with poorer LF, the surgical
outcome is less predictable. Therefore, it should be performed by more experi-
enced surgeons. A detailed description of the technique is beyond this book’s
remit.
a b
Fig. 10.10 Levator resection ptosis correction. a After exposing the levator aponeurosis cut its
medial and lateral horns. b Pull the levator down and insert a suture into the muscle belly and tarsal
plate. Check the lid height and replace if necessary. c Insert 2 more sutures similarly
134 10 Ptosis
10.5.4 Addition of a Skin and Muscle Blepharoplasty Fig. 10.11

As already mentioned, the anterior approach ptosis corrections described above
may easily be combined with skin and muscle blepharoplasty. Perform this conver-
sion after performing the ptosis correction but before bringing the levator sutures
out through the skin and tying them. Drape the excess upper edge skin and orbic-
ularis over the lower wound edge with the eye closed to ascertain how much may
safely be removed.

Any ptosis correction in which there appears to be excess upper lid skin at the end
of the procedure.
10.5.4.3 Steps
1. With the upper eyelid closed drape the upper wound edge skin and orbicularis
over the lower edge to achieve the desired skin appearance (Fig. 10.11b).
2. Make an upward cut centrally through the draped skin and orbicularis as far as
the lower wound edge (Fig. 10.11c).
3. Pull down and laterally on the flap you have created and excise the redundant
anterior lamellar triangle with Westcott spring scissors to meet the medial end
of the wound (Fig. 10.11d).
4. Pull the lateral flap down and medially and repeat the same manoeuvre to the
lateral wound end (Fig. 10.11e).
5. The blepharoplasty is now complete. Proceed with wound closure by insert-
ing your preplaced levator sutures across the wound as previously described
(Fig. 10.11f, g).
Notes: You may extend the ptosis correction wound laterally to remove more lateral
skin if required.
10.5 Operations 135
a b
c d
e f
Fig. 10.11 Conversion to blepharoplasty. a Insert the aponeurosis sutures into the tarsal plate
only. b With the upper eyelid closed drape the upper wound edge skin and orbicularis over the
lower edge to achieve the desired skin appearance. c Make an upward cut through the draped skin
and the orbicularis as far as the lower wound edge. d Excise the medial redundant anterior lamel-
lar triangle with Westcott spring scissors to meet the medial end of the wound. e Excise the lateral
triangle similarly. f With the blepharoplasty complete, proceed with wound closure as previously.
g Place a skin suture
136 10 Ptosis
a b
4mm 8mm
c d
e f
Fig. 10.12 Müllers muscle resection. a Double evert the upper lid and mark the upper border of
the tarsal plate. Using a calliper, place a row of marks 4 mm from the border. b Then place a third
row of marks again 4 mm more proximally to the previous ones. c Insert a 5/0 monofilament trac-
tion suture through the conjunctiva and Müller’s muscle along the middle row of marks. Pull down
a fold of conjunctiva and Müller’s muscle and apply two fine artery forceps across this fold span-
ning the first and third row of marks. Insert a 5/0 monofilament suture transcutaneously so that
it exits the conjunctival surface at the lateral edge of the crushed fold, just above the artery clip.
d Pass this suture in and out through the fold above the artery clip. Bring the suture out through
the skin crease medially. e Remove the artery clips, one at a time and cut along the centre of the
crush line to excise the fold of conjunctiva and Müllers. f Pull the suture ends tight to take up any
slack. g Tape them to the brow skin in a relaxed position so that they do not impair eyelid closure
10.5 Operations 137
10.5.5 Müller’s Muscle Resection Fig. 10.12
The simplest and least invasive ptosis operation is a Müller’s resection. It is seduc-
tively simple but only effective when restricted to the specific selection criteria
already mentioned. The indications for it are therefore limited. Müller’s resection
is very unlikely to over-correct a ptosis and requires no dissection. It replaces
the formerly popular, but now outdated, Fasanella Servat operation. Both sacrifice
conjunctiva and work on the principle of shortening Müller’s muscle. The latter
also sacrifices the upper tarsal plate (rarely a good idea).

Müller’s muscle modulates the effect of the levator on the lid margin. Shortening
Müller’s muscle lifts the lid by about 2 mm.

Patients with no more than 2 mm of ptosis and normal levator function. Some
surgeons advocate only operating on patients whose ptosis disappears after instill-
ing a drop of phenylephrine. While these patients invariably do well so do many
that fail to respond to the phenylephrine test. This is unsurprising as the procedure
excises Müller’s muscle rather than relying on it to lift the lid.
10.5.5.3 Steps
1. Double evert the upper lid over a large Desmarres retractor, using it as a lever
to visualize the conjunctiva above the tarsal plate.
2. Dry the conjunctiva and mark the upper border of the tarsal plate using a mark-
ing pen. Make three marks, one in the centre of the lid and one 6 mm to either
side.
3. Using a calliper, place a further row of three marks 4 mm proximal to the first
row (Fig. 10.12a).
4. Then place a third row of marks again 4 mm more proximally to the previous
ones (Fig. 10.12b).
5. Insert a 5/0 monofilament traction suture through the conjunctiva and under-
lying Müller’s muscle along the middle row of marks. Remove the Desmarres
retractor.
6. Pull downwards on the traction suture to pull down a fold of conjunctiva and
Müller’s muscle. Apply two fine artery clips (or use a Putterman clamp if avail-
able) across this fold to span the first and third row of marks (Fig. 10.12c). The
clips contain an 8 mm wide (4 mm + 4 mm) ellipse of conjunctiva and Müller’s
muscle.
138 10 Ptosis
Note: Ensure that the tips of the artery clips are pointed slightly down (as in the
diagram) to avoid creating a central lid peak.
7. Insert a 5/0 monofilament suture transcutaneously at the skin crease (approx-

imately 7 mm from the lid margin) so that it exits the conjunctival surface at
the lateral edge of the crushed fold, just above the artery clip (Fig. 10.12c).
8. Pass this same suture through the conjunctiva and Müller’s fold above the
artery clip exiting on the other side. Then pass it back. Repeat this approxi-
mately four or five times to reach the medial end of the fold (Fig. 10.12d). The
more suture passes that are made, the harder it will be ultimately to remove
the suture.
9. Bring the suture out through the skin crease medially.
10. Remove the artery clips, one at a time and cut along the centre of the crush
line to excise the fold of conjunctiva and Müllers along with the traction suture
(Fig. 10.12e, f). Allow the everted lid to flip back to its normal orientation.
11. Pull the suture ends tight to take up any slack and tape them to the brow skin
in a relaxed position so that they do not impair eyelid closure (Fig. 10.12g)
12. Apply antibiotic ointment to the eye and secure a protective shield. No pad is
required.
13. Review the patient a week later and remove the suture by cutting one end
flush with the skin and pulling on the other end. The smooth monofilament
suture slips out with minimal discomfort.
Note: In a child an absorbable suture with buried knots can be used to avoid the
need for suture removal. However, when it loosens it may cause corneal irritation,
which is why a smooth removable suture is preferred for adults.
10.5.6 Frontalis Suspension (Fox’s Pentagon) Fig. 10.13
10.5.6.1 Principle and considerations

A patient with poor levator function does not benefit from having their levator
muscle shortened. The only alternative power source available for opening the lid
is the frontalis muscle. Frontalis suspension is not technically difficult to perform
but as it is rarely needed it is harder to gain experience with this technique. Fur-
thermore, patients with poor levator function have a less satisfactory outcome from
ptosis surgery. The likelihood of under or over correction is much higher as is the
risk of symptomatic corneal exposure.
The operation works by connecting the eyelid to the brow using a sling. The
best and longest lasting sling material is undoubtedly living autogenous fascia
Lata, harvested from the patient’s own thigh. Such harvesting falls outside the
remit of this book (but is available to view on YouTube [2]). However, for the sake
of completeness I describe here the Fox pentagon frontalis suspension using a sil-
icone sling. Non-autogenous materials are more prone to infection, extrusion, and
late failure. The silicone sling may be supplied swaged onto two long, extremely
sharp, malleable needles. I strongly urge the novice not to use these as they are
10.5 Operations 139
a b
10-15 mm
2mm
c
d
f
e
Fig. 10.13 Fox’s frontalis suspension. a Mark two lid entry points 2 mm above the lashes, two
further points at the upper edge of the eyebrow, and a horizontal skin incision approximately 4 mm
long 10–15 mm above the centre of the eyebrow. b Make horizontal stab incisions using a no.
11 scalpel in the marked points and make the forehead incision. Slightly undermine the forehead
incision bluntly to create a small pocket. c Insert the Wright’s fascia needle into the lateral eyelid
incision down to the tarsal plate and advance it to exit the second skin incision. Thread the silicone
sling material through the eye of the needle and withdraw the needle pulling the sling through.
d Insert the empty Wright’s needle vertically into the lateral brow incision and advance the needle
to exit the lateral lid incision. Thread the lateral end of the silicone into the needle and withdraw
the needle and tubing from the lateral brow incision. Repeat steps for the medial brow incision.
e Enter the medial end of the forehead incision with the empty Wright’s needle, to emerge from the
medial brow incision. Thread the silicon into the needle and pull it through to the forehead incision.
Repeat on the lateral forehead. f Pass both ends of the silicone sling through a 4–5 mm length of
silicone sleeve (Watske sleeve). Adjust the tension in the sling. g Close the forehead incision with
two vertical mattress 6/0 sutures
140 10 Ptosis
dangerous. The needles bend easily as you advance them through the lid so you
receive no tactile feedback and cannot control where the tip is. Being so sharp inad-
vertent eye penetration is a real risk. Use instead a Wright’s fascia needle which is
non-malleable and semi sharp. The finger loop allows good needle tip control. Join
the ends of the sling together using a silicone sleeve which allows easy adjustment.

Severe ptosis with poor levator function (≤4 mm) interfering with vision (lid
margin encroaching on the visual axis).
10.5.6.3 Steps (Fig. 10.13)
1. Mark two skin entry points 2 mm above the lashes and aligned to be vertically
above the medial and lateral corneal limbus in primary gaze (i.e., about 11–
12 mm apart).
2. Mark two further points at the upper edge of the eyebrow. The lateral point
must be vertically lateral to the lateral canthus and the medial point vertically
medial to the medial canthus.
3. Mark a final horizontal skin incision approximately 4 mm long 10–15 mm
above the centre of the eyebrow (in a frown line if one is present). Position it
roughly above the pupil (Fig. 10.13a).
4. Make horizontal stab incisions using a no. 11 scalpel in the marked eyelid
points (protecting the eye with a metal shield) and in the two brow points
(down to bone). Do not extend them.
5. Make the forehead incision by stabbing down to bone at one end of the marked
line, then holding the scalpel still against the bone, pull the forehead skin onto
the blade to complete the 4 mm incision. This is more controlled than trying
to move the scalpel freehand. Slightly undermine the forehead incision bluntly
by inserting closed scissors or an artery clip and opening it to create a small
pocket (Fig. 10.13b).
6. Insert the Wright’s fascia needle into the lateral eyelid incision down to the
tarsal plate and advance it on the tarsal surface to just past the medial incision.
It is usual to feel considerable resistance to the needle’s passage as it is semi-
sharp by design.
7. Lift the tip to feel its location and then push the needle out through the medial
skin incision.
8. Thread the silicone sling material through the eye of the needle and withdraw
the needle pulling the sling through (Fig. 10.13c).
9. Insert the empty Wright’s needle vertically into the lateral brow incision down
to bone. Rotate it horizontally and advance slightly. Now lift the tip to confirm
that it has not engaged the periosteum.
10. Advance the needle to just past the lateral lid incision. Ensure that the eye
is protected by a metal shield held firmly by an assistant in the upper fornix
and deep to the orbital rim. Monitor the tip’s progress throughout its passage
by intermittently lifting it and feeling for it by rolling the skin and orbicularis
over it with a fingertip. The needle’s passage should be as deep as possible
10.5 Operations 141
within the lid while not breaching the conjunctival surface. It is usual to feel
resistance as noted in 6 above.
11. Lift the needle tip and advance it out through the lid skin incision taking care
to avoid damaging the silicone tubing.
Note: Silicone tubes are only strong until they are nicked by a sharp instrument
such as the needle tip or toothed forceps after which they tear and break easily.
12. Thread the lateral end of the silicone into the needle and withdraw the needle
and tubing from the lateral brow incision (Fig. 10.13d).
13. Repeat steps 9–12 for the medial brow incision.
14. Enter the medial end of the forehead incision with the empty Wright’s needle,
weaving the tip in and out as you advance to engage the frontalis. Make the
tip emerge from the medial brow incision. Again, take care to avoid damaging
the silicone sling material with the point of the needle (Fig. 10.13e).
15. Thread the silicone into the needle and pull it through to the forehead incision.
16. Repeat steps 15 and 16 from the lateral end of the forehead incision laterally.
17. Now that both ends of the silicone sling are in the forehead incision, pass
them through a 4–5 mm length of silicone sleeve (Watske sleeve). Do this by
wetting the sleeve and pushing it onto closed fine artery forceps.
18. Force the forceps open to stretch the sleeve widely enough to allow you to
feed one end of the sling through it.
19. Instruct an assistant to pull both ends of the threaded sling downwards while
you thread the second end of the silicone sling through the sleeve from the
opposite direction.
20. Push the sleeve off the artery clip while keeping it slightly open to avoid
pulling on the sling.
21. Adjust the tension in the sling by pulling on both ends until the lid is set at
the correct height (Fig. 10.13f) Remember that when you push the sleeve into
the forehead incision to bury it the sling will slacken slightly.
Note: The correct height depends on the cause of the ptosis. A young child with
congenital ptosis and a good Bell’s phenomenon will tolerate a degree of nocturnal
lagophthalmos that an elderly patient will not. If progressive external ophthalmo-
plegia is the diagnosis, the lids should be left closed at the end of surgery to avoid
corneal exposure.
22. Pre-place two vertical mattress 6/0 sutures across the forehead incision and
trim the silicone sling ends to about 10 mm. Tuck the sling ends into the
subcutaneous pocket and keep them buried by tying the preplaced sutures
tightly to close the wound.
Note: The mattress sutures prevent the sling ends from poking out through the wound
and prevent the incision from forming a depressed scar during healing.
142 10 Ptosis
The remaining incisions close spontaneously without sutures.
23. Place a lower lid margin traction suture and close the eye by taping it upwards
to the brow. Apply antibiotic ointment and an overnight pressure dressing.
24. Review the patient the following day to check the lid height, eye closure and
the cornea for exposure. Remove the traction suture unless there is significant
corneal exposure due to an overcorrection. In this case use the suture to protect
the eye until the overcorrection can be addressed.
10.5.6.4 Notes
• Under or over correction can be addressed by opening the brow incision and
tightening or loosening the sling within the sleeve.
• Alternative synthetic sling materials can be used but have no advantages. Do
not use Polyester mesh (Mersilene® Mesh) as this is prone to exposure and
incites marked fibrosis which makes it very difficult to remove should it become
infected.
• Silicone slings are very easy to remove from within the capsule which forms
around them.
• Consider giving a per-operative dose of prophylactic antibiotic to reduce the
chance of sling infection.
10.6 General Observations
10.6.1 Lower Lid Traction Suture Fig. 10.14 (See Chap. 5)
At the end of a ptosis correction consider placing a lower lid margin traction
suture to pull the lower lid upwards to help keep the operated eye closed under
a pressure dressing. This is better than pulling the upper lid down since the point
of ptosis surgery is to lift the upper lid. A traction suture is not required after a
Müller’s resection as no pressure dressing is necessary. It is optional after ptosis
surgery with normal levator function (white line advancement/aponeurosis rein-
sertion) and the decision depends on how likely a patient is to comply with the
instruction to keep the operated eye closed under the dressing. I strongly recom-
mend a traction suture for ptosis correction in the presence of reduced levator
function (levator resection and frontalis suspension) to avoid corneal abrasion by
the pressure dressing.
10.6 General Observations 143
Fig. 10.14 Lower lid traction suture. Insert a 4/0 monofilament tarsal traction suture to pull the
lower lid closed following ptosis correction to protect the eye under the dressing
10.6.2 ‘On Table’ Lid Height
Judging the desired lid height at operation can be difficult. It is influenced by

surgical swelling and the local anaesthetic induced paralysis of the orbicularis and
Müller’s muscles. The main clue is the pre-operative levator function.
As a rule of thumb under local anaesthetic set the lid 2 mm higher than desired
to compensate for orbicularis paralysis. Under a general anaesthetic assume that
lids with good levator function (12–17 mm) will rise from their ‘on table height’
when the patient is awake, those with moderate function (5–11 mm) will stay put,
and lids with poor levator function (0–4 mm) will drop. As mentioned earlier,
with white line advancement the ultimate lid height is usually correct (provided
the levator function is normal).
144 10 Ptosis
10.6.3 Post-operative Adjustment—Early Suture Removal
I recommend that all ptosis surgery patients (except those with Müller’s resection)
are reviewed on the first post-operative day for:
1. Pad removal
2. Lower lid traction suture removal (if present)
3. A check for possible overcorrection or eyelid contour deformity (peak). It is a
simple matter to remove the responsible suture(s) and correct the problem. Do
this by pulling on the knot’s suture ends (they were left long specifically for
this eventuality) to lift the knot and cut one side of the suture loop below the
lifted knot with pointed scissors. Pull the suture out. If the lid position does not
improve immediately stretch the insertion by grasping the upper lid lashes and
pulling firmly downwards while asking the patient to try and look up. If the
issue is still unresolved consider removing a further suture.
Should you notice an early under-correction reassure the patient that this is
likely to improve once the postoperative swelling resolves (and keep your fin-
gers crossed). It often does. Wait two months before reassessing the patient for
possible ptosis revision surgery.
10.6.4 Hering’s See-Saw (Fig. 10.15)
The levator muscles follow Hering’s law of equal innervation. Consequently, the
additional innervation attempting to open the ptotic lid causes upper lid retraction
of the contralateral eye. Bear in mind that the latter will resolve after successful
ptosis correction.
Fig. 10.15 Hering’s see-saw. Lifting a ptotic lid reduces the drive to the contralateral levator
which goes down as a consequence
References 145
• Involutional ptosis is the commonest acquired ptosis.

• ‘White Line’ aponeurotic repair is the simplest and best operation for correcting
involutional ptosis.
References
1. Harrad RA, Shuttleworth GN (2000) Superior rectus-levator synkinesis: a previously unrecog-

nized cause of failure of ptosis surgery. Ophthalmology 107(11):975–1981, ISSN 0161-6420,
https://doi.org/10.1016/S0161-6420(00)00170-6
2. Harvesting Autogenous Fascia Lata. https://youtu.be/RYDJbBvxK7Q
Dermatochalasis and Blepharoplasty
11
11.1 Overview
• Skin and muscle blepharoplasty.
Patients are sometimes erroneously referred for ptosis surgery when in fact their
lid margin has not dropped, and an overhanging skin fold has masked the true lid
margin. This is known as ‘dermatochalasis’ (baggy lids). Some people erroneously
call it ‘blepharochalasis’ which is a syndrome affecting younger adults and char-
acterised by recurrent, idiopathic, periocular swelling which eventually gives rise
to eyelid atrophy (cigarette paper thin skin, medial orbital fat pad atrophy, canthal
tendon and levator aponeurosis dehiscence). Dermatochalasis, on the other hand is
usually caused by aging but may also be familial.
11.2 Examination
Observe the position of the upper lid skin fold in relation to the lashes and lid
margin. If the skin fold is resting on the upper lid lashes it may cause trichiasis
(in turning of the lashes). If it overhangs the lid margin it causes a reduction in
the visual field. In both these situations clinically, significant dermatochalasis is
present and justifies surgical correction by excision of the superfluous skin fold.
11.3 Considerations
Blepharoplasty means the removal of superfluous tissue from the eyelid. In this
chapter only upper lid skin fold reduction is discussed. The secret of successful
skin and muscle blepharoplasty is accurate pre-operative marking to ensure that
148 11 Dermatochalasis and Blepharoplasty
sufficient skin remains for full eyelid closure during blinking and sleep, and that
the scar is hidden in the skin crease.
Prominent or prolapsed fat pads result from weakness of the orbital septum.
They can cause significant aesthetic concerns. Unfortunately, removing them only
adds to age related orbital volume deflation and as such is not an ideal solution.
An alternative is to shrink and tighten the overlying orbital septum using bipolar
diathermy. Perform this with the bipolar forceps tips apart. Place both tips on the
septum. Turn on the power and gradually bring the tips closer together until the
septum shrinks and tightens. This is simple to do and safe, but unfortunately its
benefits are short lived.
Prolapsed orbital fat can be removed by making perforations in the orbital sep-
tum and encouraging the fat to prolapse through these to be clamped, diathermied,
and excised. This can, on very rare occasions, cause blindness so should not be
undertaken lightly.
As aesthetic surgery is not the subject of this book, fat removal will not be
discussed further.
11.4 Upper Lid Skin and Muscle Blepharoplasty (Fig. 11.1)
11.4.1 Principle
Pinch and mark the excess skin fold with the eye closed. Then excise it.
Symptomatic overhanging skin folds causing a reduction in visual field or

trichiasis.
11.5 Steps
1. Pull the upper lid skin upwards to lift the overhanging skin fold. Instruct the
patient to keep both eyes gently closed while you mark the desired postop-
erative lid skin crease position (Fig. 11.1b). Do this before injecting local
anaesthetic using a fine tipped marker pen. In Caucasians the crease is usually
7–8 mm above the upper lid margin.
2. Gently pull and lift the skin fold away from the eye, with a pair of Moorfields
forceps, to take up all the slack. Ensure that the eyelids remain closed. Position
a second pair of forceps across the lifted fold with the lower tip on the pre-
marked skin crease. Mark the position of the upper tip on the skin. This marks
the maximum extent of the redundant fold (Fig. 11.1c).
11.5 Steps 149
a b
c d X
X + y ≥ 20 mm
e f
g h
Fig. 11.1 Blepharoplasty. a Lateral overhanging skin fold. b Mark the desired postoperative lid
skin crease position. c Mark the maximum extent of the skin fold with the eyes closed. d Complete
the skin marking by drawing an ellipse within the upper skin markings and based on the skin crease
marking. Leave at least 20 mm of skin. e Incise the skin and orbicularis. f Excise the entire skin
and orbicularis ellipse. g Insert an orbicularis suture at the lateral angle to align the wound. h Close
the skin, taking bites of the underlying aponeurosis to reform the skin crease
150 11 Dermatochalasis and Blepharoplasty
3. Repeat step 2 medially and laterally at several points along the lid as the
amount of loose skin varies (there is usually more laterally). These marks
represent the maximum amount of skin that may be safely removed without
impairing eyelid closure.
4. Complete the skin marking by drawing an ellipse that falls within the
upper skin markings and is based on the skin crease marking from step 1
(Fig. 11.1d).
Note: The ellipse must extend laterally, past the lateral canthus as there is
usually more excess skin laterally than medially. Try to stay within the orbital
region as outside the orbital area scars become more visible.
5. To cross check, measure the distance between the lower edge of the eyebrow
and the upper skin ellipse line centrally. Add this value to the planned skin
crease height. The sum of these two measurements should exceed 20 mm to
ensure that sufficient skin remains for normal blinking.
6. Inject local anaesthetic with adrenaline into the sub-orbicularis plane balloon-
ing the skin along the whole length of the ellipse.
7. Place a metal eye protecting plate in the upper fornix to avoid accidental eye
damage and ensure that an assistant holds it in place up against the superior
orbital rim.
8. Incise the skin and orbicularis along the markings with a no. 15 scalpel blade
(Fig. 11.1e). Remember to cut ‘uphill’ to prevent blood from running down
and obscuring your skin markings.
Note: Keep the skin stretched tightly between the thumb and fingers of your
other hand while performing this incision. This makes it easier to follow the skin
marking. Lax skin is difficult to cut accurately.
9. Lift the outer corner of the skin ellipse with St. Martin’s toothed forceps and
use Westcott spring scissors to finish cutting through the orbicularis to start
raising a flap in the sub orbicular plane (Fig. 11.1f).
10. Extend in this plane to remove the entire skin and orbicularis ellipse. Keep
the skin stretched throughout to make the dissection easier.
Note: An alternative to scissor dissection is to use a high temperature disposable
cautery. This reduces bleeding but takes a little practice. It is essential to pull
and lift the skin flap away from the eye to avoid accidental damage. The cautery
tip must glow to cut tissue. Because it is immediately cooled by tissue contact
develop the technique of making frequent small dabs with the tip to maintain cut-
ting. I strongly advise the inexperienced surgeon against using radio frequency
cutting diathermy as this provides no tactile feedback and makes inadvertent
globe penetration frighteningly easy.
11. Place a single interrupted absorbable orbicularis suture just above and lateral
to the outer canthus to start closing the incision (Fig. 11.1g). This approxi-
mates the wound edges and creates an angle. Check the alignment of the skin
edges before proceeding.
12. Complete the skin closure using a 6/0 or 7/0 absorbable continuous suture
(Fig. 11.1h).
Note: Geometrically the upper skin wound edge is longer than the lower one.
Therefore ‘gather’ the excess along the whole length of the closure. In the central
lid portion of the closure alternate bites should engage the levator aponeurosis
to ensure that a strong skin crease develops. This adds an ‘active’ component
to the operation which reduces the likelihood of an early recurrence.
13. Apply antibiotic eye ointment and a pressure dressing overnight to reduce the
almost inevitable lid swelling and bruising.
Note: Having both eyes padded is disorientating and unpleasant even if only for
one night. Some surgeons do not pad and prefer instead to recommend that the
patient applies ice packs to reduce the postoperative swelling. This is neither
easy for the patient nor comfortable.
11.6 Notes
• It is possible to remove only skin and to leave the orbicularis intact. However,
the subcutaneous plane is harder to dissect than the sub-orbicularis plane as the
skin and orbicularis are bound together by the orbicular fascia.
• If only skin is removed the skin crease will reform without the need of levator
aponeurosis suture bites.
• Removing skin but leaving the orbicularis risks creating a ‘stuffed sausage’
appearance with too much orbicularis filling for the remaining skin.

• Plan your skin excision carefully to leave enough behind for full eyelid closure.
Lid Lumps and Bumps
12
12.1 Overview
• Cyst excision.
• Meibomian cyst incision and curettage.
• Marking tumour surface extent and gauging its depth.
• Choosing the type of biopsy, and the size of clear margin.
• Full thickness lid margin tumour resection technique.
Eyelid bumps are either caused by cysts or by tumours. Both may distort the
lid and interfere with function through their mass effect.
12.2 Cysts
Cysts are closed epithelium lined sacs which tend to enlarge as they fill up with
shed cells or secretions. They may be developmental, as in the case of dermoid and
epidermoid cysts, or occur as inclusion cysts from epithelium accidentally buried
during surgery. If they leak, their contents incite a marked local inflammatory reac-
tion. When symptomatic, such cysts should be excised intact, by careful dissection,
to ensure all their epithelial lining is removed or they can reform. Blocked eyelid
sweat glands form clear fluid filled cysts of Moll which transilluminate. Blocked
grease glands form white cysts of Zeiss. Both occur superficially under the skin
and can easily be lanced. If they reform, they should either be de-roofed and left
to granulate or excised intact.
But by far the commonest lid bump results from a blocked meibomian gland
and is known as a meibomian cyst or Chalazion.
154 12 Lid Lumps and Bumps
12.2.1 Meibomian Cyst Incision and Curettage (I & C)

The majority of meibomian cysts settle on conservative treatment with hot
compresses. Large, persistent, or recurrent meibomian cysts require surgical
drainage.
12.2.1.2 Principle
Because meibomian glands are part of the tarsal plate they cannot easily be
excised. Incise them instead and remove the gland’s epithelial lining by thoroughly
curetting the cavity.
12.2.1.3 Steps
1. Evert and carefully inspect the meibomian orifice line and sub-tarsal surface
of the affected lid under magnification to identify the affected gland or glands.
Often the offending gland looks darker or redder than its neighbouring glands
(Fig. 12.1a). If you are unable to identify blocked gland incise at the point of
maximum swelling and hope for the best.
2. Anaesthetise the eye with proxymetacaine drops and the affected lid with
adrenaline containing local anaesthetic injections.
3. Apply a large, oval meibomian clamp to the lid to encompass the affected part
and tighten it to prevent bleeding (Fig. 12.1b).
Note: If you use a small clamp there is a high chance of missing the true position
of the cyst or part of it.
4. Evert the lid using the clamp.
5. Incise the length of the suspected gland (or area of maximum intumescence),
taking care to avoid damaging the lid margin (Fig. 12.1c).
Note: At this point you will hopefully see the gelatinous lipo-granulation contents
of the cyst emerge (Fig 12.1d). If you do not obtain the typical contents, you
may have missed the cyst. Consider performing a second incision to one side
and parallel to the first. When present, the contents are pathognomonic of a
meibomian cyst. However, they are not always found, particularly in chronic
cases where fibrosis has supervened the granulation stage.
6. Vigorously curette the cyst cavity to remove the lining to remove it and any
remaining contents (Fig. 12.1e).
7. Remove the clamp and apply firm pressure until the bleeding stops.
8. Clean the eye, removing any blood and clots, and instill antibiotic ointment.
There is no need to apply a dressing providing you have waited for the bleeding
to stop.
12.2.1.4 Warning
Beware of atypical meibomian cysts or ones that recur after incision. They might
be meibomian carcinomas! Take a biopsy of one edge when repeating the I & C.
12.3 Tumour Excision (Fig. 12. 2) 155
a b
c d
Fig. 12.1 Meibomian cyst incision & curettage. a Identify the responsible gland. b Apply and
tighten a large meibomian clamp. c Incise the tarsal plate from the conjunctival surface. d Look
for release of the pathognomonic lipo-granulomatous cyst contents. e Curette the cyst cavity
12.3 Tumour Excision (Fig. 12.2)
The obvious priorities of tumour surgery are to cure the patient while minimizing
collateral damage. The former requires knowledge of the tumour type and its true
extent. The latter involves excising the minimum tissue necessary to effect the cure.
The likely tumour type is inferred from its appearance and rate of growth (learnt
pattern recognition), combined with probability (95% of malignant lid tumours
are basal cell carcinomas). The tumour’s true extent may be obvious, as in a well
demarcated nodular basal cell carcinoma. However, infiltrative tumour margins are
difficult to discern. Therefore, use all the available clues: appearance, palpation,
and mobility (is it fixed to underlying tissues).
To determine a tumour’s surface extent, stretch the surrounding skin in all
directions. This makes it easier to see the tumour boundary by making surface
Fig. 12.2 Butcher. Tumour

surgery is destructive
texture, colour, and contour changes easier to spot. Use magnification (a slit lamp
or illuminated loops) to see details more clearly. Look specifically for:
• Skin hair or lash loss (indicates tumour infiltration of the follicles).

• Skin texture alteration viewed by surface reflection of oblique illumination (loss
of the normal fine skin wrinkles and semi-matt surface; tumours tend to be
smooth and shiny).
• Surface contour change.
• The capillary network. In tumours it is different from that of normal skin.
Time spent carefully marking the tumour margins saves wasting time later with
avoidable re-excisions.
12.3.1 First is Best
It is said that the first excision attempt has the highest cure rate. This is of course a
self-fulfilling prophecy as failure at the first attempt is likely to be due to uncertain
margins which will be no clearer the second time around. But there is also some
truth in the saying: previous attempts at excision leave scars and distort tumour
margins and tissue planes, making re-excision less certain.
12.3 Tumour Excision (Fig. 12. 2) 157
12.3.2 Clear Cutaneous Margins
Because of the difficulty in determining a tumour’s boundary with certainty it is

standard practice to excise a ‘clear safety margin’ around the tumour. For presumed
benign lesions 1–2 mm surface margins suffice. For presumed malignant lesions
4 mm margins are a reasonable compromise between incomplete excision and an
unnecessarily large tissue defect (views on this vary considerably (3–5 mm)).
12.3.3 Stretch
Eyelid skin is both mobile and elastic. This makes skin marking difficult as the
marker pen drags and distorts the skin. Clear margin measurement must be stan-
dardized to have any meaning. Get around both problems by having an assistant
keep the skin stretched during measuring, marking, and incising.
12.3.4 Deep Excision
The depth of a tumour’s extension is gauged differently from its surface markings.
Grasp the tumour and pull it to and fro noting its mobility over the underlying
tissues. If mobility is restricted, then there is likely to be deep extension. Fortu-
nately, most tumours are reluctant to cross tissue planes unless encouraged to do
so, for example by incisional biopsy. Consequently, most cutaneous lid growths
do not penetrate the orbicularis plane. So, for complete excision excise the surface
marked tumour and include an intact layer of underlying orbicularis in the speci-
men as the deep safety margin. If the tumour appears fixed, the specimen should
include the underlying tarsal plate or periosteum (depending on its location).
12.3.5 Waste Not, Want Not
It is customary to excise lesions as elliptical specimens to avoid lax ‘dog ear’

folds at either end of the closure scar (see Chap. 2). This practice results in excess
healthy tissue being sacrificed on the altar of cosmesis. I recommend removing
only the actual tissue necessary to achieve a cure for two reasons. Firstly, the so
called ‘dog ears’ tend to remodel and vanish within a year of surgery and seldom
require subsequent treatment. Secondly, the tissue spared may come in useful for
the present or for future reconstructions.
The same dictum is true when choosing reconstruction procedures. I am sus-
picious of reconstructions which require you to discard a significant quantity of
skin.
Fig. 12.3 Beware canthal

tumours. Tumours at the
canthi can spread into the
orbit silently along the
canthal tendons
BEWARE!
12.3.6 Beware the Canthi (Fig. 12.3)
At the eyelid margin a tumour readily invades the tarsal plate but cannot penetrate
deeper than the conjunctival surface. However, at the medial and lateral canthi
the canthal tendons provide a direct highway for tumour spread to the orbital rim
periosteum, from where it can quietly invade the orbit unnoticed.
12.3.7 Biopsy: Excision V Incision
Single stage or ‘one stop’ surgery is preferred by patients and is an efficient use
of resources. Therefore, excision biopsy with direct defect closure should be your
default management. However, if serious doubt exists about the nature of a large
lesion, perform an incisional biopsy first to establish the diagnosis. This biopsy
should include part of the tumour margin rather than being taken from the cen-
tre. The former shows the tumour invading normal tissue. This is helpful to the
histologist. Histological confirmation that a lesion is benign avoids excessive clear
margin excision.
12.3.8 Histology First!
Delay reconstruction of presumed malignant tumour defects until you have histo-
logical proof of tumour clearance. The only exceptions to this rule are direct defect
closure or directed laissez-faire. With these all the tumour margins are included in
the single scar. Should the subsequent histology report recommend a re-excision,
simply excise the scar with the appropriate additional safety margin.
12.4 Full Thickness Lid Margin Tumour Resection (Fig. 12. 4) 159
12.3.9 One Stop Management
There are only three options for safe ‘one stop’ management:
1. Excision and direct closure

2. Excision and ‘laissez-faire’
3. Excision with ‘on table’ frozen section histology followed by reconstruction.
This last option is time and resource intensive making it costly. Furthermore,
frozen section histology is less reliable than paraffin sections. Mohs’ surgery
is a form of sequential frozen section biopsy that may be useful in tumours
without any clear margins, but it is by no means infallible. Furthermore, it is
difficult to carry out periocularly because of the mobility of the thin tissue
planes relative to each other which makes the excision of an intact 2 mm thick
Mohs layer neigh impossible.
12.4 Full Thickness Lid Margin Tumour Resection (Fig. 12.4)
See Fig. 12.4.
a b
4 mm
c d
Fig. 12.4 Lid margin tumour resection. a Mark the visible tumour margins. b Mark a clear safety
margin. c Incise along the marking with a no. 15 scalpel. d Excise the specimen with scissors.
e Flatten the specimen on card and mark the edges with dyes for orientation
Meaningful margins can only be measured with the tissues on stretch. Care-
ful specimen marking and orientation during fixation avoid confusion when the
histological margins are reported.
12.4.2 Steps
1. Carefully mark the visible tumour edges with the lid held on stretch
(Fig. 12.4a).
2. Mark the planned clear margin (usually 4 mm) using a calliper (Fig. 12.4b).
3. Protect the eye with a metal plate under the lid and incise the skin along the
markings with a no.15 scalpel (Fig. 12.4c).
Note: Remember to cut ‘uphill’!
4. Complete the orbicularis ± tarsal plate incision with tenotomy scissors
(Fig. 12.4d).
5. Get an assistant to apply firm pressure to the area for haemostasis, while you
attend to the specimen.
6. Without releasing your hold, rinse and dry the specimen to remove blood.
Inspect all the edges and the deep surface to make sure no tumour is visible. If
it is, excise an additional specimen from that margin.
7. Place the specimen on a piece of card and spread it, unrolling the skin edges if
required.
8. Mark the specimen edges with histology marking inks for orientation
(Fig. 12.4e) and record the colours of the respective edges in the notes and
on the histology request form. Allow the inks to dry and the specimen to stick
to the cardboard for 5 min.
9. Slip the cardboard mounted specimen slowly into a formalin pot so that the
specimen remains flat during fixation. This makes the pathologist’s task easier.
12.5 Take Home Messages

• Biopsy atypical or recurrent meibomian cysts.
• Careful tumour margin marking pays dividends.
• Await proof of clearance before undertaking complex reconstructions.
• Beware of canthal tumours!
Eye Protection
13
Fig. 13.1 Moist chamber

eye protection

• Occlusive dressings
• Manual blink
• Tarsal Traction Suture
• Non-tarsal traction
• Temporary Suture tarsorrhaphy
• Permanent lateral tarsorrhaphy
• Permanent medial canthoplasty.
162 13 Eye Protection
The purpose of the eyelids is to both protect the eye and to regularly replenish
the optical surface of the pre-corneal tear film through blinking. If eyelid function
is impaired, whether by paralysis or by a tissue defect, alternative eye protection
becomes a priority.
13.2 Occlusive Dressing
The simplest protective measure is the application of an antibiotic or lubricant

ointment under an occlusive, non-stick dressing. This is the treatment of choice
for acute lid defects, such as result from lid tumour excision, while awaiting a
histology report. Similarly, use it after trauma if you are unable to repair the
lid immediately. Occlusive dressings can safely be left undisturbed for a week
if necessary.
13.3 Manual Blink (Fig. 13.2)
When eyelid closure is impaired, by paralysis or lid retraction, and there is no

significant corneal epithelial defect, teach the patient to perform a ‘manual blink’.
This reduces eye drying and discomfort during waking hours. The patient performs
this by momentarily pushing the lower lid up across the cornea to spread the
marginal tear strip across the eye to replenish the pre-corneal tear film. It needs to
be repeated frequently (as often as possible) and requires strong patient motivation
and commitment.
a b
Fig. 13.2 Manual blink. a Place a finger on the lower lid. b Push the lower lid up momentarily to
spread the pre-corneal tear film
13.5 Closing the Eye 163
13.4 ‘Cling Film’ Occlusion
When a patient is asleep, they cannot perform a ‘manual blink’. Therefore, manage
symptomatic lagophthalmos (incomplete eyelid closure) with an occlusive dress-
ing overnight. This can be made from a square of transparent plastic food wrap
film hermetically fixed around the eye with adhesive tape to create a moist cham-
ber. This is more effective than using lubricant eye ointment alone. Proprietary
transparent occlusive dressings are available as an alternative.
13.5 Closing the Eye
13.5.1 Not the ‘Grey Line’!
When the above conservative measures are insufficient or inappropriate, surgical

protection may be required. The simplest way of reliably and reversibly closing a
lid is to insert a lid margin traction suture and tape this to the skin to pull the lid
closed. Traditionally, and in my view wrongly, such sutures are inserted into the
grey line of the lid margin.
Anatomically the grey line marks the junction between the anterior lamella
of the lid (skin and orbicularis muscle) and the posterior lamella (tarsal plate
and conjunctiva). The grey colour is imparted by the muscle of Riolan (modi-
fied orbicularis of the lid margin) as viewed through extremely thin, translucent
skin (Fig. 13.3).
Meibomian orifice line
Grey line
Muscle of
Riolan
Fig. 13.3 Grey line and meibomian orifice line. The meibomian orifices mark the mid tarsal plate
thickness. The grey line marks the anterior and posterior lamellar junction
The grey line is a poor landmark as with age it becomes increasingly difficult to
discern. Far better landmarks exist on either side of the grey line: the meibomian
orifice line posteriorly, marking the mid tarsal plate thickness, and the lash line
anteriorly.
As a site for traction suture placement the grey line is woefully inadequate as
neither thin skin nor muscle have any suture holding strength. Sutures placed in
the grey line alone will cut out in a matter of hours when put on traction. For this
reason, it is customary to externalize a grey line suture through the skin, pass it
over a bolster or through tarsorrhaphy tubing and then re-enter the skin and exit
through the grey line. In this way the traction force is spread over an area of skin
making the suture less likely to cut through. Unfortunately, the pressure of the
tubing on the skin can be uncomfortable or frankly painful. It can even cause lid
margin pressure necrosis by impairing perfusion. This results in traction failure, lid
margin distortion with possible trichiasis and sometimes lash line necrosis and per-
manent lash loss. Fortunately, there exists a simple, safe, and effective alternative:
the tarsal traction suture.
13.5.2 Avoid Toxin Ptosis
Botulinum toxin injection of the upper lid levator muscle has been advocated as
a means of inducing temporary upper lid closure. Unfortunately, this is invari-
ably associated with superior rectus paresis knocking out the protective Bell’s
reflex. Furthermore, and perhaps surprisingly, on rare occasions permanent vertical
diplopia results. There are better ways to protect an eye.
13.5.3 The ‘Tarsal Traction Suture’ (see Chap. 5)

It is generally accepted that the tarsal plate is the strongest structure in the eyelid
and thus best suited for anchoring a traction suture. Furthermore, the edge of the
tarsal plate is easily identifiable on the lid margin by the meibomian orifice line
which marks the mid tarsal plane. Gently squeezing the lid margin with forceps
causes meibomian secretion egress making the orifice line easy to see. A suture
inserted perpendicularly into this ‘meibomian orifice line’ will provide strong pur-
chase for many weeks or months. Once in place it is completely painless and does
not distort or damage the lid margin. Eventually, like all sutures placed in living
tissue, the suture will migrate out through the lid margin. Slow migration is quite
different from rapid ‘cheese-wiring’ or ‘cutting out’ in so far as it leaves no scar-
ring or anatomical alteration. The cells simply part in front and re-unite behind the
migrating suture until all tension is dissipated.

Any eye requiring temporary lid closure for protection.
13.5.3.3 Steps (Fig. 13.4)
1. Grasp the full thickness of the lid margin with large forceps (such as Adson’s
or Thaller Tarsal Forceps (Altomed UK A6360)) and evert it to view the lid
margin edge on.
2. Insert a 4/0 monofilament non-absorbable suture on an atraumatic round bodied,
taper point half circle needle (e.g., 4/0 Prolene W8557 Prolene™ Ethicon, or 4/
0 Premilene® B Braun) into the meibomian orifice line perpendicularly to the
margin (Fig. 13.4a).
3. Advance the suture needle within the tarsal plate, allowing it to follow its own
curve, to exit the lid margin form the meibomian orifice line about 10–12 mm
from its insertion point (Fig. 13.4b).
4. If the needle tip exits posteriorly (trans-conjunctively) or anteriorly (transcu-
taneously), simply withdraw it slightly, adjust the tilt of the lid margin with
the grasping forceps and re-advance the needle tip. A non-cutting taper-point
needle causes minimal damage during such repeated passage. Had a cutting
needle been used, each pass would cut the tarsal plate eventually shredding and
weakening it.
a b
900
Fig. 13.4 Tarsal Traction Suture Placement. a Enter the meibomian orifice line perpendicularly
with a non-cutting needle. b Advance the needle within the tarsal plate to exit in the meibomian
line. c Tape the traction suture to the forehead securely
5. Pull the suture tight and stick it to the forehead or cheek with three layers
of adhesive tape, bending the suture 180° between layers to prevent it from
slipping through the tape (Fig. 13.4c).
13.5.4 Non-tarsal Traction (Fig. 13.5)

Sometimes it is still possible to protect an eye with traction sutures when the tarsal
plate is missing. In this situation the traction suture force must be spread to stop
it cutting through the skin. A silicone band can provide the necessary purchase
on the remaining tissues. This temporizing technique buys time while awaiting
a histology report or planning a definitive repair. During the wait, the stretched
tissues will expand.
a b
Fig. 13.5 Non-tarsal traction. a Insert a 4/0 monofilament suture through the conjunctival wound
edge and retractor and bring out through the skin and into a silicone band. Re-enter the band 5 mm
to one side in the reverse direction picking up the tissue layers. b Place additional sutures in the
same manner as the need dictates (usually 3–4). c Tape the sutures to the skin on the opposite side
of the wound under strong traction

Temporary eye protection following any full thickness eyelid defect pending
reconstruction.
13.5.4.3 Steps
1. Insert a 4/0 monofilament suture through the conjunctival wound edge.

2. With the same suture pick up any retractor tissue and bring this suture out
through the skin.
3. Now push it through the centre of a silicone band (240 retinal detachment
encircling explant) and re-enter the band 5 mm to one side in the reverse
direction.
4. Pass the needle through all the tissue layers picked up with the first bite in the
reverse direction (Fig. 13.5a) and clip both ends of this suture together.
5. Place additional sutures in the same manner as the need dictates (usually 3–4
(Fig. 13.5b).
6. Tape the sutures to the skin on the opposite side of the wound under strong
traction. Prepare the skin with a coating of tincture of benzoin and apply
three layers of tape for each pair of suture ends. Remember to alternate the
suture direction between layers to prevent the suture slipping through the tape
(Fig. 13.5c).
7. Apply antibiotic ointment to the wound and an occlusive pressure dressing.
Note: Avoid getting ointment on the adhesive tape or it will lose its adhesion.
8. Leave the dressing undisturbed until formal reconstruction.
13.5.5 Temporary Central Suture Tarsorrhaphy (Fig. 13.6)
The tarsal traction suture technique described above can be extended by passing
the same suture through the opposing eyelid margin in the same way (Fig. 13.6c).
The suture ends are then tied firmly together creating a simple, yet very effective,
temporary tarsorrhaphy (Fig. 13.6d). This can work over many weeks before suture
migration eventually causes it to fail. The suture knot should be tied medially or
laterally as far from the cornea as possible to minimise the risk of corneal irritation.
Furthermore, the suture ends should be left long (2–3 cm) to make it impossible
for the sharp cut ends to enter the palpebral aperture and irritate the eye. Because
monofilament sutures are smooth, the knot seldom irritates the cornea even when
contact occurs.
13.5.6 Temporary Lateral Suture Tarsorrhaphy (Fig. 13.6e)
The principle above may be used to create a lateral tarsorrhaphy (Fig. 13.6e). For
this I recommend you place two tarsal sutures. The more central suture takes most
a b
900
c d
Fig. 13.6 Temporary suture tarsorrhaphy. a Enter the meibomian orifice line perpendicular with
a taper point needle. b Bring the suture out through the meibomian line about 10 mm away. c Take
a strong bite of the upper lid margin in the same way. d Tie the suture ends together laterally, away
from the cornea. e Use two such sutures to create a temporary lateral tarsorrhaphy
of the strain and will loosen first through migration. Remove it when it is no longer
effective, leaving the lateral suture in place until that also fails.
In my view there is no longer a place for using tubing or bolsters when per-
forming a suture tarsorrhaphy (provided the meibomian orifice line is used for
suture placement).
13.6 Permanent Surgical Tarsorrhaphy 169
13.5.7 Notes
• Occasionally, following the removal of a tarsorrhaphy suture a mucosal bridge

will be found between the lids. This can be left to break on its own or simply
be cut without anaesthetic.
• No Temporary Surgical Tarsorrhaphy.
Because meibomian line suture tarsorrhaphy is so simple to perform, effective
and easy to repeat, I contend that there is no-longer any reason for carrying out
a temporary surgical tarsorrhaphy. The latter takes longer to perform and risks
leaving an irregular lid margin and trichiasis after it is re-opened.
13.6 Permanent Surgical Tarsorrhaphy
If a patient requires long-lasting eyelid union, as for example when managing non-
recovering seventh nerve palsy, then you must encourage the lids to heal together
firmly and permanently. The simplest way is to make the opposing lid margin
surfaces raw before suturing them together in close contact until they heal together.
This can work well but often the union is too weak to last and the lids either
separate spontaneously or else the join stretches into an unsightly and ineffective
web. The larger the area of tarsal plate contact that you create the stronger your
tarsorrhaphy.
13.6.1 Permanent (Overlap) Lateral Tarsorrhaphy (Fig. 13.7)
13.6.1.1 Principle
Create a bare area between the overlapping upper and lower tarsal plates and hold
them together with sutures until a strong permanent scar has formed. The greater
the bare area of contact the stronger the union obtained. Overlapping the tarsal
plates creates a larger area of contact than an edge-to-edge tarsorrhaphy.
It is often combined with a medial canthoplasty.
• Incomplete eye closure e.g., non-recovering facial palsy

• Atonic lower lid ectropion
• Lower lid retraction e.g., Thyroid eye disease (only when combined with
retractor recession).
a b
c d
e f
Fig. 13.7 Permanent (overlap) lateral tarsorrhaphy. a Make a 4–5 mm long incision in the lower
lid grey line up to the lateral canthus. b Excise a semicircle of anterior lamella below it, includ-
ing skin, orbicularis, and lash follicles, to expose the underlying tarsal plate. c Evert the upper lid
margin and diathermy a corresponding semicircle on the sub-tarsal conjunctiva to destroy the con-
junctiva. d Insert a 6/0 absorbable suture through the middle of the exposed lower lid tarsal plate
margin and then a bite of the upper edge of the adjacent diathermied area and tie this suture, cutting
its ends short. e Insert a 4/0 monofilament suture on a round bodied needle through the upper lid
skin, so that it exits the denuded tarsal plate close to the lateral canthus. Then take a strong, partial
thickness bite of the exposed lower lid tarsal plate. Complete this suture by taking it through the
upper lid tarsal plate, skin and through a silicone sleeve. f Place one or two 6/0 absorbable sutures
into the upper lid meibomian orifice line, bringing them down to engage the cut edge of the lower
lid orbicularis and skin. Then tie the preplaced 4/0 monofilament suture to hold the raw tarsal plate
surfaces in firm apposition, so that they unite
13.6.1.3 Steps
1. Make a 4–5 mm long incision in the lower lid grey line up to the lateral
canthus (Fig. 13.7a).
2. Based on the grey line incision, excise a semicircle of anterior lamella below
it, including skin, orbicularis, and lash follicles, to expose the underlying
tarsal plate (Fig. 13.7b). Ensure that the exposed tarsal plate surface is free
of connective tissue. Apply gentle diathermy if required.
3. Evert the upper lid margin and mark out a corresponding semicircle on the
sub-tarsal conjunctiva ensuring that it also starts at the lateral canthus. Apply
gentle diathermy to this area to destroy the conjunctiva without significantly
damaging the tarsal plate (Fig. 13.7c). Wipe off any loose necrotic conjunctiva.
4. Insert a 6/0 absorbable suture through the middle of the exposed lower lid
tarsal plate margin.
5. With the same suture take a bite of the upper edge of the adjacent diathermied
area of the everted upper lid tarsal plate (Fig. 13.7d).
6. Tie this suture and cut its ends short, so that they do not irritate the eye.
7. Insert a 4/0 monofilament suture on a round bodied needle through the upper
lid skin, just above the lashes so that it exits the denuded tarsal plate close to
the lateral canthus.
8. With the same suture now take a strong, partial thickness, bite to span the
exposed lower lid tarsal plate.
9. Complete this suture by taking it through the upper lid tarsal plate at the
medial end of the denuded tarsal crescent, so that it exits through the skin just
above the lashes (Fig. 13.7e).
10. Cut a piece of silicone tubing the length of the distance between the suture
entry and exit points and thread it onto the suture. It will act as a bolster. Clip
the untied suture ends together.
11. Place one or two 6/0 absorbable sutures into the upper lid meibomian orifice
line, bringing them down to engage the cut edge of the lower lid orbicularis
and skin. Tie the suture(s) (Fig. 13.7f).
12. Tighten and tie the preplaced 4/0 monofilament suture to hold the raw tarsal
plate surfaces in firm apposition, so that they unite during healing.
13. Before cutting the 4/0 suture ends reverse thread (using the blunt end of its
needle) one end through the tubing. By pulling on this suture, you can pull
the knot to lie inside the tubing for the patient’s comfort. Then cut both suture
ends close to the tubing.
14. No dressing is required. Remove the non-absorbable suture and bolster at two
weeks. Allow the remaining sutures to dissolve spontaneously.
Note: Such tarsorrhaphies cannot be reversed without causing distortion of the
lid margin and so should only be used when permanence is intended. They are
well camouflaged by the upper lid lashes.
13.6.2 Permanent Medial Canthoplasty (Fig. 13.8)

Medial canthoplasty is effectively a tarsorrhaphy carried out medially to the
lacrimal puncta where there is no tarsal plate to suture together. Instead, aim to
unite permanently the upper and lower limbs of the medial canthal tendons. Take
great care not to damage, or suture closed the lacrimal canaliculi during such
surgery as they lie adjacent to the tendon.
It is often combined with a lateral tarsorrhaphy.
• Non-recovering facial palsy

• Atonic lower lid ectropion
• Lower lid retraction e.g., Thyroid eye disease (only when combined with
retractor recession).
a b
c d
Fig. 13.8 Permanent medial canthoplasty. a Insert Bowman probes into the upper and the lower
canaliculi and make a ‘U’ shape skin incision around the medial canthus from punctum to punc-
tum. b Suture firm medial canthal tendon tissue adjacent to the canaliculus together with two ‘box’
sutures. c Place two horizontal mattress sutures across the skin wound. d The posterior lamella is
inverted, and the anterior lamella everted to maximise the contact area
13.6.2.3 Steps
1. Insert ‘0’ gauge Bowman lacrimal probes into the upper and the lower canali-
culi and ask an assistant to keep them in the lacrimal sac by pressing them
gently against the side of the nose.
2. Carefully make a ‘U’ shape skin incision around the medial canthus from
punctum to punctum and just outside the probes (hence also the canaliculi)
(Fig. 13.8a).
3. Separate the orbicularis by blunt dissection using pointed scissors.
4. Using a 6/0 absorbable suture on a curved needle take a strong bite of the firm
medial canthal tendon tissue adjacent to the canaliculus (Fig. 13.8b).
Note: Identify the tendon by its resistance to distraction rather than by its visi-
bility. Start at the medial canthus. If you feel the needle tip touch metal, then it is
intracanalicular and should be removed and replaced.
5. Take a similar bite with the same suture through the opposing lid in the opposite
direction to make a ‘box’ suture. Clip the two suture ends together.
6. Place a second suture adjacent to the first so that the bites extend to the ends
of the incision, close to the lacrimal puncta.
7. Withdraw the Bowman probes and tie both sutures firmly. In doing so the lid
margins become inverted so that there is no epithelium between the raw surfaces
of the upper and lower limbs of the medial canthal tendon.
8. Place two 6/0 absorbable horizontal mattress sutures across the wound, engag-
ing both the skin and the orbicularis. As you tie them, they will evert the skin
edges (Fig. 13.8c, d).
9. No dressing is required. Leave the sutures to dissolve spontaneously.
13.6.3 Lower Lid Lifting (Fig. 13.9)
The lifting of an atonic lower lid is best achieved by combining a medial cantho-
plasty with a small lateral tarsorrhaphy. Doing so transfers dynamic upper lid lift
(levator pull) to the lower lid. The effect can be enhanced by dividing the lower lid
retractors first (transconjunctivally) and placing the lower lid on upward traction
overnight with a central tarsal traction suture.
Fig. 13.9 Permanent medial canthoplasty and lateral tarsorrhaphy. Impart dynamic lift to a lower
lid with a small lateral tarsorrhaphy and medial canthoplasty

• Use the meibomian orifice line, not the grey line, for bolster-less lid margin
traction suture placement.
• Use a meibomian orifice line suture tarsorrhaphy instead of a temporary surgical
tarsorrhaphy.
Lid Reconstruction
Post Tumour Excision Repair
14
The art of surgery (Fig 14.1).
Fig. 14.1 Artist with a scalpel
14.1 Overview
• Relative importance of the upper lid
• Lid tension vectors and tissue expansion
• Direct closure of lid margin defects
• Direct closure of skin defects
• Directed Laissez-faire
• Upper to lower lid skin flap
• Cheek pedicle flap
• Mustardé lower lid switch flap
176 14 Lid Reconstruction
When faced with an eyelid reconstruction, ask first “Is reconstruction is really
necessary?” Our natural healing response has evolved over millennia to do just
that and is generally very effective. Remember the maxim “First do no harm”, as
all surgery involves further wounding, albeit with the best of intentions. So, always
attempt direct defect closure, and if that fails consider the option of doing nothing,
referred to as “Laissez-faire”. It can produce acceptable results in selected cases
and may be preferred by some patients as an alternative to further surgery.
A functioning lid requires both an anterior and a posterior lamella. Restore
both.
14.2 The Reconstruction Ladder (Fig. 14.2)
Reconstruction techniques are ranked in a hierarchy, sometimes referred to as

Gillies’ ladder (after Sir Harold Delf Gillies CBE FRCS 1882–1960). Rank the
best technique first and the most complex last:
• Direct closure (best tissue match)

• Directed laissez-faire (incomplete attempted direct closure)
• Laissez-faire (involves no surgery)
• Flaps (recruitment of adjacent tissue)
• Grafts (free transfer of distant tissue)
• Microvascular flaps (free grafts with a vascular re-anastomosis).
Fig. 14.2 The reconstruction

ladder. A hierarchy of Reconstruction ladder
reconstruction options with
the best at the bottom and the
most complex at the top. Microvascular Graft
With experience 80% of
reconstructions can be Free Graft
satisfactorily managed using
the bottom two rungs
Local Flap
Laissez-faire
Directed Laissez-faire
Direct Closure
80%
14.3 Upper Lid Essential, Lower Lid Optional! 177
Without doubt, direct closure gives the best outcomes. However, it is not always
possible. Consider leaving a wound partially closed when you cannot quite close it
completely (termed ‘directed laissez-faire’). Ultimately the size and nature of the
defect will dictate the most appropriate management choice. Consider patient pref-
erence, although that is in large part dictated by the way you present the options.
Never oversell. ‘Under promise and over deliver’ to avoid disappointment. Be
aware of the subconscious bias to promote unnecessarily complex repairs because
we as surgeons enjoy operating (or possibly derive additional financial benefit?).
I challenge you to incrementally increase your direct closure/directed laissez-
faire rate to 80% from the probable 30% at which I guess it currently stands.
14.3 Upper Lid Essential, Lower Lid Optional!
The relative functional importance of the upper lid compared with the lower lid is
often overlooked. Many papers and chapters are devoted to lower lid reconstruc-
tion using harvested upper lid tissue. This is not without risk to upper lid function
which is essential for clear vision. Without it the comfort and integrity of the eye
itself are in jeopardy. The upper lid is a ‘wash-wiper’, spreading a fresh optical
tear film across the upper 2/3 of the cornea with each blink (Fig. 14.3). Bell’s phe-
nomenon (the upward rolling of the eye during blinking) ensures that the lower
1/3 of the cornea is also kept moist by the upper lid. This means that the lower
lid is mostly redundant, a fact born out following complete lower lid margin exci-
sion without reconstruction (laissez-faire healing). Never compromise upper lid
function when you use it as a donor site.
Fig. 14.3 Wash-wiper. The upper lid spreads the tears on blinking to clean and replenish the pre-
corneal tear film, a function essential for clear vision and for corneal survival
14.4 Proof of Cure
I contend that histological proof of malignant tumour clearance is mandatory

before you undermine or alter the defect margins in case a further wider exci-
sion is needed. Therefore, avoid performing flap or graft repairs at the time of
excision biopsy, unless on table frozen section histology is available and negative.
Consequently, the only safe primary management options are direct closure with-
out undermining, partial direct closure (directed laissez-faire), or simply dressing
the defect (laissez-faire).
14.5 Eyelid Tension: Normal and Necessary
Eyelids require tension to hold them against the eye and keep them stable. When
a youthful eyelid margin is cut the tension is released and the wound edges
spring apart by about a centimetre. Loss of tension is an important factor in the
development of entropion and ectropion. Therefore, when reconstructing a lid,
restore lid margin tension ensuring that you direct it parallel with the margin.
A reconstruction that gives rise to perpendicular tension will cause lid margin
stretching and ectropion.
14.6 Don’t Undermine
The undermining of wound edges is common surgical practice. A skin flap must
be dissected free from the underlying tissues (undermined) to allow it to be raised.
However, our faces are naturally very mobile, anchored by facial ligaments in
only a few places. So, undermining wound edges for the direct closure of defects
is both unnecessary and creates avoidable scar planes. Contraction of these scar
planes during healing may cause undesirable tension vectors.
Detaching the mid face from the zygomatico-cutaneous ligament, as when lift-
ing a cheek rotation flap, leads to late progressive mid face descent which spoils
an initially satisfactory reconstruction.
There is currently a vogue for dividing the confusingly named tear trough lig-
ament from the inferomedial orbital rim in order to “re-drape” the lower lid fat
pads for aesthetic reasons instead of removing them. It will be interesting to see
what the long-term unintended effects of this will turn out to be.
14.7 Direct Closure 179
14.7 Direct Closure
The benefits of direct wound closure are obvious:
1. Primary repair at the time of tumour resection.

2. Edge to edge suturing gives the best skin colour and texture match.
3. Absence of a donor site and related morbidity.
Its limitations are:
1. Limited local tissue availability.

2. Temporary impairment of eyelid function due to raised lid margin tension.
3. Lid margin malposition (retraction, cicatricial ectropion) if the induced tension
vectors are wrongly aligned.
The direction of the closure tension is more critical than the orientation of the
resulting scar. Figure 14.4 illustrates the correct tension vectors’ orientation (black
arrows) for closing lid margin and periocular defects. The resulting closure scars
(yellow lines) end up at right angles or oblique to the lid margin, and cross skin
tension lines. The trio of vectors outside the canthi relate to the bony attachments
of the canthal tendons to which you should anchor the soft tissues.
But how is it possible to bring together the edges of a significant tissue defect?
1. Most tissues have an inherent degree of elasticity, skin and muscle more so
than tarsal plate and canthal tendon.
2. The naturally curved eyelid straightens when pulled. This change in geometry
from curve to the shorter straight line relies on the lid displacing the eye back-
wards and upwards within the orbit (Fig. 14.5), irrespective of whether it is the
upper or the lower lid that has been tightened.
3. The phenomenon of ‘tissue creep’ lengthens the lid per operatively. It comprises
the squeezing of fluid from the tissues and micro-tears of the collagen. The
more slowly you pull the tissues together, the more creep takes place.
These three mechanisms together give rise to significant lid length gain.
Fig. 14.4 Direction of wound closure vectors. a The arrows indicate the desired closure tension
vectors for lid margin defects, the lines the direction of the resulting scars. b The arrows indicate
the desired closure tension vectors for defects peripheral to the lid margins, the lines the direction
of the resulting scars
14.7.1 Tissue Expansion (Fig. 14.6)
Living tissues under abnormal tension expand or grow to reduce that tension. After
all, no-one pops from getting fat or pregnant. Ophthalmologists are familiar with
lengthened eyelids in cicatricial ectropion and even more so in the floppy eye-
lid syndrome (surgery to correct these conditions requires significant lid margin
14.7 Direct Closure 181
a b
c d
Fig. 14.5 Globe displacement by direct closure. a When a lid (A) is shortened to become a
straight line (B) the eye is pushed backwards. Direct closure of a lower lid defect b straightens the
lid margin upwards (small arrow) (c) and displaces the eye upwards (large arrow). Direct closure
of an upper lid defect d straightens the lid margin downwards (small arrow) e but still displaces
the eye upwards (large arrow)
shortening). Plastic surgeons have long used implanted subcutaneous balloons to

expand skin so that it can be used to reconstruct a defect. It is therefore surpris-
ing that few oculoplastic surgeons exploit the phenomenon of tissue expansion for
eyelid reconstruction.
Closing a large lid margin defect directly by pulling the wound edges together
creates tension that may prevent normal eyelid movement and displace the eye pos-
teriorly and upwards within the orbit as already mentioned (Fig. 14.5). However,
these changes are short-lived. The displaced eye acts as an inbuilt tissue expan-
sion balloon, applying sustained pressure to the reconstructed lid thus stimulating
it to stretch and grow. Often excessive lid tension after a significant direct closure
Fig. 14.6 Tissue expansion.

No-one bursts from getting
fat or pregnant!
prevents the eye from opening immediately. However, it is usually able to do so

again often by the second postoperative day and certainly within a week or two.
Within two months the vertical and horizontal palpebral aperture dimensions will
have returned to within 1 mm of those on the un-operated side [1, 2].
Consequently, ‘excessive tension’ is not a valid argument against direct wound
closure provided the lid tension vector rules in Fig. 14.4 are observed.
14.7.2 No Cantholysis
As explained above, raised lid margin tension is necessary for expansion to occur.
Relieving that tension by performing an elective cantholysis to enable direct clo-
sure is therefore counterproductive. Don’t do it! You end up with an unsightly web
of tissue at the cantholysis site devoid of the normal lid margin structures.
Note: Some surgeons recommend a cantholysis to allow remaining intact lateral
lid margin to move to a pre-corneal position to enhance the stability of the lid
reconstruction. This is a valid reason, but in my experience such a manoeuvre is
seldom required.
14.7.3 Closure Scar Lengthening
Direct closure wounds lengthen, a fact which is not widely recognised (Fig. 14.7).
Closing a circular defect results in a closure length approximately 1½ times the
defect’s original diameter. This is fortuitous as it counterbalances the naturally
occurring scar contraction during healing, which might otherwise pull on the lid
margin.
14.8 Direct Closure of Lid Margin Defect (Fig. 14.8) 183
D L
Circle circumference C = Π , where D is the circle

diameter.
D.Π
Closure length L = ½ C = ≈ 1.5 x D
Fig. 14.7 O to I closure. Directly closing a circular wound lengthens the closure scar by roughly
one and a half times the original defect diameter
14.8 Direct Closure of Lid Margin Defect (Fig. 14.8)
14.8.1 Principles and Considerations
This technique is the same as that for lid margin repair (described in Chap. 5)
but relies on postoperative tissue expansion to restore the lid margin length. The
resulting margin is complete with eyelashes, albeit more spaced out, something no
other repair achieves. It uses absorbable sutures which, generally, do not require
removal.
The tarsal plate is the most important structure to suture as it forms the skeleton
of the lid margin.
Attempt direct closure on most defects, irrespective of size. With experience you
will start closing defects much larger than the 1/4 to 1/3 of the lid’s length that
textbooks quote.
14.8.3 Steps
1. Insert a 6/0 absorbable suture, mounted on a 1/2 circle needle, through the tarsal
plate on either side to span the wound. Place it as close to the lid margin as
Fig. 14.8 Lid margin reconstruction by direct closure. a Grasp the full thickness of the lid ‘sand-
wich’ perpendicularly to the margin with toothed forceps and evert the edge. b Enter the anterior
tarsal plate surface perpendicularly with your suture needle. c After engaging almost the full tarsal
plate thickness, take a similar bite on the far wound edge. d In the lower lid, place 2 further sutures
below the first one in a similar fashion, in the upper lid, 3 or 4. e to h). Place a 7/0 absorbable hor-
izontal mattress suture in the margin, burying its knot. f Tie and cut the preplaced tarsal sutures.
g Tighten and tie the lid margin mattress suture. h Ensure the margin pouts. i Repair the remain-
der of the skin wound. j With lateral defects use the cut lateral canthal tendon as the lateral suture
fixation point. k Close the skin and orbicularis
14.8 Direct Closure of Lid Margin Defect (Fig. 14.8) 185
possible. Take care to align the suture bites on each side to be equidistant from
the lid margin to avoid a margin step.
(a) Grasp the full thickness of the lid ‘sandwich’ perpendicularly to the margin
with toothed forceps, about 2–3 mm from the cut edge (Fig. 14.8a). Evert
the edge slightly to improve visibility and access.
(b) Use the flat surface of the suture needle to push the skin and orbicu-
laris away, so that the needle tip enters the anterior tarsal plate surface
perpendicularly (Fig. 14.8b).
(c) As soon as the needle tip engages the tarsal plate, rotate and advance the
needle so that it emerges close to the conjunctival surface on the cut edge
of the tarsal plate, i.e., after engaging almost the full tarsal plate thickness.
(d) Retrieve and remount the needle from this first bite and grasp the far side
of the lid margin with tissue forceps, as in step 1a.
(e) Insert the needle into the cut surface of the tarsal plate close to and parallel
with its conjunctival surface. Take special care to place this bite at the same
distance from the lid margin as the first bite on the other side of the defect
(Fig. 14.8c).
(f) As soon as the needle tip engages the tarsal plate, rotate, and advance the
needle so that it emerges on the anterior surface of the tarsal plate 1½ mm
from the wound edge. Avoid engaging the orbicularis and skin (you may
have to lift them off the needle tip).
(g) Clip the two untied suture ends together with a bulldog clip and retract
them.
2. In the lower lid, place 2 further sutures below the first one in a similar fashion,
spaced about 1 mm apart (Fig. 14.8d). In the upper lid, 3 or 4 additional sutures
may be required as the tarsal plate is wider. Again, clip each pair of untied
suture ends together to aid later identification when tying.
will become buried in the lash line. This configuration will cause the lid margin
repair to pout as intended when this suture is eventually tied.
(a) With the needle enter the wound edge through the orbicularis, just anterior
to the tarsal plate surface in line with the lashes (Fig. 14.8e).
(b) Rotate the needle so that it emerges from the skin within the lash line 1½
mm from the wound edge, having engaged the orbicularis and skin.
(c) With the same needle re-enter the lid margin perpendicularly through the
meibomian orifice line on the same side (Fig. 14.8f). Rotate and advance
the needle to exit the cut tarsal plate surface close to the margin. Take
special care not to accidentally engage the first preplaced tarsal plate suture
from step 1, as this would cause problems when tying the latter.
(d) Now insert the same suture through the far wound edge in reverse order i.e.,
entering the cut tarsal plate first, exiting the meibomian line, re-entering
through the lash line and finally exiting the orbicularis just anteriorly to the
tarsal plate (Fig. 14.8g).
(e) Clip the untied suture ends together (Fig. 14.8h).
4. Now tie firmly and cut the preplaced tarsal sutures in reverse order of placement
i.e., starting with the one furthest from the lid margin (Fig. 14.8i). Once tied, the
first suture takes up most of the wound tension. This makes tying the remaining
tarsal plate sutures easy and their first throws very unlikely to slip during tying.
By the end of this step the lid margin wound should be accurately and securely
closed.
5. Tighten and tie the lid margin mattress suture (Fig. 14.8j). Confirm that it causes
the lid margin join to pout (Fig. 14.8k). Cut its ends short enough for them to
retract into the wound.
6. Either repair the remainder of the skin wound with interrupted 6/0 or 7/0
absorbable sutures which incorporate the underlying orbicularis into each bite
or suture the orbicularis as a separate layer with a magic suture (see below)
(Fig. 14.8l).
14.9 The Trans Incisional Tarsal Traction Suture (Fig. 14.9) 187
14.8.3.1 Notes
• An accurately repaired lid margin will not leave a noticeable scar or notch.
However, for larger defects the scar may stretch.
• Direct margin closure works equally well when a canthus is involved. Use
remaining canthal tendon, periosteum, or a bone screw to anchor the sutures
at the lateral wound edge (Fig. 14.8m, n).
14.9 The Trans Incisional Tarsal Traction Suture (Fig. 14.9)
The direct closure of larger defects can be made easier by placing a modified
tarsal traction suture (see Chap. 5) across the defect to reduce the tension across
the wound. Its ends may be used to apply lid traction or converted into a suture
tarsorrhaphy (see Fig. 13.6).
a b
900
c d
Fig. 14.9 Trans incisional traction suture. a Enter the meibomian orifice line with d 4/0 monofil-
ament polypropylene suture. b Advanced the needle within the tarsal plate to exit in the wound.
c Re-insert the needle into the far wound edge to engage the tarsal plate and come out through the
meibomian orifice line. d Now continue with the direct closure of the lid
14.9.2 Steps
1. Grasp the full thickness of the lid as parallel to the margin as possible with
large forceps (e.g., Toothed Adson’s) and evert the margin. As you squeeze the
lid the egress of meibomian secretions identifies the meibomian orifice line.
2. Enter the meibomian orifice line with a 4/0 monofilament polypropylene suture
on a 17 mm half circle, non-cutting needle with its tip held perpendicular to
the lid margin (Fig. 14.9a).
3. Slowly advanced the needle within the plane of the tarsal plate, allowing it
to follow its own curve to exit in the wound at the base of the tarsal plate
(Fig. 14.9b).
4. Re-insert the needle into the far wound edge to engage the tarsal plate and
come out through the meibomian orifice line (Fig. 14.9c).
5. Now continue with the direct closure of the lid defect as outlined in the previous
section (Fig. 14.9d).
6. Apply traction to the suture ends using an artery clip to approximate the wound
edges when you tighten and tie the repair sutures.
14.10 Direct Closure of a Skin Defect (Fig. 14.10)
The principles of non-marginal lid wound closure are the same as for any surgical
wound: accurate alignment of the edges and closure in layers. The main difference
periocularly is the paramount importance of the tension vector (direction) which
has already been discussed. This is because the free lid margin edge is unable
to withstand any sustained radial traction. The technique below incorporates the
magic suture, described in Chap. 5.
Potentially applicable to any periocular wound. At best, full closure is achieved. At

worst, the defect has been minimized prior to an additional graft, flap or directed
laissez-faire.
14.10 Direct Closure of a Skin Defect (Fig. 14.10) 189
14.10.3 Steps
1. Ensure adequate haemostasis.

2. Place a single, strongly anchored, buried, 4/0 or 6/0 absorbable suture in the
subcutaneous tissue layer (usually the orbicularis muscle) to span the maximum
wound diameter, orientated as in Fig. 14.4b (See also ‘The Magic Suture tech-
nique’ Chap. 5). Insert the suture so that the knot becomes buried when tied
(Fig. 14.10a).
3. Tighten this suture fully by lifting the first throw free of the tissues, rocking it
gently side to side to encourage it to slide through the tissue, and then snugging
down the throw (Fig. 14.10b). This manoeuvre may need to be repeated until
you bring the tissue edges completely together. Do not rush this step to allow
time for ‘tissue creep’ to occur.
4. Tie the suture on a bow and observe the effect that tightening has had on the
lid margin position. If there is any sign of margin retraction, remove the suture
and replace it in a more favourable alignment. Once happy with the orientation
tie it with a minimum of two additional throws.
a b
10 mm
10 mm
Fig. 14.10 Direct closure of a periocular skin defect. a Span the defect with a strongly anchored,
orbicularis muscle suture, orientated parallel to the lid margin. b Tighten this suture by lifting and
rocking the first throw side to as you pull. Once happy with the orientation tie it with a minimum
of two additional throws. c The skin edges should have been brought sufficiently close together to
suture
5. Observe the effect that the first subcutaneous suture has had on the skin mar-
gins. The skin edges should have been brought sufficiently close together
to allow suturing without undue tension. If not, add additional subcutaneous
sutures in a similar fashion.
6. Close the skin with either interrupted or a continuous suture (Fig. 14.10c).
7. Apply a pressure dressing overnight to minimise oedema.
Notes: The tissue at either end of the closure will appear lax in comparison to the
central area of maximum tension. This can give rise to a ‘dog ear’ appearance.
Ignore this as it is very likely to resolve spontaneously by tissue remodelling.
14.11 Directed Laissez-Faire (Incomplete Direct Closure)
Although direct eyelid defect closure remains the first choice, sometimes it is
impossible to achieve complete closure. In such circumstances, partially closing
the defect to reduce its size is still of benefit. Firstly, it aligns the closure tension
vector in the desired axis (see Fig. 14.4), rather than permitting the unmodified
concentric wound contraction of laissez-faire to occur. Secondly, because you have
greatly reduced the wound area left to heal by granulation, more rapid secondary
intention healing occurs. The closure sutures span and reduce the residual defect
(Fig. 14.10). Remember, they should only create tension that is parallel to the
eyelid margin, as already discussed ad nauseam. Apply antibiotic ointment and a
non-stick pressure dressing and leave it undisturbed for a week while awaiting his-
tology. All the excision margins are available for re-excision should the histology
suggest incomplete tumour removal. Healing by secondary intention often gives
excellent results and further surgery may be unnecessary. At two to three months
post excision, decide whether the outcome is functionally and aesthetically accept-
able or whether to perform a secondary reconstruction. If reconstruction proves
necessary, the tissue expansion that has already taken place in the interim will
make it less extensive.
14.11.2 Directed Laissez-Faire of a Lid Margin Defect (Fig. 14.11)
14.11.2.1 Steps
1. Preplace interrupted 6/0 absorbable sutures into the cut tarsal plate edge on
one side of the defect. Double armed horizontal mattress sutures hold strongly
and are easy to tie under tension. Two will suffice in a lower lid, three may be
needed in an upper lid. If you use simple sutures three will suffice for a lower
14.11 Directed Laissez-Faire (Incomplete Direct Closure) 191
a b
c d
e f
Fig. 14.11 Directed laissez-faire margin reconstruction. a A large lid margin defect. b Attempt
direct closure, bringing the wound edges as close as tension allows. c Repair the orbicularis and
skin as much as you can. Leave the remaining defect to granulate. d Manage a large lateral margin
defect similarly. e Reduce the horizontal defect size with sutures. f Reduce the orbicularis and skin
defect. Wait for granulation to close the remaining defect
lid and 4–5 in the upper lid. If no tarsal plate remains, insert the sutures into the
cut edge of the canthal tendon (Fig. 14.11e). Should that also be absent place
them through the orbital rim periosteum (arcus marginalis). If no periosteum
remains insert a short, self-tapping, bone screw into the orbital rim and tie the
suture to that with a clove hitch knot.
2. Span the wound with the sutures and insert them in the cut far side tarsal plate
edge (Fig. 14.11b).
3. Tie the sutures in turn, starting with the one furthest from the lid margin:
(a) When using simple sutures remember to lift the first throw, rock it a lit-
tle side to side to help it slide through the tissues and then snug it down
under tension. Ask an assistant to grasp and hold the tightened first suture
throw with the very tips of a pair of Moorfields forceps before releasing
the tension on the suture ends. Repeat this manoeuvre several times until
the wound edges stop coming any closer. Ignore the induced palpaebral
aperture distortion and globe displacement. Lock the knot with a second
single throw, asking the assistant to remove the forceps just before they are
trapped by the locking throw. Complete the knot with 1–2 further single
throws and cut the ends no shorter than 2 mm (to avoid unravelling).
(b) When using horizontal mattress sutures lift and pull the first throw, rock it
horizontally to and fro and then tighten it down snugly against the tissues.
Normally it is unnecessary to grasp the first throw as the suture tension
holds it down firmly against the tissues. The friction this causes prevents it
from slipping. Lock the first throw, as above, with 2–3 further throws and
cut the suture ends no shorter than 2 mm.
4. Repeat step 3 for the remaining suture(s). Do not rush these steps as tissue
creep is gradually occurring as you increase the tension.
5. Close the orbicularis and skin with interrupted sutures as far as the tissue
tension allows (Fig. 14.11c, f).
6. Apply a non-adherent dressing membrane, antibiotic ointment, and a pressure
dressing. Leave the dressing undisturbed for 5–7 days.
7. Continue twice daily antibiotic ointment thereafter until the remaining defect is
epithelialized. When a suture loosens, remove it to prevent irritation.
14.11.3 Directed Laissez-Faire of Skin Defect (Fig. 14.12)
This is almost identical to the direct closure of a skin defect, differing only in that
the defect is not fully closed at the end.
14.11.3.1 Steps
1. Ensure adequate haemostasis.

2. Place a single, strongly anchored, buried, 4/0 or 6/0 absorbable suture in the
subcutaneous tissue layer (usually the orbicularis muscle) to span the maximum
wound diameter, orientated as in Fig. 14.4b (See the magic suture technique
in Chap. 5). Insert the suture so that the knot becomes buried when tied
(Fig. 14.12a).
3. Tighten this suture fully by lifting the first throw free of the tissues, rocking it
gently side to side to encourage it to slide through the tissue, and then snugging
down the throw (Fig. 14.12b). This manoeuvre needs to be repeated several
14.11 Directed Laissez-Faire (Incomplete Direct Closure) 193
a b
10 mm
10 mm
Fig. 14.12 Directed laissez-faire of skin defect. a Place a magic suture across the defect. b Use it
to minimize the orbicularis defect. c Close the skin as much as tension allows. Allow granulation
to deal with the residual defect
times over a matter of minutes to encourage ‘tissue creep’, until the tissue
edges no longer advance.
Note: If your suture breaks consider using a stronger one. If it cuts out use a
horizontal mattress configuration instead.
4. Tie the suture on a bow and observe the effect that tightening has had on the lid
margin position. If there is any sign of margin retraction remove the suture and
replace it in a more favourable alignment. Once happy with the orientation ask
an assistant to grasp and hold the tightened first suture throw with the very tips
of a pair of Moorfields forceps to prevent it from slipping while you complete
the knot with a minimum of two additional throws.
5. Begin closing the skin with interrupted horizontal mattress sutures from either
end of the wound. Continue adding sutures until the skin edges can no longer
be advanced to meet (Fig. 14.12c).
6. Apply a non-stick film, antibiotic ointment, and a pressure dressing, leaving it
undisturbed for 5–7 days. The residual skin defect will granulate by secondary
intention healing.
7. Once you remove the dressing ask the patient to apply twice daily ointment to
the wound until it is fully healed. Reassure the patient that the appearance will
improve with time and that you will reassess the outcome at 2 months to decide
whether secondary reconstruction is required (it rarely is).
Note: The healing time depends on the size of the defect and on the individual’s
powers of healing.
14.12 Flaps
Pedicle flaps are peninsulas of tissue attached to a blood supply sufficient to ensure
their on-going survival. They are used in eyelid reconstruction to bring additional
tissue into the area. They also bring in a blood supply and can therefore be used as
a bed for a free graft. Flaps are less prone to shrink than free grafts. They can be
thicker and include additional tissue layers e.g., the orbicularis muscle. They must
be planned so as not to leave a significant donor site deficit i.e., only take from
where there is redundant tissue. Where possible flaps should have their pedicle
inlaid to avoid the need for secondary pedicle division surgery. Eyelid flaps can
be used to add anterior lamellar or posterior lamellar tissue. Numerous flaps have
been described. Here I shall describe only three: two anterior lamellar and one
transferring the full thickness of the lower lid margin (Fig. 14.13). The first two
are straightforward and widely applicable. The third is rarely needed but I include
it as it is the only way of reconstructing a normal upper lid margin following total
or subtotal loss.
Note: I do not find simple advancement flaps useful for two reasons. Firstly, it is
usually possible to close such a defect directly. Secondly, as you pull a flap in one
direction it narrows perpendicularly, introducing a new, undesirable force vector
(Fig. 14.14a, b).
a b
Fig. 14.13 Useful flaps. a Upper to lower lid pedicle flap. b Cheek pedicle flap. c Mustardé Lid
Switch Flap
14.12 Flaps 195
a b
Fig. 14.14 Advancement flap. a Advancement flap. b Stretching in one direction causes narrow-
ing at right angles
14.12.1 Paper Templates
It you need to transfer skin into a defect, first make a paper template of the defect
size from a piece of spare, sterile instrument wrapping paper.
14.12.1.1 Steps (Fig. 14.15)
1. Get an assistant to gently stretch the wound to its full size.

2. Fold an appropriately sized piece of paper to make is easier to insert in a
concave area (Fig. 14.15a).
3. Dry the wound and then briefly press the paper against it, unfolding it as you
do (Fig. 14.15b).
4. Remove the paper, turn it over, and cut round the blood-stained wound imprint
with scissors (Fig. 14.15c).
5. Refine the template by putting it back in the wound and trimming its edges if
necessary (Fig. 14.15d).
6. Use this paper template to mark the gently stretched skin donor site.
a b
c
d
Fig. 14.15 Making a paper template. a Fold a piece of sterile paper. b Press and unfold on the
defect. c Cut around the blood stain. d Recheck the template and refine if necessary
14.12.2 Upper to Lower Lid Skin Flap (Fig. 14.16)
See Fig. 14.16.

Transfer redundant upper lid skin into a lower lid defect on its vascular pedicle.

Lower lid defects where sufficient redundant upper lid skin is present.
14.12.2.3 Steps
1. Make a paper template of the lower lid skin defect (as described above)
(Fig. 14.16a).
2. Position the lower edge of the template on the upper lid skin crease and use
it to mark the body of the flap on the gently stretched upper lid donor skin
(Fig. 14.16b). Check that there will be sufficient skin remaining after the flap
has been transposed (minimum 20 mm between the lashes and eyebrow).
14.12 Flaps 197
a b
A C
B A1
c d
C
A
B A1 A A1
D B
C1 D
5 mm C
C1
e f
A A1
Fig. 14.16 Upper to lower lid skin flap. a Make a template of the defect. b Use it to mark a donor
flap on the upper lid. c Raise the flap and incise the skin to join the defect to the flap pedicle.
d Anchor the flap tip C into the defect C1 . e Anchor corner A1 into the upper pedicle angle A.
f Complete the skin and margin closures
3. Join the donor skin to the intended pedicle base with two parallel lines
(Fig. 14.16b). The lower line should end about 5 mm lateral to the lateral
canthus (or 5 mm medial to the medial canthus) at the level of the canthus.
The upper line should finish vertically above the lower one. The pedicle width
should be similar to the maximum flap width.
4. Intumesce the donor area with a subcutaneous injection of local anaesthetic
with adrenaline.
5. Incise the skin with a no.15 scalpel blade along the flap outline while your
assistant ensures the eye is protected with a metal guard (Fig. 14.16c).
6. Lift the tip (or edge) of the flap and dissect it free from the underlying tissue,
either as a pure skin flap or as a skin and orbicularis flap.
7. Join the lower lid defect to the base of the pedicle flap, B-D with an incision
(Fig. 14.16c). This will allow you to inlay the pedicle.
8. Anchor the tip of the flap C into the far edge of the lower lid defect C1 with
a 6/0 absorbable suture (Fig. 14.16d). Do not trim the suture ends or cut off
the needle.
9. Anchor the corner of the lateral canthal skin A1 into the upper pedicle angle
A (Fig. 14.16e). This effectively transposes the pedicle downwards. Do not
cut off the needle.
10. Use the already placed anchoring sutures to finish suturing the flap into the
recipient site (Fig. 14.16f) and tie the running suture to the short arm of an
available knot.
11. Suture the donor site closed with a running absorbable suture.
12. Ensure that the recipient bed remains stretched and immobilized, usually with
a lid margin traction suture, and apply a non-adherent film, antibiotic ointment,
and a pressure dressing. Leave the dressing undisturbed at least overnight, but
preferably for 5–7 days.
14.12.2.4 Notes
There may be a tendency for a narrow pedicle to ‘tube’ because of interface fibrous
contraction. Initial lid margin traction and subsequent massage help to avoid this
complication.
14.12.3 Cheek Pedicle Flap (Fig. 14.17)

The thicker cheek skin can be used to construct an anterior lamella for a lower lid
replacement when there is no tarsal plate remaining. Its thickness imparts a degree
of stiffness to the reconstruction. The posterior lamella can be made of advanced
fornix conjunctiva or a free mucosal graft.

Total lower lid loss requiring reconstruction.
14.12.3.3 Steps
1. Estimate the skin flap length needed by pulling the lid margin edges together
and measuring the length of the reduced defect (Fig. 14.17a). Alternatively,
use an unfolded gauze swab to measure the defect and then, keeping it held
firmly at the lateral canthus, swing the tip of the swab down like a compass
and mark the skin (Fig. 14.17b).
14.12 Flaps 199
Note: A common error is to make the flap too long which leads to the
reconstructed margin sagging.
2. Measure the vertical width of the defect without tension in order that the
reconstructed lid develops no radial tension to later cause an ectropion. Draw
the flap, based at the lateral canthus. Check that there is sufficient cheek laxity
to close the intended donor defect by pinching the skin at the flap base before
raising the flap.
3. Decide whether sufficient conjunctiva can be mobilized for the posterior
lamella by undermining the inferior conjunctival fornix. If this is not possible
consider harvesting a lower lip mucosal graft.
4. Incise the skin and raise the flap in the subcutaneous plane (dissecting deeper
risks damaging the facial nerve) (Fig. 14.17c).
5. Preplace a 7/0 absorbable suture at the lateral canthus (for later suturing of
the reconstructed margin).
6. Rotate the flap and anchor its tip B to the far end of the lid margin defect B1
with a 6/0 absorbable suture (Fig. 14.17d). Do not cut this suture as it will be
used to suture the inferior flap edge to the defect.
7. Close the donor defect by anchoring point A1 to the pedicle angle A with a
6/0 absorbable suture (Fig. 14.17e). Then suture the vertical defect with the
same suture (Fig. 14.17f).
8. Suture the lower flap edge to the defect edge with the suture from step 6.
9. Suture the free conjunctival edge to the skin to recreate the margin with the
preplaced 7/0 suture (Fig. 14.17g). Tie it to the end of the anchoring suture.
10. Apply antibiotic ointment and pad the eye firmly closed overnight.
14.12.3.4 Notes
• The cheek donor scar remains visible. The recreated lid margin is rounded and
lacks the stiffness of a normal lid margin. There is a risk of fine skin hairs
irritating the cornea.
14.12.4 Mustardé Lower Lid Switch Flap
Inclusion of the lid switch flap in this manual is an anomaly as it is neither

commonly needed nor is it a simple technique to perform. However, no better tech-
nique exists for restoring a normal functioning upper lid margin (including lashes).
Despite this it is not widely known and so I make no apology for including it for
the rare occasions when you may find it invaluable.
a b
c d
A A
B1 B B1
A1 A1
e f
A
A1 B B1
g h
Fig. 14.17 Cheek pedicle flap. a Measure the length of the reduced defect. b Or use an unfolded
swab as a compass to mark the flap. c Raise the flap and swing it into the defect, point B to B1 .
d Anchor the flap in place. e Anchor point A to corner A1 to close the donor defect. f Suture the
skin. g Suture the mucosal edge to the flap to create a new lid margin. h Put the flap on traction
using a bolster
14.12 Flaps 201

The lower lid is sacrificed to reconstruct a functioning upper lid after total or
near total upper lid loss. It is a two-stage procedure. The longer the interval
between stages, the more margin expansion will have taken place and the smaller
the ultimate lower lid defect.

Total or subtotal upper lid loss.
14.12.4.3 Steps
1st stage (Fig. 14.18).
1. Mark and cut a full thickness lower lid flap that includes the whole tarsal plate.
Base it medially (Fig. 14.18a). It must be at least 5 mm wide to include the
peripheral vascular arcade.
Note: Although the flap can be based laterally this is less convenient and there is
more risk of canalicular damage.
2. Preplace a double armed 6/0 polypropylene suture in the cut lateral canthal
tendon (Fig. 14.18b).
Note: this modification was not included in Mustardé’s original description.
3. Rotate and anchor the tip of the flap, A, into the upper lid defect by suturing
the tarsal plate to the upper lid tarsal plate remnant, A1 , or the medial canthal
tendon with a 6/0 absorbable suture (Fig. 14.18c). This causes the flap to fold
on itself and the margin to stick out at the bend because of its stiffness.
4. Starting medially, suture conjunctiva to conjunctiva with a continuous 7/0
absorbable suture as far laterally as is possible.
5. Identify the upper lid levator aponeurosis (using the pre-aponeurotic fat pad as
a landmark) and attach it to the flap tarsal plate edge with three interrupted
6/0 absorbable sutures.
6. Suture the recipient skin and orbicularis to the flap skin and orbicularis with a
6/0 interrupted or continuous suture (Fig. 14.18d). Start medially and progress
laterally as far as is possible. By this stage the eye will be obscured by the
folded lid margin flap. There will be a residual infero lateral defect.
7. Anchor the kinked proximal tarsal plate edge to the lateral canthal tendon with
the preplaced 6/0 polypropylene suture. Gradually tighten the suture to pull the
flap bend laterally as far as it will go (Fig. 14.18e).
Note: This modification was not part of Mustardé’s original description. The
addition of this suture induces tension which encourages tissue expansion.
8. Suture the lower defect in layers, starting medially and progressing as far
laterally as is possible (Fig. 14.18e).
9. Apply antibiotic ointment, a non-stick film, and an occlusive pressure dressing.
Leave this in place for 5–7 days. Subsequently apply antibiotic ointment twice
daily until the raw surfaces have healed.
a b
A1
A
>5 mm
c d
A1
A
Fig. 14.18 Lid switch flap 1st stage. a Plan a full thickness lower lid flap. b Cut the flap and place
a suture into the cut lateral canthal tendon. c Anchor the flap tip, A to the end of the defect, A1 .
d Suture the flap into the defect in layers as far laterally as possible. e Anchor the bend in the flap
tarsal plate with the lateral preplaced suture
2nd stage (Fig. 14.19).

Delay this as long as possible to allow time for revascularization and tissue
expansion. 6–12 weeks is ideal.
1. Insert a squint hook into the lid margin flap bend and pull it laterally. Decide
where to divide the lid margin pedicle so as to have sufficient lid margin for
the new upper lid and mark it. Usually, this point is about 2/3 of the way from
the flap tip, i.e., 2/3 of the flap will remain as upper lid.
14.12 Flaps 203
a b
c d
Fig. 14.19 Lid switch flap 2nd stage. a Divide the healed flap roughly 2/3 from the tip. b Freshen
the edges and insert 2 double armed sutures into the lateral canthal tendon. c Anchor the lateral
ends of the divided flap to the lateral canthal tendon. d Suture the flaps in place laterally
2. Cut the flap at the marked spot with tenotomy scissors perpendicularly to the
margin (Fig. 14.19a).
3. Freshen up the healed lateral defect edges to separate the skin from the
conjunctiva.
4. Pre-place two double armed 6/0 absorbable sutures into the lateral canthal ten-
don which is marked by the polypropylene suture placed in stage one. The latter
should now be removed (Fig. 14.19b).
5. Reattach the divided flap ends at the margin with the pre-placed 6/0 sutures,
one for the upper and the other for the lower cut edge. These sutures reform
the lateral canthus (Fig. 14.19c).
6. Complete the flap transfer by suturing conjunctiva to conjunctiva and skin to
skin with 6/0 or 7/0 absorbable sutures (Fig. 14.19d).
7. Close the lower lid margin donor defect as much as possible and leave the rest
to granulate (directed ‘laissez-faire’).
8. Apply antibiotic ointment and an overnight pressure dressing.
Note: By allowing several weeks to elapse between the first and second stages it
is usually possible to reconstruct both the upper and the lower lids from the single
lower lid flap. The priority however is to attain a functioning upper lid which is
essential for sight, the lower lid being entirely optional. If the lower lid defect cannot
be closed leave it to granulate.
14.13 Grafts
Free grafts are the simplest way of bringing additional tissue into an area. However,
their use is limited in two important respects. Firstly, they can only be applied
onto a vascularized bed from which they derive their new blood supply. Secondly,
they must survive long enough to establish this new vascular connection. In eyelid
surgery this limits them to full thickness (or split) skin, or conjunctival grafts,
where the host contact area is large in relation to the graft’s bulk and metabolic
requirement. The exception is dermis-fat grafts which are bulky in relation to their
contact area. They only survive thanks to the fat’s low metabolic rate, but even
then, the degree of fat survival is unpredictable, ranging from full retention to
total absorption.
For a graft to take it must be immobilised in intimate contact with its host bed
until new vascular channels establish. In eyelids this takes 5–7 days.
Grafts also shrink! This is hardly surprising as the graft-host interface fibrob-
lasts contract during the proliferative phase of wound healing. Split skin grafts
contract by about half their linear dimensions and full thickness skin by about a
third. For this reason, full thickness skin grafts are preferred for lid reconstruction.
Oversize the graft to compensate for the anticipated shrinkage and keep the host
bed on stretch during the haemostatic and inflammatory stages of wound healing.
Here I shall only describe skin grafting as this is the most required. The appear-
ance of healed skin grafts ranges from unnoticeable to unsightly and cannot always
be predicted. Warn the patient of this beforehand. It depends to a large extent on
the donor site chosen.
14.13.1 Skin Graft Donor Sites (Fig. 14.20)
The lateral upper lid is the preferred skin donor site for three reasons:
1. Best colour and texture match

2. Excess skin frequently available at this site
3. Easy access.
When there is insufficient skin available in the upper lid, I recommend the upper
inner arm as the next best site.
Advantages:
1. Plenty of hairless skin available.

2. Donor scar reasonably unobtrusive.
Disadvantages:
1. Poorer colour and texture match than lid skin.

2. Surgical access awkward.
14.13 Grafts 205
a b
Fig. 14.20 Skin graft donor sites. a Upper lid. b Upper inner arm
14.13.2 Alternative Sites
Postauricular and pre auricular skin are favoured by some but the former is awk-
ward to access and initially interferes with the wearing of glasses and hearing aids.
Skin availability with the latter is limited by beard growth. If the supraclavicular
fossa is used the donor scar is quite noticeable in younger patients.
14.13.3 Skin Graft Harvesting (Fig. 14.21)
14.13.3.1 Principle
Choose an available donor site, excise the required size of full thickness skin, trim
off any subcutaneous tissue, and suture the defect.
14.13.3.2 Steps
1. Make a paper template of the skin defect (Fig. 14.21a).

2. Use the template to mark out the graft on the gently stretched donor site skin
(Fig. 14.21b).
3. Intumesce the donor area with a subcutaneous injection of local anaesthetic
with adrenaline.
4. Incise the skin with a no.15 scalpel blade along the graft outline (Fig. 14.21c).
5. Lift one end of the graft and dissect it free from the underlying tissue
(Fig. 14.21d). This may be done by scratching with the scalpel tip or using
Westcott scissors (keep the graft and donor bed stretched during this dissection
to avoid accidental graft perforation).
6. Wrap the graft over your finger, deep side out, and trim off excess subcutaneous
tissue with Westcott scissors (Fig. 14.21e).
7. Suture the graft into its recipient bed with a continuous 6/0 absorbable suture
(Fig. 14.21f).
Fig. 14.21 Skin grafting. a Make a template of the defect. b Mark the graft size on the donor site.
c Incise the graft. d Excise the graft. e Strip off unwanted subcutaneous tissue. f Suture the graft
into the recipient bed
8. Use a lid margin traction suture to ensure that the recipient bed remains
stretched and immobilized.
9. Apply a non-stick film, antibiotic ointment, and a pressure dressing. Leave the
dressing undisturbed for 5–7 days to encourage vascularization.
14.13.3.3 Notes
• Many texts recommend perforating the graft in multiple places to prevent sub
graft haematoma accumulation. This is unnecessary if you achieve adequate
graft bed haemostasis and apply an effective pressure dressing. Similarly, I
deem the use of tie-over graft bolsters unnecessary. They merely serve to lift
the graft edges, while depressing the centre of the graft which can lead to a
crater-like profile.
References 207
14.13.4 Split Skin Grafts
Split skin grafts are useful when large areas of skin need to be replaced. This is
seldom the case in lid surgery. Furthermore, split skin grafts contract much more
than full thickness skin, so I advise you not to use them.
14.13.5 Mucous Membrane Grafts
Mucous membrane is occasionally required to reconstruct a posterior lamella. It

is harvested from the mouth: from the lower lip, the cheek, or the hard palate.
Mucous membrane harvesting is not something a novice should attempt, so I will
not discuss it further.
14.14 Notes
• There are, of course, many alternative and more complex ways of reconstruct-
ing lid defects, each with its own advantages and drawbacks. Some involve
discarding significant quantities of skin when compared to the original defect
size, to make them fit. Others involve extensive undermining. Both these prac-
tices go against my minimalist grain. The above basic selection should allow
you to manage most repairs simply and safely.

• The upper lid is essential, the lower optional.
• Direct defect closure under tension gives the best outcome.
References
1. Thaller VT, Then KY, Luhishi E (2001) Spontaneous eyelid expansion after full thickness eyelid
resection and direct closure. Br J Ophthalmol 85:1450–1454
2. Thaller VT, Madge SN, Chan W et al (2019) Direct eyelid defect closure: a prospective study
of functional and aesthetic outcomes. Eye 33:1393–1401. https://doi.org/10.1038/s41433-019-
0414-2
Revision Surgery
15
15.1 Overview
• Avoid
• Delay
• Analyse
• Transverse release-plasty.
15.2 Avoid
‘Getting it right the first time’ is this book’s mission. As a rule, a good primary
operation, be it for a lid malposition or a reconstruction, will avoid the need for
revision surgery. Yet despite our best efforts, reoperation is sometimes necessary.
Warn the patient of this possibility in advance.
15.3 Healing Shrinks
We know that healing tissues contract. Anticipate and allow for this shrinkage.
210 15 Revision Surgery
15.3.1 Pout
A linear scar will shorten. So, a lid margin which is smooth and flat at the end of
a repair (Fig. 15.1a) will most likely develop a notch during healing (Fig. 15.1b).
Therefore, in anticipation, create a pouting margin union at the end of surgery
(Fig. 15.1c) which smooths spontaneously during healing (Fig. 15.1d).
Fortuitously, when we directly close any defect the closure length exceeds
the defect diameter, as discussed in Chap. 12. This counteracts scar shortening
(Fig. 15.2).
Wound closures in thick skin, such as on the forehead and brow, tend to contract
perpendicularly to the surface causing a depressed scar. Make them pout with
vertical mattress sutures as described in Chap. 3.
a b
c d
Fig. 15.1 Margin notch. When you make a margin repair flat at the end of surgery a a lid margin
notch develops b due to scar contraction. Making the margin pout by the end of the repair c results
in a flat margin on healing d
a b
d
≈ 1.5 xd
Fig. 15.2 Scar lengthening. Direct closure of a lid defect diameter d a results in a scar length
≈1.5 × d b
15.5 Delay (Fig. 15.3) 211
15.3.2 Planes Contract
We create scar planes when we undermine tissues, raise flaps, or apply grafts.
These planes contract in area during healing. Graft bed contraction can result in
‘pin cushion’ distortion of what is initially a flat graft. Flap pedicles may “tube”
due to such contraction. Avoid this complication by keeping the graft or flap bed
expanded with lid margin traction sutures during initial healing. After a week, get
the patient to stretch the graft or flap by regular massage.
15.4 Faces Are Mobile
Try this experiment on yourself: place a finger anywhere on your face and observe
how far you can push the skin in all directions. With the face being so mobile
there is rarely any justification for undermining wound edges during lid surgery.
15.5 Delay (Fig. 15.3)
Avoid re-operating within a week, as early reoperation is usually accompanied

by excessive bleeding, and the local inflammation temporarily weakens the tissue
strength and suture holding ability (sutures tear out easily during this time).
Delay elective revision surgery as long as possible to allow time for scar matu-
ration and tissue remodelling to occur. Consider two months to be a minimum and
a six-to-twelve-month delay as ideal (assuming you can persuade your patients to
be patient for that long). While awaiting revision encourage patients to massage
Fig. 15.3 Delay revision. Waiting may remove the need for revision surgery
the affected lid firmly in the appropriate direction (usually toward the lid margin)
with a thin smear of 1% hydrocortisone ointment. Ask them to do this at least
twice a day for five minutes during the first 2 months. Whether steroid is more
effective than ointment base or massage alone remains to be demonstrated. At best
such massage can obviate the need for further surgery. More commonly, however,
it is a useful delaying tactic.
15.6 Analyse
Analyse the factors that have led to the primary failure to ensure that you cor-
rect them with your revision surgery. For example, chronic traction stretches the
lid margin. At re-operation you must include lid margin shortening in addition to
traction release or the lid will simply not return to its intended position. Inade-
quate lid margin tightening is a cause of persistent cicatricial ectropion following
adequate skin grafting. Not recognising an anterior lamellar deficit (caused by mid
face drop) is the commonest cause of early involutional ectropion recurrence.
15.7 Lengthen
A lid margin peak (localized retraction) occurs in response to adjacent scar con-
traction. Lengthen a linear scar by dividing any deep fibrosis and bringing in tissue.
And remember to tighten the lid margin at the same time as mentioned above.
‘Z-plasty’ is a well described and popular technique for scar lengthening
(Fig. 15.4). It pulls in adjacent skin and transforms the original linear scar into
a zigzag. The latter breaks up the scar (visually this is more aesthetic than a long
straight scar). It also prevents further contraction along the original scar axis. But
Z-plasty creates additional scars and a scar plane under each flap. It can lengthen
the original scar by 50–70%.
The ‘Transverse release-plasty’ (below) is a radically simpler alternative that
lengthens the scar by any desired amount up to 100% at the expense of creating
dog-ears. While less aesthetic, it is simple to perform and useful for correcting
localized lid margin tethering within the eyelid area where the adjacent skin is
exceptionally elastic, mobile, and remodels well.
When there is insufficient adjacent laxity use a skin flap or insert a graft.
15.8 Transverse Release-Plasty (Fig. 15.5) 213
a b
C
B1 A A
B1
A1
B A1 B
C1
c
C
B1 B
A A1
C1
Fig. 15.4 Z-plasty. a Draw a Z with lines of equal length and its stem along the scar requiring
lengthening. b Incise the marked Z and raise two flaps. c Transpose the tips of the flaps, A and B
to points A1 and B1 and suture
15.8 Transverse Release-Plasty (Fig. 15.5)
This ‘cheat’ operation can be used to quickly release a very localized lid scar to
restore lid closure when lax adjacent tissue is available. It has the advantage of
being incredibly simple and quick to perform, requiring no dissection. Its major
drawback is that it creates significant dog ears which may ultimately need late
revision.
a b
A A B
B
B1 A1 B1 A1
c d
B B
A
A1
A A1
B1
B1
Fig. 15.5 Transverse release-plasty. a Place a lid margin traction suture at the notch. Mark the
transverse incision, A–A1 . b Make the incision making sure to release the underlying scar until the
margin can be pulled straight. c Place an orbicularis suture from beyond the ends of the incision,
A–A1 . d Tightening the deep suture lengthens the original scar, B–B1 . Suture the skin
15.8.2 Principle
Cut across the middle of the scar to release its pull. Close the resulting defect by
bringing the ends of your incision together, thereby pulling in adjacent tissue.
Useful for localized lid scar tethering causing a margin peak and incomplete
eye closure.
15.8.3 Steps
1. Place a lid margin traction suture at the peak that needs correcting. Pull on this
to make the scar stand proud (Fig. 15.5a).
2. Cut across the middle of the scar, parallel to the lid margin at that point
(Fig. 15.5b, A–A1 ). Deepen and lengthen the incision until you have fully
relieved the traction. It is not essential to excise subcutaneous scar provided
you fully divide it (Fig. 15.5b).
3. While pulling on your lid margin traction suture, estimate the amount of length-
ening required by measuring the separation between the cut edges of the
transected scar. Extend the transverse incision to equal this length.
4. Place a magic suture along the length of the incision you made to bring its oppo-
site ends together (Fig. 15.5c A–A1 ). As you tighten this suture the released
scar edges move away from each other (Fig. 15.5c B–B1 ).
5. Complete the skin and orbicularis closure (Fig. 15.5d).
6. Keep the lid margin on suture traction overnight (remove at the first dressing).
Pad the eye with a pressure dressing.
15.8.4 Notes
A Z-plasty’s advantage is that it breaks up a linear scar into a zigzag one that
is less noticeable. Transverse release-plasty by contrast avoids undermining, has
fewer additional cuts, but creates more ‘dog ears’. The length of the transverse
incision (A–A1 ) determines the degree of lengthening (B–B1 ) in a 1:1 ratio.

• Avoid the need for revision surgery.
• Delay revision as long as possible.
Watering Eyes
16
16.1 Overview
• Watering eye assessment
• Lid related causes
• Lacrimal syringing.
Watering of the eyes is a very common symptom which has a surprisingly

large impact on quality-of-life scores; surprising at any rate to those who have not
suffered from it. The mechanisms of normal tear drainage remain incompletely
understood. However, eyelid margin malposition (Chaps. 6, 7, and 8) or anything
which interferes with normal blinking (such as facial nerve palsy) is likely to
cause watering. Lacrimal syringing is commonly performed as a diagnostic test but
misleads when not performed correctly. The principles of lacrimal bypass surgery
will be outlined, but details are beyond the scope of this book.
16.2 Causes (Fig. 16.1)
Tear overflow occurs for only two reasons:
• An excess production of tears or

• Inadequate drainage.
Watering is a normal physiological response to emotion (crying) or to corneal

stimulation such as from a cold wind or when peeling onions. It is also a nor-
mal response to pathological corneal irritation, such as from ingrowing eyelashes
(trichiasis) or an entropion.
218 16 Watering Eyes
Fig. 16.1 Flow balance. When inflow exceeds drainage, overflow occurs
Insufficient tear drainage is due to lid margin or punctal malposition, stenosis

or occlusion anywhere within the lacrimal drainage system, or failure of blink
associated lacrimal pumping.
16.3 Assessment
16.3.1 History
• Onset–When did it start?

• Association–Trauma? Nasal or sinus disease? Irritation (reflex watering)?
• Do the tears overflow and run down the face (epiphora)?
• What makes it worse? Does anything make it better?
• Is a discharge associated (especially on waking)? Suggests a post lacrimal
sac obstruction (mucus collecting in the lacrimal sac) unless due to an acute
conjunctivitis.
16.3 Assessment 219
16.3.2 Examination
16.3.2.1 Marginal Tear Strip

An increase in the lower lid tear meniscus (marginal tear strip) objectively supports
a history of watering.
16.3.2.2 Lacrimal Punctal Size and Position

Tears enter the drainage system from the marginal tear strip through the lacrimal
puncta (small ~0.2 mm openings on the medial upper and lower lid margins). If
these are not positioned within the marginal tear strip, tears will not enter the
drainage system. Ectropic puncta become dry and shrink, and eventually occlude.
Punctal entropion (the punctum is not visible unless the lid is everted) is not written
about but is common. It can cause watering but is usually asymptomatic.
16.3.2.3 Lid Margin Position

Entropion will cause corneal irritation and reflex watering.
Ectropion, however slight, will create a trough between the eye and the lower lid
margin in which tears collect and from which they spill out.
16.3.2.4 Lacrimal Canalicular Appearance

The canaliculi run very close to the lid margin and medial canthal tendon where
they are prone to trauma. They are only visible when inflamed or distended. This
happens when a canaliculus is colonized by actinomyces bacteria and function-
ally obstructed. Confusingly the canaliculus may still be patent to syringing. The
expulsion of yellow ‘sulphur granules’ on squeezing a distended canaliculus is
pathognomonic of actinomyces canaliculitis.
16.3.2.5 Conjunctival Appearance

Conjunctivitis is associated with increased lacrimation. A papillary conjunctivitis,
particularly when associated with itching, points to allergy. The appearance of any
discharge present helps to distinguishing the likely cause:
• A stringy discharge = allergic conjunctivitis.

• Watery = viral conjunctivitis.
• Purulent = bacterial conjunctivitis.
16.3.2.6 Corneal Appearance

Corneal punctate fluorescein staining, an epithelial defect, or a foreign body imply
reflex watering.
16.3.2.7 Lacrimal Sac

A visible bump between the bridge of the nose and medial canthus suggests a
distended lacrimal sac. Most commonly it is filled with mucus and is therefore
called a mucocoele. The presence of a mucocoele indicates nasolacrimal obstruc-

tion beyond the level of the sac. If the lacrimal sac swelling is above the medial
canthal tendon, perform a CT scan to exclude a tumour.
16.3.3 Tests
16.3.3.1 Fluorescein Dye Tests

Fluorescein Meniscus Time [1]
Insert a single drop of 2% fluorescein dye in the lateral conjunctival fornix. It
stains the ocular surface a non-fluorescent orange/yellow. Observe the eye with
a slit-lamp using cobalt blue illumination. After a little while, fluorescence starts
laterally and progresses medially along the lower marginal tear strip as the fluo-
rescein is diluted by tears. With normal tear production the meniscus fluorescence
reaches the centre of the lid within four minutes. It takes longer in dry eye patients
and is a useful indication of tear production.
Dye Clearance/Overflow
The time it takes for the yellow fluorescein colour to disappear from the eye is a
combined measure of tear production and drainage. In the absence of tear over-
flow one can assume that the dye has been drained through the lacrimal drainage
system under physiological conditions. This test is simpler, cheaper, and at least
as informative as lacrimal scintigraphy.
Corneal Staining
Corneal fluorescein staining suggests reflex lacrimation (as already mentioned).
Dye Retrieval from the Nose (Jones’Test)

Fluorescein dye retrieved from the nose confirms anatomical and physiological
patency of the drainage system. Ask the patient to blow their nose hard into a
clean tissue 5 min after ocular dye instillation. Only if blowing fails to show the
dye should you swab the nose under the inferior turbinate with a cotton bud to
look for dye (Jones 1 test). The latter is less comfortable than simply blowing the
nose.
16.3.4 Lacrimal Syringing (Fig. 16.2)

Fluorescein dye tests assess the functional state of the lacrimal drainage system.
If these indicate a lacrimal drainage obstruction, perform syringing with saline to
check the anatomical patency of the passages. Because you inject saline into the
canaliculi under pressure, syringing is not a physiological test of function. It is
also operator and technique dependent. I have frequently had patients brought to
16.3 Assessment 221
a b
c d
Fig. 16.2 Syringing. a Put the lower canaliculus on stretch. b Insert the lacrimal cannula into the
vertical portion of the canaliculus through the punctum. c Rotate the cannula laterally through 90°.
d Gently inject physiological saline
me as obstructed in whom I found a patent lacrimal system when I performed the

syringing myself.

Epiphora patients without a mucocoele and no nasal fluorescein retrieval.
16.3.4.3 Steps
1. Anaesthetise the eye with a drop of Proxymetacaine Hydrochloride 0.5%.
2. Place a small cotton wool pledget on the medial canthus, soak it with prox-
ymetacaine, and push it into the lower fornix behind the lower punctum using
the tip of the Minims® container. Wait several minutes for complete anaesthesia
before removing the pledget.
3. Fill a 2 ml Luer lock syringe with sterile saline and lock in place a 26G lacrimal
cannula. This size of syringe combines optimum tactile pressure and plunger
movement feedback.
4. Straighten the lower canaliculus by pulling the lid laterally (Fig. 16.2a) and
insert the tip of the canula perpendicularly into the punctum (Fig. 16.2b).
5. If the canula cannot enter the punctum, clinically significant punctal stenosis
is present. Use a punctum dilator/seeker to gently stretch the punctum before
reattempting lacrimal canula insertion.
6. As soon as the canula tip has engaged the punctum, rotate the syringe and
canula laterally through 90° (Fig. 16.2c) and advance the canula approximately
5 mm into the horizontal part of the canaliculus. Maintain the lateral lid traction
throughout to keep the canaliculus straight. Do not attempt to force the canula
forwards as this can create a false passage. Do not try to enter the lacrimal sac
as it has not been anaesthetized.
7. Warn the patient to expect a feeling of pressure and possibly a salty taste in
their throat.
8. Apply gentle pressure to the plunger (Fig. 16.2d) and observe:
(a) The patient’s response. Swallowing indicates saline in the throat and
consequently patent lacrimal passages.
(b) The degree of plunger resistance. In a normal lacrimal system this should
be minimal.
(c) The extent of plunger movement which equates to the volume injected.
(d) Possible fluid regurgitation through the opposite punctum, or around the
canula. There should be none. The presence of regurgitation indicates
abnormal lacrimal system resistance. Look for mucus in the regurgitated
fluid. When present it suggests an obstruction beyond the sac (as mucus
has been able to reach the sac from the eye).
16.3.5 Imaging
Lacrimal imaging seldom adds more information to a good clinical examination,

dye tests, and syringing. Image any atypical presentation that raises the possibility
of a tumour, specifically a medial canthal swelling that is predominantly above the
medial canthal tendon.
16.4 Treatment Options
Treatment should address the presumed cause of the watering.
16.4.1 Lacrimal Mucocoele Expression (Fig. 16.3)
A lacrimal sac full of mucus is prone to infection (dacryocystitis). To prevent

this, teach patients how to empty their mucocoele by pressing firmly on it. You
must first check whether you are able to empty the sac as not all mucoceles can
be expressed. The mucus usually refluxes back through the canaliculi onto the eye
from where it should be washed off. Occasionally it can be forced down a partially
obstructed nasolacrimal duct. Instruct the patient to express the sac at least twice
a day. This is particularly important in babies born with congenital nasolacrimal
obstruction, 90% of which will improve spontaneously within the first year of
16.4 Treatment Options 223
a b
Fig. 16.3 Mucocoele expression. a place a finger against the side of the nose medially to the
mucocoele. b While maintaining firm pressure against bone, roll the finger slowly onto the swelling
towards the medial canthus
life without other intervention. Perform sac expression by placing a finger against
the side of the nose just medially to the mucocoele (Fig. 16.3a). While maintain-
ing firm pressure against bone, roll the finger slowly onto the swelling towards
the medial canthus (Fig. 16.3b). Successful expression causes the mucocoele to
disappear temporarily.
16.4.2 Lacrimal Probing (± Silicone Intubation)
16.4.2.1 Paediatric Probing

Lacrimal probing is indicated in symptomatic children whose mucocoele and
watering have not resolved on expression alone during the first year or two of
life. It requires a general anaesthetic but has a high success rate. Should the first
probing fail to cure the child the second attempt should include nasal endoscopic
control to confirm that the probe enters into the nose below the inferior turbinate.
The second probing may be combined with the insertion of temporary silicone
stents which are left in place for about two months (e.g., Nunchaku tubes®, FCI
[email protected]).
Principle
Pass a smooth, blunt ended, probe through the lacrimal drainage passages to
establish the site of any obstruction and possibly overcome it.
Steps
This technique is similar to lacrimal syringing up to the point of lacrimal sac entry.
1. Pull the lid laterally to straighten the canaliculus. Dilate the lacrimal punctum
with a punctum finder-seeker, twirling it between your fingers as you push
(Fig. 16.4a). The lid margin tension provides counter pressure to the punctal
dilator.
a b 00
c d
00
00
Fig. 16.4 Lacrimal Probing. a Pull the lid laterally to straighten the canaliculus. Dilate the
lacrimal punctum with a punctum finder-seeker. b Keeping the lid on lateral stretch insert a Bow-
man 00-gauge lacrimal probe into the punctum perpendicularly. c Keeping the tip of the probe
in the canaliculus rotate the probe laterally through 90°. d Advance the probe gently along the
canaliculus until you reach a firm stop. e While maintaining gentle forward pressure on the probe,
release the lid traction and rotate the probe’s axis 90° nasally to advance it into the nasolacrimal
duct. Continue pushing the probe downwards until you reach an obstruction or encounter the floor
of the nose (another ‘hard stop’)
2. Keeping the lid on lateral stretch insert a Bowman 00-gauge lacrimal probe into
the punctum perpendicularly (Fig. 16.4b).
3. Keeping the tip of the probe in the canaliculus rotate the probe laterally through
90° (Fig. 16.4c).
4. Advance the probe gently along the canaliculus until you reach a firm stop
(Fig. 16.4d). A so called ‘hard stop’ confirms that the tip has entered the
lacrimal sac and is hitting the medial sac wall which lies on nasal bone. A ‘soft
stop’ is when the probe springs back slightly when you release it. It means
that the probe tip has encountered a fibrous obstruction within the canaliculus
and has yet to enter the sac. If you encounter a soft stop abandon further prob-
ing. You have localized a pre-sac obstruction, though it may not be the only
obstruction in the drainage system.
5. While maintaining gentle forward pressure on the probe to keep it against the
medial sac wall, release the lateral lid traction and rotate the probe’s axis 90o
nasally to advance it into the nasolacrimal duct (Fig. 16.4e). Do this gently to
avoid creating a false passage.
6. Continue pushing the probe downwards until you reach an obstruction or
encounter the floor of the nose (another ‘hard stop’). A novice may find it
difficult to distinguish between the two. Now apply more force to the probe. A
membranous obstruction will give, and you will feel the probe tip advance to
the nasal floor.
Note: Probing may be combined with nasal endoscopy to confirm nasal entry of
the probe. However, nasal endoscopy requires skill and should not be undertaken
without training.
16.4.2.2 Adult Probing

Lacrimal probing in adults has a low success rate as a treatment. It has been
reported to succeed in 50% of cases when combined with silicone intubation,
but only where no bony resistance is encountered in the nasolacrimal duct dur-
ing probing. However, probing is sometimes helpful in confirming the site of an
obstruction. Carry it out under general anaesthesia as adequate local anaesthesia
of the entire drainage pathway is difficult to achieve.
16.4.3 Punctal Stenosis
A stenosed punctum is one that will not admit a 26 G lacrimal canula without
dilatation. As dilatation with a punctum dilator/seeker has only a very temporary
effect on patency use one of the more effective remedies below.
16.4.3.1 Perforated Punctum Plug (Fig. 16.5)

The most elegant solution for enlarging a stenosed punctum is to stent it for two
months with a perforated punctum plug (FCI S.A.S.–Chirurgie Instrumentation,
20–22 rue Louis Armand, 75,015 PARIS–France). This is done under topical
anaesthesia alone, does not damage the integrity of the punctal fibroelastic ring
and allows some passage of tears while in place to discourage post-plug membrane
formation.
Fig. 16.5 Perforated

punctum plug.
Polyvinylpyrrolidone surface
modified silicone stent (to
improve wettability)
Steps

2. Place a small cotton wool pledget on the medial canthus, soak it with prox-
ymetacaine and push it into the lower fornix behind the lower punctum, using
the tip of the Minims® container. Wait several minutes for complete anaesthesia
before removing the pledget.
3. Get the plug ready for insertion by opening its sterile packet.
4. Dilate the punctum with a punctum dilator/seeker, entering perpendicularly and
then angling the dilator laterally while twisting and pushing it medially. Do this
slowly to avoid tearing the fibrous ring.
Note: The punctum plug introducer has a punctum dilator at the other end.
However, the taper on this is too short to make it useful.
5. Remove the dilator and insert the plug without delay as the fibrous ring will
contract again rapidly.
6. After confirming correct insertion of the plug, remove the plug introducer by
squeezing it. The plug should sit flush with the lid margin.
7. Remove the plug after 2–3 months under topical anaesthesia by pulling it out
with Moorfields forceps. The punctum remains enlarged.
Note: The punctal stenosis may return after several years. The stenting treatment
can be repeated if this happens.
Fig. 16.6 Nunchaku

Lacrimal intubation. Silicone
stenting tubing on introducer
stylets
16.4.3.2 Lacrimal Intubation (Fig. 16.6)

Lacrimal intubation with a silicone tube is also an effective form of stenting for
punctal stenosis but is more invasive and requires a general anaesthetic. Several
types of tubes are available. The self-retaining Nunchaku® tubes (FCI) are partic-
ularly easy to place and remove and are self-adjusting. The technique for inserting
these tubes is the same as for lacrimal probing (above) with one added step. Once
the tube on its introducer stylet is correctly positioned, grasp the stylet loosely
with Moorfields forceps, just above the silicone tube. Use the forceps to prevent
the tube from coming out as you withdraw the stylet.
An alternative form of intubation is to insert a self-retaining monocanalicu-
lar stent (e.g., LacriJet® FCI S.A.S.–Chirurgie Instrumentation, 20–22 rue Louis
Armand, 75,015 PARIS–France). However, such punctum plug retained stents do
not allow tear drainage while in place.
16.4.3.3 Punch Punctoplasty (Fig. 16.7)

This procedure is simpler and safer to perform than the previously popular, now
hopefully obsolete, ‘three snip punctoplasty’ which it replaces. The latter is no-
longer recommended as it damages the capillary action of the canaliculus. But
even a punch punctoplasty causes damage to the punctal fibroelastic ring. It has
not been shown to be superior to stenting alone.
Steps

2. Place a small cotton wool pledget over the medial canthus and push it in
place just behind the punctum and soak it using the tip of the proxymetacaine
Minims® container. Wait a few minutes for complete anaesthesia.
3. Dilate the stenosed punctum and select the punctal wall to be removed. Choose
the posterior wall if there is a slight punctal ectropion. If there is punctal entro-
pion remove the anterior wall instead. A normally positioned punctum can be
enlarged medially.
a b
Fig. 16.7 Punch punctoplasty. a Open the punctum with a finder/seeker probe. b Use a punctum
dilator to enlarge the punctum. c Use a Kelly’s punch to punch out one of the walls of the vertical
portion of the canaliculus
4. Withdraw the punctum dilator and immediately insert the tip of a Kelly tra-
beculectomy punch into the canalicular ampulla before the fibroelastic ring has
time to contract again. Punch out the chosen punctal wall.
16.4.4 Punctal Inversion Surgery (Fig. 16.8)
Age related punctal ectropion is common. It used to be corrected by retro-

punctal cautery or ‘tarsoconjunctival diamond excision’. To achieve correction
using cautery an effective symblepharon must be created. This is undesirable as it
limits independent movement between the eye and lid. Tarsoconjunctival diamond
excision is futile for two reasons. Firstly, there is next to no tarsal plate below the
punctum worth excising. Secondly, excising conjunctiva achieves nothing as it is
too elastic to add inward traction.
Lower lid retractor plication to the sub-punctal tarsal plate on the other hand is
an effective alternative. It provides an active inward pull and is the mechanism by
which retro-punctal cautery and diamond excision work on the occasions that they
do.
16.4.4.1 Steps
1. Make a short horizontal conjunctival incision 3–4 mm below the punctum, just
inferior to the medial end of the tarsal plate (Fig. 16.8b).
2. Grasp and pull on the inferior conjunctival incision edge with Moorfields for-
ceps. Insert closed scissors immediately under the conjunctiva and advance
them infero-laterally by 10 mm. Open the scissors and withdraw to bluntly
dissect a subconjunctival pocket from the incision to the middle of the inferior
fornix (Fig. 16.8c).
a b
c d
e f
Fig. 16.8 Punctal inversion surgery. a Punctal ectropion. b Make a horizontal conjunctival inci-
sion below the punctum. c Bluntly dissect a subconjunctival pocket. d Engage the retractors with an
absorbable suture, bring the needle out through the inferior edge of the tarsal plate below the punc-
tum and re-insert it through the lower conjunctival edge. e Tie the suture tightly in the wound to
bury the knot. f The retractors pull the punctum inwards on down-gaze. The suture knot is burried
3. While still holding and gently stretching the conjunctiva, insert a pair of Jayles
forceps into the pocket and grasp the lower lid retractors (found just anterior
to the conjunctiva). Confirm that you have grasped the retractors by asking the
patient to look down as far as possible. You should feel a tug on your forceps.
4. Ask the patient to look up while you pull the retractor aponeurosis out of the
wound sufficiently to engage it with a 6/0 absorbable suture (Fig. 16.8d).
5. Bring the retractor suture needle out through the inferior edge of the tarsal
plate below the punctum (Fig. 16.8e). Then re-insert the needle through the
lower conjunctival edge, so that when tied the knot is buried.
6. Tie the suture tightly in the wound to bury the knot (Fig. 16.8f). This plicates
the retractor directly to the posterior lamella below the punctum. From now on
every time the patient looks down the retractors pull the punctum inwards.
16.4.5 Lid Margin Tightening
Watering from mild punctal ectropion may simply be a result of lower lid laxity. In
this case (and after other possible explanations have been excluded) full thickness
lid margin shortening (lateral Bick resection—Chap. 8) can cure the watering.
16.4.6 Lacrimal Drainage Surgery
Full surgical details of lacrimal drainage surgery are beyond this book’s remit and
can be found in other texts. Here I shall only outline the factors that promote
success.
16.4.6.1 Dacryocystorhinostomy (Fig. 16.9)

The gold standard lacrimal bypass surgery is an external dacryocystorhinostomy
[2] (DCR). Its success rate is upwards of 90% if the obstruction is beyond
the lacrimal sac (within the nasolacrimal duct). The role of concurrent silicone
intubation in DCR remains uncertain. Factors that promote DCR success are:
a b
c d
Fig. 16.9 Dacryocystorhinostomy (DCR). Crosshatched bone is removed a to connect the sac
directly to the nose b, making the lacrimal sac part of the nasal wall. This bypasses the blocked
nasolacrimal duct. c Additionally, the crosshatched scarred common canaliculus is excised to con-
vert a DCR into a Canaliculo-DCR (CDCR). d When not enough functioning canaliculus is present
insert a glass bypass tube between the medial fornix and the nose
• Adequate haemostasis
• Creating a large bony ostium that spans the entire lacrimal sac bed
• Complete opening of the lacrimal sac top to bottom
• Suturing both the posterior lacrimal and nasal mucosal flaps to each other as
well as the anterior flaps.
The aim of the surgery is to lay fully open the lacrimal sac and make it part
of the lateral wall of the nose (Fig. 16.9b) so that the sac as such ceases to exist.
Surgical failures are usually due to not achieving the above aims. Mucosal scar
contraction can result in partial or complete reformation of the lacrimal sac. The
other cause of failure is pre-existing or surgically induced lacrimal canalicular
scarring resulting in pre-sac obstruction and persistent symptoms. Endonasal DCR
techniques are gaining popularity and in some hands the results equal those of the
external approach. However, achieving the goals outlined above is more difficult
via the limited endonasal access.
16.4.6.2 Canaliculo-Dacryocystorhinostomy (CDCR)

Where the site of drainage obstruction is before the sac, and 8 mm of proxi-
mal canaliculus is patent, the stenosed portion of the canaliculus can be resected
(Fig. 16.9c). Perform a standard DCR but in addition probe the canaliculi and
excise the stenosed portion. Then anastomose the cut ends of the canaliculi to the
lateral sac wall and intubate the system.
16.4.6.3 Trans-Canalicular Endoscopic Surgery

The advent of ever smaller endoscopes has made trans-canalicular endoscopic
surgery possible. Its place in routine lacrimal surgery remains to be established.
16.4.6.4 Lester-Jones Lacrimal Bypass Tube

When the canaliculi are insufficiently long for a CDCR the only remaining option
is to bypass the drainage system completely with a Pyrex glass tube inserted
between the medial conjunctival fornix and the nose (Fig. 16.9d). This can give
very good symptomatic relief. However, it is an option of last resort as it commits
the patient to lifelong follow up and tube maintenance. These tubes are prone to
block with mucus and frequently become displaced (inwards or outwards).
16.4.6.5 Dacryocystectomy
Surgical removal of an infected lacrimal sac (dacryocystectomy) is an option for
patients suffering recurrent dacryocystitis who are unfit for a DCR as it may be per-
formed under local anaesthesia. It prevents further infections but does not address
any watering issues. It is also indicated for the removal of lacrimal sac tumours.

• Watering of the eyes has multiple possible causes.
• It significantly affects quality of life.
• Accurate assessment is key to the correct management.
References
1. Kallarackal GU, Ansari EA, Amos N, Martin JC, Lane C, Camilleri JP (2002) A comparative
study to assess the clinical use of Fluorescein Meniscus Time (FMT) with Tear Break up Time
(TBUT) and Schirmer’s tests (ST) in the diagnosis of dry eyes. Eye (Lond) 16(5):594–600.
https://doi.org/10.1038/sj.eye.6700177. PMID: 12194075
2. McNab AA (1994) Manual of Orbital and Lacrimal Surgery Hardcover. Churchill Livingstone
ISBN 0–443–04791-x
Eye Removal
17
17.1 Overview
• Eye evisceration,
• Eye enucleation.
Eye removal is a treatment of last resort for symptom control or local tumour
management. Never underestimate its psychological impact. Loss of an eye can
trigger a prolonged bereavement reaction. Forewarn patients and their families
about this possibility.
Eye removal can be performed in one of three ways:
1. Evisceration—Removal of the cornea and all the eye’s contents (uvea) leaving
the empty sclera fully attached.
2. Enucleation—Complete removal of the intact eye by cutting all its attachments.
3. Exenteration—Radical en bloc removal of the orbital contents (including the
eyelids, conjunctiva, and periosteum), as far back as possible.
17.2 Specific Indications
Exenteration is very mutilating and fortunately only seldom required for the control
of tumour confined to the orbit. It will not be discussed further.
Enucleation is indicated for the complete removal of an intraocular tumour that
cannot be managed by less destructive means.
Evisceration is performed for severe, non-responsive endophthalmitis (effec-
tively abscess drainage) to avoid spreading the infection into the orbital tissues.
The removal of blind, painful, or unsightly eyes, which cannot be managed by
other means (topical G. Atropine 1% and G. Prednisolone 1% are very effective at
234 17 Eye Removal
controlling pain), can be done either by enucleation or by evisceration. Except for

the above specific indications, the choice is largely down to personal preference
and current fashion.
17.3 Evisceration V Enucleation
Evisceration is technically easier, quicker, and less invasive than enucleation and
results in marginally less volume loss. Hence it fits the philosophy of this book.
However, as it carries a small risk of inciting Sympathetic Endophthalmitis in the
remaining eye, great care must be taken to remove all the uveal contents leaving
no pigmented tissue behind to stimulate an immune response. Evisceration is more
painful in the immediate postoperative period as the nerve supply to the sclera
remains intact. Send the evisceration contents for histology to look for pre-existing
sympathetic uveitis or unsuspected intraocular malignancy. However, anatomical
histology cannot be obtained from an evisceration specimen.
Enucleation involves systematically dividing all the structures holding the eye
in place, including the optic nerve. An enucleated eye allows good anatomical
histopathology of suspected tumours including their degree of scleral and vortex
vein invasion. Theoretically it causes a slightly greater orbital volume loss than
evisceration, but this is not clinically significant. The extra dissection involved
results in more post-operative swelling, but there is less pain as all the sensory
nerves have been divided.
Any form of eye removal results in significant orbital volume loss which needs
to be addressed by volume replacement as part of the surgical rehabilitation.
Volume replacement is dealt with in the next chapter.
17.4 Evisceration (Fig. 17.1)
17.4.1 Principle
Remove the cornea and all the ocular contents (uvea).
17.4.2 Steps
1. Cut the conjunctiva and tenons fascia from the corneoscleral limbus through
360° (Fig. 17.1a).
2. Bluntly dissect them back with a cotton bud, no further than the rectus muscle
insertions.
3. Incise the sclera immediately behind the limbus to enter the eye.
4. Extend this incision through 360° to remove the cornea (including the limbal
epithelial stem cells) (Fig. 17.1b).
17.4 Evisceration (Fig. 17.1) 235
a b
c d
Fig. 17.1 Evisceration. a Cut the conjunctiva and tenons fascia from the corneoscleral limbus
through 360°. b Incise the sclera at the limbus and extend this to remove the cornea. c Develop
a cyclodialysis plane using an evisceration spoon. d Lift the entire eye contents out of the scleral
using the evisceration spoon
5. Develop a 360° cyclodialysis plane using an evisceration spoon (Fig. 17.1c).

Do this by holding the scleral edge on tension with toothed forceps and peeling
the iris root and attached ciliary body from the scleral spur. Gradually work
around the whole perimeter.
6. Deepen the cleft in the same manner to detach the choroid from the sclera up
to the equator all the way round.
7. Continue separating in this plane until you reach the optic nerve exit point.
Transect this final attachment with the evisceration spoon.
8. Lift the entire eye contents out of the scleral shell and into a histology pot
using the evisceration spoon (Fig. 17.1d). In young patients the contents come
out as a single, jelly-like, lump. In the elderly with liquified vitreous this runs
out before you are able to lift out the collapsed uveal tissue.
9. Examine the now empty sclera to ensure that you have not left any pigmented
uveal tissue behind. This is to minimize the risk of inciting sympathetic
uveitis. Scrape any remaining uvea out with the spoon.
10. You will have decided whether to place an orbital implant as part of the pre-
operative planning and consenting process. The default position should be to
implant, as volume replacement gives the best rehabilitation. Delay implan-
tation when infection is present (endophthalmitis, suppurative keratitis). Do
not implant if it is important to minimise the risk of late complications. An
236 17 Eye Removal
implant introduces the additional risks of infection, implant migration, and/

or exposure requiring revision surgery. (Implantation is dealt with in the next
chapter).
11. In the absence of an implant or of infection, close the sclera horizontally
with five 6/0 absorbable sutures. Close the tenons and conjunctiva with a
continuous 6/0 absorbable suture.
12. In the presence of infection do not suture. Leave the sclera open to drain. It
will usually heal spontaneously.
13. Insert a correctly sized* conformer shell to maintain the conjunctival for-
nices and prevent conjunctival prolapse. Consider placing a central suture
tarsorrhaphy to stop the conformer from falling out.
14. Apply antibiotic ointment and a pressure dressing.
*Note: Use the largest conformer shell that fits in the socket while still allowing
the eyelids to just close.
17.5 Enucleation (Fig. 17.2)
17.5.1 Principle
Divide all the eye’s connections and remove it.
17.5.2 Steps
1. Cut the conjunctiva and tenons fascia from the corneoscleral limbus through
360° (Fig. 17.2a).
2. Bluntly dissect them back with a cotton bud, to beyond the rectus muscle
insertions (Fig. 17.2b).
3. Place a Chevasse squint hook under the inferior rectus muscle close to its
insertion and use a cotton bud or the flat end of a dry ‘bread swab’ to tear
back the muscle sheath to fully expose the insertion (Fig. 17.2c).
Note: It doesn’t matter which rectus you expose first.
4. Insert a double armed ¼ circle 6/0 absorbable suture into each edge of the
muscle with a double locking pass (see Chap. 19, Fig. 19.4) and clip the
suture ends together with an artery clip (Fig. 17.2d).
5. Lift the squint hook and completely divide the muscle insertion from the globe
(Fig. 17.2e). The weight of the artery clip will retract the muscle insertion.
6. Repeat steps 3–5 above for the remaining three rectus muscles (Fig. 17.2f).
7. Insert a squint hook between the eye and the tenons infero-temporally to
engage the inferior oblique muscle insertion. Do this by feel.
8. Once you identify the inferior oblique retract it with this hook and place a
curved artery clip across the inferior oblique muscle insertion. Again, do this
by feel rather than by direct visualization.
17.5 Enucleation (Fig. 17.2) 237
a b
c d
e f
g h
Fig. 17.2 Enucleation. a Cut the conjunctiva and tenons fascia from the corneoscleral limbus
through 360°. b Bluntly dissect to beyond the rectus muscle insertions. c Place a Chevasse squint
hook under the inferior rectus muscle and tear back the muscle sheath to fully expose the insertion.
d Insert a double armed absorbable suture into the muscle with double locking passes. e Lift the
squint hook and completely divide the muscle insertion from the globe. f Repeat for the remaining
three rectus muscles. g Tag and detach the inferior oblique and the superior oblique tendon from
the globe. h Tighten the snare wire loop until it is only slightly larger than the eye. Attach a pair
of straight artery forceps to the far side of the wire loop. Use these to guide the loop posteriorly
between the globe and the detached medial rectus. i Once the snare loop is behind the eye slowly
tighten it. At the same time use the stem to push it posteriorly between the globe and lateral rectus.
j Expect strong resistance to the final snare tightening. Once the optic nerve is transected, you can
lift the eye out of the socket. There will be no bleeding
238 17 Eye Removal
i j
9. Cut between the artery clip and the sclera to divide the inferior oblique
insertion from the globe.
10. Now that it is free, pull the muscle insertion out with the clip and tag it with
a single armed 6/0 absorbable suture using a double pass locking throw. Clip
the suture ends together. The single needle distinguishes this from the rectus
muscles (which have two needles attached).
Note: The inferior oblique looks like an earthworm.
11. Repeat step 9 supero-temporally to isolate the superior oblique tendon from
the globe (Fig. 17.2g).
Note: The tendon is fibrous and runs anteromedially toward the trochlea.
12. The remining attachments holding the eye include the optic nerve, the oph-
thalmic and ciliary arteries, and the vortex veins. Crush and divide them using
an enucleation snare as follows:
(a) Tighten the snare wire loop until it is only slightly larger than the eye.
(b) Attach a pair of straight artery forceps to the far side of the wire loop so
that they are equidistant from the stem (Fig. 17.2h). Use this clip to guide
the loop posteriorly between the globe and the detached medial rectus.
Ask an assistant to keep the loop behind the globe by pushing down on
the artery clip.
(c) Slowly tighten the snare loop by turning the snare ratchet wheel. At the
same time use the stem to push it posteriorly between the globe and lateral
rectus, until it is behind the eye.
(d) Now remove the artery clip from the loop and continue tightening the
snare wire. Maintain posterior pressure with the stem of the snare to
keep the loop behind the globe. While you do this, your assistant lifts
the globe anteriorly using artery clips attached to the cut rectus insertions
(Fig. 17.2i).
(e) Expect strong resistance to the final snare tightening. This is dependent
on the snare wire thickness (a thicker gauge giving greater resistance).
You will feel a sudden ‘give’ as the optic nerve is finally transected. You
can now lift the eye freely out of the socket. There will be no bleeding
(Fig. 17.2j).
17.5.3 Notes
• It is the complete absence of bleeding when the eye is removed that makes
the enucleation snare my preferred choice. The alternative of using enucleation
scissors offers no advantages, only copious bleeding.
• An enucleated eye allows detailed histological examination.
Eye removal has huge psychological impact.

Socket Reconstruction
18
18.1 Overview
• Implantation following evisceration
• Implantation following enucleation
• Orbital implant complications.
The disfigurement resulting from eye removal is primarily due to loss of orbital
volume leading to the Post Enucleation Socket Syndrome (PESS) (see below) cou-
pled with reduced socket movement. The latter occurs because the extraocular
muscles are no longer attached to an eye and are therefore not working at their
former mechanical advantage. Artificial eye (prosthesis) movement is reduced fur-
ther by slippage in the socket. An adequately sized intraconal implant addresses
these problems (apart from the slippage).
Perform primary orbital implantation by default unless there is a positive con-
traindication, such as lack of access to follow-up treatment for possible late
complications.
18.2 Socket Lining
The largest possible artificial eye that a socket can accommodate is determined
by the surface area of its conjunctival lining. Four millilitres is about the maxi-
mum volume. A socket with insufficient conjunctival lining to accept an adequate
prosthesis must have its fornices augmented with mucous membrane grafts (never
skin which desquamates and smells in a moist socket). Therefore, treat conjunc-
tiva with respect, preserve it at eye removal surgery, and prevent it from shrinking
post-operatively by inserting a maximally sized conformer shell to maintain the
fornices until a custom prosthesis can be fitted.
242 18 Socket Reconstruction
18.3 Orbital Implantation (Fig. 18.1)
Carry out orbital implantation at the time of eye removal unless there is a strong
contraindication (such as infection). Insert a 22 mm diameter solid ball implant
(acrylic or silicone) into the orbital muscle cone using a ‘no touch’ technique.
Attach the extraocular muscles to it to keep it in place within the muscle cone and
to maximize movement.
Following evisceration place the implant within the recipient’s, now empty,
scleral shell. After enucleation wrap the implant in stored human donor sclera
(or other suitable material) and attach the extraocular muscles to the covering in
approximately their anatomical positions.
18.3.1 Implant Considerations
Measure enucleated eye volume by the water it displaces in a measuring cylinder

(Archimedes’ principle) (Fig. 18.2). The volume of tissue removed during enucle-
ation is about 7–9 ml [1], which is more than many standard texts suggest. The
volume loss from evisceration is slightly less. The actual volume loss in a partic-
ular individual depends on the size of the eye removed. This lost volume must be
completely replaced if the PESS deformity is to be avoided. Share the replacement
volume between a buried ‘motility implant’, that allows the extra-ocular muscles
to work at their optimal mechanical advantage (frontal plane diameter similar to
that of the removed eye), and an eye prosthesis (artificial eye) held in place by
the eyelids (Fig. 18.3). The prosthesis should be as light as possible to reduce
Fig. 18.1 Ball too small.

Inadequate volume
replacement causes the post
enucleation socket syndrome
18.3 Orbital Implantation (Fig. 18.1) 243
Fig. 18.2 Enucleated eye volume. Measure enucleation orbital volume loss by water displacement
5 - 7 ml 2 ml 22 mm
4 mm
Fig. 18.3 Ideal motility implant dimensions. Share the volume replacement between the prosthe-
sis and the implant. A realistic prosthesis requires a volume of 2 ml and a central thickness of 4 mm.
The implant vertical diameter should equal that of the removed eye
the mechanical load on the lower lid to avoid it stretching over time. However,
the prosthesis does require a minimum central thickness of about 4 mm to give a
realistic anterior chamber appearance. The ideal prosthesis volume is 2 – 21 /2 ml.
Subtracting this from the total volume loss leaves a volume deficit of 41 /2 to 7 ml
that needs to be replaced by the implant.
The volume of a spherical implant is determined by the formula.
4/3r 3
where r is the radius of the implant. The largest commercially available orbital
implant has a diameter (Ø) of 22 mm (radius 11 mm) and a volume of 5.6 ml. A
20 mm Ø implant has a volume of only 4.2 ml and an 18 mm Ø sphere has a mere
3.1 ml! Therefore, there is seldom any excuse for implanting an implant smaller
than 22 mm Ø.
Some authors recommend the use of ‘sizing spheres’ to determine the ideal
implant volume: “to see what fits”. This logic is flawed as orbital tissues flow at
body temperature and will therefore accommodate a range of implant volumes.
Operative swelling introduces further inaccuracy when using sizing spheres.
18.3.2 Implant Material and Shape
Many different implant materials and shapes have been tried over the years. The
ideal one is yet to be determined. A solid sphere made of acrylic or silicone is cur-
rently the best compromise. The flat face of hemispherical implants is much better
at transmitting movement to the artificial eye. Unfortunately, their sharp edges
make them very prone to late exposure and extrusion. Therefore, hemispherical
implants should no longer be used.
Porous or ‘integrated’ implants have enjoyed a vogue due to the theoretical
advantages of (a) implant migration being less likely because of stabilizing scar
tissue ingrowth into their pores and (b) the option of drilling them subsequently,
once they have become fully vascularized, in order to fit a ‘motility peg’ which
directly couples socket movement to implant movement.
Unfortunately, these theoretical advantages are counterbalanced by drawbacks.
The rough, porous implant surface makes these implants much more prone to
erode through the overlying tenons and conjunctiva and become exposed. Many
techniques for patching these exposures have been described. They mostly fail
with time. Porous implant removal for replacement is made difficult by the tissue
ingrowth and requires sharp dissection. The drilling of porous implants to fit a
motility peg has also largely fallen out of favour due to the high complication
rate (40%). Therefore, avoid using porous motility implants as they have minimal
proven advantage and significantly more complications.
Free dermis fat grafts have the advantage of being autogenous and adding to
the conjunctival lining as they epithelialize. Unfortunately, graft volume retention
is very unpredictable, ranging from complete retention to total absorption. For this
reason, reserve them for secondary socket reconstruction.
18.3.3 Implantation Following Evisceration (Fig. 18.4)
18.3.3.1 Steps
1. Incise the empty scleral shell with Stevens tenotomy scissors from the supero-
temporal edge to the optic nerve (Fig. 18.4a).
2. Make a similar incision from infero-nasally to the optic nerve.
3. Circumcise the optic nerve to release it from the sclera and to complete the
scleral bisection.
18.3 Orbital Implantation (Fig. 18.1) 245
a b
c d
e f
Fig. 18.4 Implantation post evisceration. a Incise the empty scleral shell with Stevens tenotomy
scissors from the supero-temporal edge to the optic nerve. Make a similar incision from infero-
nasally to the optic nerve. Circumcise the optic nerve to release it from the sclera and to complete
the bisection. b Place the orbital implant within a plastic sheath lubricated with viscoelastic and
insert it into an injection device. c Inject the implant into the orbit between the scleral halves.
d Suture the two scleral halves together in front of the implant with interrupted 6/0 absorbable
sutures. e Suture the tenons fascia over the sclera with interrupted 6/0 absorbable sutures. f Suture
the conjunctiva closed with a continuous 6/0 absorbable suture. g Place a conformer shell (the
largest that fits while just allowing eyelid closure)
Note: You can use a corneal punch to do this, but it can be difficult to align. The
separated scleral halves remain attached by their extraocular muscles.
4. Place the chosen orbital implant (usually 22 mm diameter solid sphere) within
a plastic sheath lubricated with viscoelastic.
5. Put the implant containing sheath into a Carter sphere introducer or similar
injection device.
6. Using the sphere introducer inject the implant into the orbit between the scle-
ral halves (Fig. 18.4b) while an assistant holds the scleral halves apart with
malleable retractors. Remove the introducer and carefully withdraw the plastic
sheath by squeezing while preventing the implant from popping out with it.
Align the scleral halves around the implant (Fig. 18.4c).
7. Suture the two scleral halves together in front of the implant with interrupted
6/0 absorbable sutures (Fig. 18.4d).
8. Suture the tenons fascia over the sclera with interrupted 6/0 absorbable sutures
(Fig. 18.4e).
9. Suture the conjunctiva closed with a continuous 6/0 absorbable suture. Tighten
it until the suture line begins to shorten to make the wound watertight
(Fig. 18.4f).
10. Insert an appropriately sized conformer shell (the largest that fits while just
allowing eyelid closure) into the conjunctival fornices to maintain them and to
prevent conjunctival prolapse (Fig. 18.4g). To do this push the conformer into
the upper fornix first. Then push the conformer posteriorly while momentarily
retracting the lower lid until it flips over the shell.
11. Apply antibiotic ointment and a pressure dressing for one day.
18.3.4 Implantation Following Enucleation (Fig. 18.5)
18.3.4.1 Steps
1. Make two cuts 180◦ apart, from the anterior opening to the equator of the
prepared, rinsed, and antibiotic soaked donor sclera shell (Fig. 18.5a).
2. Evert the donor sclera over your finger and then wrap it around the chosen
orbital implant (usually 22 mm diameter solid sphere). Tack the scleral inci-
sions closed with 6/0 absorbable sutures to stop the implant from slipping out
(Fig. 18.5b).
3. Put the sclera covered implant into a plastic sheath lubricated with viscoelas-
tic. Put the sheath into a Carter sphere introducer or similar injection device
(Fig. 18.5c).
4. If the oblique muscles are available place the introducer next to the socket
and suture the oblique muscles to the upper and lower edges of the cov-
ered implant’s scleral opening (which will end up posteriorly) in roughly their
anatomical orientations (Fig. 18.5d).
5. Now carefully position the prongs of the sphere introducer into the conjunc-
tival and tenons opening and slowly inject the implant into the rectus muscle
18.4 Orbital Implant Complications 247
cone making sure that the extraocular muscles and their pre-placed tagging
sutures are splayed and correctly orientated.
6. Carefully remove the plastic sheath by squeezing it, taking care to prevent the
implant from popping out as you do this.
7. Suture the four rectus muscles to the donor sclera anatomically, as in squint
surgery, about 8–9 mm from the optic nerve opening on the scleral shell. This
opening should end up centred between the attached recti (Fig. 18.5e).
8. Close the tenons capsule in front of the implant with interrupted 6/0
absorbable sutures (Fig. 18.5f) Note: Some authors recommend suturing both
the posterior and the anterior tenons openings in front of the implant, reporting
fewer implant extrusions as the benefit.
9. Close the conjunctiva in front of the tenons with a continuous 6/0 absorbable
suture (Fig. 18.5g). Tighten this suture until the suture line starts to shorten,
before tying it.
10. Insert an appropriately sized conformer shell (the largest that fits while just
allowing eyelid closure) into the conjunctival fornices to maintain them and
to prevent conjunctival prolapse (Fig. 18.5h).
11. Apply antibiotic ointment and a pressure dressing for one day.
18.3.4.2 Notes
• Consider adding a temporary suture tarsorrhaphy as the final step of implanta-
tion to prevent excessive chemosis from pushing out the conformer shell.
• Per operative intravenous antibiotic prophylaxis is current practice at orbital
implant insertion. The evidence for this is now being questioned in line with
the move to reduce antibiotic overuse.
18.4 Orbital Implant Complications
18.4.1 Conjunctival Cysts
Conjunctival cysts form when conjunctival epithelium is inadvertently buried dur-

ing surgery. As such they are avoidable. If a cyst occurs, it must be meticulously
excised to ensure that all the cyst wall epithelial lining is removed or else the cyst
will recur.
Note: To make visualization easier you can inject the cyst with a dye, such as
methylene blue, prior to excision.
a b
c d
e f
g h
Fig. 18.5 Implantation post enucleation. a Make two cuts 180° apart, from the anterior opening to
the equator of the donor sclera shell. b Wrap it around the orbital implant. Tack the scleral incisions
closed with 6/0 absorbable sutures. c Put the sclera covered implant into a plastic sheath lubricated
with viscoelastic. Put the sheath into an introducer. d Suture the oblique muscles to the upper and
lower edges of the covered implant’s scleral opening in their anatomical orientations. e Inject the
implant into the rectus muscle cone and suture the rectus muscles to the donor sclera. f Close the
tenons capsule in front of the implant with interrupted 6/0 absorbable sutures. g Close the conjunc-
tiva in front of the tenons with a continuous 6/0 absorbable suture. h Insert the largest conformer
shell that fits while just allowing eyelid closure
18.4.2 Early or Late Wound Dehiscence
Wound dehiscence is mainly due to poor surgical technique. Operative infection

and impaired healing are other possible reasons. If noted early, re-suture the wound
urgently. However, once bacterial and/or epithelial ingrowth have occurred around
the implant such a repair is doomed to fail again. In this situation remove the
implant, wait for the socket to heal, and then perform late secondary implantation.
18.4.3 Implant Migration
The firm attachment of the extraocular muscles to the orbital implant (directly or
indirectly to its covering material) is what holds an implant in place. The tenons
fascia and conjunctiva alone are insufficient to keep the implant within the muscle
cone. An implant can migrate axially forwards or rotate, slipping out of the muscle
cone between the recti.
18.4.3.1 Rotational Subluxation (Fig. 18.6)

Rotational subluxation is easily missed with spherical implants because they still
look spherical when tilted (tilting of a hemispherical implant is obvious). Look for
it by observing implant movement in different gaze positions.
Fig. 18.6 Implant rotational a b

subluxation. a 22 mm
diameter intraconal implant.
b A smaller implant sinks
downwards in the orbit and 22mm
causes an upward rotation of 18mm
the overlying prosthesis.
c Equatorial rectus muscle
fixation to the implant =
stable equilibrium. d Anterior
rectus muscle fixation to the c
implant = unstable
equilibrium. The posterior
pull of the recti causes
implant subluxation out of
the muscle cone
d
Rotational subluxation occurs when the implant slips out of the muscle cone
between two rectus muscles or rotates within the cone if one of the rectus muscle
insertions dehisces. It occurs for one of four reasons:
1. Rectus muscle imbalance: If only the four rectus muscles are attached to
the implant, three of them (superior, medial and inferior rectus) have a net
inward/medial pull. This may overpower the lone lateral rectus outward/lateral
pull causing the implant to rotate medially and sublux, usually infero-laterally
between the lateral and the inferior recti.
Note: Attaching the oblique muscles, which both have a net outward pull, anatom-
ically to the implant, may help to mitigate such rotation imbalance (this remains
to be proved).
2. Isolated rectus muscle dehiscence: If one of the rectus attachments slips during
healing the implant will rotate and sublux anteriorly. Remedy this by finding
and reattaching the slipped muscle surgically.
3. Undersized orbital implant: An implant whose diameter is smaller than that
of the eye that it replaces does not magically remain in the middle of the orbit.
It sinks down due to gravity to rest on the orbital floor (Fig. 18.4a, b). In this
position it is no longer central within the muscle cone and the net posterior
pull of the rectus muscles will rotate the implant by pulling its anterior pole
posteriorly, encouraging the implant to sublux infero-laterally.
4. Rectus muscle anterior insertion: Attaching the rectus muscles at the equator
of the implant creates a rotationally stable equilibrium (the implant is stable in
all gaze directions) (Fig. 18.4c). By contrast, attaching the recti at the anterior
pole of the implant or overlapping them across the front of the implant (as is
recommended by some) results in an unstable equilibrium (Fig. 18.4d) because
the centre of rotation is transferred from the implant centre to the front of
the implant. In this configuration the pull of any rectus muscle disturbs the
equilibrium, the anterior pole is pulled posteriorly, and the implant rotates out
of the muscle cone. I recommend attaching the recti in roughly their anatomical
positions as a practical compromise between the two extreme positions above.
18.4.4 Late Implant Exposure
The tenons fascia and conjunctiva tolerate rotational stresses well. They do not
tolerate crushing force between the implant and a poorly fitting artificial eye
prosthesis. Conjunctival pressure necrosis results in implant exposure. Implant
exposure causes a symptomatic increase in socket discharge. Unfortunately, by
the time a patient presents, epithelial ingrowth and bacterial colonization of the
implant capsule have already occurred. Consequently, surgical patching of the
exposure fails because it merely transforms the colonized implant capsule into
an infected cyst which eventually ruptures again, re-exposing the implant.
Biologically integrated porous implants, such as hydroxyapatite or ceramic (but
not polypropylene), do not have a capsule and can therefore be shaved down to
remove the necrotic surface until bleeding granulation is reached. The exposure
may then be patched and covered with conjunctiva. Even then, recurrent erosion
often occurs due to the roughness of the porous implant surface.
18.4.5 Post Enucleation Socket Syndrome (Fig. 18.7)
The post enucleation socket syndrome (PESS) comprises:
1. A deep upper lid hollow (superior sulcus).

2. Upper lid drooping (ptosis).
3. A sunken appearance of the artificial eye (enophthalmos).
4. Progressive lower lid stretching from supporting a heavy artificial eye (prosthe-
sis).
5. Upward tilting of the prosthesis (because the undersized implant sinks to the
orbital floor) (Fig. 18.7b).
6. Reduced artificial eye movement.
All the above stem from a primary orbital volume deficit, the result of inade-
quate enucleation volume replacement (too small an implant). If you look for it,
you will find that a degree of PESS is exceedingly common. The key to preven-
tion and management is adequate volume replacement. If the intraconal implant is
smaller than 22 mm in diameter replace it with a larger one. Additional volume
supplementation may subsequently be required with an orbital floor implant (max-
imum additional volume 2 ml) or a superior sulcus dermis-fat graft. After fitting
a new lighter artificial eye prosthesis consider lower lid tightening if necessary.
Finally consider possible ptosis correction.
Deep upper lid Sulcus
Upper lid Ptosis
Enophthalmos
Lower lid laxity
Upward prosthesis tilt
Reduced Movement
Fig. 18.7 Post enucleation socket syndrome (PESS). All the PESS signs stem from insufficient
orbital volume replacement
18.4.6 Lower Lid Laxity
The weight of the artificial eye prosthesis applies an insidious stretching force to
the lower eyelid causing it to lengthen over time. As a result, the prosthesis sinks
downward increasing the upper lid hollow (sulcus) and so marring the patient’s
appearance. The remedy is to increase the implant volume to allow a smaller,
lighter prosthesis to be fitted before tightening the lower lid. (Lid margin resec-
tion). Shortening the lid without first fitting a lighter prosthesis will fail through
further stretching. Rarely, a fascia lata lower lid sling may be necessary to support
a heavy artificial eye that cannot be reduced in weight.
18.4.7 Upper Lid Ptosis
Upper lid drooping (ptosis) is common in artificial eye wearers. It may be of the
simple ‘involutional’ type that commonly follows eye trauma or surgery. Alterna-
tively, it may be the consequence of a volume deficient socket. A smaller implant
diameter forces the levator muscle to work at a mechanical disadvantage and makes
the levator seem relatively longer. Upper lid ptosis correction is the last stage in
socket rehabilitation. Only consider it once adequate volume replacement, lower
lid tightening, and prosthesis adjustment have all been addressed. Carry it out like
any other ptosis surgery but with the artificial eye in place.

• Always implant.
• Think big! Use a 22 mm diameter solid spherical implant.
Reference
1. Thaller VT (1997) Enucleation volume measurement. Ophthalmic Plast Reconstr Surg

13(1):18–20. https://doi.org/10.1097/00002341-199703000-00003. PMID: 9076778
Thyroid Eye Disease
19
(Grave’s Orbitopathy)
Fig. 19.1 What big eyes you have cartoon. Depot orbital steroid can alleviate TED

• Immunosuppression in active (wet) thyroid eye disease.
• Orbital Triamcinolone injection
• Inferior rectus recession with lid retractor recession
254 19 Thyroid Eye Disease
• Upper lid blepharotomy

• Lower lid retractor recession.
Thyroid eye disease (TED) is a disfiguring and sight impairing autoimmune

condition for which there is currently no cure. It is the commonest cause of gaze
evoked double vision and of unilateral or bilateral lid retraction and/or proptosis.
It can threaten sight through optic nerve compression or severe corneal exposure.
Treatment is dictated by whether the disease is still active.
19.2 Wet or Dry?
Thyroid eye disease begins as an autoimmune inflammation of the eyelids and

orbital contents. During this active phase the periocular tissues are red and swollen,
earning the alternative name of ‘wet TED’. Monitor activity by noting changes
in the classical signs of inflammation [1] (Fig. 19.2). In addition to the visible
signs, active TED usually causes a deep ache in the orbit(s), especially in extreme
positions of gaze.
The inflammatory component, and along with it the ache, subside spontaneously
after several months, leaving behind a widely variable degree of lasting disfigure-
ment and functional impairment. These are the result of fibrosis and hypertrophy
of the eyelid and orbital connective tissue, muscles, and fat. Diagnose inactive
or ‘dry’ phase TED when the clinical signs become stable, and the ache and
inflammatory signs have subsided.
Immunosuppression can modify the active, wet phase, and if given early enough
may even reverse some of the changes. However, because immunosuppression has
TED Activity based on the classical features of inflammation: clinical activity score (CAS) is the sum of
all items present. A CAS ≥ 3/7 indicates active moderate to severe TED
Spontaneous retrobulbar pain
Pain on attempted up- or down gaze
Redness of the eyelids
Redness of the conjunctiva
Swelling of the eyelids
Inflammation of the caruncle and/or plica
Conjunctival oedema
Fig. 19.2 Clinical activity score. Scoring of TED severity based on the clinical signs of inflam-
mation
19.3 Immunosuppression of Active TED 255
the potential for serious side effects, reserve it for preventing visual disability
progression (when its benefits outweigh its risks).
Surgery has no place in the management of active wet TED except in rare cases
of sight threatening optic nerve compression unresponsive to systemic immunosup-
pression. In these patients, urgent surgical decompression of the orbital apex can
prevent blindness. Severe exposure keratopathy may also require urgent surgery.
19.3 Immunosuppression of Active TED
Offer immunosuppression to patients with a Clinical Activity Score [1] (CAS)

≥3. The onset of gaze dependent diplopia is a conservative threshold for starting
immunosuppression. Currently there are four immunosuppression options:
1. Steroids. These are the usual first line agent.

2. Non-steroidal immunosuppressants. Use these as adjunctive, steroid sparing
treatments.
3. Biologics (Monoclonal antibodies). These are still under investigation, expen-
sive, and carry the risk of rare but devastating side effects. Currently they are a
‘last resort’ option, but this is likely to change.
4. Orbital, low dose radiotherapy to limit extraocular muscle fibrosis. Although
this has its strong proponents the evidence base for this modality remains weak.
Sadly not all patients respond to available immunosuppression.
19.3.1 Steroids
The three options for steroids administration are:
1. Weekly high dose Methylprednisolone given intravenously or orally up to a

total cumulative dose of 8 grammes. This is the current European Group
on Graves’ Orbitopathy (EUGOGO) recommendation. Seventy five percent of
patients respond to this regime.
2. Daily oral Prednisolone. Half of patients respond to this, but the systemic
steroid side effects are greater than for weekly methylprednisolone.
3. Two monthly orbital floor depot Triamcinolone injections. This off-label treat-
ment places the steroid directly in the orbit where it is needed. It has the least
risk of systemic side effects as the total body steroid dose is comparatively low.
However, orbital injection carries the added risks of orbital haemorrhage, nee-
dle penetration of the eye and inadvertent intraocular or intravascular injection,
risks that are associated with any periocular injection. Despite these, I have
found it a very effective treatment for moderate TED. It is also a useful test of
clinical activity. The orbital ache of active thyroid eye disease usually improves
within a couple of days of an orbital triamcinolone injection. Further discussion

of immunosuppression and its risks is beyond the scope of this book.
19.4 Orbital Triamcinolone Injection [2]
Moderate active thyroid eye disease without optic nerve compression.
19.4.2 Protocol
1. Discuss the risk/benefit of this modality with the patient. Emphasise that this is
an off-label use and obtain consent.
2. Administer 40 mg Triamcinolone acetate to the orbital floor.
3. Review in 8 weeks to establish whether there has been any symptomatic
improvement. If there has not, do not repeat. If there has been an improve-
ment, ask whether the symptoms are now returning? If they are, administer
another dose. If not, review again in 8 weeks to make sure that the active phase
is over.
4. Repeat steps 2 and 3 until there is no symptom recurrence on two consecutive
visits.
5. Once the TED is inactive, discuss rehabilitative surgical options if required.
19.4.3 Steps
1. Lie the patient down comfortably in a slight head up position (to reduce orbital
venous congestion). Ask a nurse to hold the patient’s hand for reassurance.
2. Gently shake the bottle of triamcinolone to resuspend the crystals and draw up
the complete 40 mg in 1 ml dose into a 2 ml syringe. Attach a 1” (25 mm)
long 25 G disposable needle and expel the air from the syringe and needle.
3. Ask the patient to gaze at a spot on the ceiling to keep their eyes still.
4. Pull down the lower lid to expose the inferior fornix and slowly insert the
needle, bevel up, at the junction of the lateral 1/3 and medial 2/3. Advance the
needle tangentially to the eye by at least 3/4 of its length until you encounter
the bone of the orbital floor. Look for any needle related eye movement during
needle insertion (the eye should not move). The sharpness of the needle means
that you receive minimal tactile feedback or resistance. Release your pull on
the lower lid.
5. Holding the syringe and needle still, ask the patient to follow small movements
of your other hand to confirm that the eye movements are free and independent
of the needle.
19.5 Surgical Management of Inactive (Dry) Thyroid Eye Disease 257
6. Attempt to withdraw the plunger slightly while keeping the syringe still, to
ensure that the needle tip is not positioned intravascularly. If you obtain blood,
either withdraw the needle slightly and retest or abandon the injection.
7. While holding the syringe steady with one hand slowly inject using the other.
Remind the patient to keep their eye still. Warn them to expect a slight ache
as the injection proceeds. Ask the patient to tell you if their vision becomes
affected during injection (this could be a sign of intraocular injection).
8. Withdraw the needle and immediately apply moderate pressure to the closed
eye for 5 min, to raise the orbital pressure and reduce the chance of orbital
bleeding.
9. Sit the patient up for a few minutes before allowing them to stand (to avoid
postural hypotension). Check whether their vision remains unaffected and warn
them that late bruising may appear. Ensure that they are given a contact number
to report any untoward reaction.
19.4.4 Notes
• If the lower lid is too tight to pull down easily, administer the injection tran-
scutaneously. To do this place your index and middle fingers on the lateral
1/3 of the lower lid and feel for the orbital rim. Spread your fingers slightly
to stretch the skin between them to ease needle penetration and push the eye
slightly upwards through the lid with your fingertips. Now, with the syringe
needle bevel up and pointing slightly inferiorly, insert it between your two fin-
gers to skim the inferior orbital rim tangentially to the globe. Advance it until
you feel the orbital floor.
• Give the patient a courtesy phone call two days after injection to check if they
have noticed any symptom improvement, as they may forget this by the time of
their 8-week review.
19.5 Surgical Management of Inactive (Dry) Thyroid Eye

Disease
There is a hierarchy in the surgical management of inactive (‘burnt out’ or ‘dry’)

TED:
(a) Orbital decompression
First consider orbital decompression. This, the highest risk procedure, has the best
chance of restoring a normal appearance. The bone of one or more orbital walls is
removed to allow the orbital contents to prolapse into the extra space so created.
When it is justified, decompression should be performed as the first step of surgical
rehabilitation as it can affect ocular balance and eyelid position. Orbital surgery is
beyond the remit of this book.
(b) Extraocular muscle recession
TED induced double vision is a consequence of extra ocular muscle fibrosis. A

fibrosed muscle tethers the eye so limiting movement when its antagonist muscle
contracts. At first the diplopia is noticed in the gaze direction opposite to the field
of action of the affected muscle. The inferior rectus is the most commonly affected
muscle causing up-gaze diplopia and often a compensatory ‘chin up’ head posture.
The medial rectus is the second most commonly affected muscle. Any or all of the
extraocular muscles may be affected. The golden rule is only to recess the affected
muscle. Never resect its antagonist. The surgery is as straightforward to carry out
as any squint surgery, but its outcome is less certain.
19.5.1 Tips
The following tips make TED recessions more predictable.
• Suture the recessed muscle securely to the sclera at the position that it adopts
once separated from its original insertion (with the globe in the primary gaze
position).
• Suture the muscle directly to the sclera. Do not leave it on a ‘hang-back,
adjustable suture’, as is popular practice. Indirect fixation reduces the likeli-
hood of a strong union at the new insertion site (because of the abnormally
high stresses at a fibrosed muscle’s insertion). A weak reattachment allows late
drift of the muscle insertion when its anchoring suture cuts out or absorbs. This
drift is so prevalent that most strabismus surgeons deliberately under correct
their adjustable sutures in anticipation. By contrast, ‘late drift’ does not occur
if you suture the insertion to the sclera directly.
• Recessing the inferior rectus increases lower lid retraction because the lower lid
retractor’s origin is the inferior rectus. Separating the retractor origin from the
muscle belly and placing the lower lid on temporary upward traction overnight
prevents this increase in retraction.
19.5.2 Inferior Rectus Recession with Lid Retractor Recession

(Fig. 19.3)
19.5.2.1 Principle
Identify and separate the lower lid retractor origin from the inferior rectus muscle
belly. Pre-place sutures in the existing muscle insertion before detaching it from
the sclera. Suture the muscle back firmly to the sclera in the position it takes up
a b
c d
e f
h
g
Fig. 19.3 Inferior rectus recession with lid retractor recession. a Pull the eye upward and incise
the conjunctiva and tenons over the inferior rectus insertion. b Insert a Chavasse squint hook under
the insertion. c Bluntly dissect the inferior rectus muscle sheath from the muscle. d Tear the origin
of the retractor expansion off the muscle. e Pre-place a double armed, 6/0 absorbable suture into the
inferior rectus close to the insertion. f Use double pass, self-locking loops for muscle fixation. g Do
this at either side of the muscle with an additional central bite for security. h Divide the inferior
rectus insertion with Westcott scissors while taking care not to cut the pre-placed sutures. i Insert
both muscle suture needles through partial thickness sclera at the intended recession point and take
further suture bites through the original insertion where the sclera is thicker and stronger. j Make
a second suture pass through the insertion. k Pull the rectus muscle to its new insertion and tie the
suture. l Suture the conjunctiva and tenons closed over the insertion. m Put the lower lid on upward
traction overnight
i j
k l
in primary gaze. Put the lower lid on upward traction overnight so that the lower
lid retractor origin re-inserts itself more anteriorly on the muscle.

Dry phase TED patients with a chin up head posture and/or up-gaze diplopia.
19.5.2.3 Steps
1. Pre-place a limbal traction suture at 6 o’clock and pull the eye upward on
traction (Fig. 19.3a).
2. Incise the conjunctiva and tenons horizontally over the inferior rectus insertion
(6–7 mm posterior to the limbus), expose the insertion by blunt dissection and
insert a Chavasse squint hook under the insertion (Fig. 19.3b).
3. Bluntly dissect the inferior rectus muscle sheath from the muscle (Fig. 19.3c).
Do this by pushing firmly against the muscle with the flat end of a dry
triangular swab in a posterior direction.
4. Continue the dissection until the sheath appears to be fixed to the muscle
belly itself by interdigitations (roughly at the equator of the globe). These
interdigitations are the origin of the lower lid retractors. They look like the
attachment of the medial check ligament to the medial rectus.
5. Grip these interdigitations with Jayles toothed forceps and tear them off the
muscle in a posterior direction, so separating the origin of the lower lid
retractor expansion from the muscle (Fig. 19.3d).
6. Pre-place a double armed, 6/0 polyglycolic acid, suture with spatulate
1/4 circle needles, into the inferior rectus close to the insertion (Fig. 19.3e).
Use double pass, self-locking loops [1] for each fixation (Fig. 19.3f). Do
this at either side of the muscle with an additional central bite for security
(Fig. 19.3g). Place bulldog clips on the suture ends to retract them from the
operative field.
7. Divide the inferior rectus insertion with Westcott scissors while taking care
not to cut the pre-placed sutures (Fig. 19.3h). Allow the muscle to retract.
8. Temporarily release the limbal traction suture and return the eye to the primary
gaze position. Mark the newly adopted position of the released inferior rectus
on the sclera. This will be between 4 and 8 mm posterior to the original
insertion. Then retighten the limbal traction suture to pull the eye upwards for
ease of access during suturing.
9. Insert both muscle suture needles through partial thickness sclera [2] at the
marked positions (Fig. 19.3i). Check that the scleral bites are strong by slightly
lifting the needle before completing the pass.
Note: The sclera is extremely thin at this point and needle penetration of the eye
is a real risk. Never point a needle towards the eye unless it is your intention
to penetrate the eye! Avoid this risk by placing the needle tip flat (tangential)
against the sclera (Fig. 19.5).
10. Take suture bites through the original insertion where the sclera is thicker and
stronger [3].
11. Take a second bite of the insertion more centrally than the first.
Note: This two-bite configuration introduces friction which makes it easy to
adjust the suture without it slipping.
12. Again, release the limbal traction suture before pulling slowly on the rectus
muscle suture ends to advance the muscle to its new insertion (Fig. 19.3k). Tie
the suture firmly and cut the ends at least 2 mm long to prevent spontaneous
unravelling.
13. Suture the conjunctiva and tenons closed over the insertion to bury the muscle
suture (Fig. 19.3l).
14. Place a tarsal traction suture through the lid margin and put the lower lid on
upward traction overnight. This allows the lid retractor origin to reattach to
the recessed inferior rectus more anteriorly (Fig. 19.3m).
a b
c d
Fig. 19.4 Double locking suture bites. a Take a partial thickness muscle bite over the squint hook.
b With the same suture take a full thickness muscle bite on the posterior slope of the squint hook.
c Loop the first bite suture under the needle tip. d Pull the needle through the loop to lock the suture
19.5.2.4 Notes
1. Double pass, self-locking suture steps:
(a) Take a partial thickness muscle bite over the squint hook. The latter protects
the underlying sclera from the needle tip (Fig. 19.4a).
(b) With the same suture take a full thickness muscle bite on the posterior slope
of the squint hook (Fig. 19.4b).
(c) Before releasing the needle use forceps to loop the first bite suture under
the needle tip (Fig. 19.4c).
Note: Pulling on the loop lifts the needle tip making it easier to regrasp.
(d) Pull the needle through the loop. This magically locks the suture.
2. Scleral suture bites:
(a) Only use a spatulate 1/4 circle needle for suturing to the sclera.
(b) Place the needle tip flat (tangentially) against the sclera (Fig. 19.5a).
(c) Press the flat of the needle tip against the sclera to depress it slightly
(Fig. 19.5b).
(d) Cautiously advance the needle a short distance tangentially through partial
thickness sclera (Fig. 19.5c).
(e) You can check the needle tip’s progress the within the sclera by rotating
the needle slightly to lift the tip (Fig. 19.5d).
(f) Repeat steps c and d as necessary to obtain the length of bite you require.
(g) Rotate the needle out of the sclera when you have achieved the length of
bite that you require (Fig. 19.5e).
(h) Before removing the needle from the sclera, lift it slightly to check the
strength of the bite (Fig. 19.5f).
a b
c d
e f
Fig. 19.5 Scleral suture bites. a Place the needle tip flat (tangentially) against the sclera. b Depress
the sclera slightly with the flat of the needle. c Cautiously advance the needle a short distance tan-
gentially through partial thickness sclera. d Visualize the needle tip within the sclera by rotating
the needle slightly to lift the tip. Repeat steps c and d as necessary to obtain the length of bite you
require. e Rotate the needle out of the sclera when you have achieved the length of bite that you
require. f Before removing the needle from the sclera, lift it slightly to check the strength of the
bite. g Complete the suture pass
a b
c d
Fig. 19.6 Muscle insertion suture placement. a Grasp and lift the muscle insertion with toothed
forceps to stabilize it. b Place the suture needle tip flatly against the sclera under the insertion.
c Entering the insertion angle, advance the needle and exit 1/2 to 1 mm anterior to the insertion.
d Lift the needle slightly to check the strength of the bite
(i) Remove the needle from the sclera.

3. Muscle insertion suture placement (Fig. 19.6):
The sclera is thinnest just beneath a muscle insertion (about 1/4 mm thick) so
this is a bad place to insert a suture bite. The sclera anterior to the insertion is
twice as thick. Entering the angle between the muscle insertion and the sclera
reproducibly positions the needle at the correct depth within this thicker sclera.
(a) Grasp and lift the muscle insertion with toothed forceps to stabilize it
(Fig. 19.6a).
(b) Place the suture needle tip flatly against the sclera under the insertion
(Fig. 19.6b).
(c) Entering the insertion angle, advance the needle and exit 1/2 to 1 mm
anterior to the insertion (Fig. 19.6c).
(d) Lift the needle slightly to check the strength of the bite (Fig. 19.6d).
19.5.3 Eyelid Recession
The final step in the surgical treatment hierarchy is the correction of eyelid retrac-
tion, an extremely common sign of TED. It is the last option in the sequence
because both orbital decompression and squint surgery can significantly affect eye-
lid position. Only consider lid margin recession after decompression surgery and/
or squint surgery have either been performed or ruled out.
19.6 Upper Lid Blepharotomy [3] 265
Eyelid tissues in TED behave very differently from those of normal lids. Fibro-
sis is particularly strong in the peri lacrimal area in the upper lid. It is the cause
of lateral lid retraction, sometimes called ‘lateral flare’.
Lid retractors exert their action on the lid margin in four ways. Three are well
recognized:
1. The levator aponeurosis anterior attachment to skin, responsible for the lid
crease,
2. The levator aponeurosis posterior insertion to the middle and distal part of the
tarsal plate and
3. Muller’s muscle attachment to the proximal edge of the tarsal plate.
4. The fourth, generally overlooked, attachment is that of the levator/superior
rectus common tendon sheath which terminates as the superior suspensory liga-
ment of the fornix (it prevents upper fornix prolapse). Normally this attachment
has no effect on lid margin position because its only connection to the lid is via
elastic conjunctiva. However, the conjunctival fibrosis of TED transfers levator
pull directly to the tarsal plate. You see this clearly during TED lid recession
surgery. Having divided all three retractor attachments mentioned above, the
lid still moves normally until the conjunctiva is also cut. The simplest and
most effective lid margin recession operation, blepharotomy divides all four
attachments.
19.6 Upper Lid Blepharotomy [3]
Blepharotomy, as its name suggests, is a full thickness eyelid incision, parallel

with the lid margin at the level of the skin crease externally and through to above
the upper border of the tarsal plate internally. Carry it out under local anaesthesia
so that you can adjust the length of the blepharotomy according to its lid lowering
effect. Initially cut only the lateral 1/3 of the lid. If this proves insufficient extend
the incision medially in stages until you achieve the desired effect. I recommend
that you always leave the medial 1/3 intact as cutting it causes a late medial droop
contour deformity. Other authors leave an intact central ‘bridge’ instead. No post-
operative traction or dressing is required. What you see on the operating table is
the lowering you ultimately get from this procedure.
Dry phase TED patients with symptomatic upper lid retraction.

19.6.2 Steps (Fig. 19.7)
1. Mark the upper lid skin crease (usually at about 7–8 mm in Caucasians)
(Fig. 19.7a).
2. Place a protecting plate under the upper lid and ask your assistant to hold it
pushed up in the upper fornix.
3. Make a full thickness incision of the lateral 1/3 of the eyelid with a no. 15
scalpel blade (Fig. 19.7b). Extend this laterally to the orbital rim to avoid lateral
tethering from perilacrimal fibrosis.
4. Check the effect that this has on the lid position by getting the patient to look
up and down.
a
b
d
c
2/3 1/3
Fig. 19.7 Blepharotomy. a Mark the upper lid skin crease. b Make a full thickness incision of the
lateral 1/3 of the eyelid with a no. 15 scalpel blade. c To lower the lid further, extend the incision
medially in stages. d Do not incise more than the lateral 2/3 of the lid. e Suture only the skin and
orbicularis incision with a continuous suture
19.8 Lower Lid Retractor Recession 267
5. To lower the lid further, extend the incision medially in stages, always stopping
between stages to assess the lid’s height (Fig. 19.7c).
6. Do not incise more than the lateral 2/3 of the lid (Fig. 19.7d).
7. Suture only the skin and orbicularis incision with a continuous 6/0 or 7/0 suture
(Fig. 19.7e).
8. No dressing is required.
19.6.3 Note
This operation can be performed transconjunctivally by everting the lid over a

Desmarres retractor leaving the skin uncut. However, repeated lid eversion is both
difficult and uncomfortable for the patient, and the repeated stretching makes the
correct endpoint harder to determine.
19.7 No Spacers
Much has been written about interposing ‘spacers’ of various materials between the
recessed levator aponeurosis and the upper tarsal plate border. They serve no useful
purpose. They do not prevent further post-operative fibrosis. As foreign bodies
they only add to it, and they can become infected or extrude. In theory spacers
hold the divided retractors a set distance from the tarsal plate, yet in practice
the recommendation is to make them two or three times wider than the desired
recession (which negates their purpose). As thyroid lids already have increased
fibrosis, late drift only occurs if the retractors have been completely cut (hence
leave the medial 1/3 intact).
Spacer use has been particularly recommended for ‘lifting’ a retracted lower
lid. To do so it would need to be stiff (e.g., cartilage or porous polypropylene) and
be fixed to the orbital rim. At best this leads to a static lower lid, at worst to an
ectropion.
19.8 Lower Lid Retractor Recession
19.8.1 Considerations and Principle
Full thickness external lower lid blepharotomy is possible but unnecessary as gen-
erally the lower lid can be everted easily and all the layers cut from the conjunctival
surface, sparing the skin. However, because the only lifting force on the lower lid
is the orbicularis, apply upward lid margin traction with a suture overnight to avoid
an under-correction. Tightening the lid margin over a prominent eye will not help
to raise a retracted lower lid. Add additional active lower lid lift from the upper
lid levator muscle by performing a medial canthoplasty and a short (4–5 mm),
Fig. 19.8 Belt or braces. a Tightening a lower lid margin in the presence of a prominent eye
pushes the eye upwards and the lid slips downwards relative to the eye. b Performing a medial
canthoplasty and lateral tarsorrhaphy transfers upper lid lift to the lower lid
permanent, lateral tarsorrhaphy (Fig. 19.8). The latter is also helpful in masking
proptosis but should only be performed after the lid retractors have been recessed.
Dry phase TED patients with symptomatic lower lid retraction.
19.8.3 Steps
1. Insert a 4/0 monofilament tarsal traction suture. Use this to evert the lower lid
over a large Desmarres lid retractor (Fig. 19.9a, b).
2. Make an incision along the length of the conjunctiva, just proximal to the tarsal
plate. Deepen this incision to divide the underlying retractors. Ensure that it
extends medially and laterally as far as the canthi (Fig. 19.9b).
3. Remove the Desmarres retractor and pull the lower lid upwards using the trac-
tion suture. With the lid stretched upwards feel for any remaining restricting
bands through the skin and divide them with scissors (Fig. 19.9c, d). The lower
lid should now no longer be retracted. Furthermore, the lid should not move
down when the patient looks down.
4. Tape the lower lid traction suture to the forehead on stretch and apply antibiotic
ointment and a pressure dressing overnight (Fig. 19.9e).
19.8 Lower Lid Retractor Recession 269
a
b
c d
Fig. 19.9 Posterior Lower lid retractor recession. a Insert a tarsal traction suture and use this to
evert the lower lid over a large Desmarres lid retractor. b Incise the conjunctiva just proximally
to the tarsal plate. Deepen this incision to divide the underlying retractors. c Pull the lower lid
upwards, using the traction suture, to feel for any remaining restricting bands. d Divide any bands
with scissors. e Tape the lower lid traction suture to the forehead on stretch
5. Remove the traction suture the following day and assess the lower lid position.
Should there be an under-correction instruct the patient to push and hold the
lower lid upwards for a couple of minutes at least twice a day for the first two
months to stretch the internal scar.
19.8.4 Note
This technique has also been used to recess the upper lid and is the basis of
the ‘Henderson procedure’. The latter is less predictable than the Koornneef
blepharotomy and not recommended.

• Periocular triamcinolone injections are an excellent option for managing
moderate active thyroid eye disease.
• When recessing fibrosed extraocular muscles suture them directly to the sclera
to avoid late drift.
References
1. Clinical Activity Score Mourits MP (1997Jul) Prummel MF, Wiersinga WM, Koornneef L. Clin
Endocrinol (Oxf) 47(1):9–14
2. Ebner R, Devoto MH, Weil D, Bordaberry M, Mir C, Martinez H, Bonelli L, Niepomniszcze
H (2004Nov) Treatment of thyroid associated ophthalmopathy with periocular injections of tri-
amcinolone. Br J Ophthalmol. 88(11):1380–6. https://doi.org/10.1136/bjo.2004.046193.PMID:
15489477;PMCID:PMC1772392
3. Elner VM, Hassan AS, Frueh BR (2003) Graded full-thickness anterior blepharotomy for upper
eyelid retraction. Trans Am Ophthalmol Soc 101:67–73
Conclusion
20
Thank you if you’ve made it this far. Believe me it took a lot longer to write than
to read (Fig. 20.1).
Hopefully you’ve noticed that I’ve reduced my message to a few common
themes that have kept cropping up. For example, lid margin repair (Chap. 5) is
almost the same whichever part of the lid you perform it on, and it crops up
again in entropion and ectropion correction (Chaps. 8 and 9) and lid reconstruc-
tion (Chap. 14). Retractor plication is similar whether you perform it for a ptosis
correction in the upper lid (Chap. 10) or as part of an anterior lamellar reposi-
tioning in either lid, or as a retractor plication for lower lid entropion or ectropion
(Chaps. 8 and 9).
Fig. 20.1 A good read
272 20 Conclusion
Keeping eyelid surgery as simple and safe as possible has been my intention
throughout this manual. All the techniques I have described have worked reliably
well for me. Therefore, I commend them to you. Naturally, many alternative tech-
niques exist, each with its champions. And no doubt in time you will develop your
own modifications and favourites. Things do move on and so must we.
I hope that you have found at least some the concepts and techniques
interesting and that they are useful in your future practice. May they enable you
to generate fewer revisions from your routine surgery and give you more time to
devote to the more challenging problems that I have steered clear of.
There is, of course, much more to being a good surgeon than mere technique.
Listen to your patients as they have much to teach you. Follow up your own
outcomes personally, not just as a human courtesy but to complete the feedback
loop from which your techniques can evolve. Care about your patients and you
will inspire their trust and confidence. These are invaluable on the rare occasions
when a surgical outcome is suboptimal. And be realistic. Explain what is and is
not surgically possible. Under promise and overachieve! But above all, enjoy your
work and never stop learning.
10 Lid Commandments
1. Thou shalt do least harm.
2. Thou shalt use the meibomian orifice, not the grey line.
3. Thou shalt always attempt to close wounds directly.
4. Remember, nothing lasts, suture tension least of all.
5. Revere the upper lid.
6. Believe in the magic suture and white line.
7. Thou shalt not strip.
8. Thou shalt replace volume lost.
9. Suppress active and recess for inactive thyroid eye disease.
10. Speak no ill of thy less informed colleagues.

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Eyelid

ISBN 978-3-031-31526-8 ISBN 978-3-031-31527-5 (eBook)

January 2023 Geoffrey E. Rose, D.Sc., FRCOphth

Experience is simply the name we give our mistakes.

Plymouth, UK Vladimir Thaller, FRCS, FRCOphth

2.10 The Kit (Instruments) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

6.2.3 Lid/Globe Apposition and Volume Deflation . . . . . . . . 64

8.6.2 Case Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

9.7.6 Permanent (Overlap) Lateral Tarsorrhaphy

11.5 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148

14 Lid Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

15 Revision Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

17.5.3 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

19.8.3 Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268

Congratulations on choosing the eyelids as your surgical field! Being functional as

1.3 The Target (Fig. 1.1)

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 1

Fig. 1.1 Target audience

1.4 “Common Things are Common…Save Common Sense”

1.5 Less is More

1.6 The Truth, NOT the Whole Truth, and Nothing

This book builds on sound foundations handed down by generations of innovative

1.7 A Matter of Principle

1.8 Heresy, Not Hearsay

• Meibomian orifice line superiority over the grey line

1.9 Concept or Cookbook?

1.10 10,000 hour Expert?

In this book I sometimes question accepted treatments. I challenge you to do the

1.12 The Good Outcomes Secret

1.13 Style and Structure

1.14 Exceptions Prove the Rule

Occasionally I have broken my own rule by including uncommon procedures

As a single author work this book is necessarily biased. It is neither comprehensive,

• Surgery = directed scarring

2.2 Do Least Harm!

The famous exhortation to physicians to “First do no harm”, sounds laudable but is

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 7

2.3 Surgery is Directed Scarring

2.4 The Healing Response

Millennia of evolution have equipped us with amazing powers of healing. All

2.4.1 Primary Intention Healing

2.4.2 Secondary Intention Healing

2.5 Stages of Wound Healing

1. Haemostasis. Fibrin clot formation occurs within seconds to minutes of wound-

2. Inflammatory. Starting immediately, this phase continues for several days. It

2.6 Thermal Burns

Thermal burns sometimes incite an ongoing scarring (cicatricial) process which

2.7 Tension, Expansion, Migration, and Contraction

2.7.1 Tissue Expansion

2.7.2 Suture Migration

2.7.3 Contraction (Hydrocortisone Ointment and Massage)

Fig. 2.3 Dog-ears

2.9 Active v Passive Surgical Mechanisms (Fig. 2.5)

2.10 The Kit (Instruments)

1. Large-toothed tissue holding forceps e.g., Toothed Adsons

Surgery relies on accurate anatomical orientation and dissection. Visualization is

Full vasoconstriction, following local adrenaline injection, takes longer to manifest

2.12.2 Positioning (Fig. 2.6)

2.12.4 Cut Uphill

2.13 Plication v Resection