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Lower Eyelid Malposition

The lower eyelid should sit next to the eyeball at the edge of the cornea which is known as the limbus. It is suspended on the outer corner by a structure called the lateral canthal tendon and in the inner corner by the medial canthal tendon. This allows it to be analogous to a “taut clothes line”. As we age the lower eyelid tendons become more weaker leading to more laxity in the eyelid. This can cause the eyelid to either roll outwards away from the eyeball (an ectropion) or roll inwards causing the lashes to rub against the cornea (an entropion). An entropion can cause quite a sore eye. An ectropion can also be caused by chronically sun damaged skin which contracts and pulls the lower eyelid away from the eyeball. Eyelid malpositions usually require surgical treatment.

What is involved before the procedure?

You will have an assessment in the rooms paying particular attention to your concerns regarding your eyelids and eyelid position. Pre-operative facial photographs will be taken. You will be advised on whether to stop any blood thinning medications before the surgery. A thorough slit lamp examination of your eyes is important before any eyelid surgery and this will be performed to rule out corneal problems such as dry eye which could be compounded by lower eyelid surgery.  The risks and benefits of the procedure will be discussed in detail and are also visible for you to read overleaf.

What is involved during the procedure?

Ectropion or Entropion surgery is a day surgical procedure usually carried out under local anaesthetic with or without conscious sedation depending on the patient’s preference. A general anaesthetic is rarely necessary and is often counterproductive as patient co-operation helps in the surgical planning process. 

There are multiple ways of correcting an ectropion or entropion, but broadly speaking we are trying to correct the excessive eyelid laxity by tightening the eyelid. 

Lateral Tarsal Strip procedure is often employed. In this procedure a skin incision is made at the outer aspect of the eyelid and a strip is created from the tarsus which is a rigid cartilaginous structure in the lower eyelid. This is stitched to a tough structure called the periosteum. The effect of this is to tighten the eyelid and stop it from rolling inwards or outwards.

A lower eyelid Wedge excision is sometimes used to tighten the lower eyelid in an ectropion. In this procedure a pentagon wedge of the lower eyelid is excised and the remaining ends are stitched together. As some tissue has been removed, the effect is that the laxity of the eyelid is reduced. 

Sometimes a skin graft with or without eyelid tightening is required to treat an ectropion caused by sun damaged eyelid skin. 

At the end of the procedure you will have an eye pad applied over the operated eye. This is removed the NEXT MORNING and a CLEAR SHIELD provided by the day surgery then needs to be taped over the operated eye.

What is involved after the procedure?

The clear shield needs to be worn day and night for the first 48 hours after surgery and then at night for a further 5 nights. It is only to be taken off to instil antibiotic ointment or apply ice packs.

After the procedure it is normal for the swelling to increase in the first 24-36 hours. It can often track down to the lower eyelid and cheeks due to the effects of gravity.

To reduce swelling:

  • Please use Ice packs intermittently or a frozen bag of peas wrapped in a cloth and apply to your closed eyelids for the first week after the procedure. 
  • It is also useful to sleep using extra pillows if possible. 
  • Try to avoid sleeping on the same side as the eye which has just been operated on

Your blood thinners if stopped can be started the day after your procedure.

Wound care: Please keep the wound dry for the first 24 hours after surgery. The antibiotic ointment can then be applied to the wound and to the eye itself as the eye is prone to getting dry postoperatively. 

When will I need to come back to the clinic?

You will be reviewed at one week after the procedure to assess postoperative progress and remove any skin sutures if still present. The majority of the postoperative swelling settles in the first 4 weeks after surgery.

Risks of Surgery

Please read this carefully. The purpose of oculoplastic surgery is to restore good function to the eyelid and a good cosmetic outcome. Good pre- and intraoperative planning negates many risks but there are certain risks that can still apply to ectropion or entropion surgery including, but not limited to:

  • Infection
  • Excessive Pain
  • Bleeding or excessive bruising (More common in patients on blood thinners)
  • Dehiscence of the Lateral tarsal strip or pentagon wedge which may require further surgery
  • A retrobulbar haemorrhage (bleed behind the eyeball) leading to sight loss.
  • A Corneal abrasion (A scratch on the cornea during or after surgery, this is very painful, but usually settles in 48 hours)
  • In growing eyelashes at the site of surgery