Patients are often diagnosed with conjunctivitis/discharge and treated with topical antibiotics. The symptoms recur the moment these are stopped. This is probably because the dryness of the exposed conjunctiva is temporarily alleviated with the lubrication of the antibiotics, thereby stemming the apparent "discharge" produced to protect the exposure. While waiting for surgery, it is not unreasonable to sparingly lubricate the exposed tarsal conjunctiva with two to three times daily application of simple eye ointment or equivalent. This will keep the surface moist without contaminating the corneal surface and fogging the vision.
Central ectropion describes a sag downwards and/or outwards of the lid margin, without associated canthal tendon laxity. When the lid is pulled away and forward from the globe it does not spring or snap back to the globe as crisply as a taut tarsus. This laxity is traditionally corrected with a full thickness pentagon excision. Bick originally described a pentagon excision at the lateral extremity of the tarsus with reattachment to the lateral canthus. The modified Bick procedure of full thickness pentagon excision and direct closure, just under a quarter of the way in from the lateral canthus, is now the standard correction for central ectropion. It is very successful in the absence of medial or lateral canthal laxity.
The vertical incision through the tarsus should be made about 5 mm from the lateral canthal corner, so that the reconstruction does not, even after resection, rub on the corner. The amount of lid to be resected is determined by overlapping the cut edges until the margin is taut. The tissue inferior to the tarsus is excised as a triangle, thus completing the pentagon (Figure 3.2a). The meticulous apposition of the tarsal edges, with long acting absorbable sutures, dictates the appearance and strength of the final result (Figure 3.2b). Accurate marginal closure is secured with grey line and lash line sutures; after tying, the trailing ends are kept long and secured in the tying of the first skin suture before trimming. This avoids any cut ends, which may be too short, rubbing on the eye (Figure 3.2c).
If there is considerable excess skin, the above procedure can be combined with a lower lid blepharoplasty (Kuhnt-Symanovsky type procedure): excess skin is excised as a
Figure 3.2 Modified Bick procedure.
(a) Pentagon excision, (b) Tarsal closure, (c) margin and skin closure.
lateral triangle from a blepharoplasty flap and the pentagon excision to shorten the horizontal laxity is done under the flap.
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