Total tarsal eversin

In this case the attachment of the lower lid retractors to the lower border of the tarsus is lax. The inflammation and oedema of the exposed conjunctiva is often sufficient to maintain the lid in an everted position. This can occur unusually as an isolated incident,

Canaliculus

Lacrimal sac Medial orbital wall

Figure 3.9 Medial canthal resection. (a) canaliculus cut, lid to be resected. (b) marsupialisation and reattachment of resected canaliculus.

Lacrimal sac Medial orbital wall

Figure 3.9 Medial canthal resection. (a) canaliculus cut, lid to be resected. (b) marsupialisation and reattachment of resected canaliculus.

where the possibility of a mechanical/ cicatricial element has to be excluded. More usually, it presents as a long term result of untreated progressive ectropia. In these cases, surgical repair would therefore also need to include correction of whatever horizontal laxity was present.

Correction of the lower lid retractor laxity is achieved by reattachment of the retractors to the inferior border of the tarsus. A horizontal incision is made along the inferior tarsal border and the lower lid retractors identified. These can be resutured to the tarsal border as part of the conjunctival closure.

Inverting sutures raise the anterior lamella relative to the posterior lamella and are very useful when the chronically exposed conjunctiva is in the way of proper apposition of the lid to the globe, once the ectropion repair has been otherwise correctly completed. The redundant oedematous conjunctiva can be stretched inferiorly and kept in that position by long acting absorbable sutures pulled through from the anterior surface of the fornix to the skin. The track of the sutures should run inferiorly and anteriorly so they exit at the skin surface at the level of the inferior orbital rim (Figure 3.10). Here the sutures are tied over small bolsters, and can be removed after l4 days if they have not already fallen out.

It is not usually necessary to excise the redundant conjunctiva. However, if its bulk is such as to prevent correct apposition of the eyelid to the globe at the end of appropriately carried out surgery, even with the help of inverting sutures, then some of the conjunctiva can be sacrificed.

Inverting sutures may also be used as a temporary measure to control an ectropion, while waiting for definitive surgery.

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