Surgical Correction for Pediatric Epiblepharon and Trichiasis

Summary

Here, we present a protocol for surgical correction for pediatric epiblepharon and trichiasis.

Abstract

Lower eyelid epiblepharon is a condition that is common in Asian children and improves with age in most patients; however, the problem can persist until school age or even adulthood. No difference has been observed in terms of incidence in association with sex or the affected eye, and the condition mainly affects the lower eyelid, usually in both eyes. The condition typically features horizontal semilunar skin folds lying parallel to the palpebral margin that accumulate and push the eyelashes towards the ocular surface, which rub against the cornea, resulting in corneal injury and irritation symptoms that affect the daily life of the child. Surgery remains the currently preferred method for alleviating corneal irritation symptoms.

Although diverse surgical procedures are available in terms of clinical practice, the modified Hotz procedure remains the most widely used. The surgical procedure primarily focuses on two key aspects: the precise determination of the amount of skin to be removed and improving the tightness between the palpebral retractor aponeurosis and the anterior layer of the eyelid. In this study, lower eyelid epiblepharon is categorized into three distinct types based on the affected area: medial lower eyelid epiblepharon (affecting the medial skin of the lower eyelid); central epiblepharon (involving half of the lower eyelid); and total involvement Type A epiblepharon (involving the full-length of the eyelid). The surgical approach was tailored according to classification, with Type A cases receiving L-shaped excisions and Types B and C crescent-shaped incisions. The postoperative outcomes were evaluated to determine the cure rate. Most patients experienced mild postoperative reactions, and no obvious sunken scars or double lower eyelids were observed. Satisfactory results were thus obtained with mild postoperative reactions.

Introduction

The incidence of epiblepharon of the lower eyelid is 46-52.5%^1,2. The main pathogenesis is that the connection between the skin of the lower eyelid and the orbital septum fascia is not tight, while the skin and the orbicularis oculi muscle in front of the tarsus are closely connected to the underlying tarsus. This leads to the formation of horizontal wrinkles on the skin of the lower eyelid. The redundant skin and the orbicularis oculi muscle in front of the tarsus accumulate superiorly and cover the lower eyelid margin, causing the eyelashes to turn inward^3,4,5. Therefore, the surgical operation aims to deal with the problem of the eyelid margin piled up due to the wrinkles and avoid the impact of the skin and the orbicularis oculi muscle on the eyelashes.

Quickert et al.⁶ first applied the eversion suture method for correcting congenital trichiasis caused by epiblepharon of the lower eyelid. This method, which was simple to operate and has no surgical incisions, has a high postoperative recurrence rate. The modified Hotz operation is the most widely used surgical procedure, and currently, some surgical methods are also based on it. However, surgical recurrence is also a thorny problem. Chang et al.⁷ found that 9.1% of the patients had insufficient correction and 15.9% of the patients had recurrence.

The combination of the eversion suture method and surgery helps to reduce the recurrence rate (see Table 1)⁸. In addition to excising the redundant skin and orbicularis oculi muscle, the epiblepharon correction procedure adopted fixes the orbicularis oculis muscle from the upper lip of the incision to the tarsus, increasing the adhesion between the anterior and posterior layers of the eyelid and turning the eyelashes outward

Protocol

This protocol follows the ethical principles of Suzhou Eye Hospital Affiliated to Suzhou Vocational Health College and has obtained approval from the Hospital Ethics Committee, as well as informed consent from both patients and their families for this study and related videos.

1. Preoperative protocol

1. Classify lower eyelid epiblepharon as follows: medial: epiblepharon with trichiasis affecting the nasal side 1/3 of the lower eyelid; central type: affecting 1/2 of the lower eyelid; total involvement type.

2. Surgical incision design

1. Design the range and shape of the excision based on the morphology of the redundant skin.
   1. Start the first line 2 mm above the root of the eyelashes. Extend it outward along the natural curve of the lower eyelid skin and extend 2-3 mm beyond the area of inverted eyelashes.
   2. Design the second line according to the expected amount of skin cut. If the patient has prominent redundant skin medially, design the auxiliary line in an L-shape. If the redundant skin is prominent centrally or along the entire length, design it in a crescent shape.

3. Presurgery

1. Apply 0.4 mL of 2 mg proparacaine hydrochloride eye drops for surface anesthesia of the conjunctival sac. Sterilize the surgical area with povidone-iodine by scrubbing, cover the head with a sterile drape, and apply antiseptic gauze.
2. To reduce the pain response, administer 5 mL of 0.1 g lidocaine hydrochloride (containing 1:100,000 epinephrine) to the lower eyelid skin.

4. Surgery

1. Use a high-frequency electric knife to incise the skin along the predesigned incision line and extend the incision to the superficial layer of the orbicularis oculi. Excise the predesigned crescent or L-shaped lower eyelid skin along the incision line together with the superficial layer of the orbicularis oculi muscle.
2. Dissect the incision margin into the lower margin of the lower tarsus using a bipolar electrotome, taking particular care to avoid damaging important adjacent structures and nerves. Employ bipolar coagulation as hemostasis to ensure the absence of active bleeding points in the surgical field and prevent the formation of postoperative hematoma and subcutaneous ecchymosis.

5. Internal fixation and suture

1. Use a 6-0 absorbable suture for the "8-shaped" suture incorporating the preaponeurotic fascia of the lower eyelid retractor and the subcutaneous tissue adjacent to the upper margin of the incision. Adjust the tightness of the knot to restore the eyelashes to a normal position, while closely monitoring whether sutures penetrate the conjunctival surface. Apply stitches with consistent spacing and apply appropriate tension to ensure favorable wound healing.
   NOTE: Particular attention is given to the curvature and smoothness of the lower eyelid margins to prevent the development of valgus and angular deformities.
2. The slight downward displacement of the lower eyelid margin means that the skin of the lower incision can extend beyond the projection line for skin affected by the upper incision following internal fixation. Therefore, excise the skin along the projection line, while leaving skin below the incision completely flat.
3. Close the skin incision using a 7-0 non-absorbable polypropylene suture, with neither the tarsus nor the lower eyelid retractors incorporated to avoid double-eyelid plasty of the lower eyelid. Align the sutures precisely to ensure that the upper and lower lips of the incision are slightly everted, facilitating wound healing and minimizing scar formation.

6. Postoperative treatment

1. Administer tobramycin and dexamethasone ointments to both eyes after surgery and apply cold compression for 48 h.
2. Administer postoperative treatment with anti-inflammatory, anti-infection, and repair medications. Keep the wound dry.
3. Remove stitches 7 days after surgery.

Results

Efficacy assessment
Healing was defined as normal eyelid position, no deformity, ectropion of lower eyelid lashes, untouched cornea, smooth corneal epithelium, and negative fluorescein staining. In contrast, wounds were considered to be unhealed if there were complications such as abnormal eyelid position, severe scarring, partial eyelash inversion toward the eyeball, and corneal epithelial damage.

Surgical results
All surgeries were performed by a sin...

Discussion

Several surgical procedures, such as full-thickness eyelid suture^6,9, buried suture¹⁰, V-Y plasty^11,12, and excision of skin and orbicularis oculus muscle, have been used to treat trichiasis caused by redundant skin of the lower eyelid. Recently, the rotational suture technique has become quite common. This technique everts the eyelashes by fixing the subcutaneous tissue on the eye...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
6-0 absorbable suture	Johnson&Johnson	W9981
7-0 non-absorbable sutures	Johnson&Johnson	1696G
high-frequency electrotome