This video demonstrates a lateral tarsal strip procedure in a patient with lower eye lid ectropion.

Surgery Location: on-board the Orbis Flying Eye Hospital, Hue, Vietnam
Surgeon: Timothy James McCulley, Wilmer Eye Institute, USA

 

Transcript

There’s a lot of laxity. You can see that I can pull the eyelid very, very far from the eye. And what we’re gonna do is we’re gonna secure the eyelid to the lateral orbital rim to tighten the eyelid, and that’s called a lateral tarsal strip. So we’re gonna start with the canthotomy. Now, we’re gonna divide the eyelids. I angled down just a little bit to avoid injuring the upper portion of the lateral canthal tendon. So that’s the canthotomy. And then I grab the eyelid. I’m gonna hold the tarsus. I’m being careful not to injure the skin. And I cut the canthal tendon, and you see the eyelid release. So did you see how the eyelid is mobile now? Now we divide the anterior and posterior lamella of the eyelid. I’m doing this on the gray line. If you look at the anatomy, you see the meibomian glands. That marks the tarsus. You see the lashes here. Okay. So I’m trying just to cut the epithelium. There’s a little muscle. Epithelium again. Then muscle off of the tarsus. You can do this more or less, depending on how much tightening you want to do. Now, this is important: I don’t want to injure the tarsus, so I turn the scissors like this. Not like this. If I point the tips at the tarsus, they might injure the tarsus. So I point the tips away from the tarsus, and I push into the tarsus. What I’m gonna do is now cut the conjunctiva and lower lid retractors, and now you can see we have our tarsal strip. And this is a nice strip of tarsus. That’s why you call it a tarsal strip procedure. What I’m doing now is removing the epithelium from the tarsus. Now I’m gonna use cautery to stop any bleeding. So next I need to expose the lateral orbital rim. So what I’m gonna do: If you look here, you can see the orbicularis oculi muscles. I’m gonna go just posterior to the orbicularis oculi muscle. Sorry, I think my hand is gonna block your view. And then I spread. And you try to do this bluntly. Sometimes you have to do it a little bit sharply. But you try to do this bluntly. And with these scissors, they have a little curve to them. I want the curve away from the eye. Okay. So now we’re getting down… You can see there the periosteum. Right there to the bone. So now I want to check to see if my tarsal strip is the right size. If it needs to be shorter or longer. And so I’ll hold that to the bone. And then I’m going to see if I can pull it away. And there, that’s good. I like that. So I’m not gonna shorten it any. So this next part, where we secure the tarsal strip to the bone, I want to show you the needle. It’s very important to have a needle that curves 180 degrees. So it forms a half circle. That’s a 180-degree curved needle. What I want to do is go in, touch the periosteum, push down, push in, and grab like that. I’m gonna trim a little bit of the tendon off. So there’s a little bit of tendon. Tarsus ends here. Tendon starts here. I’m just cutting the tendon off. Now… I do this top corner. You want about a millimeter of tissue, all the way around your suture. A minimum of a millimeter. You want at least a millimeter of tissue. So what I do… I go down, I keep pointing up… It should come through. And then one thing is very important: Do you see the tip of my needle? I don’t let go of the back until I see the front. You don’t want to lose a needle. And then you can check to make sure you’re in bone. So you feel you’re in bone. I want this one 2 millimeters below the one that I placed. So tarsal strips are used in a lot of different surgeries we use. Not just ectropion. So both entropion and ectropion are in part the consequence of eyelid laxity or instability. And so with both entropion and ectropion, when you want to stabilize the eyelid, even though the eyelid is turning opposite directions, you use a tarsal strip to secure the eyelid. So to tighten this, I pull up, and then spread. So up, spread. I’m gonna put three throws in my knot. I grab hold, and I protect my knot, so my knot can’t be cut. So cut on top of the needle driver, please. And there. I protected my suture. Okay. Next we need to reform the canthal angle. In part to stabilize the eyelid, I want the tarsus from the upper lid sutured to the tarsus of the lower lid. Right here is the end of the tarsus. So I’m gonna remove the epithelium from right there, which is the lateral edge of the tarsus. I look here to see where that deepithelialized area is, and I want it to line up down there. And it’s almost — but I need to take a little more epithelium from here. So for this one, what I want to do is line up the epithelial edge. So this needle — it comes out just on the deepithelial edge of the epithelium, and I’m grabbing a little bit of tarsus there. And then what I want to do is go just where it’s deepithelialized. And this will reapproximate — it’ll give a sharp canthal angle. It also provides a little bit more support to the lower lid. I’ll take that 6-0 fast absorbing. I want to approximate the lash line. So I do a posterior lash line suture. Correspondingly over here. Now we do the anterior lash line. Now, sometimes you cut off these lashes, but because this gentleman has ectropion, I don’t want to remove any skin at all. And we’re not gonna cut off the lashes. Okay. And I am signing off. Thank you, everybody.

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September 15, 2019

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