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Upper and Lower Lid Internal Recession with Tarsal Graft Posterior Spacer

This video shows a combined upper lid internal recession and lower lid internal recession with placement of a tarsus posterior spacer graft in a patient with eyelid retraction due to thyroid eye disease.

Procedure: The procedure shown in this video is a combined upper lid internal recession and lower lid internal recession with tarsus posterior spacer graft in a patient with lid retraction secondary to thyroid eye disease. Introduction: Eyelid retraction can cause patient ocular discomfort and damage such as exposure keratopathy. Grafts can be effective in acting as a posterior spacer to increase lower eyelid length, but there are frequently negatives associated with different types of grafts, including infection and donor site complications. Using autologous tarsus posterior graft spacer can be a useful and effective technique that avoids some of the disadvantages associated with other graft materials. Indications/Contraindications: Indications for the procedure include eyelid retraction due to a variety of causes. Contraindications include general surgical contraindications as well as inadequate graft material, ocular surface contraindications, and inadequate anterior eye lamella. Materials/Methods: Standard eyelid surgical instrumentation was used. Results: Patient tolerated the procedure well with successful recession and resolution of his exposure keratopathy. Conclusion: Using an autologous tarsus posterior spacer graft can be an effective method for experienced surgeons to address lid retraction while avoiding risks associated with donor tissue.
The purpose of the combined upper lid internal recession and lower lid internal recession with tarsus posterior spacer graft procedure is to address complications of eyelid retraction, such as exposure keratopathy. Grafts can be used as a posterior spacer to support the eyelid, but most graft materials, including hard palate mucosa, scleral grafts, and synthetic implants have significant potential disadvantages (Wearne et al. 2004, Tan et al. 2001). Using an autologous graft from the tarsus is a relatively facile procedure for an experienced oculoplastic surgeon and can circumvent some of the adverse events associated with these other grafts. Indications for this procedure include patients with eyelid retraction due to a variety of causes, including thyroid eye disease, post-enucleation socket syndrome, and secondary to trauma or surgery. Contraindications include general surgical contraindication, such as bleeding or clotting disorders, and specific contraindications, which include inadequate tarsus for graft, inadequate anterior lamella of eyelids, and ocular surface contraindications such as inferiorly placed tube shunts. Potential complications and risks include loss of vision, diplopia, hemorrhage, infection, and corneal abrasion. Additionally, there is always a risk of upper lid re-retraction after recession procedures in thyroid eye disease.
Setup: Standard eyelid surgical instrumentation is used for this procedure. Preoperative workup: A complete eye exam, including slit lamp biomicroscopy, and evaluation and measurement of eyelid position and function should be performed. Anatomy and Landmarks: This procedure requires an intimate understanding of eyelid anatomy. Procedure Steps: 4-0 silk traction sutures are placed through the margins of the left upper and lower eyelid. The left upper eyelid is everted, and a caliper is used to measure 4 mm from the margin, which is then marked with a 15 blade. The 15 blade is then used to incise across these points. Wescott scissors are used to dissect between the tarsal graft and Mueller’s muscle, and are subsequently used to transect the attachments of the tarsal graft to the levator and excise the graft. Mueller’s muscle is dissected from the levator in standard left upper lid recession until it is adequately released.  The left lower eyelid is everted, and Wescott scissors are used to make a conjunctival incision 3 mm inferior to the tarsus across the lower eyelid. Not pictured in this video, but a 4-0 silk suture is placed through the conjunctiva for traction. The scissors are used to complete the conjunctival incision and further dissect along this plane to create a bed for the graft. The graft is then placed in this bed so that the conjunctival side is against the lower lid conjunctiva. The superior edge of the tarsal graft is sutured partial thickness to the left lower lid tarsus in a running fashion with 6-0 plain gut. The inferior edge of the graft is sutured to the conjunctiva of the recipient bed in a running fashion with the same 6-0 plain gut. Corneal protectors are removed, and upper and lower tarsal silk sutures on the left side are then tied to one another. Antibiotic ointment is applied and a light pressure dressing should be placed for three days.  
The primary aim of the combined upper lid internal recession and lower lid internal recession with tarsus posterior spacer graft procedure is to improve upper lid and lower lid elevation. This can be assessed post-operatively through measurements of lagophthalmos, marginal reflex distance, and scleral show inferior to the limbus. Ideal positive results are elimination of lagophthalmos, improvement of marginal reflex distance (MRD) to normal values between 4 and 5 mm, and improvement of scleral show inferior to the limbus. Of note, this patient did not have lagophthalmos prior to the operation, which remained consistent post-operatively, but scleral show was significantly improved. Potential negative outcomes include lack of improvement or worsening of the above measures, continued exposure keratopathy, pain, need for additional surgeries and post-operative complications, including bleeding and infection.
The combined upper lid internal recession and lower lid internal recession with tarsus posterior spacer graft procedure is a useful procedure to address eyelid retraction. Critical steps to distinguish this procedure from the standard upper and lower eyelid internal recession are adequate graft excision in the upper lid, careful dissection between the conjunctiva and the tarsus of the lower lid to create a bed for the graft, and suturing of the superior edge of the graft to the tarsus and then the inferior edge of the graft to the conjunctiva. Advantages of this procedure include avoidance of cutaneous incision, rapidity and ease of the procedure for surgeons familiar with eyelid anatomy, and excellent durability of lower lid position. Autologous tarsal graft avoids risks associated with donor tissue or synthetic grafts. Of note, use of the autologous tarsus avoids the increased risk of viral pathogens associated with scleral grafts, donor site morbidity such as hemorrhage and pain associated with hard palate mucosa grafts (Wearne et al. 2001), and implant exposure, pain, and poor eyelid mobility on downgaze associated with synthetic implants (Tan et al. 2004). Although there are significant advantages associated with his technique, there are also limitations. The primary limitation of this procedure is that it must be performed by an experienced surgeon with in-depth knowledge of eyelid anatomy and surgery, which may be challenging for new trainees and surgeons. Furthermore, although this technique has been effective for this patient with thyroid eye disease, more data is needed to adequately assess usefulness and applicability of the procedure in patients with lid retraction due to other causes. Combined upper lid internal recession and lower lid internal recession with tarsus posterior spacer graft procedure is a promising technique to address eyelid retraction but requires further study.
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Tan, J., Olver, J., Wright, M., Maini, R., Neoh, C., & Dickinson, A. J. (2004). The use of porous polyethylene (Medpor) lower eyelid spacers in lid heightening and stabilisation. British journal of ophthalmology, 88(9), 1197-1200. Wearne, M. J., Sandy, C., Rose, G. E., Pitts, J., & Collin, J. R. O. (2001). Autogenous hard palate mucosa: the ideal lower eyelid spacer?. British journal of ophthalmology, 85(10), 1183-1187.

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