Minimal lower eyelid epicanthoplasty combined with thermal contraction to treat epiblepharon in chinese children

Epiblepharon frequently occurs in Asian children. This condition is characterized by a medial skin fold extending over the upper and lower eyelid margins, thereby causing the eyelashes to contact the cornea without abnormalities of the tarsal plate and eyelid position [1, 2]. Epiblepharon may spontaneously resolve with age due to facial bone growth and altered balance of eyelid tension. However, surgical repair is indicated in subjects with persistent keratopathy or symptoms of irritation. Several methods have been used for epiblepharon repair, with bracing sutures and the Hotz procedure being the two most popular. Recurrence rates in these procedures can be as high as 29% for bracing sutures and as low as 9% using the modified Hotz procedure [3‐5], so it is important for surgeons to understand the factors contributing to high recurrence. The most likely factor may be the presence of epicanthal folds (EFs) in the Asian population [6, 7]; in our clinical experience, bracing sutures or the modified Hotz procedures leave uncorrected epicanthal folds which push the medial eyelashes against the cornea (Fig. 1). In recent years, surgeons who have adopted epicanthoplasty to treat epiblepharon have reached the consensus that the epicanthus not only influences appearance, it also prevents the restoration of lower eyelid balance for patients with epiblepharon. EFs should be considered as a tension imbalance of the lower eyelid which needs to be consistently corrected. Epicanthoplasty for epiblepharon repair may address the tangential cause of the medial EFs. However, few studies on this approach have been conducted in China, and a challenge remains to design surgical techniques that avoid scar formation and changes in appearance. We developed a simple method of minimal lower eyelid epicanthoplasty combined with thermal contraction to eliminate the lower eyelid EF without significantly changing the whole eyelid. Here we describe both the surgical procedure and outcomes in a series of Chinese children.

This study is a retrospective analysis of minimal lower epicanthoplasty combined with thermal contraction to correct epiblepharon in children. The procedures were conducted between January 2017 and August 2020 by a single surgeon (author SH) in the Ophthalmology Department of Beijing Children’s Hospital, Capital Medical University, Beijing, China. The indication for surgery was the presence of marked superficial punctate keratitis on fluorescein staining.

The present report follows the Preferred Reporting of Case Series in Surgery (PROCESS) guidelines [8]. We confirm that the current research was carried out in accordance with the principles of the Declaration of Helsinki and applicable local regulations. The study was approved by the Medical Ethics Committee of the First Affiliated Hospital of Nanchang University. Informed consents to participate in the surgery were obtained from the children’s parents.

Lower eyelid epiblepharon severity was graded according to Khwarg’s 1 to 4 classification system based on preoperative skin fold height (Fig. 2) [9].

Surgery was performed under general anesthesia. The following two techniques were used: minimal lower eyelid epicanthoplasty and thermal adjustable rotation of the lid margin. Incision design and the release of tension on the lower epicanthus are the most critical aspects of this surgery.

After induction of general anesthesia, the lower eyelid surgery line was drawn 1.5 mm below the lash line, beginning at the inner medial epicanthus and extending to the temporal limbus (Fig. 3a-1, a-2). When the nasal skin is pulled medially to allow exposure, point A may be defined as the initial incision point, marked on the EFs along the epicanthus line at the level just above the caruncle. An oblique line was drawn medially from point A in an inferonasal direction to point C; the angle of line AC was ~ 45° (Fig. 3a-1, a-2), and the length to point C was ~ 1.5 mm. Schematic diagrams (Fig. 3b-1) and Fig. 3b-2 show the incision’s natural appearance under general anesthesia. Point B was marked on the lower eyelid incision line where the subciliary line met line AB, which was on the posterior surface of the medial canthal fold and was of the same length as AC. The final shape of the ABC markings shown in Fig. 3c resembling a triangular fish tail is based on a previous publication [10] with some modifications. Local anesthesia was administered using 1% xylocaine with 0.001% epinephrine to decrease bleeding. One piece of superficial orbicularis was carefully excised to expose the tarsal plate after cutting through the skin. The malpositioned orbicularis oculi muscle fibers underneath the EFs were then removed to decrease tension until the dissection depth reached the medial canthal tendon (Fig. 4a). Release of tension crossing the medial epicanthus usually normalizes the balance of the lower eyelid, to decrease the contractions of the skin which invert the eyelash to contact the eyeball.

After exposing the medial canthal tendon, we used a needle monopolar cautery instrument (Peng’s multifunctional operational dissectors; Shuyou Medical Equipment Co., Ltd, Zhejiang, China) with power set to 5–10 W at a contraction duration of 0.5 s/point until sufficient lash eversion was reached. Adhesions between the lower eyelid retractor and tarsus were created by thermal cauterization contraction [11]. The area of thermal contraction was proportional to the severity of lash inversion (Fig. 4b). If the eyelid lashes were not sufficiently rotated, additional thermal contraction was applied to the tarsus approximately 3–4 mm below the lid margin (Fig. 4c). To open the lower angle of the medial canthus, we sutured the residual edge (point B) to the point C (the most medial point) of the lower epicanthus (Fig. 4e and f). The first suture on the epicanthus was in the inferonasal direction (Fig. 4g) and the skin was closed using interrupted 7 − 0 nylon sutures (Fig. 4h), after the excess skin overlying the lower lid surgical line was precisely and carefully resected. Postoperatively, tobramycin antibiotic ointment was applied to the incision for two weeks until the sutures were removed.

Surgical success was defined as an absence of medial ciliary contact. Under-correction was defined as ciliary contact with only the medial conjunctiva one week after surgery. All the postoperative assessments were performed in an outpatient setting. Each patient was carefully monitored for surgical complications. The post-surgical result was observed using slit lamp examination. All patients received frontal and Lateral view photographs at pre-operative and each postoperative visit (1 month, 3 months, and 6 months after the surgery). The curvature of the lid margin and inner canthus and postoperative scarring were evaluated at the same time. Vancouver scar scale (VSS) scores were collected through clinical analysis by three independent doctors, to evaluate the incisional scars in the area of the lower eyelid and medial canthus.

Refraction and best-corrected visual acuity were measured pre- and at six months post-surgery. Refractive error was determined by cycloplegic retinoscopy, which was performed by retinoscopist in dim room light with a streak retinoscope, at least 30 min after instillation of 1% cyclopentolate hydrochloride using punctal occlusion with an interval of 10 min.