Ectropion is a common disorder encountered in the clinic, and its early and adequate management is of utmost importance. Repair of involutional ectropion remains a challenge in oculoplastic surgery. Depending on its etiology and the underlying pathology, a variety of surgical procedures are described (14). The close position of MCT and orbicularis muscle with the canaliculi and lacrimal apparatus is an alarming point for surgeons in ectropion repair, as complex surgical procedures with medial eyelid resection may sacrifice medial lower eyelid tissue with disruption of the lacrimal system that may interfere with functional and cosmetic success (15, 16).
In this study, we described the effect of argon laser on lower medial palpebral conjunctiva in early cases with grade ≤2 MCT laxity. This technique aims to create a firm conjunctival scar below the lower punctum, sparing the canaliculus. This technique aims to create a firm conjunctival scar below the lower punctum, sparing the canaliculus to reverse scar everted punctum to normal position.
Jordan described current techniques for MCT laxity repair as technically difficult and do not always achieve a satisfactory outcome. These techniques only aim at firm medial fixation with little consideration to fine anatomical and physiological details of the medial canthus. Due to the hazards associated with these procedures, most surgeons avoided early MCT repair, and surgery may be delayed until the MCT laxity become advanced (16)
In our study, we used an objective measurement for evaluation correction of punctual eversion in the form of decrease of tear film meniscus measured by image j software. It is considered a unique method as none of the previous literature mentioned objective documentation of amelioration of symptoms after correction of ectropion. In this study also, we correlate the objective data in the form of tear film meniscus level with patient satisfaction after amelioration of epiphora.
There was a highly significant difference between values recorded before and after argon laser intervention regarding the height of tear film which was found to be significantly lower after the intervention compared to before it (81.1 versus 193.1 respectively). The more the degree of reduction of tear film height the more the satisfaction of patients.
To our knowledge, using of argon laser without excision of tissue, or the use of full-thickness everting sutures has not been described before. While, in their retrospective consecutive case series performed over 6 years in medial ectropion with moderate to severe medial canthal tendon laxity, Vahdani K and Thaller VT described MCT as an adjunctive procedure to standard surgery for correcting their eyelid malposition that included lateral Bick’s shortening ± medial retractor plication. Strong diathermy was applied with bipolar forceps, avoiding the canaliculus to whiten the conjunctiva and underlying Horner’s muscle. They concluded that MCT only stabilizes the medial canthus in treated cases, so it must be combined with an eyelid shortening procedure if significant laxity persists (9)
Medial lower eyelid ectropion with mild to moderate degree of MPL (Medial Palpepral Ligament) laxity is corrected with horizontal eyelid shortening procedures such as retro-punctal cautery, lazy-T procedure, medial spindle, and resection of the posterior lamellar flap. These procedures can be augmented by horizontal eyelid tightening using a lateral tarsal strip or a full-thickness pentagonal resection (17)
Medial spindle surgery involves the excision of a diamond shaped part of the conjunctiva and retractors with the sutures tied anteriorly on the skin (18). The lazy-T technique, described by Byron Smith in 1976, is another option for the treatment of medial ectropion of the lower lid. Both Horizontal and vertical eyelid shortening is achieved by full-thickness excision of a portion of the lower lid as well as the posterior lamella in a sideways (19). Both of these procedures are invasive and involve the excision of part of posterior lamella tissue to achieve inversion of the eyelid. However, the procedure described in our study is less invasive and can achieve the same effect.
In Goel and colleges study they noted that at 1 year follow up anatomical success was achieved in 28 (90%) patients and functional success in the form of the disappearance of epiphora was noted in 27 (87%) patients after lower eyelid suspension using polypropylene suture for the correction of punctal ectropion. They also mentioned that results did not correlate to the type of laxity nor the degree of ectropion (20). Raus and colleges concluded that repair of early to intermediate ectropion of the lacrimal punctum using the Raus–Garito clamp has a good functional and cosmetic outcome (21)
Argon laser on the lower medial palpebral conjunctiva has many advantages. It is a simple, easy, and quick technique that can be performed under topical anesthesia in the outpatient clinic. Furthermore, it is minimally invasive (non-incisional) and avoids excision of any part of the posterior lamella or conjunctiva. Unlike medial canthal resection procedures, it is safe for the canalicular and the lacrimal system with no risk of trauma or injury.
Limitations of the current study were the inclusion of only patients with no or early MCT laxity study. Advanced cases with punctal eversion more than grade 2 were not included. Further studies including these cases with more patients and a longer duration of follow-up are needed.