8.1 Goals

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  Epiblepharon is when a horizontal fold of redundant skin and the orbicularis oculi muscle push against the eyelashes and tilt them toward the globe (Fig. 8‑1a). ¹

  
  
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  Other possible contributing factors include a failure of the lower eyelid retractors to make contact with the skin, or a failure of interdigitation of septae in the subcutaneous plane. ^{2 ,​ 3}

  
  
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  A weak attachment of the pretarsal orbicularis muscle and skin to the tarsal plate can also lead to a redundant skin muscle fold that pushes the eyelashes against the cornea.

  
  
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  Hypertrophy of the orbicularis oculi muscle is also thought to be a possible etiologic factor. ⁴

  
  
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  These contributing factors should be addressed in order to correct lower lid epiblepharon. ⁵

  
  
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  In the presence of epiblepharon, the cilia ocular surface contact can lead to corneal and conjunctival complications (e.g., punctate epitheliopathy and abrasions on the cornea and conjunctiva) and in severe cases it may even lead to scar and pannus formation on the cornea.

  
  
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  The aim of epiblepharon repair is to externally rotate the row of lashes to prevent cilia-ocular surface touch and the complications that arise from it.

  

8.2 Advantages

Epiblepharon repair will correct or minimize cilia-ocular surface contact, ocular surface irritation, and erosions.

8.3 Expectations

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  The surgery should provide eversion of the lashes to prevent cilia-ocular surface contact.

8.4 Key Principles

The key principles in epiblepharon correction are to correct the vertical misdirection of the lashes by debulking the pretarsal orbicularis oculi muscle, removing the redundant skin, and providing tarsal fixation of the lash bearing pretarsal skin and orbicularis oculi flap.

8.5 Indications

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  In a study conducted in Japan, the incidence of epiblepharon in newborns was 46% and this decreased to 2% by 12 years of age. ⁶ It has been well described that most children will outgrow this condition and hence the decision to proceed with surgery should depend on the patient’s age and the severity of symptoms and clinical signs of ocular surface complications.

  
  
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  These should be weighed against the risks of surgery.

  
  
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  The symptoms that are frequently encountered include eye redness, epiphora, irritation, photophobia, and discharge.

  
  
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  On clinical examination, the presence of cilia-ocular surface touch should be assessed in both primary gaze and downgaze (Fig. 8‑1b).

  
  
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  The horizontal extent of the lower eyelid where the lashes are in contact with the ocular surface should be noted as this would guide the surgeon on where to focus the surgical correction (medial, central, or lateral).

  
  
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  The presence of a prominent medial epicanthal fold and its relation to the lashes in the medial aspect of the eyelid should also be recorded (Fig. 8‑2).

  
  
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  The ocular surface must be assessed for cornea and conjunctival punctate epithelial erosions, abrasions, infectious keratitis, scars or Salzmann nodules, and pannus formation. This can be further documented with the help of fluorescein staining of the ocular surface.

  
  
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  If the patient is symptomatic and/or clinical signs of ocular surface compromise are documented, they can be offered the option of surgical correction of the epiblepharon.