Cicatricial upper and lower eyelid ectropion in an ichthyosis patient. Surgical correction

Ophthalmic findings in patients with autosomal recessive lamellar ichthyosis due to TGM1 mutations in an isolated population

PURPOSE

To describe the ocular clinical characteristics of a group of Mexican patients with lamellar ichthyosis (LI) arising from TGM1 pathogenic variants.

METHODS

Ophthalmological exploration, pedigree analysis and genetic screening were performed in patients with an established clinical diagnosis of lamellar ichthyosis from families located in a small community in the Southeast of Mexico.

RESULTS

Nine patients with LI in five families were identified. There were six affected females. All patients (9/9) demonstrated eye lid abnormalities with eight patients showing lid margin abnormalities. Madarosis was present in only three individuals and corneal scarring was documented in two. All nine individuals carried biallelic TGM1 variants, either homozygously or as compound heterozygous.

CONCLUSION

Ocular anomalies are common in individuals with TGM1-related LI. The occurrence of a variety of private or rare mutations hampers the identification of a genotype-phenotype correlation for ocular anomalies in this disorder.

Treatments for Non-Syndromic Inherited Ichthyosis, Including Emergent Pathogenesis-Related Therapy

The term 'inherited ichthyosis' refers to a heterogeneous group of mendelian disorders of cornification that involve the integument with varying degrees of scaling. The management of ichthyosis poses a challenge for most physicians. Treatment options proposed in the literature include moisturizers, topical keratolytics, topical and systemic vitamin D analogues, and topical and systemic retinoids; however, some of these modalities are less reliable than others. Despite the therapeutic impasse imposed by the options above, the emergence of pathogenesis-based treatments along with novel gene therapies appear promising and hold the potential to halt or even revert disorders that arise from single genetic mutations, although research is still quite lacking in this domain. Hence, this review aims to highlight the various treatment modalities available for the management of the cutaneous manifestations of non-syndromic inherited ichthyosis, with an added emphasis on pathogenesis-targeted therapies.

A Patient With Traumatic Upper Eyelid Ectropion and Their Management by Canthopexy

ABSTRACT

Upper eyelid ectropion is rare. When it does occur, the cicatricial subset of upper eyelid ectropion is its most common manifestation. Due to its rarity, little has been published regarding its treatment. Herein, we present the case of a 27-year-old patient who suffered significant left sided facial trauma in a high-velocity motor vehicle accident, resulting in a soft tissue defect in the left lateral supra-orbital region, including loss of the lateral half of the left eyebrow. The defect was left to heal by secondary intention causing severe cicatricial upper eyelid ectropion. Several reconstructive techniques were subsequently utilized including recreating the defect and replacing like with like tissues according to the facial sub-units. Right sided upper eyelid skin was used to replace the deficient left upper eyelid skin and a scalp composite graft was harvested to replace the deficient left lateral eyebrow. Temporary tarsorrhaphy, and steroid injections were used on multiple occasions to counteract the cicatricial forces. Ultimately, permanent lateral tarsorrhaphy and upper eyelid canthopexy was needed to obtain a satisfactory functional and cosmetic result.

Unilateral upper eyelid eversion and kink associated with epidemic keratoconjunctivitis

Purpose

Upper lid eversion in adults from non-cicatricial causes is rare. We report a case of upper eyelid eversion secondary to epidemic keratoconjunctivitis (EKC).

Observations

A 37 year-old female presented with unilateral upper lid eversion. Known for left upper lid ptosis repair in childhood, the patient presented with seven-day history of severe bilateral conjunctivitis and eversion of her left upper lid three days prior. On exam, she had follicular conjunctivitis, punctate epithelial keratopathy with subepithelial infiltrates and membranes bilaterally, with an everted upper lid tarsus, and swollen and ulcerated palpebral conjunctiva. She received topical and oral prednisone to quickly reduce the inflammation, as well as moxifloxacin drops and lubrication. When the swelling subsided, the tarsus adopted a kinked and everted configuration, and was managed successfully with reversion, pressure patching, shielding and close follow-up.

Conclusions and Importamce

This is the first reported case of upper lid eversion secondary to EKC, likely due to sudden marked inflammation and edema of the posterior lamella caused by the adenoviral infection. This case was successfully managed with conservative therapy.

Successful correction of ichthyosis-related ectropion by autografts

Ectropion is a rather frequent complication of ichthyosis with negative functional and esthetic impact. Lid surgery can provide significant improvement. We report on a series of four ichthyosis patients with ongoing bilateral eye problems despite intense medical treatment (mean age 27.8 ± 14.1 years). All patients suffered from lagophthalmos. Two of the patients had only lower lid ectropion. In two of the patients' ectropion was forming on the upper lid in addition to the lower lid when closing the eye. In three of four patients, ectropion was repaired by skin grafts from the supraclavicular region. In a child with lower and upper lid ectropion prepuce was used for repair surgery. At the end of the follow-up period of about 23.0 ± 12.7 months, none of the patients revealed lagophthalmos or corneal exposure. No intraoperative or postoperative complications have been observed in our patients. Ichthyosis patients with ectropion resistant to medical treatment, benefit from surgical treatment with full layer autografts. In boys, prepuce can be successfully used as autograft.

Approach to treatment of cicatricial ectropion: a systematic review and meta-analysis comparing surgical and minimally invasive options

Cicatricial ectropion can involve the skin, subcutaneous tissue, muscle, and septum to result in chronic tearing and keratopathy. Surgery involving the orbital rim or eyelid is a common cause. Minimally invasive techniques may provide alternative options for correction, but the comparative benefit to surgery is unknown. To compare the efficacy of surgical and minimally invasive minimally invasive treatment options for cicatricial ectropion. A comprehensive literature search of Medline, EMBASE, and the Cochrane Library published from 1960 to August 2019 was performed for studies that described any treatment of cicatricial ectropion. 1391 studies were found, of which 31 had extractable data for 299 patients. Pooling of outcome data occurred for the primary and secondary outcomes. The complete and partial response rates to treatment (primary outcomes) as well as the recurrence rate and physician global assessment of cosmesis (secondary outcomes) were analyzed. Surgical correction resulted in complete correction in 79% of patients compared to 63% of hyaluronic acid treated patients. Hyaluronic acid injection had a better aesthetic outcome, but a higher recurrence rate overall. Hyaluronic acid filler with a high G' along with delayed dissolution trended toward a lower recurrence rate. Other minimally invasive treatments had little data. The literature found was limited to mostly single-center, observational studies. Hyaluronic acid may be a viable alternative for cicatricial ectropion in those patients who cannot undergo surgery. Further prospective studies are required to routinely recommend minimally invasive techniques.

Non-surgical management of congenital ichthyosis using hyaluronic acid gel injection

AIM

To test if hyaluronic acid gel injection in the upper eyelid achieves correction of congenital cicatricial ectropion and reduction in lagophthalmos, in preparation for intraocular surgery.

METHODS

This case reports the long-term outcome of hyaluronic acid gel injection in the upper eyelid for the correction of ectropion prior to cataract surgery. One millilitre of hyaluronic acid gel was injected in both the upper eyelids of a child with congenital ichthyosis in the suborbicularis plane, prior to cataract surgery.

RESULTS

Lagophthalmos reduced by 15 mm in the right eye and 13 mm in the left eye. Subsequently, the child underwent cataract surgery without any complications.

CONCLUSION

We demonstrate the long-term outcome of using hyaluronic acid gel injection for successful, non-surgical correction of cicatricial ectropion in ichthyosis.

Ocular manifestations, complications and management of congenital ichthyoses: a new look

Congenital ichthyoses (CI) are rare genetic skin keratinisation diseases characterised by generalised scaling and a variable degree of erythema and hyperkeratosis. Ocular involvement includes the eyelids, conjunctiva and all layers of the cornea. Ophthalmic input should include regular slit lamp review with the primary aim to prevent a corneal epithelial defect, secondary bacterial infection, scarring or perforation. This review highlights the current literature regarding ophthalmic findings and management of CI.

Topical tazarotene for the treatment of ectropion in ichthyosis

IMPORTANCE

Ectropion is a complication of certain subtypes of ichthyosis and is often associated with substantial medical and cosmetic consequences. At present there is no standard of care for the treatment of ectropion in this population. Retinoids cause dyshesion and thinning of stratum corneum, thereby reducing hyperkeratosis that likely underlies ectropion in patients with ichthyosis. As such, retinoids provide a potential effective treatment for ectropion in this group of patients.

OBSERVATION

We describe a patient with recessive ichthyosis for whom daily application of topical tazarotene produced rapid and persistent improvement of bilateral lower eyelid ectropion without adverse effects.

CONCLUSIONS AND RELEVANCE

Additional studies will be necessary to more fully and systematically address the safety and efficacy of topical retinoids for the treatment of ectropion in patients with ichthyosis; however, this case illustrates that topical tazarotene and other retinoids provide a potential treatment option for ectropion in this population. We encourage clinicians to explore medical therapies as alternatives to surgical intervention for the treatment of ectropion in patients with ichthyosis.