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Lower Lid Epiblepharon

INTRODUCTION Epiblepahron is a congenital bilateral condition in which the anterior skin-muscle lamella of the eyelid rides up over the eyelid margin, turning it inward toward the globe. While this simulates entropion in appearance and consequences, it is quite different in its etiology. Epiblepharon is caused by the absence of the lower eyelid crease and the fascial attachments that unite together the anterior and posterior lamellae at that point. With contraction of the orbicularis muscle the anterior lamella rides upward over the lid margin, rotating the lashes inward. The entropion is typically worse in downgaze. Epiblepharon is more common in the Asian eyelid, especially when there is significant epicanthus, and in those with a high body mass index.

CLINICAL CHARACTERISTICS Epiblepharon appears as a redundant horizontal fold of pretarsal skin and orbicularis muscle that extends upward over the lower lid margin and lash line. In some patients the lid may appear completely normal in primary gaze, with the condition developing only on downgaze. In more severe cases the condition is manifest even in the primary gaze position. The overriding skin mechanically displaces the lash-bearing mucocutaneous border backward against the cornea. Symptoms include foreign body sensation, irritation, and reflex epiphora. More than half of affected children will have a with-the-rule astigmatism. However, up to 80% of affected children may have minimal or no ocular symptoms. Epiblepharon can also be seen as an acquired condition following trauma or surgery where there is disruption of fascial attachments between the anterior and posterior lamellae. It has also been described as a finding in Graves' eye disease. Rarely epiblepharon can be seen in the upper eyelid as a developmental anomaly.

TREATMENT In many cases epiblepharon resolves spontaneously by the age of six or seven years, as the face elongates with growth. Treatment may be required, however, for significant ocular symptoms. This can be achieved in young children with the placement of full-thickness eyelid sutures of the Quickert-Rathbun type. This creates a scar band between the anterior and posterior lamellae that simulates the normal eyelid crease. In older children or where the fold is large, excision of an ellipse of skin with reformation of the crease will give better results.


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