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Response to Professor Bajaj
Submit responseDear Editor
We read with interest the comments of Professor Bajaj and colleagues and wish to respond to the points raised as follows.
Firstly, we are in complete agreement that the horizontal laxity of the eyelid should be evaluated pre-operatively and indeed this was done. This led to the necessity for 9 of the patients (28%) to undergo primary adjunctive procedures as stated in the article. Indeed 12 adjunctive procedures were performed on 10 eyelids of these 9 patients, emphasising the importance of this aspect.
Concerning the fixation of the implant and the risk of posterior migration, none of the authors has any experience of using Prolene or another non-absorbable suture in this context; we therefore cannot comment on whether this reduces the tendency to upward or forward migration of the superior aspect of the plate and are unaware of any data on this. We would however make the observation the posterior slippage allowed by incising the orbital septum is a desirable effect to improve lid motility on downgaze, and not an effect that we would wish to reduce. However, we suspect that this effect is not dependent on the type of fixation between the tarsus and the superior aspect of the Medpor plate.
Regarding the subset of patients with previous hard palate or donor sclera, it was not our experience that these eyelids were more likely to have a poor outcome, however as only 2 eyelids fell into this subset, then we do not have the data to comment further on this point.
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A Perspective on Porous Polyethylene Lower Lid Spacers
Submit responseDear Editor
We read with interest the article on the use of Medpor lower eyelid spacers by Tan et al. [1]. The article critically evaluates the utility of this type of a spacer for retraction of the lower lid. We would like to raise a few pertinent issues which may assist in a better understanding of this challenging entity.
In this article, the authors have not included the assessment of horizontal lid laxity in their preoperative evaluation of patients. Preoperative assessment of horizontal lid laxity and the integrity of the Canthal tendons is vital for deciding the adjunctive procedure to be undertaken. This could be in the form of a lid shortening procedure or strengthening of the canthal tendons, which should ideally be performed along with the primary procedure [2]. Otherwise the desired effect of placing a spacer may not be achieved. Moreover, if it is done as a secondary procedure, it may be complicated as it may need to be combined with implant trimming or exchange.
Further, it has been mentioned in the article that the orbital septum was incised to allow the implant to slip behind the orbital rim in downgaze, in cases where lid dynamicity was required. Here it needs to be emphasized that extra care should be taken for securely fixing the implant to prevent its posterior migration, which could lead to a host of undesirable sequelae. We suggest that a non-absorbable suture with good tensile strength such as Prolene should be used for fixating the implant to the lower border of the tarsus. This would ensure a more permanent and stable fixation and minimize the chances of extrusion or migration of the spacer.
The authors have mentioned that some patients had had previous procedures such as hard palate and scleral spacers to correct lower lid retraction. It is a common clinical experience that a second or subsequent surgery is usually associated with a multitude of poor prognostic factors. It would be very interesting to know if the authors encountered any special problems in this subset of patients due to prior cicatrization or increased weight and thickness of the lower lid which could reduce the effectiveness of the Medpor spacer.
References
(1) Tan J, Olver J, Wright M, Maini R, Neoh C, Dickinson AJ. The use of porous polyethylene (Medpor) lower eyelid spacers in lid heightening and stabilisation. Br J Ophthalmol. 2004 Sep;88(9):1197-200.
(2) Patel BC, Patipa M, Anderson RL, McLeish W. Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip. Plast Reconstr Surg. 1997 Apr;99(5):1251-60
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