Response to comment on: Upper eyelid levator-recession and anterior lamella repositioning through the gray-line - Avoiding a skin-crease incision.

Sir,

We thank the authors[1] for their interest toward our article[2] and insightful points raised. The main pathology for meibomian gland inversion in patients with facial nerve palsy is meibomian gland dysfunction. This has been demonstrated to progress on the ipsilateral side in facial palsy based on meibography in at least two studies.[34]

With regard to upper eyelid retraction, in many patients with upper eyelid cicatricial margin entropion, upper eyelid retraction may appear variably when the patient visually concentrates on a target in primary position and also be concealed by the upper eyelid skin fold. In such patients, we deliberately aim for a mild ptosis both to anticipate for late rise in eyelid height and also for the benefit in dry eye. We agree with your hypothesis that a levator recession is essential in most cases of upper eyelid cicatricial margin entropion in order to minimize incomplete correction or early failure. These cases often require multiple procedures due to ongoing cicatricial disease. This may also explain the relatively high rate of revision surgery in most of the published series.

Trichiasis is often due to metaplastic lashes in the presence of cicatricial margin entropion. We would not label lash contact as a result of anterior lamella droop being trichiasis.

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