The role of enophthalmos in involutional entropion

Complete Preservation of Orbital Fat by Restoration of Attenuated Orbital Septa Using an Acellular Dermal Matrix in Lower Blepharoplasty

BACKGROUND

We hypothesized that application of acellular dermal matrix (ADM) over the orbital septum overlying the herniated orbital fat to tighten and strengthen the attenuated orbital septum in lower blepharoplasty would allow successful repositioning of the herniated orbital fat within the bony orbit.

METHODS

The author prospectively compared the cosmetic outcomes of lower blepharoplasty using ADM with standard blepharoplasty. We evaluated recurrence of eyelid bulging and tear trough deformity, volume of the lower periorbital region, and enophthalmos and eyelid droop 1 year after surgery.

RESULTS

Twenty-two of the 24 enrolled patients completed the study. There was no significant difference in recurrence of eyelid bulging and tear trough deformity between standard blepharoplasty and blepharoplasty with ADM graft groups. In the standard blepharoplasty group, the volume of the lower periorbital region decreased significantly after surgery. In the blepharoplasty with ADM graft group, there was no significant change in the volume of the lower periorbital region after surgery. In the standard blepharoplasty group, there was no significant change in eyelid droop on either side after surgery. In the blepharoplasty with ADM graft group, the eyelid droop decreased significantly after surgery on the right side but showed no significant change on the left side. There was no significant change in enophthalmos after surgery for either group.

CONCLUSIONS

This study demonstrated that ADM graft provided effective support for maintaining the replaced orbital fat in lower blepharoplasty. In the long-term, blepharoplasty with ADM graft might be effective in slowing development of age-related enophthalmos.

LEVEL OF EVIDENCE IV

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The Spectrum of Aesthetic Canthal Suspension

Aesthetic canthal suspension can be an effective adjunct to lower eyelid blepharoplasty. Understanding the anatomy and function of the lateral canthal tendon is critical for preoperative evaluation and surgical decision making. In this article, the authors discuss the lateral canthal terminology, anatomy, and aging changes. Various canthal suspension procedures, including open and closed canthal suspension, commissure sparing open canthoplasty, and canthopexy, are described. Finally, the preoperative evaluation, postoperative course, and complications of surgery are reviewed.

Assessment of the Safety and Efficacy of Prolapsed Orbital Fat Resection During Involutional Entropion Repair

PURPOSE

To assess the recurrence rate of involutional entropion in patients treated with a combined approach including a modified Bick procedure, excision of preseptal orbicularis muscle, and conservative resection of prolapsed orbital fat.

METHODS

A retrospective chart review of patients undergoing repair of involutional entropion with the combined procedure including orbital fat resection and a second group with standard entropion repair without orbital fat resection was performed. Only patients with follow-up greater than 6 months were included in the study.

RESULTS

Seventy eyelids of 54 patients met all inclusion criteria for the combined procedure group over a 9-year period from 2008 to 2016. Average follow-up was 46.9 months. There was a documented recurrence of entropion in 1 eyelid during the follow-up period (1.4%). The remaining 69 cases had successful subjective and objective results without need for any additional procedures. In the group undergoing entropion repair without fat resection, 22 eyelids of 19 patients had the required follow-up period with a recurrence rate of 4.5% (p > 0.05).

CONCLUSIONS

The authors demonstrate good surgical success with a combined approach of a modified Bick procedure, preseptal orbicularis excision, and conservative orbital fat resection. Conservative fat resection during entropion repair was found to be safe, and the combined procedure was found to be effective with a rate of recurrent entropion of 1.4% on extended follow-up.The authors propose that orbital fat prolapse contributes to the mechanics of involutional entropion and that conservative orbital fat resection during surgical repair of entropion can be done safely, resulting in low recurrence rates.

Age-related Changes in Globe Position

PURPOSE

To longitudinally evaluate for changes in globe position as part of the natural aging process.

METHODS

A Cleveland Clinic Foundation imaging database of all head imaging scans performed from 1995 to 2017 was used to identify adults with normal orbits undergoing imaging studies at least 20 years apart. A total of 100 patients (200 globes) who had CT or MRI scans were studied. Globe position was determined by measuring the distance from the anterior aspect of the cornea to the zygomaticofrontal processes baseline. Clinically significant changes in globe position were defined as changes of ≥2 mm posteriorly (enophthalmos) or anteriorly (exophthalmos).

RESULTS

On average, globe projection decreased by 0.25 ± 2.3 and 0.26 ± 2.2 mm in the right and left eyes, respectively. Clinically significant enophthalmos with age was measured in 55 (27.5%) globes in 35 (35%) individuals, while clinically significant exophthalmos with age was measured in 43 (21.5%) globes in 26 (26%) individuals. The proportion of cases that developed enophthalmos, exophthalmos, or experienced no change were not significantly different from each other (p = 0.26). No patients developed clinically significant enophthalmos in one eye and exophthalmos in the other.

CONCLUSIONS

Adults may develop clinically significant enophthalmos, exophthalmos, or no change in globe position over a 20-year period. This lack of uniform change in globe position with age impacts surgical considerations for treatment of the aging periocular region.

"The influence of orbital vector on involutional entropion and ectropion"

PURPOSE

This study aimed to evaluate the effect of orbital vector and other biometric parameters (i.e. axial globe length, axial globe projection) on the development of involutional entropion or ectropion.

METHODS

In this cross-sectional study, 167 eyes from 132 patients were included. Of these eyes, 128 had involutional entropion and 39 had involutional ectropion, all of lower lids. The axial globe projection was measured using Hertel exophthalmometry; axial globe length was assessed by A-mode ultrasound; and orbital vector was determined clinically. Patient-specific categorical variables and continuous variables were compared using the chi-square test and the two-sided t test, respectively. Correlations were derived using the Pearson correlation.

RESULTS

The percentage of females was 59% and 33.3% in the entropion group and in the ectropion group, respectively. A significant association was found between the gender and type of eyelid malposition (p = 0.015). Exophthalmometry reading was greater in the ectropion group than in the entropion group (17.7 ± 2.5 versus 10.8 ± 3.7 mm, respectively; p < 0.001). There was no significant correlation between axial globe length and exophthalmometry reading. Positive orbital vectors were observed in 87.5% of eyelids with involutional entropion. Negative orbital vectors were observed in 92.3% of eyelids with involutional ectropion (p < 0.001). Patients with negative orbital vectors showed greater axial globe projection than patients with positive orbital vectors (18.0 ± 2.1 versus 10.6 ± 3.5 mm, respectively; p < 0.001).

CONCLUSIONS

There is an association between orbital vector measurement and involutional entropion and ectropion. Measuring the orbital vector may help predict the development of these lid malpositions.

Lateral tarsal strip plus skin-muscle flap excision in the treatment of lower eyelid involutional entropion

This article examines the effectiveness of skin-muscle flap excision in conjunction with a lateral tarsal strip for the treatment of involutional entropion. Ninety-six eyelids in 83 consecutive patients with involutional entropion were treated using a standardized surgical procedure. All patients underwent lower eyelid tightening with a lateral tarsal strip, dissection of a skin-muscle flap inferiorly through a subciliary incision and excision of redundant skin as well as orbicularis muscle. Follow-up data was obtained by retrospective chart review and telephone interviews. 80 patients were included in this study. The only exclusion criteria was failure to attend the 1 week follow-up appointment, n = 3. There was only one recurrence which was mild and revised under local anesthesia. Two patients had overcorrection with mild ectropion but did not require additional surgery. In those that completed their initial post-operative visit, the average time follow-up time was 502 days. Excision of a skin-muscle flap is a useful addition to lateral tarsal strip surgery in the treatment of involutional entropion and is a quick procedure producing excellent functional and cosmetic results. To our knowledge, this is the first cohort of patients to be reported using this technique where all patients had a standardized surgical approach. Additional studies are needed to compare long-term outcomes of this technique against other surgical treatments.

Age-matched, case-controlled comparison of clinical indicators for development of entropion and ectropion

Purpose. To analyze the clinical findings associated with involutional entropion and ectropion and compare them to each other and to age-matched controls. Methods. Prospective, age-matched cohort study involving 30 lids with involutional entropion, 30 lids with involutional ectropion, and 52 age-matched control lids. Results. The statistically significant differences associated with both the entropion and ectropion groups compared to the control group were presence of a retractor dehiscence, presence of a “white line,” occurrence of orbital fat prolapse in the cul-de-sac, decreased lower lid excursion, increased lid laxity by the snapback test, and an increased lower lid distraction. Entropion also differed from the control group with an increased lid crease height and decreased lateral canthal excursion. Statistically significant differences associated with entropion compared to ectropion were presence of a retractor dehiscence, decreased lateral canthal excursion, and less laxity in the snapback test. Conclusion. Entropic and ectropic lids demonstrate clinically and statistically significant anatomical and functional differences from normal, age-matched lids. Many clinical findings associated with entropion are also present in ectropion. Entropion is more likely to develop with a pronounced retractor deficiency. Ectropion is more likely to develop with diminished elasticity as measured by the snapback test.

Efficacy of the Quickert procedure for involutional entropion: the first case series in Asia

PURPOSE

To report the efficacy of the Quickert procedure in the first case series of involutional entropion in an elderly Asian population, and to introduce the technique to Asian ophthalmologists including general ophthalmologisits and ophthalmic trainees.

METHODS

We conducted a retrospective review of 13 consecutive patients underwent the Quickert procedure for involutional entropion by occasional eyelid surgeons at Tokushima University Hospital or Mino Tanaka Hospital from September 2003 to April 2010. Demographic data, including gender, age, history of previous eyelid surgery, systemic disease, recurrence of entropion, postoperative complications, and symptoms were analyzed.

RESULTS

There were 5 male (38.5%) and 8 female (61.5%) subjects with a mean age of 77.8 years. Three patients underwent previous surgery for entropion were included. Entropion was rectified in all patients by a single Quickert procedure, and no recurrence was observed for a maximum of 89 months after the surgery. Although notching of the eyelid margin and mild symblepharon were observed in one patient, no symptoms associated with these complications were reported.

CONCLUSION

The Quickert procedure can be one of the surgical procedures of choice for involutional entropion and should be common surgical approach for occasional eyelid surgeons in Asia as well as in western countries.

Entropion-ectropion: the influence of axial globe length on lower eyelid malposition

PURPOSE

To evaluate the effect of axial globe length and other biometry parameters on age-related lower eyelid malposition.

METHODS

Consecutive patients with involutional lower eyelid malposition underwent preoperative biometry with Zeiss IOL Master and Hertel's exophthalmometer prior to surgery. Patients with other causes of eyelid malposition and thyroid eye disease were excluded. GraphPad InStat was used for t test and chi-square statistical analysis.

RESULTS

Data on 57 eyelids of 52 Caucasian patients were collected. There were 28 ectropions and 29 entropions. The mean axial globe length in the ectropion group (23.5 mm, standard deviation ± 0.9) was significantly longer than in the entropion group (22.7 mm, standard deviation ± 1.03) (p = 0.008). There was significant sex predilection, with entropion more common in women and ectropion more common in men (p = 0.03). The mean axial globe projection in the ectropion group was 16.6 mm (standard deviation ± 2.4) and in the entropion group was 14.6 mm (standard deviation ± 2.7) (p = 0.002). There was no statistical difference in age, keratometry, amount of astigmatism, and cylinder axis.

CONCLUSION

Involutional eyelid malposition directly correlates with axial globe length with the ectropion group having lengthier eyes compared with the entropion group. Hence, axial globe length could be an influential factor in the onset of involutional eyelid malposition.

Involutional entropion and ectropion of the lower eyelid: prevalence and associated risk factors in the elderly population

PURPOSE

To determine the prevalence of involutional entropion and ectropion of the lower eyelid in the elderly population; to examine how these disorders are related to gender, age, skin color, and axial ocular globe projection; and to define the incidence of associated ocular surface and pathologic eyelid findings.

METHODS

An ophthalmic survey was conducted in 24,565 elderly people. All participants underwent ophthalmic examination by general ophthalmologists to identify entropion and ectropion. Information about associated ocular surface and pathologic eyelid findings were collected from all patients with involutional eyelid malposition. Patients with involutional entropion and ectropion underwent measurements of the axial ocular globe projection. The Pearson chi-square test and the Mann-Whitney U test were performed.

RESULTS

The prevalence of involutional entropion was 2.1%; 1.9% in men and 2.4% in women. The prevalence of involutional ectropion was 2.9%; 5.1% in men and 1.5% in women. Dry eye syndrome, lower retractor laxity, and superficial punctate keratopathy were seen significantly more often in patients with involutional entropion than in those with involutional ectropion (p < 0.001). Chronic conjunctivitis was significantly more common in patients with involutional ectropion than in those with involutional entropion (p < 0.001). The axial ocular globe projection was significantly smaller in patients with involutional entropion than in those with involutional ectropion (p < 0.001).

CONCLUSIONS

The prevalence of involutional entropion and ectropion in the elderly population is 2.1% and 2.9%, respectively. The axial ocular globe position plays a pathogenic role in involutional lower eyelid malposition.

[Surgical management of entropion]

Entropion is an inward folding malposition of the eyelid margin. As a result of persistent entropion and trichiasis severe complications of the conjunctiva and the cornea can occur, which can lead to loss of visual acuity. Conservative forms of therapy mostly provide only a temporary solution and are generally used in preoperative care or if surgical intervention is unfeasible. The main therapeutic means is surgery. Normally congenital entropion recedes throughout the first 12 months of life, so that surgery is not needed immediately. Spastic inflammatory entropion disappears with successful treatment of the inflammation. Senile entropion is caused by three different pathological mechanisms: loss of lid laxity, loss of tension of lower lid retractors and alterations to the musculus orbicularis. These can be corrected with the procedures developed by Wies and also by Quickert and Jones. The surgeon should be careful to avoid an overcorrection with iatrogenic ectropion. Finally, cicatricial entropion can occur as a consequence of persistent inflammation or injuries. In this case free mucosa grafts may be necessary.

Correction of Involutional Entropion with Suborbicularis Septal and Lateral Canthal Tightening

BACKGROUND

Involutional entropion, or infolding of the margin of the eyelid, is a common eyelid malposition affecting the elderly that can lead to significant morbidity when not corrected. It is notable for both functional and cosmetic sequelae. Numerous surgical techniques have been described to correct this defect; however, because of its multifactorial pathophysiology, no single procedure has been entirely satisfactory. In this study, the authors present a simple and effective surgical procedure that addresses the salient pathophysiology and successfully corrects this defect with minimal morbidity or chance of recurrence.

METHODS

Two hundred fifty-three patients (409 eyelids) with involutional entropion who underwent surgical repair from 1995 to 2004 were analyzed. All patients were symptomatic, ranging in age from 61 to 96 years (115 men and 138 women). All patients underwent lateral canthal lysis, suborbicularis and supraorbicularis undermining, canthoplasty, and lateral muscle suspension with septal tightening.

RESULTS

All 409 eyelids with symptomatic involutional entropion were successfully corrected. All patients were satisfied with both the functional and cosmetic outcome and experienced a short recovery time. Objective examination revealed a marked improvement in static and dynamic lower eyelid position and alleviation of the herniated lateral orbital fat. There were no complications or entropion recurrences.

CONCLUSIONS

Involutional entropion is frequently encountered in the elderly. Ideal treatment addresses horizontal lid laxity, improves vertical support, prevents preseptal orbicularis override, and reinserts the lower lid retractors. With the direct, easily executed and effective surgical procedure presented here, both functional and aesthetic improvements can be obtained. This procedure should be included among the techniques used by every surgeon who treats functional and cosmetic problems in the periocular region.

Simple effective surgery for involutional entropion suitable for the general ophthalmologist

OBJECTIVE

To compare the long-term success, recurrence, and complication rate of involutional entropion surgery using the lateral tarsal strip and everting sutures when performed by surgeons in training (resident or fellow) and specialist oculoplastic surgeons (attending supervising physician).

DESIGN

Prospective, interventional, comparative, clinical case series.

PARTICIPANTS

Adult patients with involutional entropion.

METHODS

Lateral tarsal strip and everting sutures (LTS+ES) by residents, fellows, or attending supervising physician. A minimum of 12 months of postoperative follow-up was required.

MAIN OUTCOME MEASURES

Patients' symptoms and clinical examination to confirm a normal eyelid position (no entropion or secondary ectropion) at rest and with forced orbicularis contraction with the topical amethocaine (tetracaine) test. This test is described.

RESULTS

Fifty-five consecutive patients, aged 57 to 91 years (mean, 77 years) underwent LTS+ES surgery on 62 eyelids. Surgery was performed by a consultant ophthalmic oculoplastic surgeon (attending supervising physician) in 8 eyelids and by 20 different trainees, residents, and fellows in 54 eyelids. Six patients died (11%) within 6 months of surgery and 2 patients (3.5%) were lost to follow-up, resulting in 47 evaluable patients (54 eyelids). The follow-up period was 12 to 34 months (mean, 18 months). Fifty-three of 54 eyelids (98%) had a successful outcome with no recurrence. The surgery was effective when performed by different grades of surgeon (P>0.4).

CONCLUSIONS

The LTS+ES is a simple operation for the correction of involutional entropion that can be performed effectively by both residents and fellows.

Consecutive Ectropion After the Wies Procedure

PURPOSE

To describe the clinical features and management difficulties of the ectropions after Wies procedure for lower eyelid involutional entropion in 4 patients.

METHODS

Case series.

RESULTS

All ectropions had developed within 2 months of the Wies procedure. Common structural features with cicatricial contraction of the anterior lamella and buckling of the tarsal plates were evident. Maximal horizontal eyelid shortening and excision of anterior lamella scar tissue allowed correction.

CONCLUSIONS

Consecutive ectropion is caused by secondary cicatricial changes, which can be difficult to manage. Untreated horizontal laxity and postoperative scarring are likely contributory factors in its development. The authors recommend excision of anterior lamella scar tissue combined with large full-thickness wedge excision as an effective treatment.

Tarsal strip combined with modified Quickert-Rathbun sutures for involutional entropion

BACKGROUND

Involutional entropion is a common problem in the elderly population. The author describes a method of repair of involutional entropion that is a combination and modification of two existing surgical techniques.

METHODS

Review of the cases of 20 consecutive patients (22 lids) who underwent surgery for involutional entropion. All surgical procedures were performed by the author. Repair consisted of a tarsal strip procedure combined with a modification of the Quickert-Rathbun suture technique. All patients had at least 1 year of follow-up.

RESULTS

Surgery was successful in 21 (95%) of the 22 eyelids. One patient was noted to have recurrent entropion at 21 months. The average length of follow-up was 33.3 months (range 12 to 79 months).

INTERPRETATION

The surgical technique described is straightforward and reliable for the correction of involutional entropion.

Effective small-incision surgery for involutional lower eyelid entropion

OBJECTIVE

The aim of this study was to develop an effective and minimally invasive operation to correct lower eyelid entropion that would address both the horizontal and vertical laxity.

DESIGN

A prospective, noncomparative, interventional case series.

PARTICIPANTS

Thirty-five consecutive patients with involutional entropion, aged 62 to 92 years (mean, 77.1 years), had surgery on 45 lower eyelids. Of the 45 procedures, 33 (73%) had a primary procedure and 12 (27%) were reoperations.

INTERVENTION

A lateral tarsal strip with diagonal tightening of the orbital septum and lower lid retractors to the lateral orbital rim was performed via a 1-cm lateral canthal incision.

MAIN OUTCOME MEASURES

Complications and surgical outcome were monitored clinically for between 12 and 24 months after surgery.

RESULTS

The results were analyzed from 42 eyelids (33 patients) with a mean follow-up of 17.1 months (range 12-24 months). Two patients died and one dropped out of the study 3 months after the second eyelid operation. In 36 cases (86%), the entropion was cured. Transient lateral orbital rim tenderness was noted in six cases (14%), and one patient had a wound infection. Anatomic recurrences were detected in six eyelids of six patients, and five of these (83%) were asymptomatic.

CONCLUSIONS

This surgical approach has been found effective in 86% of eyelids. Adequate clinical followup has proven essential for accurate evaluation of entropion surgery.

Involutional entropion and ectropion of the Asian lower eyelid

PURPOSE

A clinical observation showed that involutional entropion of the lower eyelid in Asians may occur more commonly than ectropion. A review of surgical cases was performed to examine this hypothesis.

METHODS

A retrospective review of the number of Asian lower lid involutional ectropion and entropion repairs was performed in three different clinical practice settings. These data were compared and statistically analyzed with similar data for non-Asian patients.

RESULTS

The frequency of ectropion among Asians was significantly less than in non-Asians (chi-square, p < 0.001). Asian entropion repair represented 11.4% of the 604 eyelid operations performed on Asians, whereas Asian ectropion repair made up only 1.5% of cases. Non-Asian entropion and ectropion repairs were 3.7% and 6.2%, respectively, of the 1,849 eyelid procedures performed on non-Asians.

CONCLUSIONS

Because of the normal anteriorly protruding position of the orbital fat within the Asian lower eyelid, Asians may be more predisposed than whites to the development of involutional entropion rather than ectropion. Removal of lower eyelid fat should be considered in entropion repair of the Asian lower eyelid.

The role of enophthalmos in the development of involutional ectropion

PURPOSE: This prospective study was performed to evaluate whether there is an association between enophthalmos and involutional ectropion. METHODS: Hertel exophthalmometric measurements were obtained from 31 patients with involutional ectropion and from 30 control patients who were age- and sex-matched. RESULTS: Eighteen patients had bilateral ectropion and 13 patients had unilateral ectropion. The mean of the exophthalmometric measurements of the eyes with ectropion was 12.67 +/- 2.48 (SD) mm. The mean of the exophthalmometric measurements of the control patients was 12.80 +/- 2.87 (SD) mm in the right eye and 12.83 +/- 2.93 (SD) mm in the left eye. The difference between the eyes of the patients and the controls was not statistically significant (p>0.05). In the affected eyes of the patients with unilateral ectropion, the mean exophthalmometric value was 13.15 +/- 2.51 (SD) mm, and in the unaffected eyes of the patients, the mean exophthalmometric value was 13.07 +/- 2.56 (SD) mm. This difference was not statistically significant either (p>0.05). CONCLUSION: Patients with involutional ectropion do not have more enophthalmos than the age- and sex-matched normal population. This study does not suggest an association between enophthalmos and involutional ectropion.