Everting suture correction of lower lid involutional entropion

Outcomes of combined procedures compared to various single techniques for involutional entropion

BACKGROUND

To describe the outcomes of triangular tarsectomy and limited orbicularis myectomy with lower eyelid retractor plication compared to an everting sutures (ES) technique or lateral tarsal strip (LTS) procedure for the correction of lower eyelid involutional entropion.

METHODS

A nonrandomized clinical study was carried out at two tertiary eye hospitals between January 2016 and December 2019. Patients in Group A underwent triangular tarsectomy and limited orbicularis myectomy with lower eyelid retractor plication. Group B had ES, and Group C underwent a LTS procedure. All participants were operated by one surgeon and underwent 1-year follow-up.

RESULTS

A total of 78 patients in whom 84 eyelids were affected by lower eyelid involutional entropion were included in the study. The success rate was higher in Group A compared to Group B and Group C (100% vs. 86.7% vs. 95.8%; P < 0.05). Recurrence at a 1-year follow-up was noted in only four (13.3%) eyelids in Group B and one (4.2%) in Group C. However, patient's in Group C experienced a higher frequency of minimal postoperative complications, including short-term pain (100%), tenderness on the lateral canthal area (100%), tightness of the eyelid (91.7%), and ecchymosis (54.2%) compared to Group A. Patients of Group B experienced minimal or no postoperative complications.

CONCLUSIONS

Triangular tarsectomy and limited orbicularis myectomy with eyelid retractor plication may be considered the standard procedure for correcting lower eyelid involutional entropion with no recurrence compared to LTS technique or minimally invasive and cost-effective ES procedure.

Comparison of postoperative recurrence rates between percutaneous and transconjunctival approaches for involutional entropion

Lower eyelid entropion is the second most common disease seen after ptosis in oculoplastic outpatients. In this study, we performed percutaneous and transconjunctival shortening of the anterior and posterior layers of the lower eyelid retractor (LER) to treat lower eyelid involutional entropion. This study aimed to examine the recurrence rate and complications of the percutaneous and transconjunctival approaches. This was a retrospective study of procedures conducted from January 2015 to June 2020. The LER shortening was performed for lower eyelid involutional entropion on 103 patients (116 eyelids). From January 2015 to December 2018, LER shortening using the percutaneous approach was implemented; from January 2019 to June 2020, the transconjunctival approach was used to shorten the LER. All patient charts and photographs were retrospectively reviewed. Recurrence occurred in 4 patients (4.3%) in the percutaneous approach. No recurrence was observed in any patient in the transconjunctival approach. Temporary ectropion occurred in 6 patients (7.6%) when the percutaneous approach was used; all cases healed within 3 months after surgery. The study did not reveal any statistically significant difference in recurrence rates between the percutaneous and transconjunctival approaches. We achieved results equal to or better than percutaneous LER shortening by combining transconjunctival LER shortening with horizontal laxity shortening, such as lateral tarsal strip, pentagonal resection, and orbicularis oculi muscle resection. However, it is necessary to be careful about temporary ectropion after surgery when percutaneous LER shortening alone is performed for lower eyelid entropion.

Comparison of the cutaneous orbicularis oculi excision treatment with the inferior eyelid margin fixation treatment for congenital lower eyelid entropion

PURPOSE

To modify the traditional surgical approach to treat patients diagnosed with congenital lower eyelid entropion using inferior eyelid margin fixation of the orbicularis eyelid muscle.

METHODS

Ninety-six participants (180 eyes) with congenital lower eyelid entropion diagnosed between January 2019 and April 2021 were included in this study. The patients were divided into Group A (cutaneous orbicularis oculi excision treatment) and Group B (inferior eyelid margin fixation treatment). The efficiency and recurrence rate of treatments were used to compare the two treatments.

RESULTS

There was no significant difference in age, sex, and eyes distribution in both groups. And higher efficiency rate was found in Group B (P < 0.05). And Group A had a higher recurrence rate in the follow-up after surgical treatment (P < 0.05).

CONCLUSIONS

This modified inferior eyelid margin fixation of the orbicularis eyelid muscle treatment is an ideal procedure with a high degree of efficacy and low recurrence rate in patients with congenital lower eyelid entropion.

Lateral tarsal strip procedure for involutional ectropion: A retrospective analysis of 85 cases and a comprehensive literature review

Purpose

To evaluate the postoperative effect of the lateral tarsal strip (LTS) procedure in treating lower eyelid involutional ectropion.

Methods

A retrospective study was performed on 85 eyelids in 67 patients with involutional ectropion who underwent LTS procedure. Pre- and postoperative lower eyelid laxity and ocular symptoms as well as perioperative complications were evaluated. Snap back test was performed to evaluate the elasticity of lateral canthal tendon loosening and, a lower lid distraction test was performed to evaluate the degree of severity before surgery. Ocular surface diseases were evaluated by the Ocular Surface Disease Index (OSDI), and symptoms including conjunctivitis, corneal ulcer, dry eye syndrome, and ocular pain were recorded. All patients were evaluated within one week and during the follow-up period of 4.2 ​± ​8.3 months. Furthermore, we reviewed the studies that also investigated the surgical effect of the LTS procedure in the literature from 1979 to 2019.

Results

The success rate was 95%. Only four eyelids required a second surgical intervention. Seventy-three (86%) eyelids had an excellent position after surgery, 9 (11%) only little improvement, and three had no improvement. No significant difference was found in the postoperative effects between different degrees of ectropion (p ​> ​0.05). No statistical correlation was found between surgical improvements and the ectropion severity (P ​> ​0.05). Fifty-two out of 85 eyes had no discomfort after the surgery. Mild complications included epiphora in 13 eyes (three cases caused by lacrimal punctum eversion), ocular pain in 12 eyes, wound hemorrhage in 12 eyes, and edema in 9 eyelids immediately after surgery, in which 91.2% (n ​= ​21) disappeared within one week and did not need any further treatment.

Conclusions

The lateral tarsal strip procedure can provide an aesthetically pleasing result for correcting the mild to moderate lower eyelid ectropion while maintaining decent eyelid function.

Two-paired Mini-incisional Entropion Surgery for Involutional Entropion

PURPOSE

The aim of this study is to describe "2-paired mini-incisional entropion surgery" for involutional entropion.

METHODS

This study was a retrospective single-surgeon case series. Patients who underwent different entropion surgeries were reviewed. Patients with involutional entropion were divided into 3 groups according to the type of surgery performed by a single surgeon: 2-paired mini-incisional entropion surgery; transconjunctival retractor reinsertion; or transcutaneous retractor reinsertion. Patients were followed up to 35 months after the surgery. Operation time, complications, and success were compared between groups.

RESULTS

Sixty-six lower eyelids of 60 patients were evaluated. The recurrence was 7.7% in the transcutaneous group, was 5.9% in the 2-paired mini-incisional entropion surgery group, and was 5.3% in the transconjunctival group. The total chance of success in 24-month period was 94.7% in the transconjunctival approach group, was 94.1% in the 2-paired mini-incisional entropion surgery group, and was 92.3% in the transcutaneous group.

CONCLUSION

The 2-paired mini-incisional entropion surgery can be used for entropion repair alone or in combination with horizontal tightening surgeries.

Comparison of the two techniques for involutional lower eyelid entropion: A retrospective study

Evaluation of the surgical outcome and the patient satisfaction between the modified Wies technique and the Jones retractor plication technique for involutional lower eyelid entropion without horizontal eyelid laxity. Patients who underwent the modified Wies technique (group 1) and the Jones retractor plication technique (group 2) for correction of involutional lower eyelid entropion without horizontal eyelid laxity between January 2014 and January 2020 were retrospectively reviewed. Patients with horizontal eyelid laxity; cicatricial, congenital or iatrogenic entropion; and less than 6 months of follow-up time were excluded. The main outcome measures were the recurrence rate, correct anatomical position of the eyelid, symptom relief, and postoperative complications for both groups. 37 patients (41 eyes) in Group 1 and 34 patients (34 eyes) in Group 2 were enrolled in the study. Mean age ± SD was 75.6 ± 8.5 years in Group 1 and 73.4 ± 7.9 years in Group 2 (p:0.255). The mean follow-up time (range) was 24.3 (6-80) months in group 1 and 25.3 (6-78) months in group 2 (p:0.818). Two patients in Group 1 and seven patients in Group 2 had a recurrence during the follow-up period (p:0.07). Based on the results of the study, it seems that the modified Wies technique may be a good alternative in suitable patients, as it has satisfactory surgical results.

Modified everting sutures combined with reattachment to the inferior tarsal plate for involutional lower eyelid entropion: A new technique

Background

This study evaluated the outcomes of a new modified Wies technique for patients with involutional lower eyelid entropion without horizontal eyelid laxity.

Methods

This case series retrospectively analyzed consecutive patients with entropion who underwent surgery between January 2014 and March 2019 by the same experienced surgeon. Horizontal eyelid laxity, lower eyelid retractor function, and orbicularis muscle overriding were recorded before and after surgery. The recurrence rate and complications were also evaluated. This technique consisted of modified everting sutures combined with reattachment of the lower eyelid retractors to the inferior tarsal plate.

Results

This new technique was performed on 28 eyes in 25 patients (mean age, 71.0±8.0 years; range, 56–87 years). Nine patients (36%) were women and 16 (64%) were men. Lower lid entropion was present in the right eye in 14 patients (56%), the left eye in eight patients (32%), and both eyes in three patients (12%). The mean follow-up period was 27.3±12.4 months (range, 6–60 months). No intraoperative complications were observed. All patients’ symptoms were alleviated. One patient (3.6%) had recurrence after 2 years (success rate, 96.4%). The remaining 27 eyes maintained a satisfactory and comfortable eyelid position. No patients had problems with scarring.

Conclusions

The approach described herein proved to be safe and feasible in eyes with involutional lower eyelid entropion without horizontal eyelid laxity. These advantages of this procedure include the lack of a conjunctival scar, punctal eversion, and lateral canthal angle deformation. A low recurrence rate and a long interval to recurrence were also observed.

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.

Randomized Controlled Trial Comparing Everting Sutures with a Lateral Tarsal Strip for Involutional Lower Eyelid Entropion

INTRODUCTION

To compare the anatomical and functional outcome and changes in the quality of life (QoL) over time of the lateral tarsal strip (LTS) versus the Quickert everting sutures (ES) for the repair of primary involutional lower eyelid entropion.

METHODS

Forty-five patients (54 eyes) with primary involutional lower eyelid entropion were recruited in a prospective randomized clinical trial over 3-year period. Twenty-six eyes were randomized to the LTS technique and 28 to the ES procedure. Primary outcome was the anatomical correction of the eyelid at the final assessment in 1 year. Secondary outcomes were function and symptoms assessment with a QoL questionnaire at 6 months. Fisher's exact test was used for the statistical analysis of success rate and gender study and Mann-Whitney U test and logistic regression analysis were used for age study. The Wilcoxon and Mann-Whitney U tests were used for the analysis of the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25).

RESULTS

At the 6-month follow-up, 25 eyes (96.2%) of the LTS group and 20 (71.4%) of the ES group had favorable outcome (P = 0.025). There were one and eight eyes, respectively, with early recurrence. At the final 12-month evaluation, 23 eyes (88.5%) in the LTS group and 16 eyes (57.1%) in the ES group were successful. Three (11.5%) and 12 (42.9%) eyes respectively showed postoperative recurrence. There was a statistically significant difference between the two groups (P = 0.015) for the primary outcome, whereas age and gender did not influence success. The NEI VFQ-25 showed statistically significant subjective improvement from baseline in most categories of the QoL. No significant difference between the two procedures was detected at 6 months.

CONCLUSION

This study suggests that the LTS procedure has a superior surgical success rate and reduction of symptoms compared with the ES for the repair of involutional lower eyelid entropion. Both procedures showed similar improvement of the postoperative QoL.

TRIAL REGISTRATION

International Clinical Trials Registry Platform identifier: ACTRN12616000620426.

Mini-incisional entropion repair for correcting involutional entropion: Full description and surgical outcome

The aim of the study was to report the surgical outcome of mini-incisional correction method to treat involutional entropion.This is a retrospective interventional case series of 46 eyelids in 31 patients with involutional entropion and significant ocular irritation. In this technique, after turning the lower eyelid inside out, threads are introduced into it through the conjunctiva close to the inferior fornix. The lower lid retractor and tarsus are then connected using threads. These threads are applied at 3 locations of the lower eyelid and tightening them results in the eyelid being everted and the correction of entropion. Surgical success was defined as no contact between the eyelashes and the globe during forced closure of the eyelids. Surgical failure was defined as persistence of the eyelashes remaining in contact with the globe or cosmetic dissatisfaction.During the mean follow-up period of 22.1 months (range, 12-34 months), 43 of the eyelids (93.5%) were successfully corrected. Two patients (3 eyelids) experienced recurrence: 1 had involutional entropion combined with a cicatricial component, and the other had blepharospasm and apraxia of eyelid opening related to Parkinsonism. No postoperative complications such as overcorrection, suture-knot exposure, or ocular irritation were observed.Our mini-incisional entropion repair is based on reinforcement of the lower eyelid retractors using transconjunctival buried sutures. This technique is a quick, simple, and predictive for involutional entropion repair, and has a high success rate.

Surgical correction of involutional lower lid entropion with lateral canthal eyelid block excision and imbrication of the capsulopalpebral ligament using non-buried non-resorbable imbricating sutures versus buried resorbable imbricating sutures

PURPOSE

To compare the results of surgical correction of involutional lower eyelid entropion using either buried resorbable imbricating sutures or non-buried non-resorbable sutures that were removed after five to seven days.

METHODS

Retrospective analysis of a two-surgeon series. Analysis of the charts of patients surgically treated for involutional lower eyelid entropion between January 2011 and December 2014 with a minimum follow-up of 12 months.

MAIN OUTCOME MEASURES

Recurrence rate, postoperative complications.

RESULTS

We included 281 eyelids of 240 patients. Of these, 89 eyelids had been treated with buried resorbable imbricating sutures (surgeon WvdB) and 192 with non-buried non-resorbable sutures (surgeon DP). Of the 281 eyelids, 77 eyelids had undergone previous entropion surgery. In the buried resorbable suture group (group R), the mean follow-up was 30 months (range 12 to 61 months) versus 39 months (range 14 to 60 months) in the non-buried non-resorbable group (group NR) (p = 0.07). With a follow-up of up to 18 months, the recurrence rate was 2.2% in group R and 4.2% in group NR (p = 0.73). With a similar follow-up, the recurrence rate was 3.9% after primary surgery versus 2.6% in recurrent cases (p = 0.73). Minor postoperative complications and side-effects were seen in 5.3% (15/281).

CONCLUSION

We found no difference in the recurrence rate between the use of buried resorbable imbricating sutures and non-buried non-resorbable sutures and between primary versus recurrent cases. We conclude that we can safely use buried resorbable imbricating sutures in involutional entropion. It yields comparable results and omits the need for suture removal.

The Prevalence of Lower Eyelid Fornix Fat Prolapse: A Diagnostic Measure of Involutional Entropion

Purpose:

In our experience, lower lid involutional entropion is commonly associated with inferior fornix fat prolapse and non-eversion of the tarsal plate. We aimed to assess the prevalence of this sign as an early diagnostic indicator of lower lid involutional entropion in symptomatic and control groups.

Methods:

Prospective, comparative, observational case series. Fornix fat prolapse and failure of tarsal eversion in patients with involutional entropion were studied. Fornix fat prolapse was assessed by pulling the lower lid margin to the inferior orbital rim and comparing the meniscus of the protruding fat. The absence of tarsal eversion and lid laxity were also assessed. Patients were reassessed following correction using radiofrequency entropion surgery.

Results:

Sixty eyes of 50 Caucasian patients with involutional entropion underwent entropion correction. Fornix fat prolapse was found preoperatively in 83.3% (50 eyes), with complete reversal of fat prolapse in 76% (38 eyes) over a mean follow-up of 18.9 months, after successful surgery (P < 0.01). None of the 100 eyes (50 patients) in the control group showed fornix fat prolapse or absence of lower lid tarsal eversion (P < 0.01).

Conclusion:

There is high prevalence of fornix fat prolapse and failure of tarsal eversion (BB sign) in involutional entropion, with reversal after successful eyelid surgery. The absence of fornix fat prolapse in normal controls suggests that this is an important, underlying anatomical etiology, with diagnostic and prognostic value.

Involutional entropion repair combining the modified Bick quick strip procedure with Quickert rotational sutures

PURPOSE

The purpose of the study was to determine the results of involutional entropion repair by combining the modified Bick strip procedure with Quickert rotational sutures.

METHODS

A retrospective review of consecutive patients with involutional entropion who underwent repair by combined Bick and Quickert technique from January 2013 to December 2017 was performed.

RESULTS

A total of 43 cases of involutional entropion repair were preformed in this time period. Fourteen eyelids of 12 patients had the combined procedure. There were no failures with a median follow-up of 29 months. Mean operative time, recorded in 10 patients, was 15 ± 2.2 minutes. Complications were minimal.

CONCLUSIONS

The combination of the modified Bick quick strip procedure and Quickert sutures requires minimal surgical dissection and provides excellent results for the treatment of involutional entropion.

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.

Success rate of nurse-led everting sutures for involutional lower lid entropion

PurposeTo evaluate safety and long-term recurrence rate of entropion in patients having everting sutures (ES) for involutional entropion by ophthalmic nurses in a real clinical setting.Patients and methodsRetrospective notes review of all patients who had an outpatient ES by our trained ophthalmic nurses over 2 year's time period. Outcome measures were complication and recurrence rates. Those with less than 3 years' recorded follow-up were contacted by paper questionnaire.Results90 lids of 82 patients analysed. Mean age was 78 (range 54-97). In total, 82% had no entropion surgery before, whereas 13% had previous ES and 5% one or more other procedures. Questionnaires were sent to 38, with return rate of 81%. Recurrence rate was 21.1% after 36-60 months follow up from nurse-performed ES, with mean time to recurrence of 15 months (SD 13 months). A total of 32% of patients died during the follow-up period. Mean time between the procedure and death is 20.5 months. When ES were repeated twice (11 patients), recurrence rate was still 20%. No patients had any complications.ConclusionES can be safely performed by ophthalmic nurses, with success rate comparable to the same technique performed by ophthalmologists.

The prevalence of glaucoma in patients undergoing surgery for eyelid entropion or ectropion

Purpose and design

The aim of this study was to establish the prevalence of known glaucoma in patients undergoing ectropion or entropion surgical repair. In this study, retrospective review of case series was performed.

Participants

All patients who underwent ectropion or entropion surgery in a tertiary medical center between 2007 and 2014 were included. The etiology of eyelid malpositioning was involutional or cicatricial.

Methods

The medical files of the study participants were reviewed for the presence and type of glaucoma, medical treatment, duration of treatment, and the amount of drops per day. These data were compared to a matched control group of 101 patients who underwent blepharoplasty for dermatochalasis in the same department during the same period.

Main outcome measure

In this study, the prevalence of glaucoma in individuals with ectropion or entropion was the main outcome measure.

Results

A total of 227 patients (57% men, mean age: 79.2 years) who underwent ectropion or entropion surgery comprised the study group and 101 patients who underwent upper blepharoplasty for dermatochalasis comprised the control group. Compared to four patients in the control group (4%, P=0.01), 30 of the study patients (13.2%) had coexisting glaucoma. Of 30 glaucomatous patients, 25 had primary open-angle glaucoma for a mean duration of 10.3 years. The glaucomatous patients were treated with an average of 2.7 antiglaucoma medications.

Conclusion

An increased prevalence of known glaucoma in patients undergoing ectropion or entropion repair surgery was found. This observation may indicate that the chronic usage of topical anti-glaucoma eyedrops may lead to an increased risk of developing eyelid malpositions, especially in elderly patients.

Correction of involutional entropion with retractor redirection

The study aims to report the surgical outcome of a retractor redirection procedure for involutional entropion repair for Asians. The study included all cases diagnosed with involutional entropion and significant ocular irritation who presented from 2008 to 2012. Sixty-seven eyelids in 54 patients were included in this study. All cases were operated on by one surgeon and had a minimum of 12-months follow-up. Success was defined as cases showing no recurrence of entropion with forceful eyelid squeezing postoperatively. A retrospective chart review was performed to assess the success rate, recurrences and complications of the procedure. During a mean follow-up period of 26.2 months (range, 12-53 months), 5 patients died during the study period. Two eyelids (3%) of one patient had a recurrence at 34 months postoperatively. One eyelid (1.5%) with a significant horizontal laxity developed postoperative ectropion and required a secondary horizontal shortening procedure. No other postoperative complications or dissatisfaction were reported. The retractor redirection procedure aims to repair the retractors and prevent orbicularis muscle overriding via inserting the retractors to the anterior lamellae. It yields a long-term success rate of 95.5% and is an effective technique for correcting involutional entropion.

The efficacy of the combined procedure in involutional entropion surgery: a comparative study

PURPOSE

To evaluate the efficacy of the combined procedure in the management of involutional entropion.

METHODS

In this study, we reviewed 45 eyes of 36 patients who underwent the combined procedure (lateral tarsal strip, retractor tightening, and everting sutures) for the management of involutional lower eyelid entropion and compared the results with 31 eyes of 25 patients who underwent the Wies procedure. Exclusion criteria included previous lower eyelid surgery and follow-up of less than 6 months.

RESULTS

No patients demonstrated entropion on the first postoperative day. The mean follow-up period was 18.4 months (6 to 52 months) in the Wies group and 22.6 months (6 to 59 months) in the combined procedure group. During the follow-up period, 9 of 31 eyes in the Wies group presented with recurrence and only 1 of 45 eyes in the combined procedure group presented with recurrence (p = 0.001). The average time of recurrence was 4.8 months in the Wies group. Recurrence occurred at 2 months postoperatively in the patient in the combined procedure group. Six of the 9 recurrences in the Wies group were managed by the combined procedure. None of these patients had further recurrence after correction. Three patients complained about a visible incision line after the Wies procedure.

CONCLUSIONS

The combined procedure seems to be more effective than the Wies procedure in the management of involutional entropion. The combined procedure addresses the three major causative factors in involutional entropion and makes it possible to perform the surgery using a small incision.

Current concepts of ocular adnexal surgery

Ophthalmic Plastic and Reconstructive Surgery is a specialized area of ophthalmology that deals with the management of deformities and abnormalities of the eyelids, lacrimal system and the orbit. An ophthalmoplastic surgeon is able to identify and correct abnormalities of the ocular adnexae such as ectropion, lid retraction, conjunctival scarring with severe entropion, that can cause secondary ocular surface disorders; manage patients with watering eye, and when needed intervene with a dacryocystorhinostomy by external or endonasal approach and moreover minimize disfigurement following enucleation or evisceration and prevent further corneal damage, alleviate complains of tearing and grittiness, but also cosmetic complaints in patients with Graves' orbitopathy. Aim of this manuscript was to review current established and recently evolving surgical procedures.

A lateral approach to lower eyelid entropion repair

The authors describe a simple technique that highlights the use of the sagittal anatomy of the lower eyelid to aid identification of the retractors during involutional entropion repair. This anatomy is exposed following lateral canthotomy and inferior cantholysis. The orbital septum is seen to enclose the fat pad and fuse with the retractors above it prior to insertion into the tarsus. The septum, orbicularis, and skin are incised from the lateral approach, allowing exposure of the retractors for tarsal reattachment, and the procedure is completed with a lateral tarsal strip. Forty-eight procedures in 42 patients with involutional entropion were performed using this technique and 90% and 89% of primary and recurrent entropion, respectively, were successfully repaired. Mean operating time was 30 minutes. The lateral approach to a standard procedure for entropion repair can reduce operating time and technical difficulty.

Botulinum toxin for lower lid entropion correction

This prospective clinical study was designed to evaluate the efficacy of botulinum toxin for temporary treatment of senile and congenital lower lid entropion. Seventeen patients with senile entropion and three children with congenital entropion were treated with botulinum toxin injection into the preseptal orbicularis muscle of lower lid. This resulted in transient relieve of the condition, which lasted for a period of 8-26 weeks. This technique is easy and effective for senile entropion as well as certain cases of congenital entropion.

Clinical Study of Single-Suture Inferior Retractor Repair for Involutional Entropion

PURPOSE

To evaluate the clinical efficacy of a simplified single-suture inferior retractor repair technique for involutional entropion.

METHODS

A retrospective study of 20 patients (26 eyelids), followed for 6 months at our hospital, who showed no severe horizontal lid laxity were operated on for involutional entropion. After subciliary incision, the inferior retractor was identified and repaired by reattaching the superior edge of the inferior retractor to the inferior edge of the lower tarsus by a single suture using 5-0 prolene.

RESULTS

26 eyelids of 20 patients (80.8%) were treated successfully without recurrence. Complications were seen in 5 eyelids, 2 were overcorrections and 3 were recurrences of entropion. Recurred cases were reoperated on and showed good postoperative results after the second surgery.

CONCLUSIONS

The simplified single-suture inferior retractor repair had good results in patients with involutional entropion without severe horizontal lid laxity. Moreover, this procedure had a short operation and recovery time. In unilateral cases, we could achieve more symmetric appearance when compared with bilateral surgeries.

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.

Modified retractor plication technique in lower lid entropion repair: a 4-Year follow-up study

BACKGROUND

Lower eyelid entropion is an eyelid malposition characterized by inward rotation of the eyelid margin associated with potentially significant discomfort and, occasionally, keratopathy. In this study we evaluated and compared the efficacy of two surgical techniques of retractor plication for involutional lower lid entropion repair.

METHODS

Sixty-two consecutive patients (62 eyes) with involutional lower lid entropion were included. Of the 62, 34 underwent the Jones retractor plication technique, and 28 underwent a modification of this technique that simplifies the procedure. We evaluated horizontal lid laxity, medial canthal tendon laxity and lower lid excursion before and after surgery, and determined the rate of entropion recurrence in the two groups. All measures were obtained before and 1 month, 6 months, 1 year, 2 years, 3 years and 4 years after surgery.

RESULTS

Preoperatively, there was no statistically significant difference between the two groups in any of the measures studied. Postoperatively, the mean amount of horizontal lid laxity was significantly less in the modified technique group than in the Jones technique group (6.86 mm [standard deviation (SD) 0.41 mm] vs. 7.30 mm [SD 0.64 mm]) (p < 0.05). Similarly, the mean amount of medial canthal tendon laxity in the resting position was significantly less in the modified technique group than in the Jones technique group (1.90 mm [SD 0.56 mm] vs. 1.25 mm [SD 0.43 mm]) (p < 0.05). The rate of entropion recurrence was significantly lower in the modified technique group (7.1%) than in the Jones technique group (14.7%) (p < 0.05).

INTERPRETATION

The modified retractor plication technique showed encouraging results in terms of successful and long-lasting lower lid entropion repair.

Entropion correction by fornix-based suture placement: use of the Quickert-Rathbun technique in ten dogs

The objective of this study was to evaluate fornix-based suture placement as a method for entropion correction in the dog. Lower eyelid entropion with resultant trichiasis was corrected in 10 dogs using fornix-based suture placement similar to that employed in the Quickert-Rathbun technique used in man. A double-ended suture was placed originating at the deepest extent of the fornix and exiting the lid 1-2 mm from the eyelid margin. Degree of correction was assessed visually immediately after surgery and at re-examination with a follow-up period of up to 6 months. Fornix-based suture placement led to immediate eversion of the eyelid in each case and thus amelioration of the trichiasis in all dogs. In two cases eyelid eversion initially appeared over-corrected and in two cases exposure of conjunctival tissue was evident initially at the palpebral margin. In all cases, however, such complications were transient with long-term results giving an acceptable apposition between ocular surface and eyelid margin in all adult dogs. In three juvenile dogs on which the technique was used, further surgical treatment was required as the puppies grew. Fornix-based suture placement is a novel approach to entropion correction in the dog which yields acceptable results in the majority of suitable cases without recourse to incisional surgery.