【In Press】Anterior lamellar recession for management of upper eyelid cicatricial entropion and associated eyelid abnormalities

AIM: To evaluate the functional and aesthetic outcomes of upper eyelid cicatricial entropion correction using anterior lamellar recession (ALR) with addressing the associated conditions including dermatochalasis, brow ptosis, blepharoptosis, and lid retraction. METHODS: Chart review of patients with upper lid cicatricial entropion who had undergone ALR from 2013 to 2016 was reviewed. Success was defined as the lack of any lash in contact with the globe, no need for a second procedure, and acceptable cosmesis at the final follow up. RESULTS: Sixty eight patients (97 eyelids) were operated by ALR with simultaneous correction of associated lid problems in each case when necessary. The mean follow-up time was 17.8mo (range, 6.0-24.0mo).Concomitantly, levator tucking was performed in 19 eyelids (19.6%), upper lid retractor recession in 18 eyelids (18.6%), and internal browpexy in 31 eyelids (32.0%). In 95.8% of patients (CI: 0.85-0.96), satisfactory functional and cosmetic outcome was achieved with a single surgical procedure. CONCLUSION: Based on the principles of lamellar recession and concurrently addressing the associated lid problems, this approach is an effective and safe treatment of upper eyelid cicatricial entropion.     

Management of upper eyelid cicatricial entropion

Purpose: There is a paucity of published data on the management of upper eyelid cicatricial entropion. We report on our results using such techniques as lamella repositioning, recession or augmentation and terminal tarsal rotation. Design: Observational retrospective case series. Participants: Consecutive cases of upper eyelid cicatricial entropion of two specialist oculoplastic centres (Corneoplastic Unit, East Grinstead, UK and South Australian Institute of Ophthalmology, Adelaide, Australia) were reviewed over a 7‐year period. Methods: All patients underwent anterior lamellar repositioning or terminal tarsal rotation. Main Outcome Measures: Success was defined by two definitions: anatomical success was defined where the lid margin was restored to its normal position. Complete success was defined where there were no eyelashes touching the globe. Gain or loss (≤ or ≥2 Snellen lines) in best corrected visual acuity using a Snellen chart and resolution of any corneal epitheliopathy at final follow‐up were also recorded (as graded by experienced oculoplastic consultants). Results: Fifty‐two procedures were performed on 41 patients (11 bilateral). All patients underwent either an anterior lamellar repositioning or a terminal tarsal rotation. Trachoma, previous upper lid surgery, Stevens–Johnson syndrome and meibomian gland dysfunction were the commonest underlying diagnoses. Ninety‐eight per cent of the group had a normal anatomical lid position at follow‐up. Nine eyelids (17%) of the group had recurrence of trichiasis. Conclusion: This large case series demonstrates that upper eyelid cicatricial entropion is managed effectively utilizing procedures that involve recession and reposition. We recommend that excision of tissue is avoided, especially in pathology that has a progressive immunological cicatricial drive.     

Efficacy of lamellar division for correcting cicatricial lid entropion and its associated features unrectified by the tarsal fracture technique

OBJECTIVE : To determine the efficacy of lamellar division for correcting cicatricial lid entropion and its associated features unrectified by the tarsal fracture technique. METHODS : Fifty patients (92 lids) diagnosed as having cicatricial lid entropion were operated by the tarsal fracture technique. There was defective lid closure in 34/92 lids, irregular lid margin in 48/92 lids, distichiatic or metaplastic cilia in 28/92 lids and a history of previous entropion surgery in 34/92 lids. All patients were followed up for one year and the surgical failures at the end of this period were subjected to lamellar division. These subjects were further followed up for one more year./ RESULTS : An overall success rate of 28.26% (26/92 lids) was obtained with the tarsal fracture technique. A correction was achieved in all the 20 lids having cicatricial entropion without any associated features. However, this technique succeeded in only six of the remaining 72 lids (8.33%) with a history of previous surgery or the associated features stated above. Furthermore, it was not effective in correcting associated anomalies such as defective lid closure, irregular lid margin and distichiatic or metaplastic cilia. Reoperation using lamellar division gave good correction in 97% of the lids (64/66). CONCLUSIONS : Lamellar division is a better procedure for treating cicatricial lid entropion, especially in patients with associated complications or with a previous history of entropion surgery.     

Eyelid retractor surgery as an adjunct to cicatricial ectropion repair

Purpose : To evaluate the effectiveness of eyelid retractor repair in cicatricial ectropion of the lower eyelid. Methods : The study design was a prospective case series. One hundred and twenty eight eyelids were operated on in 100 consecutive patients with cicatricial ectropion. All patients underwent lower eyelid retractor repair via a conjunctival approach combined with skin replacement to the anterior lamella with or without a horizontal lid tightening procedure. When only medial ectropion was present, a medial‐based transpositional skin flap was used to repair the anterior lamella (26 eyelids). The remaining eyelids with ectropion involving all or most of the eyelid underwent upper‐to‐lower eyelid lateral‐based transpositional skin flap repair (92 eyelids), or full thickness free skin grafting (10 eyelids). Horizontal lid tightening was performed by lateral canthoplasty in 123 eyelids. Results : Relief of cicatricial ectropion symptoms was reported in 90% of patients overall. A normal punctum position was achieved in 70% of eyelids, overall, and was highest (88%) with a medial‐based transpositional skin flap. Conclusions : Eyelid retractor repair combined with skin replacement and horizontal lid shortening is an effective procedure for cicatricial ectropion.     

Modified grey line split with anterior lamellar repositioning for treatment of cicatricial lid entropion

To determine the success rate of surgery of modified grey line split with anterior lamellar repositioning in patients with cicatricial lid entropion and to determine the risk factors of failure of the procedure, 40 patients (84 lids) with either lid involvement caused by cicatricial lid entropion of different etiologies were enrolled in this study. All the lids were operated on using the technique of modified grey line split and anterior lamellar repositioning. The success of the procedure was assessed by restoration of anatomical and physiological functioning of the lid without any residual symptom to the patient. Patients were examined initially at weekly intervals for 1 month and subsequently followed up at 2, 3, and 12 months following surgery. Among the various causes for cicatricial lid entropion, infectious etiology (72/84 lids) was found to be the most common one. A success rate of modified grey line split with anterior lamellar repositioning was 88.09% (74/84 lids). The underlying etiology of cicatricial lid entropion was the sole predictor of failure of surgery. Those with the etiology of infection had more than 6 times the odds of surgery failure (OR: 6.73; 95% CI: 2.79-16.73) as compared to a patient without infectious etiology. The role of other factors such as the age of the patient, degree of entropion, previous entropion surgery, the lid (upper or lower) involved, irregular lid margin, and defective lid closure were statistically insignificant. The underlying etiology of cicatricial lid entropion is the only risk factor that significantly influences the outcome of surgery with this technique. Otherwise, this procedure gives good results with fewer complications in patients with cicatricial lid entropion.     

Amniotic membrane transplantation in entropion surgery.

PURPOSE: To evaluate the role of amniotic membrane transplantation in the management of cicatricial eyelid entropion. DESIGN: Prospective, noncomparative interventional case series. PARTICIPANTS: Eighteen consecutive patients with cicatricial entropion. METHODS: A gray line lid split procedure with vertical anterior lamella repositioning was performed on 25 eyelids (upper or lower) of 18 patients with moderate to severe cicatricial entropion. Preserved human amniotic membrane (AM) was used to cover the bare tarsus up to the lid margin and secured with running 7-0 Vicryl. Impression cytology of the AM was performed at various stages postoperatively to study the epithelialization process. MAIN OUTCOME MEASURES: (1) Reepithelialization of bare tarsus, (2) extent of tarsal shrinkage, (3) recurrence of entropion. RESULTS: All the AM grafts took well. The most common complication was hemorrhage below the graft, which occurred in six cases. Complete success with no lashes touching the globe was achieved in 22 of 25 (88%) lids after a minimum follow-up of 12.0 months. The mean follow-up was 17.8 months. Two cases (qualified success) had recurrent trichiasis treated successfully with electrolysis. One case with severe trachomatous upper lid entropion recurred 14 months after surgery. The AM accelerated the epithelialization of bare tarsus; this was demonstrated by lack of fluorescein staining and reversion to skin color within 2 to 3 weeks. However, AM could not prevent tarsal shrinkage. Impression cytology demonstrated that features of conjunctival epithelium were present for the first postoperative month, but this was gradually replaced by squamous metaplasia, with keratinization appearing as early as 3 weeks postoperatively. CONCLUSIONS: The use of AM in a lid split procedure for correction of cicatricial entropion helps the bare tarsus epithelialize rapidly and improves the initial cosmetic result of surgery.     

两种术式治疗重度上睑瘢痕性睑内翻的疗效比较

目的：比较显微镜下Hotz法联合睑缘切开皮瓣转位术和单纯Hotz法治疗重度上睑瘢痕性睑内翻的临床效果。

方法：回顾性分析2017-07/2019-07在我院接受上睑内翻倒睫矫正术的患者60例84眼,试验组32例42眼采用显微镜下Hotz法联合睑缘切开皮瓣转位术,对照组28例42眼采用单纯Hotz法。术后随访观察至12mo, 记录患者主观症状、睑缘位置、睫毛外翻情况及满意度。

结果：试验组单眼平均手术时间长于对照组(40.8±2.57min vs 28.5±2.64min,P<0.01)。术后1、12mo,试验组治愈率分别为100%、95%,对照组治愈率分别为95%、76%,术后12mo试验组治愈率优于对照组(P=0.013)。 术后1mo两组患者满意度无差异(Z=1.1825,P=0.2371),术后12mo试验组患者满意度高于对照组(Z=3.7346,P<0.01)。

结论：对于重度上睑瘢痕性睑内翻,显微镜下Hotz法联合睑缘切开皮瓣转位术虽手术时间长于单纯Hotz法,但其远期疗效优于单纯Hotz法,术后12mo患者满意度较高。     

Central corneal dellen: a complication of upper eyelid tarsotomy

PURPOSE: To report a rare complication of central corneal dellen that developed after a tarsotomy procedure to correct cicatricial entropion. METHOD: Central corneal dellen developed in a 60-year-old woman 3 months after a tarsotomy procedure for correction of cicatricial upper eyelid entropion. Eversion of the upper eyelid showed a retracted and buckled tarsal plate and the presence of a 5 x 10-mm depression between the edge of the tarsoconjunctival flap and lower tarsal bridge. RESULTS: The recalcitrant corneal defect was reversed when the upper eyelid tarsoconjunctival surface contour was restored by full-thickness tarsal incisions designed to flatten the dome-shaped tarsal plate. CONCLUSION: An upper eyelid defect producing suboptimal lid-globe apposition during lid closure can lead to dellen formation because of focal corneal dehydration as the result of an altered tear meniscus.     

儿童眼球突出继发下睑退缩的手术探讨

目的 探讨儿童眼球突出继发下睑退缩的手术方式和效果.设计回顾性病例系列.研究对象北京儿童医院不同原因所致眼球突出合并下睑退缩、内翻倒睫患儿8例(14眼),年龄1岁3个月～8岁4个月.方法 所有病例采用下睑缩肌后徙联合睑板内固定术.术后随访6～12个月.主要指标术前术后下睑缘中央至瞳孔反光点距离(MRD2)、下睑内翻倒睫...     

Lower eyelid reconstruction of traumatically caused cicatricial entropion with amniotic membrane or mucosal membrane grafts

BACKGROUND: A retrospective evaluation was undertaken of eyelid reconstruction with amniotic membrane or oral mucosal membrane transplantation in patients with lower lid cicatricial entropion after orbital surgery. PATIENTS AND METHODS: Seven patients (four women) were treated with a scar tissue dissection and an amniotic membrane or mucosal membrane transplantation between 2003 and 2006 (Five amniotic membrane grafts and two oral mucosal membrane grafts). In selected cases additional procedures like a lateral tarsal strip operation, a tarsal fracture, or the reinsertion of the lower lid retractors were performed. RESULTS: All patients showed a favourable postoperative result with a good anatomic correction of the entropion and a regression of the preoperative disturbances. All the grafts took well. Two patients had to be reoperated twice and one patient three times as a result of a relapse of the cicatricial entropion. However, as well in these patients the anatomical and functional result was favourable at the end. CONCLUSIONS: The difficult scar dissection with the subsequent amniotic membrane or oral mucosal membrane transplantation seems to be an appropriate procedure to reconstruct complicated cicatricial entropion after orbital surgery.     

Retractor plication for lower lid entropion in ocular cicatricial pemphigoid

The surgical treatment of lower lid entropion in ocular cicatricial pemphigoid has previously met with limited success and conventional techniques have in some cases caused disease progression. We have treated lower lid entropion in this condition with retractor plication, avoiding surgery to the conjunctiva in five patients (seven eyelids) over the past five years with successful correction of the condition and symptomatic improvement in all patients. It has not led to an acute exacerbation of the condition in any patient and we recommend it as the procedure of choice in the surgical management of entropion in this disorder.     

Anterior tarsal V-wedge resection for cicatricial entropion

PURPOSE: To determine the effectiveness of using a radiofrequency instrument to resect a V-shaped tarsal wedge for the correction of cicatricial upper eyelid entropion. METHODS: Prospective evaluation of 16 upper eyelids of 11 consecutive patients. RESULTS: The operation was successful in all 16 eyelids, with excellent cosmetic and functional outcomes. CONCLUSIONS: Tarsal V-wedge resection is an effective alternative to other complicated techniques in the management of upper eyelid cicatricial entropion.     

异体巩膜条睑板延长术治疗复发性瘢痕性睑内翻

目的：探讨异体巩膜条睑板延长术治疗复发性瘢痕性上睑内翻的手术疗效。方法：对27例(36只眼)复发性瘢痕性上睑内翻患者采用从睑板沟切断睑板的方法，在睑板铁损区嵌入异体巩膜条，延长睑板，松解瘢痕。结果：28只眼内翻矫正，8只眼复发，3只眼再次手术后矫正。结论：采用异体巩膜条睑板延长术治疗复发性瘢痕性眼睑内翻，手术方法简便，损伤小，可反复操作，疗效满意，异体巩膜易于获得及保存，是一种值得推广的手术方法。     

睑板部分切除联合脱细胞真皮植入矫正瘢痕性上睑内翻临床观察

目的 评估睑板部分切除联合脱细胞真皮植入矫正瘢痕性上睑内翻的临床疗效.方法 对严重眼化学伤或热烧伤致瘢痕性上睑内翻的病人11例(13只眼睑),均行睑板部分切除联合脱细胞真皮植入术.术后随访5～20个月(平均10个月).结果 11只眼睑内翻获得成功矫正.有2只眼睑内翻复发,再次手术后睑内翻获得成功矫正.荧光素染色试验显示术后所有患者角膜上皮缺损明显减少.术前泪膜破裂时间(BUT)为(4.46±1.20)s,术后3个月延长至(6.92±1.32)s,差异具有统计学意义(P＜0.01);术后泪液分泌量(Schirmer I试验)与术前相比较差异无统计学意义(P＞0.05).结论 用睑板部分切除联合脱细胞真皮植入术来治疗由眼部化学伤或热烧伤引起的伴有眼睑变形的瘢痕性上睑内翻是一种安全有效的方法.     

Surgical outcome of involutional lower eyelid entropion correction using transcutaneous everting sutures in Chinese patients

To evaluate the clinical efficacy of transcutaneous everting sutures for lower eyelid involutional entropion in Chinese patients. A retrospective, non-comparative, interventional case series. This retrospective study consecutively reviewed the medical records of all patients with involutional lower eyelid entropion who underwent transcutaneous everting suture for entropion correction at the Department of Ophthalmology, Caritas Medical Centre, from 1st January 2010 to 31st October 2013. Exclusion criteria included concurrent eyelid pathologies such as malignant tumor, infection, cicatricial entropion, post-operative follow-up period of <3 months, significant horizontal lid laxity, and aged <60 years at the time of surgery. The primary outcome measures were recurrence rate and complications. Secondary outcome measures included patient demographic data, type and number of everting sutures, duration of operation, timing of stitch removal, duration of follow-up, as well as each patient’s medical history and current medications. Thirty-four eyelids of 28 patients were included. The average age was 78.2 ± 7.3 years and the male to female ratio was 4:3. In this series, 26.5 and 2.9 % of eyelids underwent entropion correction whilst receiving aspirin and warfarin, respectively. The mean duration of post-operative follow-up was 13.2 ± 10.5 months. The recurrence rate was 11.8 % at a mean of 9.0 ± 6.0 months. There were no peri-operative or post-operative complications observed. A transcutaneous everting suture was found to be a quick and effective means to correct senile involutional lower lid entropion in Chinese patients with no complications despite the continued use of anti-coagulation therapy in >25 % of our cases.     

Surgical correction of entropion and excess upper eyelid skin in congenital cutis laxa: a case report

Congenital cutis laxa is a rare generalized inherited elastosis, characterized by the appearance of premature aging and skin laxity with mild to severe systemic anomalies. Ocular manifestations include excess skin in the eyelids, ptosis and lower lid ectropion. Of the hyperelasticity syndromes – Ehlers Danlos, Pseudoxanthoma elasticum and cutis laxa – only cutis laxa has normal skin wound healing. The diagnosis must therefore be established before surgical options for treatment are considered. We report an unusual case of a 5-month-old male child with cutis laxa who presented with upper lid entropion secondary to severe redundant upper eyelid skin. An anterior lamellar repositioning procedure successfully corrected the lid margin malposition with complete relief of symptoms.     

Surgical correction of entropion and excess upper eyelid skin in congenital cutis laxa: a case report

Congenital cutis laxa is a rare generalized inherited elastosis, characterized by the appearance of premature aging and skin laxity with mild to severe systemic anomalies. Ocular manifestations include excess skin in the eyelids, ptosis and lower lid ectropion. Of the hyperelasticity syndromes - Ehlers Danlos, Pseudoxanthoma elasticum and cutis laxa - only cutis laxa has normal skin wound healing. The diagnosis must therefore be established before surgical options for treatment are considered. We report an unusual case of a 5-month-old male child with cutis laxa who presented with upper lid entropion secondary to severe redundant upper eyelid skin. An anterior lamellar repositioning procedure successfully corrected the lid margin malposition with complete relief of symptoms.     

Orbicularis oculi muscle transposition for repairing involutional lower eyelid entropion

Purpose

To describe a simple technique for involutional entropion correction and to present the findings of a retrospective interventional case series study.

Methods

We studied a consecutive series of 414 patients (609 eyelids). Patients presenting with involutional entropion in the absence of lateral canthal tendon laxity underwent orbicularis oculi muscle (OOM) transposition from pretarsal position to corresponding preseptum without horizontal shortening or resection of the orbicularis muscle.

Results

Immediate resolution of entropion and associated ocular symptoms was achieved in 607 eyelids (99.67 %). An early postoperative complication was localized lid swelling that gradually subsided within one week. Over-correction occurred in six cases and resolved with pressure dressing, mostly one or two days post-operation. At final follow-up, a significant improvement in eyelid position was achieved in 579 eyelids (95.07 % ). There was mild recurrence of entropion in 30 eyelids (4.93 %). The mean follow-up was 6.84 months (range, 6–12 months).

Conclusions

Orbicularis oculi muscle transposition is a reasonably successful procedure with a high success rate, and is particularly suitable for patients for whom there exits overriding of the preseptal OOM over the pretarsal OOM.     

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.