The histopathology of involutional ectropion and entropion

Objective: Involutional ectropion and entropion are characterized by excessive horizontal eyelid length, which is thought to be secondary to laxity of the medial and lateral canthal tendons and to the stretching of the tarsus. Histopathological features of the surgical eyelid specimens from patients with involutional ectropion and entropion were evaluated.Design: Prospective histopathological study.Participants: Eighteen full-thickness eyelid specimens from patients with involutional ectropion and entropion were obtained during horizontal eyelid shortening procedures performed at the Ministry of Health Ankara Training and Research Hospital.Methods: All specimens were fixed in 4% formaldehyde solution and sectioned sagittally. Hematoxylin-eosin, periodic acid-Schiff, and Masson's trichrome staining were done for all specimens. Histopathologic alterations of the tarsal plate, the palpebral portion of the orbicularis muscle, and the conjunctiva were examined.Results: The patients ranged in age from 60 to 80 years. The main histopathologic features of the ectropic eyelids included collagen degeneration and elastosis of the tarsal plate, increased amounts of adipose tissue in the distal tarsus, and subacute inflammation and epidermalization of the tarsal conjunctiva. Specimens from patients with involutional entropion generally had milder degrees of these histopathological features.Conclusions: The causes of the excessive horizontal length of the eyelid, which is thought to be secondary to laxity of the medial and lateral canthal tendons, may be collagen degeneration and elastosis of the tarsal plate and canthal tendons.     

Pathogenesis of Involutional Ectropion and Entropion: The Involvement of Matrix Metalloproteinases in Elastic Fiber Degradation

Purpose:?To determine the elastic fiber content and ultrastructure as well as the expression of elastin-degrading enzymes in biopsy specimens from patients with involutional ectropion and entropion.

Materials and Methods:?Twenty consecutive patients with involutional ectropion (group 1) and twenty consecutive patients with entropion (group 2) were matched with twenty control patients (basal cell carcinoma) regarding age and gender. Full-thickness eyelid resections performed in study and control patients were examined by light and transmission electron microscopy, computer-assisted measurements, and immunohistochemistry using antibodies against matrix metalloproteinase (MMP)-2, MMP- 7, and MMP-9. The Kruskal-Wallis test and the Pearson chi-square test were performed.

Results:?Histopathologic analysis of the surgical specimens from patients with involutional ectropion and entropion showed a significant loss of elastic fibers in the eyelid skin, the pretarsal orbicularis oculi muscle, the perimeibomian tarsal stroma, and the intermeibomian tarsal stroma (P < 0.001). Residual elastic fibers revealed an abnormal ultrastructure. Immunohistochemistry demonstrated a significant overexpression of MMP- 2, MMP-7, and MMP-9 in the eyelid skin, the pretarsal orbicularis oculi muscle, the perimeibomian tarsal stroma, the intermeibomian tarsal stroma, and the conjunctiva in groups 1 and 2 compared to controls (P < 0.001).

Conclusions:?The present findings indicate that upregulation of elastolytic enzymes contributes to elastic fibre degradation in patients with involutional ectropion and entropion.     

Lower eyelid retractor (white-line) advancement to correct tarsal ectropion

Objective

To describe a modification of trans-conjunctival, lower eyelid retractor advancement to correct tarsal ectropion.

探讨Medpor下睑插片联合外眦睑板条悬吊术治疗重度麻痹性下睑外翻

目的　探讨Ｍｅｄｐｏｒ下睑插片联合外眦睑板条悬吊术治疗重度麻痹性下睑外翻的临床疗效。方法　回顾性系列病例研究。收集１６例（１６眼）重度麻痹性下睑外翻患者的临床资料,所有患者均采用Ｍｅｄｐｏｒ下睑插片联合外眦睑板条悬吊术治疗。记录并比较１６例患者术前及术后１周、３个月、１２个月的眼睑闭合不全量、下睑退缩量、角膜上皮分级、下睑水平及垂直松弛度等级。结果　１６例患者术后下睑外翻均矫正,随访期内均未见复发。术后１周、３个月、１２个月,下睑退缩量、眼睑闭合不全量均较术前明显下降,差异均有统计学意义（均为Ｐ＜０．０５）;术后各时间点间比较,差异均无统计学意义（均为Ｐ＞０．０５）。随访期间各患者的角膜上皮分级、水平及垂直松弛度等级均较术前明显改善,随访期末均为０级或１级。无１例患者术后出现眶内出血、感染及内植入物暴露、排斥、移位等严重并发症。结论　采用Ｍｅｄｐｏｒ下睑插片联合外眦睑板条悬吊术治疗重度麻痹性下睑外翻,可在保留患者视功能的前提下矫正下睑外翻及眼睑闭合不全,有效改善患者眼表状况及外观,且术后效果较为稳定。     

Rotation mattress suture: a powerful adjunct for ectropion correction

We describe an effective adjunctive suture technique for severe forms of both tarsal and marginal ectropion in a case series of 28 patients undergoing the rotation mattress suture technique for ectropion repair. Forty eyelids, followed for 1 to 5 years (average, 2.5 years), underwent tarsal or marginal ectropion repair, using the rotation mattress suture technique. Transient notching was noted in 31 eyelids (78%) but persisted in only 1 case (3%). Twenty-five eyelids (63%) had 0.5 to 1.0 mm of eyelid retraction. There were only 2 cases (5%) of recurrent ectropion. We found that excluding transient changes and predictable, mild lower eyelid retraction, the rotation mattress suture provides a powerful adjunctive reparative option for difficult cases of ectropion with low complication and failure rates.     

外侧睑板条悬吊联合下睑缩肌前徙术治疗老年性睑内翻

目的:观察和评价外侧睑板条悬吊联合下睑缩肌前徙术治疗老年复杂性睑内翻的方法及疗效。方法:老年性睑内翻患者主要病因有:眼睑松弛、下睑缩肌张力降低、眼轮匝肌变化,根据病因选择患者使用外侧睑板条悬吊联合下睑缩肌前徙术,术中观察眼睑位置不可过度外翻。结果:本组19例31眼诊断老年复杂性睑内翻的患者行外侧睑板条悬吊联合下睑缩肌前徙术,随访8～50mo,疗效确切。结论:外侧睑板条悬吊联合下睑缩肌前徙术是治疗老年复杂性睑内翻的有效方法。     

下睑缩短联合内眦部险缘缝合矫治麻痹性下险外翻

目的探讨下睑缩短联合内眦部睑缘缝合治疗麻痹性下睑外翻的疗效。方法对9例（9只眼）面瘫导致的麻痹性下睑外翻经药物及针灸治疗1年以上无效者,采用下睑经典眼袋切口,做下睑中外1／3楔形睑板切除联合上下泪小点鼻侧部分睑缘缝合,使下睑缘位置正常,睑外翻得以矫正。结果随访6—41个月,9例患者下睑外翻均得到矫正,无并发症发生。结论下睑缩短联合内眦部睑缘缝合矫治麻痹性下睑外翻疗效良好。     

Causes of involutional ectropion and entropion--age-related tarsal changes are the key

PURPOSE: To measure tarsal plates across various age-groups, to determine whether tarsal size changes with increasing age and whether size correlates with involutional ectropion and entropion. METHODS: Comparative, observational, case-control study design. Data were obtained for length and height of tarsus in each of the four eyelids. The data were constructed to determine: (I) right-to-left-side comparison data, (II) sex difference data, (III) age normal data, (IV) involutional entropion data, (V) involutional ectropion data. RESULTS: (I) There is no difference in tarsal dimensions between right and left sides; (II) males have larger tarsal dimensions than females; (III) tarsal plates are on average smaller in older age ranges; (IV) patients with entropion have smaller than average age-normal tarsal plates; (V) patients with ectropion have larger than average age-normal tarsal plates. CONCLUSIONS: (I) Right and left tarsal plates have equal dimensions, and involutional changes likely occur on both right and left sides equally frequently; (II) males have larger tarsal plates than females and entropion is more frequent in females and ectropion in males; (III) tarsal plates may have a general tendency to atrophy or shrink with age; this may explain why some eyelids develop entropion and others ectropion; (IV) entropion results from the mechanical effect of an atrophied or smaller than age-normal, partially or fully disinserted, tarsal plate being overcome by the normal or increased tone of the preseptal/pretarsal orbicularis muscle; (V) ectropion results from an age-normal or larger than normal tarsal plate mechanically overcoming the normal or decreased tone of the preseptal/pretarsal orbicularis muscle in combination with medial/lateral canthal tendon laxity.     

Anatomical basis of "senile" ectropion

A study of 20 patients with bilateral ectropion was undertaken to determine the exact anatomical etiology of the horizontal eyelid laxity which leads to "senile" (involutional) ectropion. Two previous studies on normal people have shown a slight increase in the horizontal length of the lateral canthus with increased age. The results of the 20 patients with ectropion revealed that the lateral canthal tendon is significantly increased in horizontal length as compared with normal, age-matched controls. Therefore, surgery directed to the repair of the attenuated, horizontally lax, lateral canthus is more appropriate than full-thickness block or tarsal resection of the normal eyelid in the palpebral fissue. Additionally, since normal full-thickness eyelid tissue is not resected, the horizontal length of the palpebral fissue will not be shortened. This results in a more pleasing cosmetic appearance as well as an improved functional result.     

应用外翻严重度评分评价涤纶心脏补片联合睑板缩短术治疗麻痹性下睑外翻的手术疗效

目的 应用外翻严重度评分（ESS）评价涤纶心脏补片联合睑板缩短术治疗麻痹性下睑外翻的手术疗效。设计 回顾性病例系列。研究对象 2017年5月至2019年6月北京同仁医院手术治疗的麻痹性下睑外翻患者7例（7眼）,其中男性5例（5眼）,平均年龄（70±9）岁。方法 手术方法为将涤纶心脏补片修剪至合适尺寸后内侧固定于内眦韧带及内侧眶缘,外侧固定于外侧眶缘,同时联合行睑板缩短术。基于眼外观照相的ESS对下睑外翻的位置和程度,有无巩膜暴露、睑结膜暴露、泪膜过多、结膜充血、眦角圆顿、泪小点外翻的体征逐项评分,最高分为8分。应用ESS评分评价术前下睑外翻严重度及术后疗效。平均随访（19±10）个月。主要指标 ESS评分及手术并发症。结果 术前ESS评分4.5~8分,中位数为8分;术后随访终点ESS评分0~1分,中位数为0分;较术前显著好转（Z=-0.756,P=0.017）。无欠矫及复发,成功率100%。植入物无移位或脱位。结论 涤纶心脏补片联合睑板缩短术应用于麻痹性下睑外翻的治疗安全有效,外翻严重度评分是一种直观并可量化的评价方法。（眼科, 2020, 29： 386-390）     

Involutional entropion repair with fornix sutures and lateral tarsal strip procedure

PURPOSE: To evaluate the long-terrm effectiveness of fornix suture placement combined with a lateral tarsal strip procedure in correcting involutional entropion. Published reports regarding various surgical techniques and results are reviewed. METHODS: This retrospective study reviewed 119 patients with involutional lower eyelid entropion who underwent surgical repair between January 1987 and May 1999 at the Bascom Palmer Eye Institute. Exclusion criteria included follow-up duration of less than 6 months, previous lower eyelid blepharoplasty, previous conjunctival surgery other than chalazion removal, or cicatricial entropion. The three surgical subsets were (1) combined lateral tarsal strip and fornix sutures: (2) fornix sutures alone; and (3) lateral tarsal strip procedure alone. The chart review was complemented by a telephone questionnaire to assess the long-term clinical outcome, complications, and patient satisfaction. RESULTS: One hundred fifty-two eyelids in 119 patients were included. One hundred twenty-five eyelids had combined surgery (lateral tarsal strip with fornix sutures), 9 eyelids had only fornix suture repair, and 18 eyelids had repair with only the lateral tarsal strip procedure. The recurrence rate in these three surgical subsets was 1.6%, 33%, and 22%, respectively, with average follow-up of 36 months. One case of incisional cellulitis was encountered. Postoperative ectropion was not seen in the group having the combined lateral tarsal strip and fornix suture procedure. CONCLUSIONS: Suture advancement of the lower eyelid retractors in conjunction with a lateral tarsal strip procedure is a simple, quick, physiologic, and effective approach in achieving long-lasting correction for involutional entropion.     

Age-related medial ectropion of the lower eyelid

Background : A simplified procedure is proposed for the repair of medial lower eyelid age-related ectropion. Methods : A posterior horizontal incision is made in the medial half of the lower eyelid at the inferior border of tarsus. The lower eyelid retractors are exposed and then plicated to the tarsus without excision of posterior lamellae or the use of everting sutures. The lid is then shortened horizontally with excision of a pentagonal section or lateral tarsal strip procedure. Results : The procedure was performed in six patients successfully without complication. Conclusions : This is an effective method for repair of lower lid medial age-related ectropion.     

Correction of involutional lower eyelid medial ectropion with transconjunctival approach retractor plication and lateral tarsal strip

AIM: We describe the technique and our results in managing lower eyelid involutional medial ectropion using a combination of lateral tarsal strip to address horizontal eyelid laxity, and transconjunctival inferior retractor plication to address inferior retractor dehiscence. METHODS: Patients with symptoms of epiphora or signs of medial ectropion were offered this procedure. All had the following characteristics: medial lower eyelid eversion, punctal eversion >3 mm, medial canthal tendon laxity <4 mm, significant horizontal eyelid laxity and lacrimal systems that were patent to syringing. RESULTS: A total of 24 eyelids of 17 patients underwent this procedure over a 12-month period. The mean age of the patients was 79.7 years; 11 were male and six were female. The mean follow-up time was 18 months. Two eyes had undergone previous surgery. All patients had restoration of the eyelid margin to the globe and relief of symptoms. No complications were noted. DISCUSSION: These results suggest that excision of posterior lamellar tissue is not necessary for correction of involutional medial ectropion. Transconjunctival plication or reattachment of retractors is easy to perform and allows for the repair of more than the medial portion of the retractors if required.     

Microscopic anatomy of the lower eyelid in asians

PURPOSE: To study the microscopic anatomic relation of the capsulopalpebral fascia, orbital septum, and tarsus of the lower eyelid in Asians. The anatomic differences between the Asian and non-Asian upper eyelid have been well described by various authors, but the differences of the lower eyelid have not been well characterized microscopically. The microscopic anatomy of the lower eyelid in non-Asians was well studied, but in Asians, despite the presence of gross differences, there were very limited studies on the microscopic anatomy. A thorough knowledge of the Asian lower eyelid anatomy is essential for surgical exploration of the eyelid. It may also explain the higher prevalence of eyelid disorders such as epiblepharon and entropion in Asians. METHODS: Ten normal Asian lower eyelids from 10 formalin-fixed cadavers (mean age, 67.5 years) were harvested and studied with light microscopy after staining with Masson trichrome. RESULTS: There was no fusion of the orbital septum and the capsulopalpebral fascia at the lower border of the tarsal plate in 7 specimens and a very limited fusion of these tissues in 3 specimens. The average distance from the inferior tarsal border to the first observable smooth muscle nuclei of the inferior retractors was 1.44 mm. The average tarsal plate thickness was 1.36 mm and the average tarsal plate height was 4.12 mm. CONCLUSIONS: The Asian lower eyelid anatomy differs from its non-Asian counterpart. There was no consistent fusion between the capsulopalpebral fascia and the orbital septum inferior to the inferior tarsal border. No extension of the capsulopalpebral fascia to the skin was observed. The average distance between the inferior retractors and the inferior tarsal plate was 1.44 mm in the normal Asian lower eyelid.     

Role of the lower lid retractors in involutional ectropion repair

AIM. To outline the role of the lower lid retractors in correction of involutional ectropion. METHODS. Eight eyelids with a tarsal ectropion were included in the study. Clinical clues to help identify weakness of the lower lid retractors were documented. A transconjunctival lower lid retractor reattachment with concommitant correction of horizontal lid laxity and lamellar dissociation was performed. RESULTS. Stable eyelid position was obtained in 7 of the 8 cases. One case had a lateral ectropion due to a wound dehiscence. CONCLUSIONS. This small study helps better define the clinical presentations of retractor weakness and provides evidence of a systematic approach in correcting involutional ectropion.     

Conjunctival cytology features of giant papillary conjunctivitis associated with ocular prostheses

PURPOSE: In this study, the conjunctival cytology features of giant papillary conjunctivitis (GPC) associated with ocular prosthesis wear was examined. METHODS: In a prospective study, 12 consecutive patients diagnosed with GPC associated with ocular prosthesis wear were examined. Impression cytology specimens were taken from the upper eyelid tarsal conjunctiva, the bulbar conjunctiva, and the lower eyelid tarsal conjunctiva of each socket, with the contralateral eye serving as a matched control. RESULTS: The randomized impression cytology specimens showed no significant change in goblet cell density or epithelial cell morphology when comparing the GPC and control specimens. The GPC specimens did have a statistically significant increase in conjunctival inflammation and mucous strands on all three sample areas. In addition, the GPC specimens from the upper and lower tarsal conjunctiva had a honeycomb pattern consistent with giant papillae. CONCLUSIONS: This is the first report to describe the honeycomb pattern created by giant papillae on impression cytology and the changes of GPC on the lower tarsal conjunctiva.     

Congenital ectropion: three case reports and literature review

To report 3 cases of congenital ectropion because of their rarity and confusing classification. Case 1: JPT, 2 days old, male, negro. Left upper eyelid eversion with chemosis was present, passive to mechanic reduction. Compressive occlusion was done with ectropion regression in 48 hours. Case 2: AJL, 6 years old, female, Caucasian, with Down syndrome. The left eye had hyperemia, lagophthalmos and inferior leucoma. She received horizontal shortening (superior and inferior tarsal strip) and skin grafts, and after 2 months the patient did not return. Case 3: GSD, 4 years old, male, Caucasian, with Down syndrome. His signs and treatment were the same as in case 2. According to Picó's classification the first case is classified as grade II due to eyelid eversion during the passage through the birth canal, more frequent in black people. Cases 2 and 3 represent grade III that is due to eyelid skin alteration, and the association with Down syndrome is observed. Treatment for ectropion grade III is always surgical, as it was done in these cases. We do not agree with Picó's classification, the only one found in medline, because there are no articles confirming the existence of grade I (absent tarsus), grade II should be called congenital upper eyelid eversion, grade IV (microphthalmos and orbital cyst) is a disease of the orbit. Grade III refers to true ectropion, because horizontal enlargement of superior and inferior eyelids (megaloblepharon).     

Anterior lamella actinic changes as a factor in involutional eyelid malposition

PURPOSE: We conducted a noncomparative, retrospective chart review of 45 patients and 51 eyelids with the diagnosis of involutional entropion or ectropion that underwent full-thickness lower eyelid shortening between June 2001 and February 2004, in whom the severity of actinic damage was analyzed in relation to the eyelid position. Patients with any different surgical approach or other primary causes of abnormal eyelid position, such as paralytic, congenital, or mechanical factors, were excluded. METHODS: After excision, all eyelid specimens were examined by a single anatomic pathologist, who was masked to the type of eyelid malposition. The extent of dermal actinic change was evaluated under light microscopy, according to a previously validated grading system. RESULTS: Fifty-one eyelids from 26 male and 19 female patients were analyzed. The mean age at the surgery was 76 +/- 10 years (range, 52 to 92 years), affecting one side in 39 cases and both sides in 6 cases. The most frequent eyelid malposition was ectropion, which affected two thirds of the cases (35 eyelids). Half of the patients presented with mild actinic skin changes; however, the severity of the histologic skin actinic changes was significantly worse in patients with ectropion in comparison to those with entropion (p < 0.0001). CONCLUSIONS: Actinic damage affecting the anterior lamella of the lower eyelid contributes as an additional factor in final eyelid position in patients with involutional eyelid changes. More severe and extensive actinic changes were present in eyelids with ectropion.     

异种脱细胞真皮基质联合邻位皮瓣修复眼睑全层缺损的临床观察

目的 观察异种脱细胞真皮基质联合邻位皮瓣Ⅰ期修复眼睑恶性肿瘤切除术后眼睑全层缺损的临床疗效.万法 35例(35眼)眼睑恶性肿瘤患者,其中基底细胞癌21例,睑板腺癌13例,鳞状细胞癌1例;累及上睑者12例,累及下睑者23例.所有患者均行术中冰冻并根据冰冻结果确定切缘,肿物切除后眼睑有不同程度全层缺损.取异种脱细胞真皮基质替代结膜睑板组织,根据皮肤缺损大小做邻近滑行或转位皮瓣修补眼睑缺损.术后观察皮瓣及口腔修复膜愈合情况、有无眼睑闭合不全及睑球粘连.结果 随诊半年,异种脱细胞真皮基质已完全溶解,被爬行结膜上皮覆盖,皮瓣愈合良好、无一例皮瓣坏死.其中28例患者术后恢复良好,无眼睑闭合不全及睑内、外翻.4例患者出现轻度眼睑闭合不全,均无暴露性角膜炎.3例患者出现轻度睑球粘连.结论 异种脱细胞真皮基质可替代睑板结膜组织,联合邻位皮瓣治疗眼睑恶性肿瘤切除术后的眼睑全层缺损有较好的临床疗效,可减少患者因取口唇黏膜或行二次眼睑重建的痛苦.     

Cutaneous melanoma of the eyelid. Clinicopathologic features.

The authors reviewed the clinical and histopathologic features of 32 patients with cutaneous malignant melanoma of the eyelid. The lower eyelid was more frequently the site of origin than the upper eyelid (21 patients, 66% of cases). A clinical diagnosis of melanoma was made in only 2 of 13 patients (15%) for whom the clinical diagnosis was listed. Clinical findings of pigmentation, ulceration/hemorrhage, or growth were documented in 25 (78%) patients. The histopathologic classification of the melanomas included nodular (19 patients, 59%), superficial spreading (7 patients, 22%), and lentigo maligna (6 patients, 19%). Associated histopathologic findings included solar elastosis (13 patients, 41%), nevus (12 patients, 38%), and basal cell carcinoma (4 patients, 13%). One of eighteen patients with follow-up data available died of metastatic melanoma.