带蒂皮瓣睫毛转位术矫正复杂瘢痕性睑内翻的疗效

目的:探讨带蒂皮瓣睫毛转位术治疗复杂瘢痕性睑内翻的临床效果。方法:对严重瘢痕性睑内翻伴大量乱睫、双行睫,及以往行过一次或多次倒睫矫正术复发患者68例115眼行带蒂皮瓣睫毛转位术治疗,随访6～32(平均23.3)mo,观察术后睑缘形态及睫毛情况。结果:术后6mo内2眼、6mo后3眼有少许乱睫(<6根)发生,再次行电解治愈;余患眼上睑睑缘形态良好,睫毛背离眼球表面,无倒睫复发,无并发症发生;6mo治愈率91.7%(55/60,8例术后6mo后失访)。结论:带蒂皮瓣睫毛转位术对复杂瘢痕性睑内翻有较好疗效,复发率低。     

Scleral homograft inlay for correction of cicatricial entropion and trichiasis.

In the management of trachomatous cicatricial entropion and trichiasis numerous surgical options are available to the surgeon, who, however, must choose the correct technique suitable to the severity of the condition. In general, severe cases do better with a graft of mucous membrane or skin. In this paper the use of another graft material, homologous sclera, in correcting entropion and trichiasis is discussed. A 1.5 to 2 mm wide strip of fresh or preserved sclera was used as an inlay in a grey-line split technique with severance of pretarsal and Riolan's fibres in 155 entropion corrections in 136 patients. There was a success rate of 92.3% during the observation period of 15 months. Isolated trichiatic lashes were seen in 7.7%. Minor complications occurred, such as granulomas and partial sloughing of grafts, but did not affect the ultimate results.     

睑内翻改良手术的设计与效果观察

目的探讨一种治疗上睑瘢痕性睑内翻的改良手术方法的效果。方法设计上睑瘢痕性睑内翻的改良手术,包括:上睑重睑术皮肤切口、睑板楔形切除、皮肤部分切除及自穹隆部球结膜进针的褥式缝合线等。临床应用442例619眼,随访6个月,观察其矫正效果。结果本组442例(619眼)中,3例(3眼)3个月后仍有2~3根睫毛方向不正,接触眼球,经睫毛电解后痊愈。余439例(616眼)获得较为满意的治疗效果及美容效果。结论作者设计的上睑内翻改良手术,融合了传统的睑内翻矫正术及现代美容手术的优点,效果良好。     

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.     

Lid splitting with lash resection for cicatricial entropion and trichiasis.

Lid margin splitting at the gray line with resection of the lash-bearing anterior lamella of the eyelid is a simple and effective treatment for cicatricial entropion and trichiasis. Twenty-six patients underwent this procedure with good results.     

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.     

改良缝线法矫正儿童特发性下睑内翻倒睫

目的:评价改良缝线法治疗儿童特发性下眼睑内翻倒睫的效果。方法:应用改良缝线法治疗儿童特发性下眼睑内翻倒睫。结果:本组72例中治愈43例,好转25例,失败4例。总有效率94%。结论:缝线法对于儿童特发性下眼睑内翻倒睫具有良好的手术疗效,且手术操作简单,损伤小。     

瘢痕性天疱疮35例临床分析

目的:探讨瘢痕性天疱疮临床特点,为临床诊治提供帮助。方法:回顾性分析2002-01/2008-01我科诊治的35例瘢痕性天疱疮临床特点。结果:瘢痕性天疱疮平均发病年龄为62.4岁,男女性别比为20∶15,病史平均3.3a,51.43%以口腔黏膜病变首发,31.43%以眼部病变首发,眼睑内翻倒睫/慢性结膜炎和干眼/角膜病变为5/4/2,17.14%以其它黏膜病变首发。经过治疗,71.43%(25/35)患者症状消失或缓解超过3mo,14.29%(5/35)患者症状反复或无明显缓解,14.29%(5/35)患者中途退出治疗。治疗过程中37.14%(13/35)患者出现全身其它异常,其中6例出现肝功能异常,2例终止治疗,肾功能异常2例,1例终止治疗,血液系统异常3例,1例退出治疗,心肌梗塞1例,退出治疗,明显血压升高1例。结论:瘢痕性天疱疮是一种慢性病,多发于老年人,男性稍多于女性,眼组织经常受累,多表现为干眼症、睑球粘连和内翻倒睫。瘢痕性天疱疮治疗复杂,经常需要多学科协作。     

Current orbital literature

Cicatricial entropion is an acquired process caused by scarring of the inner eyelid with mechanical shortening of the posterior lamella. We present two consecutive patients with cicatricial entropion as the heralding sign of allergic blepharoconjunctivitis. A 12-year-old girl and a 41-year-old man presented to a referral oculoplastics practice with ocular irritation and conjunctival symblepharon. Neither patient had a history of allergic ocular symptoms. Slit lamp examination revealed marked conjunctival scarring of all four eyelids in each patient. Conjunctival scraping and cell staining revealed eosinophils and polymorphonuclear leukocytes. No evidence of infection, including Chlamydia and Herpes zoster, was detected. Asymptomatic allergic blepharoconjunctivitis should be included in the differential diagnosis of cicatricial entropion. Conjunctival scraping may be helpful in the diagnosis.     

Ocular manifestations in a case of childhood cicatricial pemphigoid

PURPOSE: Cicatricial pemphigoid is a rare chronic autoimmune disease, characterized by progressive alterations on the skin and mucous membranes. Ocular lesions consists of chronic conjunctivitis, progressive subepithelial fibrosis on the conjunctival fornix together with symblepharon formation, obstruction of the Meibomian ducts, sicca syndrome, and occasionally, entropion associated with consequent trichiasis and corneal ulcers. METHODS: A 9-year-old patient with cicatricial pemphigoid with severe eye involvement came to our observation. A complete anamnesis, ophthalmologic examination, and systemic evaluation, including serum antibody levels evaluation and biopsies of mouth, vulva, parotid, and intestine mucosa, were performed. RESULTS: Ocular examination showed blepharospasm, conjunctival hyperemia, symblepharon, total cicatricial corneal leucoma, severe dryness, trichiasis, and eyelid edema. The results of medical and surgical treatment are reported. CONCLUSIONS: Given the serious clinical picture, possibly due to a late diagnosis, it was not possible to avoid relapse and appearance of new cicatricial adherences for which we considered wait and see the most appropriate approach, protecting the anterior segment of both eyes, sacrificing their function. Further follow-up was not possible as the patient died. An early diagnosis would have had a significant influence on the clinical course and on the response to therapy.     

Cicatricial entropion caused by asymptomatic allergic conjunctivitis

Cicatricial entropion is an acquired process caused by scarring of the inner eyelid with mechanical shortening of the posterior lamella. We present two consecutive patients with cicatricial entropion as the heralding sign of allergic blepharoconjunctivitis. A 12-year-old girl and a 41-year-old man presented to a referral oculoplastics practice with ocular irritation and conjunctival symblepharon. Neither patient had a history of allergic ocular symptoms. Slit lamp examination revealed marked conjunctival scarring of all four eyelids in each patient. Conjunctival scraping and cell staining revealed eosinophils and polymorphonuclear leukocytes. No evidence of infection, including Chlamydia and Herpes zoster, was detected. Asymptomatic allergic blepharoconjunctivitis should be included in the differential diagnosis of cicatricial entropion. Conjunctival scraping may be helpful in the diagnosis.     

Prevalence of cicatricial trachoma in an indigenous population of Central Australia: the Central Australian Trachomatous Trichiasis Study (CATTS)

BACKGROUND: Trachoma is one of the leading causes of blindness worldwide, resulting from conjunctival scarring, upper lid entropion and trichiasis, leading to corneal scarring and opacification. This study was designed to investigate the current prevalence of cicatricial trachoma in an indigenous population within Central Australia and help determine whether trachoma remains a public health issue. METHODS: Participants aged 40 and over were recruited from patients attending one of 16 remote ophthalmology clinics held at indigenous communities in Central Australia within the Northern Territory. Once informed consent had been obtained, each patient underwent examination for evidence of trachomatous scarring, trachomatous trichiasis and corneal opacities. Results were collated and compared with previous prevalence surveys. RESULTS: Among the sample (n = 181), there were 97 patients (54%; 95% CI 46.7-61.3) with trachomatous scarring, 15 patients (8%; 95% CI 2.8-13.2) with trichiasis and 5 patients (3%; 95% CI 0.5-5.5) with corneal opacities. CONCLUSION: This study suggests that, although the prevalence of the cicatricial and blinding consequences of trachoma may be decreasing in patients aged 40 years or greater, when compared with the current prevalence in other areas of Australia, trachoma still remains a public health issue in Central Australia.     

Operative Entropiumkorrektur

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.     

The association between epilation and corneal opacity among eyes with trachomatous trichiasis

AIM: To examine the association between epilation and corneal opacity (CO) among trichiasis patients presenting for surgery. METHODS: Cross sectional data from the STAR trial were utilised. Patients presenting for trichiasis surgery in Wolayta Zone, Ethiopia, were evaluated for current trichiasis status. Number of inturned lashes, evidence of epilation, level of entropion, trichiasis duration, and CO were collected. The primary outcome was prevalence of CO, stratified by entropion and epilation status. RESULTS: Approximately 10% of eyes with mild entropion had CO, regardless of epilation status. Among eyes with moderate entropion, epilated eyes were less likely to have CO than non-epilated eyes (21% v 34% p = 0.002). The same association was seen in eyes with severe entropion: 43% of epilated eyes while 74% of non-epilated eyes had CO (p<0.0001). Presence of CO increased with age. Adjusted models showed a protective effect of epilation in eyes with moderate or severe entropion (OR: 0.51; 95% CI: 0.32 to 0.83 and OR: 0.24; 95% CI: 0.13 to 0.45, respectively). Among eyes with mild entropion there was no difference in the prevalence of CO comparing eyes that were epilated with those that were not epilated. CONCLUSION: Entropion was the most significant predictor of CO. Cross sectional associations suggest that epilation may not be helpful for eyes with mild entropion, but may offer protection against CO in eyes with moderate to severe entropion. Epilation should not be a substitute for trichiasis surgery, however, as 43% of eyes with severe entropion that were epilated still had CO.     

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.     

AN OPERATION FOR ENTROPION AND TRICHIASIS:A COMPOSITE OF METHODS FOR LID MARGIN ROTATION

Abstract
An operation for entropion/trichiasis is presented which is applicable to both upper and lower lids, and for grades of distortion from mild to severe. It is suitable for gross trachomatous lid disease in Aboriginal patients, and also for the discomfort of chronic cicatricial trichiasis in aged Caucasians.
No new procedure is proposed. The method combines features of several well tried operations to free the inturned lid margin and resuture it in proper apposition.     

Cicatricial entropion following docetaxel (Taxotere) therapy

We report eyelid margin changes in 3 patients after docetaxel treatment for breast cancer. These patients were referred to Cincinnati Eye Institute for eyelash abnormalities and/or epiphora and all had been treated with docetaxel in the near past. The ophthalmic complaints started soon after chemotherapy. All 3 cases showed varying degrees of palpebral mucosal inflammation and cicatricial changes leading to marginal entropion. The first patient exhibited very prominent eyelid margin inflammation and diffuse trichiasis without madarosis. The second patient had extensive madarosis and abnormally curved, thin eyelashes with punctal and canalicular obstruction. Her marginal entropion was most prominent at the medial lower eyelids. The last patient showed significant lash misdirection in a scattered distribution and patchy madarosis along with pseudomembranes blocking the puncta. All of these eyelid abnormalities occurred soon after docetaxel treatment for advanced breast cancer. Such changes in the absence of questioning for previous docetaxel use in history taking.     

【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.     

Diagnostics and pharmacological treatment of ocular cicatrical pemphigoid

Ocular cicatricial pemphigoid (OCP) is an autoimmune disease characterize by mucous membrane fibrosis and skin changes resulting with scarring. The pathogenic mechanisms of ocular cicatricial pemphigoid are incompletely understood. Antibasement membrane antibodies which lead to subepithelial blistering, granulation tissue and inflammatory infiltrate formation in the substantia propria are thought to be the main pathophysiological mechanisms in cicatricial pemphigoid. It has been found eosinophils and increased collagen type I and III. Human leukocyte antigen HLA-DR2, HLA-DR4 and DQw7 genotypes have been identified as conferring increased susceptibility to the development of this disease. Ocular cicatrical pemphigoid (OCP) is one of the forms of bullous pemphigoid. Initial symptoms of ocular pemfigoid are not characteristic. Conjunctival fibrosis may cause severe entropion, trichiasis, symblepharon, dry eye syndrome, corneal epithelial erosions or ulceration. Secondary glaucoma is one of the most frequent complications. Ocular cicatricial pemphigoid may be chronic, acute, or subacute disease with periodic exacerbation of conjunctival inflammation. The treatment in this disease are topical drops or ointment (lubricants, corticosteroids, antibiotics, antiglaucomatous). Oral dapsone and corticosteroids may control the activity of the disease. In other progressive cases immunosuppressive drugs must be used (azathioprine, cyclophosphamide, methotrexate, mycophenolan mofetil, daclizumab, intravenous immunoglobulin therapy). To make an early diagnosis of ocular cicatricial pemphigoid, biopsy and immunohistochemical analysis of conjunctiva should be performed in every case of persistent conjunctival inflammation.     

Trichiasis

Trichiasis is a lid margin disorder in which the eyelashes are misdirected toward the ocular surface. It is a major cause of ocular morbidity. Trichiasis is secondary to inflammation and scarring of the eyelash follicles. There is a frequent association between trichiasis and cicatricial entropion and the correct diagnosis is mandatory for a successful treatment. There are several options for the management of trichiasis and the main purpose is to eliminate the anomalous cilia and improve the patient’s comfort. Temporary measures include eye lubricants, contact lenses, and mechanical epilation. Surgical treatments have initial success but long-term results are poor and recurrences are frequent. Definitive trichiasis treatments include bipolar electrolysis, radiofrequency ablation, cryotherapy and laser ablation, and surgical procedures. The techniques are described in detail along with possible complications and outcome.