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.     

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.     

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.     

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.     

Comprehensive, combined anterior and transcaruncular orbital approach to medial canthal ligament plication

PURPOSE: To assess the efficacy of a comprehensive technique for correction of severe punctal and medial lower eyelid ectropion and lower eyelid retraction associated with medial canthal ligament (MCL) laxity. METHODS: A comprehensive technique that plicates the anterior and posterior crura of the MCL was performed on 8 eyelids of 6 patients with punctal ectropion and MCL laxity. Preoperative and postoperative symptoms, punctal ectropion, medial lower eyelid ectropion, lower eyelid retraction, lagophthalmos, and exposure keratopathy were evaluated. RESULTS: At an average of 13 months (range, 8-17 months), preoperative symptoms of epiphora and discomfort improved or resolved in all eyes. Punctal ectropion improved in all eyes and completely resolved in 75% of eyes. Medial lower eyelid ectropion was corrected in all eyes, when present. Lower eyelid retraction, lagophthalmos, and exposure keratopathy improved in all eyes. In 1 case, edema of the caruncle and semilunar fold persisted for 6 months. CONCLUSIONS: Combined anterior and transcaruncular MCL plication is an effective and safe procedure for addressing severe punctal and medial lower eyelid ectropion that accompanies MCL laxity and is difficult to correct by other methods. This procedure provides stable, 3-dimensional support to the medial lower eyelid and punctum.     

Orbicularis oculi muscle extirpation in a combined procedure for involutional entropion

Many factors are important in the pathophysiology of involutional entropion, including defects of the lower eyelid retractors, canthal tendon laxity, and acquired enophthalmos. The role of the overriding preseptal orbicularis oculi muscle is often ignored in modern techniques of entropion repair. The author describes a technique of extirpation of the preseptal orbicularis oculi muscle combined with repair of the lower eyelid retractors and a lateral tarsal strip procedure for the repair of primary and recurrent involutional entropion. Lateral canthal tendon laxity is recognized in most patients in this age group and must be corrected to avoid postoperative overcorrection and ectropion. Removal of the preseptal muscle had no clinical effect on the lacrimal pump and did not cause any significant cicatricial eyelid abnormalities. This combined procedure has been used in 50 eyelids of 40 patients with excellent functional and cosmetic results. Orbicularis extirpation is not advocated in combination with a marginal rotation procedure.     

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.     

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.     

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.     

Consecutive ectropion after the Wies procedure

PURPOSE: To describe the clinical features and management difficulties of the ectropions after Wies procedure for lower eyelid involutional entropion in 4 patients. METHODS: Case series. RESULTS: All ectropions had developed within 2 months of the Wies procedure. Common structural features with cicatricial contraction of the anterior lamella and buckling of the tarsal plates were evident. Maximal horizontal eyelid shortening and excision of anterior lamella scar tissue allowed correction. CONCLUSIONS: Consecutive ectropion is caused by secondary cicatricial changes, which can be difficult to manage. Untreated horizontal laxity and postoperative scarring are likely contributory factors in its development. The authors recommend excision of anterior lamella scar tissue combined with large full-thickness wedge excision as an effective treatment.     

A comparative study of two procedures for repair of involutional lower lid entropion

OBJECTIVE: The study compares the use of Jones' retractor plication and the Wies procedure as a primary procedure for the repair of involutional lower lid entropion in the absence of horizontal lid shortening. DESIGN: Retrospective case series comparison. PARTICIPANTS: One hundred two cases with at least 6 months follow-up after primary surgery for involutional lower lid entropion performed between 1993 and 1996. INTERVENTIONS: Two groups were compared: Jones' retractor plication was performed in one group and the Wies procedure in the other; neither group had horizontal shortening of the lower eyelid. MAIN OUTCOME MEASURES: The rates of cure, recurrence, and overcorrection of the lower lid entropion. RESULTS: Jones' retractor plication was performed in 37 (36%) patients and the Wies procedure in 65 (64%). Two of the 37 (5%) Jones cases had recurrent entropion develop, both at 31 months after surgery, compared with 1 1 of 65 (17%) recurrences after the Wies procedure (P = 0.81); recurrence after Wies procedure was earlier, at a median of 6 months after surgery. There were 20 of 65 (31 %) overcorrections after the Wies procedure and 4 of 37 (11 %) after the Jones procedure (P < 0.02); one quarter of each group required secondary repair of the overcorrection (5 of 20 after failed Wies procedure; 25% after failed Jones procedure). Overall, there were 6 of 37 (16%) unsatisfactory results after the Jones procedure in contrast to 31 of 65 (48%) after the Wies procedure (P < 0.001). CONCLUSIONS: These data provide strong evidence (P < 0.001) that, in the absence of horizontal shortening of the lower eyelid, a successful outcome is more likely after Jones retractor plication than after the Wies procedure.     

Evaluation of the medial canthus blepharoplasty using the lazy-T method

PURPOSE: To evaluate the efficacy of surgical "Lazy-T" method used to correct ectropion of the lower punctum with the inferior lid laxity and the medial canthal tendon. METHOD AND MATERIAL: Between January 2004 and February 2005, four patients of mean age 67 years (+/-12) were operated with this method. In two patients, one eyelid was operated; the other two patients underwent bilateral lid surgery. Preoperative qualifications included: subjective assessment of epiphora (range 0-10 points), where 0 represents loss of epiphora and 10 points maximum intensification with ectropion of the lower punctum, laxity of the inferior eyelid more than 10 mm, and laxity of the medial canthal tendon of 2-nd degree or more. Two subjects, who expressed their consent, underwent lacrimal scintigraphy. Surgical technique included excise of the middle part of the lid at its full thickness, laterally from lower punctum, and correction of the conjunctiva. The follow-up period was 6 months on average. RESULTS: All patients reported reduction of epiphora of 5 points on the average. Eyelid laxity decreased by mean 4.5 mm (+/- 1.0 mm). In two patients epiphora regressed, in two others - decreased. All patients evaluated the cosmetic result as satisfactory. CONCLUSIONS: The "Lazy-T" correction is an effective procedure, which restores the lower punctum into its normal anatomical position. It is a simple surgical technique that can free patients from epiphora.     

Primary and secondary transconjunctival involutional entropion repair

PURPOSE: Lower eyelid involutional entropion is a significant disorder of the aging population resulting from horizontal eyelid laxity, overriding orbicularis oculi muscle, and attenuation of the lower eyelid retractors. The purpose of this study is to describe the long-term results of transconjunctival entropion repair. DESIGN: Interventional noncomparative case series. PARTICIPANTS: Thirty-six eyelids in 31 patients. METHODS: Charts were reviewed of all transconjunctival entropion repairs, which included myectomy, retractor fixation, and horizontal shortening performed by three oculoplastic surgeons between January 1993 and January 1999. Cases with less than 12 months follow-up were excluded. MAIN OUTCOME MEASURES: Entropion recurrence. RESULTS: Thirty-six lids in 31 patients were followed for mean of 31.5 months (12.5-79). Six of 36 lids (16.7%) had postoperative complications. Recurrent entropion occurred in 3 of 36 lids (8.3%) an average 16.3 months (7-35) after surgery. An average of 6 trichiasis lashes (1-10) occurred in 4 of 36 lids (11.1%) at a mean of 2.25 months (1-4) after surgery. There were no overcorrections. Three of 36 lids (8.3%) required additional surgery. CONCLUSIONS: Entropion recurrence after three-step transconjunctival repair is within the 0% to 30% reported recurrence for other repair techniques but more frequent than reported for a similar transcutaneous procedure. The 8.3% recurrence rate might have resulted from inadequate myectomy, inadequate retractor fixation, cicatricial changes directly related to the transconjunctival incision, or progressive involutional changes. Trichiasis was the most frequent complication. Transconjunctival entropion repair may be slightly less effective than transcutaneous repair.     

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。     

Transcaruncular approach to medial canthal tendon plication for lower eyelid laxity

PURPOSE: A new operation to correct lower eyelid laxity was evaluated. METHODS: A new transcaruncular, orbital approach to posterior medial canthal tendon plication was performed on eight orbits of four cadavers, which were then analyzed with computed tomography or histologic techniques. The procedure was also performed on 23 eyelids of 15 patients with lower eyelid medial canthal tendon laxity, alone or in conjunction with other procedures. These patients were followed up for a mean of 12 months. RESULTS: Improved postoperative eyelid position, epiphora, and superficial punctate keratopathy were found. Radiographic and histologic analysis demonstrated consistency of suture placement without involvement of contiguous anatomical structures. CONCLUSIONS: This procedure appears to be a safe, reproducible, and effective corrective procedure for medial canthal tendon laxity and lagophthalmos. When combined with lateral lower eyelid tightening, it is also an effective treatment for lower eyelid retraction and superficial punctate keratopathy. Other potential advantages and complications of this procedure are described in comparison to other reported surgical methods used to address medial canthal tendon laxity and malpositions of the medial lower eyelid.     

Posterior layer advancement of the lower eyelid retractor in involutional entropion repair

PURPOSE: To examine effectiveness of posterior layer advancement of the lower eyelid retractor in involutional entropion repair. METHODS: Fifty lower eyelids (30 right and 20 left, average patient age 75.5 years) of 43 patients with involutional entropion underwent surgery. All cases were observed for at least 1 year postoperatively. During surgery, after detaching the anterior and posterior surfaces of the lower eyelid retractor, we positively advanced and fixed the posterior layer of the lower eyelid retractor to the tarsus. The anterior layer was used as reinforcement for the posterior layer. When lower eyelid retraction was intraoperatively observed, the suture was changed to fix to a more undercorrected position. RESULTS: Of the 50 patients, only 1, who was the second case operated on, showed recurrent entropion 5 months postoperatively, but following a repeat operation using the same procedure no recurrence was seen in the next 2 years. Three eyelids showed a low degree of ectropion in the early postoperative period, but all improved within 1 month. No postoperative lower eyelid retraction was observed in any patient. CONCLUSIONS: Posterior layer advancement of the lower eyelid retractor is useful for entropion repair.     

Role of reinsertion of the lower eyelid retractor on involutional entropion

AIMS: To verify and evaluate the effect of reinsertion of the lower eyelid retractor aponeurosis to correct involutional entropion. METHODS: The involutional entropion is one affection that occurs mainly in the lower eyelid of patients over 60 years old. The surgical techniques proposed to correct this condition are based on correction of horizontal laxity-the preseptal orbicularis muscle overrides the pretarsal muscle, and the reinsertion of the lower eyelid retractor aponeurosis. 30 patients clinically diagnosed with involutional entropion and randomly selected underwent reinsertion of the lower eyelid retractor aponeurosis to the tarsal plate, without horizontal shortening or resection of the skin or orbicularis muscle. RESULTS: Good anatomical and functional correction was achieved in 96.6% of the patients and no recurrence was observed on 29 month follow up examination. The surgical result was very satisfactory. CONCLUSIONS: It was concluded that this procedure is effective and has low recurrence rate, showing the important role of the reinsertion of the lower eyelid retractor aponeurosis in this surgical correction.     

Combined pentagonal resection and inferior retractor plication in involutional entropion

Background

To describe the effectiveness of combined pentagonal resection and inferior retractor plication (PR?+?IRP) based on the Hill’s procedure for the treatment of primary involutional lower eyelid entropion in the Chinese population.

Methods

This is a retrospective review of 52 eyelids of 46 patients who underwent PR?+?IRP for treatment of involutional entropion between May 2009 and May 2017. Patient demographics, presence of pre-operative laxity, post-operative outcome and presence of complications were all recorded from electronic patient records.

Results

A total of 52 eyelids of 46 patients received PR?+?IRP. None had recurrence of entropion, 1 (2.1%) had residual entropion, 2 eyelids (4.4%) had lower eyelid notching, 1 eyelid (2.2%) had infection and 1 eyelid (2.2%) had overcorrection. The overall success rate was 90.4%.

Conclusion

Combined PR?+?IRP is an effective surgical procedure for primary involutional entropion with low recurrence rate. However, it may carry risk of eyelid notching post-operatively.

     

外眦成形及下睑外翻缝线联合术治疗退行性下睑内翻的效果

 目的 探讨联合外眦成形、下睑外翻缝线以及睑板前轮匝肌切除术治疗退行性下睑内翻的疗效。设计 回顾性病例系列。研究对象 北京同仁眼科中心19例（23眼）退行性下睑内翻患者。方法 手术包括外眦成形矫正水平眼睑松弛,睑板前轮匝肌切除解除眼轮匝肌骑跨,下穹窿皮肤缝线折短下睑缩肌。观察术前术后患者眼睑形态、位置,有无溢泪等。随访8~12个月。主要指标 眼睑形态、位置,有无溢泪。结果 到最后随访时,所有患者下睑对称无畸形;1例患者（1眼）在睁眼时下眼睑与眼表贴附不紧密,但无明显内外翻及溢泪发生。随访期间无复发或过矫现象发生。结论 针对多种致病因素的联合外眦成形、睑板前轮匝肌切除以及下穹窿皮肤缝线术治疗退行性下睑内翻简单有效。     

Medical ectropion repair. A new procedure

The lazy-T procedure described by Smith corrects medial ectropion of the lower lid by combining a horizontal full-thickness shortening of the lid with excision of conjunctiva and tarsus inferior to the punctum to invert the lid. However, some cases of senile medial ectropion involve an element of vertical traction on the skin as well as horizontal lid laxity. A new procedure is described that makes use of skin gained from horizontal lower lid shortening in the form of a medially based transposition flap to produce vertical skin lengthening. It is useful to treat medial ectropions that have horizontal laxity along with cicatricial components and has successfully relieved this condition in eight patients.