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.     

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.     

Upper Lid Entropion Post Ptosis Correction: Is Tarsal Buckling the Cause?

Purpose: To report two cases of the rare complication of entropion following involutional ptosis surgery and its successful management.

Methods: Clinical findings and management of the patients are presented.

Results: Case 1: An 89-year-old female underwent aponeurosis advancement surgery for left involutional ptosis. Post-operatively she achieved good lid height, but had developed entropion of the upper lid which resulted in a persistent corneal epithelial defect. The patient underwent repeat surgery during which the aponeurosis was found to be inserted into the lower part of middle one third of tarsus with the tarsus itself being extremely thin. The aponeurosis was reinserted into upper third of tarsus, followed by greyline split with anterior lamellar repositioning. Post-operatively the patient achieved good lid height with correction of the entropion.Case 2: A 70-year-old male who had previously undergone bilateral brow lift and ptosis correction two years ago, was referred with right upper lid entropion. During surgery the aponeurosis was found to be inserted into the lower part of middle one third of tarsus, with a very thin tarsus. This patient was also managed by reinserting aponeurosis into upper third of tarsus with grey line split and anterior lamellar repositioning following which he achieved good lid height and correction of the entropion.

Comment:Entropion has rarely been reported as a complication of ptosis surgery. This case series highlights the importance of taking special care when advancing the aponeurosis, in cases where the tarsus is thin, as it may result in vertical buckling of the tarsus.     

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.     

【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.     

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 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 (UCE) 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 (95%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 UCE.     

Congenital horizontal tarsal kink: a simple surgical correction.

A case is reported in which a simple anterior lamellar repositioning procedure was used successfully to repair an upper lid entropion associated with a horizontal tarsal kink. This obviates the need for the more complex and destructive procedures which have previously been described for the treatment of this condition.     

Inferior retractor plication surgery for lower lid entropion with trichiasis in ocular cicatricial pemphigoid.

AIMS--To assess the outcome of inferior retractor plication surgery for lower lid entropion in patients with ocular cicatricial pemphigoid (OCP). This technique avoids surgery on the conjunctiva that can result in exacerbations of disease activity. METHODS--This prospective study assessed the outcomes of a standard 'Jones' type plication in 14 lids of 10 patients with OCP. Seven patients were taking systemic immunosuppression and no patients had conjunctival inflammation for the 4 months before surgery. RESULTS--Life table analysis showed a 77% chance of anatomical success at 2 years and a 54% chance of completely preventing lash-globe touch. The surgery did not cause clinical activation of conjunctival inflammation or other complications. Anatomical failure was primary (n = 2) and due to late cicatrisation (n = 1). Three further cases had restoration of normal anatomy but the patients had persistently misdirected lashes that touched the globe. CONCLUSION--This technique gives good anatomical success over long periods and is particularly safe when there is no conjunctival inflammation present before 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.     

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.     

Comparison of three techniques for repair of involutional lower lid entropion: a three-year follow-up study

OBJECTIVE: The aim of this study was to quantify the efficacy of three different surgical techniques for entropion repair in a 3-year follow-up study: (1) the Fox procedure, (2) everting sutures and (3) a modified technique of lower lid retractor plication. METHODS: We included in our study 32 eyelids of 32 consecutive patients with involutional lower lid entropion; 10 lids underwent the Fox procedure, 13 the everting sutures and 9 the modified retractor plication. We evaluated the pre- and postoperative horizontal lid laxity (HLL), the pre- and postoperative lower lid excursion (LLE) and the number of recurrences in each patient group. Statistical analysis was performed with the non-parametric Mann-Whitney test and the exact Fisher's test where appropriate. RESULTS: Only the modified retractor plication technique showed statistically significant differences in HLL and LLE (p < 0.05). In the group treated with this technique, there was a lower incidence of entropion recurrence (p < 0.05). The everting suture technique showed a statistically significant improvement of the LLE only (p < 0.05). The Fox procedure did not show any statistically significant improvement of the studied parameters. CONCLUSIONS: The modified retractor plication technique gave the best results in terms of improvement of HLL and LLE and a lower incidence of entropion recurrence compared to the two other techniques studied.     

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.     

Cryotherapy for trichiasis in ocular cicatricial pemphigoid.

Trichiasis is a common and potentially sight threatening complication of ocular cicatricial pemphigoid and is usually secondary to cicatricial entropion. This study aimed to assess the success and complications of eyelid cryotherapy for trichiasis in a group of patients with long term follow up. The case records of all patients with ocular cicatricial pemphigoid that attended the external disease clinic at Moorfields Eye Hospital from 1980 to 1992 were reviewed. Each eyelid was divided into three horizontal zones. Cryotherapy was delivered with an Amoilette cryoprobe for approximately 30 seconds. Failure of the cryotherapy was defined as a regrowth of the eyelashes within the treated zone that either required epilation for symptom control or caused keratopathy. Ninety two lid zones were treated, involving 25 lids of 12 patients. The cumulative chance of success decreased rapidly to 40% over the first year. Thereafter, the chance of success declined slowly to 34% at 4 years. Complications included lid notching (n = 2), tarsal atrophy (n = 1), altered lid contour (n = 1), and temporarily raised intraocular pressure (n = 1). All patients had quiescent disease at the time of the cryotherapy and no patients showed increased conjunctival disease activity after treatment. Six patients were taking systemic immunosuppression medication. When ocular cicatricial pemphigoid is quiescent, lid cryotherapy has an acceptable complication rate. The major reason for recurrence of the trichiasis was attributed to inadequate follicle freezing.     

A trial of surgery for trichiasis of the upper lid from trachoma.

Three surgeons operated on upper eye lids of northern Omani villagers for trichiasis due to trachoma using a standardised protocol. The lids were graded as minor trichiasis, five or fewer lashes; major trichiasis, six or more lashes; and lid closure defect. Operative success was defined as no lash/eyeball contact and complete gentle lid closure. One hundred and sixty five lids with major trichiasis were allocated by random number tables to one of five operations: bilamellar tarsal rotation (Ballen), tarsal advance and rotation (modified Trabut), eversion splinting (grey line), tarsal advance (lid split), and tarsal grooving (Streatfield-Snellen) operations. Bilamellar tarsal rotation was significantly more successful than eversion splinting (chi 2 = 7.0, p less than 0.01); tarsal advance (chi 2 = 12.4, p less than 0.001), and tarsal grooving (chi 2 = 23.7, p less than 0.001), but not significantly more successful than tarsal advance and rotation (chi 2 = 2.9, p greater than 0.05). Two of 32 (6%) lids with lid closure defect were successfully treated with tarsal advance; trichiasis was relieved in nine and lid closure defect in 10. It is suggested that bilamellar tarsal rotation and tarsal advance and rotation are effective operations for major trichiasis, but tarsal advance is ineffective where trichiasis and lid closure defect coexist.     

Senile (atonic) entropion.

The etiology and surgery of senile entropion are reviewed. Many of the presumptive causes of this clinical entity including the vague neurological etiology which caused it to be labeled "spastic" have been found baseless, and the explanation of the elder Fuchs, later confirmed by Duke-Elder, that the cause of senile entropion is due to degenerative tissue changes has been found to be more logical and more compatible with the anatomic findings. There have always been two methods of surgical repair of senile entropion: (1) unwinding the lid by resection of horizontal strips of skin or skin and muscle, and (2) by resection of vertical spindles and triangles of tissue to tauten the lids horizontally. I prefer the latter technique.     

Congenital malposition of the eyelid system: epiblepharon, lower and upper lid entropium. Differential diagnosis, complications and therapy

Epiblepharon is a relatively common congenital anomaly and has to be distinguished from entropion, a rare congenital condition. Both cause trichiasis and irritation of the globe. Early surgery prevents severe ocular complications. The very rare congenital entropion of the upper lids, in particular, which is based on a tarsal anomaly known as the tarsal kink, requires primary surgical treatment to prevent keratopathy, corneal ulceration, and blindness in newborns. Epiblepharon can usually be treated adequately with a special suture technique; for congenital entropion, however, a skin-muscle resection is often necessary. Congenital entropion in adults can be treated with good results using a modified lid-split technique. In congenital entropion of the upper lid the tarsal kink has to be resected and the anterior lamella transposed upward and tightened. Postoperative treatment with a therapeutic contact lens accelerates healing of the keratopathy. Good results, both functional and cosmetic, can be achieved with the techniques described in this paper.     

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.     

A contribution to the surgery of the trachomatous entropion and trichiasis

Although the WHO document WHO/PBL/93.29 recommends the bilamellar tarsal rotation operation for trachomatous entropion, we will describe another operation that has proved to be very reliable. It is a combined method, consisting of the modified tarsal wedge resection and the eversion splinting-grey line incision. A possible additional correction of the grey line incision on the first postoperative day improves the results. A total of 708 eyes with moderate trachomatous entropion and major trichiasis underwent this surgery, but only 508 of these were followed up during a 6-month period. The rate of failed operations, which consisted of incomplete closure of the lids or more than two inverted lashes remaining, was 6.9%.