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.     

Everting suture correction of lower lid involutional entropion

AIMS: To assess the long term efficacy of everting sutures in the correction of lower lid involutional entropion and to quantify the effect upon lower lid retractor function. METHODS: A prospective single armed clinical trial of 62 eyelids in 57 patients undergoing everting suture correction of involutional entropion. Patients were assessed preoperatively and at 6, 12, 24, and 48 months postoperatively. The main outcome variables were lower lid position and the change in lower lid retractor function. RESULTS: When compared with the non-entropic side, the entropic lid had a greater degree of horizontal laxity and poorer lower lid retractor function. These differences however, were not significant. At the conclusion of the study and after a mean follow up period of 31 months, the entropion had recurred in 15% of the patients. There were no treatment failures in the group of five patients with recurrent entropion. The improvement in lower lid retractor function after the insertion of lower lid everting sutures did not reach statistical significance. There was no significant difference between the treatment failure group and the group with a successful outcome with regard to: the degree of horizontal lid laxity or lower lid retractor function present preoperatively; patient age or sex; an earlier history of surgery for entropion. There was neither a demonstrable learning effect nor a significant intersurgeon difference in outcome. The overall 4 year mortality rate was 30%. CONCLUSIONS: The use of everting sutures in the correction of primary or recurrent lower lid involutional entropion is a simple, successful, long lasting, and cost effective procedure.     

External (subciliary) vs internal (transconjunctival) involutional entropion repair

PURPOSE: To compare surgical outcomes of internal (transconjunctival) vs external (subciliary) involutional entropion repair. DESIGN: Retrospective, consecutive case series. METHODS: Electronic medical record review of all patients who underwent involutional entropion repair at the Jules Stein Eye Institute over a 4-year period was performed. MAIN OUTCOME MEASURES: Anatomic and functional success, recurrence rate, and complications. RESULTS: Forty-nine eyes (39 patients) were operated. Twenty-nine eyes underwent subciliary incision repair; 20 eyes underwent transconjunctival repair, both with lower lid retractors reinsertion. Good correlation was found between two masked observers in grading surgical outcome (on a scale of 1 to 4) (r = .76, P < .001). Forty-two cases (84%) achieved good surgical repair and improvement in symptoms. Recurrence was noticed in 4 eyes (8.2%). Recurrence was higher with the internal approach (15% vs 3% with subciliary incision), but this was not statistically significant (P = .14). Complications included: three cases (8.2%) with mild eyelid retraction that were treated conservatively, three cases with postoperative ectropion (all in the external approach, two of which lateral canthal resuspension was not performed), and two cases (4.1%, one case in each group) with pyogenic granuloma. CONCLUSIONS: Surgical correction of involutional entropion by reinsertion of lower eyelid retractors has similar outcome with internal (transconjunctival) and external (subcilliary) approaches. Although not statistically significant, internal repair may result in a higher recurrence rate, whereas external repair may show more postoperative ectropion, most probably attributable to scarring of the anterior lamella. Lateral canthal resuspension, when needed, may reduce the rate of postoperative ectropion.     

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。     

Lid retractors desinsertion in acquired ptosis and involutional lower lid entropion: surgical implications.

BACKGROUND: An association exists between upper and/or lower lid retractors' desinsertion and acquired ptosis and/or involutional lower lid entropion. METHOD: By highlighting the similarities that exist in the anatomy of the upper and lower lid retractors a possible pathophysiological mechanism leading to acquired ptosis and involutional lower lid entropion is suggested. As a logical consequence, in case of desinsertion, it is proposed to reattach the lid retractors to the tarsus. RESULTS: With this simple "physiological" surgical approach it is possible to treat with success a great majority of acquired ptosis and/or involutional lower lid entropion. CONCLUSION: Repairing upper and/or lower lid retractors' desinsertion can cure acquired ptosis and/or involutional lower lid 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.     

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.     

Tissue glue aided lid repositioning in temporary management of involutional entropion.

PURPOSE: To evaluate the efficacy of the use of tissue glue in temporary management of involutional entropion. METHODS: Ten consecutive patients aged 68-74 years presenting senile entropion were included in the study. Lid repositioning as to achieve a slight ectropion was done by application of cyanoacrylate glue in the lower lid crease using a 20-G cannula. Patients were followed at 1 day, 7 days and finally at 14 days. Assessment of correction and, if absent, duration of correction was recorded. Any other ocular or dermatological complications of the application were also recorded. RESULTS: All the patients had successful correction at day 1. In two patients adhesions broke at day 6, in one patient at day 7, in 3 at day 9 and 2 at day 11. Two patients maintained correction at 2 weeks. No ocular or dermatological reactions were noted. CONCLUSIONS: Tissue glue aided lid repositioning is an effective method for temporary management of involutional entropion.     

Reanimation of the paretic eyelid using gold weight implantation. A new approach and prospective evaluation

Sixty-one lid-loading procedure, performed by the author, were evaluated prospectively. Simple, gold weight implantation, combined with lower lid retractor recession, placement of fascia lata, and lateral tarsal strip tightening is effective for promoting voluntary closure and correction of lower lid paralytic ectropion. Placement of a heavier gold weight, in combination with mullerectomy, is a reliable new approach for mimicking involuntary blink without ptosis.     

下睑缩肌后徙与切断手术治疗轻度下睑退缩

目的探讨下睑缩肌后徙或切断手术治疗轻度下睑退缩的临床效果。方法手术多在局麻下进行，采用经典的下睑袋皮肤切口。打开下眶隔，将眶脂肪向下推，暴露下睑缩肌的前表面，沿下睑板下缘处分离下睑缩肌，将下睑缩肌完全分离至下穹隆。于穹隆水平处切断或将其后徙缝合于下穹隆处结膜面。患者取坐位观察下睑位置，以下睑位于下方角膜缘上0．5mm为宜。术后1周、1月及6月测量下睑位置，观察其变化情况。结果11例（14眼），随访6—20月，平均7．3月，获良好效果。12眼在双眼平视时下睑位于角膜下缘，2眼仍残存下睑退缩约0．5mm。全部病例下睑退缩较术前有极大的改善，手术效果良好。结论下睑缩肌后徙或切断手术治疗轻度下睑退缩可获得较好的功能和美容效果。对于轻度下睑退缩的治疗是一种较理想的方法。     

Lateral canthal tendon tuck.

Senile and involutional entropion is occasionally associated with a marked relaxation of the canthal tendons. A simple adjunctive procedure to the imbrication of the lower lid retractors for the correction of senile entropion is described. This adjunctive procedure--the lateral canthal tendon tuck--should further reduce the remarkably low recurrence rate associated with the imbrication surgical procedure that directly corrects the pathophysiology of senile entropion.     

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.     

Involutional entropion and ectropion of the Asian lower eyelid

PURPOSE: A clinical observation showed that involutional entropion of the lower eyelid in Asians may occur more commonly than ectropion. A review of surgical cases was performed to examine this hypothesis. METHODS: A retrospective review of the number of Asian lower lid involutional ectropion and entropion repairs was performed in three different clinical practice settings. These data were compared and statistically analyzed with similar data for non-Asian patients. RESULTS: The frequency of ectropion among Asians was significantly less than in non-Asians (chi-square, p < 0.001). Asian entropion repair represented 11.4% of the 604 eyelid operations performed on Asians, whereas Asian ectropion repair made up only 1.5% of cases. Non-Asian entropion and ectropion repairs were 3.7% and 6.2%, respectively, of the 1,849 eyelid procedures performed on non-Asians. CONCLUSIONS: Because of the normal anteriorly protruding position of the orbital fat within the Asian lower eyelid, Asians may be more predisposed than whites to the development of involutional entropion rather than ectropion. Removal of lower eyelid fat should be considered in entropion repair of the Asian lower eyelid.     

Corneal topography in involutional ectropion of the lower eyelid: preoperative and postoperative evaluation

PURPOSE: The shape and position of the eyelids affect corneal topography. This study evaluated preoperative and postoperative corneal topography in involutional ectropion of the lower eyelid. METHODS: Eighteen patients with unilateral involutional lower eyelid ectropion underwent ophthalmic examinations and corneal topography before surgical correction and at the 6-month postoperative interval. Corneal topographies were evaluated with the Holladay Diagnostic Summary package. The fellow eyes served as controls. Parameters evaluated included the regularity of astigmatism (RA), steep refractive power (SRP), flat refractive power (FRP), and total astigmatism (TA). RESULTS: Preoperatively, RA was found significantly decreased in the eyes with ectropion compared with the fellow eyes, whereas differences in other parameters were statistically nonsignificant. Postoperatively, RA was significantly increased, whereas SRP was significantly reduced. The percentage of eyes with with-the-rule astigmatism (WTRA) was increased postoperatively, although astigmatic axis changes were not systematic. CONCLUSIONS: Postoperative topographic changes may be related to either restoration of symmetry in the upper and lower lid apposition on the cornea or to rearrangement of the tear film. Further research will be required to assess whether corneal topographic findings could be used as an index of the severity of eyelid laxity and to evaluate the effects of topographic changes on corneal and total optical aberrations.     

Transconjunctival Entropion Repair – The Backdoor Approach

Abstract

Purpose: To present a modified transconjunctival approach for involutional entropion repair.

Methods: This study is a retrospective consecutive single surgeon case series using a transconjunctival approach for involutional lower lid entropion (ILLE) repair.

Results: Eleven eyes were operated for involution entropion with 9 cases of complete resolution. Two patients required further Jones’ retractor plication.

Conclusion: Transconjunctival involutional lower lid entropion repair is a time-efficient, safe, and efficacious technique. The scar free technique described leads to full restoration of lower lid anatomy. In contrast to other reports we found a relatively low rate of recurrence on follow-up.     

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.     

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.     

Involutional entropion and ectropion

Entropion and ectropion are very common among old people. These malpositions concern mostly the lower lids. Involutional entropion and ectropion have some pathophysiologic mechanisms in common: lower lid horizontal laxity and lid retractor detachment. However, orbicularis muscle hypertrophy occurs only in entropion, and excess of posterior lamella has to be considered in ectropion. Clinical examination will guide surgical treatment. The authors present the main surgical procedures according to clinical findings. The goal is to prevent recurrence.     

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.     

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.