Involutional lower eyelid entropion: causative factors and therapeutic management

Treatment of Cicatricial Lower Eyelid Ectropion with Suture of Horner Muscle Combined with Fascia Transplantation

This case series aimed to describe a new technique for correcting contractures and deformities that reliably addresses lacrimal punctum deviation and severe cicatricial lower eyelid ectropion. This was a technical description and a retrospective interventional case series. Eyelid ectropion and lacrimal punctum deviation were treated surgically by grafting the fascia lata and suturing the tarsus-Horner muscle. In total, three patients underwent this surgery: one for burns, one for lower eyelid tumor resection, and the other for an orbital floor fracture following a motorcycle accident, all resulting in ectropion. All patients previously had failed ectropion correction procedures, including scar revision, skin grafting, auricular cartilage grafting, and lateral tarsal strips. The mean follow-up was 15.8 (12.5-18.5) months. Furthermore, all patients showed resolution of lower eyelid ectropion and significant improvement in lower eyelid contracture, with a mean increase of 4.0 (2.5-5) mm. No severe complications were observed, and they reported a significant improvement in ocular surface symptoms. Our study shows that tacking of the tarsus and Horner muscles in combination with fascia lata grafting is effective in correcting refractory cicatricial lower eyelid ectropion with deviation of the tear punctum.

Transcanthal Canthopexy for Involutional Lower Eyelid Entropion Corrects Horizontal Laxity

In this prospective observational study, we aimed to examine improvements in horizontal laxity after lower eyelid retractor advancement and transcanthal canthopexy for involutional lower eyelid entropion. The study included 19 sides in 15 patients with involutional entropion who underwent transcanthal canthopexy with the advancement of the lower eyelid retractor. Using the pinch test, the distance from the lowest part of the corneal limbus to the eyelid margin was measured using callipers. All measurements were performed preoperatively and at postoperative 3 and 6 months. Using the pinch test, the distance from the lowest part of the corneal limbus to the lower eyelid margin was significantly shortened during each postoperative follow-up period. None of the included cases experienced recurrence. Our results indicated that transcanthal canthopexy could preserve postoperative horizontal tightness.

Horizontal eyelid shortening alone versus combined procedures for the correction of involutional lower eyelid entropion

BACKGROUND

Conventionally, management of involutional entropion involves correcting both vertical and horizontal laxity, however the optimal surgical approach is debated.

OBJECTIVE

To compare the recurrence rate of horizontal lower eyelid shortening alone with combined surgical approaches for correction of involutional lower eyelid entropion.

METHODS AND MATERIAL

A retrospective, comparative, consecutive case series of patients undergoing surgery for involutional lower eyelid entropion with both horizontal and vertical laxity. Patients were categorized based on the procedure as: Group 1, horizontal shortening alone, Group 2, horizontal shortening with everting sutures), and Group 3, horizontal shortening with retractor plication.

RESULTS

Of the 249 procedures (31 bilateral) performed on 218 patients, 54 (22%) involved horizontal eyelid shortening alone (Group 1), while 80 (32%) had this combined with everting sutures (Group 2), and 115 (46%) with retractor plication (Group 3). The anatomical success rates for Groups 1, 2, and 3 were 93, 94, and 90% (P = 0.69), respectively. Similarly, reported symptom improvements were 94, 93, and 93% for these groups (P = 0.91). After an average follow-up of 15.7 months (median 10; range 6-81), Group 1 (eyelid shortening alone) had a 7% (4/54) recurrence, compared to 8% (16/195) in Groups 2 and 3 (combined procedures) (P = 1.0). Complications were minor, with no significant difference between groups.

CONCLUSION

Eyelid shortening alone appears to be as effective as combined techniques for involutional entropion with both horizontal and vertical eyelid laxity. Nevertheless, procedure selection should consider primary pathogenic factors.

Evaluation of outcomes of lower eyelid entropion and ectropion surgical repair

<b><br>Introduction:</b> The imbalance of external and internal forces acting on the lower eyelid can result in entropion and ectropion, both of which cause ocular irritation and loss of proper eye protection. Potential complications of untreated cases include recurrent inflammation of the conjunctiva and cornea, conjunctival neovascularization, corneal abrasion or perforation, and ultimately even loss of vision. Although various surgical techniques are used to address this problem, their long-term outcome and effectiveness are still under discussion. </br> <b><br>Aim:</b> To evaluate outcomes of surgery for entropion and ectropion, including a modified Wheeler's method for entropion correction.</br> <b><br>Methods:</b> A non-comparative study (prospective and retrospective groups) included 100 patients operated on in two university hospitals' plastic surgery departments for lower eyelid entropion or ectropion, following formal ethics approval. The prospective group included 50 patients assessed preoperatively and at 3 and 12 months postoperatively. The retrospective group was comprised of 50 patients (2012-2018), whose preoperative documentation and clinical examinations were analyzed. The main outcome measures were change between pre- and postoperative patient-reported symptoms (VAS scale), ectropion/entropion grading scale (EGS/EnGS), quality of life (WHOQOL-BREF), and occurrence of complications.</br> <b><br>Results:</b> The differences in the severity of all symptoms before and after surgery evaluated with the VAS scale were statistically significant in both groups (p <0.05). We observed 6 recurrences (12%) in the prospective group and 9 (18%) in the retrospective group, with minor complications. Very good functional and esthetic postoperative results were confirmed in 70% (79) of the whole group and in 13 patients (81.3%) treated with the modified Wheeler's method. In the prospective group, the Mann- Whitney U test for dependent variables revealed significant improvement in the somatic, psychological, and environmental domains, with no significant change in the social relationships domain.</br> <b><br>Conclusions:</b> The results following entropion/ectropion surgery prove the effectiveness of the methods used. Complementing them with the modified Wheeler's method brought an increase in the number of very good outcomes. Surgery of lower eyelid malposition contributed to reduced symptoms and improved quality of life. The rates of postoperative sequelae were low.</br>.

Bidirectional tightening of the anterior lamella for involutional lower eyelid entropion

OBJECTIVE

Involutional entropion of the lower eyelid is commonly encountered in the elderly population. An ideal surgical method is supposed to address the underlying horizontal and vertical lower lid laxity simultaneously. This study aims to assess the effectiveness of bidirectional tightening of the anterior lamella to correct involutional lower lid entropion.

METHODS

A prospective, noncomparative interventional case series was conducted from January 2017 to June 2021. Patients with involutional lower eyelid entropion received procedures combining lateral canthus-sparing orbicularis suspension with marginal rotating sutures to tighten the anterior lamella horizontally and vertically. The aesthetic appearance, postoperative complications, and patient satisfaction were evaluated.

RESULTS

A total of 50 patients (56 eyelids) with a mean age of 73.1 ± 10.5 years were included. The mean follow-up period was 23.7 ± 17.1 months. All patients had immediate resolution of entropion and associated ocular symptoms. There were no recurrences or other major postoperative complications. Mild temporary ectropion was observed in 4 patients (4 eyelids) without the need for surgical intervention.

CONCLUSION

The procedure of bidirectional anterior lamellar tightening restores the tension balance of eyelid margin. It provides a simple, successful, and less invasive option to treat involutional lower eyelid entropion.

Anterior versus posterior retractor reinsertion with a lateral tarsal strip for involutional entropion repair: A multicentric experience

PURPOSE

The aim was the comparison of two different approaches to re-insert the inferior eyelid retractors within addition to lateral tarsal strip at lower eyelid involutional entropion (LEIE) surgical correction.

METHOD

This multicentric retrospective case series involved 233 consecutive patients (195 eyelids) who underwent LEIE repair. All the lids had a lateral tarsal strip (LTS) in addition to the reinsertion of retractors onto the tarsal plate via the anterior approach (group 1) or the posterior approach (group 2). The desired normal position of the eyelids at 6-month follow-up was considered 'surgical successes, while entropion recurrence and overcorrection (ectropion) were considered 'surgical failures'.

RESULTS

One-hundred ninety-one (82%) surgeries were included in group 1 and 42 (18%) in group 2. The success rate was 92.1% (176 lids) in group 1 and 85.7% (36 lids) in group 2 (p = 0.188). The recurrence rate was statistically higher for group 2 (14.3%) than for group 1 (3.7%) (p = 0.016). Overcorrection only described in group 1 (3.1%). Both groups had a similar complication rate (p = 0.268), with trichiasis being the most frequent (14, 6%). Ten eyelids (47.6%) from the 21 overall failures were satisfactorily reoperated, and the remaining ones were treated conservatively.

CONCLUSION

The anterior or posterior approach to reinsert lower eyelid retractors to tarsal plate in addition to LTS to correct LEIE can provide a similar outcome. However, the anterior approach achieves a slightly higher success rate with fewer recurrences but with a higher overcorrection rate.

Correction of Involutional Entropion by Excising Redundant Skin and Pretarsal Orbicularis Muscle without Vertical and Horizontal Tarsal Fixation

PURPOSE

This study evaluated the effect of the excision of redundant skin and pretarsal orbicularis muscle, without vertical or horizontal tarsal fixation, on the correction of involutional entropion.

METHODS

This retrospective interventional case series recruited patients with involutional entropion who underwent excision of redundant skin and pretarsal orbicularis muscle, without vertical or horizontal tarsal fixation, from May 2018 to December 2021. Preoperative clinical characteristics and surgical outcomes, including recurrence at 1, 3, and 6 months, were determined by reviewing the medical charts. Surgical treatment included the excision of redundant skin and pretarsal orbicularis muscle, without any tarsal fixation, and simple skin suture.

RESULTS

All 52 patients (58 eyelids) attended every follow-up visit and were thus included in the analysis. Among 58 eyelids, 55 (94.8%) had satisfactory results. The recurrence rate was 3.45% (two eyelids) and the overcorrection rate was 1.7% (one eyelid).

CONCLUSIONS

Excision of only redundant skin and the pretarsal orbicularis muscle, without capsulopalpebral fascia reattachment or horizontal lid laxity correction, is a simple surgery for correcting involutional entropion.

Changes in Lacrimal Punctum Position and Tear Meniscus Height after Correction of Horizontal Laxity in Involutional Lower Eyelid Entropion

Purpose

To examine changes in the position of the lower eyelid punctum and tear meniscus height (TMH) after correction of horizontal laxity of the lower eyelid in involutional lower eyelid entropion.

Methods

This prospective, observational study included 42 sides of 36 patients with involutional entropion who underwent a lateral tarsal strip procedure or transcanthal canthopexy (+ lower eyelid retractor advancement). The horizontal distance from the medial margin of the lower lacrimal punctum to the medial canthus was measured using ImageJ software. TMH was measured using anterior segment optical coherence tomography. All measurements were performed preoperatively, at postoperative 3-month and at postoperative 6-month.

Results

The lower lacrimal punctum significantly shifted laterally at 3-month follow-up and slightly returned toward its original position at 6-month follow-up (Friedman's test, P  <  0.001). Although the differences did not reach statistical significance, TMH in the lower eyelid increased at 3-month follow-up and then slightly decreased at 6-month follow-up (Friedman's test, P = 0.076).

Conclusions

The results of this study imply that lateral shift of the lower lacrimal punctum prevents effective drainage of tears accumulated in the lacrimal lake, resulting in increased TMH after correction of horizontal laxity of the lower eyelid in involutional entropion.

Pretarsal orbicularis oculi muscle tightening with skin flap excision in the treatment of lower eyelid involutional entropion

BACKGROUND

To evaluate a modified technique for involutional entropion correction in a retrospective cohort study.

METHODS

The patients with involutional entropion eyelid were corrected by tightening the pretarsal orbicularis oculi muscle and excising the excess skin of the lower eyelid. The patients received correction surgery from April 2013 to March 2019 were followed up for more than 6 months postoperatively. The outcome measures included the complications and the recurrence rates.

RESULTS

Total 152 patients (169 eyes) were included. The mean follow-up period was 29.6 months (range: 6-36 months). Postoperative ectropion (over-correction) was observed in 1 patient with 1 eyelid (0.59%); yet, no further surgery was needed for this patient. Recurrence of entropion was found in 1 patient (0.59%). The patient with recurrent entropion received repeated surgery with the same method and achieved a good eyelid position.

CONCLUSIONS

This study demonstrated that tightening the pretarsal orbicularis oculi muscle and excising the excess skin of the lower eyelid could be an effective surgical method to correct lower eyelid involutional entropion. This method is technically easy with a low recurrence rate and not associated with significant complications in Asians.

Comparison of the two techniques for involutional lower eyelid entropion: A retrospective study

Evaluation of the surgical outcome and the patient satisfaction between the modified Wies technique and the Jones retractor plication technique for involutional lower eyelid entropion without horizontal eyelid laxity. Patients who underwent the modified Wies technique (group 1) and the Jones retractor plication technique (group 2) for correction of involutional lower eyelid entropion without horizontal eyelid laxity between January 2014 and January 2020 were retrospectively reviewed. Patients with horizontal eyelid laxity; cicatricial, congenital or iatrogenic entropion; and less than 6 months of follow-up time were excluded. The main outcome measures were the recurrence rate, correct anatomical position of the eyelid, symptom relief, and postoperative complications for both groups. 37 patients (41 eyes) in Group 1 and 34 patients (34 eyes) in Group 2 were enrolled in the study. Mean age ± SD was 75.6 ± 8.5 years in Group 1 and 73.4 ± 7.9 years in Group 2 (p:0.255). The mean follow-up time (range) was 24.3 (6-80) months in group 1 and 25.3 (6-78) months in group 2 (p:0.818). Two patients in Group 1 and seven patients in Group 2 had a recurrence during the follow-up period (p:0.07). Based on the results of the study, it seems that the modified Wies technique may be a good alternative in suitable patients, as it has satisfactory surgical results.

Corneal Topographic Analysis in Patients with Involutional Lower Eyelid Entropion

Purpose: To analyze the corneal morphology before and after surgery by the advancement of posterior lower eyelid retractors (LERs) alone or in combination with a lateral tarsal strip (LTS) for lower eyelid involutional entropion.Methods: We retrospectively analyzed the cases of 24 consecutive elderly patients (24 eyelids) who underwent posterior layer advancement of LERs alone or in combination with an LTS for involutional entropion. All patients underwent general ophthalmological examinations including best-corrected visual acuity (BCVA), fundus examination, and slit lamp microscopy. The degree of corneal damage was evaluated using the area (A) and density (D) classification of corneal fluorescein staining. Corneal topography was measured using anterior segment optical coherence tomography (AS-OCT). The parameters were steep keratometry (Ks), flat keratometry (Kf), average keratometry (AveK), cylindrical power (CYL), central corneal thickness (CCT), and total higher-order aberrations (HOAs) within a 4-mm diameter.Results: There was no significant difference in the Ks, Kf, AveK, CYL or CCT values between before and after surgery. The HOAs were significantly decreased after surgery. In the AD classification, both the A and D values were significantly decreased after surgery. Significant correlations were observed between preoperative mean HOAs and the mean of A classification, and between preoperative mean HOAs and the mean of D classification.Conclusion: Involutional entropion does not appear to significantly affect corneal morphology before or after posterior LER advancement alone or in combination with an LTS. However, this surgery is thought to result in an improvement of corneal disorders and consequent improvement of HOAs.

Comparison of the Postoperative Outcomes of Posterior Layer Advancement and Modified Iliff Suturing to Correct Involutional Lower Lid Entropion

Involutional lower lid entropion is treated surgically with either incision or rotational suturing. The authors have obtained good results with the modified Iliff suture (MIS) procedure. Here, the authors compare the efficacy and postoperative outcomes of MIS and posterior layer advancement. This study included Japanese patients with a normal snap-back test, who underwent primary surgery for correcting involutional lower lid entropion, performed by the same surgeon, from April 2009 to March 2017, and who were followed up for at least 24 months postoperatively. Posterior layer advancement was performed on 50 eyelids of 48 patients (19 men, 29 women; mean age 74.1 ± 8.7 years) and MIS was performed on 50 eyelids of 40 patients (16 men, 24 women; mean age 77.3 ± 7.5 years). The authors compared the postoperative follow-up duration, recurrence rate, and operating time between groups. Postoperative follow-up duration was 34.5 ± 7.4 months in the posterior layer advancement and 32.3 ± 8.1 months in the MIS group (P = 0.180). Recurrence rate was 6% (3 cases) in the posterior layer advancement group and 4% (2 cases) in the MIS group (P > 0.999). Operating time was significantly shorter in the MIS group (5.8 ± 1.1 minutes) than in the posterior layer advancement group (31.6 ± 4.1 minutes, P < 0.001). Modified Iliff suture is less invasive than posterior layer advancement and has similar postoperative outcomes; thus, it is useful for treating involutional lower lid entropion.

Ocular Surface Pain: A Narrative Review

Ocular surface pain is a frequent cause of visits to an eye care provider and has a substantial impact on healthcare cost, yet a complete understanding of its causative factors and tools for diagnostic workup are notably missing in many eye clinics. The cornea has the densest sensory innervation in the human body and has the potential to be a powerful producer of pain. Pain can manifest as a result of a noxious stimulus or disruption in the ocular surface anatomy (nociceptive pain), or it can result from abnormalities in the ocular surface neurosensory apparatus itself (neuropathic pain). Novel advances in neurobiology have sought to differentiate the two entities, particularly to identify when chronic dry eye symptomatology is driven by neuropathic ocular pain. In this review, we seek to provide an overview of the prevalence, physiologic factors, and management of ocular surface pain complaints.

Modified everting sutures combined with reattachment to the inferior tarsal plate for involutional lower eyelid entropion: A new technique

Background

This study evaluated the outcomes of a new modified Wies technique for patients with involutional lower eyelid entropion without horizontal eyelid laxity.

Methods

This case series retrospectively analyzed consecutive patients with entropion who underwent surgery between January 2014 and March 2019 by the same experienced surgeon. Horizontal eyelid laxity, lower eyelid retractor function, and orbicularis muscle overriding were recorded before and after surgery. The recurrence rate and complications were also evaluated. This technique consisted of modified everting sutures combined with reattachment of the lower eyelid retractors to the inferior tarsal plate.

Results

This new technique was performed on 28 eyes in 25 patients (mean age, 71.0±8.0 years; range, 56–87 years). Nine patients (36%) were women and 16 (64%) were men. Lower lid entropion was present in the right eye in 14 patients (56%), the left eye in eight patients (32%), and both eyes in three patients (12%). The mean follow-up period was 27.3±12.4 months (range, 6–60 months). No intraoperative complications were observed. All patients’ symptoms were alleviated. One patient (3.6%) had recurrence after 2 years (success rate, 96.4%). The remaining 27 eyes maintained a satisfactory and comfortable eyelid position. No patients had problems with scarring.

Conclusions

The approach described herein proved to be safe and feasible in eyes with involutional lower eyelid entropion without horizontal eyelid laxity. These advantages of this procedure include the lack of a conjunctival scar, punctal eversion, and lateral canthal angle deformation. A low recurrence rate and a long interval to recurrence were also observed.

The Role of Overriding Preseptal Orbicularis Oculi Muscle in Development of Involutional Lower Eyelid Entropion: Microscopic Viewpoints

The aim of this study was to demonstrate the extent of preseptal orbicularis oculi muscle (OOM) override onto the pretarsal OOM in the lower eyelids. In this experimental microscopic study, 22 exenterated specimens from 22 Japanese cadavers were prepared as full-thickness sagittal sections. All exenterated specimens were devoid of lower eyelid entropion. The tarsal dimension and distance from the lower tarsal edge to the tip of overriding OOM were microscopically measured. The rotation axis of the tarsus was presumed to pass through the tarsal centroid and the distance from an estimated tarsal centroid to the lower tarsal edge was calculated. Consequently, 2 eyelids did not exhibit any overriding of the OOM. In the remaining 20 eyelids with OOM override, the average distance of the overriding OOM was found at a level covering 48.0% of the whole tarsal height. In 15 out of the 20 eyelids, the tip of the overriding OOM was located lower than the centroid. These microscopic findings suggest that overriding of the preseptal OOM does not always produce an inward rotational force on the tarsus.

Postoperative changes in status of meibomian gland dysfunction in patients with involutional entropion

PURPOSE

To examine postoperative changes in the status of meibomian gland dysfunction in patients with involutional entropion.

METHODS

This prospective, interventional study included 10 eyelids of 8 patients with involutional entropion who underwent posterior layer advancement of the lower eyelid retractors and either a lateral tarsal strip or transcanthal canthopexy procedure. The following features were examined for evaluation of meibomian gland dysfunction and dry eye: the presence or absence of eyelid abnormalities (irregular eyelid margin, vascular engorgement, and plugged meibomian gland orifices), Marx line score, meibum expression score, loss of the meibomian glands, A (area) and D (density) scores for corneal fluorescein staining, and tear breakup time. All the measurements were performed before and 6 months after surgical correction of involutional entropion.

RESULTS

Regarding the findings of meibomian gland dysfunction, irregular eyelid margin, vascular engorgement, and plugged meibomian gland orifices improved only in 1 eyelid of 1 patient (P = 0.317, P = 1.000, and P = 1.000, respectively) postoperatively. The scores of Marx line, meibum expression, and loss of meibomian glands did not statistically change after surgery (P = 0.157, P = 0.705, and P = 0.317, respectively). The D score was statistically improved after surgery (P = 0.046), although the difference between the pre- and postoperative A score was not statistically significant (P = 0.083). Tear breakup time did not change after surgery (P = 0.705).

CONCLUSIONS

Our study indicates that meibomian gland dysfunction does not resolve after surgical correction of involutional entropion.