Relationship of Horizontal Lower Eyelid Laxity, Involutional Entropion Occurrence, and Age of Asian Patients

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.

"How sad it is! I shall grow old, and horrible, and dreadful" - The ups and downs of cell senescence

This issue of the Biomedical Journal contains a special section about cell senescence. The reader gets an insight into the crosstalk between immune system and senescent cells, into an approach to fight aging by tweaking macronutrient intake, and also learns about the connection that does (not) exist between body mass and cancer risk. Further articles in the current issue give details about the effect of Damask rose on PCOS, illustrate the issues gender bias may exert in research studies, go into a joint drug approach in ischemia-reperfusion injury, and a promising tool to diagnose Parkinsonian disorders. Two articles dive into challenges related to obstructive sleep apnea, another article explores the benefits a composite mixture may have for improving bone cement material, with lastly a research team presenting a modified procedure to managing involutional lower eyelid entropion in individuals of Asian descent. Finally, BMJ issue 46-3 is complemented with a correspondence about mpox spreading from endemic areas to other parts of the world.

A novel surgical correction technique of involutional entropion by combined triangular tarsectomy, orbicularis muscle tightening and inferior retractor plication

PURPOSE

Describing a novel collective technique for treatment of involutional entropion of the lower eyelids in patients aged 55 years old or more.

METHODS

A prospective comparative study included 56 patients (69 eyelids), recruited from the outpatient clinic of Tanta University Eye Hospital, presented with involutional lower eyelid entropion either primary or secondary. They were divided into: 1- Group A 42 eyelids with excessive horizontal lid laxity (pinch test > 8.0 mm), who underwent Combined tarsectomy of a triangle with base down and horizontal tightening of orbicularis muscle. 2- Group B: 27 eyelids with excessive horizontal lid laxity (pinch test < 8.0 mm) who underwent vertical tightening of orbicularis muscle. Follow up of the patients up to 12 month and satisfaction recording were done.

RESULTS

The mean age of Group A was 60.08 ± 8.38 and of Group B was 55.10 ± 7.40. An overall high success rate (91.07%) and a low recurrence rate (8.92%) with a high post-operative satisfaction, both functionally and cosmetically (96.42%), were reported.

CONCLUSION

Combined procedures with addressing the horizontal tightening was associated with a higher success rate and a lower recurrence rate.

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.

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.

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.

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.

A Comparison of Surgical Outcomes of Two Combination Surgeries for Involutional Entropion: Fixing 3 vs 2 Pathologic Components

The purpose of this study was to compare the surgical outcomes of two combinational surgeries for involutional entropion: Inferior retractor tightening (IRT) + lateral tarsal strip (LTS) + skin muscle excision (SME) vs LTS + SME. The authors reviewed the records of 2 groups which were made up of 80 (85 eyelids) and 58 (63 eyelids) involutional entropion patients with 71.4 and 71.8 years on average respectively. The 2 groups were categorized into Group A and Group B by different surgical techniques. The former underwent IRT + LTS + SME surgery between April 2004 and February 2014, while the latter received LTS + SME surgery between March 2014 and February 2018. The authors evaluated the surgical outcomes of 2 combinational surgeries. In Group A, 84 out of 85 (98.8%) lids were successfully corrected and 1 (1.2%) lower eyelid suffered from recurrence during the follow-up period of 26.5 ± 4.6 months. Two canthal deformity cases occurred in this group. In Group B, 62 out of 63 (98.2%) lids were successfully treated and there was 1 (1.8%) case of recurrence during the follow-up period of 21.0 ± 10.0 months. No cases of complications were noted. IRT + LTS + SME procedure took 26.4 ± 2.4 minutes and LTS + SME procedure took 20.6 ± 3.9 minutes (P < 0.001). The LTS + SME technique exhibited a comparable success rate with the IRT + LTS + SME operation. LTS + SME appeared to be significantly faster and safer compared to the IRT + LTS + SME procedure.

Involvement of Inward Upper Eyelid Push on the Lower Eyelid during Eyelid Closure in Development of Involutional Lower Eyelid Entropion

Purpose

To examine whether an inward upper eyelid push on the lower eyelid margin during eyelid closure is involved in involutional lower eyelid entropion.

Methods

This prospective observational study included 34 sides from 27 patients with involutional lower eyelid entropion. The positional relationship between the upper and the affected lower eyelid margins during eyelid closure were examined before and after posterior layer advancement of the lower eyelid retractors. In addition, we preoperatively examined whether the affected lower eyelid turned in during a voluntary maximum force eyelid closure from the normal position. We then held the upper eyelid away from the lower eyelid during a voluntary maximum force eyelid closure to eliminate the influence of an inward upper eyelid push on the lower eyelid margin. At the time, we investigated whether the affected lower eyelid turned in. All these examinations were performed from the normal lower eyelid position.

Results

Although the upper eyelid margin was on the lower eyelid margin before surgery, this was corrected after surgery in all patients. All affected lower eyelids turned in after voluntary maximum force eyelid closure. However, the lower eyelid margin did not show an inward rotation with holding of the upper eyelid away from the lower eyelid.

Conclusions

These results indicate that an inward upper eyelid push on the lower eyelid is involved in development of an involutional lower eyelid entropion.

A Review of Eyelid Margin Malpositions: A Unique Spectrum in a South-East Asian Tertiary Hospital

PURPOSE

Due to the anatomical differences between the Asian and non-Asian eyelid, the authors hypothesize a different spectrum of eyelid margin malposition conditions seen in Singapore as compared with a predominant Caucasian population. The purpose of the study is to describe the spectrum of eyelid margin malpositions that were operated in a South-East Asian Tertiary Hospital.

METHODS

Retrospective study involving all patients who required surgery for eyelid margin malpositions over a 2-year period. The etiology and ethnic spread of patients were analyzed for each eyelid margin malposition.

RESULTS

A total of 249 eyelids (144 patients) were analyzed. There were 127 Chinese (88.2%), 8 Malays (5.6%), 6 Indians (4.2%), 2 Indonesians (1.4%), and 1 Korean (0.7%). Epiblepharon (53.4%) was the commonest surgery performed, followed by entropion (25.7%) and ectropion (20.9%). Among patients with epiblepharon and entropion, Chinese patients formed the overwhelming majority (>95%). There were no Eurasians or Indians who presented with epiblepharon or entropion. Among patients with ectropion, there was a higher representation of Indian patients (16.7%).

CONCLUSIONS

This study shows that the spectrum of eyelid margin malpositions in Singapore is unique and that developmental epiblepharon remains the commonest eyelid margin malposition requiring surgery. In terms of involutional eyelid margin malpositions, entropion is more common than ectropion, especially among the Chinese. The similarity in terms of eyelid involvement and ethnic distribution of both epiblepharon and involutional entropion suggests that there is a common factor in both these conditions, which the authors infer is due to the unique anatomy of the Asian eyelid.

Eight-flap anastomosis in external dacryocystorhinostomy

AIMS

To examine the surgical outcome of external dacryocystorhinostomy (DCR) with eight-flap anastomosis (8-flap ex-DCR).

METHODS

A retrospective chart review was performed for 55 sides of 51 patients with nasolacrimal duct obstruction who underwent 8-flap ex-DCR. The patients were followed up postoperatively at 1, 2, 4, 8 and 12 weeks, and evaluations were continued with 12-week follow-ups until postoperative 12 months. Anatomical success was defined as no reflux on lacrimal irrigation at 12 months. Functional success was defined as no epiphora at postoperative 12 months. The presence of epistaxis and postoperative surgical site infections were checked in all patients. The presence of granulation tissue around the ostium, under nasal endoscopy, was also examined on 14 sides of 14 patients, at each visit.

RESULTS

Anatomical success was demonstrated on all sides, and functional success was obtained from 54 sides (98.2%) of 50 patients. One patient experienced postoperative intermittent epiphora on one side. The patients did not show granulation tissue, epistaxis or surgical site infection throughout the observation period.

CONCLUSIONS

The 8-flap ex-DCR showed complete anatomical success and favourable functional success with no postoperative complications.