Posterior Lamellar Eyelid Reconstruction With Acellular Dermis Allograft in Severe Cicatricial Entropion

Treatment of Eyelid Entropion: A Historical Review

PURPOSE

The purpose of this study was to review the long history of entropion, with emphasis on its significance to the specialty of ophthalmology, and the numerous methods developed to treat cicatricial and involutional forms of the condition.

METHODS

An extensive medical literature review was performed, identifying publications containing information on entropion and associated conditions. Foreign language manuscripts were translated using online resources.

RESULTS

A total of 920 manuscripts published between 1505 and 2023 were reviewed. While the majority were written in English, 38.5% were foreign language works. For much of history, both cicatricial and involutional entropion were managed by shortening the anterior lamella. Horizontal eyelid margin or posterior tarsal incisions were often added for cicatricial disease. Later, different tissues were grafted into the defects created by these incisions. A variety of measures were used to temporize in patients with involutional entropion. Surgical treatment of this condition evolved to include methods of suture rotation, orbicularis weakening or redirection, tarsal stabilization, lid margin shortening, and eyelid retractor repair.

CONCLUSIONS

Entropion and its management are described throughout recorded history. For much of this time, cicatricial entropion was the most common form of the disease, in great part secondary to the prevalence of trachoma. The social impact of these conditions was a primary factor in the establishment of ophthalmology as a medical specialty and the creation of dedicated eye hospitals. Publications describing the treatment of involutional entropion appear with increasing frequency after the mid-19th century. Arguably, more procedures have been described for entropion than for any other ophthalmic condition.

Use of biomaterials in the reconstruction of posterior lamellar eyelid defects: a systematic review and meta-analysis

Eyelid defects can occur secondary to tumours, trauma, burns, and congenital factors. Among the most challenging aspects of eyelid reconstruction is the rebuilding of a tarsal substitute due to its delicate and multi-layered tissue composition. Attempts to use biomaterials for posterior lamellar reconstruction are intended to provide an alternative to traditional autograft reconstructions. In this review, we aimed to assess the types of biomaterials used for the reconstruction of the posterior lamella associated with eyelid defects and the associated clinical outcomes. A literature search was conducted on Pubmed, Prospero, Dynamed, DARE, EMBASE, and COCHRANE databases. A total of 15 articles fulfilled the inclusion criteria, and 129 patients with 142 eyelids reconstructed, using artificial grafts, were included in the review. Acellular dermis allograft (AlloDerm®, LifeCell) (n = 49) was the most common artificial graft used. A meta-analysis was performed, which demonstrated a pooled success rate of artificial grafts of 99% (95% CI 96-100, p = 0.05; I2 = 40%, total complications seen 39% (95% CI 96-100, p = 0.05; I2 = 40%) and re-operation rates of 5.6% (n = 8). The biomaterials used demonstrated an overall success rate of 99%, which is similar if not greater than that reported with the use of traditional autograft reconstruction techniques, with similar complications and fewer re-operations than autografts. This suggests that clinicians should consider the clinical use of artificial grafts for posterior lamellar reconstruction.

Combined Surgical Strategies Adjusted to Clinical Evaluations for Severe Upper Eyelid Cicatricial Entropion and Trichiasis

BACKGROUND

The management of cicatricial entropion and trichiasis represents a therapeutic challenge. The authors determined the long-term stability of combined surgical procedures in severe cases.

METHODS

The authors retrospectively studied consecutive patients with severe upper eyelid cicatricial entropion and trichiasis treated between 2019 and 2021 at Beijing Tongren Eye Center. Combined surgical procedures adjusted to clinical evaluations were performed. Clinical characteristics, procedures, and surgical outcomes were retrieved.

RESULTS

The authors included data on 58 eyelids (25 left and 33 right) from 39 patients (19 males and 20 females). The mean age was 54.81 years. Follow-up averaged 20.67 months. Common diagnoses were chemical injury, trachoma, and chronic conjunctivitis. Seven eyelids with eyelid margin entropion were successfully treated using anterior lamellar recession and gray line split. Seven eyelids with eyelid margin entropion and posterior lamellar deficits were effectively treated using anterior lamellar recession, gray line split, and posterior lamellar lengthening. Thirty-eight eyelids with recalcitrant eyelid margin entropion were treated using anterior lamellar recession and gray line split with graft, with a success rate of 94.74% and 89.47%, 3 and 6 months after the operation, respectively. Six eyelids with recalcitrant eyelid margin entropion and posterior lamellar deficits were effectively treated using anterior lamellar recession, gray line split with graft, and posterior lamellar lengthening. Among various grafts, pediculated orbicularis muscle was significantly different from banked sclera or resected tarsus ( P = 0.011, P < 0.001).

CONCLUSIONS

In severe upper eyelid cicatricial entropion and trichiasis, combined surgical procedures showed good functional and cosmetic results with excellent long-term stability.

Therapeutic Contact Lenses in the Treatment of Corneal and Ocular Surface Diseases-A Review

Therapeutic contact lenses (TCLs) are often used in the management of a wide variety of corneal and ocular surface diseases (OSDs). Indications of TCL include pain relief, enhancing corneal healing, corneal sealing, corneal protection, and drug delivery. For painful corneal diseases such as bullous keratopathy, epidermolysis bullosa, and epithelial abrasions/erosions, bandage contact lenses (BCLs) provide symptomatic relief. Postoperatively in photorefractive keratectomy or laser epithelial keratomileusis, BCLs also alleviate pain. In severe OSDs such as severe dry eye, Stevens-Johnson syndrome/toxic epidermal necrolysis, gas-permeable scleral contact lenses are often used to enhance corneal healing. BCLs are used post-keratoplasty, post-trabeculectomy, and post-amniotic membrane transplantation to enhance healing. BCLs, with or without glue adhesives, are used to seal small corneal perforations and sometimes also used as bridging treatment before penetrating keratoplasty in larger corneal perforations. In patients with eyelid conditions such as trichiasis, ptosis, and tarsal scarring, BCLs are also effective in forming a mechanical barrier to protect the cornea. A relatively new use for TCLs is in ocular drug delivery where TCLs are used to maintain therapeutic concentrations of medication on the ocular surface. Contraindications of the use of TCLs include infective keratitis, corneal anesthesia, and significant exposure keratopathy with inadequate eyelid position or movement. Complications of TCL include infective keratitis, corneal hypoxia and associated complications, corneal allergies and inflammation, and poor lens fit. Overall, TCLs are effective in the treatment of corneal and OSDs but contraindications and complications must be considered.

Treatment of Oculoplastic and Ocular Surface Disease in Eyes Implanted with a Type I Boston Keratoprosthesis in Southern China: A Retrospective Study

INTRODUCTION

This study aimed to describe the clinical features, surgical management of the eyelid and ocular surface, and outcomes of 16 patients implanted with a Boston type I keratoprosthesis (KPro).

METHODS

A retrospective, single-center, consecutive case series of 16 patients with Stevens-Johnson syndrome (1), ocular chemical burns (12), and ocular thermal burns (3) implanted with KPro was studied. All subjects were men aged 27-51 years. Surgical treatment and outcomes for eyelid malposition, symblepharon, and glaucoma were assessed.

RESULTS

From September 2010 to February 2019, 29 patients were admitted to Zhongshan Ophthalmic Center for KPro implantation, of whom 16 (55%) required eyelid or ocular surface surgeries to maintain hydration and protect the corneal tissue, which is vulnerable to epithelial defects. Forty-one adnexal surgical procedures were performed. The most common indication for surgery was symblepharon, and the most frequent procedures were symblepharon lysis with ocular mucous membrane grafts and amniotic membranes (7) and full-thickness skin grafts to the eyelids (7). Preoperative conjunctival injection and corneal staining were documented in 9 (56%) and 8 (50%) eyes, respectively, and at up to 4 months postoperative follow-up (the last adnexal surgery before KPro) were recorded in 3 (19%, p = 0.03) and 2 (12%, p = 0.02) eyes, respectively. Glaucoma drainage devices were inserted in six patients. One patient with Stevens-Johnson syndrome underwent FP7 Ahmed glaucoma valve (AGV) implantation inferotemporally and developed plate exposure 2 months postoperatively. Five patients underwent FP8 AGV implantation with tube insertion into the vitreous cavity due to the scarred conjunctiva and limited subconjunctival space. In the study period, intraocular pressure (IOP) was in the normal range, and no tube or plate exposure was observed.

CONCLUSION

The ocular environment is critical for successful KPro surgery. A multidisciplinary approach for any lid and ocular surface abnormality in ocular burns or Stevens-Johnson syndrome is important to improve the quality of the ocular surface and accommodate KPro and AGV, which is vital for maintaining vision after KPro surgery. FP8 AGV may be feasible for IOP control in adult KPro cases with restricted subconjunctival space.

Autologous dermis graft versus conchal cartilage graft for managing lower eyelid retraction: A comparative study

PURPOSE

Lower eyelid management is challenging. The conchal cartilage is often considered a spacer of choice for treating lower eyelid retraction. However, dermis graft has also recently been shown to be a viable spacer. The aim of this study was to compare the efficacy of dermis graft to that of conchal cartilage graft in this indication.

METHODS

A retrospective comparative study was conducted in patients who underwent lower eyelid lengthening with autologous dermis graft (group 1) or autologous conchal cartilage graft (group 2). The main outcome measure was the reduction in inferior scleral show (ISS) assessed by three independent masked surgeons. Secondary outcome measures was the assessment of lagophthalmos and corneal keratitis. Complications were also recorded.

RESULTS

Twenty-five eyelids of 23 patients were included: 11 and 14 eyelids, respectively in group 1 (dermis graft) and group 2 (conchal cartilage graft). Patient mean follow-up was 12.3 (±12.5) and 7.1 (±7.7) months, respectively. No statistical differences in postoperative ISS reduction, lagophthalmos and exposure keratitis was observed (p = 0.540, p = 0.946, p = 0.934, respectively). Three patients experienced a grade I Clavien-Dindo complication in group 1 and one patient experienced a grade II complication in group 2 (p = 0.540).

CONCLUSION

Autologous dermis grafts and conchal cartilage grafts provide favorable outcomes without major complications.

Posterior Lamellar Reconstruction of the Lower Eyelid With a Gingivoalveolar Mucosal Graft

The anterior and posterior lamellae should be simultaneously reconstructed to repair the upper and lower eyelid's full thickness defects after resection of a malignant tumor. The author described a gingivoalveolar mucosal graft for posterior lamellar reconstruction of the lower eyelid. Between November 2014 and September 2017, 11 patients (6 women, 5 men; mean age 62.7 years) with 13 posterior lamellar defect of lower eyelid underwent reconstruction with gingivoalveolar mucosal graft. The defects ranged from 10 x 8 mm to 20 x 10 mm. For 11 lower eyelid defects, the anterior lamellar defect was previously reconstructed with an appropriate local flap. The remaining 2 defects were repaired with graft only. The mean follow-up period was 15.3 months. The pathologic diagnoses were squamous cell carcinoma for 8 lower eyelid lesions and basal cell carcinoma for the remaining 5 lower eyelid lesions. No case of necrosis and infection was observed in any flap or graft. Also, there was not observed ectropion or lid laxity at lower eyelids. However, redness developed in 1 eye, but healed in 1 week. Donor areas completely improved with secondary healing with no any complication. Gingivoalveolar mucosal graft is a reliable and easy accessible choice for posterior lamellar reconstruction of eyelid defects. While the gingival mucosal part provides a stable and tight structural support for marginal palpebral area, the alveolar part occupies the conjunctival side without causing corneal irritation.

Long-Term Results for Entropion Repair by Tarsal Margin Rotation With Posterior Lamella Superadvancement

PURPOSE

To report the long-term stability of tarsal margin rotation and posterior lamellar superadvancement (TMR PLS) for the repair of upper eyelid cicatricial entropion.

METHODS

A retrospective chart review was performed from January 2000 through December 2014 to identify all patients who had TMR PLS at the authors' institution. Charts were reviewed for demographic information, recurrence of entropion or trichiasis, and surgical complications. Failure was defined as return of entropion. Patients with greater than 24 months of follow up were included.

RESULTS

A total of 30 TMR PLS procedures were performed during the review period. Nineteen cases from 14 patients were included in the final analysis. None of the 19 cases demonstrated recurrence of entropion over an average follow-up period of 78.3 months. Eight cases demonstrated trichiasis after TMR PLS, 5 of which required treatment.

CONCLUSION

This case series suggests that TMR PLS for the treatment of upper eyelid cicatricial entropion has excellent long-term stability.

Modified tarsotomy for the treatment of severe cicatricial entropion

PurposeTo analyze the efficacy of modified tarsotomy for the management of severe cicatricial entropion.MethodsTwenty-seven eyelids of 18 patients who underwent modified tarsotomy between March 2011 and July 2013 were retrospectively assessed. The data collected included patient demographics, etiology of cicatricial entropion, and surgical history. Outcome measures included surgical success rate, preoperative and postoperative eyelid position, and surgery-related complications.ResultsMean follow-up time was 13.2 months (range, 6-25.4 months), and the success rate was 81.8% (22 of 27 eyelids). Complications included eyelid margin notching (n=1) and blepharoptosis secondary to avascular necrosis of the distal marginal fragment (n=1), both were corrected by minor surgical intervention.ConclusionsThe study findings suggest modified tarsotomy is effective for the correction of severe cicatricial entropion.

Extensive full-thickness eyelid reconstruction with rotation flaps through "subcutaneous tunnel" and palatal mucosal grafts

AIM

To reconstruct the extensive full-thickness defects of eyelids is a challenge for the plastic surgeon because of their complex anatomy and special functions. This article presents and discusses an improved surgical technique in which the orbicularis oculi myocutaneous flap is rotated through a "subcutaneous tunnel" in conjunction with a palatal mucosal graft employed for lining.

METHODS

Data from 22 eyes with extensive full-thickness eyelid defects from various causes between 2009 and 2013 were analyzed in this study. After the different layers of eyelid were separated completely, a temporally based orbicularis oculi myocutaneous flap was designed following fishtail lines and was mobilized, leaving the base of the pedicle intact with a submuscular tissue attachment. The flap was then rotated through a "subcutaneous tunnel" to the defect, and the donor site was closed primarily. Posterior lamellar reconstruction was performed with a mucosal graft harvested from the hard palate.

RESULTS

All the flaps were survived without any healing problems. There was no corneal irritation, flap contraction, or significant donor-site morbidity in the follow-up period. The incision scars were almost invisible. The defects were repaired completely, and the evaluations showed satisfactory function and appearance.

CONCLUSION

This technique is an improved single-stage operation and can be applied to repair large, full-thickness eyelid defects from various causes. With our method, the functional and aesthetic results can be obtained in either the upper or lower eyelids.