Transconjunctival entropion repair - the backdoor approach

Transconjunctival Approach for Involutional Entropion: Suggestions and Drawbacks

Background

Most current surgical approaches in involutional lower eyelid entropion (ILLE) repair focus upon lower eyelid retractor (LER), mainly through transcutaneous approaches. We have opted to use the transconjunctival approach because of the hidden postoperative scar and the shortest reach to the LER. Here, based on our experience, we present our suggestions and note some of the drawbacks regarding ILLE repair by the transconjunctival approach.

Methods

Two surgeons performed entropion repair on 14 eyelids in 13 patients. Repairs were performed by a transconjunctival approach, where a part of the conjunctiva was at first incised with a scalpel, and the conjunctiva and LER were then separated at the lower edge of the tarsus with scissors. The anterior and posterior aspects of the LER were peeled off, and the LER was dissected into sheets. The LER was then fixed to the anterior-inferior border of the tarsus, and the conjunctiva was sutured. No postoperative gauze, tape dressings, or even suture removal were required.

Results

Mean operating time was 32.6 minutes. Recurrence was observed in one of 14 patients at an average of 6.6 months postoperatively.

Conclusions

We reported our suggestions and drawbacks of the transconjunctival approach for ILLE repair. We recommend sufficiently detaching the anterior-posterior aspects of the LER and fixing the LER to the anterior-inferior border of the tarsus. Drawbacks of this technique include the possibility of an insufficient correction in cases with a positive pinch test and medial traction test. Conversely, no further treatment or maintenance is required postoperatively.

Comparison of postoperative recurrence rates between percutaneous and transconjunctival approaches for involutional entropion

Lower eyelid entropion is the second most common disease seen after ptosis in oculoplastic outpatients. In this study, we performed percutaneous and transconjunctival shortening of the anterior and posterior layers of the lower eyelid retractor (LER) to treat lower eyelid involutional entropion. This study aimed to examine the recurrence rate and complications of the percutaneous and transconjunctival approaches. This was a retrospective study of procedures conducted from January 2015 to June 2020. The LER shortening was performed for lower eyelid involutional entropion on 103 patients (116 eyelids). From January 2015 to December 2018, LER shortening using the percutaneous approach was implemented; from January 2019 to June 2020, the transconjunctival approach was used to shorten the LER. All patient charts and photographs were retrospectively reviewed. Recurrence occurred in 4 patients (4.3%) in the percutaneous approach. No recurrence was observed in any patient in the transconjunctival approach. Temporary ectropion occurred in 6 patients (7.6%) when the percutaneous approach was used; all cases healed within 3 months after surgery. The study did not reveal any statistically significant difference in recurrence rates between the percutaneous and transconjunctival approaches. We achieved results equal to or better than percutaneous LER shortening by combining transconjunctival LER shortening with horizontal laxity shortening, such as lateral tarsal strip, pentagonal resection, and orbicularis oculi muscle resection. However, it is necessary to be careful about temporary ectropion after surgery when percutaneous LER shortening alone is performed for 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.

A 2-step Procedure for Entropion Treatment: Eyelid Splitting and Full-thickness Everting Sutures

Background:

This study aimed to evaluate the clinical efficacy of the 2-step procedure used for treating entropion patients: (1) performing a grey line split incision and recessing the anterior lamella; (2) using full-thickness everting sutures of the eyelid to enhance the rotating effect.

Methods:

In total, 31 eyelids of 21 patients were reviewed (male–female ratio = 11:10), with each patient having either upper or lower, or both eyelid entropion due to various causes. All patients underwent the two-step procedure by eyelid splitting and full-thickness everting sutures at the Bundang Cha Hospital from August 2014 until July 2018.

Results:

The mean follow-up duration was 24.3 months (range, 14–107 months). The causes of entropion included involutional entropion (15 eyelids), congenital entropion (10 eyelids), and cicatrical entropion (6 eyelids). Surgery was re-performed on 16 eyelids due to recurrences from previous electrolysis or surgical correction of entropion such as capsulopalpebral fascia repair, full-thickness rotating suture, or folliculectomy. The two-step procedure was performed on all 31 eyelids, and 9 eyelids received additional excision of skin. After the 2-step procedure, patients showed improvement in symptoms, and all were satisfied with the contour of their eyelids. During the follow-up period, there were no recurrences or complications.

Conclusion:

A two-step procedure involving eyelid splitting and full-thickness everting sutures is an effective surgical method to treat entropion due to various causes, when compared with other conventional methods.

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.

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.