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Ophthalmology (2001) 108: 989-993
=A9 2001 American Academy of=20 Ophthalmology

Original Articles

Primary and secondary transconjunctival involutional entropion = repair=20

Todd Cook, MD1, Mark = J.=20 Lucarelli, MD1, Bradley N. Lemke, MD1=20 2 and Richard K. Dortzbach, MD1 =

1 Department of Ophthalmology and Visual = Sciences,=20 Oculoplastics Service, University of Wisconsin-Madison, Madison,=20 Wisconsin
2 Division of Ophthalmic and Facial Plastic = Surgery,=20 Davis Duehr Dean Medical Center, Madison, Wisconsin

Reprint requests to Todd Cook, MD, University of=20 Wisconsin-Madison, Department of Ophthalmology and Visual Sciences, 600 = Highland=20 Ave., Madison, WI 53702


3D""   =20 Abstract
Top
Abstract
Introduction
Surgical technique
Methods
Results
Discussion
References
 
P= URPOSE:=20 Lower eyelid involutional = entropion=20 is a significant disorder of the aging population resulting = from=20 horizontal eyelid = laxity,=20 overriding orbicularis oculi muscle, and attenuation of the=20 lower eyelid = retractors. The=20 purpose of this study is to describe the long-term results of = transconjunctival entropion repair.

DESIGN: Interventional noncomparative case series.

PARTICIPANTS: Thirty-six eyelids=20 in 31 patients.

METHODS: Charts were reviewed of all transconjunctival entropion=20 repairs, which included myectomy, retractor fixation, and=20 horizontal shortening performed by three oculoplastic = surgeons=20 between January 1993 and January 1999. Cases with less than = 12=20 months follow-up were excluded.

MAIN OUTCOME MEASURES: Entropion recurrence.

RESULTS: Thirty-six lids in 31 patients were followed for mean of = 31.5=20 months (12.5=9679). Six of 36 lids (16.7%) had postoperative=20 complications. Recurrent entropion occurred in 3 of 36 lids=20 (8.3%) an average 16.3 months (7=9635) after surgery. An = average=20 of 6 trichiasis lashes (1=9610) occurred in 4 of 36 lids = (11.1%) at a=20 mean of 2.25 months (1=964) after surgery. There were no=20 overcorrections. Three of 36 lids (8.3%) required additional=20 surgery.

CONCLUSIONS: Entropion recurrence after three-step transconjunctival=20 repair is within the 0% to 30% reported recurrence for other=20 repair techniques but more frequent than reported for a = similar=20 transcutaneous procedure. The 8.3% recurrence rate might have = resulted from inadequate myectomy, inadequate retractor = fixation,=20 cicatricial changes directly related to the transconjunctival = incision, or progressive involutional changes. Trichiasis was = the=20 most frequent complication. Transconjunctival entropion = repair=20 may be slightly less effective than transcutaneous = repair.=20


3D""   =20 Introduction
Top
Abstract
Introduction
Surgical technique
Methods
Results
Discussion
References
 
I= nvolutional=20 entropion of the lower eyelid is a=20 common, acquired malady in the aging population, that = degrades the=20 functional and cosmetic quality of life.1=20 Horizontal eyelid laxity,=20 overriding of the preseptal orbicularis muscle, and = attenuation of=20 the lower eyelid=20 retractors have been implicated in the pathophysiology of=20 involutional entropion.2=9610=20 Many methods have been described for repair of primary and = recurrent=20 disease with recurrence rates ranging from 0% to 30%.1=963,6,11=9625=20 In 1993, Dresner and Karesh26=20 described a method of repair that addressed the major=20 pathophysiologic components and avoided the potential scar = from an=20 infraciliary incision by use of a transconjunctival approach. = There=20 were no entropion recurrences over a follow-up period of 9 to = 18=20 months. The purpose of this study is to describe the = effectiveness of=20 transconjunctival entropion repair over a longer follow-up=20 period.


3D""   =20 Surgical technique
Top
Abstract
Introduction
Surgical technique
Methods
Results
Discussion
References
 
L= ateral=20 canthotomy and inferior cantholysis are performed with = straight iris=20 scissors. The monopolar electrosurgical unit with a = microdissection=20 needle is used to incise the remaining orbicularis muscle, = exposing=20 the periosteum of the lateral orbital rim. In 14 eyelids a 3-mm horizontal by = 8-mm vertical=20 periosteal flap was developed at the lateral orbital wall = near=20 Whitnall=92s tubercle.

The lower lid is then retracted inferiorly and anteriorly, and = the=20 conjunctiva is incised 2 mm below the inferior tarsal border = from the=20 lateral canthus to 4 mm below the medial punctum. A flap of=20 conjunctiva and lower eyelid=20 retractors is developed sufficiently to allow direct suturing = of the=20 retractors later in the case. The orbital septum is then = identified=20 and incised. The preseptal orbicularis muscle fibers are = excised in a=20 strip 3- to 4-mm wide along the length of previous incision = with=20 the microsurgical needle or straight iris scissors. Care is=20 taken to avoid buttonholing the skin. Cautery is applied=20 generously. The terminal edge of the lower lid retractors is = then=20 reattached to the anterior, inferior border of the tarsus = with three=20 or more interrupted, buried 6-0 polyglactin sutures.=20 Reattachment of the lower eyelid retractors brings the = conjunctival=20 edges into apposition. The conjunctival edges are not = sutured.=20

Horizontal laxity is next addressed with lateral tarsal strip=20 formation. The lower eyelid is=20 resuspended to periosteum inside the orbital rim at the level = of=20 Whitnall=92s tubercle (22 eyelids) or to a periosteal = flap27=20 (14 eyelids) with two=20 interrupted 5-0 polypropylene or polyglactin sutures. The = lateral=20 canthal angle is then reformed with a 6-0 polyglactin suture. = The=20 deep orbicularis is reapproximated with one or two buried 6-0 = polyglactin sutures, and the skin incision is closed with 6-0 = fast-absorbing gut suture in a running fashion.


3D""   =20 Methods
Top
Abstract
Introduction
Surgical technique
Methods
Results
Discussion
References
 
A= =20 retrospective chart review was conducted of all patients who=20 underwent involutional entropion repair between January 1993=20 and January 1999 by three oculoplastic surgeons (RKD, BNL, = MJL)=20 at the University of Wisconsin=96Madison, and the Davis = Duehr=20 Dean Medical Center, Madison, Wisconsin. Data relating to=20 demographics, ocular and periocular surgical history, surgical=20 technique, and postoperative course were obtained. All = postoperative=20 evaluations involved the surgeon of record examining the = subject=20 in the clinic. Provocative testing for recurrence or latent=20 entropion was performed by asking seated subjects to squeeze=20 the eyelids closed = maximally.=20 Subjects with follow-up of less than 1 year were = excluded.=20


3D""   =20 Results
Top
Abstract
Introduction
Surgical technique
Methods
Results
Discussion
References
 
S= ixty=20 eyelids in 52 patients = underwent=20 involutional entropion repair as described. Thirty-six lids = in 31=20 patients had follow-up of greater than 12 months. Mean = follow-up was=20 31.5 months (median, 27.5; range, 12.5=9679). Seventeen = patients were=20 men (55%) and 14 women (45%), with a mean age of 75.8 years = (median,=20 76; range, 58=9692). There were 23 right eyelids (74%) and 13 = left eyelids (26%). Five patients = (16%)=20 underwent bilateral entropion repair. Twenty-nine (81%) of = the=20 repairs were primary, and seven (19%) were secondary (Table=20 1). The primary surgery of the secondary cases was done=20 elsewhere. One patient had concurrent ptosis surgery on the=20 ipsilateral upper eyelid.=20


View = this=20 table:
[in = this window]
[in a new window]
  		Table 1. Secondary Entropion = Repairs =

 = ;
Seven=20 of 36 repairs (19.4%) in 6 of 31 patients (19.4%) resulted in = postoperative complications (Table=20 2). There were no overcorrections. One of 29 primary = entropion=20 repairs (3.4%) and 2 of 7 secondary (28.5%) entropion repairs = resulted in recurrent entropion. Overall, entropion recurred = in 3 of=20 36 repairs (8.3%) at an average of 16.3 months = postoperatively=20 (range, 7=9635). Two of three recurrences occurred in eyelids that were fixed to the=20 lateral orbital rim with a periosteal flap. One entropion=20 recurrence involved fixation of the tarsal strip with = polyglactin=20 suture; two recurrences involved polypropylene suture. =


View = this=20 table:
[in = this window]
[in a new window]
  		Table 2. Complications =

 = ;
Three=20 of 36 eyelids (8.3%) in 3 = of 31=20 patients (9.7%) required additional eyelid surgery, including 2 with = recurrent=20 entropion. One other patient is anticipating surgical = correction of=20 recurrent entropion. Trichiasis lashes were seen = postoperatively in=20 4 of 36 (11.1%) eyelids=20 at a mean of 2.25 months (range, 1=964) despite normal eyelid margin position. All = patients with=20 postoperative trichiasis had a history of preoperative = trichiasis.=20 All trichiasis lashes except one occurred in the middle third = of the=20 operative lid. Three of four lids complicated by trichiasis = were=20 adequately controlled with manual epilation (1 to 5 = procedures); one=20 required cryotherapy.


3D""   =20 Discussion
Top
Abstract
Introduction
Surgical technique
Methods
Results
Discussion
References
 
D= resner=20 and Karesh26=20 logically proposed that a definitive involutional entropion = repair=20 should address all of the components leading to the problem = and=20 reported an esthetically and structurally sound method for = repair.=20 The lack of recurrent entropion in the follow-up time range = of 9 to=20 18 months of that study was encouraging. Jones et al18=20 emphasized the value of long-term follow-up in entropion = surgery.=20 Glatt28=20 has recently pointed out the relationship of the apparent = success=20 rate to the rigor of the postoperative evaluation. =

This study with a similar group of subjects undergoing a = procedure=20 analogous to that of Dresner and Karesh26=20 with mean follow-up of almost 3 years identified recurrent = trichiasis=20 and recurrent entropion as complications. The 8.3% recurrence = rate=20 reported here is within the 0% to 30% range of reported = recurrence=20 for other entropion repair procedures1=963,6,11=9613,24=20 but is well beyond the 0% to 4% recurrence rate reported by=20 Charonis and Gossman,12=20 Corin et al,21=20 and Glatt28=20 for similar procedures using the transcutaneous approach. = Charonis=20 and Gossman reported on 42 eyelids of 35 patients after=20 transcutaneous involutional entropion repair, which included=20 horizontal shortening and myectomy. Postoperatively = (follow-up: mean,=20 33 months; range, 5=9658) there were no recurrences; one = patient had=20 two trichiatic lashes, and one patient had a pyogenic = granuloma. No=20 patient had overcorrection or cicatricial ectropion develop. = In=20 addition, no cosmetic sequelae from the transcutaneous = incision were=20 reported. With mean follow-up of 12 months (range, 3=9636), = Corin et al=20 reported no recurrence in 21 eyelids of 15 patients who = underwent=20 transcutaneous entropion repair with modified lateral tarsal = strip=20 and myectomy. Glatt reported manifest entropion recurrence in = 2 of 51=20 eyelids (4%) = using=20 Corin=92s technique with mean follow-up of 25 months (range, = 6=9658). In=20 this report latent entropion was elicited during office = examination=20 with forcible eyelid = squeezing=20 in the seated and/or supine position in an additional five = eyelids. Of these, = three were=20 completely asymptomatic, two had minor superficial punctate=20 keratopathy, and all believed they had substantial = improvement=20 compared with their preoperative condition.

The higher entropion recurrence rate with transconjunctival = repair=20 might theoretically result from cicatricial shortening of the = posterior lamella associated with the conjunctival incision. = One=20 patient (Patient 2, Tables=20 1 and 2) who underwent secondary entropion repair did = have=20 recurrent entropion develop, which was due to posterior = lamella=20 cicatrization. In the other recurrences in this series, = prominent=20 cicatricial changes were not appreciated. Other reports of=20 transconjunctival surgical approaches to the orbit and lid = have not=20 been complicated by cicatricial entropion. Baylis et = al29=20 reported no entropion in 122 cases of lower eyelid blepharoplasty = followed=20 for 24 months. Zarem and Resnick30=20 also used this method for blepharoplasty in 104 patients with = 24-month follow-up and had no entropion complications. Tenzel = and=20 Miller31=20 used the transconjunctival approach for orbital fracture = repair=20 in 23 patients without entropion complication after 36 = months.=20 Fedok32=20 reported no entropion in 45 patients, as did Jackson et = al33=20 in 200 patients undergoing facial fracture repair with the=20 transconjunctival approach. Westfall et al34=20 only identified one case of cicatricial entropion in 1200=20 transconjunctival procedures. Allowing the apposed edges of=20 conjunctiva to heal by secondary intention may allow = increased=20 cicatricial changes contributing to recurrent entropion. The = results=20 of Dresner and Karesh26=20 and Zarem and Resnick30=20 suggest this risk must be quite small.

Inadequate myectomy or inadequate advancement of the lower eyelid retractors to = the=20 anterior, inferior tarsus may have also contributed to = recurrence,=20 although such recurrence might have been expected to occur = earlier in=20 the postoperative course. Individual predisposition to = chronic eyelid squeezing or rubbing may = lead to=20 entropion and subsequent recurrence after surgical repair. = Ongoing=20 involutional change of the periocular and orbital tissues may = have=20 also contributed to recurrence. In office examination, = provocative=20 testing by the surgeon at longer follow-up intervals may have = also=20 contributed to the entropion recurrence rate reported in this = series,=20 as suggested by Glatt.28=20 There was no apparent advantage of periosteal flap fixation = of the=20 lateral eyelid to the = orbital rim or=20 of suture material type for lateral eyelid fixation; however, = the=20 numbers were too small for statistical confirmation.

The limited aesthetic advantage of avoiding an infraciliary=20 incision with the transconjunctival approach may ultimately = be=20 a disadvantage in terms of efficacy. In 1977 Wray et al35=20 compared 45 transconjunctival and 45 transcutaneous orbital=20 fracture repairs. In the former group, there was one = entropion=20 complication attributed to poor incision position; no = entropion=20 occurred in the latter group. More interesting was that 19 of = 45 subciliary incisions were complicated by ectropion. = Although=20 this ectropion rate is greater than reported elsewhere,12=20 it demonstrates the cicatricial changes that can occur in the = anterior lamella with a transcutaneous surgery. These changes = may=20 help prevent recurrent entropion. Data supporting this=20 hypothesis come from Dortzbach and McGetrick,24=20 who reported two overcorrections and no entropion recurrences = when=20 combining creation of a scar barrier at the junction of = pretarsal and=20 preseptal orbicularis muscle with an infraciliary = transcutaneous=20 incision in involutional entropion repair of 38 lower eyelids followed for an = average=20 of 3.9 years.

An additional advantage of the transcutaneous approach in = preventing=20 recurrent entropion is the option of not manipulating the = lower=20 eyelid retractors if = they are=20 found in acceptable anatomic position at the time of surgery. = Hawes=20 and Dortzbach10=20 were not able to demonstrate detachment of the lower eyelid retractors as = a=20 component of involutional entropion with histologic evaluation = in=20 eight involutional entropion cases. The lack of entropion = recurrence=20 reported by Charonis and Gossman12=20 and Corin et al21=20 using techniques that did not include manipulation of the = lower=20 eyelid retractors = also calls=20 into question the value of manipulating the lower eyelid retractors.

Trichiasis is a rarely reported complication of transcutaneous=20 involutional entropion repair,1=963,6,11,12,14,18=9624,28,36=20 occurring in 0% to 7% of cases. Trichiasis has not been = reported=20 for transconjunctival repair.26=20 It is not clear whether these series considered recurrent = trichiasis=20 as a complication of entropion repair. Trichiasis can be = difficult to=20 diagnose in the setting of entropion, because abnormal lash = position=20 may easily be mistakenly attributed to abnormal eyelid position. All = four cases=20 (11.1%) complicated by postoperative trichiasis in this study = had=20 preoperative trichiasis. Scheie and Albert37=20 reported trachoma, ocular cicatricial pemphigoid, = Stevens-Johnson=20 syndrome, blepharitis, and previous chemical burns as = predisposing=20 factors for trichiasis. Two of four subjects with recurrent=20 postoperative trichiasis lashes had predisposing factors. One = subject had a preoperative history of chronic conjunctivitis=20 thought to be secondary to abnormal eyelid position, and one=20 subject had a chalazion that was incised and drained at the=20 time of entropion repair. Most trichiasis recurrences = occurred=20 in the middle third of the eyelid where surgical = manipulation=20 was extensive, including manual eyelid retraction and = plication=20 of the lower eyelid = retractors=20 to the anteroinferior tarsal edge. Surgical trauma in this = area could=20 have made trichiasis recurrence more likely. In this study,=20 consequences of recurrent trichiasis included additional = clinic=20 visits, additional procedures, significant ocular discomfort, = and=20 lower subject satisfaction with the outcome of entropion = repair.=20 Subjects at risk of developing postoperative trichiasis seem = to be=20 those with preoperative trichiasis. The data from this series = suggest=20 that recurrent trichiasis can be a significant complication = of=20 entropion repair. Careful examination for and treatment of = trichiasis=20 preoperatively is encouraged to improve postoperative = results.=20

On the basis of the results of this study, we have made the=20 following modifications to our approach to involutional = entropion=20 repair. Careful preoperative examination is done to = differentiate=20 trichiasis from abnormal eyelid position. Patients with=20 trichiasis or a history of trichiasis are counseled regarding = the=20 possibilities for postoperative recurrence. The = transconjunctival=20 approach is favored in primary involutional entropion repair = with=20 suspected lower eyelid=20 retractor dehiscence. For patients with recurrent = involutional=20 entropion, a transcutaneous approach is generally = selected.=20

The retrospective and noncomparative nature of this study is = a=20 significant limitation. The relatively small number of patients=20 meeting the required direct follow-up of 1 year or more is a=20 reflection of the referral nature of the authors=92 practices = and=20 is a further limitation. Longer follow-up of a larger number = of=20 patients would be more ideal. A prospective, randomized, = longitudinal=20 study comparing the transcutaneous and transconjunctival = approaches=20 would provide more meaningful data.

Finally, it is logical that the definitive involutional = entropion=20 repair should address all of the components leading to the = problem.=20 Unfortunately, the most fundamental component of involutional = entropion is time. Because of ongoing pathoanatomic = involutional=20 changes, some low rate of entropion recurrence may be = unavoidable.=20


3D""   =20 Footnotes
 
The authors = have no=20 commercial interest in any of the products described. =


3D""   =20 References
Top
Abstract
Introduction
Surgical technique
Methods
Results
Discussion
References
&nb= sp;

  1. Dryden R.M., Leibsohn J., Wobig J. Senile entropion. = Pathogenesis=20 and treatment. Arch Ophthalmol 1978;96:1883-1885.[Medline]=20
  2. Hsu W.M., Liu D. A new approach to the correction of = involutional=20 entropion by pretarsal orbicularis oculi muscle fixation. Am J = Ophthalmol=20 1985;100:802-805.[Medline]=20
  3. Rainin E.A. Senile entropion. Arch Ophthalmol=20 1979;97:928-930.[Medline]=20
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  21. Corin S., Veloudios A., Harvey J.T. A modification of = the lateral=20 tarsal strip procedure with resection of orbicularis muscle for = entropion=20 repair. Ophthalmic Surg 1991;22:606-608.[Medline]=20
  22. Carroll R.P., Allen S.E. Combined procedure for repair = of=20 involutional entropion. Ophthal Plast Reconstr Surg = 1991;7:123-127.[Medline]=20
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  24. Dortzbach R.K., McGetrick J.J. Involutional entropion = of the=20 lower eyelid. Adv = Ophthal Plast=20 Reconstr Surg 1983;2:257-267.
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  32. Fedok F.G. The transconjunctival approach in the trauma = setting:=20 avoidance of complications. Am J Otolaryngol 1996;17:16-21.[Medline]=20
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  34. Westfall C.T., Shore J.W., Nunery W.R., et al. = Operative=20 complications of the transconjunctival inferior fornix approach. = Ophthalmology=20 1991;98:1525-1528.[Abstract] =
  35. Wray R.C., Jr, Holtmann B., Ribaudo J.M., et al. A = comparison of=20 conjunctival and subciliary incisions for orbital fractures. Br J = Plast Surg=20 1977;30:142-145.[Medline]=20
  36. Hill J.C., Feldman F. Tissue barrier modifications of a = Wheeler=20 II operation for entropion. Arch Ophthalmol 1967;78:621-623.[Medline]=20
  37. Scheie H.G., Albert D.M. Distichiasis and trichiasis: = origin and=20 management. Am J Ophthalmol 1966;61:718-720.[Medline]=20
Received for publication March 24, 2000. Accepted for = publication=20 January 2, 2001.


3D""=20 Abstract=20 of this Article
3D""=20 Reprint=20 (PDF) Version of this Article
3D""=20 Similar = articles found in:=20
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3D""=20 PubMed=20 Citation
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3D""=203D""=20 Cook,=20 T. || Dortzbach,=20 R. K.
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