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Ophthalmology (2000) 107: 1982-1988
=A9 2000 American Academy of=20 Ophthalmology

Original Articles

Effective small-incision surgery for involutional lower eyelid entropion=20

Jane M. Olver, FRCOphth1 and = Jonathan A. Barnes, FRCOphth1

1 Western Eye Hospital and the Eye = Department,=20 Charing Cross Hospital, London, UK

Reprint requests to * Jane M. Olver, FRCOphth, = Western Eye=20 Hospital, Marylebone Road, London NW1 5YE, England


3D""   =20 Abstract
Top
Abstract
Introduction
Participants and methods
Results
Discussion
Conclusions
References
 
O= BJECTIVE:=20 The aim of this study was to develop an effective and minimally=20 invasive operation to correct lower eyelid entropion that would = address both the horizontal and vertical laxity.

DESIGN: A prospective, noncomparative, interventional case = series.=20

PARTICIPANTS: Thirty-five consecutive patients with involutional=20 entropion, aged 62 to 92 years (mean, 77.1 years), had = surgery on 45=20 lower eyelids. = Of the 45=20 procedures, 33 (73%) had a primary procedure and 12 (27%) = were=20 reoperations.

INTERVENTION: A lateral tarsal strip with diagonal tightening of the=20 orbital septum and lower lid retractors to the lateral = orbital rim=20 was performed via a 1-cm lateral canthal incision. =

MAIN OUTCOME MEASURES: Complications and surgical outcome were = monitored=20 clinically for between 12 and 24 months after surgery. =

RESULTS: The results were analyzed from 42 eyelids (33 patients) with = a=20 mean follow-up of 17.1 months (range 12=9624 months). Two = patients died=20 and one dropped out of the study 3 months after the second = eyelid operation. In 36 cases = (86%), the=20 entropion was cured. Transient lateral orbital rim tenderness = was=20 noted in six cases (14%), and one patient had a wound = infection.=20 Anatomic recurrences were detected in six eyelids of six patients, = and=20 five of these (83%) were asymptomatic.

CONCLUSIONS: This surgical approach has been found effective in 86% = of eyelids. Adequate = clinical=20 followup has proven essential for accurate evaluation of = entropion=20 surgery.


3D""   =20 Introduction
Top
Abstract
Introduction
Participants and methods
Results
Discussion
Conclusions
References
 
I= nvolutional=20 entropion is a common condition among the elderly in which = turning in=20 of the lower eyelid causes = irritation, tearing, redness, and photophobia. Rarely, = untreated=20 entropion may result in a corneal ulcer. The main factor = giving rise=20 to involutional entropion is the progressive degeneration of = elastic=20 and fibrous tissues within the lid occurring with increased = age. This=20 causes an imbalance between the usual forces acting on the = lower=20 eyelid, and the = resulting=20 eyelid laxity, both = horizontal=20 (tarsal plate and orbicularis) and vertical (lower eyelid retractors and = orbital=20 septum), allows the orbicularis to override.

Medical treatment with lubricants, taping, or orbicularis=20 chemodenervation with botulinum toxin A offer only temporary=20 correction of eyelid=20 position and relief of symptoms1;=20 surgery remains the mainstay for permanent treatment.2=9630=20 Different operations have been described that address the=20 pathophysiologic factors4=9631=20 with apparently acceptable surgical outcomes.4,5,14,18,20,23,24,27=9631=20 So many operations have been described that it raises the = question=20 of whether surgical correction is ever 100% curative. It is=20 generally accepted that, for the best results, surgery should = address both horizontal and vertical laxity.3,7,9,12,14,16,18,20=9624,27=9629=20 Follow-up is particularly difficult in this group of elderly=20 patients because they may be too unwell to report for = follow-up,=20 they may move, or they may die.30=20 Often, the clinical follow-up is too short to establish the = long-term=20 results.

There is a need for involutional entropion to be corrected with=20 minimal surgical intervention and morbidity, producing an = effective,=20 sustained result. In this study, we aimed to perform eyelid surgery via a = small=20 lateral canthal incision that addressed both horizontal and = vertical=20 lid laxity. This approach was developed from the observation = that by=20 placing the convexity of the thumb laterally below the tarsal = plate=20 to compress and tighten the lower eyelid superolaterally, the = entropion=20 could be abolished and the lower eyelid skin crease could be = restored, thus=20 mimicking the effects of surgery (Figs=20 1, 2). We also aimed to set a minimum standard for = evaluating the=20 results of entropion surgery consisting of clinical = assessment of all=20 patients at least 1 year after surgery.



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  		Figure 1. Diagram showing = left=20 lower eyelid=20 involutional entropion A, and its abolition by thumb=20 compression B, which shortens and elevates the lower = lid=20 laterally, as well as compressing the orbital fat. =

 = ;


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  		Figure 2. Clinical = correlate=20 showing left lower eyelid entropion and = thumb=20 compression mimicking the effect of surgery: A, = entropion=20 front view. B, entropion side view. C, effect = of thumb=20 compression front view. D, effect of thumb = compression side=20 view. =

 = ;
This=20 study was organized as a prospective, noncomparative, = interventional=20 case series of involutional entropion patients. Surgery was=20 undertaken by an oculoplastic service in two UK teaching = hospitals.=20


3D""   =20 Participants and methods
Top
Abstract
Introduction
Participants and methods
Results
Discussion
Conclusions
References
 
<= STRONG>Participants
Thirty-five=20 consecutive patients with involutional entropion (13 white = males and=20 22 white females) were included (patients with cicatricial = entropion=20 were excluded). Their informed consent for this procedure was = received. The study patients represented 45 lower eyelids, 27 being unilateral = procedures=20 (11 right and 16 left lower eyelids) and 9 bilateral = procedures.=20 Primary operations were performed on 33 eyelids (73%), and reoperations = were=20 performed on 12 eyelids=20 (27%; Table=20 1). One patient had had two previous procedures. None of = the=20 participants had undergone this technique previously. =


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  		Table 1. Reoperation = Patients=97Details of=20 Previous Surgery =

 = ;
Both=20 intermittent and constant entropion were included in this = study.=20 Intermittent entropion was operated on if it occurred several = times=20 daily and was symptomatic. Details of preoperative horizontal = eyelid laxity are summarized in = Table=20 2. Horizontal eyelid=20 laxity more than 8 mm was noted in 33 eyelids (79%). These = included=20 10 of the 11 recurrences, that is, 90% of the recurrences had = horizontal eyelid laxity = more than 8=20 mm.


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  		Table 2. Surgical Outcome for = Involutional=20 Lower Lid Entropion with Respect to Preoperative Lid Laxity = at=20 Primary or Repeat Surgery (N =3D 42 eyelids) =

 = ;
One=20 surgeon (JMO) performed all the operations in this study.

Methods
The preoperative assessment of each = patient was=20 recorded on a standard proforma. This included details of any = previous entropion surgery and measurements of the vertical = palpebral=20 aperture, margin reflex distances, lower lid skin crease, = lower eyelid excursion, and = horizontal eyelid laxity. = Horizontal=20 laxity was assessed by the pinch test, and each eyelid was classified as = either=20 less than 8 mm (not lax) or more than 8 mm (lax). Medial = canthal=20 tendon laxity was assessed by the lateral distraction test, = with the=20 patient looking in primary gaze and graded according to the=20 horizontal distance reached by the punctum in relation to the = cornea.

Surgical procedure
The = procedure was=20 performed via a 10-mm lateral canthotomy incision. After a = lateral=20 cantholysis, the lateral orbital rim was prepared as for a = lateral=20 tarsal strip (LTS) Fig=20 3. A standard LTS32,33=20 was then fashioned to a suitable length to correct for the = horizontal=20 eyelid laxity. A = double-ended=20 5-0 nonabsorbable suture was placed through the strip but was = not=20 secured to the lateral orbital rim until later.



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  		Figure 3. Diagram showing = surgical=20 landmarks and principles of surgery. =

 = ;
A=20 6-0 silk traction suture was then placed through the grey = line medial=20 to the LTS to elevate the eyelid and=20 to provide access to the area referred to here as the = lateral=20 triangle. This area is defined as that formed anteriorly = by the=20 orbital septum, orbicularis muscle, and skin, and posteriorly = by=20 the conjunctiva and anterior part of the lower eyelid retractors. = (The lateral=20 fat pad is visible between these anterior and posterior = lamellae and=20 acts as an important landmark at surgery.) Thus the apex of = the=20 lateral triangle is formed by the fusion of the retractors = and=20 orbital septum and lies approximately 4 mm below the inferior = border=20 of the tarsal plate (Fig=20 3).

Then, in this procedure, the retractors were separated from = the=20 conjunctiva at a position approximately 8 to 12 mm below the = lower=20 edge of the tarsal plate. Toothed forceps were used to grasp = the=20 retractors within the eyelid to=20 demonstrate that the retractors had been correctly identified = and=20 that diagonal tightening of them would influence lid = function. A=20 double-ended 5-0 nonabsorbable suture was placed through the=20 retractors (subconjunctivally) and attached to the periosteum = at the=20 lateral orbital rim, but was left loose at this stage. This = suture=20 elevated and diagonally tightened the retractors.

A second suture was placed in the orbital septum between the = fat=20 pad and the orbicularis at a level below the retractor suture = and was=20 similarly attached to the lateral orbital rim, immediately = below the=20 retractor suture. This suture tightened the orbital septum=20 horizontally. (If lid laxity is mild, a single suture = captures both=20 the retractors and orbital septum) [Fig=20 4].



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  		Figure 4. Preoperative = view of the=20 lateral triangle with a suture in the tarsal plate (lateral = tarsal=20 strip), separate sutures in the anterior part of the lower = eyelid retractors, = and the=20 orbital septum attached to the lateral orbital rim. The = intervening=20 lateral fat pad is clearly visible. =

 = ;
The=20 LTS was sutured to the lateral orbital rim before the retractor = and=20 orbital septal sutures (Fig=20 5). These permanent sutures were protected by two-layered = closure: 6-0 absorbable mattress sutures to the orbicularis = and 8-0=20 absorbable interrupted sutures to the skin. The lateral = canthal angle=20 is reformed using a buried 6-0 absorbable suture. Additional=20 procedures such as medial canthal tendon stabilization or = lateral fat=20 pad reduction were undertaken if indicated.



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  		Figure 5. A, = diagram showing=20 the three sutures passing through the periosteum at the rim = and=20 B, showing these sutures secured. =

 = ;
Outcome=20 measures
A successful surgical result (cure) occurred when = the=20 lower eyelid = was in=20 apposition with the globe and with the lower punctum in its = usual=20 anatomic position. This position should be maintained in all=20 positions of gaze and on voluntary and involuntary forced = eyelid closure. Effective lower = eyelid retractor action was = recognized by lower eyelid=20 excursion and the presence of a lower eyelid skin crease on = downgaze.=20

Each patient was assessed clinically 1 to 3 weeks after surgery=20 and then at 3- to 4-month intervals for a minimum of 1 year. = At=20 each visit, the patients were asked whether they had experienced = any=20 recurrence of their symptoms. They were examined macroscopically=20 before and after forced orbicularis action (voluntary and = with=20 the amethocaine provocation test). Biomicroscopic examination = of the external eye was performed, and any complications were = noted. Eyelid = measurements of=20 lower lid excursion, lower lid skin crease, and residual = horizontal=20 eyelid laxity were = also=20 made.


3D""   =20 Results
Top
Abstract
Introduction
Participants and methods
Results
Discussion
Conclusions
References
 
O= f the 35=20 patients (45 eyelids) = enrolled in=20 this study, results were available for 33 patients (42 eyelids) because two = patients=20 died during the follow-up period and one patient was lost to=20 followup 3 months after the second eyelid was operated on. = Clinical=20 followup ranged between 12 and 24 months (mean, 17.1 months). =

Separate retractor and orbital septal sutures were used in 35=20 eyelids, and a = single combined=20 suture was used in the remaining seven eyelids. Other eyelid procedures were performed = in=20 four eyelids: = two medial=20 canthal tendon stabilizations and two lateral fat pad=20 reductions.

A cure was achieved in 36 eyelids=20 (86%; Table=20 2). There were no cases of overcorrections. There were no = cases=20 of lower eyelid=20 retraction occurring after this procedure. Recurrence of the=20 entropion occurred in six eyelids of six patients. Of = these,=20 only one had undergone previous eyelid surgery (everting = sutures)=20 and was not found to have had horizontal eyelid laxity before = surgery.=20 For the remaining eyelids, = all had=20 undergone primary procedures and all of these had = preoperative=20 horizontal eyelid = laxity.=20 Siting two sutures (orbital septum and retractors) rather one = combined suture had a beneficial effect on the outcome of the = procedure, with a success rate of 32 of 35 eyelids (91%) for two = sutures,=20 compared with four of seven eyelids=20 (57%) for a single suture (Table=20 3).


View = this=20 table:
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  		Table 3. Surgical Outcome with = Respect to=20 Number of Sutures Used at Primary or Repeat Surgery (N =3D = 42 eyelids) =

 = ;
The=20 timing of the recurrences was as follows:=20
  1. Three of six patients (50%) experienced recurrence = within=20 6 months after surgery,
  2. Two of six patients (33%) experienced recurrence = between=20 12 and 18 months after surgery, and
  3. One of six patients (16%) experienced recurrence = between=20 18 and 24 months after surgery.=20

There was a discrepancy between the objective results of surgery = observed by the ophthalmologist and the patients=92 symptoms. = In=20 five eyelids (five = patients) with=20 entropion recurrence, this was detected only by the examining = ophthalmologist with the patients remaining asymptomic. In = the sixth=20 case of recurrence, the patient reported mild symptoms. The = recurrent=20 entropion was mild in three eyelids where we observed = posterior=20 marginization of the mucocutaneous junction. Therefore, only = one of=20 45 eyelids had=20 symptomatic recurrence, representing 98% symptomatic success. =

All recurrences, asymptomatic and symptomatic, were treated = by=20 Rathbun-Quickert everting sutures because there was no residual=20 horizontal laxity detected (all had <8 mm horizontal eyelid laxity after = surgery).=20 To date, this has anatomically cured these recurrences = (minimum=20 further follow-up of 12 months).

Other complications after surgery included one lateral canthal=20 wound infection, which occurred within 2 weeks of surgery and = settled with medical treatment. Six patients experienced = transient=20 lateral orbital rim discomfort for less than 4 weeks. Figure=20 6 shows the postoperative appearance after left LTS with=20 diagonal retractor and orbital septal tightening.



View = larger=20 version (97K):
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  		Figure 6. Appearance = after left=20 horizontal shortening with retractor and orbital septal = tightening:=20 A, front view, primary gaze; B, side view, = primary=20 gaze; C, front view, down gaze; D, side view, = down=20 gaze. =

 = ;

3D""   =20 Discussion
Top
Abstract
Introduction
Participants and methods
Results
Discussion
Conclusions
References
 
P= revious=20 studies strongly suggest that both horizontal and vertical = laxity=20 should be addressed to maximize the surgical success of = involutional=20 entropion correction.14,18,20,23,24,27=9629=20 We described an operation based on horizontal lid shortening = by=20 the lateral tarsal strip and on diagonal tightening of the = orbital=20 septum and lower lid retractors for the correction of = involutional=20 entropion. This approach is based entirely at the lateral = canthal=20 angle, enabling the surgeon to address both factors via one = incision.=20 We included patients with primary and recurrent involutional=20 entropion. It is of note that only one of the patients = requiring=20 reoperation had previously had surgery to shorten the eyelid horizontally, while 10=20 patients (91%) were noted to have significant residual = horizontal=20 eyelid laxity. = This adds=20 support to the belief that horizontal laxity must be = addressed if=20 surgery is to be successful.14,18,20,23,24,27=9629=20

Vertical lid laxity is corrected by tightening the orbital = septum=20 and lower lid retractors using the diagonal sutures. The = importance=20 of tightening the lower lid retractors has been advocated = since=20 the early 1960s.6,11,14=9616,18,20,21=9624,27=20 In particular, the anterior part of the lower eyelid retractors = stabilizes=20 the lower border of the tarsal plate and pulls the lid at the = level of the lower skin crease in down gaze. The retractors=20 consist of the capsulopalpebral fascia and inferior tarsal = muscle,=20 and they may be attenuated, although rarely dehisced, in = involutional=20 entropion. Also, their effect is compromised by lower lid sag = secondary to involutional horizontal eyelid laxity, and they = may=20 also be relatively "weakened" by aging enophthalmos, although = this=20 suspected association has not been confirmed.34=20

Before surgery, the lower lid skin crease (usually found 4 mm=20 below the lash line) was not apparent unless the eyelid was = "unflipped." After=20 surgery, this crease was permanently restored, confirming the = physiologic pull of the retractors. Also, the lower eyelid excursion was compromised = with the=20 eyelid inturning, = but=20 when unflipped, appeared normal. We did not detect any significant=20 difference between the preoperative and postoperative lower=20 eyelid excursion, = similar to=20 that observed by Wright et al.30=20

Another effect of the diagonal sutures is to compress the=20 precapsulopalpebral fascial fat pad; fat prolapse is = suspected as=20 having a minor mechanical role in destabilizing the lid=20 margin.35=20 In our series, the use of separate sutures (retractor and = orbital=20 septal) was more effective than a single suture, providing = greater=20 support to overcome the vertical lid laxity.

It is inevitable that there will be some failures after = entropion=20 surgery if the patients are monitored over a long period. The = success rates of other studies are summarized in Table=20 4. Collin and Rathbun14=20 stated in 1978 (page 1063): "No operation designed to correct = the=20 ageing changes that affect the lid tissues can be completely=20 successful, since by definition these changes are = progressive."=20 Indeed in our series, in the reoperation group, the interval = between=20 the previous entropion surgery ranged from 6 months to 13 = years.=20 Therefore when assessing a surgical procedure, an attempt = should be=20 made to follow-up patients to determine at least the = short-term=20 failures. We regard short-term follow-up as up to one year = after=20 surgery, medium-term follow-up as between 1 and 2 years, and=20 long-term follow-up more than 2 years after surgery. Several = previous=20 studies had a minimal follow-up of 1 to 7 months after=20 surgery,11,15,17,18,20,25,26,27=20 but few fulfilled the criteria we have set in this study, = namely=20 of a minimum follow-up up of 1 year based on clinical=20 examination.16,23,24,30=20 Although most recurrences take place very early, often within = 6=20 months,28=20 our study shows that we had further recurrences after that = period,=20 supporting the need for longer follow-up when evaluating the=20 results.


View = this=20 table:
[i= n=20 this window]
[in a new window]
  		Table 4. Review of Success Rates = in Other=20 Procedures =

 = ;
Collin=20 and Rathbun14=20 (page 1064) also stated: "Follow-up studies after entropion=20 procedures are, however, notoriously inaccurate, since the = population=20 is aged." Studies should therefore include data on the number = of=20 patients who have been lost to follow-up for whatever = reason.17,28=9630,36=20 In this study, we were able to account for all the patients = operated=20 on and examine 94% of patients at least 1 year after = surgery.=20

The anatomic success rate may initially appear modest when = compared=20 with other techniques where the apparent success rate is = often=20 greater but follow-up shorter (see Table=20 4). An exact comparison with other studies is not = possible=20 because of different study designs and, in particular, of = different=20 protocols for follow-up. In this series, asymptomatic = entropion=20 recurrences were detected, with 98% of cases having = symptomatic=20 improvement, yet only 86% having anatomic success. It is not = clear=20 why there was this discrepancy, and it may be because we were = observing the patients closely and noted the lid malposition = before=20 patients=92 symptoms developed.36=20 We speculate that because the eyelid=20 was stabilized by the horizontal tightening, there was = recurrent=20 entropion with constant lash=96corneal contact rather than = the=20 skin=96corneal touch found in a destabilized eyelid flipping in = and out.=20 These findings support the argument for clinical follow-up = rather=20 than relying on the elderly patients=92 elective return for = further=20 assessment.28=20

An ideal operation should be effective, cause minimal discomfort = and morbidity, give an aesthetic result, and have a lasting=20 effect. This operation not only restores normal lid function, = but also gives a rapid rehabilitation with few complications=20 and an excellent cosmetic outcome. As with other procedures=20 performed at the orbital margin, transient discomfort was = apparent=20 at the orbital rim at a rate consistent with that described=20 after the lateral tarsal strip procedure.27=20


3D""   =20 Conclusions
Top
Abstract
Introduction
Participants and methods
Results
Discussion
Conclusions
References
 
I= n this=20 prospective, noncomparative study, we described a minimally = invasive=20 surgical technique for the correction of involutional = entropion that=20 is highly effective in both primary and reoperation patients. = The=20 operation addresses the two main etiologic factors in = involutional=20 entropion. It gives rapid postoperative rehabilitation and an = aesthetic result because of the short lateral canthal = incision and=20 fine-gauge dissolvable skin suture used. We recommend a = minimum=20 clinical followup of 1 year when evaluating surgery for = involutional=20 entropion, with up to 2 years being preferable.


3D""   =20 Footnotes
 
The authors have no propriety = interest in=20 this study.


3D""   =20 References
Top
Abstract
Introduction
Participants and methods
Results
Discussion
Conclusions
References
&nb= sp;

  1. Steel D.H.W., Hoh H.B., Harrad R.A., Collins C.R. = Botulinum toxin=20 for the temporary treatment of involutional lower lid entropion. Eye=20 1997;11:472-475.[Medline]=20
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  27. van den Bosch W.A., Rosman M., Stijnen T. Involutional = lower=20 eyelid entropion. = Ophthalmic Surg=20 Lasers 1998;29:581-586.[Medline]=20
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  29. O=92Sullivan E.P., Howe L.J., Barnes E., et al. Factors = affecting=20 the success rate of the Quickert and Wies procedures for lower lid = entropion=20 [letter]. Orbit 1999;18:61-73.
  30. Wright M., Bell D., Scott C., Leatherbarrow B. Everting = suture=20 correction of lower lid involutional entropion. Br J Ophthalmol=20 1999;83:1060-1063.[Abstract/Full=20 Text]
  31. Dalgleish R., Smith J.L.S. Mechanics and histology of = senile=20 entropion. Br J Ophthalmol 1966;50:79-91.[Medline]=20
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Received for publication January 11, 2000. Accepted for = publication=20 June 12, 2000.


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