Outcomes of combined procedures compared to various single techniques for involutional entropion

Abstract

BACKGROUND:

To describe the outcomes of triangular tarsectomy and limited orbicularis myectomy with lower eyelid retractor plication compared to an everting sutures (ES) technique or lateral tarsal strip (LTS) procedure for the correction of lower eyelid involutional entropion.

METHODS:

A nonrandomized clinical study was carried out at two tertiary eye hospitals between January 2016 and December 2019. Patients in Group A underwent triangular tarsectomy and limited orbicularis myectomy with lower eyelid retractor plication. Group B had ES, and Group C underwent a LTS procedure. All participants were operated by one surgeon and underwent 1-year follow-up.

RESULTS:

A total of 78 patients in whom 84 eyelids were affected by lower eyelid involutional entropion were included in the study. The success rate was higher in Group A compared to Group B and Group C (100% vs. 86.7% vs. 95.8%; P < 0.05). Recurrence at a 1-year follow-up was noted in only four (13.3%) eyelids in Group B and one (4.2%) in Group C. However, patient's in Group C experienced a higher frequency of minimal postoperative complications, including short-term pain (100%), tenderness on the lateral canthal area (100%), tightness of the eyelid (91.7%), and ecchymosis (54.2%) compared to Group A. Patients of Group B experienced minimal or no postoperative complications.

CONCLUSIONS:

Triangular tarsectomy and limited orbicularis myectomy with eyelid retractor plication may be considered the standard procedure for correcting lower eyelid involutional entropion with no recurrence compared to LTS technique or minimally invasive and cost-effective ES procedure.

Introduction

Entropion is a unilateral or bilateral condition in which the eyelid margin rotates inward from its normal anatomical position, resulting in the eyelashes being directed posteriorly to the globe and rubbing against and irritating the ocular surface.[1] Involutional entropion is the most common form of lower eyelid malposition and usually occurs in elderly individuals.[1,2,3] Cicatricial entropion commonly occurs in the upper eyelid due to burns, trauma, infection, or inflammation but rarely in the lower eyelid.[4] If untreated, entropion may result in severe ocular symptoms, including corneal thinning, vascularization, keratitis, and scarring.[1,2,5,6]

The lower eyelid is supported by the tarsus, orbicularis oculi muscle, lower eyelid retractors, and medial and lateral palpebral ligaments, with the palpebral ligaments and tarsus responsible for the horizontal stabilization of the eyelid and the eyelid retractors maintaining its vertical position.[2,7] The pathogenesis of involutional entropion is multifactorial. It includes horizontal lid laxity, lateral canthal tendon laxity, the overriding of the preseptal orbicularis oculi muscle over the pretarsal orbicularis muscle, and the disinsertion or dehiscence of the vertical lower lid retractor.[4,7,8] In particular, the disinsertion or weakening of the lower lid retractor can cause the preseptal orbicularis to migrate superiorly and override the pretarsal orbicularis oculi muscle, thereby causing the inward rotation of the eyelid against the globe.[2,3,7,8,9]

Various nonsurgical and surgical techniques have been proposed to correct lower eyelid entropion. An everting sutures (ES) technique has been used for centuries and remains a simple, rapid, and noninvasive option.[10,11,12,13,14,15] However, this ES technique offers an easy and nonincision-based sutural technique with better postoperative cosmesis but the recurrences is more than others surgical procedures.[16,17] Other nonsurgical procedures include taping the lower eyelid and injecting botulinum toxin type-A into the lower eyelid. Both options temporarily relieve the discomfort associated with entropion for up to 6 months.[18] In turn, surgical procedures typically fall into the following categories: (1) excision of the skin and orbicularis muscle (e.g., Hotz procedure); (2) production of fibrosis of the lower lid; (3) strengthening the lower portion of the orbicularis muscle; and (4) tightening of the capsulopalpebral fascia attached to the inferior border (e.g., Jones procedure).[19]

Unfortunately, recurrence is likely following surgical procedures involving excision of the skin and orbicularis muscle.[19] While procedures involving the production of fibrosis in the lower lid – such as buried sutures, the injection of alcohol, the use of cautery, and Michel suture clips – may help prevent a recurrence, they do not affect the underlying eyelid laxity. As such, due to their high cure rates, many surgeons favor surgical techniques which aim to increase the tone of the pretarsal portion of the orbicularis relative to the rest of that muscle (i.e. Wheeler's operation).[19]

Lateral tarsal strip (LTS) alone is a successful procedure for the management of horizontal laxity and as well as lateral canthal laxity and is not taking into the consideration LL retractors disinsertion in the cases of involutional entropion and ectropion.[19,20-21] Accordingly, researchers have proposed an alternative surgical method to correct involutional entropion, involving the excision of a triangular piece of the tarsal plate and conjunctiva combined with the tightening of the skin and muscle of the lower lid through a skin incision below the lateral canthus and the tightening of the tarsal plate and orbital septum by dividing the lateral palpebral ligament and reattaching it over the lateral orbital margin.[19,22] The present study aimed to assess and compare outcomes following triangular tarsectomy and limited orbicularis myectomy with lower eyelid retractor plication versus ES alone or LTS alone for the correction of lower eyelid involutional entropion.

Methods

Study setting and sample size

This was a nonrandomized clinical study carried out between January 2016 and December 2019. A meticulous ophthalmic evaluation, including the Pinch test, snap back test, and lateral distraction test, was performed to confirm the eyelid margin malposition. Patients with lower eyelid primary involutional entropion were selected in this study according to the selection criteria and who have followed up to 1 year of the entropion surgery. We categorized all patients into three groups. We excluded all the patients who were associated with acute eye conditions, recurrent entropion, suspected ophthalmic malignancy, an ophthalmic socket, other eyelid deformities, and previous history of eyelid surgery. The research followed the tenets of the Declaration of Helsinki as amended in 2008.

Group allocation

Group A and Group C consisted of all patients presenting with involutional entropion of the lower eyelid to the Bangladesh Eye Hospital, Dhaka. All patients in these groups were of middle to high socioeconomic status and complained of watering and foreign body sensations in the affected eye. Group B consisted of all primary involutional entropion patients who underwent cataract surgery screening at the Sheikh Fazilatunnesa Mujib Eye Hospital and Training Institute. Most patients in this group (80.7%) resided at a single outreach camp in a rural area, were of lower socioeconomic status, and had been selected for cataract screening with donor agencies covering the cost of the cataract surgery. The remaining patients (19.3%) suffered from lower lid entropion with ocular and systemic comorbidities. All patients in this group complained of loss of vision in one or both eyes, watering, and foreign body sensations.

Three different approaches were taken to correct the involutional entropion. Patients in Group A underwent surgical correction involving triangular tarsectomy and limited orbicularis myectomy with lower eyelid retractor reinsertion to address all causative factors, including minimal to moderate horizontal laxity, attenuation of eyelid retractors, and overridden by the preseptal orbicularis oculi muscle. The involutional entropion was corrected in Group B using a noninvasive ES technique. Patients of Group C, the lower lid entropion, presented with only horizontal lid laxity and lateral canthal tendon laxity which is corrected by LTS procedure alone. A sac patency test was performed to exclude obstruction of the lacrimal drainage system in all cases.

Surgical technique (group A)

After infiltration of local subcutaneous anesthesia and instillation of topical anesthesia into the conjunctival surface, an infraciliary incision 2 mm below the eyelash was made to expose the orbicularis oculi muscle, while a parallel incision was made approximately 3–7 mm below the lid margin. A 4 mm wide band of muscle was exposed from the orbicularis down to the tarsus, divided in the midline and reflected and excised to each side. The skin was not excised or trimmed in this technique. In addition, a small portion of the preseptal orbicularis muscle was excised. A triangular-shaped full-thickness base-down tarsectomy with the apex towards the lid margin was performed. The tarsus was sutured using 6-0 vicryl sutures, and the lower eyelid retractor was reattached to the anterior surface of the tarsus [Figure 1]. The skin was then closed without any trimming required. The total surgical time was approximately 25–30 min.

Figure 1.

Preoperative photographs of skin marking of lower eyelid just below the 2 mm of lash line, exposure and marking of orbicularis oculi muscle, base down triangular tarsectomy, reattachment of the tarsus and closure of the skin wound of a patient (Group A)

Everting sutures technique (group B)

Patients in Group B underwent a nonincisional ES technique using double-armed 6-0 vicryl sutures. The sutures were placed at three subsidiary positions in the eyelid's central, medial, and lateral aspects. The needle was passed downwards through the skin approximately 2 mm below the eyelash and then onward through the anterior lamella, picking up the inferior lid retractors and piercing the conjunctiva just above the fornix. Subsequently, the sutures were rotated 3 mm and moved upward in the same manner before the needle exited the skin approximately 2 mm below the lash line and 3 mm from the first suture. The central knot was tied, followed by the medial and lateral knots. All knots were tightened to create a slight initial overcorrection (i.e., mild ectropion) [Figure 2a and b]. The reinsertion of the lower lid retractors transferred their pull on the anterior surface of the tarsus and created a horizontal barrier to the preseptal orbicularis oculi muscle by forming a fibrotic scar in the suture tracts. The entire procedure took approximately 10 min.

Figure 2.

(a and b) Preoperative and postoperative photographs of Everting sutures technique in the left lower eyelid of a 65-year-old male patient (Group B)

Lateral tarsal strip procedure (Group C)

A lateral canthotomy incision of about 10 mm is usually made in the lateral skin and canthus (canthotomy), and then blunt dissection is performed through the orbicularis oculi to expose the periosteum of the lateral orbital wall. An inferior cantholysis was performed. Measuring the expected amount of LTS strip with pulled the eyelid toward the lateral canthus. Both anterior and posterior lamella of the lateral lower eyelid strip is gently separated along the grey line. Then anterior lamella is trimmed to make an LTS strip, followed by scraping the tarsal conjunctiva of the LTS. The assessed amount of LTS is fixed to the periosteum of the lateral orbital wall by a 5/0 Proline suture, which is at least 2 mm superior to the medial canthus. Finally, the lateral canthus is reconstructed with a 6/0 vicryl buried suture into a gray line, followed by the closure of the wound layer by layer with 6/0 vicryl sutures accordingly. The approximate surgical time was about 20 min. The procedure is demonstrated in Figure 3.

Figure 3.

Involutional entropion of right lower eyelid, marking of a lateral canthotomy skin incision, lateral canthotomy, and inferior cantholysis, Making a lateral tarsal strip (LTS), restoration of right lower eyelid margin after 1 month of LTS (Group C)

Follow-up and outcome measurement

Various demographic, clinical, and outcome variables were assessed. Preoperative and postoperative photographs were taken and compared for each patient. Following the correction procedure, rates of recurrence and postoperative complications were assessed in each group. Each case was assessed according to both reliefs of symptoms (i.e., watering and foreign body sensation) and restoration of the lower eyelid margin in both primary and downward gaze positions. A successful outcome was defined as a normal eyelid position at rest and an inability to induce entropion upon forceful closure of the eyelid. Patients were routinely followed up to assess outcomes at 1 day, 1 week, 6 weeks, 3 months, 6 months, 9 months, and 12 months following the procedure. Those who were lost to follow-up were excluded from the final analysis.

Statistical analysis

Data were analyzed using SPSS software, version 16 (IBM Corp., Armonk, NY, USA). Descriptive results were presented as frequencies and percentages. Differences between the two groups were compared using a Student's t-test or a Chi-squared test, as appropriate. The level of statistical significance was set at P < 0.05.

Ethical considerations

Informed written consent was obtained from all patients. The study received ethical clearance from the concerned institute.

Results

The present study included 78 patients in whom 84 eyelids were affected by lower eyelid involutional entropion, including 29 patients with 30 affected eyelids in Group A, 28 patients with 30 affected eyelids in Group B, and 21 patients with 24 affected lower eyelids in Group C. Patients ranged in age from 55 to 86 years, with a mean age of 67.93 ± 7.83 years, 66.96 ± 7.39 year, and 66.67 ± 9.85 years in Groups A, B, and C, respectively (P > 0.50). There was a significant difference in the gender distribution of the study subjects. There were 40 (51.3%) males and 38 (48.7%) females. The male (15, 71.4%) was higher compared to female (6, 28.6%) in Group C. Involutional entropion was identified in the right lower eyelid in 45 (53.6%) cases, and the left lower eyelid in 39 (46.4%) cases. Most patients (92.3%) had unilateral entropion. Bilateral involvement occurred only in six (7.7%) patients. Bilateral involutional entropion was in Group A (16.7%), Group B (33.3%), and Group C (50%) [Table 1].

Table 1.

Demographic and clinical characteristics of patients with involutional entropion undergoing surgical correction involving triangular tarsectomy and limited orbicularis myectomy with lower eyelid retractor plication (Group A) versus everting sutures alone (Group B), and lateral tarsal strip (Group C) (n=78)

Parameter	Group A (n=29), n (%)	Group B (n=28), n (%)	Group C (n=21), n (%)	Total (n=78), n (%)
Age (years)
Mean±SD	67.93±7.83*	66.96±7.39*	66.67±9.85	67.16±0.75
Median (range)	67 (55–86)	65 (56–83)	63 (54–87)	65 (54–87)
Gender
Male	13 (44.8)	12 (42.9)	15 (71.4)	40 (51.3)
Female	16 (55.2)	16 (57.1)	6 (28.6)	38 (48.7)
Affected eyelid**	30 (35.7)	30 (35.7)	24 (28.6)	84
Right lower lid	13 (43.3)	18 (60.0)	14 (57.3)	45 (53.6)
Left lower lid	17 (56.7)	12 (40.0)	10 (42.7)	29 (46.4)

*Differences between the two groups for this variable were not statistically significant according to a t-test (P>0.05), **Percentages for this variable were calculated out of a total of 84 affected eyelids, including 30 in Group A, 30 in Group B, and 24 in Group C, Percentages for this variable do not add up to 100% as some patients may have had more than one disease. SD: Standard deviation

No significant postoperative complications were observed in either Group A or Group B, apart from minimal pain, scarring, punctal malposition, and tightness of the lower eyelid. The frequency of minimal pain and tenderness on the lateral canthal area was present few days in all patients (100%) in Group C. Ecchymosis [Figure 4] was higher (13, 54.2%) in Group C compared to Group A (12, 40%) and Group B (02, 6.7%). However, these complications were resolved quickly, with postoperative pain managed with a short course (3–5 days) of nonsteroidal anti-inflammatory drugs. Skin scarring was noted in only one (3.3%) case in Group A and three (12.5%) in Group C. Two (6.7%) cases of lower punctal ectropion in Group A were managed with revision surgery. Punctal malposition was noted in four (16.7%) in Group C, which was managed conservatively. Tightness of the lower eyelid was complained of in 22 (91.7%) in Group C. Overcorrection was observed in three (12.5%) eyelids in Group C. In contrast, no overcorrection was found in Group A and Group B. All symptoms were alleviated entirely (100%) within 2 weeks of the disciplinary procedure.

Figure 4.

Postoperative ecchymosis of the lower eyelid (Group C)

At the 1-year follow-up, recurrence was noted in four eyelids (13.3%) in Group B and only one (4.2%) in Group C. Recurrence occurred between 3 and 11 months following the ES technique and LTS procedure. In contrast, no cases of recurrence were observed in Group A at any point over the 12-month interval [Table 2]. Overall, the success rate was 100% in Group A, 86.7% in Group B [Table 2], and 95.8% in Group C (P < 0.05). The cosmetic outcome was excellent in all cases, regardless of the method of entropion correction.

Table 2.

Outcomes of patients with involutional entropion undergoing surgical correction involving triangular tarsectomy and limited orbicularis myectomy with lower eyelid retractor plication (Group A) versus everting sutures alone (Group B), and lateral tarsal strip (Group C) (n=78)

Parameter	Group A n=eyelids=30, n (%)	Group B n=eyelids=30, n (%)	Group C n=eyelids=24, n (%)	Total (n=84), n (%)
Postoperative complications*
Short-term pain (up to 5 days)	25 (83.3)	5 (16.7)	24 (100.0)	54 (64.3)
Ecchymosis	12 (40.0)	2 (6.7)	13 (54.2)	27 (32.1)
Scarring	1 (3.3)	0	3 (12.5)	4 (4.7)
Punctal malposition	2 (6.7)	0	4 (16.7)	6 (7.1)
Tightness of lower lid	1 (3.3)	0	22 (91.7)	23 (27.4)
Tenderness on lateral orbital rim	0	0	24 (100.0)	24 (28.6)
Overcorrection (up to 2 weeks)	0	0	3 (12.5)	3 (3.6)
Recurrence* (months)
At 3	0	1 (3.3)	0	1 (1.2)
At 6	0	2 (6.7)	1 (4.2)	3 (3.6)
At 12	0	4 (13.3)	1 (4.2)	5 (5.9)
Success rate*	30 (100.0)**	26 (86.7)**	23 (95.8)**	79 (94.0)

*Percentages for this variable were calculated out of a total of 84 affected eyelids, including 30 in Group A, 30 in Group B, and 24 in Group C, **Differences between the three groups for this variable were statistically significant according to a Chi-squared test (P<0.05)

Discussion

Entropion correction primarily aims to rotate the eyelashes and lid margin away from the globe and prevent slippage between the lamellae.[1,2] However, the optimal method of achieving this goal depends on the patient's clinical presentation and any underlying pathological factors.[4,7,8] Many surgical techniques are available for the correction of entropion, of which the most common are ES, Wies, Quickert, and Jones procedures and the application of a LTS.[9,14,19,23] In addition, different techniques may be needed to achieve a successful outcome and prevent a recurrence.[8,23] In cases of eyelid laxity, an increase in tone or resection of the tarsus may be required, after which the eyelid retractors can be reconnected to the tarsus.[18]

An ES technique is an affordable and straightforward method of entropion correction which can be performed rapidly, often upon the patient's first visit to the hospital.[24,25,26] The sutures help to plicate the attenuated inferior eyelid retractors and transfer their pull to the anterior surface of the lower tarsus. They also create a horizontal barrier to prevent the preseptal orbicularis oculi muscle migration. The successful outcome of this procedure depends on forming a fibrotic scar along the suture tracks.[27] In our study, 6-0 Vicryl™ sutures were used because of their greater strength and slower absorption (8 weeks), allowing for a tighter and more persistent suture and thereby prolonging and strengthening the repair process. However, care must be taken to ensure that the medial suture is not overly tightened, potentially resulting in lower punctual eversion.[28] The ES technique alone is guaranteed for 18–24 months.[24]

In our study, most patients were in their seventh decade of life. Elderly individuals are most vulnerable to the risk of entropion due to the natural loss of rigidity and tone of the ocular adnexal tissue due to ageing.[3]

Most patients in our study (92.3%) had unilateral entropion, while bilateral entropion was identified in only six cases (7.7%). Moreover, a slight preponderance of females compared to male patients (56.2% vs. 43.8%) in Group A and Group B, but male (71.4%) is preponderance in Group C. In contrast, other researchers have reported bilateral disease being three times more common, with a higher incidence in women than men due to the smaller size of the tarsus in the former.[2,29]

In our study, patients with involutional entropion of the lower eyelid allocated to Group A underwent a triangular tarsectomy and limited myectomy with lower eyelid plication. This surgical procedure was designed to correct horizontal laxity, forming a scar to prevent the overriding of the preseptal orbicularis muscle while plicating the lower eyelid retractor to the tarsus. This procedure resulted in a recurrence and success rate of 0% and 100%, respectively, over a 1-year follow-up period. Restoration of the eyelid margin with good cosmesis was achieved in all cases. All patients of group C underwent an LTS procedure for the correction of involutional entropion with a 95.8% success rate up to a 1-year follow-up.

In contrast, the patient in Group B underwent a nonincisional ES technique. Initial symptoms were alleviated after 2 weeks. However, the recurrence and success rate were 13.3% and 86.7%, respectively, over a 1-year follow-up period. Following the procedure, the first instance of recurrence was noted at 3 months and the latest at 11 months. The overall cosmetic outcome was excellent.

Moderate-to-severe complications from entropion repair are infrequent, but minimal complications may that are resolve spontaneously or corrected by revision surgery.[9,17,25] In this study, minimal postoperative complications were observed in Groups A and C rather than Group B. Minimal pain (83.3% vs. 100%), ecchymosis (40% vs. 54.2%), tenderness on the lateral canthal area (0% vs. 100%), tightness of the eyelid on the globe (3.3% vs. 91.7%), and punctal malposition/ectropion (6.7% vs. 16.7%) in Group A versus Group C. None of the patients in Group B reported minimal or no postoperative complications. Sen and Yalcinsoy reported a success rate of 96.4% over a mean follow-up period of 27 months using an incision-based modified ES technique, while Han et al. reported an overall success rate of 93.5% after mini-incisional entropion repair involving sutures.[26,30] A study by Rougraff et al. demonstrated a success rate of 78% using fornix sutures and LTS with a minimum of 18 months’ follow-up.[31]

Unfortunately, the ES technique is a simple procedure and the results depend on a fibrotic scar throughout the sutural tract.[16,17] Mohammed and Ford reported a recurrence rate following ES correction of 20% among 90 affected eyelids over a 3-year follow-up period.[9] Moreover, Wright et al. found overall recurrence following this technique to be 15% over a 31-month follow-up period.[25] An evaluation of mini-incisional-based transconjunctival buried sutures by Mocan et al. revealed a recurrence rate of 6.5%, while Seiff et al. noted recurrence in one out of 28 eyes (3.6%) after 2 years when using a modified incision-based ES technique with inferior lid retractor reattachment.[16,27]

Other researchers have reported recurrence rates of 11%–30% following various correction techniques.,[23,32,33] While Quickert sutures represent the most straightforward approach to entropion correction.[34] Their main limitation is the high rate of recurrence (22%–58.8% over 18–34 months).[25,35,36] The additional plication of the inferior lid retractor via a skin incision may better stabilize the tarsus, thereby preventing recurrence. At the same time, limited resection of the pretarsal orbicularis muscle can help to prevent any further overriding. An LTS procedure or horizontal wedge resection may also be helpful in addressing horizontal lid laxity.[37] Horizontal lid laxity is usually the primary pathogenic factor in age-related entropion; as such, recurrence is significantly more likely when horizontal eyelid shortening is not addressed at either the primary repair stage or at reoperation.[7,38] Seiff et al. noted good outcomes after primary entropion surgery in 99% of 180 patients in whom the lower eyelid was shortened compared with 78% of 133 patients in whom the eyelid was not shortened (P < 0.001).[16]

López-García et al. reported that recurrence is observed in 17.4% of eyelids after correction of involutional entropion by LTS procedure.[39] In a randomized controlled trial, Scheepers et al. found that the recurrence rate at 18 months was significantly lower among patients treated with ES plus LTS compared to ES alone (0% vs. 21%; P = 0.02).[40] Another study found that the 14-month recurrence rate was only 6.90% among 30 cases of lower eyelid entropion corrected using a combined LTS and ES procedure compared to 2.94% among 34 cases of eyelid entropion corrected through Quickert procedure.[41] No cases of recurrence were observed by Rabinovich et al. after LTS with infraciliary sutures in 44 eyes with lower eyelid involutional entropion.[42]

Limitations of the study included a small sample size and a short follow-up period. It is recommended for long-term studies with large sample sizes.

Conclusions

A triangular tarsectomy and limited orbicularis myectomy with lower eyelid retractor plication is a safe and effective procedure for correcting involutional entropion with no recurrence. The LTS is also a standard technique with a minimal recurrence rate and minimal postoperative morbidities. However, an ES technique can be a simple, noninvasive, rapid option, which may be useful for rural or camp-based patients and those with comorbidities or contraindications to invasive surgery. The procedure may also represent a cost-effective option for patients who cannot afford more expensive or complex procedures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.