Abstract
Objective
To report the efficacy of “Xeno-ADM combined with inferior eyelid margin fixation” for entropion accompanied by lower eyelid retraction.
Methods
A retrospective review of 28 patients (48 eyes) diagnosed with lower eyelid entropion accompanied by lower eyelid retraction was performed. The follow-up period lasted more than 6 months. MRD2, angle between the eyelashes and the corneal surface, ocular discomfort symptoms, and complications were recorded and used to evaluate the efficacy and safety.
Results
Twenty eight patients (48 eyes) were included, within 6 months after surgery, 45 eyes (93.75%) had complete relief from ocular discomfort, while 3 eyes (6.3%) showed partial improvement; 48 eyes (100%) had complete resolution of the foreign body sensation; 15 eyes (83.3%) had complete relief from lacrimation, and 3 eyes (16.7%) showed partial improvement, MRD2 was from 7.2 (7.0, 7.5) mm to 5.5 (5.0, 5.5) mm (Z = -3.995, P < 0.01). The angle between the eyelashes and the cornea was from 36.76 (32.18, 38.49) to 68.23 (67.30, 70.31) (Z = -6.031, P < 0.01). And no other complications, such as infection, rejection, and dislocation, were observed.
Conclusion
Xeno-ADM combined with inferior eyelid margin fixation is reasonably successful in managing entropion accompanied by lower eyelid retraction.
Keywords: Entropion, Lower eyelid retraction, Inferior eyelid margin fixation, Xeno-ADM
Introduction
Lower eyelid entropion is the second most common condition among patients in oculoplastic clinics, following upper eyelid ptosis [1]. The friction of eyelashes against the cornea can lead to symptoms such as eye pain, irritation, itching, burning sensation, tearing, photophobia, conjunctival congestion, discharge, and even vision loss [2]. While there is extensive research on its pathogenesis and treatment, reports on the treatment of entropion combined with lower eyelid retraction are relatively scarce, and current literature primarily focuses on TAO-related lower eyelid retraction and entropion. In clinical practice, we have observed that a subset of patients with lower eyelid entropion also presents with lower eyelid retraction, but without TAO, which piqued our interest. Because of lower eyelid retraction, the eyelashes are in a lowered position, the surface area of eyelash contact with the cornea increases during eye movement. As a result, patients with this condition tend to experience more severe eye irritation symptoms and more severe corneal damage than those with simple entropion. For these patients, performing only an entropion correction surgery may lead to worsening of lower eyelid retraction, impacting appearance. In some cases, the traditional surgical correction may even be suboptimal, with a higher risk of recurrence. Consequently, we conducted a study to investigate the etiology and treatment of.
Object and method
Object
This was a retrospective case study. A total of 28 patients (48 eyes) diagnosed with lower eyelid entropion accompanied by lower eyelid retraction were collected from the Affiliated Eye Hospital of Nanchang University from August 2022 to April 2024, including 12 Males and 16 females. The patients' ages ranged from 10 to 78 years, with a postoperative follow-up period of 6 to 12 months. There were four patients aged 35 years or older (range: 57–78), all of whom were recurrent cases of involutional entropion following prior surgical correction.
Inclusion criteria: (1) All patients had lower eyelid entropion accompanied by lower eyelid retraction. (2) Patients exhibited corneal irritation symptoms such as foreign body sensation, photophobia, lacrimation, and eye redness. (3) Orbital CT scan revealed no extraocular muscle hypertrophy, thyroid function panel and TRAb showed no abnormalities.
Exclusion criteria: (1) Patients with systemic or intraocular diseases. (2) A history of keloid formation with significant scar proliferation at other sites. (3) Patients who underwent eyelid retraction correction surgery before or during the follow-up period due to eyelid trauma or other reasons. (4) Patients with poor compliance who could not attend follow-up visits as scheduled.
The trial process adhered to the Declaration of Helsinki, and all parents of the children provided informed consent and signed informed consent forms. All surgeries were performed by the same physician.
Surgical method
A skin incision line was Marked 2 mm from the lower eyelid lash root using methylene blue. The skin was incised along the Marked line, and the orbicularis oculi muscle was wedge-shaped and dissected about 5–8 mm towards the orbital rim until the inferior tarsus margin was exposed, revealing the junction between the lower eyelid septum and the lower eyelid retractors. The connection between the lower eyelid margin and the lower eyelid retractors was moderately dissected, releasing the traction of the lower eyelid retractors on the lower tarsus. The orbicularis oculi muscle and underlying tissues were separated towards the eyelash root, while preserving the subcutaneous tissue of the lower eyelid. An acellular xenogeneic pig dermal matrix (Yantai Zhenghai Biological Technology Co., Ltd., batch numbers SP220801, SP240201) was folded and placed on the surface of the lower eyelid retractors. A 6–0 absorbable suture was used to intermittently suture the upper edge of the graft to the lower edge of the tarsus, and the lower edge of the graft was sutured to the lower eyelid retractors at the inferior orbital rim. During surgery, patients were instructed to cooperate by opening and closing their eyes, adjusting the height of the lower eyelid Margin to be 1–2 mm above the lower edge of the cornea.
Using a 6–0 absorbable suture, the cut edge of the orbicularis oculi muscle was intermittently sutured to the deep Margin of the Xeno-ADM, forming a force transmission between the orbicularis oculi muscle and the lower eyelid retractors, typically requiring 3–4 sutures. The eyelid Margin and eyelashes were observed to ensure they returned to a normal anatomical position, with the eyelashes directed away from the cornea, curving downwards and forming an angle of 80° −110° with the corneal surface. The skin below the incision was pulled and flattened to achieve a tension-free closure of the upper lip skin, and excess skin and a small amount of orbicularis oculi muscle were removed. A continuous 6–0 suture was used to close the skin incision, and the sutures were removed 7 days postoperatively. (Fig. 1).
Fig. 1.
a Skin was incised, (b) lower eyelid retractors were moderately dissected, (c) Xeno-ADM was folded and placed, (d) the skin incision was closed
Preoperative examination and observation indicators
Patient gender, age, and preoperative ophthalmic examination results were recorded. Preoperative and postoperative clinical symptoms and signs related to the patients were documented, such as foreign body sensation, lacrimation, and ocular discomfort (preoperative: present or absent; postoperative: completely relieved, partially improved, or unchanged). Preoperative and postoperative follow-up included recording the results of corneal fluorescein staining under slit lamp examination, measuring palpebral fissure height, the distance from the corneal light reflex to the lower eyelid margin (margin reflex distance, MRD2), and the angle between the eyelashes and the corneal surface (Fig. 2). Eyelid laxity tests were conducted, and the Hertel exophthalmometer was used to measure the degree of exophthalmos, MRD2 was defined as the vertical distance from the corneal light reflex to the lower eyelid margin.
Fig. 2.
The picture was taken parallel to the eyeball in the temporal side, and the Angle between the nearest three eyelashes and the cornea was measured by imagej software, and the average was taken (if the eyelashes intersected the surface of the cornea, the degree was recorded as negative)
Efficacy evaluation
Successful surgical outcomes were defined by symmetrical lower eyelid positioning when the eye is in primary gaze. This was achieved when: (1) the lower eyelid margin aligned with the inferior corneal limbus, or the bilateral MRD2 values were equal (ΔMRD2 = 0), (2) Lashes in proper anterior orientation accompanied by a smooth eyelid contour. An unsatisfactory outcome was defined as > 1 mm scleral show (lower lid margin below the inferior corneal limbus).
Statistical analysis
SPSS 27.0 software was used for statistical analysis of the data. After normality test, MRD2 data and the difference between preoperative and postoperative values did not conform to normal distribution, so M (P25, P75) was used to describe the results. Wilcoxon signed-rank sum test was used to compare MRD and Angle between eyelashes and cornea between patients before and after surgery. P < 0.05 was considered statistically significant.
Result
A total of 48 lower eyelids from 28 patients with entropion accompanied by lower eyelid retraction were included and surgically repaired using the proposed modified procedure. Representative preoperative and postoperative photographs are shown in Fig. 3. Demographic data and results are summarized in Table 1.The average degree of exophthalmos measured 15.36 ± 0.55 mm. Among the affected eyes, the measurement range spanned from 14.5 mm to 16 mm, with the Maximum measurement reaching 16 mm.
Fig. 3.
a before surgery, (b) 1 week postoperatively after suture removal, (c) 6 months after surgery
Table 1.
Demographics of patient population and surgical outcomes
| Follow-up duration after surgery: > 6 months (All cases) | |
|---|---|
| Patient characteristics | |
| Male, n | 12 |
| Female, n | 16 |
| Unilateral/bilateral, n/n | 8/20 |
| Total no. of patients (eyes: od/os), n | 28(48: 22/26) |
| Mean age ± deviation, year | 26.18 ± 18.27 |
| Range of age, year | 10–78 |
| Surgical outcome (%) | |
| Success rate (success cases/total) | 95.9(46/48) |
| Recurrence rate (recurrence of entropion/total) | 0 |
| Recurrence rate (recurrence of lower eyelid retraction/total) | 4.1(2/48) |
| Complication rate (symblepharon, infection or wound dehiscence) | 0 |
| Overcorrection rate (ectropion) | 0 |
Comparison of Preoperative and Postoperative Symptoms: Preoperatively, 48 eyes (100%) experienced ocular discomfort, 46 eyes (95.8%) reported a foreign body sensation, and 18 eyes (37.5%) experienced tearing. Postoperatively, 45 eyes (93.75%) had complete relief from ocular discomfort, while 3 eyes (6.3%) showed partial improvement; 48 eyes (100%) had complete resolution of the foreign body sensation; 15 eyes (83.3%) had complete relief from tearing, and 3 eyes (16.7%) showed partial improvement.
The preoperative MRD2 was 7.2 (7.0, 7.5) mm, and at one month postoperatively, it was 5.2 (5.0, 5.5) mm, with a statistically significant difference compared to preoperative values (Z = −3.996, P < 0.01); at six months postoperatively, it was 5.5 (5.0, 5.5) mm, also showing a statistically significant difference compared to preoperative values (Z = −3.995, P < 0.01). The preoperative angle between the eyelashes and the cornea was 36.76 (32.18, 38.49), and at one month postoperatively, it was 68.22 (67.12, 71.31), which was statistically significant compared to preoperative values (Z = −6.031, P < 0.01); at six months postoperatively, it was 68.23 (67.30, 70.31), again showing a statistically significant difference compared to preoperative values (Z = −6.031, P < 0.01).
Postoperative efficacy: Up to the end of follow-up, all patients were satisfied with postoperative appearance, postoperative relief of photophobia, lacrimation, foreign.
body sensation and other uncomfortable symptoms. Two patients experienced recurrent lower eyelid retraction, presenting with 2.0 mm of retraction in the right eye preoperatively, which improved to 0.5 mm postoperatively. There were no recurrent cases of entropion and trichiasis.
Discussion
Lower entropion is a very common abnormal eyelid position [3], and there have been many studies on its pathogenesis and treatment [4–7].However, there are few reports on entropion accompanied by lower eyelid retraction, and the current reports mainly focus on lower eyelid retraction, entropion and trichiasis related to TAO [8, 9]. In clinical work, we found that some patients with entropion accompanied by lower eyelid retraction were not accompanied by TAO, which we referred to as non-TAO-related entropion and trichiasis combined with lower eyelid retraction. These patients were mainly Young people, and among the 28 patients in this study, juvenile patients accounted for 35.7% (10/28). Patients under 30 years old accounted for 78.57% (22/28), which was consistent with the results of our clinical observation.
The pathogenesis of these patients is still unclear. In order to explore the pathogenesis, we reviewed the patient's medical records and found that these patients have the following characteristics: 1. All the symptoms were acquired, and 5 cases had a history of entropion operation. 2. The exophthalmos of all affected eyes were larger than 14 mm. 3. All affected eyes were accompanied by refractive errors and diopter ≥ −3.0D. 4. Horizontal relaxation experiment (-). The position of the palpebral margin depends on the balance of horizontal, longitudinal and sagittal forces, and can be summarized into the following aspects according to anatomical factors: the horizontal tension of the ligaments of the inner and outer canthus, the length and tension of the lower eyelid, the tension of the lower palpebral retractor, the integrity of the fornix and conjunctiva of the eyelid, the position of the canthus ligament, the tension of the orbicularis oculi and the degree of exophthalmos. Therefore, we believe that these patients are mainly due to their own physical exophthalmos, and the increase in the diopter causes a further elongation of the ocular axis, which disrupts the balance of the strength of the palpebral margin.
After analyzing the characteristics of such patients, we can easily find that the simple correction operation of entropion cannot achieve good correction effect. The principle of entropion surgery is to strengthen or weaken the tension in one or more directions, so that the strength of the palpebral margin can be restored to balance. The focus of the intervention is on the excision of the orbicularis oculi muscle, the modified Hotz procedure [10] and the Quickert suture [11]. Individuals under 30 tend to have firmer skin with greater tension [12]. The excision of the orbicularis oculi muscle can exacerbate lower eyelid retraction, leading to an increase in scleral show, which significantly affects appearance. Even without tissue removal, the insufficient support of the lower eyelid caused by proptosis cannot be improved.
Therefore, during the surgical procedure, we first need to reduce the downward and inward pulling force of the posterior layer of the eyelid, appropriately reposition the lower eyelid retractor, and for eyelid retraction caused by the surgery, we will first thoroughly release the scar tissue, making every effort to restore the orbital septum and the lower eyelid retractor. Next, we will enhance the support of the posterior layer of the lower eyelid by implanting materials. Currently, the corrective materials used clinically for lower eyelid retraction mainly include autologous tissue, allogeneic tissue, and synthetic materials, each with its own advantages and disadvantages [13–16], Although autologous materials eliminate the risk of rejection, they require additional surgical wounds, resulting in more postoperative pain, increased nursing costs, and higher infection risks. Allogeneic sclera is limited by source availability and requires additional preservation costs. The Medpor implant is obviously harder than the natural eyelid; its poor elasticity leads to a rigid eyelid, and its surface is rough and prone to exposure after operation [17, 18].. We have chosen acellular xenogeneic pig dermal matrix (Xeno-ADM). At present, acellular dermal matrix has been widely used in clinical settings [19–22], with significant advantages: the volume of the acellular dermal matrix does not change after absorption [23],it can induce the orderly ingrowth of autologous fibroblasts and capillaries, and ADM is used to replace the tarsus in eyelid reconstruction [24, 25].After complete vascularization in six months, retraction is not significant, and it still retains a certain degree of firmness, with its safety having been validated [26].
Zhuang [27] interposed the AXDM between the inferior tarsal border and transected lower eyelid retractors, with the vertical dimension standardized at three times lower lid recession distance. In contrast, based on the average adult palpebral fissure length of approximately 27.88 mm, we employed a 2 × 3 cm acellular dermal matrix (ADM) graft in the surgical procedure. The ADM was folded in half and secured superior to the lower eyelid retractors at both the inferior tarsal border and orbital rim, achieving a vertical height of approximately 1.5 cm. This effectively extends the tarsus, providing support to the lower eyelid margin while preserving the normal lower eyelid retractor, allowing it to contract and move Xeno-ADM together, preventing the lower eyelid from appearing stiff. Additionally, this provides a pivot point for flipping the tarsus when correcting eyelid entropion.
Inferior eyelid margin fixation has been proved effective for congenital lower eyelid entropion [28]. The incision is designed to be 2 mm below the lower eyelid margin, allowing for concealment of the incision while avoiding damage to hair follicles. A wedge-shaped incision is made in the orbicularis oculi muscle, which preserves as much of the anterior layer of the lower eyelid as possible and prevents a stepped appearance at the incision site after suturing. Dissection is performed beneath the orbicularis oculi muscle towards the lower eyelid margin, which avoids affecting the subcutaneous vascular network and lymphatic drainage, while also facilitating a broader area of scar adhesion between the anterior and posterior layers of the eyelid, resulting in a more secure attachment. The upper edge of the implanted Xeno-ADM is fixed to the lower edge of the tarsus, effectively extending the tarsus and allowing us to pull and secure the eyelash side of the orbicularis oculi muscle to an appropriate position. This creates a stronger rotational force that pulls downward and inward compared to simply securing it to the tarsus. Additionally, the upper edge of the Xeno-ADM provides a pivot point for the tarsus to flip, allowing the eyelashes at the eyelid margin to better turn outward, effectively correcting lower eyelid entropion while also addressing lower eyelid retraction (Fig. 4).
Fig. 4.
Xeno-ADM provides a pivot point for the tarsus to flip, allowing the eyelashes at the eyelid margin to better turn outward, effectively correcting lower eyelid entropion while also addressing lower eyelid retraction
In this study, two patients experienced recurrence of lower eyelid retraction six months postoperatively. We believe the main reasons for this are the absorption of Xeno-ADM six months after surgery and slight displacement of the material due to the movement of the lower eyelid following the absorption of the sutures, both of which contribute to a decrease in lower eyelid support. During the postoperative follow-up period, no recurrence of entropion or trichiasis was observed in any of the patients.
This study has some limitations that should be noted. The sample size is insufficient, which limits the statistical power and generalizability of the findings. Additionally, the follow-up period was quite short, A longer follow-up period would be necessary to fully evaluate the intervention's efficacy and clarify any potential long-term complications or side effects. Extending the duration of observation would help provide a more comprehensive assessment of the treatment's long-term impacts.
Conclusion
We propose that for patients with entropion accompanied by lower eyelid retraction, Xeno-ADM combined with inferior eyelid margin fixation can provide dual improvements in both function and appearance, making it a safe and effective treatment option for this condition.
Acknowledgements
Not applicable.
Authors’ contributions
Yangbin Fang: Conception of the study, data acquisition and analysis, interpretation of the data and writing the manuscript. Qin Huang, Hongfei Liao: Designing the work, interpretation of the data and substantive revision of the manuscript. Qin Huang,Yangbin Fang, Yao Lai: Data acquisition, interpretation of the data. Qin Huang, Hongfei Liao: interpretation of the data and substantive revision of the manuscript. All authors have read and approved the final manuscript.
Funding
1. Jiangxi Provincial Health Commission Science and Technology Program (20242BAB25490). 2. Foundation of Jiangxi Educational Committee (76L0022TT9) 3. Jiangxi Provincial Health Commission Science and Technology Program (202410298).
Data availability
The datasets generated during and analyzed during the current study are not publicly available due to human data but are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study followed the tenets of the Declaration of Helsinki and was approved by the Ethics Committee of Affiliated Eye Hospital of Nanchang University. Written informed consents were obtained from all participants.
Consent for publication
All the patients included in this study gave written informed consent for their personal or clinical details along with any identifying images to be published in this study.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Hongfei Liao, Email: lhfzf@126.com.
Qin Huang, Email: 17757167@qq.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated during and analyzed during the current study are not publicly available due to human data but are available from the corresponding author on reasonable request.