Effective Small-incision Surgery for Involutional Lower Eyelid Entropion

Jane M. Olver, FRCOphth, Jonathan A. Barnes, FRCOphth

Objective: The aim of this study was to develop an effective and minimally invasive operation to correct lower eyelid entropion that would address both the horizontal and vertical laxity. Design: A prospective, noncomparative, interventional case series. Participants: Thirty-ve consecutive patients with involutional entropion, aged 62 to 92 years (mean, 77.1 years), had surgery on 45 lower eyelids. Of the 45 procedures, 33 (73%) had a primary procedure and 12 (27%) were reoperations. Intervention: A lateral tarsal strip with diagonal tightening of the orbital septum and lower lid retractors to the lateral orbital rim was performed via a 1-cm lateral canthal incision. Main Outcome Measures: Complications and surgical outcome were monitored clinically for between 12 and 24 months after surgery. Results: The results were analyzed from 42 eyelids (33 patients) with a mean follow-up of 17.1 months (range 1224 months). Two patients died and one dropped out of the study 3 months after the second eyelid operation. In 36 cases (86%), the entropion was cured. Transient lateral orbital rim tenderness was noted in six cases (14%), and one patient had a wound infection. Anatomic recurrences were detected in six eyelids of six patients, and ve of these (83%) were asymptomatic. Conclusions: This surgical approach has been found effective in 86% of eyelids. Adequate clinical followup has proven essential for accurate evaluation of entropion surgery. Ophthalmology 2000;107:19821988 2000 by the American Academy of Ophthalmology. Involutional entropion is a common condition among the elderly in which turning in of the lower eyelid causes irritation, tearing, redness, and photophobia. Rarely, untreated entropion may result in a corneal ulcer. The main factor giving rise to involutional entropion is the progressive degeneration of elastic and brous tissues within the lid occurring with increased age. This causes an imbalance between the usual forces acting on the lower eyelid, and the resulting eyelid laxity, both horizontal (tarsal plate and orbicularis) and vertical (lower eyelid retractors and orbital septum), allows the orbicularis to override. Medical treatment with lubricants, taping, or orbicularis chemodenervation with botulinum toxin A offer only temporary correction of eyelid position and relief of symptoms1; surgery remains the mainstay for permanent treatment.230 Different operations have been described that address the pathophysiologic factors4 31 with apparently acceptable surgical outcomes.4,5,14,18,20,23,24,2731 So many operations have been described that it raises the question of whether surgical correction is ever 100% curative. It is generally accepted that, for the best results, surgery should address both horizontal and vertical laxity.3,7,9,12,14,16,18,20 24,2729
Originally received: January 11, 2000. Accepted: June 12, 2000. Manuscript no. 200009. From the Western Eye Hospital and the Eye Department, Charing Cross Hospital, London, England. The authors have no propriety interest in this study. Reprint requests to Jane M. Olver, FRCOphth, Western Eye Hospital, Marylebone Road, London NW1 5YE, England.

Follow-up is particularly difcult in this group of elderly patients because they may be too unwell to report for follow-up, they may move, or they may die.30 Often, the clinical follow-up is too short to establish the long-term results. There is a need for involutional entropion to be corrected with minimal surgical intervention and morbidity, producing an effective, sustained result. In this study, we aimed to perform eyelid surgery via a small lateral canthal incision that addressed both horizontal and vertical lid laxity. This approach was developed from the observation that by placing the convexity of the thumb laterally below the tarsal plate to compress and tighten the lower eyelid superolaterally, the entropion could be abolished and the lower eyelid skin crease could be restored, thus mimicking the effects of surgery (Figs 1, 2). We also aimed to set a minimum standard for evaluating the results of entropion surgery consisting of clinical assessment of all patients at least 1 year after surgery. This study was organized as a prospective, noncomparative, interventional case series of involutional entropion patients. Surgery was undertaken by an oculoplastic service in two UK teaching hospitals.

Participants and Methods

Participants
Thirty-ve consecutive patients with involutional entropion (13 white males and 22 white females) were included (patients with
ISSN 0161-6420/00/$see front matter PII S0161-6420(00)00358-4

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2000 by the American Academy of Ophthalmology Published by Elsevier Science Inc.

Olver and Barnes Effective Minimally Invasive Entropion Surgery

Table 1. Reoperation PatientsDetails of Previous Surgery
Type of Entropion Surgery Everting sutures Wies Lateral tarsal strip Wedge excision Jones plication Quickert No. of Patients 2 7 1 1 1 1 Residual Horizontal Eyelid Laxity 2 6 0 1 1 1

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

cicatricial entropion were excluded). Their informed consent for this procedure was received. The study patients represented 45 lower eyelids, 27 being unilateral procedures (11 right and 16 left lower eyelids) and 9 bilateral procedures. Primary operations were performed on 33 eyelids (73%), and reoperations were performed on 12 eyelids (27%; Table 1). One patient had had two previous procedures. None of the participants had undergone this technique previously. Both intermittent and constant entropion were included in this study. Intermittent entropion was operated on if it occurred several times daily and was symptomatic. Details of preoperative horizontal eyelid laxity are summarized in Table 2. Horizontal eyelid laxity more than 8 mm was noted in 33 eyelids (79%). These included 10 of the 11 recurrences, that is, 90% of the recurrences had horizontal eyelid laxity more than 8 mm. One surgeon (JMO) performed all the operations in this study.

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

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Table 2. Surgical Outcome for Involutional Lower Lid Entropion with Respect to Preoperative Lid Laxity at Primary or Repeat Surgery (N 42 eyelids)
Type of Surgery Primary Surgery Outcome Success (cure) Failure (recurrence) Horizontal Eyelid Laxity 8 mm 8 0 Horizontal Eyelid Laxity 8 mm 18 5 Reoperation Horizontal Eyelid Laxity 8 mm 0 1 Horizontal Eyelid Laxity 8 mm 10 0

Methods
The preoperative assessment of each patient was recorded on a standard proforma. This included details of any previous entropion surgery and measurements of the vertical palpebral aperture, margin reex distances, lower lid skin crease, lower eyelid excursion, and horizontal eyelid laxity. Horizontal laxity was assessed by the pinch test, and each eyelid was classied as either less than 8 mm (not lax) or more than 8 mm (lax). Medial canthal tendon laxity was assessed by the lateral distraction test, with the patient looking in primary gaze and graded according to the horizontal distance reached by the punctum in relation to the cornea. Surgical Procedure. The procedure was performed via a 10-mm lateral canthotomy incision. After a lateral cantholysis, the lateral orbital rim was prepared as for a lateral tarsal strip (LTS) Fig 3. A standard LTS32,33 was then fashioned to a suitable length to correct for the horizontal eyelid laxity. A double-ended 5-0 nonabsorbable suture was placed through the strip but was not secured to the lateral orbital rim until later. A 6-0 silk traction suture was then placed through the grey line medial to the LTS to elevate the eyelid and to provide access to the area referred to here as the lateral triangle. This area is dened as that formed anteriorly by the orbital septum, orbicularis muscle, and skin, and posteriorly by the conjunctiva and anterior part of the lower eyelid retractors. (The lateral fat pad is visible between these anterior and posterior lamellae and acts as an important landmark at surgery.) Thus the apex of the lateral triangle is formed by the fusion of the retractors and orbital septum and lies approximately 4 mm below the inferior border of the tarsal plate (Fig 3). Then, in this procedure, the retractors were separated from the conjunctiva at a position approximately 8 to 12 mm below the

lower edge of the tarsal plate. Toothed forceps were used to grasp the retractors within the eyelid to demonstrate that the retractors had been correctly identied and that diagonal tightening of them would inuence lid function. A double-ended 5-0 nonabsorbable suture was placed through the retractors (subconjunctivally) and attached to the periosteum at the lateral orbital rim, but was left loose at this stage. This suture elevated and diagonally tightened the retractors. A second suture was placed in the orbital septum between the fat pad and the orbicularis at a level below the retractor suture and was similarly attached to the lateral orbital rim, immediately below the retractor suture. This suture tightened the orbital septum horizontally. (If lid laxity is mild, a single suture captures both the retractors and orbital septum) [Fig 4]. The LTS was sutured to the lateral orbital rim before the retractor and orbital septal sutures (Fig 5). These permanent sutures were protected by two-layered closure: 6-0 absorbable mattress sutures to the orbicularis and 8-0 absorbable interrupted

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

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

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Olver and Barnes Effective Minimally Invasive Entropion Surgery

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

sutures to the skin. The lateral canthal angle is reformed using a buried 6-0 absorbable suture. Additional procedures such as medial canthal tendon stabilization or lateral fat pad reduction were undertaken if indicated.

Outcome Measures
A successful surgical result (cure) occurred when the lower eyelid was in apposition with the globe and with the lower punctum in its usual anatomic position. This position should be maintained in all positions of gaze and on voluntary and involuntary forced eyelid closure. Effective lower eyelid retractor action was recognized by lower eyelid excursion and the presence of a lower eyelid skin crease on downgaze. Each patient was assessed clinically 1 to 3 weeks after surgery and then at 3- to 4-month intervals for a minimum of 1 year. At each visit, the patients were asked whether they had experienced any recurrence of their symptoms. They were examined macroscopically before and after forced orbicularis action (voluntary and with the amethocaine provocation test). Biomicroscopic examination of the external eye was performed, and any complications were noted. Eyelid measurements of lower lid excursion, lower lid skin crease, and residual horizontal eyelid laxity were also made.

these had preoperative horizontal eyelid laxity. Siting two sutures (orbital septum and retractors) rather one combined suture had a benecial effect on the outcome of the procedure, with a success rate of 32 of 35 eyelids (91%) for two sutures, compared with four of seven eyelids (57%) for a single suture (Table 3). The timing of the recurrences was as follows: 1. Three of six patients (50%) experienced recurrence within 6 months after surgery, 2. Two of six patients (33%) experienced recurrence between 12 and 18 months after surgery, and 3. One of six patients (16%) experienced recurrence between 18 and 24 months after surgery. There was a discrepancy between the objective results of surgery observed by the ophthalmologist and the patients symptoms. In ve eyelids (ve patients) with entropion recurrence, this was detected only by the examining ophthalmologist with the patients remaining asymptomic. In the sixth case of recurrence, the patient reported mild symptoms. The recurrent entropion was mild in three eyelids where we observed posterior marginization of the mucocutaneous junction. Therefore, only one of 45 eyelids had symptomatic recurrence, representing 98% symptomatic success. All recurrences, asymptomatic and symptomatic, were treated by Rathbun-Quickert everting sutures because there was no residual horizontal laxity detected (all had 8 mm horizontal eyelid laxity after surgery). To date, this has anatomically cured these recurrences (minimum further follow-up of 12 months). Other complications after surgery included one lateral canthal wound infection, which occurred within 2 weeks of surgery and settled with medical treatment. Six patients experienced transient lateral orbital rim discomfort for less than 4 weeks. Figure 6 shows the postoperative appearance after left LTS with diagonal retractor and orbital septal tightening. Table 3. Surgical Outcome with Respect to Number of Sutures Used at Primary or Repeat Surgery (N 42 eyelids)
Type of Surgery Primary Surgery Outcome Success Recurrence Combined Suture 3 2 Separate Sutures 23 3 Reoperation Combined Suture 1 1 Separate Sutures 9 0

Results
Of the 35 patients (45 eyelids) enrolled in this study, results were available for 33 patients (42 eyelids) because two patients died during the follow-up period and one patient was lost to followup 3 months after the second eyelid was operated on. Clinical followup ranged between 12 and 24 months (mean, 17.1 months). Separate retractor and orbital septal sutures were used in 35 eyelids, and a single combined suture was used in the remaining seven eyelids. Other eyelid procedures were performed in four eyelids: two medial canthal tendon stabilizations and two lateral fat pad reductions. A cure was achieved in 36 eyelids (86%; Table 2). There were no cases of overcorrections. There were no cases of lower eyelid retraction occurring after this procedure. Recurrence of the entropion occurred in six eyelids of six patients. Of these, only one had undergone previous eyelid surgery (everting sutures) and was not found to have had horizontal eyelid laxity before surgery. For the remaining eyelids, all had undergone primary procedures and all of

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Figure 6. Appearance after left horizontal shortening with retractor and orbital septal tightening: A, front view, primary gaze; B, side view, primary gaze; C, front view, down gaze; D, side view, down gaze.

Discussion
Previous studies strongly suggest that both horizontal and vertical laxity should be addressed to maximize the surgical success of involutional entropion correction.14,18,20,23,24,2729 We described an operation based on horizontal lid shortening by the lateral tarsal strip and on diagonal tightening of the orbital septum and lower lid retractors for the correction of involutional entropion. This approach is based entirely at the lateral canthal angle, enabling the surgeon to address both factors via one incision. We included patients with primary and recurrent involutional entropion. It is of note that only one of the patients requiring reoperation had previously had surgery to shorten the eyelid horizontally, while 10 patients (91%) were noted to have signicant residual horizontal eyelid laxity. This adds support to the belief that horizontal laxity must be addressed if surgery is to be successful.14,18,20,23,24,2729 Vertical lid laxity is corrected by tightening the orbital septum and lower lid retractors using the diagonal sutures. The importance of tightening the lower lid retractors has been advocated since the early 1960s.6,11,14 16,18,20,2124,27 In particular, the anterior part of the lower eyelid retractors stabilizes the lower border of the tarsal plate and pulls the lid at the level of the lower skin crease in down gaze. The retractors consist of the capsulopalpebral fascia and inferior tarsal muscle, and they may be attenuated, although rarely

dehisced, in involutional entropion. Also, their effect is compromised by lower lid sag secondary to involutional horizontal eyelid laxity, and they may also be relatively weakened by aging enophthalmos, although this suspected association has not been conrmed.34 Before surgery, the lower lid skin crease (usually found 4 mm below the lash line) was not apparent unless the eyelid was unipped. After surgery, this crease was permanently restored, conrming the physiologic pull of the retractors. Also, the lower eyelid excursion was compromised with the eyelid inturning, but when unipped, appeared normal. We did not detect any signicant difference between the preoperative and postoperative lower eyelid excursion, similar to that observed by Wright et al.30 Another effect of the diagonal sutures is to compress the precapsulopalpebral fascial fat pad; fat prolapse is suspected as having a minor mechanical role in destabilizing the lid margin.35 In our series, the use of separate sutures (retractor and orbital septal) was more effective than a single suture, providing greater support to overcome the vertical lid laxity. It is inevitable that there will be some failures after entropion surgery if the patients are monitored over a long period. The success rates of other studies are summarized in Table 4. Collin and Rathbun14 stated in 1978 (page 1063): No operation designed to correct the ageing changes that affect the lid tissues can be completely successful, since by denition these changes are progressive. Indeed in our series,

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Olver and Barnes Effective Minimally Invasive Entropion Surgery

Table 4. Review of Success Rates in Other Procedures
No. Cases c.40 15 27 14 38 50 23 Follow-up No. NS NS All All All All All Method NS NS Clinical evaluation Clinical evaluation Clinical evaluation Clinical evlauation Clinical evaluation Clinical evaluation A. Clinical evaluation B. Clinical evaluation Duration Reported on 8 yrs experience 10 mos 684 mos (mean, 20 mos) 417 mos (mean, 8 mos) 678 mos (mean, 47 mos) 1563 mos (mean, 38 mos) 918 mos Recurrences None Overcorrections

Author Wies 19555 Jones et al (1972)11 Collin & Rathbun (1978)14 Dryden et al (1978)15 Dortzbach & McGetrick (1983)18 Nowinski (1991)23 Dresner & Karesh (1993)24 Van den Bosch et al (1998)27 Danks & Rose (1998)28

Procedure Horizontal full thickness incision Retractor plication Quickert procedure Retractor reattachment Retractor reattachment horizontal shorten Retractor reattachment, lateral tarsal strip, & orbicularis extirpation Transconjunctival retractor reattachment, lateral canthal resuspension orbicularis excision Retractor reattachment horizontal shorten fat excision A. Wies or Jones plication B. Quickert or lateral tarsal strip with retractor reattachment

Slight in several cases None None 1 (96% success) None 2 (86% success) None None None None 2 (95% success) 2 (96% success) None

266 405

All 360 A. 152 B. 208

580 mos (mean, 42 mos) A. 154 mos (mean, 35 mos) B. 154 mos (mean, 35 mos)

9 (91% success) A. 15 (75% success) B. 1 (99% success)

12 1

NS not stated. Italics indicate information that is assumed.

in the reoperation group, the interval between the previous entropion surgery ranged from 6 months to 13 years. Therefore when assessing a surgical procedure, an attempt should be made to follow-up patients to determine at least the short-term failures. We regard short-term follow-up as up to one year after surgery, medium-term follow-up as between 1 and 2 years, and long-term follow-up more than 2 years after surgery. Several previous studies had a minimal follow-up of 1 to 7 months after surgery,11,15,17,18,20,25,26,27 but few fullled the criteria we have set in this study, namely of a minimum follow-up up of 1 year based on clinical examination.16,23,24,30 Although most recurrences take place very early, often within 6 months,28 our study shows that we had further recurrences after that period, supporting the need for longer follow-up when evaluating the results. Collin and Rathbun14 (page 1064) also stated: Follow-up studies after entropion procedures are, however, notoriously inaccurate, since the population is aged. Studies should therefore include data on the number of patients who have been lost to follow-up for whatever reason.17,28 30,36 In this study, we were able to account for all the patients operated on and examine 94% of patients at least 1 year after surgery. The anatomic success rate may initially appear modest when compared with other techniques where the apparent success rate is often greater but follow-up shorter (see Table 4). An exact comparison with other studies is not possible because of different study designs and, in particular, of different protocols for follow-up. In this series, asymptomatic entropion recurrences were detected, with 98% of cases having symptomatic improvement, yet only 86% having

anatomic success. It is not clear why there was this discrepancy, and it may be because we were observing the patients closely and noted the lid malposition before patients symptoms developed.36 We speculate that because the eyelid was stabilized by the horizontal tightening, there was recurrent entropion with constant lash corneal contact rather than the skin corneal touch found in a destabilized eyelid ipping in and out. These ndings support the argument for clinical follow-up rather than relying on the elderly patients elective return for further assessment.28 An ideal operation should be effective, cause minimal discomfort and morbidity, give an aesthetic result, and have a lasting effect. This operation not only restores normal lid function, but also gives a rapid rehabilitation with few complications and an excellent cosmetic outcome. As with other procedures performed at the orbital margin, transient discomfort was apparent at the orbital rim at a rate consistent with that described after the lateral tarsal strip procedure.27

Conclusions
In this prospective, noncomparative study, we described a minimally invasive surgical technique for the correction of involutional entropion that is highly effective in both primary and reoperation patients. The operation addresses the two main etiologic factors in involutional entropion. It gives rapid postoperative rehabilitation and an aesthetic result because of the short lateral canthal incision and ne-gauge dissolvable skin suture used. We recommend a minimum

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Ophthalmology Volume 107, Number 11, November 2000

clinical followup of 1 year when evaluating surgery for involutional entropion, with up to 2 years being preferable.
19. van der Meulen JC. Radical correction of senile entropion and ectropion. Plast Reconstr Surg 1983;71:318 23. 20. Wesley RE, Collins JW. Combined procedure for senile entropion. Ophthalmic Surg 1983;14:4015. 21. Schaeffer AJ. Variation in the pathophysiology of involutional entropion and its treatment. Ophthalmic Surg 1983;14:6535. 22. Carroll RP, Allen SA. Combined procedure for repair of involutional entropion. Ophthal Plast Reconstr Surg 1991;7: 1237. 23. Nowinski TS. Orbicularis oculi muscle extirpation in a combined procedure for involutional entropion. Ophthalmology 1991;98:1250 56. 24. Dresner SC, Karesh JW. Transconjunctival entropion repair. Arch Ophthalmol 1993;111:1144 8. 25. Charonis GC, Gossman MD. Involutional entropion repair by posterior lamella tightening and myectomy. Ophthal Plast Reconstr Surg 1996;12:98 103. 26. Mauriello JA Jr, Abdelsalam A. Modied corncrib (inverted T) procedure with Quickert suture for repair of involutional entropion. Ophthalmology 1997;104:504 7. 27. van den Bosch WA, Rosman M, Stijnen T. Involutional lower eyelid entropion: results of a combined approach. Ophthalmic Surg Lasers 1998;29:581 6. 28. Danks JJ, Rose GE. Involutional lower lid entropion. To shorten or not to shorten? Ophthalmology 1998;105:20657. 29. OSullivan EP, Howe LJ, Barnes E, et al. Factors affecting the success rate of the Quickert and Wies procedures for lower lid entropion [letter]. Orbit 1999;18:6173. 30. Wright M, Bell D, Scott C, Leatherbarrow B. Everting suture correction of lower lid involutional entropion. Br J Ophthalmol 1999;83:1060 3. 31. Dalgleish R, Smith JLS. Mechanics and histology of senile entropion. Br J Ophthalmol 1966;50:79 91. 32. Anderson RL, Gordy DD. The tarsal strip procedure [case report]. Arch Ophthalmol 1979;97:2192 6. 33. Olver JM. Surgical tips on the lateral tarsal strip. Eye 1998; 12:100712. 34. Kersten RC, Hammer BJ, Kulwin DR. The role of enophthalmos in involutional entropion. Ophthal Plast Reconstr Surg 1997;13:195 8. 35. Raina J, Foster JA. Obesity as a cause of mechanical entropion. Am J Ophthalmol 1996;122:1235. 36. Glatt HJ. Follow-up methods and the apparent success of entropion surgery. Ophthal Plast Reconstr Surg 1999;6:396 400.

References
1. Steel DHW, Hoh HB, Harrad RA, Collins CR. Botulinum toxin for the temporary treatment of involutional lower lid entropion: a clinical and morphological study. Eye 1997;11: 4725. 2. Wheeler JM. Spastic-entropion correction by orbicularis transplantation. Am J Ophthalmol 1939;22:477 83. 3. Fox SA. Relief of senile entropion. Arch Ophthalmol 1951; 46:424 31. 4. Kirby DB. Surgical correction of spastic senile entropion. Am J Ophthalmol 1953;36:1372 80. 5. Wies FA. Spastic entropion. Trans Am Acad Ophthalmol Otolaryngol 1955;59:503 6. 6. Jones LT. The anatomy of the lower eyelid and its relation to the cause and cure of entropion. Am J Ophthalmol 1960;29 36. 7. Foulds WS. Surgical cure of senile entropion. Br J Ophthalmol 1961;45:678 82. 8. Bick MV. Surgical management of orbital tarsal disparity. Arch Ophthalmol 1966;75:386 9. 9. Hill JC, Feldman F. Tissue barrier modications of a Wheeler II operation for entropion. Arch Ophthalmol 1967;78:6213. 10. Schimek RA. Modication of buried horizontal suture for entropion. Am J Ophthalmol 1970;70:236 9. 11. Jones LT, Reeh MJ, Wobig JL. Senile entropion. A new concept for correction. Am J Ophthalmol 1972;74:3279. 12. Schaefer AJ. Senile entropion. Ophthalmic Surg 1974;5:33 8. 13. Leber DC, Cramer LM. Correction of entropion in the elderly: a muscle ap procedure. Plast Reconstr Surg 1977;60:704 9. 14. Collin JRO, Rathbun JE. Involutional entropion. A review with evaluation of a procedure. Arch Ophthalmol 1978;96: 1058 64. 15. Dryden RM, Leibsohn J, Wobig J. Senile entropion. Pathogenesis and treatment. Arch Ophthalmol 1978;96:18835. 16. Schaeffer AJ. Lateral canthal tendon tuck. Ophthalmology 1979;86:1879 82. 17. Saunders DH, Shannon GM, Nicolitz E. The corncrib repair of senile entropion. Ophthalmic Surg 1980;11:128 30. 18. Dortzbach RK, McGetrick JJ. Involutional entropion of the lower eyelid. Adv Ophthal Plast Reconstr Surg 1983;2:257 67.

1988