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BJO Online First, published on March 21, 2018 as 10.1136/bjophthalmol-2017-311635
Clinical science

Non-incisional eyelid everting suture technique for


treating lower lid epiblepharon
Ji Won Seo,1 Sunah Kang,2 Chanjoo Ahn,2 Bita Esmaeli,3 Ho-Seok Sa2,3

1
Department of Ophthalmology, Abstract of the eyelid and the lower lid retractor through
Inje University Ilsan Paik Background  This study investigated surgical outcomes a skin incision and changing the eyelash direc-
Hospital, Goyang, Korea
2
Department of Ophthalmology, of full-thickness eyelid everting sutures for lower lid tion.1 2 5 Although these incisional techniques have
Asan Medical Center, University epiblepharon and influential factors leading to surgical been quite successful in surgical outcome, they have
of Ulsan, College of Medicine, failure. several drawbacks such as cutaneous scarring,
Seoul, Korea Methods  A retrospective review was conducted of change of appearance, and ectropion and retraction
3
Orbital Oncology and related to skin excision.6 General anaesthesia is also
patients with lower lid epiblepharon who underwent
Ophthalmic Plastic Surgery,
Department of Plastic Surgery, surgical correction using the full-thickness eyelid everting required in most patients undergoing an incisional
The University of Texas MD suture technique. Lower lid epiblepharon was assessed surgery.1
Anderson Cancer Center, preoperatively using a morphological classification (class The full-thickness eyelid everting suture tech-
Houston, Texas, USA I–IV) according to the horizontal skin fold height and nique, or Quickert procedure, was originally
a functional classification (grade 0–3) according to the described in 1971 for the treatment of entropion
Correspondence to and has been often used in the setting of spastic
severity of keratopathy. Four stitches with 5-0 coated
Dr Ho-Seok Sa, Department of
Ophthalmology, Asan Medical polyglactin 910 sutures per eyelid were made, and all entropion or early involutional entropion.7 The
Center, University of Ulsan, procedures were conducted under local anaesthesia in full-thickness everting suture technique has been
College of Medicine, Seoul, an office-based setting. To assess surgical outcomes, we thought to correct a lower lid epiblepharon by
05505, Korea; ​lineblue@​ evaluated undercorrection at 1 month and surgical failure creating a scar between the skin, orbicularis and
hanmail.​net
at 6 months after the procedure. Several factors affecting eyelid retractor and changing the eyelash direction.8
Received 20 November 2017 surgical failure were also investigated We describe a modified technique for full-thick-
Revised 2 March 2018 Results  Sixty-eight eyes of 41 patients were included. ness eyelid everting sutures under local anaesthesia
Accepted 8 March 2018 There were no eyes showing an undercorrection at to correct lower lid epiblepharon and its surgical
1 month. Keratopathy was significantly improved at 6 outcome. We also evaluate the factors associated
months postoperation (P<0.01). All patients showed with an increased risk of surgical failure to gain
good cosmesis without undesired creation of a lower lid further insights into the appropriate indications for
crease and no significant complications. Sixty-one eyes this approach in cases of lower lid epiblepharon.
(89.7%) showed surgical success. Three patients (7.3%)
required additional incisional surgery due to recurring Patients and methods
irritation. The rate of surgical failure was significantly We performed a non-comparative, retrospec-
different between the patient groups classified by tive and observational case series analysis. This
preoperative severity of keratopathy (P=0.026) and lower study was approved by the Institutional Review
lid horizontal skin fold height (P<0.001). Multiple logistic Board of Asan Medical Center under the tenets
regression analysis revealed that the lower lid horizontal of the Helsinki declaration. Consecutive patients
skin fold height was significantly correlated with surgical with lower lid epiblepharon who underwent an
failure (OR 18.367, P=0.002). epiblepharon correction using full-thickness eyelid
Conclusion  Non-incisional eyelid everting sutures have everting suture technique by a single ophthalmol-
utility for the correction of lower lid epiblepharon with ogist (HSS) between October 2013 and January
advantages including its simplicity, being performed in 2016 were reviewed. The following patient data
office under local anaesthesia and minimal changes in were collected: age, gender, symptoms, severity of
appearance. We suggest mild to moderate epiblepharon keratopathy, lower lid horizontal skin fold, suture
with class I or II horizontal skin fold height and grade material, number of stitches and the symptoms
1 or 2 keratopathy as the criteria for considering this and signs following surgical correction. Complete
suture procedure. slit-lamp examination results, anterior segment
photographs after fluorescein staining and preop-
erative and postoperative facial photographs were
also collected. Functional and morphological
Introduction classifications of the lower lid epiblepharon were
Epiblepharon occurs more commonly in East- conducted preoperatively using anterior segment
Asian children.1 2 This condition is characterised by and facial photographs (figure 1). Morphologies
redundant horizontal pretarsal skin folds that may were categorised from class I to IV in accordance
extend over the lid margin and invert the lashes to with the epiblepharon classification system and
To cite: Seo JW, Kang S,
the cornea.3 Another study reported the eyelash in based on lower lid horizontal skin fold height
Ahn C, et al. Br J Ophthalmol
Epub ahead of print: [please patients with epiblepharon is directed upright to (figure 1A).9 10 Functional classification from
include Day Month Year]. touch the cornea, irrespective of skin redundancy.4 grade 0 to 3 was made in accordance with the
doi:10.1136/ Conventional surgical treatments have focused on severity of keratopathy induced by cilio-corneal
bjophthalmol-2017-311635 making an adhesion between the anterior lamellae touch (figure 1B).11
Seo JW, et al. Br J Ophthalmol 2018;0:1–6. doi:10.1136/bjophthalmol-2017-311635 1
Copyright Article author (or their employer) 2018. Produced by BMJ Publishing Group Ltd under licence.
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Clinical science

Figure 1  (A) Preoperative morphological classification of the lower lid epiblepharon according to the horizontal skin fold height of the lower lid. (B)
Preoperative functional classification of the lower lid epiblepharon according to the severity of keratopathy induced by cilio-corneal touch.

The surgical indications in this study for full-thickness eyelid Windows software. A P value of ≤0.05 was considered statisti-
everting suturing for epiblepharon correction were as follows: cally significant.
(1) chronic irritative symptoms related to lower lid epiblepharon;
(2) keratopathy of grade 1 or 2 caused by cilio-corneal touch,
or keratopathy of grade 3 with unilateral lower lid epibleph- Full-thickness eyelid everting suture technique
aron; and (3) age below 15 years. We recommend conventional All procedures were performed in an office setting under local
incisional surgery, instead of the suture method, to treat bilat- anaesthesia without sedation. A eutectic mixture of lidocaine
eral lower lid epiblepharon with keratopathy of grade 3 in each and prilocaine (EMLA cream; Astra, Sodertalje, Sweden) was
eye. The exclusion criteria for our current study subjects were a applied to the lower lid skin for 30 min prior to the infiltrative
history of previous lower lid surgery or an insufficient postoper- local anaesthesia to lessen the pain of injection. Topical anaes-
ative follow-up period, that is, less than 6 months. thetic drops with 0.5% proparacaine hydrochloride (Alcaine;
The parents of our study subjects were fully informed of the Alcon, Puurs, Belgium) were applied to the eyes. The child
advantages and potential disadvantages of our suture method patient was placed on a procedure bed in a supine position so
compared with conventional incisional surgery. Informed that the vertex rested on the end of the bed. The surgeon was
consent to the procedure was received in all cases. An ante- seated at the head of the procedure bed. An assistant was seated
rior segment photograph after fluorescein staining and a facial on the side of the surgeon’s non-dominant hand and stabilised
photograph preoperatively, and at 1 month and 6 months post- the patient’s head. Patient’s parent was also seated nearby to
operatively, was taken for all patients. A single blinded observer assist the procedure by holding the child’s hands or arms and by
reviewed these photographs to evaluate the preoperative func- reassuring the child patient. The patient was encouraged to keep
tional and morphological classifications and the postopera- the eyes gently closed throughout the procedure. The lower
tive keratopathy related to epiblepharon. To assess surgical lid was then subcutaneously infiltrated with a mixture of 2%
outcomes, we evaluated both undercorrection and surgical lidocaine and 1:100 000 epinephrine using a 30-gauge needle.
failure. Undercorrection was defined as a keratopathy related Distraction techniques, including talking about unrelated issues,
to cilio-corneal touch 1 month after the procedure. Surgical playing music, and massaging or shaking the patient’s lower lid
failure was defined as postoperative keratopathy of any grades and cheek during local infiltration, were accompanied. A small
causing subjective irritative symptoms, or keratopathy of grade amount of local anaesthetic was administrated initially, and a
2 or 3 regardless of irritative symptoms at 6 months postoper- subsequent injection was performed to finish the anaesthesia in a
atively. We evaluated several factors that may have contributed minute after the initial site has been numbed. A subconjunctival
to the failure of the full-thickness eyelid everting suture proce- local administration was followed.
dure including age, sex, the preoperative severity of keratopathy A taper point needle of 5-0 Vicryl (Ethicon; Johnson and
as a functional factor and the preoperative lower lid horizontal Johnson, Livingston, UK) suture was inserted through the skin
skin fold height as a morphological factor. The comparison 1 mm below the lower lid lash line (figure 2A). With the lower
of surgical failure according to morphological and functional lid fully everted not to damage the globe by the needle, the
classifications was analysed using the Kruskal-Wallis test, and suture emerged through the inferior conjunctival fornix 3 mm
several factors affecting surgical failure were evaluated using the below the inferior tarsal border (figure 2B). The needle was then
logistic regression. Statistical analysis was performed using the directed back to pass through the inferior fornix 2 mm adjacent
Wilcoxon signed-rank test to compare the severity of preoper- to the first exit point travelling obliquely through the orbicu-
ative and postoperative keratopathy. Statistical analyses were laris muscle to exit through the skin of the lower lid (figure 2C).
performed using SPSS (V.21.0; SPSS, Chicago, Illinois, USA) for The suture was then tied tightly on the skin (figure 2D). The
2 Seo JW, et al. Br J Ophthalmol 2018;0:1–6. doi:10.1136/bjophthalmol-2017-311635
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Clinical science
underwent a bilateral procedure, and 14 underwent a unilateral
procedure using the full-thickness eyelid everting suture tech-
nique. Operating time for each eyelid was within 20 min in all
cases. The mean age was 8.4±2.9 years, ranging from 4 to 14
years. The mean postoperative follow-up was 8.6±3.5 months,
ranging from 6 to 18 months. The preoperative severity of
keratopathy in the study cohort was graded as follows: grade
1, 28 eyes (41.2%); grade 2, 33 eyes (48.5%); grade 3, 7 eyes
(10.3%). The preoperative lower lid horizontal skin fold heights
among the study subjects were classed as follows: class I, 21 eyes
(30.9%); class II, 31 eyes (45.6%); class III, 12 eyes (17.6%);
class IV, 4 eyes (5.9%).
At the first follow-up at 1 month postoperatively, there was no
eye showing keratopathy that resulted from an undercorrection.
The postoperative severity of keratopathy at 6 months was graded
as follows: grade 0, 52 eyes (76.5%); grade 1, 12 eyes (17.7%);
grade 2, 4 eyes (5.8%). There were significant reductions in the
severity of postoperative keratopathy at 6 months compared
with the preoperative grades (P<0.001, Wilcoxon signed-rank
test). Sixty-one eyes (89.7%) showed surgical success, but seven
eyes (10.3%) of seven patients revealed surgical failure following
epiblepharon correction using the suture technique. Their preop-
erative keratopathy grade and skin fold class (grade/class) were
Figure 2  Full-thickness eyelid everting suture technique (surgeon’s 3/IV, two patients; 2/IV, one patient; 1/IV, one patient; 3/III, one
view). (A) A taper point needle of 5-0 Vicryl (Ethicon; Johnson and patient; 2/III, one patient; 3/II, one patient. Three cases (7.3%,
Johnson, Livingston, UK) suture was inserted through the skin 1 mm 7/41 patients; 4.4%, 3/68 eyes) of surgical failure successfully
below the lower lid lash line. (B) The suture emerged through inferior underwent modified Hotz surgery for additional epiblepharon
conjunctival fornix 3 mm below the inferior tarsal border. (C) The repair, all of which had have preoperative class IV of lower lid
needle was then directed back to pass through the inferior fornix horizontal skin fold. The other four cases of surgical failure were
2 mm adjacent to the first exit point travelling obliquely through the only given artificial tears because the irritation was minimal
orbicularis muscle to exit through the skin of the lower lid. (D) The (table 1). There were 14 patients (24 eyes) who were followed
suture was tied tightly on the skin. (E) A second suture was placed in up for 12 months or longer, and 13 patients (23 eyes) remained
the same fashion approximately 2 mm laterally to the first suture. (F) All in the same postoperative outcome at the last follow-up. One
sutures were placed in the same horizontal plane. patient (one eye) who had shown surgical success at 6 months
revealed recurrence (grade 1 keratopathy with irritation) at 12
first suture was placed 1–2 mm laterally to the lower punctum. months postoperatively. The patient had preoperative grade 3
The second suture was placed in the same fashion approximately keratopathy and class III of lower lid horizontal skin fold, and he
2 mm laterally to the first suture (figure 2E) and the third at was successfully managed with artificial tears after recurrence.
3–4 mm laterally to the second. The fourth suture was placed The surgical success, in accordance with the preoperative
5–6 mm laterally to the third. All sutures were placed in the same severity of keratopathy, was as follows: grade 1, 96.4% (27/28
horizontal plane (figure 2F). The patients were instructed to eyes); grade 2, 90.9% (30/33 eyes); grade 3, 57.1% (4/7 eyes)
apply 3% ofloxacin eye ointment (Tarivid ophthalmic ointment; (figure 3A). Surgical success in accordance with the preopera-
Santen Pharmaceutical, Osaka, Japan) to the stitches three times tive lower lid horizontal skin fold height was as follows: class
a day for 1 week. The sutures remained in place until they were I, 100.0% (21/21 eyes); class II, 96.8% (30/31 eyes); class
degraded by an inflammatory reaction. III, 83.3% (10/12 eyes); class IV, 0% (0/4 eyes) (figure 3B).
The rate of surgical failure was significantly different between
Results the patient groups classified by preoperative severity of kera-
A total of 68 eyes of 41 patients (23 boys and 18 girls) were topathy and lower lid horizontal skin fold height (P=0.026 and
enrolled in this study (table 1). Twenty-seven of these patients P<0.001, Kruskal-Wallis test, figure 3). Multiple logistic regres-
sion analysis of age, sex, preoperative keratopathy and lower lid
skin fold height revealed that only the lower lid skin fold height
Table 1  Characteristics of the 41 study patients (68 eyes) with a was significantly correlated with surgical failure (OR 18.367,
lower lid epiblepharon who underwent surgical correction using the 95% CI 2.998 to 112.507, P=0.002; table 2).
full-thickness eyelid everting suture technique There were no significant complications arising from the
Age, years (SD) 8.4±2.9 full-thickness eyelid everting suture technique. No patient devel-
Sex (M/F) 23/18 oped a lower lid ectropion or an acute inflammatory reaction
Bilaterality of epiblepharon such as a suture abscess. All patients showed good postoperative
 Bilateral, patients 27 cosmesis without undesired creation of a lower lid crease.
 Unilateral, patients 14
Follow-up periods, months (±SD) 8.6±3.5 (range, 6–18)
Discussion
Surgical success, eyes (%) 61/68 (89.7%)
In the present study, the success rate of the everting suture tech-
Timing of recurrence, months (±SD) 4.9±3.2 (range, 3–12)
nique for lower lid epiblepharon was 89.7% (61/68 eyes) and
Reoperation with incisional technique, patients (%) 3/41 (7.3%)
only 4.4% (3/68 eyes) required a reoperation with additional
Seo JW, et al. Br J Ophthalmol 2018;0:1–6. doi:10.1136/bjophthalmol-2017-311635 3
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Clinical science

Figure 3  Success rates of epiblepharon repair using the full-thickness eyelid everting suture technique according to (A) the preoperative severity of
keratopathy and (B) the preoperative lower lid horizontal skin fold height; Kruskal-Wallis test.

incisional surgery. Notably, no eyelid showed any undesired lash line. We believe this modification enables to avoid creating
creation of a visible lower lid crease after the procedure. We also an unattractive lower lid crease and reinforces the everting of
found that it is important to select appropriate candidates for the lid margin.
this technique, and a mild to moderate lower lid epiblepharon There have been some Asian studies on everting suture tech-
with a class I or II horizontal skin fold height and grade 1 or 2 niques,13 14 but high recurrence rates in those studies have gener-
keratopathy could be the proper indications. ated less attention to this method. Hayasaka et al13 reported
There have been some studies on the everting suture tech- a 24.3% (36/148 eyes) recurrence rate with 6 months of
nique for lower lid epiblepharon,8 12–14 but our study has follow-up. A comparison study between a modified Hotz surgery
distinctive aspects in terms of modifying previously described (88 patients) and everting suture technique (9 patients) for
techniques and designating appropriate indications. Quickert et epiblepharon reported a success rate of 83% and 55%, respec-
al8 described an everting suture technique for lower lid epibleph- tively.14 Neither studies had a classification system to assess the
aron; they placed 4-0 chromic gut sutures from the inferior tarsal severity of epiblepharon.13 14 Hayasaka et al,13 who enrolled a
border to the skin of the normal eyelid crease line. Although large number of patients, placed two 3-0 silk sutures from the
they did not mention about specific indications for the suture inferior conjunctival fornix to 3 mm below the eyelid margin
procedure, they achieved resolution of the epiblepharon and and removed the stitches 1 week after the procedure. Their tech-
creation of a lower lid crease in all 18 eyelids with a minimum nique does not seem to create an undesired lower lid crease, but
follow-up of 6 months.8 O’Donnell and Collin12 placed three a high recurrence rate may have been due to the use of transient
to four 4-0 absorbable gut sutures to make a lower lid crease. non-absorbable sutures and the absence of specific indications
They performed everting sutures in 13 patients with cilio-cor- for the suture procedure. We assumed that only two temporary
neal touch present only in downgaze or adduction, or with silk sutures may not be enough to make a secure scar barrier to
only few trichiasis lashes in primary position.12 Twelve patients correct the epiblepharon, and the suture procedure should be
showed a satisfactory result and only one patient required addi- used only for a mild to moderate epiblepharon.
tional incisional surgery, even though 4 of the 13 patients had There were some peculiar factors that could achieve a high
recent surgery or were lost to follow-up.12 These two Western success rate without undesired creation of a lower lid crease in
studies reported high success rates using absorbable sutures, and our current study, including narrower indicators and modifications
their techniques focused on a creation of a lower lid crease for to previously described techniques. First, in most cases, we used
treating epiblepharon.8 12 Given that epiblepharon is common the eyelid suture procedure to treat mild to moderate epibleph-
in East-Asian children, however, surgeons should know that
aron. We were aware from experience that the more severe form
a lower lid crease is not desirable by East-Asian beauty stan-
of epiblepharon has a higher likelihood of recurrence after a suture
dards.1 2 11 We modified these techniques to make a suture from
procedure, and we recommend an incisional technique as the
the inferior conjunctival fornix to the skin near the lower lid
initial treatment in any bilateral severe epiblepharon cases. We only
performed the suture procedure in patients with a keratopathy of
grade 3 if they had unilateral epiblepharon. It was because that
Table 2  Multiple logistic regression analysis of variable factors
the suture procedure can avoid incisional surgery of the normal
associated with surgical failure.
contralateral eyelid, which is inevitable when using a conventional
Surgical failure* predictors OR 95% CI P value incisional technique.9 Some Western studies commented that
Age 1.387 0.892 to 2.155 0.146 bilateral suture procedure should be performed even in patients
Sex 1.552 0.147 to 16.396 0.715 with unilateral epiblepharon to achieve symmetry of lower lid
Preoperative severity of keratopathy 1.640 0.380 to 7.086 0.508 crease.8 12 However, our technique does not create an undesired
Preoperative lower lid skin fold height 18.367 2.998 to 112.507 0.002 crease or forms it just under the lash line, so there is no need for
*Surgical failure was defined as postoperative moderate to severe keratopathy bilateral procedure. Second, we modified the suturing technique to
regardless of irritative symptoms or keratopathy causing subjective irritative generate more stitches using a longer-standing absorbable suture
symptoms at 6 months postoperatively. in order to maximise the effect of everting the eyelid. Quickert
4 Seo JW, et al. Br J Ophthalmol 2018;0:1–6. doi:10.1136/bjophthalmol-2017-311635
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Clinical science
previously evaluated the extent of the skin excision required
according to the horizontal skin fold height in cases of lower lid
epiblepharon and reported that a higher skin fold required more
aggressive surgical correction. We therefore recommend that func-
tional and morphological evaluations should be performed prior to
surgical correction of epiblepharon.
The full-thickness eyelid everting suture technique has one
notable limitation in that its correction effect can be lower than
that of conventional incision. Nevertheless, the suturing approach
is a viable alternative to the incision technique due to several advan-
tages including its simplicity, excellent cosmesis, short operation
time, relatively low cost and no requirement for general anaesthesia
or unnecessary bilateral surgery. First, the full-thickness everting
suture technique is easy to perform and only minimally invasive,
and all of our current study patients (aged from 4 to 15 years)
underwent this procedure in an office under local anaesthesia. Our
experience with child patients has made it clear that a good local
anaesthetic technique is the key to a successful procedure session of
a younger age group. Once a child patient feels pain or fear, it often
becomes difficult to get the patient back to a calm status. A numbing
Figure 4  Representative child patients who underwent epiblepharon cream application prior to the injection of local anaesthetic, distrac-
correction using the full-thickness eyelid everting suture technique. (A) tion techniques and proper verbal reassurances proved to be useful
Preoperative anterior segment photograph showing cilio-corneal touch to relieve pain as well as fear of injection in these young patients.
by the lower lid epiblepharon. (B) The cilio-corneal touch was resolved Second, the everting suture technique provides excellent cosmesis
in the lower lid 6 months after the suture procedure. (C) Preoperative and very little alterations in the original appearance of the patient
facial photograph. (D) Postoperative photograph at 6 months after by changing the eyelash direction without skin excision (figure 4).
bilateral suture procedure. A good cosmetic outcome with no alterations It also provides a fast recovery with few complications. Asian
to the patient’s original appearance was achieved. (E) Preoperative patients and their parents may well be dissatisfied with the signif-
facial photograph. (F) Postoperative photograph at 6 months after icant changes in appearance that can occur following incisional
bilateral suture procedure showing a good cosmetic and functional surgery.11 Also, in conventional incisional surgery, bilateral surgery
outcome. (G) Preoperative facial photograph who had a right lower lid is needed to ensure bilateral symmetry even if the patient only has
epiblepharon. (H) Postoperative photograph at 6 months after unilateral a unilateral lower lid epiblepharon.9 The everting suture technique
suture procedure. The right epiblepharon was well corrected and both helps to avoid unnecessary incisional surgery on a normal oppo-
lower eyelids look symmetrical. site eyelid by preserving the original appearance. Third, it is more
cost-effective than incisional surgery for the treatment of lower lid
epiblepharon. In South Korea, the cost of bilateral surgery with the
et al8 stated their technique as placement of two or three stitches everting suture procedure is US$300 compared with US$1200 for
of chromic catgut, and Hayasaka et al13 placed two stitches of incisional surgery.
non-absorbable 3-0 silk sutures and removed them 1 week after the The limitations of this study mainly come from its retrospec-
procedure. In our current study series, we used 5-0 coated Vicryl tive design, small number of patients and relatively short-term
(polyglactin 910) to make the stitches, which also do not need to follow-up. Further studies with a longer follow-up are likely to
be removed. Vicryl is slower-absorbing than chromic catgut and is be needed to address whether the long-term outcomes of the
known to be completely absorbed at between 56 and 70 days post- full-thickness eyelid everting suture technique may be poor.
implantation.15 It can therefore create a better barrier for keeping However, considering that the follow-up period in our present
the lower lid everted compared with chromic catgut or temporary study was at least 6 months, with an average of 8.6 months,
silk sutures by inducing a sufficient inflammatory reaction.13 14 16 and that some cases of epiblepharon resolve spontaneously with
Furthermore, we placed four stitches per lid which are more than age,1 5 11 we are confident that the everting suture technique will
those of the previous techniques, and two of which were placed prove to be a very useful surgical option for this condition.
in the medial portion where the lower lid epiblepharon is more
significant.14
Conclusion
There were seven cases of treatment failure (10.3%) in our
Non-incisional eyelid everting suturing is a viable approach to the
current study series. Analysis of these patients revealed cases of
correction of lower lid epiblepharon due to its simplicity, capacity
severe preoperative ketatopathy of grade 3 and a high horizontal
to be an office-based treatment conducted under local anaes-
skin fold height of the lower lid (class III or IV) was associated with
thesia, low impact on appearance and avoidance of unnecessary
the surgical failure (P<0.05). We also found that the horizontal
bilateral surgery. To prevent recurrences, it is important to select
skin fold height of the lower lid was the most significant deter-
appropriate candidates that can be a mild to moderate lower lid
minant of surgical failure by a multiple logistic regression analysis
epiblepharon with a class I or II horizontal skin fold height and
(OR 18.367, P=0.002). Full-thickness everting sutures rotate the
grade 1 or 2 keratopathy.
eyelid margin anteriorly and cause fibrotic adhesion between the
orbicularis oculi and the lower lid retractors to prevent overriding Contributors  Conception and design: HSS. Analysis and interpretation of data: all
of the preseptal orbicularis.8 However, this technique could not authors. Drafting the article or revising it critically for important intellectual content:
generate and sustain barriers that were sufficient to pull the skin JWS, BE, HSS. Final approval of the version to be published: HSS.
downward in a lower lid with a high horizontal skin fold due to Funding  This research received no specific grant from any funding agency in the
the significant force of the upward traction. Khwarg and Choung9 public, commercial or not-for-profit sectors.

Seo JW, et al. Br J Ophthalmol 2018;0:1–6. doi:10.1136/bjophthalmol-2017-311635 5


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Clinical science
Competing interests  None declared. 7 Quickert MH, Rathbun E. Suture repair of entropion. Arch Ophthalmol
1971;85:304–5.
Patient consent  Parental/guardian consent obtained.
8 Quickert MH, Wilkes TD, Dryden RM. Nonincisional correction of epiblepharon and
Ethics approval  The Institutional Review Board of Asan Medical Center. congenital entropion. Arch Ophthalmol 1983;101:778–81.
Provenance and peer review  Not commissioned; externally peer reviewed. 9 Khwarg SI, Choung HK. Epiblepharon of the lower eyelid: technique of surgical repair
and quantification of excision according to the skin fold height. Ophthalmic Surg
© Article author(s) (or their employer(s) unless otherwise stated in the text of the
Lasers 2002;33:280–7.
article) 2018. All rights reserved. No commercial use is permitted unless otherwise
expressly granted. 10 Khwarg SI, Lee YJ. Epiblepharon of the lower eyelid: classification and association
with astigmatism. Korean J Ophthalmol 1997;11:111–7.
11 Kim MS, Sa HS, Lee JY. Surgical correction of epiblepharon using an epicanthal
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Non-incisional eyelid everting suture


technique for treating lower lid epiblepharon
Ji Won Seo, Sunah Kang, Chanjoo Ahn, Bita Esmaeli and Ho-Seok Sa

Br J Ophthalmol published online March 21, 2018

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