Tarsal Buckling and Entropion after Levator Aponeurosis Advancement in Patients with Floppy Eyelid Syndrome.

Two patients with floppy eyelid syndrome presented with severe eye pain and foreign body sensation after recent levator aponeurosis advancement. The examination in both patients was notable for entropion of the upper eyelid, and upper lid eversion revealed deformity of the tarsus in both patients. Surgical revision with full-thickness horizontal tarsotomy and limited excision of the abnormal tarsus corrected the deformity. The authors propose a mechanism for this phenomenon and a modification of surgical technique that may prevent this complication.

Cicatricial Entropion in Chronic Cicatrizing Conjunctivitis: Potential Pathophysiologic Mechanisms and Long-Term Outcomes of a Modified Technique.

PURPOSE: The purpose of this study was to assess the long-term outcomes of severe cicatricial entropion repair with mucous membrane grafting in patients with chronic cicatrizing conjunctivitis and report histopathological changes in the eyelid margin area. METHODS: Prospective interventional study included 19 patients with severe cicatricial entropion with trichiasis (N = 20 eyelids; 19 upper and 1 lower eyelid) who underwent anterior lamellar recession (with back cuts) and mucous membrane grafting cover for bare anterior tarsus, lid margin, and 2 mm of marginal tarsus, and had a minimum 6 months of follow-up. The anterior lamella and metaplastic eyelid margins were sent for routine Haematoxylin and Eosin and special staining with Masson trichrome stain. RESULTS: The etiologies were chronic Stevens-Johnson syndrome (N = 6), chemical injury (N = 11), and drug-induced pseudopemphigoid (N = 2). Five eyes had undergone entropion correction in the past, and 9 had electroepilation for trichiasis. Entropion was well corrected (without residual trichiasis) in 85% of eyelids with primary surgery. The etiology-wise success rates were 100% for Stevens-Johnson syndrome, 72.7% for chemical injury, and 100% for drug-induced pseudopemphigoid. Three eyelids with failure belonged to chemical injury, and trichiasis in these eyes could be managed with subsequent interventions except in 1 case. All eyelids had no entropion at a mean follow-up of 10.8 months (range, 6-18). Histopathological evaluation of anterior lamella (N = 10) and eyelid margins revealed significant fibrosis in subepithelial, perimysium (muscle of Riolan), and perifollicular areas. CONCLUSION: Anterior lamellar recession combined with mucous membrane grafting achieves good cicatricial entropion correction except in eyes with chemical injury. The eyelid margins in these eyes have persistent inflammation, and fibrosis involving lash follicles.

Association of topical glaucoma medications with lacrimal drainage obstruction and eyelid malposition.

BACKGROUND/OBJECTIVES: Adverse effects of topical glaucoma medications (TGMs) may include development of ocular adnexal disorders. We undertook a study to determine the effect of TGMs on the risk of developing lacrimal drainage obstruction (LDO) and eyelid malposition. SUBJECTS/METHODS: All patients 66 years of age and older in Ontario, Canada initiating TGM and all patients diagnosed with glaucoma/suspected glaucoma but not receiving TGM from 2002 to 2018 were eligible for inclusion in this retrospective cohort study. Using validated healthcare administrative databases, cohorts were identified with TGM and no TGM patients matched 1:2 on sex and birth year. The effect of TGM treatment on risk of surgery for LDO and lid malpositions was estimated using Kaplan-Meier and Cox proportional hazards models. RESULTS: Cohorts included 122,582 patients in the TGM cohort and 232,336 patients in the no TGM cohort. Among the TGM cohort there was decreased event-free survival for entropion (log-rank P < 0.001), trichiasis (P < 0.001), and LDO (P = 0.006), and increased ectropion-free survival (P = 0.007). No difference in ptosis-free survival was detected (P = 0.78). For the TGM cohort there were increased hazards for entropion (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.12-1.37; P < 0.001), trichiasis (HR 1.74, 95% CI 1.57-1.94; P < 0.001), and LDO (at 15 years: HR 2.39, 95% CI 1.49-3.85; P = 0.004), and a decreased hazard for ectropion (HR 0.89, 95% CI 0.81-0.97; P = 0.008). No association between TGM treatment and ptosis hazard was detected (HR 0.99, 95% CI 0.89-1.09; P = 0.78). CONCLUSIONS: TGMs are associated with an increased risk of undergoing surgery for LDO, entropion, and trichiasis.

Skin-redraping epicanthoplasty combined with the modified Hotz procedure to treat recurrent trichiasis in adults caused by congenital entropion.

OBJECTIVE: To report the efficacy of skin-redraping epicanthoplasty combined with the modified Hotz procedure for the management of recurrent trichiasis in adults caused by congenital entropion. METHODS: A retrospective chart review of nine recurrent trichiasis patients caused by congenital entropion was performed. All the patients were adults, and the follow-up period lasted more than 6 months. Success was defined as no recurrence of the trichiasis. RESULTS: The mean age of the patients was 22.7 ± 2.83 years, and the mean period of follow-up was 10.8 ± 4.15 months. The complete correction of trichiasis was observed in all patients, and there was no recurrence during the follow-up period. The ratio of the medial sclera area to the cornea area was enhanced from 0.25 ± 0.08 to 0.37 ± 0.11. Preoperatively, five patients were categorized as grade 2, and four patients were categorized as grade 3 of the Taylor classification, and all the patients were categorized as grade 0 after surgery. The preoperative severity of keratopathy was grade 3 in six patients and grade 2 in three patients. The preoperative lower lid horizontal skin fold heights were class 4 in six patients and class 3 in three patients. All the patients were grade 0 and class 1 after surgery. CONCLUSION: Skin-redraping epicanthoplasty combined with the modified Hotz procedure is reasonably successful in managing recurrent trichiasis in adults.

Corneal Complications Secondary to Involutional Entropion at Presentation.

PURPOSE: To determine the frequency and significance of corneal complications at presentation of involutional entropion in an Australian population. Patient demographics and duration of symptoms were collated to assess how these factors related to presentations. METHODS: Case records were retrospectively interrogated at an Oculoplastic Ophthalmology practice over a 15-year period to identify patients with lower eyelid involutional entropion. All patients had ophthalmic examination by an ophthalmologist. Patients meeting inclusion criteria had data collected including detailed assessment of corneal examination findings. RESULTS: The final cohort included 203 patients of which 50.7% were male. The mean age was 75.1 years. Cornea findings at presentation included superficial punctate keratopathy (69%), no change (25.6%), corneal ulcer (4%), and other (1%). One percent of patients had vision loss attributable to complications of entropion. Range of duration of symptoms was 2 weeks to 6 years with a mean of 11.5 months. CONCLUSIONS: At presentation, involutional entropion has mild corneal findings with 95.1% of patients demonstrating superficial punctate keratopathy or normal corneal epithelium. Vision loss is a rare complication and was observed in 1% of patients in this study, all with preexisting corneal pathology.

Clinical Manifestations in Patients Wearing Ocular Prostheses.

PURPOSE: This study aimed to assess upper and lower eyelid shapes and changes in patients wearing ocular prostheses. METHODS: The authors retrospectively reviewed the clinical records of patients wearing ocular prostheses. Clinical manifestations, including superior sulcus deepening, ptosis, upper and lower eyelid entropion, upper and lower eyelid ectropion, upper and lower eyelid retraction, and upper and lower eyelid socket contracture were investigated. RESULTS: For those patients who underwent evisceration, the most common clinical manifestations of the eyelid were superior sulcus deepening and ptosis (35%, respectively), whereas lower eyelid entropion and lower eyelid retraction were the second most common manifestations (25%, respectively). Among those patients who underwent enucleation, the most common eyelid changes were lower eyelid entropion (45.5%), and ptosis and lower eyelid socket contracture were the second most common alterations (36.4%, respectively). Finally, superior sulcus deepening, upper eyelid entropion, and lower eyelid retraction occurred in 27.3% of patients, respectively. CONCLUSIONS: Upper eyelid ptosis, superior sulcus deepening, and lower eyelid entropion and retraction were the most common clinical manifestations in patients wearing ocular prostheses. When following up with patients with ocular prostheses, it is important to check these eyelid changes and consider making appropriate corrections.

Lower eyelid involutional entropion following cataract surgery.

OBJECTIVES: To determine whether cataract surgery is associated with an increased risk of subsequent lower eyelid entropion and evaluate potential associated factors. METHODS: This retrospective cohort study included consecutive patients undergoing first eye cataract surgery over a 10-year period at a single institution (n = 14,574). The fellow phakic eye served as control. Patient records were evaluated up until either the time of second eye cataract surgery or any other intraocular or adnexal surgery. The primary outcome was the rate of entropion repair in both the pseudophakic (exposed) group and the phakic control group. Groups were compared using relative risk and Kaplan-Meier analysis. Multivariate logistic regression was used to compare pre-specified characteristics of those patients that underwent entropion repair in their pseudophakic eye with those that did not. RESULTS: A fourfold higher relative risk of undergoing entropion repair was observed in eyes that had undergone cataract surgery compared with the fellow unoperated eye (95% confidence interval 1.6-9.8; P < 0.001) with an increased risk at all timepoints between 1 and 12 years according to Kaplan-Meier analysis (P = 0.001). Median time to entropion repair after cataract surgery was 58 months (range 3-124). Documented intraoperative patient factors such as patient or eye movement, eyelid squeezing, pain or anxiety were an independent risk factor for subsequent entropion (P < 0.0001). CONCLUSIONS: Cataract surgery is associated with an increased risk of subsequent lower eyelid entropion. Surgeons should be aware of this risk in the pre- and post-operative assessment of patients undergoing cataract surgery.

Lower eyelid entropion in thyroid eye disease.

PURPOSE: To report the clinical features, ultrasound biomicroscopic features, and management outcome in patients presenting with thyroid eye disease (TED) and lower eyelid entropion. METHODS: Retrospective interventional case review of patients with TED presenting with lower eyelid entropion over a 12-year period. RESULTS: Five patients (eight eyes) of a total of 1211 presented with lower eyelid entropion as one of the presenting signs of TED (0.41%). The average age was 28.8 years (18-39 years), and three patients were males. Three had systemic hyperthyroidism, and two were euthyroid. Four (80%) had bilateral TED, three had inactive disease, and two were active. The average Hertel exophthalmometry reading was 24.6 mm. All patients had upper lid retraction. Four (80%) had concomitant lower eyelid retraction. Entropion was medial in five and complete in three eyes. Symptomatic corneal epitheliopathy was noted in four eyes. UBM was performed in four eyes which showed a thickened middle lamella. In four eyes (three patients), the entropion was managed conservatively as the patient was not contemplating surgery for proptosis. In the remaining four eyes (two patients) orbital decompression was performed and the lower eyelid retractor release corrected the symptomatic entropion. The average follow-up was 11.6 months (range 1-30). CONCLUSION: Lower eyelid entropion is a rare presenting sign in TED. The mechanism is multifactorial and could be caused by the thickened and fibrosed lower lid retractors, as demonstrated by UBM. Young age and globe projection may play a role. Decompression approaches that involve lower lid retractor release correct the entropion.

Lower eyelid malposition following repair of complex orbitofacial trauma.

PURPOSE: To compare the incidence of lower eyelid malposition following repair of isolated orbital floor fractures with that of complex orbitofacial fractures (defined as multi-wall fractures or prior orbital fracture repairs requiring revision) by oculofacial plastic surgeons via a transconjunctival or swinging eyelid approach. METHODS: Retrospective review of 175 patients who underwent surgical repair of orbital fractures at our institution. The primary outcomes were the occurrence of lower eyelid malposition (ectropion, entropion, and eyelid retraction) and the need for subsequent surgical correction. RESULTS: Of 95 patients with isolated orbital floor fractures, 4 developed eyelid malposition (4.2%), 1 of which required surgical repair (1.1%). Of 80 patients with complex orbitofacial fractures (48 multi-wall fractures, 32 secondary revisions), 10 had pre-operative eyelid malposition and were excluded from further analysis. Fourteen of the remaining 70 patients developed postoperative eyelid malposition (20%), 3 of which required surgical repair (4.3%). The difference in the occurrence of eyelid malposition between groups was statistically significant (p = .001), but the difference in rates of those requiring subsequent repair was not (p = .182). There was no statistically significant difference in the occurrence of eyelid malposition when considering other surgical factors including lateral canthotomy, conjunctival closure, implant material, or anterior rim screws. CONCLUSIONS: The incidence of lower eyelid malposition following orbital fracture repair via a fornix-based approach was significantly higher for the repair of complex orbitofacial fractures than for isolated floor fractures. However, very few patients in either group required surgical repair for eyelid malposition. Surgical factors including implant material did not affect outcomes.

The upper eyelid levator weakening procedure for the correction of severe cicatricial entropion caused by trachoma.

BACKGROUND: Trachoma-induced upper eyelid cicatricial entropion (UCE) is a common and challenging eyelid disease. Surgeons have developed various surgical techniques to address UCE in the world. However, there are few reports about surgery for Chinese patients. Our study aims to evaluate the esthetic and functional outcomes of correction of trachoma-induced UCE using upper eyelid levator weakening combined with tarsotomy and an anterior lamella recession procedure in China. METHODS: A retrospective non-comparative study was performed in the Ophthalmology Department of Second Affiliated Hospital of Guangzhou University of Chinese Medicine from January 2017 to December 2019. Thirty-six patients (56 eyelids) with severe UCE caused by trachoma, defined as shortening and retraction of the posterior lamella, were collected. Upper eyelid levator weakening combined with tarsotomy and an anterior lamella recession procedure was done on all patients. The mean follow-up time was 11.6±2.71 months (range, 6-24 months). RESULTS: Among the patients, 48 eyelids (85.7%) achieved complete success. Recurrence was observed in 4 eyelids (7.1%). No other severe complications occurred. CONCLUSIONS: This case series showed that upper eyelid levator weakening combined with tarsotomy and an anterior lamella recession procedure is a safe and effective treatment for severe trachoma-induced UCE in Chinese patients.

A theory of unified pathogenesis for tarsal ectropion and involutional entropion.

Tarsal ectropion and involutional entropion are two frequent age-related lower eyelid malpositions with a mirrored clinical presentation. The recent anatomical confirmation of two layers of lower eyelid retractors makes it possible to conceive of the role of each of these layers in the stability of the two palpebral lamellae and their involvement in the pathogenesis of these two malpositions. This study proposes a theory of common pathogenesis involving an involutional change in only the lower lid retractors, leading to the description of two new clinical-anatomical entities.

Shallow periorbital injection of triamcinolone acetonide in treatment of lower eyelid entropion related to thyroid-associated ophthalmopathy: Three case reports.

INTRODUCTION: Entropion and secondary trichiasis can lead to irritative symptoms and essential damage of ocular surface. There is no literature reporting the lower eyelid entropion related to thyroid-associated ophthalmopathy (TAO), let alone the treatment. Treatment based on etiology may yield effective and sustained results. We report 3 case reports of lower eyelid entropion associated with TAO, and provide an effective and persistent alternative to cure this entropion via the administration of shallow periorbital injections of triamcinolone acetonide (TA). PATIENT CONCERNS: Three patients presented irritative symptoms of ocular surface and diplopia. DIAGNOSIS: According to thyroid dysfunction, physical examination, and imaging findings of extraocular muscle involvement, TAO and unilateral or bilateral lower eyelid entropion were diagnosed. INTERVENTIONS: We administered shallow periorbital injections of TA to the affected eye at 3- to 4-week intervals depending on clinical response. OUTCOMES: All patients underwent complete correction of the lower eyelid entropion and no recurrence was found. CONCLUSION: The cause of lower eyelid entropion related to TAO might be the immunoinflammatory reaction of the lower eyelid retractors, enhancing the traction of pulling the lower eyelid inferoposteriorly. This condition can be treated with shallow periorbital injections of TA. Histopathological evidence and randomized controlled trials are expected to confirm our hypothesis.

A conjunctival-sparing surgical technique for lower eyelid cicatricial entropion repair in ocular cicatricial pemphigoid.

Purpose: To present five cases of lower eyelid cicatricial entropion secondary to ocular cicatricial pemphigoid (OCP) successfully repaired with a conjunctival-sparing surgical technique.Methods: The records of one surgeon (SKF) were reviewed to identify patients with lower eyelid cicatricial entropion secondary to OCP who underwent repair with a conjunctival-sparing technique between September 1, 2016 and October 18, 2017. The medical records were reviewed and extracted data included: age, gender, past medical history, current medical and OCP status, clinical examination, details of entropion repair surgery, and outcome.Results: Five patients (three female, two male) were included with ages ranging from 44 to 93 years. All had biopsy proven OCP, which was in remission at the time of surgery, and all were currently receiving immunomodulatory medications. All patients were symptomatic from cicatricial entropion secondary to OCP and underwent successful lower eyelid entropion repair with a conjunctival-sparing technique described herein, involving infraciliary rotation with suture fixation of the orbicularis muscle to the tarsus. Other contributing mechanisms of eyelid malposition including horizontal eyelid laxity and orbicularis oculi override were addressed simultaneously with lateral tarsal plication or orbicularis muscle debulking, resulting in 100% anatomic success and relief of symptoms with no cases of OCP reactivation, and with good durability with an average 13.9 months follow up (range 6.5-22 months).Conclusions: Successful repair of lower eyelid cicatricial entropion in immunomodulated patients with OCP can be achieved without disease reactivation using a surgical technique that spares the conjunctiva and lower eyelid retractors.

Subtle Eyelid Retraction after Lower Blepharoplasty.

BACKGROUND: Lower blepharoplasty is one of the commonest cosmetic surgeries performed in the United States. The delicate balance of the lower eyelid may be detrimentally altered in lower blepharoplasty, leading to lower eyelid retraction with the attendant functional and cosmetic consequences. Marginal reflex distance-2 (MRD2) is an insensitive measure for subtle lower eyelid retraction, and the MRD2 at the lateral limbus (MRD2limbus) and tarsal marginal show (TMS) may be more sensitive in identifying eyelid retraction and eversion. METHODS: This is a cohort study of consecutive patients undergoing lower blepharoplasty with skin pinch removal, laser resurfacing, or skin pinch removal with prophylactic lateral canthal resuspension. Mean follow-up was 22.1 weeks. RESULTS: There was no significant difference in MRD2 after surgery after either laser resurfacing, skin pinch, or skin pinch with canthoplasty, either after surgery or between groups. MRD2limbus was significantly increased after surgery in the skin pinch only group (p < 0.05). There was a significant difference in postoperative MRD2limbus in the skin pinch with canthoplasty group compared to that in the skin pinch only group (p < 0.05). TMS was significantly increased after both laser resurfacing (p < 0.001) and skin pinch only (p < 0.05), and both postoperative groups demonstrated significantly increased TMS compared to skin pinch with canthoplasty (p < 0.05). CONCLUSIONS: MRD2limbus and TMS are more sensitive markers for lower eyelid retraction than MRD2. Subtle eyelid retraction and eversion occur after anterior lamellar work and can be prevented with prophylactic lateral canthal resuspension.

Entrópio palpebral severo pós cirurgia de correção de ptose / Severe eyelid entropion after ptosis correction surgery

Resumo Paciente de 69 anos evoluiu com entrópio palpebral severo após cirurgia de correção de ptose palpebral pela técnica de reinserção da aponeurose do músculo levantador da pálpebra superior. Realizada reintervenção onde foi diagnosticado uma fixação da aponeurose em uma posição muito inferior e feita uma refixacação no 1/3 superior do tarso, com melhora do quadro funcional e estético com boa satisfação da paciente. Devido às suturas em topografia mais inferior, o tarso adquire forma de U em decorrência do dobramento no centro da placa tarsal e da rotação inferior da sua metade superior resultando no entrópio. Este caso ressalta a importância do cuidado quanto a localização da inserção da aponeurose do MLPS, principalmente nos paciente idosos, como forma de evitar o encurvamento vertical do tarso.

Abstract Sixty-nine (69) year old patient with severe upper eyelid entropion following surgical correction of ptosis through levator muscle aponeurosis advancement and reinsertion. The aponeurosis advancement appeared to be much lower than typically intended, and surgical repair was performed via aponeurosis re-fixation into the superior 1/3 of the tarsal plate, with subsequent improvement in the aesthetic and functional outcome, and a satisfied patient. Due to the inferiorly located tarsal sutures, the tarsal plate acquires a U-shape due to a central fold and an inferior rotation of its upper half, resulting in entropion formation. This case highlights the importance of taking great care when advancing the levator muscle in ptosis due to levator aponeurosis dehiscence, particularly in elderly patients, so as to avoid vertically folding the superior tarsal plate.

Involutional lower eyelid entropion: causative factors and therapeutic management.

PURPOSE: To summarize proposed causative factors and the outcomes of surgical practices for involutional lower eyelid entropion. METHODS: We reviewed the literature on proposed causative factors and the outcomes of surgical practices for involutional lower eyelid entropion, searched on PubMed. RESULTS: Vertical and horizontal laxities of the lower eyelid, and overriding of the preseptal orbicularis oculi muscle onto the pretarsal orbicularis oculi muscle have been proposed as the major causes of involutional lower eyelid entropion. Treatment procedures have been developed over the years to address one or more of these causative factors. CONCLUSIONS: Various causative factors and treatment procedures have been advocated to explain and correct involutional lower eyelid entropion. The appropriate procedure is chosen according to the patient's condition, such as the presence of vertical laxity, horizontal laxity, and orbicularis oculi muscle overriding. A combination of these procedures to correct multiple factors further decreases the recurrence rate.

Deepening Fornix Technique Using Central Split-Medium Thickness Skin Graft to Treat Contracted Anophthalmic Sockets.

PURPOSE: The aim of thhis study was to present the outcomes of postauricular split-medium thickness skin graft (SMTSG) to treat anophthalmic sockets with contracted fornices. METHODS: This case series enrolled patients with grade 2 or 3 anophthalmic sockets between 2015 and 2016. Data were collected on patient demographics, objective and subjective parameters preoperatively and 180 days postoperatively. Success of the surgery was graded on the height of the graft, the depth of the superior and inferior fornices, and presence/abscence of lagophthalmos, entropion, and ability to retain an external prosthesis. RESULTS: Eighteen patients were enrolled with a mean age of 35.9 ±â€Š18 years. The median height of the graft was 22 mm (25% quartile = 18.75) when removed and 20 mm (25% quartile = 16) postoperatively. The median depth of the superior fornix was 6.5 mm (25% quartile = 4.5 mm) preoperatively and 10 mm (25% quartile = 8 mm) postoperatively (P = 0.5). The median inferior fornix depth was 7 mm (25% quartile = 3.5 mm) preoperatively and 8 mm (25% quartile = 5 mm) (P = 0.27) postoperatively. Preoperatively, there were 13 (72.2%) patients with lagophthalmos, 10 (44.4%) with entropion, 3 (37.5%) with poor prosthesis retention, and 5 (62.5%) who were unable to retain the prosthesis. Postoperatively, 7 (38.9%) patients had lagophthamos, 1 (5.6%) had entropion, and all the patients could retain the prosthesis. None of the sockets had a foul odor postoperatively. CONCLUSIONS: Postauricular SMTSG achieves successful outcomes for the treatment of contracted anophthalmic sockets, reshaping the anterior socket surface and deepening the fornices.