Retractor Plication versus Retractor Plication and Lateral Tarsal Strip for Eyelid Entropion Correction

Abstract

Purpose:

Involutional entropion is a common lower lid malposition. Addressing both the horizontal and the vertical lower eyelid laxity in patients with involutional entropion seems to have a more long-lasting effect on maintaining lower eyelid stability; however, there is some disagreement as to which approach is the best surgical intervention. The aim of this study was to determine differences in the surgical outcome of Jones retractor plication (JRP) alone versus Jones retractor plication with a lateral tarsal strip (JRP + LTS) for the treatment of involutional entropion.

Methods:

A retrospective case series comparison of 118 patients with primary involutional lower eyelid entropion was performed. Jones retractor plication alone was performed in 61 patients, and JRP + LTS in 57 patients. The baseline characteristics of the 2 groups were similar. Patients were retrospectively evaluated from a retrospective case-note review 3 weeks and 6, 12, 18, and 24 months postoperatively. Successful surgery was defined as a normal eyelid position.

Results:

A total of 115 patients fulfilled the inclusion criteria, 60 in the JRP group and 55 in the JRP + LTS group. Ten patients (16.5%) in the JRP group and 2 patients (3.5%) in the JRP + LTS group had a recurrence of the entropion at or before their 24-month follow-up visit (p = 0.03).

Conclusions:

These data provide strong evidence that the success rate at 24 months is higher in patients treated with the JRP + LTS procedure compared with JRP alone.

Keywords

Entropion Eyelid laxity Jones retractor plication Lateral tarsal strip Lower eyelid

Introduction

Involutional entropion is a common lower lid malposition. Ocular discomfort and epiphora are the most common findings in patients with entropion. Corneal ulceration is the most sight-threatening complication with the potential development of microbial keratitis and a subsequent risk of vision loss (1). The etiology has been hypothesized to be a combination of degenerative tissue changes including horizontal lid laxity (1), vertical lid laxity with attenuation or disinsertion of the lower lid retractors (2-4), and over-riding of the preseptal orbicularis muscle (5).

Several surgical procedures have been described for the treatment of involutional lower eyelid entropion that address one or more of these anatomic factors (4-10). The Jones retractor plication (JRP) is a relatively simple technique that addresses the vertical lid laxity by tightening the inferior retractors and is advocated by many surgeons because it has a higher success rate compared with other procedures (11).

Addressing both the horizontal and the vertical lower eyelid laxity in patients with involutional entropion seems to have a more long-lasting effect on maintaining lower eyelid stability (12). Some disagreement exists as to which approach is the best surgical intervention for patients with lower eyelid entropion, and few adequately powered, comparative trials have been conducted to date that have demonstrated the superiority of a single technique.

We conducted a retrospective case series comparison assessing the efficacy of JRP combined with horizontal eyelid shortening by the lateral tarsal strip (LTS) procedure compared with JRP alone for the treatment of involutional entropion.

Materials and Methods

Patients

This study was conducted at the Eye Clinic of the University of Milan, San Giuseppe Hospital, Milan, Italy, was approved by the local ethics committee, and adhered to the tenets of the Declaration of Helsinki. From a retrospective case-note review of patients operated on for involutional lower eyelid entropion at San Giuseppe Hospital, we selected all the JRP + LTS procedures and all the JRP alone procedures meeting the inclusion criteria. All participants reviewed and signed the informed consent for this retrospective study. The JRP alone procedures were performed between November 2010 and April 2011. From May 2011 to December 2012, the same surgeon chose to perform all operations with the JRP + LTS technique based on the advantages of the combined techniques (12).

Exclusion criteria included a history of previous lower lid surgery and excessive horizontal eyelid laxity exceeding 13 mm. Horizontal eyelid laxity was determined using the pinch test. This test is performed by grasping the skin over the central lower lid tarsal plate and pulling the lower lid away from the globe. The distance between the globe and the posterior aspect of the lower lid is then measured and recorded as the horizontal eyelid laxity measurement (13). For patients with bilateral disease, only the first eyelid operated was included in the analysis.

From a retrospective case-note review, follow-up visits scheduled 3 weeks and 6, 12, 18, and 24 months after surgery were reviewed and included in the analysis. All patients had a minimum follow-up of 24 months to ensure that late failures were detected. All procedures were performed under local anesthesia by a single expert ophthalmic plastic surgeon (S.R.).

The commonly used postoperative regimen was amoxicillin 2 g/day for 6 days PO and tobramycin 3 mg/mL and dexamethasone 1 mg/mL eyedrops fixed combination 4 times a day for 2 weeks for both procedures.

Outcomes

The main outcome measure was the entropion recurrence rate of JRP + LTS and LTS. A secondary outcome was the incidence of early and long-term complications.

Statistical Methods and Sample Size

Power calculations revealed that 55 patients were required per treatment group in order to have 90% power to detect a significant difference between the 14.7% entropion recurrence rate reported by Altieri et al for JRP alone (14) and the 2% entropion recurrence rate reported by Barnes et al for LTS and everting sutures (15). To our knowledge, no study has been performed that analyzed the success rate of JRP + LTS; therefore, we considered the Barnes et al study to be the closest appropriate study for the sample size calculation. A total of 118 patients were enrolled in the study. Fisher exact test was used for statistical analysis.

Surgical Methods

Surgery was performed under local anesthesia in all patients. Local anesthesia included tetracaine eyedrops in the conjunctival sac and subcutaneous infiltration of the lower eyelid with equal parts by volume of 2% lidocaine containing 1:200,000 epinephrine and 0.5% bupivacaine. For JRP + LTS, the lateral canthus was also infiltrated down to the periosteum along with the lateral third of the upper eyelid.

Jones retractor plication. The skin and superficial fascia were incised along the inferior border of the tarsus of the lower eyelid, starting at the junction of the inner and middle one-third of the eyelid and extending laterally just beyond the lateral canthus following the contour of the lid margin. The skin was dissected along the lower border of the incision from the orbicularis muscle to just above the orbital rim. Next, the orbicularis muscle was grasped centrally, just below the lower border of the tarsus, and incised by sharp dissection. Through this opening, scissors were passed into the suborbicular space, dissecting it medially and laterally. The orbicularis was cut horizontally at the lower border of the tarsus from the medial to the lateral side, separating the septal and tarsal orbicularis. The preseptal orbicularis was separated from the orbital septum over the entire length of the incision inferiorly for approximately 12 mm. The orbital fat was exposed and part of it was removed. A 4-0 polyglactin suture was placed through the skin, then the retractors about 8 mm below the tarsus, through the inferior border of the tarsus, and then the superior border of the skin. Skin closure was performed with interrupted 6-0 polyglactin suture.

Jones retractor plication and lateral tarsal strip. After the JRP procedure was performed as described above, a lateral canthotomy and inferior cantholysis were initially performed. A “tarsal strip” was fashioned from the lateral lower eyelid by stripping the superior mucocutaneous junction tissue, debriding conjunctival epithelium posteriorly, excising the anterior lamella, and making a linear incision inferiorly to create a “tendon” of the tarsal plate. The length of the fashioned tendon was determined by assessing the desired tension required to tighten the lower eyelid. The tarsal strip was attached to the internal lateral orbital rim with a double-armed 5-0 polyglactin suture by creating a slipknot at the tendon and passing the 2 suture ends through the internal orbital portion of the lateral orbital rim periosteum. Lateral canthal reformation was achieved with a single buried 6-0 polyglactin suture. Deep buried 6-0 polyglactin suture was used to close the lateral canthal orbicularis muscle followed by skin closure with interrupted 7-0 polyglactin suture.

Results

Of 118 patients reviewed, the JPR technique was performed in 61 patients and the JPR + LTS in 57. Among these patients, 115 patients fulfilled the inclusion criteria and were included in the study (mean age 75 years, range 58-91). Three patients had incomplete follow-up (1 died before the 18-month follow-up and 2 were lost to follow-up) and were excluded from the analysis. Results were available for 115 patients, 60 in the JRP group and 55 in the JRP + LTS group. Both the JRP and JRP + LTS groups were similar with respect to age, sex, and eye operated (Tab. I; sex, Fisher exact test 0.85; laterality, Fisher exact test 0.85).

Table I

PATIENT POPULATION CHARACTERISTICS

	JRP	JRP + LTS
Age, y, mean (SD)	74 (5.5)	75 (5.2)
Male	31	27
Female	29	28
Right eye	27	26
Left eye	33	29

JRP = Jones retractor plication; LTS = lateral tarsal strip.

Primary Outcome

Ten patients (16.5%) in the JRP group and 2 patients (3.5%) in the JRP + LTS group had a recurrence of entropion at or before the 24-month follow-up visit (p = 0.03). In the JRP group, 4 patients (6.7%) had a recurrence of entropion at the 6-month follow-up visit, 4 patients (6.7%) had a recurrence at the 12-month follow-up visit, and 2 patients (3.3%) had a recurrence at the 18-month follow-up visit. In the JRP + LTS group, 1 patient (1.8%) had a recurrence of entropion at the 6-month follow-up visit and 1 patient (1.8%) had a recurrence at the 12-month follow-up visit. Figure 1 shows the Kaplan-Meier plot of the cumulative probability of recurrence in the 2 groups. Two cases of ectropion occurred in the JPR group and required surgical correction.

Fig. 1

Kaplan-Meier plot of the cumulative probability of recurrence in the Jones retractor plication (JRP) and JRP + lateral tarsal strip (LTS) groups.

Secondary Outcome

No serious complications occurred in either group. In the JRP + LTS group, 1 patient (1.8%) had suture granulomas at the lateral canthotomy that required re-exploration and resuturing. No complications occurred in the JRP group during the follow-up.

Discussion

To our knowledge, this is the first study comparing the efficacy of JRP and JRP + LTS for the treatment of involutional entropion. Numerous surgical techniques have been described to correct involutional entropion (16). The large number of procedures suggests that the pathogenesis of involutional entropion is multifactorial and that no one technique is entirely satisfactory. The goal of the surgery should be to treat the underlying pathogenic mechanism: horizontal lid laxity, vertical lid laxity with attenuation or disinsertion of the lower lid retractors, and overriding of preseptal orbicularis muscle. Although correction of a single pathogenic factor may be successful in some patients who have a predominant involutional change responsible for the entropion, a review of published reports suggests that correction of at least 2 of these 3 involutional changes confers a higher long-term success rate (Tab. II) (5, 7, 10, 16-33). The recurrence rate ranges from 0% to 17%, with variable lengths of follow-up. Techniques addressing all 3 factors responsible for involutional entropion have an even lower recurrence rate (0%-5%) (7, 10, 16, 25-33).

Table II

COMPARISON OF PUBLISHED TECHNIQUES ADDRESSING THE PATHOGENIC FACTORS CAUSING ENTROPION

Author	Technique	Factor addressed	No. of cases	Follow-up, mo	Recurrence rate, %
Saunders	“Corncrib” wedge resection	Horizontal laxity with/without overriding	58	17	3
Hill	Modified Wheeler II	Horizontal laxity with overriding	26	>6	17
Hecht	“Bowlegs” pentagonal wedge resection	Horizontal laxity with overriding	22	Not reported	0
Corin	Orbicularis resection with LTS	Horizontal laxity with overriding	21	3-36	0
Hurwitz	Modifies Bick or Fox	Overriding with/without horizontal laxity	90	>3	3
Dryden	Retractor attenuation repair	Retractor attenuation with overriding	12	4-17	16
Iliff	Fornix suture	Retractor attenuation with overriding	22	>12	9
Hornblass	Variable	Variable	129	>6	16
Boboridis	Retractor plication	Retractor disinsertion	37	>6	5
Boboridis	Wies procedure	Retractor disinsertion	65	>6	17
Danks	Eyelid tightening	Horizontal laxity	180	8	1
Danks	No lid shortening	Variable	133	5	8
Dresner	Retractor reinsertion with LTS	Horizontal laxity, vertical laxity, overriding	23	9-18	0
Nowinsky	Orbicularis extirpation with retractor reinsertion	Horizontal laxity, vertical laxity, overriding	50	15-63	Not reported
Dortzbach	Retractor reinsertion with horizontal tightening	Horizontal laxity, vertical laxity, overriding	38	6-78	0
Hsu	Orbicularis fixation with LTS with retractor tuck	Horizontal laxity, vertical laxity, overriding	112	6-36	0
Carroll	Retractor tuck with resect anterior lamella with LTS	Horizontal laxity, vertical laxity, overriding	127	33	0
Jackson	Retractor imbrication with wedge resection	Horizontal laxity, vertical laxity, overriding	28	8-48	0
Schaeffer	Retractor imbrication with LCT tuck	Horizontal laxity, vertical laxity, overriding	100	24	1
Wesley	Retractor reinsertion with LTS	Horizontal laxity, vertical laxity, overriding	26	6-32	0
Allen	Retractor reinsertion with wedge resection	Horizontal laxity, vertical laxity, overriding	46	15-42	0
Hedin	Retractor reinsertion with wedge resection	Horizontal laxity, vertical laxity, overriding	45	7-53	0
Rainin	Fornix suture with wedge resection	Horizontal laxity, vertical laxity, overriding	20	3-54	5
Mauriello	Base down triangle and inverted T closure	Horizontal laxity, vertical laxity, overriding	63	7-100	0

LCT = lateral canthal tendon; LTS = lateral tarsal strip.

In order to vertically stabilize the eyelid, the reinsertion of the lower lid retractor was obtained using the JPR technique. Although this procedure does not directly address the issue of orbicularis override, the skin incision into the anterior lamella will invariably create a cicatricial barrier between the lamellae that minimizes the vertical overriding of the preseptal orbicularis (34). Furthermore, direct retractor reinsertion offers the advantage of an open survey of the lower eyelid pathology and the opportunity to remove preaponeurotic fat and redundant skin.

The Wies procedure (35), in which a full-thickness horizontal lid split with everting sutures is used to indirectly engage the retractors, has a relatively high rate of recurrence (17%) (36). Even Wies reports (37) a 10% recurrence rate, and a high rate of overcorrection is a well-recognized complication of this procedure (38).

Several procedures have been described to tighten the lower eyelid horizontally (39, 40), by lateral tarsal strip procedure (6), full-thickness partial eyelid resection (20, 21, 25, 26, 41), or tightening the inferior lateral canthal tendon (42). We prefer the lateral tarsal strip procedure because it addresses the underlying pathology of lateral canthal tendon laxity. This procedure permits preservation of the almond shape configuration of the lateral canthal angle, avoiding phimosis or eyelid notching.

In our study, JRP + LTS was more effective than JRP for correcting involutional entropion with a lower recurrence rate. Lateral tarsal strip alone was not investigated in our study, and determining whether LTS alone is as effective as JRP + LTS needs to be clarified in future randomized prospective studies. The recurrence rate in JRP + LTS in our study was 3.5%, and previous studies of LTS alone had a recurrence rate of 14% to 22% (34, 43), suggesting that the combined procedure may be more efficacious. Difference in the follow-up time between the 2 groups could be considered a weakness of this study; nevertheless, this difference does not bias the results as failures occurred at a fairly early stage based on the survival curve.

In conclusion, this is the first study comparing the outcome of JPR + LTS versus JPR alone. Both techniques were found to be safe without serious complications during the follow-up. Our data support the notion that addressing both the horizontal and the vertical lower eyelid laxity in patients with involutional entropion seems to have a more long-lasting effect on maintaining lower eyelid stability.

Footnotes

Financial Support: No financial support was received for this submission.

Conflict of Interest Statement: None of the authors has conflict of interest with this submission.

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