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Wedge resection of the tarsal plate combined with the modified Hotz procedure for correction of involutional lower eyelid entropion
Wedge resection of the tarsal plate combined with the modified Hotz procedure for correction of involutional lower eyelid entropion Jianxin Ni, MD, Xi Chen, MD, Shengjie Zhou, MD, Jia Liu, MD, Ben Chen, MD ABSTRACT ● Objectives: To investigate the outcomes for correction of involutional lower eyelid entropion by wedge resection of the tarsus combined with the modified Hotz procedure. Design: Retrospective study. Participants: Patients with lower eyelid involutional entropion that was surgically repaired by wedge resection of the tarsal plate combined with the modified Hotz procedure. Methods: In a consecutive series of 43 patients with involutional lower eyelid entropion, wedge resection combined with the modified Hotz procedure was performed with an average follow-up period of 29.6 months (range, 6–62 months). Results: Among the patients, 93% had an excellent outcome within the follow-up period. For one patient, the outcome of both eyes was poor. For another patient, incision dehiscence of the eyelid margin in one eye occurred after the stitches were removed. The incision was sutured again, and it healed well. One patient complained of foreign body sensation in one eye after removal of the skin stitches. The complaint was resolved after wearing a corneal contact lens. No other significant complications occurred. Conclusions: In our clinic, tarsal plate wedge resection combined with the modified Hotz procedure has been highly effective for correction of involutional lower eyelid entropion. Although this approach does not directly address lateral canthal tendon laxity, it does preserve the eyelid in case there is a future need for reconstruction due to ocular surface disease or trauma. Thus, wedge resection of the tarsal plate combined with modified Hotz procedure is a safe and effective method for involutional lower eyelid entropion.
Involutional lower eyelid entropion is a very common eyelid malposition seen in general ophthalmic practice, and the morbidity of this condition increases with age. It is characterized by an inward rotation of the lower eyelid margin against the globe, resulting in ocular surface irritations such as foreign body sensation, epiphora, and photophobia. The etiology has been attributed to several pathological changes such as horizontal eyelid laxity due to decreased tension of the tarsus, medial canthal tendon, or lateral canthal tendon; dehiscence or disinsertion of the lower eyelid retractors; overriding of the preseptal orbicularis muscle over the pretarsal orbicularis muscle; squeezing of the upper eyelid; and enophthalmos after atrophy of orbital fat.1 Nonsurgical medical treatment, including botulinum toxin injection, eye drops, and ointment, are temporary and only alleviate the symptoms.2 In contrast, numerous surgical techniques have been described and the rate of recurrence is different for each.3–6 For well-chosen surgical repair procedures, the outcome is satisfactory and usually permanent. In this study, we used the modified Hotz procedure combined with wedge excision of the tarsus to treat this condition.
MATERIALS
AND
METHODS
This was a retrospective study of 43 consecutive patients with involutional lower eyelid entropion surgery
performed by one of the co-authors (J.N.) from March 2010 to January 2016. The inclusion criterion was based on the diagnosis of involutional lower eyelid entropion characterized by the inward turn of the lower eyelid and a history of symptoms of ocular irritation, such as eye rubbing, epiphora, and photophobia. Patients with any other etiology of entropion, such as congenital, cicatricial, paralytic, or spasmodic entropion, were excluded. Patients with trichiasis were also excluded. All procedures were performed at the Department of Ophthalmological Plastic Surgery, Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China. Each patient was followed for at least 6 months. Ethics review board approval was obtained from Affiliated Eye Hospital, Wenzhou Medical University, and written informed consent was obtained from every patient. Treatment of every patient complied with the tenets of the Declaration of Helsinki. During follow-up examinations, any ocular discomfort, including photophobia, epiphora, or foreign body sensation, was recorded. A provocation test for recurrent or latent entropion was performed by asking seated subjects to try their best to close their eyelids. Surgical outcomes were evaluated according to the shape of the lower eyelid and touching of the lashes with the ocular surface (lashocular touching). Surgical outcomes were graded as “excellent” when the eyelid was in the normal anatomic
& 2018 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jcjo.2018.02.010 ISSN 0008-4182/17 CAN J OPHTHALMOL — VOL. ], NO. ], ] 2018
1
Correction of involutional lower eyelid entropion—Ni et al. position and there was no lash-ocular touching, “fair” when the inward turn of eyelid was improved and there were 5 or fewer lash-ocular surface touchings, and “poor” when there were more than 5 lash-ocular surface touchings or ectropion developed. The outcomes of the lash-ocular touching were evaluated by 3 ophthalmologists who were blinded to the treatment of each patient and who were independent of this study.
Surgical technique
The procedure was performed under local anesthesia. The lower eyelid and lateral conjunctiva were infiltrated with 2.5 mL 2% lidocaine with 2.5 mL 0.75% bupivacaine containing 1:100 000 epinephrine. A transverse skin incision was made 2 mm below the lower eyelashes and extended about 1 cm laterally and inferiorly along the crow’s feet. Dissection was first performed subcutaneously in the tarsal plate region and then between the orbital septum and preseptal orbicularis muscle. The fusion of the capsulopalpebral fascia and orbital septum was exposed by pushing the orbital fat down. A small amount of orbital fat was removed if it protruded excessively. The pretarsal orbicularis muscle was then partially removed. Wedge resection of the tarsus. Two 5-0 silk traction sutures were placed through the eyelid margin in the lateral region of the eyelid approximately 1 cm apart. A wedge resection of the tarsus and, as necessary, a minimal resection of the pretarsal orbicularis muscle were performed. The amount excised was adjusted according to the degree of eyelid laxity and had minimal or no effect on the final tone or stability of the lower eyelid margin. The displaced ends of the tarsus were brought into proximity by pulling the traction sutures. The tarsal borders were approximated with one 5-0 Polydioxanone suture without malposition or twisting of the eyelid margins. The orbicularis oculi and the skin of the eyelid margin were then approximated (Fig. 1A).
Modified Hotz procedure. The lateral two thirds of the fusion of the capsulopalpebral fascia and orbital septum was anchored to the pretarsal orbicularis muscle with two 5-0 Polydioxanone sutures (Fig. 1B). The redundant skin and orbicularis muscle were marked and trimmed when the patient was asked to look straight ahead. A strip of the preseptal orbicularis muscle was excised if it was hyperplastic. The skin and eyelid margin were closed with interrupted 6-0 silk sutures. Moderate pressure was applied for at least 24 hours. The skin sutures were removed 6 to 7 days postoperatively.
RESULTS Fifty-four eyes of 43 patients underwent primary or recurrent involutional lower eyelid entropion repair. There were 20 males and 23 females with an average age of 70.5 years (range, 53–91 years) at the time of surgery. Of these patients, 11 cases were bilateral and 32 were unilateral. Three of the patients had recurrent entropion, and all others had primary involutional entropion. During the follow-up period, only 1 patient reported ocular discomfort that was similar to what they had experienced before treatment. The surgical outcomes of 42 patients were excellent over a mean follow-up period of 29.6 months (range, 6–62 months). Involutional entropion recurred in both eyes of 1 patient whose surgery was performed early in the series. There were 2 minor complications during the follow-up period. In one, incision dehiscence of the eyelid margin occurred after the stitches were removed. The incision was resutured, and it healed well. In the other, the patient reported foreign body sensation in 1 eye after the skin stitches were removed. The lateral margin of eyelid and globe were touching because of edema of the lateral eyelid margin. After wearing a contact lens for 2 weeks, the edema faded away (Fig. 2). No other significant complications occurred. Figure 3 shows a preoperative and
Fig. 1 — Wedge resection and modified Hotz procedure. A, Wedge resection of the tarsal plate. B, In the modified Hotz procedure, the tarsal plate was reapproximated, and the fused capsulopalpebral fascia and orbital septum was fixed to the pretarsal orbicularis muscle.
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CAN J OPHTHALMOL — VOL. ], NO. ], ] 2018
Correction of involutional lower eyelid entropion—Ni et al.
Fig. 2 — An 86-year-old female reported foreign body sensation of her right eye after the skin stitches were removed. The lateral margin of eyelid and globe were touching because of edema of lateral eyelid margin.
7-month postoperative photograph of a patient who underwent the repair surgery.
DISCUSSION Both the horizontal and vertical pathological changes of the lower eyelid in involutional entropion should be effectively addressed to avoid recurrence. These changes include decreased tension of the tarsus and the lateral and medial canthal tendons along with the lower eyelid retractors.1 Also contributing to the condition is the overlapping of the preseptal orbicularis muscle with the pretarsal orbicularis muscle.1 Scheepers et al. conducted a prospective randomized trial that compared the efficacy of everting sutures combined with a lateral tarsal strip with the efficacy of everting sutures alone in the treatment of involutional entropion.7 There was no recurrence during the 18-month follow-up of any of the patients with everting sutures
combined with a lateral tarsal strip. In contrast, 6 patients had recurrences after everting sutures alone. Lee et al. reported that simple posterior layer advancement of the lower eyelid retractors was enough for repair of involutional entropion in the absence of horizontal laxity.8 Horizontal laxity of the lower eyelid plays a very important role in development of involutional entropion. Many authors have proposed various procedures for eyelid shortening, including the tarsal strip procedure,4 tarsal wedge excision,9 lateral canthal tendon tuck,10 and transcanthal canthopexy.11 Of these, the tarsal strip procedure has been the most frequently performed for correcting horizontal laxity. Although horizontal laxity can be addressed more thoroughly by the tarsal strip procedure, abscesses or granulomas can occur at the lateral canthal region because of meibomian glands that remain within the strip. Moreover, the procedure is more time-consuming and complicated than others.12–14 Several simpler tarsal partial resection procedures have been described to correct horizontal laxity.15–19 These techniques have a very high rate of success with few complications during the follow-up period. Our technique is similar to the lateral resection procedure described by Leibovitch15 except that we did not excise the skin and the location was more medial. Many techniques have been described for correction of vertical laxity, which is mainly attributed to attenuation or disinsertion of the lower eyelid retractors.20–22 The modified Hotz procedure is simpler and easier to perform compared with posterior layer advancement of the lower eyelid retractor procedure8,11 or the Jones’ procedure.20 Moreover, in our patients, folding of the lower eyelid retractors was responsible for the vertical laxity, and inversion of the eyelid margin was also present. Therefore, we proposed that the modified Hotz procedure could be a very effective method for correcting both the vertical laxity and inverted eyelid margin. The preseptal orbicular muscle overlapping the pretarsal orbicular muscle and the eyelid margin aggravated the inverted rotation of the eyelid margin. Therefore, excision of a strip of the preseptal orbicular muscle was effective in avoiding recurrence as reported by others.23 In addition, excision of redundant skin in the transverse incision was invaluable in preventing entropion recurrence, and it provided a smoother and more aesthetically pleasing appearance of the lower eyelid.
CONCLUSIONS
Fig. 3 — A 53-year-old male with right lower eyelid involutional entropion. A, The slack and inverted right lower eyelid before operation. B, The corrected slack and inverted lower eyelid 7 months after the operation.
In our clinic, wedge resection of the tarsal plate combined with the modified Hotz procedure has been highly effective for correction of involutional lower eyelid entropion. Although this approach does not directly address lateral canthal tendon laxity, it does preserve the eyelid in case there is a future need for reconstruction due to ocular surface disease or trauma. Thus, wedge resection CAN J OPHTHALMOL — VOL. ], NO. ], ] 2018
3
Correction of involutional lower eyelid entropion—Ni et al. of the tarsal plate combined with modified Hotz procedure is a safe and effective method for involutional lower eyelid entropion. REFERENCES 1. Benger RS, Musch DC. A comparative study of eyelid parameters in involutional entropion. Ophthalmic Plast Reconstr Surg. 1989;5: 281-7. 2. Steel DH, Hoh HB, Harrad RA, Collins CR. Botulinum toxin for the temporary treatment of involutional lower lid entropion: a clinical and morphological study. Eye (Lond). 1997;11:472-5. 3. Jones LT, Reeh MJ, Wobig JL. Senile entropion. A new concept for correction. Am J Ophthalmol. 1972;74:327-9. 4. Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol. 1979;97:2192-6. 5. Quickert MH, Rathbun E. Suture repair of entropion. Arch Ophthalmol. 1971;85:304-5. 6. Khan SJ, Meyer DR. Transconjunctival lower eyelid involutional entropion repair: long-term follow-up and efficacy. Ophthalmology. 2002;109:2112-7. 7. Scheepers MA, Singh R, Ng J, et al. A randomized controlled trial comparing everting sutures with everting sutures and a lateral tarsal strip for involutional entropion. Ophthalmology. 2010;117:352-5. 8. Lee H, Takahashi Y, Ichinose A, Kakizaki H. Comparison of surgical outcomes between simple posterior layer advancement of lower eyelid retractors and combination with a lateral tarsal strip procedure for involutional entropion in a Japanese population. Br J Ophthalmol. 2014;98:1579-82. 9. Olali C, Burton V, Samalila E. Involutional lower eyelid entropion: combined Wheeler’s and Wedge resection of tarsal plate. West Afr J Med. 2010;29:117-9. 10. Schaefer AJ. Lateral canthal tendon tuck. Ophthalmology. 1979;86: 1879-82. 11. Ishida Y, Takahashi Y, Kakizaki H. Posterior layer advancement of lower eyelid retractors with transcanthal canthopexy for involutional lower eyelid entropion. Eye. 2016;30:1469-74. 12. Jordan DR, Anderson RL. The lateral tarsal strip revisited. The enhanced tarsal strip. Arch Ophthalmol. 1989;107:604-6. 13. Weber PJ, Popp JC, Wulc AE. Refinements of the tarsal strip procedure. Ophthalmic Surg. 1991;22:687-91.
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14. Hsuan J, Selva D. The use of a polyglactin suture in the lateral tarsal strip procedure. Am J Ophthalmol. 2004;138:588-91. 15. Leibovitch I. Lateral wedge resection: a simple technique for repairing involutional lower eyelid entropion. Dermatol Surg. 2010;36:1412-8. 16. Mauriello JA, Abdelsalam A. Modified corncrib (inverted T) procedure with Quickert suture for repair of involutional entropion. Ophthalmology. 1997;104:504-7. 17. Hedin A. Senile entropion−cure rate by retractor tightening and horizontal shortening. Acta Ophthalmol Scand. 1997;75:443-6. 18. Rainin EA. Senile entropion. Arch Ophthalmol. 1979;97:928-30. 19. Roberts MA, Baddeley P, Sinclair N, Lane CM. The lower lid diamond: a simple entropion repair to correct both horizontal and lower-lid retractor laxity. Ophthal Plast Reconstr Surg. 2012;28:44-6. 20. Boboridis K, Bunce C, Rose GE. A comparative study of two procedures for repair of involutional lower lid entropion. Ophthalmology. 2000;107:959-61. 21. Wright M, Bell D, Scott C, Leatherbarrow B. Everting suture correction of lower lid involutional entropion. Br J Ophthalmol. 1999;83:1060-3. 22. Asamura S, Kakizaki H, Shindou E, Itani Y, Isogai N. What is the best strategy for Asians with involutional entropion? J Craniofac Surg. 2014;25:972-5. 23. Marabotti A, Bedei A, Lanza G, Cariello A, Giannecchini I. Involutional entropion surgery: a modified technique. Ophthalmologica. 2001;215:169-73.
Footnotes and Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article. From the Department of Ophthalmological Plastic Surgery, Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China. Originally received May. 25, 2017. Final revision Feb. 7, 2018. Accepted Feb. 13, 2018. Correspondence to Jianxin Ni, MD, Department of Ophthalmological Plastic Surgery, Affiliated Eye Hospital, Wenzhou Medical University, 270 Xueyuan Road, Wenzhou, Zhejiang, Wenzhou 325000 China; [email protected]
Involutional lower eyelid entropion is a very common eyelid malposition seen in general ophthalmic practice, and the morbidity of this condition increases with age. It is characterized by an inward rotation of the lower eyelid margin against the globe, resulting in ocular surface irritations such as foreign body sensation, epiphora, and photophobia. The etiology has been attributed to several pathological changes such as horizontal eyelid laxity due to decreased tension of the tarsus, medial canthal tendon, or lateral canthal tendon; dehiscence or disinsertion of the lower eyelid retractors; overriding of the preseptal orbicularis muscle over the pretarsal orbicularis muscle; squeezing of the upper eyelid; and enophthalmos after atrophy of orbital fat.1 Nonsurgical medical treatment, including botulinum toxin injection, eye drops, and ointment, are temporary and only alleviate the symptoms.2 In contrast, numerous surgical techniques have been described and the rate of recurrence is different for each.3–6 For well-chosen surgical repair procedures, the outcome is satisfactory and usually permanent. In this study, we used the modified Hotz procedure combined with wedge excision of the tarsus to treat this condition.
MATERIALS
AND
METHODS
This was a retrospective study of 43 consecutive patients with involutional lower eyelid entropion surgery
performed by one of the co-authors (J.N.) from March 2010 to January 2016. The inclusion criterion was based on the diagnosis of involutional lower eyelid entropion characterized by the inward turn of the lower eyelid and a history of symptoms of ocular irritation, such as eye rubbing, epiphora, and photophobia. Patients with any other etiology of entropion, such as congenital, cicatricial, paralytic, or spasmodic entropion, were excluded. Patients with trichiasis were also excluded. All procedures were performed at the Department of Ophthalmological Plastic Surgery, Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China. Each patient was followed for at least 6 months. Ethics review board approval was obtained from Affiliated Eye Hospital, Wenzhou Medical University, and written informed consent was obtained from every patient. Treatment of every patient complied with the tenets of the Declaration of Helsinki. During follow-up examinations, any ocular discomfort, including photophobia, epiphora, or foreign body sensation, was recorded. A provocation test for recurrent or latent entropion was performed by asking seated subjects to try their best to close their eyelids. Surgical outcomes were evaluated according to the shape of the lower eyelid and touching of the lashes with the ocular surface (lashocular touching). Surgical outcomes were graded as “excellent” when the eyelid was in the normal anatomic
& 2018 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jcjo.2018.02.010 ISSN 0008-4182/17 CAN J OPHTHALMOL — VOL. ], NO. ], ] 2018
1
Correction of involutional lower eyelid entropion—Ni et al. position and there was no lash-ocular touching, “fair” when the inward turn of eyelid was improved and there were 5 or fewer lash-ocular surface touchings, and “poor” when there were more than 5 lash-ocular surface touchings or ectropion developed. The outcomes of the lash-ocular touching were evaluated by 3 ophthalmologists who were blinded to the treatment of each patient and who were independent of this study.
Surgical technique
The procedure was performed under local anesthesia. The lower eyelid and lateral conjunctiva were infiltrated with 2.5 mL 2% lidocaine with 2.5 mL 0.75% bupivacaine containing 1:100 000 epinephrine. A transverse skin incision was made 2 mm below the lower eyelashes and extended about 1 cm laterally and inferiorly along the crow’s feet. Dissection was first performed subcutaneously in the tarsal plate region and then between the orbital septum and preseptal orbicularis muscle. The fusion of the capsulopalpebral fascia and orbital septum was exposed by pushing the orbital fat down. A small amount of orbital fat was removed if it protruded excessively. The pretarsal orbicularis muscle was then partially removed. Wedge resection of the tarsus. Two 5-0 silk traction sutures were placed through the eyelid margin in the lateral region of the eyelid approximately 1 cm apart. A wedge resection of the tarsus and, as necessary, a minimal resection of the pretarsal orbicularis muscle were performed. The amount excised was adjusted according to the degree of eyelid laxity and had minimal or no effect on the final tone or stability of the lower eyelid margin. The displaced ends of the tarsus were brought into proximity by pulling the traction sutures. The tarsal borders were approximated with one 5-0 Polydioxanone suture without malposition or twisting of the eyelid margins. The orbicularis oculi and the skin of the eyelid margin were then approximated (Fig. 1A).
Modified Hotz procedure. The lateral two thirds of the fusion of the capsulopalpebral fascia and orbital septum was anchored to the pretarsal orbicularis muscle with two 5-0 Polydioxanone sutures (Fig. 1B). The redundant skin and orbicularis muscle were marked and trimmed when the patient was asked to look straight ahead. A strip of the preseptal orbicularis muscle was excised if it was hyperplastic. The skin and eyelid margin were closed with interrupted 6-0 silk sutures. Moderate pressure was applied for at least 24 hours. The skin sutures were removed 6 to 7 days postoperatively.
RESULTS Fifty-four eyes of 43 patients underwent primary or recurrent involutional lower eyelid entropion repair. There were 20 males and 23 females with an average age of 70.5 years (range, 53–91 years) at the time of surgery. Of these patients, 11 cases were bilateral and 32 were unilateral. Three of the patients had recurrent entropion, and all others had primary involutional entropion. During the follow-up period, only 1 patient reported ocular discomfort that was similar to what they had experienced before treatment. The surgical outcomes of 42 patients were excellent over a mean follow-up period of 29.6 months (range, 6–62 months). Involutional entropion recurred in both eyes of 1 patient whose surgery was performed early in the series. There were 2 minor complications during the follow-up period. In one, incision dehiscence of the eyelid margin occurred after the stitches were removed. The incision was resutured, and it healed well. In the other, the patient reported foreign body sensation in 1 eye after the skin stitches were removed. The lateral margin of eyelid and globe were touching because of edema of the lateral eyelid margin. After wearing a contact lens for 2 weeks, the edema faded away (Fig. 2). No other significant complications occurred. Figure 3 shows a preoperative and
Fig. 1 — Wedge resection and modified Hotz procedure. A, Wedge resection of the tarsal plate. B, In the modified Hotz procedure, the tarsal plate was reapproximated, and the fused capsulopalpebral fascia and orbital septum was fixed to the pretarsal orbicularis muscle.
2
CAN J OPHTHALMOL — VOL. ], NO. ], ] 2018
Correction of involutional lower eyelid entropion—Ni et al.
Fig. 2 — An 86-year-old female reported foreign body sensation of her right eye after the skin stitches were removed. The lateral margin of eyelid and globe were touching because of edema of lateral eyelid margin.
7-month postoperative photograph of a patient who underwent the repair surgery.
DISCUSSION Both the horizontal and vertical pathological changes of the lower eyelid in involutional entropion should be effectively addressed to avoid recurrence. These changes include decreased tension of the tarsus and the lateral and medial canthal tendons along with the lower eyelid retractors.1 Also contributing to the condition is the overlapping of the preseptal orbicularis muscle with the pretarsal orbicularis muscle.1 Scheepers et al. conducted a prospective randomized trial that compared the efficacy of everting sutures combined with a lateral tarsal strip with the efficacy of everting sutures alone in the treatment of involutional entropion.7 There was no recurrence during the 18-month follow-up of any of the patients with everting sutures
combined with a lateral tarsal strip. In contrast, 6 patients had recurrences after everting sutures alone. Lee et al. reported that simple posterior layer advancement of the lower eyelid retractors was enough for repair of involutional entropion in the absence of horizontal laxity.8 Horizontal laxity of the lower eyelid plays a very important role in development of involutional entropion. Many authors have proposed various procedures for eyelid shortening, including the tarsal strip procedure,4 tarsal wedge excision,9 lateral canthal tendon tuck,10 and transcanthal canthopexy.11 Of these, the tarsal strip procedure has been the most frequently performed for correcting horizontal laxity. Although horizontal laxity can be addressed more thoroughly by the tarsal strip procedure, abscesses or granulomas can occur at the lateral canthal region because of meibomian glands that remain within the strip. Moreover, the procedure is more time-consuming and complicated than others.12–14 Several simpler tarsal partial resection procedures have been described to correct horizontal laxity.15–19 These techniques have a very high rate of success with few complications during the follow-up period. Our technique is similar to the lateral resection procedure described by Leibovitch15 except that we did not excise the skin and the location was more medial. Many techniques have been described for correction of vertical laxity, which is mainly attributed to attenuation or disinsertion of the lower eyelid retractors.20–22 The modified Hotz procedure is simpler and easier to perform compared with posterior layer advancement of the lower eyelid retractor procedure8,11 or the Jones’ procedure.20 Moreover, in our patients, folding of the lower eyelid retractors was responsible for the vertical laxity, and inversion of the eyelid margin was also present. Therefore, we proposed that the modified Hotz procedure could be a very effective method for correcting both the vertical laxity and inverted eyelid margin. The preseptal orbicular muscle overlapping the pretarsal orbicular muscle and the eyelid margin aggravated the inverted rotation of the eyelid margin. Therefore, excision of a strip of the preseptal orbicular muscle was effective in avoiding recurrence as reported by others.23 In addition, excision of redundant skin in the transverse incision was invaluable in preventing entropion recurrence, and it provided a smoother and more aesthetically pleasing appearance of the lower eyelid.
CONCLUSIONS
Fig. 3 — A 53-year-old male with right lower eyelid involutional entropion. A, The slack and inverted right lower eyelid before operation. B, The corrected slack and inverted lower eyelid 7 months after the operation.
In our clinic, wedge resection of the tarsal plate combined with the modified Hotz procedure has been highly effective for correction of involutional lower eyelid entropion. Although this approach does not directly address lateral canthal tendon laxity, it does preserve the eyelid in case there is a future need for reconstruction due to ocular surface disease or trauma. Thus, wedge resection CAN J OPHTHALMOL — VOL. ], NO. ], ] 2018
3
Correction of involutional lower eyelid entropion—Ni et al. of the tarsal plate combined with modified Hotz procedure is a safe and effective method for involutional lower eyelid entropion. REFERENCES 1. Benger RS, Musch DC. A comparative study of eyelid parameters in involutional entropion. Ophthalmic Plast Reconstr Surg. 1989;5: 281-7. 2. Steel DH, Hoh HB, Harrad RA, Collins CR. Botulinum toxin for the temporary treatment of involutional lower lid entropion: a clinical and morphological study. Eye (Lond). 1997;11:472-5. 3. Jones LT, Reeh MJ, Wobig JL. Senile entropion. A new concept for correction. Am J Ophthalmol. 1972;74:327-9. 4. Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol. 1979;97:2192-6. 5. Quickert MH, Rathbun E. Suture repair of entropion. Arch Ophthalmol. 1971;85:304-5. 6. Khan SJ, Meyer DR. Transconjunctival lower eyelid involutional entropion repair: long-term follow-up and efficacy. Ophthalmology. 2002;109:2112-7. 7. Scheepers MA, Singh R, Ng J, et al. A randomized controlled trial comparing everting sutures with everting sutures and a lateral tarsal strip for involutional entropion. Ophthalmology. 2010;117:352-5. 8. Lee H, Takahashi Y, Ichinose A, Kakizaki H. Comparison of surgical outcomes between simple posterior layer advancement of lower eyelid retractors and combination with a lateral tarsal strip procedure for involutional entropion in a Japanese population. Br J Ophthalmol. 2014;98:1579-82. 9. Olali C, Burton V, Samalila E. Involutional lower eyelid entropion: combined Wheeler’s and Wedge resection of tarsal plate. West Afr J Med. 2010;29:117-9. 10. Schaefer AJ. Lateral canthal tendon tuck. Ophthalmology. 1979;86: 1879-82. 11. Ishida Y, Takahashi Y, Kakizaki H. Posterior layer advancement of lower eyelid retractors with transcanthal canthopexy for involutional lower eyelid entropion. Eye. 2016;30:1469-74. 12. Jordan DR, Anderson RL. The lateral tarsal strip revisited. The enhanced tarsal strip. Arch Ophthalmol. 1989;107:604-6. 13. Weber PJ, Popp JC, Wulc AE. Refinements of the tarsal strip procedure. Ophthalmic Surg. 1991;22:687-91.
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14. Hsuan J, Selva D. The use of a polyglactin suture in the lateral tarsal strip procedure. Am J Ophthalmol. 2004;138:588-91. 15. Leibovitch I. Lateral wedge resection: a simple technique for repairing involutional lower eyelid entropion. Dermatol Surg. 2010;36:1412-8. 16. Mauriello JA, Abdelsalam A. Modified corncrib (inverted T) procedure with Quickert suture for repair of involutional entropion. Ophthalmology. 1997;104:504-7. 17. Hedin A. Senile entropion−cure rate by retractor tightening and horizontal shortening. Acta Ophthalmol Scand. 1997;75:443-6. 18. Rainin EA. Senile entropion. Arch Ophthalmol. 1979;97:928-30. 19. Roberts MA, Baddeley P, Sinclair N, Lane CM. The lower lid diamond: a simple entropion repair to correct both horizontal and lower-lid retractor laxity. Ophthal Plast Reconstr Surg. 2012;28:44-6. 20. Boboridis K, Bunce C, Rose GE. A comparative study of two procedures for repair of involutional lower lid entropion. Ophthalmology. 2000;107:959-61. 21. Wright M, Bell D, Scott C, Leatherbarrow B. Everting suture correction of lower lid involutional entropion. Br J Ophthalmol. 1999;83:1060-3. 22. Asamura S, Kakizaki H, Shindou E, Itani Y, Isogai N. What is the best strategy for Asians with involutional entropion? J Craniofac Surg. 2014;25:972-5. 23. Marabotti A, Bedei A, Lanza G, Cariello A, Giannecchini I. Involutional entropion surgery: a modified technique. Ophthalmologica. 2001;215:169-73.
Footnotes and Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article. From the Department of Ophthalmological Plastic Surgery, Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China. Originally received May. 25, 2017. Final revision Feb. 7, 2018. Accepted Feb. 13, 2018. Correspondence to Jianxin Ni, MD, Department of Ophthalmological Plastic Surgery, Affiliated Eye Hospital, Wenzhou Medical University, 270 Xueyuan Road, Wenzhou, Zhejiang, Wenzhou 325000 China; [email protected]