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 Table of Contents  
Year : 2018  |  Volume : 111  |  Issue : 4  |  Page : 132-136

Lower lid retractors tucking with gray-line splitting procedure in the management of lower eyelid involutional entropion with misdirected lashes

Department of Ophthalmology, Ain Shams University, Cairo, Egypt

Date of Web Publication13-Feb-2019

Correspondence Address:
Mahmoud A El-Samkary
104 Street, 5th Settlement, New Cairo, Cairo, 11321
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejos.ejos_36_18

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Purpose The aim was to assess the outcome of a surgical technique of lower lid retractors tucking with gray-line splitting procedure in the management of patients with unilateral lower eyelid involutional entropion with misdirected lashes.
Patients and methods This prospective case series included 60 patients with unilateral lower eyelid involutional entropion with misdirected lashes and no previous history of entropion correction surgery. Patients with cicatricial and traumatic lower lid entropion were excluded. Eyelid margin splitting was done first along the gray line, then lower lid retractors tucking was done through a transcutaneous incision using three horizontal 5-0 vicryl sutures and redundant skin was excised. All patients were followed up at 1 day, 1 week, and 3, 6, and 12 months postoperatively.
Results Success rate after 1 year was 92.6% (n=50/54) and recurrence occurred in 7.4% (n=4/54). Overall, six patients were excluded owing to incomplete follow-up and excluded from statistics. Postoperative temporary ectropion occurred in 85% in the first 3 weeks. Patient opinion and satisfactions reached up to 92% at the end of the year.
Conclusion Lower lid retractors tucking with gray-line splitting is a highly effective, simple surgical technique that is less traumatizing to conjunctiva and has good cosmetic results.

Keywords: gray-line splitting, involutional entropion, lower lid retractors, tucking

How to cite this article:
El-Samkary MA. Lower lid retractors tucking with gray-line splitting procedure in the management of lower eyelid involutional entropion with misdirected lashes. J Egypt Ophthalmol Soc 2018;111:132-6

How to cite this URL:
El-Samkary MA. Lower lid retractors tucking with gray-line splitting procedure in the management of lower eyelid involutional entropion with misdirected lashes. J Egypt Ophthalmol Soc [serial online] 2018 [cited 2019 May 21];111:132-6. Available from: http://www.jeos.eg.net/text.asp?2018/111/4/132/252177

  Introduction Top

Entropion is the inward turning of the eyelid and is most commonly seen as an aging phenomenon produced by attenuation or detachment of the lower eyelid retractors and associated with horizontal eyelid laxity [1].

If untreated, this condition can cause ocular discomfort, corneal abrasions resulting from misdirected lashes, microbial keratitis, corneal vascularization, and visual loss [2].

Involutional entropion is the most common type seen in general ophthalmic practice, and its prevalence increases with age [3]. It has been attributed to multiple factors, including medial and lateral canthal tendon laxity, atrophy or dehiscence of the lower lid retractors, over-ride of the preseptal part over the pretarsal part of orbicularis oculi muscle, and enophthalmos [4].

Many surgical techniques have been used for managing entropion with varying success rates. Because of the multifactorial nature of the disease, no entirely satisfactory surgical technique has been reported yet [5],[6].

The aim of this study was to evaluate the efficacy of lower eyelid tucking with gray-line splitting procedure in the management of patients with unilateral lower eyelid involutional entropion with misdirected lashes.

  Patients and methods Top

The study was approved by the Research Ethical Committee at Faculty of Medicine, and all procedures conformed to the guidelines provided by the World Medical Association Declaration of Helsinki on ethical principles for medical research involving humans. In all cases, the patients signed an informed consent and agreed to allow the use of photographs for scientific purposes. The study included 60 patients who presented to the outpatient clinic of Ain Shams University Hospital, Cairo, between March 2016 and December 2017 diagnosed with unilateral inward rotation of the lower eyelid with misdirected lashes.

Full ophthalmic examination was performed for all patients by the same examiner including auto refraction (RM8800; Topcon, Tokyo, Japan), best-corrected visual acuity, ocular motility, pupillary reflexes, intraocular pressure measurement with Goldmann applanation tonometer (GAT; Haag-Streit, Bern, Switzerland), slit lamp examination, corneal sensation testing, and staining to rule out dry eye and corneal surface irregularities.

Mode of onset of entropion was considered for each case, and complete eyelid examination was performed noting the contour of the eyelid and direction of the lashes, detecting any accompanying eyelid abnormalities.

The amount of horizontal lid laxity was assessed by measuring the distance between the center of the posterior lid margin and the limbus, Pinch test, in comparison to the other healthy eye and by the snap back test, with grading from 0 to 4, where most patients varied between grade 2 and grade 4. Indirect assessment of lower lid retractors function was done by measuring the higher resting lower lid position in millimeters in up and down gaze (lower lid excursion), and comparing it with the healthy eye. All patients were photographed preoperatively.

Excluded patients include cicatricial and traumatic entropion patients, or with distichiasis, patients with severely scarred conjunctiva as in cases of autoimmune diseases, and patients with the previous history of lower lid entropion surgery.

Surgical technique

The technique was performed by the same surgeon in Ain Shams university hospital. Local anesthesia (2% lidocaine mixed with 1 : 100 000 adrenaline) was administered subcutaneously 1–2 mm below the ciliary line along the length of the involved eyelid. Eyelid margin splitting was performed first with an incision 1–2 mm in depth made along the gray line with a Bard-Parker blade no. 11 in accordance with the horizontal extent of the marginal entropion from the lateral commissure to just lateral to the lacrimal punctum ([Figure 1] and [Figure 2]a–c).
Figure 1 Surgical technique. (a) Incision along the length of the upper eyelid margin through the gray line. (b) Three interrupted 5-0 vicryl sutures passed horizontally in the lower lid retractor and then passed through the tarsus and tied securely. (c) Removing excessive redundant skin.

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Figure 2 Case 1. (a) Preoperative photograph of a case with left lower lid involutional entropion. (b) Postoperative appearance after 1 week from the surgical repair, with complete resolution.

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Skin was incised 3–5 mm below the lid margin with the no. 11 scalpel blade along the length of the involved eyelid. Dissection was performed downward between the tarsus and the pretarsal anterior lamella using Westcott scissors. Further dissection, with careful hemostasis, was performed through the septum until the lower eyelid fat pads were seen and the lower eyelid retractors were identified.

Horizontal 5-0 ‘vicryl’ sutures (Ethicon, Cincinnati City, USA) were passed in the middle of the lower lid retractors then through the lower edge of tarsus without retractors disinsertion (tucking). Two similar sutures were placed medial and lateral to the first suture. All three sutures were then tied securely, aiming for initial overcorrection ([Figure 1]b).

Redundant skin and small part of preseptal part of orbicularis oculi at the lower edge of the wound were excised using Stevens scissors to match the upper skin wound edge. Skin was closed using interrupted 6/0 ‘vicryl’ (Ethicon) and mattress sutures to re-form the inferior lid crease. At the end of the surgery, the eyelid was dressed using topical antibiotic, and cold compresses were applied for the first 24 h postoperatively.

Postoperative criteria

Postoperative medications included oral antibiotic (ciprofloxacin three times/day for 3 days), topical antibiotic eye drops (gatifloxacin three times/day for 1 week) and topical antibiotic eye ointment (fusidic acid twice a day for 1 week until removal of sutures) on the wound, and artificial tears (carboxymethylcellulose sodium eye drops four times daily). Patients were followed up on the first postoperative day and after 1 week. Then follow-up visits were after 3 and 6 months, and after 1 year for evaluation of success rate and assessment of patient satisfaction. At each visit, the cornea was assessed for dryness, and the eyelid position was examined; horizontal lid laxity was assessed in each visit as described before by the same examiner. The procedure was considered a success if there was complete resolution of symptoms, adjusted lid position, no rubbing lashes, and an acceptable cosmetic appearance.

Statistical analysis

All data were collected and statistically analyzed using SPSS for windows version 20.0 (SPSS Inc., Chicago, Illinois, USA). Qualitative data were presented as numbers and percentages whereas quantitative data were presented as means±SD. Paired t-test was used to compare preoperative and postoperative data. The significance of the data was determined by the probability value. P greater than 0.05 was considered insignificant, P less than or equal to 0.05 was considered significant, and P less than or equal to 0.01 was considered highly significant.

  Results Top

This study included 60 eyes of 60 patients with clinical diagnosis of unilateral lower eyelid involutional entropion, comprising 36 males and 24 females. Only 54 patients completed 1 year follow-up, and six were lost to follow-up.

The age of the study group ranged from 60 to 72 years, with mean age of 63.0 years (SD=2.16) ([Table 1]).
Table 1 Patients’ demographics

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The mean preoperative lower lid excursion in the affected lid was 3.8 mm (SD=0.9) compared with 4.1 mm (SD=1.2) in the healthy eyelid of the same patient, and the difference was not statistically significant (P=0.099).

The mean postoperative lower lid excursion in the affected lid after 1 year was 4.4 mm (SD=1.1), which changed significantly from the preoperative values (P=0.042) ([Table 2]).
Table 2 Preoperative and postoperative lid measurements

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The mean preoperative horizontal lid laxity was 8.2 mm (SD=2.4) in the affected lid and 8.1 mm (SD=1.9) in the healthy lid of the same patient, which was not significantly different (P=0.758). The mean postoperative horizontal lid laxity improved to 7.4 mm (SD=2.3), which was significantly different from the preoperative value (P=0.031).

Success rate after 1 year was 92.6% (n=50/54) and the failure rate was 7.4% (n=4/54). Patients with recurrent entropion were surgically corrected by horizontal lid shortening procedure.

Temporary postoperative ectropion was present in 85% of patients from the first postoperative day up to 3 weeks, and eye lubricants were used to protect the cornea. Lid edema and subconjunctival hemorrhage were common temporary findings. The wound in all patients healed with minimal scarring ([Figure 3]).
Figure 3 Case 2. Postoperative after 3 months with acceptable scar.

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The opinion of all patients concerning eyelid shape and position, direction of lashes, corneal irritation, and their overall satisfaction was assessed through a direct questionnaire and statistically analyzed, and the mean satisfaction reached 92%.

  Discussion Top

Involutional entropion is one of the most commonly encountered eyelid malpositions which usually involves the lower lid. It is important to differentiate involutional entropion from other causes of entropion, because the effective treatment differs [7]. The most effective surgical procedure in the treatment of involutional entropion remains controversial.

It was found that loss of lower lid retractors function has an important role in the development of involutional entropion as proved by Jones et al. [8], together with horizontal laxity as reported by Benger and Musch [9].

This study depends on strengthening the action of lower lid retractors by tucking, which corrects vertical lid laxity, and excision of the redundant lax skin and small part of preseptal horn of orbicularis oculi correcting horizontal lid laxity which decrease the force on lower edge of tarsus plate, improving the appositional pressure of the lid during the eyelid closure. Retractor tucking procedure is rather a simple technique that does not require full retractors dissection, as in retractors plication procedure, and so it is a less time-consuming surgical procedure and less traumatizing to the conjunctiva, as the advantage of our partial thickness transcutaneous incision is preserving the physiological functions of palpebral conjunctiva, thus avoid scaring and fibrosis which could lead to dry eye. Lower lid splitting at the gray line decreases the incidence of corneal rubbing resulting from the misdirected lashes, which occurred by the appositional pressure during the eyelid closure, by inducing more fibrosis pushing away the posterior lamella and strengthening the lid margin.

Many surgical procedures are used for everting sutures to produce vertical tightening, as an indirect technique for treatment of involutional entropion. These sutures strengthen lid retractors by attaching it to the anterior lid lamella and reducing the upward movement of the preseptal orbicularis muscle [10],[11]. Although the technique is rapid, it is considered a temporary technique with high recurrence rate, and some patients complain of post-operative inflammatory reaction around the sutures.

Collin and Rathbun [12] reported that improvement in lower lid retractor function using Quickert’s everting sutures resulted in an increase in lower lid excursion. On the contrary, Wright et al. [13] reported no significant improvement of lower lid retractor function after everting sutures. Moreover, Tsang et al. [11] reviewed the outcomes of everting sutures, excluding patients with eyelid laxity. The authors found a 12% recurrence at 9-month follow-up compared with 7.4% after 12 months in our study, including patients with eyelid laxity.

Serin et al. [5] described that scar formation and retractor tightening after full-thickness incision of Wies procedure may not be strong enough to keep the lids in a normal position over time. In addition, horizontal laxity was not addressed in their procedure, and some patients complained about a visible incision line.

Some studies addressed the lower lid retractors together with lid margin splitting. Malhotra et al. [14] reported a success rate of 90% after a 3-year follow-up after gray-line splitting, retractors recession, lateral-horn lysis, and anterior lamellar repositioning in cases of cicatricial lower lid entropion, but 38% of cases required a second operation within the first year, compared with 7.4% with recurrence in our study, only with retractors tucking and gray-line splitting. The higher recurrence rate they had could be attributed to the cicatricial nature of the entropion, whereas our technique proved to be more effective in involutional entropion.

Choi et al. [7] studied the outcomes of eyelid margin splitting and anterior lamellar repositioning in patients with lower eyelid marginal entropion, reporting a success rate of 90% after 16.7 months, which was close to ours (92.6%) after 1 year. This technique induces more fibrosis between layers, which may lead to ectropion, which is more effective in cicatricial entropion although it may be a drawback in involutional entropion.Sahasrabudhe and Salian [15] studied the results of Jones procedure for correction of senile entropion, taking 4/0 silk plication sutures passing through the skin, the lower orbicularis muscle, the lower lid retractors, and the upper part of the orbicularis muscle. There was no recurrence in any of the cases, but an aggressive fibrotic and inflammatory response occurred in the lid tissues 2 weeks after the insertion of sutures, whereas in our study, postoperative reaction was mild to moderate as we respected the anatomy of the lid and skin was sutured separately from the muscle, resulting in an invisible skin scar. ([Figure 3]) On the contrary, Boboridis et al. [16] reported a recurrence rate of 5% after Jones retractor plication technique.

  Conclusion Top

Our surgical technique represents an effective simple direct technique for the treatment of involutional entropion that combines horizontal lower eyelid shortening and retractors tucking thus reinforcing the vertical traction power of lower lid. Cosmetic and functional outcomes are excellent following surgical repair, with good long-term success and low recurrence rate.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Deka A, Saikia S. Lower lid entropion correction with botulinum toxin injection. Oman J Ophthalmol 2010 3:158.  Back to cited text no. 1
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Serin D, Buttanri IB, Karslioglu S, Sevim MS, Buttanri B, Akbaba M. The efficacy of the combined procedure in involutional entropion surgery: a comparative study. Korean J Ophthalmol 2013; 27:405–408.  Back to cited text no. 5
Scheepers MA, Singh R, Ng J, Zuercher D, Gibson A, Bunce C et al. A randomized controlled trial comparing everting sutures with everting sutures and a lateral tarsal strip for involutional entropion. Ophthalmology 2010; 117:352–355.  Back to cited text no. 6
Choi YJ, Jin HC, Choi JH, Lee MJ, Kim N, Choung HK, Khwarg SI. Correction of lower eyelid marginal entropion by eyelid margin splitting and anterior lamellar repositioning. Ophthalmic Plast Reconstr Sur 2014; 30:51–56.  Back to cited text no. 7
Jones LT, Reeh MJ, Wobig JL. Senile entropion: a new concept for correction. Am J Ophthalmol 1972; 74:327–329.  Back to cited text no. 8
Benger RS, Musch DC. A comparative study of eyelid parameters in involutional entropion. Ophthalmic Plast Reconstr Sur 1989; 5:281–287.  Back to cited text no. 9
Hwang SW, Khwarg SI, Kim JH, Kim NJ, Choung HK. Lid margin split in the surgical correction of epiblepharon. Acta Ophthalmol (Copenh) 2008; 86:87–90.  Back to cited text no. 10
Tsang S, Yau GS, Lee JW, Chu AT, Yuen CY. Surgical outcome of involutional lower eyelid entropion correction using transcutaneous everting sutures in Chinese patients. Int Ophthalmol 2014 34:865–868.  Back to cited text no. 11
Collin JR, Rathbun JE. Involutional entropion: a review with evaluation of a procedure. Arch Ophthalmol 1978; 96:1058–1064.  Back to cited text no. 12
Wright M, Bell D, Scott C, Leatherbarrow B. Everting suture correction of lower lid involutional entropion. Br J Ophthalmol 1999; 83:1060–1063.  Back to cited text no. 13
Malhotra R, Yau C, Norris JH. Outcomes of lower eyelid cicatricial entropion with grey-line split, retractor recession, lateral-horn lysis, and anterior lamella repositioning. Ophthalmic Plast Reconstr Sur 2012; 28:134–139.  Back to cited text no. 14
Sahasrabudhe VM, Salian RR. Study of Jones procedure for senile entropion. Indian J Appl Res 2016; 5:9.  Back to cited text no. 15
Boboridis K, Bunce C, Rose GE. A comparative study of two procedures for repair of involutional lower lid entropion. Ophthalmology 2000; 107:959–961.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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