2013

Orbit, 2013; 32(5): 271! Informa Healthcare USA, Inc.

ISSN: 0167-6830 print / 1744-5108 online

DOI: 10.3109/01676830.2013.815230

ORIGINAL ARTICLE

Transconjunctival Entropion Repair – The BackdoorApproach

Andreas J. Kreis, Fariha Shafi, and Simon N. Madge

Victoria Eye Unit, Hereford County Hospital, Hereford, United Kingdom

ABSTRACT

Purpose: To present a modified transconjunctival approach for involutional entropion repair.

Methods: This study is a retrospective consecutive single surgeon case series using a transconjunctival approachfor involutional lower lid entropion (ILLE) repair.

Results: Eleven eyes were operated for involution entropion with 9 cases of complete resolution. Two patientsrequired further Jones’ retractor plication.

Conclusion: Transconjunctival involutional lower lid entropion repair is a time-efficient, safe, and efficacioustechnique. The scar free technique described leads to full restoration of lower lid anatomy. In contrast to otherreports we found a relatively low rate of recurrence on follow-up.

Keywords: Advancement, entropion, transconjunctival

INTRODUCTION

Involutional or acquired lower eyelid entropion(ILLE) is common eyelid malposition affecting theelderly population.1–3 Local eye symptoms range fromdiscomfort and itching to redness and tearing due tocorneal irritation by the malpositioned lid and lashes.Severe cases may cause chronic ocular surface diseasewith subsequent decrease of visual acuity.1,4–6

The mechanism of ILLE is believed to be adisinsertion of the lower lid retractors combinedwith lower lid laxity as well as overriding of theorbicularis muscle.7,8 As medical management isconsidered ineffective especially in the long-term,the gold standard for ILLE repair is a surgicalapproach and should address each of the mechanicalcauses of ILLE mentioned previously, specifically thereinsertion of the lower lid retractors and tighteningof the lower lid by shortening.4,9–12

Reinsertion of the lower lid retractors can beachieved through a cutaneous infralash incision(external) or internally through a transconjunctivalapproach.1,13–16

We present our experience of a modified version ofan internal, transconjunctival approach, which isquick to learn, provides anatomical restitution ofeyelid anatomy and has a low failure rate.

MATERIAL AND METHODS

This study is a retrospective consecutive singlesurgeon case series. All cases underwent a transcon-junctival approach for ILLE repair (Figure 1) underthe senior author’s care (SM). At follow-up, patientswere assessed for relief of symptoms, absence ofentropion and correct anatomical position of theeyelid (Figure 2).

Battery-operated high-temperature cautery(Hotwire) is used to make a full length, lower lidsubtarsal transconjunctival incision (Figure 3). Thedehisced lower eyelid retractors are easily identified(Figure 4) and after clear exposure are separated fromthe inferior lid tarsus, again using the Hotwire.

The retractor layer is then separated from theunderlying conjunctiva, allowing advancement of the

Correspondence: Andreas J. Kreis, Victoria Eye Unit, The County Hospital, Stonebow Road, Hereford HR1 2BN, United Kingdom. E-mail:mrkreis@gmail.com

Received 7 May 2013; Accepted 10 June 2013; Published online 14 August 2013

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layer, rather than a simple plication. Advancementand reinsertion of the retractors to the anterior-inferior tarsal border and adjacent orbicularis-oculimuscle are then performed with a slight medial shift

of the retractors (Figure 5). The medial shift isimportant to compensate for the amount of lidshortening through a lateral tarsal strip (LTS) thatwill follow (Figure 6). Interrupted 6-0 polyglycolicsutures are used to secure the inferior retractors(Figure 4) and 6.0 Nylon for the skin. Lid shortening isthen performed as desired, using a LTS in our hands.

RESULTS

Eleven eyes of 9 patients were identified, one of whichhad previous ipsilateral surgery for ILLE. Proceduretime varied from 25–35 minutes (including LTSformation). At last follow-up (mean 7.5, range 4–10months) 9 cases had complete resolution of entropionwith satisfactory eyelid position, no significant scar-ring and were free of symptoms. Two patientsrequired further Jones’ retractor plication. Minortransient chemosis was seen in 2 patients at the one-week follow-up visit, but did not persist beyondthis time.

FIGURE 1. Presence of an involutional lower eyelid entropion.

FIGURE 2. Postoperative result showing normal lower eyelidposition.

FIGURE 3. Subtarsal transconjunctival incision using theHotwire.

FIGURE 5. Placing a suture into anterior-inferior tarsal border.

FIGURE 4. Pacing a suture into retractors.

272 A. J. Kreis et al.

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DISCUSSION

We describe a transconjunctival involutional lower lidentropion (ILLE) repair that is quick to perform, safeand appears to be an efficacious technique. Thetechnique is quick to learn, leads to little if anyexternal scarring and provides complete anatomicalcorrection of the aetiological involutional factors. Webelieve that advancement of the retractors, rather thansimply plication (as implied by some authors,1,4,14,15,17

combined with an associated compensating medialshift of the retractors, is key to a successful functionaloutcome.

Most entropion surgical techniques described,either external or internal, include plication of theretractors to the tarsus, combined with a lower lidshortening.1,4,12–17 These techniques all address disin-sertion of the lower lid retractors, lower lid laxity aswell as overriding of the orbicularis muscle which aregenerally accepted to be the leading factors for lowerlid entropion.7,8 However, all techniques may have acommon complication, secondary cicatricial pro-cesses, which may result in secondary ectropion orentropion depending on the approach used.

The conjunctival approach avoids a cutaneousincision and may decrease the risk of post-operativecicatricial retraction associated with externalrepair,13,15 but higher post-operative entropion recur-rence rates may occur secondary to cicatricial shorten-ing of the posterior lamella associated with theconjunctival incision.1,14

Kakizaki et al. demonstrated definitive doublelayers of the lower eye lid retractors, an anterior andposterior layer. Fingerlike extensions of the anteriorlayer were demonstrated to be extending into theanterior lamella via the perimysial space of thepretarsal and preseptal orbicularis oculi. The posteriorlayer represents the deep dense fiorbi of the capsu-lopalpebral fascia that extend to the inferior border ofthe tarsal plate.18,19

Our modified technique using an internal conjunc-tival approach with advancement of the lower eyelidretractors to this anterior-inferior tarsal border andadjacent orbicularis oculi muscle,18 combined with anLTS, provides a swift anatomical correction of invo-lutional entropion with no significant external lowerlid scarring. We initially tried simply plicating theretractors internally to the anterior-inferior tarsus,however, it became clear that advancement of theretractors to the same location was associated withmore successful, long-term outcomes. In addition, wefound that moving the retractors slightly medially-compensating for the lateral movement of the lidduring LTS formation—for reinsertion to the lowerexternal tarsus decreases traction and possibly aconsecutive scaring reaction of the tissues, hencelowering the risk of a secondary cicatricialentropion.20

Although the advancement technique has beenused previously with varying success in ILLE, itremains in our opinion one key factor to functionalsuccess.13,14,16,17 The combination of advancementand the second key factor, the compensating medialshift of the retractor muscles for the LTS however hasto our knowledge not been performed nor describedin previous publications. In contrast to recent reportsusing advancement or plication techniques only,1,13,16

we found a relatively low rate of recurrence onfollow-up.

This technique is quick to learn, safe, time efficient(around 30 minutes), anatomically logical and is alsoapplicable to recurrent entropia. However, furtherstudies are necessary to establish the long-termsuccess of this technique compared with to otherapproaches of involutional entropion repair.

DECLARATION OF INTEREST

The authors report no conflicts of interest. The authorsalone are responsible for the content and writing ofthe paper.

REFERENCES

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FIGURE 6. Lid shortening through LTS.

Transconjunctival Entropion Surgery 273

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