Eyelid malpositions such as ectropion, turning out of the eyelid, and entropion, turning in of the eyelid, can lead to discomfort, visual difficulties, and aesthetic disfigurement. Entropion (Fig. 1) has many causes, which must be excluded by clinical examination. Involutional entropion of the lower eyelid was previously known as senile entropion, as it commonly affects older patients. Surgical treatment of entropion has been shown to positively impact quality-of-life .
We aimed to provide an update on current surgical practice and thought. PubMed and Embase databases were searched for involutional entropion from November 2, 2011 to May 28, 2015 to capture the period since the most recent Cochrane Systematic Review . The search results yielded 199 articles.
After a review of the titles and abstracts, articles on noninvolutional types of entropion, other articles unrelated to the topic, and duplicates were excluded. There were 19 relevant primary research studies with a total of 1534 patients [3▪,4▪,5,6▪▪,7,8▪,9,10▪,11,12,13▪,14–21]. Twelve of the 19 (63%) were published in the most recent 24 months [3▪,4▪,5,6▪▪,7,8▪,9,10▪,11,12,13▪,14]. This article summarizes the current research on surgical practices for involutional lower eyelid entropion.
DEMOGRAPHICS AND CLINICAL FACTORS
Investigators continue to seek better understanding of the factors associated with the condition.
A lax eyelid is unstable. In involutional entropion, horizontal or vertical laxity or both are present. The classic triad associated with involutional entropion is dehiscence of the lower eyelid retractors, horizontal lid laxity, and overriding of the orbicularis oculi muscle. One common method to identify horizontal laxity, known as the pinch test (distraction test), involves pinching the central eyelid away from the globe . An eyelid is considered positively lax if the pinch test value is greater than 8 mm. In 2014, Michels et al.[8▪] prospectively compared a series of 30 patients with entropion with patients who had either ectropion or normal eyelids. The findings reinforced the notion that both entropion and ectropion share many findings. However, entropion was more often associated with retractor dehiscence and eyelid laxity in patients suffering from ectropion.
Jones described enophthalmos as another change associated with involutional entropion . Subsequent studies have had mixed results, with some supporting the association [24,25] and others not . Jyothi et al. took a novel approach in examining the effect of axial globe length on eyelid malposition. The authors reviewed 57 Caucasian patients with entropion or ectropion. Patients with entropion had relatively shorter axial lengths, with a mean of 22.7 mm, whereas patients with ectropion had mean 23.5 mm. Based on the correlation between eyelid malposition and axial globe length, the authors suggest exophthalmometry may serve as a proxy for axial globe length . Clinically, patients with less prominent eyes are typically the ones with entropion. The association may be due to globe position or axial length or both.
There are ethnic differences in the incidence of ectropion versus entropion, with the latter being more common among Asian patients . Consistent with this, over half of the studies from our period of review originated from East Asia (10 of 19) and accounted for 72% of the patients [3▪,4▪,5,6▪▪,7,10▪,12,15,17,19]. Two studies specifically looked at the factors associated with entropion in Asian patients [7,12].
Nishimoto et al. used the pinch test to assess the extent that laxity contributes to entropion. A positive pinch test correlated with entropion with a similar occurrence of entropion in different age groups in patients with a positive pinch test. The rate of positive pinch tests increased from 7.4% in patients aged 40 years to 50.0% in patients aged 90 years or older. Asamura et al.  attributed the overlap of the preseptal orbicularis muscle onto the pretarsal portion as a critical abnormality in their series of Asian patients.
Temporary measures for the relief of involutional entropion include the use of lubricants and eyelid taping. Botulinum toxin injections to the overriding orbicularis muscle may also provide transient relief . However, definitive repair of both entropion and ectropion is surgical and often involves horizontal lid tightening . Specific treatments for involutional entropion include more conservative Quickert everting sutures, standard lateral tarsal strip (LTS) procedures, and combinations of procedures. The optimal approach addresses all of the anatomic factors contributing to entropion, which varies between patients. Sixteen of the articles in the review were interventional studies (Table 1). These consisted of four retrospective cohort studies [6▪▪,11,13▪,15] and 12 case series [3▪,4▪,5,7,9,10▪,14,16,17,19–21].
Lower eyelid retractors
Strengthening the action of the lower lid retractors by an incisional or nonincisional approach is one of the core components of involutional entropion repair.
Everting sutures involve placing mattress sutures through the full thickness of the eyelid. Everting sutures cause a scar tract from the lower eyelid retractors to the pretarsal tissues. The scar results in persistent lid eversion of variable duration after suture removal or dissolution. Traditionally, everting sutures have been recommended for temporary repair of involutional entropion. The procedure is especially useful for patients who are unable to tolerate more invasive surgery, for example, patients taking anticoagulant and antiplatelet medications, typically allowing them to remain on these medications.
In 2014, two studies looked at everting sutures to correct the condition [3▪,10▪]. Jang et al.[3▪] reviewed the long-term outcomes of using Quickert everting sutures. The authors used 5-0 polyglactin sutures in contrast to the Quickert's original method , which employs chromic sutures. Recurrence at 2 years reached nearly 50%. Patients with more eyelid laxity had a higher chance of recurrence. This is an expected finding, since everting sutures do not address horizontal lid laxity. Male patients also had higher rates of recurrence. Tsang et al.[10▪] also reviewed outcomes of everting sutures. They excluded patients with eyelid laxity. The authors found a 12% recurrence at 9 months’ follow-up. Historically, absorbable sutures have been recommended to promote inflammation. The subsequent scar within the eyelid is thought to enhance the everting effect. Tsang et al.[10▪] modified the technique by using 5-0 nonabsorbable sutures (silk), which were removed after 2 weeks. A previous study on entropion  showed that 4-0 silk and 4-0 chromic everting sutures had similar outcomes at 3 months’ follow-up, with a modest cost saving associated with the use of silk. Given the short follow-up interval, the overall data remain limited regarding the efficacy of different suture types.
Transconjunctival retractor advancement
Jones first described transconjunctival entropion repair in 1960 , but transconjunctival advancement of the lower lid retractors did not receive significant attention until Dresner and Karesh . Their landmark paper added orbicularis myectomy to the procedure and emphasized repair of all three correctable anatomic abnormalities.
In 2013, Kreis et al. evaluated a transconjunctival approach. The authors evaluated 11 eyes in which combined retractor advancement and LTS was successful in nine cases, and two required further Jones retractor plication. Placing the retractor advancement sutures medially compensated for eventual horizontal lid tightening.
Transcutaneous retractor advancement
Lee et al.[6▪▪] compared simple posterior layer advancement of lower eyelid retractors alone and with an LTS procedure for involutional entropion in a Japanese population. Patients with horizontal lid laxity benefited from combined retractor advancement and LTS, whereas patients without horizontal lid laxity did well with retractor advancement alone. The success rate in the appropriately treated groups was 100%, whereas patients with horizontal eyelid laxity treated with retractor advancement alone only reached a 91.3% success rate. The results underscore the importance of precise selection of specific surgical approaches tailored to individual patients.
Horizontal eyelid tightening
Horizontal lid laxity significantly influences the surgical repair of entropion. In patients with laxity-associated involutional entropion, multiple studies from the last 18 months [3▪,6▪▪,11,13▪] indicate a consensus that the recurrence rate will be higher when the eyelid is not horizontally tightened.
Asamura et al. explored the use of a procedure usually used for ectropion for the correction of involutional entropion. They used a modified Kuhnt–Szymanowski–Smith method, in which a pentagonal wedge of tissue is removed from the lateral eyelid. In 27 patients, they found a 100% success rate with a follow-up of 20 months. Given the similar predisposing factors for involutional entropion and ectropion, especially horizontal lid laxity, the authors propose their modified technique as a quick and successful means of correction.
Chan and Looi  described a small modification of the LTS suture technique. The approach, the Looi suture, involves passing a double-armed 5-0 braided nonabsorbable suture first from the lateral orbital rim, then through the tarsal strip. The suture is passed twice through the strip. This approach seems to offer a dual action of horizontal tightening by both plicating the strip and securing the eyelid to the orbital rim laterally. The authors achieved a 95% success rate in 39 patients.
Orbicularis oculi muscle
Horizontal eyelid tightening may not always be necessary. Ding et al.[4▪] investigated entropion repair in patients without horizontal laxity. They had a 95% success rate in their retrospective review of over 400 patients in which they simply transposed the orbicularis. The technique involves moving the pretarsal orbicularis to its corresponding preseptum location. Rabinovich et al. also incorporated adjustment of the orbicularis by using epiblepharon surgical techniques. They used a combination of buried infraciliary rotation sutures and horizontal tightening. The sutures were placed through the orbicularis muscle and tarsus on both sides of the subciliary incision to rotate the eyelid margin outward.
One small study  treated entropion with of CO2 laser resurfacing. The idea was to induce anterior lamellar cicatrization to correct the inturned eyelid. Only the overriding orbicularis component of entropion is addressed. It would be interesting to see whether the approach could serve as adjunct to other treatments. Overall, laser treatment would seem to have limited application in those populations most at risk of entropion, such as Asian patients, owing to the potential for scarring and pigmentary changes.
Combined surgical approaches
Combined surgical approaches include multiple techniques to address the three components of involutional entropion. Advancement of the lower lid retractors was advocated by Jones to address the vertical lid malposition. Addressing horizontal laxity may require excision of a portion of the lateral eyelid or LTS.
Evidence base for combined surgery
In the 2011 Cochrane update, Boboridis and Bunce  identified one randomized controlled trial from 2010  that met their inclusion criteria. Scheepers et al. investigated 63 patients with primary involutional lower lid entropion. Participants were randomized to everting sutures alone or everting sutures and LTS. At 18 months’ follow-up, nearly 80% treated with everting sutures alone had successful repair, compared with 100% of those treated with the combined approach. The difference was statistically significant. There was a trend for the six patients whose treatment failed with everting sutures alone to have greater horizontal laxity, as measured by the pinch test . Failure with everting sutures alone in the setting of horizontal laxity would be an expected finding. The sample size calculation indicated that 220 patients were needed, so with more participants the trend may have achieved statistical significance.
Several newly published articles have sought to modify techniques and improve success for involutional entropion repair. Most have involved incisional approaches with the aim of addressing the vertical and horizontal components.
In 2012, Miletic et al. described a modified Jones and Quickert procedure in which transcutaneous exposure and plication of the lower lid capsulopalpebral fascia (Jones procedure) was performed with both absorbable and nonabsorbable sutures. This was combined with a pentagonal horizontal shortening of the lower eyelid, with attachment of the retractors to the tarsal plate (Quickert). The success rate was 89% in a series of 101 patients . Roberts et al. described a similar combined technique. The authors performed full thickness diamond-shaped lower eyelid excision with lower lid retractor plication. Those patients all had lower lid entropion without significant lateral canthal tendon laxity. For 42 eyes, the success rate was 92% at the 14-month follow-up . The modified technique was considered effective for the repair of involutional entropion in patients without significant lateral canthal tendon laxity.
Two 2014 studies looked at the combination of LTS with another procedure. Ranno et al.[13▪] evaluated the Jones procedure alone vs. the Jones procedure with LTS. Jones retractor plication alone was performed in 61 patients, and 16.5% of them developed recurrence at or before their 24-month follow-up. The combined Jones and LTS group included 55 patients, and only 3.6% of them developed recurrence at or before their 24-month follow-up. The authors concluded that addressing the horizontal lid laxity with LTS resulted in longer lasting correction. Rabinovich et al. evaluated the combination of everting sutures with LTS. The suture component consisted of subcutaneous mattress sutures that incorporated partial thickness tarsal bites. In cases where orbicularis override was a significant contributor to entropion, myectomy was considered before the fixation suture was placed. The authors reported no recurrences . They concluded that their combined technique is a highly effective method of repair.
Serin et al. compared combined retractor tightening, LTS, and everting sutures vs. Weiss repair of entropion. For 45 eyes in the combined surgical group there was only one recurrence (2.2%). The second group underwent the Weiss procedure, which involved a transverse skin incision and retractor advancement sutures passed through the orbicularis and skin. The second group included 31 eyes, 29% of which developed recurrence after an average of 18.4 months of follow-up. The authors concluded that the success rate and cosmetic result of the combined surgical repair of entropion are preferable to the Weiss procedure alone.
All of the studies from Asia involving incisional procedures reported on repair by the transcutaneous route. Asamura et al. proposed an approach specific to Asian patients with involutional entropion. Their surgical approach involved combining procedures, including retractor advancement and modified Hotz and Wheeler methods. This method helps to tighten horizontal laxity and advance the lower eyelid retractors. All of the patients in the series were asymptomatic postoperatively.
Nakauchi and Mimura  evaluated the Jones procedure vs. a combined Jones and Hotz procedure. The Hotz procedure involves the placement of five or six ciliary-everted sutures between the tarsus and dermis. The recurrence rate was 30% in the group who received only the Jones procedure, compared with 5% in the group who received the combined procedure. The authors recommend combined approaches for Asian patients.
Miyamoto et al. studied lower lid retractor plication with absorbable sutures combined with horizontal lid tightening by excision of a rectangle of lateral eyelid margin. The authors reported 100% success in 13 consecutive patients.
Recent studies have investigated the clinical features of involutional entropion. Shorter axial length may represent a new association. Although entropion and ectropion share similar features, retractor dehiscence is seen more often in entropion and horizontal laxity in ectropion. For entropion, both nonincisional and incisional approaches to the retractors remain in use. Over half of the patients treated with nonincisional everting sutures may retain durable repair at 2 years. In the absence of horizontal laxity, incisional approaches limited to advancement of the dehisced retractors may be sufficient for effective repair. However, in the presence of a positive pinch test, repairing horizontal laxity lowers the recurrence rate.
Financial support and sponsorship
This work was supported by the Department of Ophthalmology, University of Hong Kong, Cyberport, Hong Kong.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
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