This combined procedure addresses multiple anatomic factors causing involutional entropion: the lateral tarsal strip is suspended to reduce horizontal laxity, and infraciliary rotation sutures are placed to stabilize the tarsus, evert the lower eyelid, and decrease orbicularis override. This approach is both efficient and effective, with a low risk of complications.
To create the lateral tarsal strip, first Westcott scissor are used to perform a lateral canthotomy and inferior cantholysis. After determining and marking the length of lid to be shortened, the skin and orbicularis muscle are separated from the anterior tarsal face. The skin on the margin is removed, in order to de-epithelialize the lateral tarsal strip. A 15 blade is used to scrape the conjunctival epithelium. Next, an infraciliary incision is made 2 to 3 mm below the margin. Westcott scissors are used to dissect straight posteriorly, exposing the tarsus. Using 6-0 or 5-0 Vicryl suture, buried interrupted sutures are placed subcutaneously through the orbicularis muscle, deep to superficial and then superficial to deep. A partial thickness horizontal bite of tarsus is taken to provide everting force. The suture is then tied down. This is performed 3 or 4 times along the length of the lid, until the end of the canthotomy incision. Both arms of a 5-0 Prolene double-armed suture are placed through the tarsal strip from anterior to posterior. A cotton-tip applicator is used to identify the orbital rim, and the suture is passed through the periosteum of the lateral orbital rim. The second arm of that suture is placed through the periosteum in the same manner. This Prolene suture is not yet tied down. Instead, 6-0 Vicryl suture is passed in a cerclage fashion through the gray line, at the outer aspect of the upper and lower lids, and tied down to recreate a sharp lateral canthal skin angle. The ends of the Vicryl suture are cut. Revisiting the Prolene that was previously passed through the tarsal strip and periosteum, the suture is tied down and cut. It is tied very snugly, while ensuring that there is no skin incorporated. The skin incision is closed using 6-0 plain gut suture in a running fashion.
Involutional lower eyelid entropion leading to ocular surface irritation and corneal damage
Contraindications include active local infection, bleeding diathesis or anticoagulation, and general medical conditions that would otherwise prevent the patient from tolerating surgery.
A full ophthalmic exam should be conducted, with special attention towards determining the type of entropion (e.g. congenital, spastic, cicatricial, or involutional). This procedure is particularly suited for involutional entropion, and other types of entropion may require a different approach. The patient should also be evaluated for other possible causes of ocular surface irritation.
This technique offers the advantage of targeting multiple causes of involutional entropion in a single procedure (tarsal instability, orbicularis override, and horizontal lid laxity). The septum is never opened, which minimizes the associated risks of retrobulbar hemorrhage or orbital infection. With appropriate selection of patients with the anatomic factors addressed in this surgery, the disadvantages are minimal.
Overcorrection or recurrence of entropion are possible complications. However, the risk of recurrence is low, due to the everting cicatrization that occurs as the infraciliary incision heals. In a study of 36 patients having this procedure, Rabinovich, Freitag et al. showed a complication rate of 0%, with no overcorrection or recurrence observed during follow-up.
Rabinovich A, Allard FD, Freitag, SK. Lower eyelid involutional entropion repair with lateral tarsal strip and infraciliary rotation sutures: Surgical technique and outcomes. Orbit. 2014; 33(3):184-188. Available from: http://www.tandfonline.com/doi/abs/10.3109/01676830.2014.894540.