Orbicularis Oculi Muscle Extirpation in a Combined Procedure for Involutional Entropion THADDEUS S. NOWINSKI, MD
Abstract: Many factors are important in the pathophysiology of involutional entropion, including defects of the lower eyelid retractors, canthal tendon laxity, and acquired enophthalmos. The role of the overriding preseptal orbicularis oculi muscle is often ignored in modern techniques of entropion repair. The author describes a technique of extirpation of the preseptal orbicularis oculi muscle combined with repair of the lower eyelid retractors and a lateral tarsal strip procedure for the repair of primary and recurrent involutional entropion. Lateral canthal tendon laxity is recognized in most patients in this age group and must be corrected to avoid postoperative overcorrection and ectropion. Removal of the preseptal muscle had no clinical effect on the lacrimal pump and did not cause any significant cicatricial eyelid abnormalities. This combined procedure has been used in 50 eyelids of 40 patients with excellent functional and cosmetic results. Orbicularis extirpation is not advocated in combination with a marginal rotation procedure. Ophthalmology 1991; 98:1250-1256
Involutional entropion is one of the most common eyelid malpositions seen in clinical practice. Surgical procedures abound for its repair, yet recurrences remain common. Multiple factors are important in the pathogenesis of involutional entropion, including dehiscence, attenuation, or disinsertion ofthe lower eyelid retractors, horizontal canthal tendon laxity, upward migration and overriding of the preseptal orbicularis oculi muscle, and possibly enophthalmos secondary to aging. 1-6 Many anterior lamellar procedures have been recorded for the repair of involutional entropion. Celsus7 advocated an excision of skin and orbicularis muscle during the 1st century. Hotz8 advocated formation of a scar barrier by Originally received: October 28, 1990. Revision accepted: March 7, 1991 . From the Oculoplastics Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia. Presented at the American Academy of Ophthalmology Annual Meeting, Atlanta, Oct/Nov 1990. Reprint requests to Thaddeus S. Nowinski,' MD, Oculoplastics Service, Wills Eye Hospital, Ninth and Walnut Sts, Philadelphia, PA 19107.
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direct suturing of skin to the tarsus. Vialeix 9 advocated partial excision of the pretarsal orbicularis oculi muscle. Wheeler lO described procedures for transposing a strip of preseptal orbicularis muscle to the periosteum of the zygoma or resection and tightening the preseptal orbicularis to form a physical barrier to prevent its upward migration. Sisler ll modified Wheeler's technique with horizontal to vertical redirection of strips of preseptal orbicularis oculi muscle. Hill and Feldman l2 and Stasior l3 modified Wheeler's concepts and performed a lid shortening procedure in selected cases. The modification performed by Hill and Feldman was considered the procedure of choice of most oculoplastic surgeons as recently as 20 years ago. 14 However, a relatively high recurrence rate and a lack of adequate correction of the underlying anatomic defect of the lower eyelid retractors allowed these procedures to fall into disfavor. Jones et aIlS described an approach to the lower eyelid retractors to directly repair the clinical posterior lamella anatomic defect seen in most cases of involutional entropion. This procedure and its variations have become the current procedure of choice for the repair of entropion, This approach was based on an increased knowledge of
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Fig 1. Involutional entropion.
for conjunctival abrasions, chemosis, injection, corneal abrasions, thinning, ulceration, scarring, and blood vessel ingrowth. " Each patient was evaluated by the author for clinical signs of involutional entropion including instability and inward rotation of the tarsal eyelid, overriding of the preseptal orbicularis oculi muscle on the pretarsal portion, and loss of downward excursion of the lower eyelid on downgaze. Overriding of the preseptal portion of the orbicularis oculi muscle on the pretarsal portion was evaluated in the resting state, after blinking, and after forceful lid closure. Lower eyelid excursion was evaluated in primary gaze and downgaze. Lid margin position was evaluated in resting state. All lid margins could be reapproximated by digital eversion with minimal tension. The fornix was evaluated for signs of a deep fornix relative to the opposite side and for the presence of a white line suggesting a retractor disinsertion. Horizontal laxity was evaluated by pinching the lower eyelid and noting the excursion away from the globe and the amount of movement of the inferior punctum laterally on horizontal traction. Patients with symblepharon or conjunctival or subconjunctival scarring were excluded.
PROCEDURE
Fig 2. The orbicularis muscle is incised after an infraciliary incision is made. Forceps tent the skin anteriorly to aid dissection. A skin-muscle flap is dissected away from the orbital septum.
lower eyelid pathophysiology and attempted to reapproximate the normal lower eyelid anatomy and significantly improve the rate of success. However, recurrences occur if horizontal laxity or orbicularis override are not recognized and repaired. 16- 18 A combined procedure is described for the repair of primary and recurrent involutional entropion in 50 eyelids in 40 patients. Repair of the lower eyelid retractors, horizontallaxity, and overriding preseptal orbicularis oculi muscle is used in a predictable and functional approach to this common eyelid malposition.
SUBJECTS AND METHODS Fifty eyelids of 40 patients who presented between July 1985 and July 1989 with involutional entropion were repaired with this combined technique. Eight patients (ten eyelids) had histories of previous repairs by other surgeons. All patients complained of foreign body sensation, redness, and discharge. Slit-lamp examination included inspection
The lower eyelid and lateral canthus are infiltrated with 2% lidocaine hydrochloride with 1: 100,000 epinephrine mixed in equal portions with 0.5% bupivacaine hydrochloride. A 4-0 silk traction suture is placed through the eyelid margin and the eyelid is retracted superiorly, thus placing tension on the posterior lamellar layers of the conjuctiva, tarsus, eyelid retractors, and orbital septum. The looser anterior lamellar skin and orbicularis oculi muscle can be mobilized anteriorly (Figs 1, 2). A # 15 Bard Parker blade is used to make a subcilliary incision through the skin beginning just lateral to the punctum. This incision can be extended to the lateral palpebral raphe if horizontal laxity is obviously present. If horizontal laxity is absent, or if the surgeon is unsure if horizontal tightening is necessary, the initial incision should extend only across the lower eyelid. This can be extended into the lateral canthal area later if necessary. The skin and orbicularis muscle inferior to the incision are grasped with forceps and tented anteriorly. The orbicularis muscle is then incised centrally with Westcott scissors. This approximates the juncture of the pretarsal and preseptal orbicularis layers. The tips of the scissors should be directed inferiorly so a plane is developed between the postorbicularis fascia and the orbital septum. Damage to the posterior lamellar structures may occur if the scissors are directed perpendicular to the incision and dissection inadvertently extends too deep. One blade of the scissors is passed bluntly in the avascular postorbicularis fascia plane and the incision is extended in both directions with a few snips with minimal dissection. Dissection is continued in a plane between the orbicularis muscle and the orbital septum to just below the inferior orbital rim. This is facilitated by the traction suture, which keeps tension on the orbital septum. 1251
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Fig 3. The orbital septum has been incised to expose the fat pads of the lower eyelid (arrow). These are analogous to the preaponeurotic fat pad of the upper eyelid.
Fig 5. Top, The preseptai orbicularis muscle (straight arrow) is dissected away from the skin (curved arrow) down to the area over the inferior orbital rim. Bottom, The preseptai orbicularis muscle (arrow) is then extirpated across the entire eyelid. Fig 4. The lower eyelid retractor band (straight arrow) is identified as a white band posterior to the orbital fat (curved arrow). Blunt and sharp dissection isolates this band from the surrounding structures.
An incision is made through the orbital septum well inferior to the fusion of the septum and retractor band. The multilayered septum is then opened horizontally in both directions to expose the orbital fat pads (Fig 3). Gentle pressure on the globe will help identify the fat, the key anatomic landmark for the lower eyelid retractors (Fig 4). The orbital fat is retracted to expose the underlying white retractor band. If identification is difficult, the patient is asked to look downward and the normal excursion of the retractors can be observed. Blunt dissection cleans the retractor band and it is inspected for dehiscence or attenuation. Attention is drawn to the skin-muscle flap. The inferior skin edge is grasped with forceps and another forceps grasps the underlying orbicularis muscle. Countertension is applied, and a snip incision opens a plane between the two. The preseptal orbicularis oculi muscle is sharply dissected away from the skin across the entire eyelid. This is extended down to the inferior orbital rim and across 1252
the entire incision. Care is taken to avoid buttonholing ofthe thin eyelid skin. The muscle is then extirpated with sharp dissection (Fig 5). The retractor band is advanced and sutured to the inferior border of tarsus with 5-0 Vicryl suture on a spatula needle (Fig 6). The anterior border of tarsus must be avoided to prevent postoperative ectropion. Eyelid position and contour are evaluated in primary gaze and downgaze. The amount of effect of the retractors can be titrated as desired by suture placement and adjustment. A "hang back" suture to the inferior border of the tarsus can be used if a smaller effect on the vertical tightening is desired. Excess orbital fat can be easily removed if desired. No effort is made to suture the orbital septum. A horizontal eyelid tightening procedure, the lateral tarsal strip procedure, may be performed if desired. 19 A lateral canthotomy is performed and followed by transection of the inferior crus of the lateral canthal tendon. The eyelid is split at the gray line, and a tarsal strip is fashioned from the posterior lamella and anchored to the lateral orbital wall periosteum to correct the canthal malposition and elevate the lateral canthus (Fig 7). A small amount of excess skin is removed from the
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Fig 8. Immediate postoperatively.
steroid ointment is applied four times a day. The nylon sutures are removed in I week.
RESULTS
Fig 6. The lower eyelid retractor band is advanced and anchored to the inferior border of tarsus to stabilize the eyelid vertically. Care is taken not to suture the retractors to the anterior border of tarsus.
Fig 7. A lateral tarsal strip procedure has been performed to horizontally tighten and stabilize the eyelid. The anterior lamella of the eyelid is then trimmed.
inferior edge of the incision as necessary. The lower eyelid incision is closed with a running 6-0 nylon suture. The lateral canthal skin is closed with interrupted nylon sutures (Fig 8). A firm pressure patch is applied. An antibiotic-
During the study period, 40 patients were identified with involutional entropion with symptoms of redness, tearing, and foreign body sensation. Results of slit-lamp examination showed conjunctival injection, chemosis, and corneal and conjunctival abrasions. Ten patients presented with bilateral entropion. Previous surgery had been performed by other surgeons on eight patients, including two with bilateral entropion. Surgical procedures consisted of pentagon resection combined with full-thickness sutures, the corn crib procedure, or tucking of the orbital septum. There were 22 men (6 bilateral) and 18 women (4 bilateral). Ages ranged from 56 to 98 years (mean, 80 years, unilateral and bilateral; median, 82 years). Mean followup was 3.15 years (range, 1.25 to 5.25 years). Each entropic eyelid underwent direct repair of the lower eyelid retractors and extirpation of the preseptal orbicularis oculi muscle. Forty-two eyelids also received a lateral tarsal strip procedure (Fig 7). Postoperative evaluation included slit-lamp examination and external examination. To evaluate the effect of removal of the preseptal orbicularis oculi muscle on the lacrimal pump system, each patient was specifically questioned about excess tearing, and the dye disappearance test (DDT) and Jones 1 test were performed on both eyes at each postoperative evaluation. In the 30 unilateral patients, the opposite eye was used for comparison for the DDT, while the bilateral cases were evaluated for symmetry. Three patients complained of intermittent unilateral excess tearing postoperatively and demonstrated an asymmetrical DDT and Jones 1 test (Figs 8, 9). Lacrimal irrigation demonstrated a partial nasolacrimal obstruction on that side. No patient had bilateral excess tearing. None 1253
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of these patients were significantly bothered by the tearing and no patient desired surgical intervention for the tearing. Overcorrections occurred in two patients in which no horizontal tightening was performed (Fig 10). A lateral tarsal strip procedure was performed in the office to correct the abnormality. Punctal eversion with mild ectropion was seen in one patient at 1 week after surgery and resolved with localized massage. Suture granulomas occurred in four patients at the lateral canthus after a tarsal strip procedure. These resolved with excision and/or local steroid injection. Orbicularis extirpation was combined with a marginal rotation (Weis) procedure in an additional patient with involutional entropion. The patient exhibited a greater than expected initial overcorrection. All full-thickness. sutures were removed within 1 week and massage was vigorously applied for a few weeks. A small overcorrection remained that required no additional treatment.
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Fig 9. Three months postoperatively with stable eyelid margin position and contour.
DISCUSSION Lower eyelid retractor weakening, horizontal laxity, overriding of the preseptal orbicularis oculi muscle, and relative enophthalmos are recognized factors in the etiology of involutional entropion. Most current procedures correct only one or two of these factors and recurrences remain common. The surgeon must recognize the different pathophysiologic factors involved in the evolution of involutional entropion and its repair must be based on the correction of the anatomic defects to yield the best functional and aesthetic results. The lower eyelid retractors have a firm insertion on the inferior border of tarsus and are essential for stabilization of the tarsal plate and function of the lower eyelid. Because postoperative lagophthalmos followed many of their septal tuck procedures, Jones et al lS recognized the true anatomic defect in most cases of involutional entropion and devised a direct repair of the lower eyelid retractors and associated vertical laxity.20 Excellent results were obtained. This technique remains the basis for an anatomic repair of attenuation, dehiscence, or possible disinsertion of the retractor band of the lower eyelid. However, this technique is not adequate by itself in cases with significant horizontal laxity or preseptal orbicularis override and recurrences occur if these factors are not addressed. A combined procedure is necessary or preferable in many cases. True or relative horizontal eyelid laxity is present to some degree in almost all patients in the age groups with involutional entropion. Canthal tendon laxity, especially laterally, is the most common factor oflower eyelid laxity. The lateral tarsal strip procedure described by Anderson and Gordy I 9 repairs canthal malposition and accomplishes shortening of the eyelid, while avoiding phimosis and a lid notch. Correction of horizontal laxity has been advocated in the literature in a small percentage of cases when combined with repair of the lower eyelid retractors. 14- 17 In the patients in this study, 42 of 50 eyelids were determined preoperatively or intraoperatively to re1254
Fig 10. Postoperative overcorrection. This required a subsequent lateral tarsal strip procedure.
quire horizontal eyelid tightening. It is important to reevaluate the need for horizontal laxity repair intraoperatively after placing sutures to repair the lower eyelid retractors. A displacement of the eyelid may occur at this point, indicating a more apparent true or relative horizontal laxity than was evident during the preoperative evaluation. Overcorrections occurred in two patients in whom no horizontal tightening was performed. These patients presented early in the series and the surgeon was probably reluctant to perform a horizontal tightening procedure unless an obvious amount oflaxity was found at the preoperative evaluation. Almost all patients in this age group demonstrated some need for horizontal tightening. The lateral tarsal strip procedure is advocated in most cases of involutional entropion repair combined with retractor repair and orbicularis extirpation. Dortzbach and McGetrick4 also advocate plication of the inferior crus of the medial canthal tendon when laxity of the medial eyelid is demonstrated. However, medial canthal procedures may produce kinking or malfunction of the canaliculus. It is difficult to position the medial canthus as posteriorly
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as desired without affecting canalicular function. The tarsal strip procedure is used alone when horizontal laxity exists. A slight lateral displacement of the lacrimal puncta has not been a functional or cosmetic problem. The lateral tarsal strip procedure is especially useful in recurrent cases in which prior eyelid shortenings have resulted in phimosis despite recurrent horizontal laxity of the eyelids. The preseptal orbicularis oculi muscle loses its firm attachments to the underlying orbital septum as well as the extensions to the skin, allowing upward and forward movement over the pretarsal portion with blinking or moderate contraction. This encourages inward rotation of the eyelid margin and tarsal sling if loss of the firm adhesion afforded by the lower eyelid retractors leads to instability. Orbicularis oculi muscle surgery gained great attention this century as the focus for the repair of involutional entropion. However, with the advent and emphasis ofthe more anatomic retractor approach, the role of the orbicularis muscle in entropion repair has largely been abandoned. Hsu and Liu 21 recently reintroduced an orbicularis bolstering procedure, but addressed the lower eyelid retractors and horizontal laxity only indirectly. The main intent of all of the orbicularis transposition or strengthening procedures has been to form a physical tissue barrier to prevent overriding of the preseptal portion. However, if the stability of the inferior tarsus and remainder of the posterior lamella is not addressed directly, these procedures often fail. Most of these procedures involved simple or intricate methods of tightening or transposing strips of pretarsal or preseptal orbicularis muscle to promote this barrier. A retractor repair and the lateral tarsal strip procedure was previously utilized for involution entropion by the author, but persistent orbicularis upward migration and override persisted despite a stable position of the eyelid margin. Removal of the preseptal orbicularis oculi muscle seems a more logical method to address the problem of overriding orbicularis oculi muscle by removing the actual anatomic correlate for this problem. This also stimulates adherence of the lower eyelid skin to the orbital septum, thus further stabilizing the anterior lamella and removing a force that tips the lid margin inward. There have been no cases of extensive subcutaneous scarring leading to cicatricial ectropion in this series. The adherence of the skin to the underlying orbital septum could theoretically cause rigidity and loss of some mobility of the lower eyelid (Marcos Doxanas, Richard Dortzbach, Bradley Lemke; personal communications). These findings have been minimal in these 50 procedures, and the overall appearance and function of the lower eyelid has been satisfactory. Excision of only a conservative amount of skin from the lower eyelid is also stressed. This simple and easily performed technique has proven to be an important adjunct to lower eyelid retractor repair and correction of horizontal laxity. Marginal rotation of the lower eyelid is often utilized for involutional and cicatricial entropion and redirects tension forces on the anterior lamella near the lid margin. 22 Creation of a scar barrier prevents upward movement of the preseptal orbicularis oculi muscle. Although
a small overcorrection is desired initially, this usually resolves spontaneously, partly due to contraction of the orbicularis muscle. 23 Orbicularis extirpation apparently removed this compensating factor and encouraged the development of a cicatricial overcorrection. Orbicularis extirpation is not recommended as an adjunct to marginal rotation because of the tendency to accentuate overcorrection. The deep heads of the preseptal (Jones) muscle are felt to be important in the lacrimal outflow pump through its attachments to the lacrimal crest and diaphragm. Patients with a seventh nerve palsy often experience symptoms of excess tearing due to loss of the lacrimal pump. Disruption of a large portion of the preseptal orbicularis oculi muscle could affect the lower eyelid pump and result in excess tearing. Jones warned that the inner one third of the eyelid should not be involved in entropion repair to avoid injury to the lacrimal pump.20 However, an incision that extends well within the inner one third of the eyelid is used in this technique and excision of preseptal orbicularis muscle in this area has not resulted in excess tearing. Only 3 of our 40 patients complained of postoperative intermittent excess tearing, and all demonstrated a partial nasolacrimal obstruction on lacrimal irrigation. The majority of the patients had no subjective or objective findings consistent with loss of lacrimal pump. The relationship, if any, between the patients with the unilateral partial nasolacrimal obstruction and involutional entropion is unknown. Recurrent entropion is difficult to repair as both the underlying pathophysiologic factors and abnormal scar barriers need to be evaluated and addressed. This combined procedure offers a logical approach to the repair of recurrent entropion by correction of the anterior and posterior lamellar defects. A direct correction of the anatomic and iatrogenic defects is accomplished with the combined procedure and yielded excellent results for the ten recurrent eyelids in this series, regardless of the type of initial surgical procedure. In summary, involutional entropion repair remains a difficult clinical problem for the practicing ophthalmologist. Surgical techniques are numerous, yet no single method corrects the anatomic findings found in most cases and recurrences remain common. The surgeon must recognize the multiple anatomic defects that contribute to the pathophysiology of involutional entropion. Any technique that will survive the test of time must recognize these principles and eliminate the overriding preseptal orbicularis muscle, repair the dehiscence, attenuation, or disinsertion of the lower eyelid retractors, and reapproximate the lid margin to the globe by correcting the horizontal canthal tendon laxity. I believe the techniques and results documented in this report are direct applications of these principles and provide superior functional and aesthetic results. Advantages to the combined procedure include: (1) the procedure is anatomic and addresses the underlying anatomic findings; (2) both anterior and posterior lamellae defects are repaired; (3) the preseptal orbicularis muscle is removed and prevents override; (4) lateral canthal deformity and horizontal laxity are repaired without excision 1255
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of normal full-thickness eyelid; (5) the lower eyelid retractors are directly repaired; (6) the procedure is ideal for local anesthesia and can be titrated intraoperatively; (7) lid notching, lagophthalmos, and phimosis are avoided; (8) the lacrimal pump is clinically unaltered; and (9) the procedure is a logical approach for the repair of recurrent involutional 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. Collin JRO, Rathbun JE. Involutional entropion. A review with evaluation of a procedure. Arch Ophthalmol 1978; 96: 1058-64. 3. Dalgleish R, Smith JLS. Mechanics and histology of senile entropion. Br J Ophthalmol1966; 50:79-91. 4. Dortzbach RK, McGetrick JJ. Involutional entropion of the lower eyelid. Adv Ophthalmic Plast Reconstr Surg 1983; 2:257-67. 5. Hawes MJ, Dortzbach RK. The microscopic anatomy of the lower eyelid retractors. Arch Ophthalmol1982; 100:1313-8. 6. Nowinski T, Anderson RL. Advances in eyelid mal positions. Ophthalmic Plast Reconstr Surg 1985; 1:145-8. 7. Celsus. As cited in: Hirschberg J. The History of Ophthalmology. Vol. 1: Antiquity. Bonn: JP Wayenborgh, 1982; 244-5. 8. Hotz FC. Eine neue Operation fOr Entropium und Trichiasis. Arch f Augenh 1880;9:68-80. Simultaneously published: Hotz FC. A new operation for entropion and trichiasis. Arch Ophthalmol1879; 8:24963.
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9. Vialeix V. Le traitement de choix de I'entropion dit spasmodique description d'un procede operatoire. Ann Ocu11929; 166:102-5. 10. Wheeler JM. Spastic-entropion correction by orbicularis transplantation. Am J Ophthalmol1939; 22:477-83. 11. Sisler HA. A biomechanical and physiological approach to corrective surgery for senile entropion. Ann Ophthalmol1973; 5:483-95. 12. Hill JC, Feldman F. Tissue barrier modifications of a Wheeler II operation for entropion. Arch Ophthalmol1967; 78:621-3. 13. Stasior OG. Entropion. In: Callahan MA, Callahan A, eds. Ophthalmic Plastic and Orbital Surgery. Birmingham: Aesculapius, 1979;84-5. 14. Hargiss JL. Inferior aponeurosis vs orbital septum tucking for senile entropion. Arch Ophthalmol1973; 89:210-3. 15. Jones LT, Reeh MJ, Wobig JL. Senile entropion: a new concept for correction. Am J Ophthalmol1972; 74:327-9. 16. Dryden RM, Leibsohn J, Wobig J. Senile entropion: pathogenesis and treatment. Arch Ophthalmol1978; 96:1883-5. 17. Schaefer AJ. Variation in the pathophysiology of involutional entropion and its treatment. Ophthalmic Surg 1983; 14:653-5. 18. Wesley RE, Collins Jw. Combined procedure for senile entropion. OphthalmiC Surg 1983; 14:401-5. 19. Anderson RL, Gordy DO. The tarsal strip procedure. Arch Ophthalmol 1979; 97:2192-6. 20. Jones LT, Reeh MJ, Tsujimura JK. Senile entropion. Am J Ophthalmol 1963; 55:463-9. 21. Hsu WM, Liu D. A new approach to the correction of involutional entropion by pretarsal orbicularis oculi muscle fixation. Am J Ophthalmol 1985; 100:802-5. 22. Wies FA. SpastiC entropion. Trans Am Acad Ophthalmol Otolaryngol 1955; 59:503-6. 23. Baylis HI, Cies WA, Kamin OF. Overcorrections of the Wies procedure. Ann OphthalmoI1977; 9:744-8.
Abstract: Many factors are important in the pathophysiology of involutional entropion, including defects of the lower eyelid retractors, canthal tendon laxity, and acquired enophthalmos. The role of the overriding preseptal orbicularis oculi muscle is often ignored in modern techniques of entropion repair. The author describes a technique of extirpation of the preseptal orbicularis oculi muscle combined with repair of the lower eyelid retractors and a lateral tarsal strip procedure for the repair of primary and recurrent involutional entropion. Lateral canthal tendon laxity is recognized in most patients in this age group and must be corrected to avoid postoperative overcorrection and ectropion. Removal of the preseptal muscle had no clinical effect on the lacrimal pump and did not cause any significant cicatricial eyelid abnormalities. This combined procedure has been used in 50 eyelids of 40 patients with excellent functional and cosmetic results. Orbicularis extirpation is not advocated in combination with a marginal rotation procedure. Ophthalmology 1991; 98:1250-1256
Involutional entropion is one of the most common eyelid malpositions seen in clinical practice. Surgical procedures abound for its repair, yet recurrences remain common. Multiple factors are important in the pathogenesis of involutional entropion, including dehiscence, attenuation, or disinsertion ofthe lower eyelid retractors, horizontal canthal tendon laxity, upward migration and overriding of the preseptal orbicularis oculi muscle, and possibly enophthalmos secondary to aging. 1-6 Many anterior lamellar procedures have been recorded for the repair of involutional entropion. Celsus7 advocated an excision of skin and orbicularis muscle during the 1st century. Hotz8 advocated formation of a scar barrier by Originally received: October 28, 1990. Revision accepted: March 7, 1991 . From the Oculoplastics Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia. Presented at the American Academy of Ophthalmology Annual Meeting, Atlanta, Oct/Nov 1990. Reprint requests to Thaddeus S. Nowinski,' MD, Oculoplastics Service, Wills Eye Hospital, Ninth and Walnut Sts, Philadelphia, PA 19107.
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direct suturing of skin to the tarsus. Vialeix 9 advocated partial excision of the pretarsal orbicularis oculi muscle. Wheeler lO described procedures for transposing a strip of preseptal orbicularis muscle to the periosteum of the zygoma or resection and tightening the preseptal orbicularis to form a physical barrier to prevent its upward migration. Sisler ll modified Wheeler's technique with horizontal to vertical redirection of strips of preseptal orbicularis oculi muscle. Hill and Feldman l2 and Stasior l3 modified Wheeler's concepts and performed a lid shortening procedure in selected cases. The modification performed by Hill and Feldman was considered the procedure of choice of most oculoplastic surgeons as recently as 20 years ago. 14 However, a relatively high recurrence rate and a lack of adequate correction of the underlying anatomic defect of the lower eyelid retractors allowed these procedures to fall into disfavor. Jones et aIlS described an approach to the lower eyelid retractors to directly repair the clinical posterior lamella anatomic defect seen in most cases of involutional entropion. This procedure and its variations have become the current procedure of choice for the repair of entropion, This approach was based on an increased knowledge of
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Fig 1. Involutional entropion.
for conjunctival abrasions, chemosis, injection, corneal abrasions, thinning, ulceration, scarring, and blood vessel ingrowth. " Each patient was evaluated by the author for clinical signs of involutional entropion including instability and inward rotation of the tarsal eyelid, overriding of the preseptal orbicularis oculi muscle on the pretarsal portion, and loss of downward excursion of the lower eyelid on downgaze. Overriding of the preseptal portion of the orbicularis oculi muscle on the pretarsal portion was evaluated in the resting state, after blinking, and after forceful lid closure. Lower eyelid excursion was evaluated in primary gaze and downgaze. Lid margin position was evaluated in resting state. All lid margins could be reapproximated by digital eversion with minimal tension. The fornix was evaluated for signs of a deep fornix relative to the opposite side and for the presence of a white line suggesting a retractor disinsertion. Horizontal laxity was evaluated by pinching the lower eyelid and noting the excursion away from the globe and the amount of movement of the inferior punctum laterally on horizontal traction. Patients with symblepharon or conjunctival or subconjunctival scarring were excluded.
PROCEDURE
Fig 2. The orbicularis muscle is incised after an infraciliary incision is made. Forceps tent the skin anteriorly to aid dissection. A skin-muscle flap is dissected away from the orbital septum.
lower eyelid pathophysiology and attempted to reapproximate the normal lower eyelid anatomy and significantly improve the rate of success. However, recurrences occur if horizontal laxity or orbicularis override are not recognized and repaired. 16- 18 A combined procedure is described for the repair of primary and recurrent involutional entropion in 50 eyelids in 40 patients. Repair of the lower eyelid retractors, horizontallaxity, and overriding preseptal orbicularis oculi muscle is used in a predictable and functional approach to this common eyelid malposition.
SUBJECTS AND METHODS Fifty eyelids of 40 patients who presented between July 1985 and July 1989 with involutional entropion were repaired with this combined technique. Eight patients (ten eyelids) had histories of previous repairs by other surgeons. All patients complained of foreign body sensation, redness, and discharge. Slit-lamp examination included inspection
The lower eyelid and lateral canthus are infiltrated with 2% lidocaine hydrochloride with 1: 100,000 epinephrine mixed in equal portions with 0.5% bupivacaine hydrochloride. A 4-0 silk traction suture is placed through the eyelid margin and the eyelid is retracted superiorly, thus placing tension on the posterior lamellar layers of the conjuctiva, tarsus, eyelid retractors, and orbital septum. The looser anterior lamellar skin and orbicularis oculi muscle can be mobilized anteriorly (Figs 1, 2). A # 15 Bard Parker blade is used to make a subcilliary incision through the skin beginning just lateral to the punctum. This incision can be extended to the lateral palpebral raphe if horizontal laxity is obviously present. If horizontal laxity is absent, or if the surgeon is unsure if horizontal tightening is necessary, the initial incision should extend only across the lower eyelid. This can be extended into the lateral canthal area later if necessary. The skin and orbicularis muscle inferior to the incision are grasped with forceps and tented anteriorly. The orbicularis muscle is then incised centrally with Westcott scissors. This approximates the juncture of the pretarsal and preseptal orbicularis layers. The tips of the scissors should be directed inferiorly so a plane is developed between the postorbicularis fascia and the orbital septum. Damage to the posterior lamellar structures may occur if the scissors are directed perpendicular to the incision and dissection inadvertently extends too deep. One blade of the scissors is passed bluntly in the avascular postorbicularis fascia plane and the incision is extended in both directions with a few snips with minimal dissection. Dissection is continued in a plane between the orbicularis muscle and the orbital septum to just below the inferior orbital rim. This is facilitated by the traction suture, which keeps tension on the orbital septum. 1251
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Fig 3. The orbital septum has been incised to expose the fat pads of the lower eyelid (arrow). These are analogous to the preaponeurotic fat pad of the upper eyelid.
Fig 5. Top, The preseptai orbicularis muscle (straight arrow) is dissected away from the skin (curved arrow) down to the area over the inferior orbital rim. Bottom, The preseptai orbicularis muscle (arrow) is then extirpated across the entire eyelid. Fig 4. The lower eyelid retractor band (straight arrow) is identified as a white band posterior to the orbital fat (curved arrow). Blunt and sharp dissection isolates this band from the surrounding structures.
An incision is made through the orbital septum well inferior to the fusion of the septum and retractor band. The multilayered septum is then opened horizontally in both directions to expose the orbital fat pads (Fig 3). Gentle pressure on the globe will help identify the fat, the key anatomic landmark for the lower eyelid retractors (Fig 4). The orbital fat is retracted to expose the underlying white retractor band. If identification is difficult, the patient is asked to look downward and the normal excursion of the retractors can be observed. Blunt dissection cleans the retractor band and it is inspected for dehiscence or attenuation. Attention is drawn to the skin-muscle flap. The inferior skin edge is grasped with forceps and another forceps grasps the underlying orbicularis muscle. Countertension is applied, and a snip incision opens a plane between the two. The preseptal orbicularis oculi muscle is sharply dissected away from the skin across the entire eyelid. This is extended down to the inferior orbital rim and across 1252
the entire incision. Care is taken to avoid buttonholing ofthe thin eyelid skin. The muscle is then extirpated with sharp dissection (Fig 5). The retractor band is advanced and sutured to the inferior border of tarsus with 5-0 Vicryl suture on a spatula needle (Fig 6). The anterior border of tarsus must be avoided to prevent postoperative ectropion. Eyelid position and contour are evaluated in primary gaze and downgaze. The amount of effect of the retractors can be titrated as desired by suture placement and adjustment. A "hang back" suture to the inferior border of the tarsus can be used if a smaller effect on the vertical tightening is desired. Excess orbital fat can be easily removed if desired. No effort is made to suture the orbital septum. A horizontal eyelid tightening procedure, the lateral tarsal strip procedure, may be performed if desired. 19 A lateral canthotomy is performed and followed by transection of the inferior crus of the lateral canthal tendon. The eyelid is split at the gray line, and a tarsal strip is fashioned from the posterior lamella and anchored to the lateral orbital wall periosteum to correct the canthal malposition and elevate the lateral canthus (Fig 7). A small amount of excess skin is removed from the
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Fig 8. Immediate postoperatively.
steroid ointment is applied four times a day. The nylon sutures are removed in I week.
RESULTS
Fig 6. The lower eyelid retractor band is advanced and anchored to the inferior border of tarsus to stabilize the eyelid vertically. Care is taken not to suture the retractors to the anterior border of tarsus.
Fig 7. A lateral tarsal strip procedure has been performed to horizontally tighten and stabilize the eyelid. The anterior lamella of the eyelid is then trimmed.
inferior edge of the incision as necessary. The lower eyelid incision is closed with a running 6-0 nylon suture. The lateral canthal skin is closed with interrupted nylon sutures (Fig 8). A firm pressure patch is applied. An antibiotic-
During the study period, 40 patients were identified with involutional entropion with symptoms of redness, tearing, and foreign body sensation. Results of slit-lamp examination showed conjunctival injection, chemosis, and corneal and conjunctival abrasions. Ten patients presented with bilateral entropion. Previous surgery had been performed by other surgeons on eight patients, including two with bilateral entropion. Surgical procedures consisted of pentagon resection combined with full-thickness sutures, the corn crib procedure, or tucking of the orbital septum. There were 22 men (6 bilateral) and 18 women (4 bilateral). Ages ranged from 56 to 98 years (mean, 80 years, unilateral and bilateral; median, 82 years). Mean followup was 3.15 years (range, 1.25 to 5.25 years). Each entropic eyelid underwent direct repair of the lower eyelid retractors and extirpation of the preseptal orbicularis oculi muscle. Forty-two eyelids also received a lateral tarsal strip procedure (Fig 7). Postoperative evaluation included slit-lamp examination and external examination. To evaluate the effect of removal of the preseptal orbicularis oculi muscle on the lacrimal pump system, each patient was specifically questioned about excess tearing, and the dye disappearance test (DDT) and Jones 1 test were performed on both eyes at each postoperative evaluation. In the 30 unilateral patients, the opposite eye was used for comparison for the DDT, while the bilateral cases were evaluated for symmetry. Three patients complained of intermittent unilateral excess tearing postoperatively and demonstrated an asymmetrical DDT and Jones 1 test (Figs 8, 9). Lacrimal irrigation demonstrated a partial nasolacrimal obstruction on that side. No patient had bilateral excess tearing. None 1253
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of these patients were significantly bothered by the tearing and no patient desired surgical intervention for the tearing. Overcorrections occurred in two patients in which no horizontal tightening was performed (Fig 10). A lateral tarsal strip procedure was performed in the office to correct the abnormality. Punctal eversion with mild ectropion was seen in one patient at 1 week after surgery and resolved with localized massage. Suture granulomas occurred in four patients at the lateral canthus after a tarsal strip procedure. These resolved with excision and/or local steroid injection. Orbicularis extirpation was combined with a marginal rotation (Weis) procedure in an additional patient with involutional entropion. The patient exhibited a greater than expected initial overcorrection. All full-thickness. sutures were removed within 1 week and massage was vigorously applied for a few weeks. A small overcorrection remained that required no additional treatment.
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Fig 9. Three months postoperatively with stable eyelid margin position and contour.
DISCUSSION Lower eyelid retractor weakening, horizontal laxity, overriding of the preseptal orbicularis oculi muscle, and relative enophthalmos are recognized factors in the etiology of involutional entropion. Most current procedures correct only one or two of these factors and recurrences remain common. The surgeon must recognize the different pathophysiologic factors involved in the evolution of involutional entropion and its repair must be based on the correction of the anatomic defects to yield the best functional and aesthetic results. The lower eyelid retractors have a firm insertion on the inferior border of tarsus and are essential for stabilization of the tarsal plate and function of the lower eyelid. Because postoperative lagophthalmos followed many of their septal tuck procedures, Jones et al lS recognized the true anatomic defect in most cases of involutional entropion and devised a direct repair of the lower eyelid retractors and associated vertical laxity.20 Excellent results were obtained. This technique remains the basis for an anatomic repair of attenuation, dehiscence, or possible disinsertion of the retractor band of the lower eyelid. However, this technique is not adequate by itself in cases with significant horizontal laxity or preseptal orbicularis override and recurrences occur if these factors are not addressed. A combined procedure is necessary or preferable in many cases. True or relative horizontal eyelid laxity is present to some degree in almost all patients in the age groups with involutional entropion. Canthal tendon laxity, especially laterally, is the most common factor oflower eyelid laxity. The lateral tarsal strip procedure described by Anderson and Gordy I 9 repairs canthal malposition and accomplishes shortening of the eyelid, while avoiding phimosis and a lid notch. Correction of horizontal laxity has been advocated in the literature in a small percentage of cases when combined with repair of the lower eyelid retractors. 14- 17 In the patients in this study, 42 of 50 eyelids were determined preoperatively or intraoperatively to re1254
Fig 10. Postoperative overcorrection. This required a subsequent lateral tarsal strip procedure.
quire horizontal eyelid tightening. It is important to reevaluate the need for horizontal laxity repair intraoperatively after placing sutures to repair the lower eyelid retractors. A displacement of the eyelid may occur at this point, indicating a more apparent true or relative horizontal laxity than was evident during the preoperative evaluation. Overcorrections occurred in two patients in whom no horizontal tightening was performed. These patients presented early in the series and the surgeon was probably reluctant to perform a horizontal tightening procedure unless an obvious amount oflaxity was found at the preoperative evaluation. Almost all patients in this age group demonstrated some need for horizontal tightening. The lateral tarsal strip procedure is advocated in most cases of involutional entropion repair combined with retractor repair and orbicularis extirpation. Dortzbach and McGetrick4 also advocate plication of the inferior crus of the medial canthal tendon when laxity of the medial eyelid is demonstrated. However, medial canthal procedures may produce kinking or malfunction of the canaliculus. It is difficult to position the medial canthus as posteriorly
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as desired without affecting canalicular function. The tarsal strip procedure is used alone when horizontal laxity exists. A slight lateral displacement of the lacrimal puncta has not been a functional or cosmetic problem. The lateral tarsal strip procedure is especially useful in recurrent cases in which prior eyelid shortenings have resulted in phimosis despite recurrent horizontal laxity of the eyelids. The preseptal orbicularis oculi muscle loses its firm attachments to the underlying orbital septum as well as the extensions to the skin, allowing upward and forward movement over the pretarsal portion with blinking or moderate contraction. This encourages inward rotation of the eyelid margin and tarsal sling if loss of the firm adhesion afforded by the lower eyelid retractors leads to instability. Orbicularis oculi muscle surgery gained great attention this century as the focus for the repair of involutional entropion. However, with the advent and emphasis ofthe more anatomic retractor approach, the role of the orbicularis muscle in entropion repair has largely been abandoned. Hsu and Liu 21 recently reintroduced an orbicularis bolstering procedure, but addressed the lower eyelid retractors and horizontal laxity only indirectly. The main intent of all of the orbicularis transposition or strengthening procedures has been to form a physical tissue barrier to prevent overriding of the preseptal portion. However, if the stability of the inferior tarsus and remainder of the posterior lamella is not addressed directly, these procedures often fail. Most of these procedures involved simple or intricate methods of tightening or transposing strips of pretarsal or preseptal orbicularis muscle to promote this barrier. A retractor repair and the lateral tarsal strip procedure was previously utilized for involution entropion by the author, but persistent orbicularis upward migration and override persisted despite a stable position of the eyelid margin. Removal of the preseptal orbicularis oculi muscle seems a more logical method to address the problem of overriding orbicularis oculi muscle by removing the actual anatomic correlate for this problem. This also stimulates adherence of the lower eyelid skin to the orbital septum, thus further stabilizing the anterior lamella and removing a force that tips the lid margin inward. There have been no cases of extensive subcutaneous scarring leading to cicatricial ectropion in this series. The adherence of the skin to the underlying orbital septum could theoretically cause rigidity and loss of some mobility of the lower eyelid (Marcos Doxanas, Richard Dortzbach, Bradley Lemke; personal communications). These findings have been minimal in these 50 procedures, and the overall appearance and function of the lower eyelid has been satisfactory. Excision of only a conservative amount of skin from the lower eyelid is also stressed. This simple and easily performed technique has proven to be an important adjunct to lower eyelid retractor repair and correction of horizontal laxity. Marginal rotation of the lower eyelid is often utilized for involutional and cicatricial entropion and redirects tension forces on the anterior lamella near the lid margin. 22 Creation of a scar barrier prevents upward movement of the preseptal orbicularis oculi muscle. Although
a small overcorrection is desired initially, this usually resolves spontaneously, partly due to contraction of the orbicularis muscle. 23 Orbicularis extirpation apparently removed this compensating factor and encouraged the development of a cicatricial overcorrection. Orbicularis extirpation is not recommended as an adjunct to marginal rotation because of the tendency to accentuate overcorrection. The deep heads of the preseptal (Jones) muscle are felt to be important in the lacrimal outflow pump through its attachments to the lacrimal crest and diaphragm. Patients with a seventh nerve palsy often experience symptoms of excess tearing due to loss of the lacrimal pump. Disruption of a large portion of the preseptal orbicularis oculi muscle could affect the lower eyelid pump and result in excess tearing. Jones warned that the inner one third of the eyelid should not be involved in entropion repair to avoid injury to the lacrimal pump.20 However, an incision that extends well within the inner one third of the eyelid is used in this technique and excision of preseptal orbicularis muscle in this area has not resulted in excess tearing. Only 3 of our 40 patients complained of postoperative intermittent excess tearing, and all demonstrated a partial nasolacrimal obstruction on lacrimal irrigation. The majority of the patients had no subjective or objective findings consistent with loss of lacrimal pump. The relationship, if any, between the patients with the unilateral partial nasolacrimal obstruction and involutional entropion is unknown. Recurrent entropion is difficult to repair as both the underlying pathophysiologic factors and abnormal scar barriers need to be evaluated and addressed. This combined procedure offers a logical approach to the repair of recurrent entropion by correction of the anterior and posterior lamellar defects. A direct correction of the anatomic and iatrogenic defects is accomplished with the combined procedure and yielded excellent results for the ten recurrent eyelids in this series, regardless of the type of initial surgical procedure. In summary, involutional entropion repair remains a difficult clinical problem for the practicing ophthalmologist. Surgical techniques are numerous, yet no single method corrects the anatomic findings found in most cases and recurrences remain common. The surgeon must recognize the multiple anatomic defects that contribute to the pathophysiology of involutional entropion. Any technique that will survive the test of time must recognize these principles and eliminate the overriding preseptal orbicularis muscle, repair the dehiscence, attenuation, or disinsertion of the lower eyelid retractors, and reapproximate the lid margin to the globe by correcting the horizontal canthal tendon laxity. I believe the techniques and results documented in this report are direct applications of these principles and provide superior functional and aesthetic results. Advantages to the combined procedure include: (1) the procedure is anatomic and addresses the underlying anatomic findings; (2) both anterior and posterior lamellae defects are repaired; (3) the preseptal orbicularis muscle is removed and prevents override; (4) lateral canthal deformity and horizontal laxity are repaired without excision 1255
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of normal full-thickness eyelid; (5) the lower eyelid retractors are directly repaired; (6) the procedure is ideal for local anesthesia and can be titrated intraoperatively; (7) lid notching, lagophthalmos, and phimosis are avoided; (8) the lacrimal pump is clinically unaltered; and (9) the procedure is a logical approach for the repair of recurrent involutional 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. Collin JRO, Rathbun JE. Involutional entropion. A review with evaluation of a procedure. Arch Ophthalmol 1978; 96: 1058-64. 3. Dalgleish R, Smith JLS. Mechanics and histology of senile entropion. Br J Ophthalmol1966; 50:79-91. 4. Dortzbach RK, McGetrick JJ. Involutional entropion of the lower eyelid. Adv Ophthalmic Plast Reconstr Surg 1983; 2:257-67. 5. Hawes MJ, Dortzbach RK. The microscopic anatomy of the lower eyelid retractors. Arch Ophthalmol1982; 100:1313-8. 6. Nowinski T, Anderson RL. Advances in eyelid mal positions. Ophthalmic Plast Reconstr Surg 1985; 1:145-8. 7. Celsus. As cited in: Hirschberg J. The History of Ophthalmology. Vol. 1: Antiquity. Bonn: JP Wayenborgh, 1982; 244-5. 8. Hotz FC. Eine neue Operation fOr Entropium und Trichiasis. Arch f Augenh 1880;9:68-80. Simultaneously published: Hotz FC. A new operation for entropion and trichiasis. Arch Ophthalmol1879; 8:24963.
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9. Vialeix V. Le traitement de choix de I'entropion dit spasmodique description d'un procede operatoire. Ann Ocu11929; 166:102-5. 10. Wheeler JM. Spastic-entropion correction by orbicularis transplantation. Am J Ophthalmol1939; 22:477-83. 11. Sisler HA. A biomechanical and physiological approach to corrective surgery for senile entropion. Ann Ophthalmol1973; 5:483-95. 12. Hill JC, Feldman F. Tissue barrier modifications of a Wheeler II operation for entropion. Arch Ophthalmol1967; 78:621-3. 13. Stasior OG. Entropion. In: Callahan MA, Callahan A, eds. Ophthalmic Plastic and Orbital Surgery. Birmingham: Aesculapius, 1979;84-5. 14. Hargiss JL. Inferior aponeurosis vs orbital septum tucking for senile entropion. Arch Ophthalmol1973; 89:210-3. 15. Jones LT, Reeh MJ, Wobig JL. Senile entropion: a new concept for correction. Am J Ophthalmol1972; 74:327-9. 16. Dryden RM, Leibsohn J, Wobig J. Senile entropion: pathogenesis and treatment. Arch Ophthalmol1978; 96:1883-5. 17. Schaefer AJ. Variation in the pathophysiology of involutional entropion and its treatment. Ophthalmic Surg 1983; 14:653-5. 18. Wesley RE, Collins Jw. Combined procedure for senile entropion. OphthalmiC Surg 1983; 14:401-5. 19. Anderson RL, Gordy DO. The tarsal strip procedure. Arch Ophthalmol 1979; 97:2192-6. 20. Jones LT, Reeh MJ, Tsujimura JK. Senile entropion. Am J Ophthalmol 1963; 55:463-9. 21. Hsu WM, Liu D. A new approach to the correction of involutional entropion by pretarsal orbicularis oculi muscle fixation. Am J Ophthalmol 1985; 100:802-5. 22. Wies FA. SpastiC entropion. Trans Am Acad Ophthalmol Otolaryngol 1955; 59:503-6. 23. Baylis HI, Cies WA, Kamin OF. Overcorrections of the Wies procedure. Ann OphthalmoI1977; 9:744-8.
