Dr.Nidhi Pandey, Dr.SWATI JAIN
Abstract
Aim: To report a case series of upper eyelid cicatricial margin entropion with retraction, corrected through a grey-line approach only. We remind readers of the grey-line approach to levatorrecession and lamellar repositioning surgery.
Method: A retrospective review of clinic notes and photographs of patients who underwent grey-line split, levator recession and anterior lamellar repositioning without a skin crease incision, from December 2015 – 2016. Indications for surgery included mild to moderate cicatricial margin upper eyelid entropion, tarsal curling andmeibomian gland inversion. Patients requiring spacer interposition to lengthen the posterior lamella, were excluded from the study. Parameters of study included lid margin position, lid height, ocular surface health and symptom improvement.
Results: Eleven eyelids of eight patients were included in the study, and underwent the procedure described. Lid margin position measured as the Marginal Reflex Distance (MRD1) lowered (improved) in 72.7% of patients. Lid margin eversion was achieved in all eyes (100%). Corneal punctate epithelial erosions markedly improved, being present in 72.7% of patients pre-operatively, and only 9.1% post operatively. Eight of 11 eyes showed symptomatic improvement, with six (54.5%) being completely asymptomatic and two achieving partial relief.An added observation was a Pretarsal show asymmetry in some patients which improved in 36.4% of surgeries post operatively.
Conclusion: Upper eyelid levator recession with grey-line split and anterior lamella repositioning can all be performed via the plane of the split, avoiding a skin incision. Normal lid margin apposition was achieved in all eyes; 91% demonstrating a clear cornea, and 72% having symptomatic improvement.
Key Words : Cicatricial changes , upper lid , Levator Recession , Grey Line split single incision
Introduction
Anterior lamellar repositioning [ALR] is a well known, simple and widely popular method for treating both upper and lower eyelidcicatricial margin entropion.[1-3,5-7]Welsh [1] described ALR with grey-line split (GLS) and suture repositioning for correcting cicatricial entropion in 1969. Some other published techniques have added a lid crease incision with GLS to recess the levator.[2,3 ,4]Studies that describe GLS with recession of the anterior lamellar and no lid crease incision, do not describe concurrent levator recession (LR).[6, 7,8]We report results of a procedure of ALR and LR through a single GLS for upper eyelid cicatricial changes. [Figure 1 a and b]
Materials and method
The study method wasa retrospective review of case notes and photographs of all consecutive patients undergoing the described procedure, over the one year period, from December 2015– December 2016. All surgeries were performed at a singlecentre. The study was approved by the institutional ethics committee .All patients in this study had cicatricial changes in upper lidand underwent a GLS, upper eyelid levator recession, and ALR without a skin crease incision. Patients with severe retraction requiring mucous membrane grafting at the same time as lamella repositioning, or patients with incomplete medical records were excluded. All procedures were performed or supervisedby a single surgeon . Outcomes were assessed based on the review of medical case notes and comparison of standardized preoperative and postoperative clinical photographs assessed by an independent reviewer. Primary outcome measures were as follows: 1) improvement in eyelid margin position and retraction2) improvement in symptoms and 3) improvement in ocular surface health.
Surgical technique
All procedures were performed under local anesthesia (with bupivacaine 0.25% and 1:200,000 adrenaline) and intravenous sedation.
A grey-line incision was first made along the length of the upper eyelid using a No. 15 Bard-Parker blade from the lateral commissure to a point just lateral to the lacrimal punctum. [Figure 2] Dissection was performed between the tarsus and pretarsal orbicularis oculi, using westcott scissors, to reach the superior margin of tarsus. [Figure 3a] Placing the tarsus on traction by the aid of an assistant, the anterior lamella was stretched away from the tarsus to help expose the orbital septum and levator aponeurosis.[Figure 3b] The orbital septum was incised and the levator aponeurosis exposed.Placing the levator aponeurosis on traction by the aid of an assistant,
The septum was further dissected medially and laterally to fully expose levatorpalpebraesuperioris (LPS). LPS and its aponeurosis were subsequently dissected off Muller’s muscle and recessed for approximately three to four mm. [Figure 4 a – c] Tarsal curling was managed by polishing of the anterior surface of tarsus with a no.15 Bard-Parker blade. [Figure 5] The composite flap of skin and pre-tarsal orbicularis was recessed, sutured to anterior tarsal surface using three to four interrupted six-zero absorbable mattress sutures, leaving up to two mm of tarsus visible below the anterior lamella margin. Where anterior lamella was horizontally contracted causing cicatricial lash ptosis, posterior radial incisions were made at the lid margin to restore normal lash direction. [Figure 6]
Post-operatively, all patients were prescribed chloramphenicol ointment four times per day for seven days and a review arranged at two weeks, and subsequently at two months.
Results
Eleven eyelids of eight patients (5 female) underwent the procedure over the time period of the study. The mean age at surgery was 65.6 years (range 46 to 81).Of the eight patients , three patients underwent bilateral surgery , three had surgery to the left eye, and two to the right eye. The presenting complaints were, most commonly, a combination of symptoms of itching, soreness and watering in four patients (50%), foreign body sensation in two (25%), asymmetry between the lids in one (12.5%) and scratchiness in one (12.5%). The patient with asymmetry as presenting complaint was found to have meibomian gland inversion and chronic meibomian gland disease and hence was advised lid eversion surgery .Significant past ocular history included facial nerve palsy in two patients (25%).
The ocular surface changes included inferior punctate epithelial erosions (PEE) in four eyes (36.3%), superotemporal PEEs in three (27.27%), diffuse PEEs in one (9%). Only three eyes had clear corneas at presentation (27.27%), the remainder demonstrating superficial corneal punctate staining. Indications for surgery included meibomian gland inversion (MGI) plus MGD in five eyes (45.5%), MGI with MGD ,Entropion and tarsal curling in two (18.18%), entropion plus lash ptosis in two (18.18%),MGI in one (9%), and entropion in one eye (9%). All 11 eyes underwent a GLS with ALR and LR. Follow up at two weeks was uneventful in seven eyes, three eyes had swelling and one patient complaining of irritation. At two months post-operative review , one eye had trichiatic lashes, which were epilated and one eye had residual lash ptosis. The change of lid height and position is demonstrated in the table. [ Table1 ]
The MRD 1 value lowering ,was considered as a parameter of reversal of lid retraction associated with cicatricial lid changes .The lowering achieved was by two mm in four eyes (36.36%), by one mm in two eyes (18.18%) and three mm in two eyes (18.18%). It increased by 1 mm in one eye and 0.5 mm in one eye which could be attributed to suboptimal recession of levator. There was no change in one eye. The mean lowering of upper eyelid was two mm. The additional parameter observed was PTS asymmetry ,which was zero in four patients who had unilateral or bilateral surgery (36.36%) (2 having improved and 2 unchanged), and increased by two mm in one eye (9.09%) and by one mm in one eye (9.09%).Both these patients with an increased asymmetry were suffering from facial palsy ,therefore lids had to be lowered more than the fellow eye .
Six eyes (54.54%) were totally asymptomatic after two months follow up. Two eyes (18.18%) showed partial symptomatic relief and were diagnosed with MGD and managed conservatively. One eye had persistent eyelid edema and had a loose vicryl suture leading to ocular surface irritation, and this was relieved by suture removal. One eye had residual lash ptosis at two months follow up and persistent MGD which was treated conservatively. One eye had residual trichiatic lashes which were manually epilated. Lid margin eversion was achieved in all eyes.[Figure 7]The cornea was clear in all eyes but one at the final follow up.
Discussion
Cicatricial upper eyelid entropion occurs due to shortening of the posterior lamellar and resultant in-turning of the lid margin, and may be secondary to various aetiologies. These range from trachoma to advanced meibomian gland dysfunction (MGD). Other causes include vernal keraroconjunctivitis, herpes zoster ophthalmicus, burns, Stevens-Johnson’s syndrome and ocular cicatricial pemphigoid. Published techniques for correction are multiple , and their success may depend on the underlying cause and so selection of an appropriate technique for the pathology should be a consideration. The original description of ALR with GLS by Welsh, for the correction of trachomatous cicatricial entropion, did not involve a lid crease incision.
However, he made a vertical cut along the anterior lamella at lateral canthal area to lift the anterior lamella and sutured the two lamellae using non absorbable sutures, four to six mm away from the lash line.[1] This procedure was further modified by various surgeons. Sodhi et al additionally made two to three mm vertical incisions through the medial (1mm lateral to the lacrimal punctum) and lateral anterior margin of the tarsal plate to aid lid splitting into anterior and posterior lamellae [7] and also added full thickness posterior lamella sutures at the level of the fornix back onto the skin.[8]Seiff et al combined the original procedure with terminal tarsal rotation.[9 ] As previously discussed , other authors have reported lid crease incision and lifting the anterior lamella off the posterior with or without a GLS [5, 6, 7] the obvious advantage being to avoid surgery to the conjunctiva and hence improve safety in conditions such as OCP.[2]
GLS with ALR via a lid crease and LR has been used to correct a wide spectrum of lid margin abnormalities as described above . Kemp et al have included treatment of meibomian gland migration but as stated, have used a skin crease incision for their procedures.[3]Ross has shown a 98% anatomical success rate of achieving normal lid margin position using ALR or terminal tarsal rotation, again involving a skin crease incision.[12]
Our case series demonstrates surgical correction of subtle changes such as meibomian gland inversion[Figure 8], lash ptosis and tarsal curling [Figure 9]due to advanced MGD which may cause bothersome symptoms. Chronic MGD leads to structural changes in the lid margin, which may not be identified if not carefully assessed at examination, and these may result in symptoms of scratchiness, irritation and soreness. In our case series, only one eye had frank entropion, the remaining having one or more of following changes 1)lash ptosis, 2)MGI, 3) tarsal curling, and 4) trichiasis. To the best of our knowledge, previously published reports have not demonstrated use of this procedure to correction these changes. The percentage improvement of symptoms was 72.72% and was comparable to earlier such series .[2,10 – 12] Changes in lid height and pretarsal show have not been documented in previous reports.
This case series involves LR in order to correct the associated lid retraction, which has not been mentioned in previous studies through a grey line split approach . Cicatricial entropion involves lid retraction due to posterior lamellar contraction, therefore a simple ALR will not be able to fully address the ocular surface compromise. The combination of repositioning the offending anterior lamella and ensuring complete lid closure is proposed as a better procedure for treating cicatricial lid changes.
We acknowledge the limitations of this study in that there are only a small number of patients treated in this preliminary study. Longer follow up is required to assess the long term efficacy of this procedure , however a skin crease does not appear to be essential in correction of upper eyelid cicatricial margin entropion .
Conclusion
ALR with only a GLS avoids a skin incision, and LR can also effectively be performed through the plane thus created. A grey-line incision should be preferred to conjunctival incisions in cicatrizing conditions to avoid trauma to the conjunctiva. The levator, if recessed a few millimeters , adds to the lengthening of posterior lamella thereby reducing posterior lamella retraction and improving lagophthalmos. Although only a small pilot study, we remind authors that levator recession can easily be performed through a grey-line split and avoids both a lid crease incision with skin scar or a conjunctival incision.
References
1.Welsh NH . The Treatment of Cicatricialentropion . South African Med.J.1969;15:172-175
2.Mark J Elder ,R.Collin .Anterior Lamellar Repositioning and Grey Line Split for Upper Lid Entropion in Ocular Cicatricial pemphigoid. Eye 1996;10:439-442
3.EJKemp,JRO Collin .Surgical management of upper lid entropion . British Journal of Ophthalmology 1986;70:575-579
4.Upreet Dhaliwal ,Praveen Monga and Ved Gupta .Comparison of three surgical procedures of differing complexity in the correction of trachomatous upper lid entropion: a prospective study . Orbit 2004 ;23 ,4 :227-239
5.M C Rhatigan , JL Ashworth,K Goodall , B. Leatherbarrow.Correction of blepharoconjunctivitis-related upper eyelid entropion using the anterior lamellar reposition technique. Eye 1997;11:118-120
6.Raniaa. Ahmed ,Saunch H. Abdelbaky . Short term outcomes of anterior lamellar reposition in treating trachomatous trichiasis .Journal of Ophthalmology .2015
7.PunitaKumariSodhi , Usha Yadav and D. K. Mehta . Efficacy of lamellar division for correcting cicatricial lid entropion and its associated features unrectified by the tarsal facture technique.Orbit2002 ;21:9-17.
8.PunitaKumariSodhi , Usha Yadav ,Ravidra M Pandey and DK Mehta . modified grey line split with anterior lamella repositioning for treatment of cicatricial lid entropion . Ophthalmic surgery and lasers ; march/april 2002 ; 33, 2
9 . Stuart R Seif,Susan R. Carter , Jose LuivTovilaY canals and Philip H. Choo. Tarsal margin rotation with posterior lamella superadvancement for the management of cicatrcicial entropion of the upper eyelid.American Journal Of Ophthlamology1999 ; 127:67-71.
10.Y.M. Yeung, C.-Y.Hon and C.-K. Ho. A simple surgical treatment for upper lid trichiasis.Ophthalmic Surgery and Lasers1997 ;28: 74–76.
11.I. V. Koreen, A. Taich and V. M. Elner. Anterior lamellar recession with buccalmucous membrane grafting for cicatricial entropion .Ophthalmic Plastic and Reconstructive Surgery2009 ;25: 180–184.
12.AH Ross, PS Cannon, D Selva and R Malhotra. Management of upper eyelid cicatricial entropion. Clinical and Experimental Ophthalmology 2011 ;39(6): 526-36.
Table 1:pre and postoperative lid height and position ,corneal health and residual disease
| Eyelid | Indication | Cornea- pre operative status | Procedure | Cornea-
Post operative status |
Lid Height and Position | Residual Disease |
| 1 | MGD +MGI* | Superotemporal PEEs | GLS+ALR+LR+TS | Clear | Everted 1mm higher | blepharitis |
| 2 | Entropions | Clear | GLS + ALR +LR | Clear | Everted 0.5mm higher | Blepharitis |
| 3 | MGD + MGI | Inferior
PEEs |
GLS+ALR+LR | Clear | Everted
2mm lower |
Nil |
| 4 | MGD +MGI* | Inferior
PEEs |
GLS+ALR+LR | Clear | Everted 2mm
lower |
Nil |
| 5 | Entropion + MGI+MGD+Tarsal curling |
Clear | GLS+ALR+LR+TS | Inferior
PEEs |
Everted 3mm
lower |
Trichiasis |
| 6 | Entropion + MGI+MGD+Tarsal curling |
Clear | GLS+ALR+LR+TS | Clear | Everted 3mm lower | Nil |
| 7 | MGI | Superotemporal
PEEs |
GLS+ALR+LR+TS | Clear | Everted 2mm
lower |
Nil |
| 8 | Entropion +
Lash ptosis |
Inferior
PEEs |
GLS+ALR+LR+RC | Clear | Everted 2mm
Lower |
Lash ptosis |
| 9 | Entropion +
Lash ptosis |
Inferior
PEEs |
GLS+ALR+LR+RC | Clear | Everted 1mm
lower |
Nil |
| 10 | MGD + MGI | Superotemporal
PEEs |
GLS+ALR+LR | Clear | Everted 1mm
lower |
Eyelid edema** |
| 11 | MGD+MGI | Diffuse PEEs | GLS+ALR+LR | Clear | Everted Nil change | MGD |
*Associated Facial nerve palsy
** One case had loose suture . Edema resolved after removal
MGD – Meibomian Gland Disease
MGI – Meibomian Gland Eversion
GLS – Grey Line Split
ALR – Anterior Lamellar repositioning
LR – Levator Recession
TS – Tarsal Curling
RC – Radial Cuts
PEE – Punctate Epithelial Erosions
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