Management of
Trachomatous Cicatricial Entropion of the Upper Eye Lid: Our Modified Technique
Department Ophthalmology,
Background: Management of trachomatous
cicatricial entropion of the upper eye lid presents a difficult problem. Many surgical
approaches have been developed to address it. We report the functional and
cosmetic results of our modified surgical technique we have developed in the
management of trachomatous cicatricial entropion of the upper eye lid. Methods:
45 lids of 43 patients having trachomatous cicatricial entropion of upper eye
lids were operated by our modified surgical technique in which we combine
bilamellar tarsal margin rotation procedure with blepharoplasty. The technique
and results were evaluated in a follow up period of up to 40 months. Results:
In all 45 upper eye lids, the normal eyelashes rotated away from the surface of
the eye and were no longer in contact of the eye ball in all position of gaze.
All eyes had adequate lid closure and regular lid margin. No eye had any
overhanging baggy fold of skin at operation site. Three eyes had conjuctival
granuloma which was excised under local anaesthesia Three eyes needed Diode laser
ablation to treat isolated cilia posterior to normal lash line. Three eyes had
mild over correction which regressed without any surgical intervention. One lid
had segmental necrosis of distal part of eye lid which recovered spontaneously
in following days. Conclusion:
Our modified technique of combining bilamellar tarsal rotation procedure (BTR)
with blepharoplasty appears to be an effective surgical technique in the
management of the trachomatous cicatricial entropion of the upper eye lid. It achieves
successful anatomical correction along with more acceptable cosmetic
appearance.
Key words: trachomatous cicatricial
entropion, bilamellar tarsal rotation, Blepharoplasty, Electrolysis,
Cryotherapy
Introduction
Cicatricial
Entropion of upper eye lid in association with trachoma is the leading cause of
blindness worldwide and is only second to cataract as an over all cause of
blindness.1 About 5.5 million people are blind or at risk of
blindness as a consequence of Trachoma.2 Being situated in high
trachoma endemic area a large part of Omani population has been effected by
this disease. A National survey conducted in Oman in 1996-97 showed that 17.5%
of population above 40 years of age was having trachomatous trichiasis and
cicatricial entropion of the the upper eye lids.3 Although similar
rates of active disease are observed in male and female children, the later
sequel of trachoma like trichiasis, entropion ,and corneal opacity are more
common in women than men. Moreover scarring and consequent blindness increases
with age and is commonly seen in older adults.4 Repeated infection
with Chlamydia trachomatis causes scarring of tarsal conjuctiva which pulls the
lid margin towards eye and the lashes with it. There is posterior migration or
conjunctivalization of meibomian glands and rounding of lid margin.5
There is fibrosis, thickening and distortion of tarsal plate, spastic
contraction of marginal fibers of Orbicularis Oculi, contraction of
subconjuctival fibrous tissue, increase in weight of eye lid and laxity of skin
and ptosis.6,7
Various
surgical modalities are used to address this problem. Cryotherapy has been advocated and used for treatment of
trichiasis but cryotherapy, electrolysis,
argon or diode laser and electrosurgery all are known to produce further
scarring and worsening the condition they are designed to treat, therefore
all must be used with discretion and
with due regard to underlying pathology.5,8
Other surgical techniques described include tarsal wedge resection,9
transverse tarsotomy10, Lamellar
division, Lid splitting with anterior lamella repositioning 11,
Tarsal margin rotation with posterior lamella superadvancement 12
and 180 degree tarsal margin rotation
with a posterior lamella advancement.13 Various grafting techniques
which involved sclera, nasal septum,
mucous membrane, hard palate
mucosal graft etc have been described to
slow down cicatricial process and to maintain the surgical repositioning of the tissue 14,15.
These all add to the complexity of the surgery and graft viability is
unpredictable due to poor vascularity of these scarred lids.12 The fact that so many techniques exists
suggests that none of them offers ultimate solution.
Bilalamellar tarsal rotation
was the most common technique applied to correct the trachomatous cicatricial
entropion of upper eye lid. This procedure is associated with crowding of the
skin and an overhanging baggy fold of skin over the lid margin, which gave an
unacceptable cosmetic appearance especially in unilateral cases. In an attempt
to reduce the postoperative complications of this procedure, We decided to
modify the technique of entropion correction by combining bilalamellar tarsal
rotation with blepharoplasty in which very good cosmetic effect was achieved in
addition to successful and adequate correction of upper lid entropion.
This study was
conducted at Sohar hospital, Sultanate of Oman. We selected the patients who
had cicatricial entropion of upper eye lids due to trachomatus etiology. A
total of 45 eyes of 43 patients were selected and operated by our modified
technique. Cases of recurrent entropion, districhiasis and short lids due to
distortion of tarsal plate as a result of scarring were excluded from the
study.
All
operations were done under local anaesthesia. Upper lid skin was marked 6 mm
above eye lash margin comparing with that of other eye; and extending from lateral canthus to just
lateral to the punctum medially. Upper limit of the skin to be excised was
marked by just picking up the skin with forceps and allowing the lids just to
meet on gentle closure. Skin flap was designed in a cat’s ear fashion, central
height of the flap being double than the medial and lateral part of the flap. Medial
and lateral end of the skin marks were raised towards medial and lateral ends
of upper eye brow and a cat’s ear pattern was created to prevent clumping and
hooding of the skin at time of suturing the skin (Fig-1). After marking, lid
was infiltrated with 3-4 cc of local anesthetic solution made by mixing 10cc of
0.5% bupivacaine with 0.3cc of 1:1000 adrenalin. Incision was made with a No.15
blade and cat’s ear pattern of skin excised with blunt end scissors, taking
care not to damage orbicularis oculi muscle and underlying fat (Fig-2). Haemostasis
was secured by cauterizing any bleeding point.
One
drop of amethocan was instilled in the conjuctival sac and a lid guard placed
on the conjunctival side of upper lid.
Site of tarsal plate incision was measured 3mm from the lid margin to
tarsal plate. While assistant holding lid guard firmly a horizontal incision 3 mm
above the lid margin was made through the orbicularis oculi to the full
thickness of tarsal plate and conjunctiva.
This was completed by scissors to involve both the medial and lateral
ends of tarsal plate. Thus the lid throughout its entire thickness was divided into
a 3 mm distal fragment and remaining proximal fragment (Fig-3).
Fig-1: Cat’s
Ear pattern
Fig-2:
Excision of skin with blunt end scissors
Fig-3: Division of lid into distal and proximal fragments
Three
6/0 vicryl sutures with double arm spatula needles were taken. First needle of first suture was passed
through a 1 mm bite of tarsal conjunctiva
of proximal fragment and about half of
thickness of tarsal plate near middle of eye lid, so that needle emerged
through cut edge of tarsal plate of the proximal fragment. Second needle of the
same suture was passed in same fashion about 4 mm apart from the first on the
conjuctival side and it similarly emerged through cut edge of the tarsal
plate. This suture was placed in the
center of the lid and bulldog was applied on the two strands of the suture.
Other two double armed needle sutures were placed in an identical manner on the
either side of the first suture being 4 mm away from it and 4 mm from each
other. Care was taken that lateral and medial suture must reach the lateral and
medial end of the incision.
Now
the two needles of central suture were passed through the orbicularis oculi and
skin of distal lid fragment being anterior to the tarsal plate. It emerged
through the skin just immediately anterior to the eye lash line and its width
being equal to that in the proximal fragment (Fig-4). All the needles of other
sutures were passed in the same manner, taking care that width of bite being
same as that in proximal fragment.
Fig-4: Passing needles for suturing
Firstly
the central suture was tied under appropriate tension with 3 single knots
followed by medial and lateral sutures so as to produce slight overcorrection
without notching and buckling of tarsal plate. Skin was mobilized easily. Skin
edges were closed with 6/0 vicryl. The edges fitted nicely and snugly into
already crafted cat’s ear pattern and there was no hooding. Rest of skin was
closed with interrupted suture 6 mm apart which also picked up underlying
apponeurosis of the levater muscle to create the skin crease. All sutures were
tied without tension (Fig. 5).
Fig-5: Sutures tied without tension
Gentamicin
eye ointment and pressure eye pad applied for 24 hours. Next morning eye pad was removed and wound
was examined and entropion correction was evaluated. Gentamicin ointment was continued for 2-3 weeks and
sutures were removed on 10th day of surgery. Patients were followed up on 2nd
week, one month and at 6 month interval. Follow up ranged from
Results
Out of 43 patients
10 were males whose age ranged from 55 to 77 years and 33 females whose age ranged from 48 to 65
years having cictricial entropion of upper eye lids who were operated by our
modified technique. Two females had
bilateral surgeries and total 18 right eyes and 27 left eyes were operated. A successful outcome was defined as one in
which normal upper lid margin lash
rotated away and were no longer in contact with the globe in all
position, no clumping of redundant skin
at the operation side, regular lid margin and a good cosmetic out look . This
combined procedure was successful in all 45(100%) upper eye lids of 43 patients
and produced functionally and cosmetically good results ( Fig 6 and Fig. 7). Three
(6.97%) eyes had conjunctival granuloma which was excised under local
anaesthesia in OPD. Three (6.97%) eyes needed Diode Laser ablation to treat
isolated cilia posterior to normal lash. One (2.32%) lid had segmental necrosis
of distal part of eye lid which recovered spontaneously in following days.
Three
(6.97%) eyes had mild over correction with everted lid margin looking quite red
and inflamed during immediate postoperative period. But during following weeks
these healed with a good cosmetic result without any surgical intervention. All (100%) eye had adequate lid closure,
regular lid margin and no eye lid had a baggy overhanging fold of skin at the
operation site. cosmetic appearance was quite acceptable even in unilateral
cases.
Discussion
Management of trachomatous
cicatricial entropion of the upper eye lid presents a difficult problem. Many
surgical approaches have been developed to address this problem with variable
results.
Trabute
in 1949 described a 180-degree tarsal margin rotation with a limited posterior
lamella advancement.13 Collin modified it with advancement of
posterior lamella up to the inferior edge of the rotated tarsal margin.9
It was observed that failure to recess the levator off from the anterior tarsal surface resulted in
lagophthalmos12. Ballen devised Bialmellar tarsal rotation procedure
in 1964 for the management of cicatricial entropion of upper lid. This was
further elaborated in WHO manual as simple procedure for management of cicatricial entropion of upper lid,16,17
in which lid is incised through all the layers parallel to lid margin and
resutured so that lid margin is rotated
away and eye lashes are no longer in contact with globe. The technique was adopted by many
surgeons and was found to be most effective and a successful way of treating
entropion. Early trial of surgery for upper lid entropion conducted in
In this study we combined
the Bilamellar tarsal rotation (BTR) procedure with blepharoplasty in which before incising the tarsal
plate a strip of skin of cat’s ear
pattern measured according to laxity of
skin is excised and BTR procedure is completed later.
To
our knowledge there has been no study which combines the two procedures to
address both the functional and cosmetic aspect of of entropion surgery. Our
cases showed good cosmetic appearance and no recurrence in follow up period. We
stress the importance of precise marking of the skin to be excised, which can
be easily lifted up with just closure of lids (to avoid post op defective
closure). Surgical technique should be meticulous with adequate haemostasis.
Care should be taken not to cut or disturb the fibers of Orbicularis Oculi,
orbital fat and fibers of levater aponeurosis 9. Tarsal incision
should be made at distance of 3 mm or just greater than this from the lid
margin to avoid interruption of marginal vascular arcade and post operative
necrosis of distal fragment 14,15,
where as too big distal fragment will result in gross over correction. Moreover
it is important to tie the sutures under appropriate tension without buckling
the tarsus and to have regular round lid margin. Although follow-up of some of our
cases is relatively short, our modified technique of bilamellar tarsal rotation
(BTR) procedure with blepharoplasty appears to be more effective functionally
and more acceptable cosmetically in managing the trachomatous cicatricial
entropion upper eye lid. We will report long term follow up in due course of
time.
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