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 Table of Contents  
Year : 2020  |  Volume : 21  |  Issue : 3  |  Page : 210-215

Can orbicularis oculi excision improve the long-term success of trachomatous upper lid entropion correction?

Department of Ophthalmology, Tanta University, Tanta, Egypt

Date of Submission19-Feb-2020
Date of Decision25-Mar-2020
Date of Acceptance02-Apr-2020
Date of Web Publication23-Sep-2020

Correspondence Address:
MD Amr M Awara
Department of Ophthalmology, Tanta University, 33, El Guiesh Street, Tanta 31111
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/DJO.DJO_17_20

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Background Management of trachomatous cicatricial entropion of the upper eyelid continues to be a challenging problem. Long-standing cicatrization induces a spasm of orbicularis muscle which adds to the severity of the condition. We supposed that orbicularis muscle excision, if added to the standard technique of correction, may improve the outcome and long-term stability of the lid margin.
Patients and methods The study included 61 patients suffering from moderate to severe degrees of upper lid trachomatous cicatricial entropion. They were divided into two groups: group A included 31 cases (56 eyelids) for whom bilamellar tarsal rotation procedure with orbicularis muscle dissection and excision from all over the tarsal plate was done to allow for free rotation and group B included 30 cases (50 eyelids) for whom the same technique without orbicularis muscle excision was performed. All cases were followed up for 12 months postoperatively. Lid margin and eyelash position, eyelid closure, improvement of symptoms, aesthetic appearance, overcorrection or undercorrection, and recurrence were assessed at each visit.
Results The short-term results showed anatomical success, adequate lid closure, and regular lid margin in all cases of both groups with 12.5% of cases having moderate overcorrection in group A, which regressed without any surgical intervention. The long-term recurrence rate was significantly lower in group A (7%) than in group B (24%) after 1 year of follow-up (P=0.031). There were no cases of secondary lagophthalmos or retraction, and the aesthetic alterations were accepted by all patients.
Conclusion This modified technique proved to be safe, quick, and easy to perform. It increased the long-term stability of the eyelid margin after correction, resulting in high patient satisfaction with good cosmetic and functional outcomes for a long period.

Keywords: cicatricial entropion, orbicularis excision, tarsal rotation, trachoma

How to cite this article:
Awara AM, Shalaby OE, Shafik HM. Can orbicularis oculi excision improve the long-term success of trachomatous upper lid entropion correction?. Delta J Ophthalmol 2020;21:210-5

How to cite this URL:
Awara AM, Shalaby OE, Shafik HM. Can orbicularis oculi excision improve the long-term success of trachomatous upper lid entropion correction?. Delta J Ophthalmol [serial online] 2020 [cited 2022 Jun 26];21:210-5. Available from: http://www.djo.eg.net/text.asp?2020/21/3/210/295874

  Introduction Top

According to the WHO, trachoma is currently endemic in 57 countries, most of which are in Africa and Asia, causing a negative economic impact on these countries [1]. Trachomatous cicatricial entropion is still seen and represents a real challenge, despite the enhancement of primary health-care programs in Egypt. Entropion and trichiasis are present in various grades of severity in endemic areas with different methods and modifications for its correction [2],[3]. The key to the success of each technique depends on the correction of the different pathological mechanisms involved in the disease process [4]. A combination of different procedures may be needed to tackle each pathological insult. Among these procedures is the bilamellar tarsal rotation procedure (BTRP), which was devised by Ballen in 1964 and was further elaborated in a WHO manual as one of the established simple techniques for the correction of different grades of cicatricial upper lid entropion [5],[6].

In cicatricial entropion, there are disturbed anatomical and physiological factors in both anterior and posterior lid lamellae. The role of overriding preseptal orbicularis oculi muscle in the development of lower lid entropion has been discussed in different studies [7],[8]. However, its role in cicatricial entropion is still not clear. It is supposed that alterations of the posterior lamella by the cicatrizing process and chronicity of the trachomatous infection add a spastic element to the pathogenesis of entropion. So, pretarsal orbicularis together with the relative strength of its marginal fibers causes posterior pull of the eyelid and inward rotation. This pathogenesis was supported from previous studies in leprosy patients in a trachoma endemic region. It was noticed that there was less trichiasis and entropion among leprosy patients with lagophthalmos than among those who had normal orbicularis function [4].

Based on the assumption that the pretarsal orbicularis muscle may be indulged in the pathogenesis of upper lid trachomatous entropion, we aimed to evaluate the surgical outcome after adding of pretarsal orbicularis excision to the standard BTRP.

  Patients and methods Top

The study and data collection conformed to the local laws and adhered to the tenets of the Declaration of Helsinki. It was conducted after the approval of the Ethics Review Committee of Tanta University, Faculty of Medicine. Each patient signed a written informed consent to participate in the study and for publication of data of the study after explaining the nature of surgery.

Study design and participants

This is an institutional, prospective, interventional comparative study that took place in Tanta University Hospital (a tertiary eye hospital in Egypt) in the period between January 2017 and January 2019.

A total of 61 patients (106 eyelids), with moderate to severe post-trachomatous upper lid cicatricial entropion and trichiasis, were included in the study. The diagnosis of trachoma was based on the clinical criteria recommended by the WHO [9]. They were divided into two groups:
  1. Group A included 31 patients (56 eyelids) in whom pretarsal orbicularis oculi strip excision was added to the standard technique of BTRP.
  2. Group B included 30 patients (50 eyelids) in whom BTRP was performed without orbicularis muscle excision.

Trachomatous entropion with lid gap on closure, marked irregular lid margin, those with previous upper lid surgery, or other cicatricial etiologies for entropion were excluded from the study. Patients who did not complete at least 1 year of follow-up were also excluded.

Surgical technique

In group A, after upper eyelid infiltration anesthesia, a lid crease skin incision was made and deepened through the orbicularis muscle to the tarsal plate ([Figure 1]a). The orbicularis muscle was dissected from the overlying skin and the pretarsal part was freed from all over the tarsal plate till the roots of the eyelashes with an excision of 4–5 mm strip of the pretarsal orbicularis freeing the anterior surface of the tarsus, and leaving skin only to cover the tarsal surface ([Figure 1]b and c). The tarsus was incised (full thickness to involve the palpebral conjunctiva) at 4 mm from the roots of the lashes and four everting sutures of 5/0 Vicryl were taken ([Figure 1]d and e). Tightening of the sutures everted the eyelid by rotating the distal fragment. Titrating the tightness of the sutures allowed good adjustment of the lid contour ([Figure 1]f). The skin incision was closed with 6/0 Prolene sutures. Lid margin split was included if metaplastic rubbing lashes were associated.
Figure 1 (a–f) Steps of surgical technique in group A.

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The surgical technique in group B was the same but without orbicularis muscle excision.

Postoperative combined antibiotic steroid eye drops were used for 2 weeks with artificial tears for 1 month. All patients were followed up weekly for 1 month and then every 3 months for 1 year. Skin sutures were removed after 7 days while Vicryl sutures were left to dissolve to allow for more fibrosis with early removal if signs of infection or granuloma were seen.

Subjective assessment of early and late postoperative satisfaction was judged by a satisfaction score. The patients were asked to complete a satisfaction assessment questionnaire that included three questions based on the disappearance of symptoms, aesthetic appearance and lid position; Q1: did the symptoms disappear as you expected before surgery? Q2: how would you judge the surgical intervention in terms of aesthetic appearance? Q3: how would you judge the postoperative lid position and closure? The patients were asked to classify their postoperative level of satisfaction as 0: I am not satisfied, 1: I am moderately satisfied, and 2: I am very satisfied. The patients were classified into three distinctive groups based on the score of the questionnaire (0–3: unsatisfied, 4–6: moderately satisfied, and 7–9: highly satisfied).

Objective assessment was done by a panel of three physicians considering the anatomical eyelash globe incongruity, eyelid closure, aesthetic appearance, overcorrection, or recurrence at each visit. Recurrence was defined as lash globe contact and overcorrection as marked lash and margin eversion. Anatomical success was defined as absence of eyelash–ocular surface contact in all directions of gaze with complete eye closure.

Statistical analysis

Statistical analysis was performed using SPSS 16.0 statistical software package (SPSS Inc., Chicago, Illinois, USA). Results were presented as frequencies and percentage for qualitative data and as mean and SD for quantitative variables. Z test was used to compare percentages between the two groups. The results were considered statistically significant if the P value was less than 0.05.

  Results Top

Group A included 31 patients (56 eyelids); six cases were unilateral and 25 were bilateral. The mean age was 39.93±8.40 years (30–80 years). Eight patients were men (25.8%) and 23 (74.2%) patients were women. Group B included 30 patients (50 eyelids): 10 cases were unilateral and 20 patients were bilateral. The mean age was 41.79±9.32 years (34–78 years). Ten (33.3%) patients were men and 20 (66.7%) patients were women. There was no statistically significant difference between the two groups regarding age (P=0.408) or sex (P=0.519).

The mean follow-up time was 13.2 months. Concerning the short-term results (within the first 6 months), anatomical success was achieved in 98 and 90% of eyelids in group A and group B, respectively. All cases, in both groups, had adequate lid closure and regular eyelid margins. Concerning the early postoperative aesthetic appearance, all patients complained of lid edema and skin crowding which was similar in both groups. This complaint was relieved during the first 3 months postoperatively. Stitch infection was noticed in 14% of cases which necessitated early Vicryl suture removal. Lid closure was good and aesthetic appearance was accepted by all patients in both groups from the third month.

Early postoperative mild overcorrection was intended in all cases of both groups ([Figure 2]). Moderate overcorrection was noticed in 12.5% of eyelids in group A and on follow-up, it regressed and the lid margin returned to normal anatomical position by the third month ([Figure 3]).
Figure 2 (a) Intended mild overcorrection of the upper eyelid first week postoperatively in group A, (b) third week postoperatively, (c) third month regressed overcorrection, (d) sixth month postoperative maintained normal lid margin position.

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Figure 3 (a) Preoperative severe upper eyelid cicatricial entropion with trichiasis, (b)first week postoperatively with marked overcorrection, (c) sixth month postoperatively in group A.

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The long-term postoperative follow-up at 12 months showed recurrence of entropion in 7 and 24% of eyelids in group A and group B, respectively. Recurrence was significantly lower in group A than in group B at the ninth and 12th postoperative month (P=0.044 and 0.031, respectively, [Table 1]).
Table 1 Recurrence rate

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Regarding the patient satisfaction score, there was no significant difference between the two groups at the first postoperative month. Starting from the third postoperative month, group A showed significantly higher levels of moderate (4–6) and high (7–9) satisfaction than group B, which continued till the 12th postoperative month (93.6 and 66.7%, respectively, P=0.016, [Table 2]).
Table 2 Patient satisfaction

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  Discussion Top

Management of trachomatous upper eyelid cicatricial entropion depends on the severity of the condition, thickness of the tarsus, presence or absence of eyelid retraction, keratinization of marginal tarsoconjunctiva, and association with rubbing lashes or trichiasis.

The worldwide BTRP is complicated by the fact that there are no well-accepted guidelines for patient selection. Its choice is based on surgeon-related or program-related factors rather than evidence related to surgical outcome [10].

Many modifications on BTRP have also been used with variable degrees of success. From retrospective studies, the recurrence rate has ranged from 17 to 50%, depending on the number of years of follow-up. Even under the best circumstances, recurrence is likely to be at least 15% per year. It should be recognized that BTRP will never be successful in 100% of patients with trichiasis [10],[11],[12],[13],[14].

We are adopting the BTRP technique for correction of moderate to severe upper lid cicatricial entropion in our hospital for many years with early anatomical success. However, we have noticed late recurrence with long-term follow-up, where some patients may be tolerating without obvious complaints.

We definitely agree with El Toukhy et al. [10] that variable follow-up periods can significantly influence the recurrence rate. In the present clinical trial, the recurrence rate increased from 1.7 and 10% at 6 months to 7.1 and 24% at 12 months in group A and group B, respectively. Early peak of failure is usually due to surgery-related factors, wound healing, or could be the result of new metaplastic changes from a progressive cicatricial disease [15],[16].

The long-standing cicatrization leads to relative shortening of the posterior lamella and induces a spasm of the pretarsal orbicularis muscle. The latter is considered an added factor to the severity of the condition [17]. So, we thought that the presence of such spastic part of the orbicularis muscle may contribute to this late recurrence and to the metaplastic changes. Thus, orbicularis muscle strip excision may relieve the spasm of the lid anterior lamella.

Defective lid closure and lagophthalmos have been reported after the tarsal rotation procedure [11]. Although the pretarsal orbicularis strip was excised, in the present study, it did not affect blinking, lid closure, or induce lagophthalmos in any case.

Concerning the aesthetic appearance, lid notching and buckling were reported after tarsal rotation in different studies [18],[19],[20]. In the current study, aesthetic outcome was poor in the first month due to lid edema, everting Vicryl sutures, and overhanging baggy fold of skin on the overcorrected lid margin. Patients got acceptable aesthetic appearance, in both groups, from the third month after resolution of edema, suture absorption, and regression of overcorrection. Neither notching nor buckling was seen in either group. Careful and meticulous dissection of the pretarsal orbicularis under surgical microscope was required to avoid lash follicle injury and subsequent madarosis.

Symptomatic improvement and patient satisfaction were variable during the follow-up period as patient discomfort was multifactorial. Discomfort was not only due to lash globe contact but also due to tear film instability and ocular surface damage which is considered to be the main cause of patient discomfort and reduced visual acuity [21],[22].

In the present study, most of the patients were moderately satisfied in the early postoperative period. The satisfaction score increased (moderate–highly satisfied) to 93.6% in group A versus 66.7% in group B at 12 month. Unsatisfied patients were due to recurrence of entropion and dry eye which was augmented by the tarsal fracture. The short-term anatomical success (at 6 months) was not significantly different between the two groups (group A, 98.3% and group B, 90%, P=0.152). At 12 months, anatomical success was significantly higher in group A (93%) than in group B (76%).

To our knowledge, there were no previous studies for this innovative, combined BTRP and pretarsal orbicularis excision technique. It proved to be relatively quick and easy to perform with lower recurrence rate on a long-term basis.

  Conclusion Top

Combined standard BTRP with pretarsal orbicularis strip excision increased the long-term lid margin stability and patient satisfaction without affection of the cosmetic or functional outcome.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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