Surgical management of patients with corneal lesions due to lid pathologies

Table 1 Research publications regarding surgical management of patients with corneal lesions due to lid pathologies

Ref.	Year	Type of study	Results	Conclusions
Gu et al[3]	2009	Prospective cohort study with 14 patients	Acellular dermis was effective in reducing the palpebral aperture (P = 0.002), lagophthalmos (P = 0.016), and lengthening the upper eyelid height by reducing the upper margin-reflex distance (P = 0.008). There were 2 cases of recurrence because of the shrinkage of graft (70%) and 3 cases of conjunctival granulomas postoperatively	Acellular dermis grafting with insertion of therapeutic contact lenses is an effective and simple measure for rectifying severe cicatricial entropion both structurally and functionally
Swamy et al[4]	2008	Prospective with 147 eyelid operations	Ninety-four per cent of patients noted symptomatic improvement. The postoperative complications included excess keratin (29%), recurrence of cicatricial entropion (4.1%), punctuate epithelial erosion (2.7%), graft shrinkage (0.7%) and donor site bleeding (2.0%)	Cicatricial Entropion with hard palate mucous membrane grafting for both upper and lower eyelid surgery offers high symptomatic and anatomical cure rates
Hintschich[5]	2008	Review
Marcet et al[6]	2015	Review		Understanding the demographics and factors linked to involutional entropion allows clinicians to better identify the condition and those most at risk. However, there is insufficient evidence to conclude that a short axial length is an independent risk factor for entropion. Recent advances in surgical techniques have fueled interest in minimally invasive procedures. It is crucial to address each patient’s unique anatomical abnormalities with precision
Han et al[11]	2019	Retrospective interventional case series of 46 eyelids in 31 patients with involutional entropion and significant ocular irritation	During the mean follow-up period of 22.1 months (range, 12-34 months), 43 of the eyelids (93.5%) were successfully corrected. Two patients (3 eyelids) experienced recurrence: 1 had involutional entropion combined with a cicatricial component, and the other had blepharospasm and apraxia of eyelid opening related to Parkinsonism. No postoperative complications such as overcorrection, suture-knot exposure, or ocular irritation were observed	Mini-incisional entropion repair based on reinforcement of the lower eyelid retractors using transconjunctival buried sutures is quick, simple, and predictive for involutional entropion repair, and has a high success rate
Qurban and Kamil[12]	2022	Quasi-experiment study recruiting 50 patients with twenty-five patients in each group	Recurrence of the condition was observed in eight (32%) out of twenty-five patients in group A, who underwent the standard Weis surgical procedure, whereas only one (4%) out of the twenty- five patients of group B who underwent the modified surgical technique with external tamponade experienced recurrence	The modified surgical technique for entropion repair using an external tamponade has a favorable outcome with minimal recurrence and symptomatic relief
Cheung et al[14]	2018	Retrospective review of 52 eyelids of 46 patients who underwent pentagonal resection + inferior retractor plication for treatment of involutional entropion	A total of 52 eyelids of 46 patients received pentagonal resection + inferior retractor plication. None had recurrence of entropion, 1 (2.1%) had residual entropion, 2 eyelids (4.4%) had lower eyelid notching, 1 eyelid (2.2%) had infection and 1 eyelid (2.2%) had overcorrection. The overall success rate was 90.4%	Combined pentagonal resection + inferior retractor plication is an effective surgical procedure for primary involutional entropion with low recurrence rate; the authors report eye-lid notching as a complication
Koreen et al[17]	2009	Retrospective interventional case series (35 eyelids, 26 patients)	The success rate of primary repair was 77% (27 of 35 eyelids) with a mean follow-up time of 2.5 +/- 1.9 years. Four eyelids (11%) underwent repeat grafting for recurrent entropion secondary to graft shrinkage (3 eyelids) and graft dislocation (1 eyelid) for a cumulative success rate of 89%. The remaining 4 eyelids (11%) had recurrent entropion that was managed surgically with a technique other than repeat grafting	Anterior lamellar recession with buccal mucous membrane grafting is an effective surgical approach for the treatment of moderate to severe cicatricial entropion
Malhotra et al[18]	2012	Retrospective, 5-year, single-center, consecutive case series of patients with lower eyelid cicatricial margin entropion (21 eyelids, 19 patients)	The study included 21 eyelids from 19 patients (mean age 577 years) with cicatricial entropion: 38% of eyelids required a second procedure within a year, with 10% and 5% needing a third and fourth within three years. Common revisions were anterior lamellar repositioning, mucous membrane grafts, and everting sutures. Three patients had significant inferior fornix loss, and 90% of eyelids showed improvement after repeated surgeries, with mucosal grafts used in some cases. Lower eyelid elevation was 1 mm in 32% of patients, and lateral retraction improved in 47%	Lower eyelid gray-line split, inferior retractor recession, lateral-horn lysis, and anterior lamella repositioning is of value as a lash-preserving procedure in moderate-to-severe cicatricial lower eyelid entropion, particularly where tarsoconjuctival contraction or eyelid margin distortion exists
Kadyan et al[19]	2010	Prospective interventional case series; 7 patients, 9 procedures	Residual lashes were noted in three patients. In two cases, the lashes were isolated and managed successfully by a single electrolysis treatment. One patient needed further anterior lamellar excision for residual remnant of trichiatic cilia at the lateral edge of the lid. All patients were satisfied with their post-operative appearance. None of the patients showed exacerbation of disease or needed additional immunosuppression as a consequence of the lid surgery	Anterior lamellar excision with spontaneous granulation is a straightforward and effective method for managing aberrant eyelashes. This technique minimized the risk of disease exacerbation, particularly in cases of ocular cicatricial pemphigoid, by limiting conjunctival manipulation. Additionally, it reduced post-operative lash-globe contact, enhancing patient outcomes
Wu et al[20]	2010	Retrospective consecutive case series of 26 eyelids with severe, recurrent, or segmental cicatricial entropion	The functional success rate was 90.5%, and the cosmetic success rate was 100%	The eyelash resection procedure is a safe, effective, and cosmetically acceptable procedure for treatment of severe, recurrent, or segmental cicatricial entropion
Chi et al[22]	2016	Consecutive series of 27 eyelids (15 upper and 12 lower eyelids) of 18 patients (9 men and 9 women)	The success rate was 81.8% (22 of 27 eyelids). Complications included eyelid margin notching (n = 1) and blepharoptosis secondary to avascular necrosis of the distal marginal fragment (n= 1), both were corrected by minor surgical intervention	Modified tarsotomy is effective for the correction of severe cicatricial entropion
Singh et al[25]	2021	Case series (Six eyelids of five patients)	Entropion resolved in all patients with restoration of eyelid margin and reduction in ocular discomfort. Trichiasis was present in all six eyelids (100%) preoperatively and resolved completely in all but one case (83% success rate) with three residual focal trichiatic lashes in the temporal area, which was successfully managed with radiofrequency ablation. There were no recurrences of trichiatic or distichiatic lashes at a median follow-up duration of 16 months (range, 12-18 months)	Labial mucosa can be effectively used to resolve recurrent cicatricial entropion by spacing the anterior lamella and reconstructing the lid margin and posterior lamella, leading to a low recurrence rate
Takahashi et al[26]	2014	Retrospective case series (3 patients with congenital entropion); authors also measured the diameters of the pre tarsal Orbicularis Oculi Muscle fibers in these patients and compared them with those measured in the previously reported 67 eyelids of 41 Japanese patients with congenital epiblepharon	Successful correction was achieved in all three patients without recurrence during 12-months of follow-up. No patient exhibited lower eyelid ectropion or lower eyelid retraction. The mean diameter of the pretarsal Orbicularis Oculi Muscle fibers was 21.9 μm (range, 20.5-23.7 μm), which was not significantly different from that of the congenital epiblepharon (25.3 μm; range, 18.1-34.7 μm; P = 0.272, Mann-Whitney U test)	Posterior layer advancement of the lower eyelid retractor is a useful surgical option for treatment of congenital entropion. No histological evidence of pretarsal Orbicularis Oculi Muscle hypertrophy was shown in congenital entropion, which demonstrated that debulking of the pretarsal Orbicularis Oculi Muscle may not be significant for correction of this entity
Huang et al[27]	2023	Comparison prospective study; ninety-six participants (180 eyes) with congenital lower eyelid entropion diagnosed between January 2019 and April 2021 were included in this study. The patients were divided into Group A (cutaneous orbicularis oculi excision treatment) and Group B (inferior eyelid margin fixation treatment)	No significant difference in age, sex, and eyes distribution in both groups. And higher efficiency rate was found in Group B (P < 0.05). And Group A had a higher recurrence rate in the follow-up after surgical treatment (P < 0.05)	The authors modified inferior eyelid margin fixation of the orbicularis eyelid muscle treatment is an ideal procedure with a high degree of efficacy and low recurrence rate in patients with congenital lower eyelid entropion
Khuu et al[28]	2023	Retrospective chart review. Twelve patients (19 eyelids). The mean patient age was 7.1 ± 6.1 years (range, 0.2-22 years)	The described entropion repair technique was successful and without recurrence in 17 eyelids (89%). There were no cases of ectropion, lid retraction, or other complications. There were two eyelids (11%) that had entropion recurrence after first procedure. Repeated repair resulted in success with no recurrence at last follow-up	Subciliary rotating sutures combined with a modified Hotz procedure effectively correct congenital lower eyelid entropion. Since this technique avoids manipulating the posterior layer of the lower eyelid retractors, it is beneficial when retractor reinsertion provides insufficient improvement. It also helps minimize the risk of eyelid retraction and overcorrection in specific cases
Burton et al[29]	2015	Review		No trials specifically evaluated whether interventions for trichiasis prevent blindness, but some showed modest vision improvement. Full-thickness incision of the tarsal plate with lash-bearing lid margin rotation was the most effective technique, preferably performed in the community. Both ophthalmologists and trained ophthalmic assistants can perform the surgery, and results were comparable using silk or absorbable sutures. Post-operative azithromycin improved outcomes, with low recurrence rates overall
Singh[30]	2022	Review		Treatment options for congenital and acquired distichiasis are similar, with no specific algorithms available. Managing acquired distichiasis in cicatrizing ocular surface diseases is challenging, with current treatments yielding success rates of 50%-60%. Procedures like electroepilation or direct cryotherapy are less effective compared to surgical excision of distichiatic lashes, which involves splitting the anterior and posterior lamella under direct visualization. Marginal tarsectomy, with or without a free tarsoconjunctival graft, has shown favorable results in both congenital and acquired cases. However, the exact differences in normal vs distichiatic lashes, including depth and growth patterns, remain unclear. Research into the depth of distichiatic eyelashes could improve the outcomes of procedures like cryotherapy or radiofrequency-assisted epilation, which are currently done without precise visualization
Woo and Kim[31]	2016	Review		While epiblepharon may improve as the face grows, surgical correction is necessary when significant corneal damage occurs due to lash contact. Surgical treatment should prioritize techniques that are both effective and low-risk, while avoiding the formation of a lower eyelid crease
Ma et al[33]	2020	Comparative study	In the surgical and nonsurgical groups, the baseline astigmatism magnitude was similar (2.22 ± 1.39 and 2.26 ± 1.46 D, P = 0.87). Complete resolution of keratopathy at 6 months was 71.4% and 11.5%. The astigmatism magnitude in the surgical group differed among baseline and 3 months (2.25 ± 1.23 D) and 6 months postoperatively (1.97 ± 1.28 D) (P = 0.001)	The surgical group exhibited greater improvement in keratopathy compared to the nonsurgical group, despite having more severe baseline pathology. A reduction in with-the-rule astigmatism was observed six months postoperatively, particularly in patients with higher initial astigmatism. However, the extent of this change was minimal, and the overall outcomes did not significantly differ from those of nonsurgical treatment
Sung and Lew[34]	2019	Retrospective was series study including 72 eyelids of 36 children with epiblepharon and epicanthal folds	Eyelid contour was normalized and the cilia touch was resolved after the epicanthal tension-releasing procedure	The epicanthal tension-releasing procedure combined with orbicularis oculi ring myotomy resulted in positive surgical outcomes. Clinical findings aligned with pathology and the success of the procedure suggest that medial epicanthal fibrosis is the primary cause of epiblepharon and epicanthal folds
Yan et al[35]	2016	Retrospective case control (67 patients-mean age, 5.7 ± 2.6 years- and 178 controls. All patients presented with epicanthus	All patients showed successful surgical outcomes according to improvement of symptoms and lack of cilia-cornea contact. There were no cases of recurrence or other complications	Obesity can exacerbate lower eyelid epiblepharon, which can be effectively treated using the rotating suture procedure and the L-plasty procedure. The L-plasty procedure is particularly recommended for patients who also have significant epicanthus
Lailaksiri et al[38]	2024	Retrospective cohort study; 30 patients (76% females; average age 608 ± 12 years) with facial palsy who underwent implantation of either the traditional pretarsal gold weight or a new supratarsal model	The new model group had significantly better eyelid contour, less weight prominence, less weight migration and less eyelid ptosis than the traditional model group. Improvement of lagophthalmos was not statistically significant between the two groups. The 24-month reoperative rate was 53.3% in the standard group vs 13.3% in the new model group	The author’s newly designed supratarsal gold weight showed superior postoperative outcomes than the standard traditional model
Chung et al[39]	2020	Case report		Severe lagophthalmos successfully released with pentagonal wedge resection, fat redistribution, and full-thickness skin graft
Medina et al[40]	2022	Case report		Multiple contributing factors for severe ectropion of left lower eyelid treated with lateral tarsal strip procedure and full-thickness skin graft
Ghafouri et al[43]	2014	Retrospective review of case series (forty-one lower eyelids of 31 patients with involutional ectropion underwent surgical repair)	Surgical success with anatomical correction of involutional ectropion was achieved in 39 of 41 eyelids (95.1%). There were no perioperative or postoperative complications. Two of 41 (4.9%) eyelids had recurrence of ectropion 7 and 18 months after the procedure	The combination of a lateral tarsal strip and internal retractor reattachment using full-thickness eyelid sutures effectively resolves horizontal eyelid laxity and tarsal instability, making it a successful technique for correcting involutional ectropion of the lower eyelid
Vahdani et al[44]	2021	Retrospective case-note review; twenty-four eyelids of 21 treated patients (17 males; 81%) with lower eyelid cicatricial ectropion	Comparing the outcomes of modified Bick’s procedure + full-thickness skin grafting vs modified Bick’s procedure + monopedicle myocutaneous flap there was no statically significant difference in terms of anatomical (P = 0.48) and functional (P = 1.0) success rates. No cases of failure or recurrence were noted during the follow-up period	Anterior lamellar deficit ectropion arises without visible scarring. It is essential to thoroughly address both the horizontal laxity and the anterior lamellar deficit linked to this condition to reduce the chances of early failure and recurrence. The combination of medialized buccal pad (modified Bick’s procedure) with full-thickness skin graft or myocutaneous flap is a safe and effective treatment for this type of "cicatricial ectropion" and demonstrates a low rate of early recurrence
Korteweg et al[45]	2014	Cross-sectional outcome (30 cases of paralytic ectropion)	Lateral periosteal flap canthoplasty assessed through Ectropion Severity Score proved to be reliable and sensitive to the presence of ectropion. Significant improvement of the ectropion sequelae was measured after a mean follow-up period of 2 years. In 3 cases (13%), a revision procedure was necessary because of relapse of lower eyelid sagging after a mean time of 1.9 years	The periosteal flap canthoplasty is an effective technique that provides lasting results for patients with paralytic ectropion. This same periosteal flap can also be utilized in revision procedures