Modified Jones Procedure for Primary Lower Lid Senile Entropion

Purpose: To assess the outcome and complications after modified Jones procedure for primary lower lid senile entropion.
Methods: Interventional case series of 57 eyes of 51 patients selected on non-probability purposive basis from Ophthalmology
department, Bakhtawar Amin Medical and Dental College/Hospital, Multan from January, 2016 to December, 2017.
Permission was taken from ethical review committee. All the patients reporting to Ophthalmology department, Bakhtawar
Amin Medical and Dental College/Hospital diagnosed as having lower lid senile entropion were included. Patients having
associated medial or lateral canthus laxity, history of previous entropion surgery or patients unfit for surgery having any
uncontrolled medical condition were excluded. All patients underwent modified Jones procedure and followed up for 6
months.
Results: 57 eyes of 51 patients were included in this study. All patients underwent Jones procedure under local anesthesia.
Age of the patients range from 53 years to 78 years (mean of 66.78 years). 31(60.78%) patients were female while
20(39.21%)were male. 06 (11.76%) patients had bilateral disease while 45(88.23%) had unilateral disease.52 (91.22%) eyes
were totally corrected (Table 1), 02 (3.5%) eyes were overcorrected, 03 (5.26%) eyes had recurrence which needed repeat
surgery. As far as complications are concerned 15 (26.31%) eyes had bruising, 02(3.50%) eyes developed hematoma. 01
(1.75%) eye had wound infection, 02(3.50%) eyes had overcorrection and 02(3.5%) eyes had wound dehiscence.
Conclusion: Modified Jones procedure is an effective option for correction of primary lower lid senile entropion. It has a
good outcome, low recurrence rate with fewer complications.
Keywords: Entropion, Jones procedure

INTRODUCTION 

Senile entropion of the lower eyelid is a common involutional lid malposition. Due to inward rotation of the lid margins the lashes cause continuous irritation of the conjunctiva and may result in corneal insult which may range from punctate epitheliopathy to corneal ulceration1. Various factors contribute in pathophysiology of lower lid senile entropion. These include overriding of pre-septal orbicularis over pre-tarsal, lower lid retractors weakness, horizontal lid laxity and enophthalmos2. The definitive treatment of entropion is surgical. Various surgical techniques have been devised to cater different pathophysiological mechanisms causing entropion. These include lid everting sutures, Weiss procedure, Jones and Quickert etc. Entropion due to overriding of part of orbicularis is treated primarily with Weiss procure, however recurrent cases and those with lower lid retractor weakness are treated with Jones procedure. In this study we have shown that any type of primary involutional entropion without significant canthal laxity can be treated with modified Jones procedure successfully with fewer recurrences and complications.


Modified Jones procedure is an effective option for correction of primary lower lid senile entropion. It has a good outcome, low recurrence rate with fewer complications.


1. Head of Ophthalmology Department Bakhtawar Amin Medical and Dental College, Multan
2. Assistant Professor, Isra postgraduate Institute of ophthalmology, Al Ibrahim Eye Hospital, Karachi
3 Associate Professor Bakhtawar Amin Medical and Dental College, Multan
4. Consultant Ophthalmologist, Bakhtawar Amin Medical and Dental College, Multan
5. Senior Registrar, Ophthalmology Department, Bakhtawar Amin Medical and Dental College, Multan
6. Medical Officer, Ophthalmology Department, Bakhtawar Amin Medical and Dental College, Multan


Correspondence. Dr. Syed Hassan Raza Jafri, Professor of
Ophthalmology, Department of Ophthalmology, Bakhtawar Amin
Medical and Dental College, Northern Bypass Road, Multan.
Cell: 0333-2114785, E-mail: shjafri77@hotmail.com


Received. May 2019 Accepted: June 2019


In this study we have tried a slightly modified approach by adding a step from Hotz procedure by fixing the skin and orbicularis to the tarsal plate thus reducing recurrences through making a barrier between pre tarsal and pre septal Orbicularis. Additionally the   wound was closed in a single layer fashion taking bites from all the layers simultaneously, from lower wound edge passing through inferior portion of the lower lid retractors, taking a bite again through the superior part of retractors and exiting through the superior wound margin with adhering it to superior.

MATERIAL AND METHODS

Patients were selected on non-probability purposive basis from Ophthalmology department, Bakhtawar Amin Medical and Dental College Hospital, Multan from January 16 to December 17 (02 years). Permission was taken from ethical review committee. All the patients reporting to Ophthalmology department, Bakhtawar Amin Medical and Dental College Hospital diagnosed as having primary lower lid senile entropion were included. Patients having other causes of entropion such as enophthalmos, lid and canthal laxity or previous entropion correction were excluded. Patients were followed up for 6 months. Preoperative and postoperative photographs of the patients were taken on every visit. Completeocular examination was done with special attention to demarcate the pathology causing entropion. Overriding was confirmed by applying gentle pressure on the lid margin which alleviated overriding and corrected the entropion. Lower lid retractor weakness was delineated by demonstrating lower lid lag on downgaze and noted accordingly. Any concomitant corneal or conjunctival damage was noted and addressed accordingly. Routine preoperative investigations including viral markers were done for all patients. Modified Jones procedure was performed in all cases. The incision line was marked 4 mm inferior to the lid margin. Local infiltration with 2 ml of Lignocaine with adrenaline 1:1000 was injected over infraorbital foramina as infraorbital block. After proper sterile draping a horizontal incision was made parallel to lid margin to incise skin and orbicularis. Traction sutures with 4/0 silk were applied at the superior and inferior wound margins. The junction of lower tarsal plate and lower lid retractors is identified. Blunt dissection was carried out in the horizontal plain of the lower lid retractors up to the inferior orbital rim. The excessive skin from the lower wound margin was excised elliptically to ensure lower lid blepharoplasty. This steps adds a lot in success of the procedure. Three 6/0 polygalactin sutures were passed parallel to each other, starting portion of lower tarsal plate.This step is a small modification to add the benefits of Hotz procedure to avoid recurrences. The sutures were tied ensuring slight overcorrection. Readjustment were done with larger and deeper bites, if there was inadequate correction. Additional skin to skin sutures were placed to close wound gaps between the main sutures. Antibiotic ointment was applied over wound and eye pads were applied for 24 hours. On 1st day follow up bandage was removed and antibiotic ointment was prescribed for thrice daily application. The skin sutures were removed on 1st week follow up. The deep sutures were removed on 2nd week follow up. Subsequent follow ups were done at 3 month and 6 month post operatively. Photographs were taken on each follow up and any complication or recurrence was noted and managed accordingly.

RESULTS

57 eyes of 51 patients were included in this study. All patients underwent modified Jones procedure under local anesthesia. Age of the patients range from 53 years to 78 years (mean of 66.78 years). 31(60.78%) patients were female while 20(39.21%)were male. 06 (11.76%) patients had bilateral disease while 45(88.23%) had unilateral disease. 52(91.22%) eyes were totally corrected (Table 1), 02 (3.5%) eyes were overcorrected, 03 (5.26%) eyes had recurrence which needed repeat surgery. As far as complications are concerned (table 2)15 (26.31%) eyes had bruising, 02(3.50%) eyes developed hematoma. 01 (1.75%) eye had wound infection, 02(3.50%) eyes had overcorrection and 02(3.5%) eyes had wound dehiscence.







DISCUSSION

Senile lower lid entropion is a common lid malformation. Despite its most common cause being involutional due to laxity of tissues, conditions like Ocular Cicatricial Pemphigoid and Steven Johnson Syndrome4 also play their role. The tarsal plate of the lower lid is smaller as compared to upper lid. The relatively bigger and stronger pre septal portion of orbicularis easily rides over the weaker and smaller pre tarsal part which in turns rolls the lid margin inside. The choice of surgical procedure for management of involutional entropion is simple. At first other causes of entropion like cicatrization or epiblepharon are excluded through examination. Any canthal laxity has to be addressed. If there is no laxity and the entropion is mild, lid everting sutures can relieve the problem, but it’s a temporary solution which usually lasts not more than 18 months. Weiss procedure is adopted for a permanent correction especially if there is overriding of orbicularis parts. If there is mild laxity then Quickert5 procedure can be done. Jones procedure is conventionally reserved for recurrences and cases in which there is lower lid retractor weakness3. We performed Jones procedure as a primary procedure in all types of involutional entropion except those having gross lid or canthal laxity and have proved it be beneficial in acquiring good results and limiting recurrence rate. We did a small modification of the conventional Jones procedure. Instead of closing and repairing in layers, we did it with single sutures passing through all layers. Additionally we add a little effect of Hotz procedure by taking a bite from the upper part of the lower tarsal plate, thus fixing the skin and orbicularis to the tarsal plate to ensure lid stability and avoiding chances of recurrence through making a barrier between the pre tarsal and pre tarsal orbicularis. Modifications of plication of lower lid retractors have been tried by various surgeons. Nakauchi K et al6 have described and performed a similar approach with a recurrence rate of only 5%. Altieri M7 performed a modified plication approach with 7.1% as compared to 14.7% recurrence with conventional approach. Involutional lower lid entropion is more common in females as compared to males. The reason for this is attributed to the presence of a relatively smaller and thinner lower tarsal plate in females as compared to males8. In our study females were 60.78% as compared to 39.21% males. The studies by Damascenoet al9 and Borboridis K et al10 have comparable female preponderance. However Fattah A11 and Sahasrbudhe S12 have shown a contrast with higher male preponderance. In our study the success rate was 91.22%. This is comparable to Simon et al with 91.8%, Nakauchi K et al6 with 95% and Alteiri M et al7 with 92.9%. As far as complications are concerned, we experienced overcorrection in 02 (3.5%). This is slightly encouraging then Fattah A11 who reported 11% overcorrection. Mild overcorrection is desirable at the end of surgery as it tends to squeeze back a little as the post-operative edema settles. However larger overcorrections need to be addressed to avoid epiphora and exposure. We performed lateral tarsal strip in patients with overcorrection in whom the lid alignment was completely restored after the procedure. 3(5.26%) patients had recurrence. This is comparable to Simon et al13 with 8.2%, Nakauchi et al6 with 5% and Alteiri et al7 with 7.1%. Two cases of recurrence were treated with a repeat Jones procedure, while in one patient there was lateral and medial canthal laxity which developed 5 months after surgery. This patient was treated with canthal tightening and lid shortening. Hematoma developed in 2(3.5%) patients. One case resolved spontaneously while in one patient the wound was opened to drain the hematoma. Periorbital bruising was quite common which appeared in 15(26.31%) patients. However all cases had spontaneous improvement within 2 weeks without any alteration in the surgical outcome. Wound dehiscence was noted in 2(5.3%) patients, and treated with re suturing on the skin wound. One (1.75%) patient had a wound infection. The causes of infection were identified as improper use of post-operative antibiotic ointment, uncontrolled diabetes, left over sutures because of not following up properly for suture removal. The suture were removed and sent for culture and sensitivity, wound drained and oral antibiotics prescribed. The patient responded well with a good final outcome.

CONCLUSION

Modified Jones procedure is an effective option for correction of primary lower lid senile entropion. It has a good outcome, low recurrence rate with fewer complications.

 1. Nika Bagheri. The Eyelids. In: The Wills Eye Manual. 7th ed. Philadelphia: Wolters Kluwer. 2017: 256.
2. Frank W Newell. The Eyelids. In:Ophthalmology principles and concepts. 8th ed. St. Louis: Mosby. 1992: 198-9.
3. James C Tsai. Lids. In: Oxford American handbook of  Ophthalmology. 1sted. New York: Oxford. 2011: 119.
4. Vaughan and Asbury. Lid and lacrimal apparatus. In: General Ophthalmology. 18th ed. New York: Lange. 2011: 69.
5. Kanski JJ. Eyelids. In: Clinical ophthalmology. 8th ed. London: Elsevier. 2015: 49-51.
6. Ashok Garg. Eyelids. In: Oculoplasty and reconstructive surgery made easy. 1st ed. New Delhi: Jaypee. 2009: 63-66.
7. Fredrick Hampton. Eyelids. In: Ocular differential diagnosis. 9th ed. New Delhi: Jaypee Highlights. 2012: 74.
8. Timothy L Jackson. Oculoplastics. In: Moorfield Manual of Ophthalmology. 1st ed. Philadelphia: Mosby Elsevier. 2008: 16.
9. Collins JRO. Eyelids and trichiasis. In: A manual of systemic eyelid surgery. 2nd ed. Edinburgh: Churchill Livingstone, 1995: 13-4.
10. Quikert M, Rathbun E. Suture repair of entropion. Arch Ophthalmol, 1971; 85:304–5.
11. AG Tyres, JRO Collins. Entropion. In: Color atlas of ophthalmic plastic surgery. 2nd ed. Boston: Butterworth Heinemann. 2001: 72-80
12. Nakauchi K1, Mimura O. Combination of a modified Hotz procedure with the Jones procedure decreases the recurrence of involutional entropion. ClinOphthalmol. 2012; 6:1819-22.
13. Altieri M1, Kingston AE, Bertagno R, Altieri G. Modified retractor plication technique in lower lid entropion repair: a 4-year followup study. Can J Ophthalmol. 2004 Oct; 39(6):650-5.
14. Bashour M et al. causes of involutional ectropion and entropion, age related tarsal changes are the key. Ophthalmic plastrecontr Surg. 2002; 16(2):131-41.
15. Damasceno RW, Osaki MH, Dantas PE, Belfort RJR. Involutional entropion and ectopion: clinicopathologic correlation between horizontal eyelid laxity and eyelid extracellular matrix. OphthalPlastReconstrSurg 2011; 27:321–6.
16. Boboridis K, Bunce C, Rose GE. A comparative study of two procedures for repair of involutional lower lid entropion. Ophthalmology 2000; 107:959–61.
17. Abdel Fattah ME, ElSayed EMEH, Abdel Kader KSED, Abdel Badia SM. Wies operation with horizontalshortening versus retractor tightening with horizontal shortening for management of lower eyelid senile entropion. Discussed thesis in Zagazig University, Egypt 2007:http://www.publications.zu.edu.eg/ Pages/PubShow. AspxID=18624 &pubID=19.
18. Vallabhanath P, Carter SR. Ectropion and entropion. CurrOpinOphthalmol. 2002; 11:345-51.
19. Hoda M Kamel. Weiss procedure versus Jones procedure in the surgical correction of acquired lower eyelid involutional entropion. Menoufin medical journal. 2017; 128-132.
20. Ben Simon GJ, Molina M, Schwarcz RM, McCann JD, Goldberg RA. External (subciliary) vs internal (transconjunctival) involutional entropion repair. Am J Ophthalmol.2005. 139:482–7.
 





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