Interventions for treating an inward turning lower eyelid in the elderly

Entropion is the inward turning of the eyelid, causing rubbing of the eyelashes and eyelid skin against the surface of the eye. It is one of the commonest forms of eyelid problems in older people and it more frequently involves the lower eyelid. In the early stages not all people require treatment but eventually every movement of the eye or eyelid causes trauma to the corneal surface which may lead to infection and ulceration with visual impairment. Surgery in the form of horizontal and vertical eyelid tightening is needed when the condition is severe and causes trauma to the cornea. The review authors searched the medical literature and found a single trial that met the inclusion criteria of the review. Sixty-three participants with lower eyelid entropion were enrolled and randomised to either everting sutures alone or everting sutures and a lateral tarsal strip. Eight participants were lost to follow-up. The trial showed that the combination of horizontal and vertical eyelid tightening with everting sutures and lateral tarsal strip is highly efficient for entropion compared to vertical tightening with everting sutures alone. Further research is needed to provide more credible evidence for the comparison of surgical treatments to correct an inward turning eyelid.

Authors' conclusions: 

A single RCT showed that the combination of horizontal and vertical eyelid tightening with everting sutures and lateral tarsal strip is highly efficient for entropion compared to vertical tightening with everting sutures alone. Retrospective case series studies also support the combined surgical repair but details from these studies on specific surgical techniques cannot be included in the analysis.

Evidence from a single RCT is unlikely to change clinical practice and thus it is still our view that there is a clear need for more randomised studies comparing two or more surgical techniques for entropion surgery addressing the recurrence and complications rate.

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Background: 

Entropion is a condition in which the eyelid margin turns in against the eyeball. Involutional or senile entropion is one of the most common lower lid malpositions in the elderly. The interventions described and currently used for the treatment of this condition are surgical in nature, although non-surgical temporary medical treatment for the early stages of entropion has also been reported. The relative effectiveness of these interventions has not yet been resolved.

Objectives: 

To examine the effect of interventions for involutional entropion and to assess whether any method is superior to any other.

Search strategy: 

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 10), MEDLINE (January 1950 to November 2011), EMBASE (January 1980 to November 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com),ClinicalTrials.gov (http://clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 2 November 2011. We also searched oculoplastic textbooks, conference proceedings from the European and American Society of Ophthalmic Plastic and Reconstructive Surgery (ESOPRS, ASOPRS), European Ophthalmological Society (SOE), the Association for Recearch in Vision and Ophthalmology (ARVO) and American Academy of Ophthalmology (AAO) for the years 2000 to 2009 to identify relevant data. We attempted to contact researchers who are active in this field for information about further published or unpublished studies.

Selection criteria: 

We included randomised controlled trials (RCTs) with no restriction on date or language comparing two or more surgical methods for correction of involutional lower eyelid entropion in people older than 60 years of age with involutional lower lid entropion.

Data collection and analysis: 

Each review author independently assessed study abstracts identified from the electronic and manual searches. Author analysis was then compared and full papers for appropriate studies were obtained according to the inclusion criteria. Disagreements between the authors were resolved by discussion.

Main results: 

We identified one RCT which met our inclusion criteria and was included in this review. Sixty-three participants with primary involutional lower eyelid entropion were randomised to everting sutures alone or everting sutures with a lateral tarsal strip. Eight participants were lost to follow-up. The trial indicates that the combined procedure for horizontal and vertical eyelid tightening in the form of everting sutures and lateral tarsal strip is highly curative for involutional entropion compared to vertical tightening in the form of everting sutures alone. The superiority of the combined approach is also supported by many good quality uncontrolled studies on specific surgical procedures but these were not included in the analysis as they were not part of the inclusion criteria.

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