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ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 507-511

Wies procedureversusJones procedure in the surgical correction of acquired lower eyelid involutional entropion


Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission21-Jul-2016
Date of Acceptance02-Oct-2016
Date of Web Publication25-Sep-2017

Correspondence Address:
Mona M Mohammed Allam
Berket El Sabae, 32651
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.215452

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  Abstract 

Objective
The aim of this study was to compare the effect of Wies procedure withthatof Jones procedure in the primary repair of lower eyelid involutional entropion.
Background
Involutional entropion(senile entropion) is a general instability of the lid structures with age with inward rotation of the eyelid margin. The eyelashes rub against the inferior cornea and bulbar conjunctiva causing irritation. This finally leads to impaired optical function of the ocular surface. Different methods have been described aiming at treating one or several of the etiological factors of the involutional entropion.
Patients and methods
In the current comparative prospective study, 30patients(31 eyelids) with senile lower eyelid involutional entropion without horizontal eyelid laxity were selected and divided into two groups. Group 'A' included 16 eyelids of 15patients that were corrected using Wies procedure and group 'B' included 15 eyelids of 15patients that were corrected using Jones procedure.
Results
In the group subjected to Wies procedure, during the follow-up period(6months), 12(85.7%) cases were successful, two cases were missed from follow-up, and two(14.3%) cases were unsuccessful(undercorrection in one case and recurrence in the other). However, in the group subjected to Jones procedure, 14(93.3%) cases were successful and only one(6.7%) case was unsuccessful(overcorrection occurred). In the Wies group, nine(64.3%) cases showed cosmetically accepted results and five(35.7%) did not. However, in the Jones group, 12(80%) cases showed cosmetically accepted results and three(20%) cases did not(P=0.03). In the Wies group, eight(57.1%) patients were satisfied and six(42.9%) were not. However, in the Jones group, 13(86.7%) patients were satisfied and two(13.3%) were not(P=0.55).
Conclusion
Jones procedure is more likely successful, cosmetically acceptable, and satisfactory to the patients compared with Wies procedure.

Keywords: primary repair, involutional entropion, Jones procedure, Wies procedure


How to cite this article:
Kamel El-Sobky HM, Mandour SS, Mohammed Allam MM. Wies procedureversusJones procedure in the surgical correction of acquired lower eyelid involutional entropion. Menoufia Med J 2017;30:507-11

How to cite this URL:
Kamel El-Sobky HM, Mandour SS, Mohammed Allam MM. Wies procedureversusJones procedure in the surgical correction of acquired lower eyelid involutional entropion. Menoufia Med J [serial online] 2017 [cited 2019 Sep 18];30:507-11. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/507/215452


  Introduction Top


Involutional entropion(senile entropion) is the inward rotation of the eyelid margin with age[1]. Entropion is more common in women than in men, with a prevalence of 2.4% in women and a prevalence of 1.9% in men[2]. Factors thought to play a role in the development of involutional entropion are dehiscence of lower eyelid retractors, over-riding of preseptal orbicularis oculi muscle(OOM) over the pretarsal OOM, horizontal lid laxity, and enophthalmos[3]. However, enophthalmos has not been shown to be a significant factor. Surgical therapy is the treatment of choice addressing these factors, especially lower lid retractor(LLR) dehiscence[4],[5],[6],[7],[8],[9],[10],[11].

Eyelashes rub against the inferior cornea and bulbar conjunctiva causing irritation[4],[6],[8],[9],[10],[11],[12]. This leads to an impaired optical function of the ocular surface through chronic irritation of the conjunctiva and the cornea. Hence, early intervention is required because tear film instability, conjunctiva scarring, recurrent corneal abrasions, corneal ulceration, superficial corneal opacities, and vascularization are blinding conditions[1],[13],[14]. Hence, the current study was conducted.


  Patients and Methods Top


Before initiating this study, the protocol, the informed consent form, and any other written information to be given to patients were reviewed and approved by the Ethics Committee of the Menoufia University Hospital.

This prospective comparative study included 30patients(31 eyelids) with senile lower eyelid involutional entropion who were selected from the Outpatient Clinic in the Department of Ophthalmology of Menoufia University Hospital and Tanta University Hospital, from May 2015 to May 2016. The patients were divided into two groups. Group 'A' included 16 eyelids of 15patients corrected using Wies procedure and group 'B' included 15 eyelids of 15patients corrected using Jones procedure.

Inclusion criteria

Patients with primary involutional lower eyelid entropion and cooperative patients who were fit for local anesthesia were included in the study.

Exclusion criteria

Those with horizontal eyelid laxity, lateral canthus tendon(LCT) laxity, medial canthus tendon(MCT) laxity, and recurrence were excluded from the study.

Methods

All patients included in this study were subjected to complete ophthalmic examination including digital eversion test, snap-back test, distraction test, MCT laxity test, LCT laxity test, OOM tone check test, bell phenomenon test, Schirmer test using Whatman paper(Ophtechnics Unlimited, Haryana, India), fluorescein corneal test, and lacrimal system patency test. The disinsertion or dehiscence of LLRs was evaluated.

Procedure

All cases were examined under local infiltrative and surface anesthesia. Approximately 2–3ml of 2% lidocaine with 1:100000 dilution of adrenaline was injected subcutaneously across the whole length of the lower lid.

GroupA('Wies' procedure)

Sterile preparation: Askin incision was marked 4mm inferior to the lashes. Local anesthesia was induced across the whole length of the eyelid. Alid guard was placed to protect the globe. The lower eyelid was stabilized with '4–0' silk traction suture and clamped to the guard and drape. Full-thickness stab incision was made. The inferior fat pad was exposed with blunt dissection behind the preseptal OOM.

The lower eyelid retractors were identified as a visible white fibrous tissue layer between the inferior fat pad and the conjunctiva. Three double-armed 6–0 sutures were applied through the conjunctiva and LLRs. Sutures were passed anterior to the tarsal plate to exit inferior to the lashes. The sutures were tied under enough tension just to evert the lid margin. The skin was closed with interrupted sutures. Skin sutures were removed after 7days. Double-armed sutures were removed after 14days.

GroupB('Jones' procedure)

Sterile preparation: Skin incision was marked at the lower border of the tarsal plate 4mm below the lashes from the punctum to the lateral canthus. Local anesthesia was induced across the whole length of the eyelid. Alid guard was placed to protect the globe. The lower eyelid was stabilized with a 4–0 silk traction suture and clamped to the guard and drape.

A horizontal skin incision 4mm from lashes was made with a no.15 blade. The orbicularis muscle was cut. The skin and the orbicularis muscle layer were reflected up to expose the tarsal plate and down to expose the orbital septum and the underlying fat pad.

The lower eyelid retractors were dissected from the tarsus and conjunctiva. The orbital septum was opened and the lower eyelid retractors were dissected. Three long-acting 6–0 absorbable plicating sutures were passed through the LLRs, through the lower border of the tarsal plate and out through the LLRs. The sutures were tied. The excess of the retractors was excised. The skin was closed with interrupted sutures. Skin sutures were removed after 7days. Plicating sutures were removed after 14days.

Statistical analysis

All data were collected, tabulated, and statistically analyzed using SPSS 19.0 for Windows (SPSS Inc., Chicago, Illinois, USA) and MedCalc 13 for Windows (MedCalc Software bvba, Ostend, Belgium).

Pvalue more than 0.05 was considered nonsignificant and P value less than 0.05 was considered significant.


  Results Top


Thirty patients(31 eyelids) with involutional entropion underwent surgical repair; only one patient had bilateral entropion. Jones' retractor plication was performed in 15(50%) patients, five(33.3%) of whom were male and 10(66.7%) were female, whereas Wies procedure was performed in 15(50%) patients, six(40%) of whom were male and nine(60%) were female[Table1]. Entropion was mild in two cases, moderate in 13cases, and severe in one case in Wies procedure, whereas in Jones procedure entropion was moderate in 13cases and severe in two cases[Table2].
Table 1: Sex distribution in the two studied groups

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Table 2: Entropion grades in the two studied groups

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Punctate epithelial erosion was mild(grade0) in two cases, moderate in 13cases(eight were of grade1 and five of grade2), and severe(grade3) in one case in the Wies procedure group, whereas in the Jones procedure group punctate epithelial erosion was moderate in 13cases(six were of grade1 and seven of grade2), and severe(grade3) in two cases. Dry eye was mild(grade1) in two cases, moderate(grade2) in 13cases, and severe(grade3) in one case in the Wies procedure group, whereas in the Jones group it was moderate(grade2) in 13cases and severe(grade3) in two cases. Bell's phenomenon test was good in all cases. Lacrimal system was patent in all cases. Horizontal eyelid laxity, MCT laxity, and LCT laxity were absent in all cases, whereas OOM overaction and LLR dehiscence were found in all cases.

The operation time in the Wies procedure group ranged from 20 to 40min(mean±SD: 30.1±6.8min), whereas in the Jones procedure group it ranged from 20 to 45min(mean±SD: 33.9±8.7min). The only intraoperative complication was bleeding, which occurred in two(12.5%) cases in the Wies procedure group and in one case in the Jones procedure group. During the follow-up period(6months), in group 'A', 12(85.7%) cases were successful[Figure 1], two cases were missed from follow-up, and two(14.3) cases were unsuccessful. However, in group 'B', 14(93.3%) cases were successful and only one(6.7%) case was unsuccessful. Recurrence of entropion occurred in one(7.1%) case of the Wies procedure group6months postoperatively[Figure 2], whereas no recurrent cases of entropion were noticed in the Jones procedure group during the follow-up period.
Figure 1: Case no. 7, group A.

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Figure 2: Case no. 9, group A.

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Hematoma in the lower eyelid region occurred in two(14.3%) cases of the Wies procedure group and in one(6.7%) case in the Jones procedure group[Figure 3]. Undercorrection occurred in one(7.1%) case in the Wies procedure group. The entropion shifted from grade2 to grade1, whereas in the Jones procedure group no undercorrection occurred in any case. Overcorrection occurred in one(6.7%) case in the Jones procedure group. One of the sutures(central) was removed but overcorrection was still found[Figure 4], whereas in the Wies procedure group no overcorrection occurred.
Figure 3: Case no. 15, group B.

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Figure 4: Case no. 5, group B.

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Edema occurred in two(14.3%) cases in the Wies procedure group and in one(6.7%) case in the Jones procedure group. In the Wies procedure group nine(64.3%) cases had cosmetically acceptable results and five(35.7%) cases did not, whereas in the Jones procedure group12(80%) cases had cosmetically acceptable results and three(20%) cases did not(P=0.03)[Table3]. In the Wies procedure group eight(57.1%) patients were satisfied and six(42.9%) were not, whereas in the Jones procedure group13(86.7%) cases were satisfied and two(13.3%) were not(P=0.55)[Table4].
Table 3: Cosmetic appearance in the two studied groups

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Table 4: Patient satisfaction in the two studied groups

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  Discussion Top


Different methods have been described for treating involutional entropion[15],[16],[17]. The current study compared Jones retractor plication procedure with Wies procedure as a primary surgical intervention for repair of involutional lower eyelid entropion without horizontal eyelid laxity.

In the current study, difference between sexes in the two groups was statistically significant indicating a higher incidence of involutional entropion in female than in male population. This is in agreement with many studies. In a study by Boboridis etal.[18], there were 41male and 61female patients. In a study by Damasceno etal.[2], the prevalence was 2.4% in female patients and 1.9% in male patients. This is due to smaller tarsal plates in female than in male populations(Bashour and Harvey, 2000).

However, this is in disagreement with the study by Abdel Fattah etal.[19], in which the number of male patients was 20, whereas the number of female patients was six, and with the study by Sahasrabudhe and Salian[1], in which the number of male patients was 26 and the number of female patients was 25; however, they did not explain the cause.

In the current study, recurrence occurred only in one(7.1%) case that underwent Wies procedure and no recurrence occurred in Jones procedure, indicating a higher incidence rate of recurrence with Wies compared with Jones procedure. This is in agreement with many studies. In the study by Boboridis etal.[18], recurrence occurred in 11cases that underwent Wies procedure and in two cases that underwent Jones procedure(P=0.81).

In the study by Abdel Fattah etal.[19], recurrence occurred in one case that underwent Wies procedure and no recurrent cases of entropion were noticed in Jones procedure. In the study by Serin etal.[20], recurrence occurred in nine eyes that underwent Wies procedure and in only one in the combined procedure group(P=0.001). In the study by Sahasrabudhe and Salian[1], no recurrent cases occurred.

In the study by Simon etal.[21], which included 49 eyes with LLR reinsertion, subciliary incision repair was performed in 29 eyes and transconjunctival repair was performed in 20 eyes. Recurrence was noticed in four(8.2%) eyes. It was higher in the transconjunctival approach(15vs. 3% with subciliary incision). This is due to full-thickness incision in Wies procedure creating cicatrization at the conjunctiva.

In the study by Nakauchi and Mimura(2012), three cases that underwent Jones procedure reported recurrence, whereas in the combined procedure group there was only one recurrent case. The recurrence rate was 5%. In the study by Ranno etal.(2014), 10patients who underwent the Jones procedure and two patients who underwent the combined procedure reported recurrence. In the study by Altieri etal.(2004), the rate of entropion recurrence was lower in the modified technique group(7.1%) than in the Jones technique group(14.7%). In the study by Shaheen[22], which evaluated the surgical outcome of involutional entropion repair with lower eyelid tightening both horizontally and vertically, no cases of recurrence were recorded.

In the current study, overcorrection occurred in one (6.7%) case that underwent Jones procedure, whereas no overcorrection occurred in cases that underwent Wies procedure, indicating a higher incidence of overcorrection in Jones than in Wies procedure. This is because Jones procedure is a powerful procedure and overcorrection is a common complication [22].

However, this is in disagreement with the study by Abdel Fattah etal.[19], in which no cases of overcorrection occurred in Jones procedure, whereas overcorrection was observed in one eyelid in Wies procedure, and with the study by Boboridis etal.[18], in which 20(31%) secondary ectropion occurred after Wies procedure compared with four(11%) after Jones procedure, mentioning that this is a well-recognized complication of this procedure.


  Conclusion Top


Jones procedure is more likely successful, cosmetically acceptable, and satisfactory to the patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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2.
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Abdel Fattah ME, El-Sayed 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. Available from: http://www.publications.zu.edu.eg/Pages/PubShow.aspx?ID=18624&&pubID=19. [Last accessed 2016 Jun].  Back to cited text no. 19
    
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Ben SimonGJ, MolinaM, SchwarczRM, McCannJD, GoldbergRA. External(subciliary) vs internal(transconjunctival) involutional entropion repair. Am J Ophthalmol 2005. 139:482–487.  Back to cited text no. 21
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table1], [Table2], [Table3], [Table4]



 

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