Comparison of everting sutures and the lateral tarsal strip with or without everting sutures for involutional lower eyelid entropion: A meta-analysis

There are three pathophysiologies of involutional entropion, vertical laxity (VL), horizontal laxity (HL), and overriding of the preseptal orbicularis. The effects of methods to correct VL only, HL only, or both VL and HL in patients with involutional entropion were compared using the published results of randomized controlled trials (RCTs). To find RCT studies that investigated methods to correct involutional entropion, a systematic search was performed from database inception to April 2020 in the Medline, EMBASE, and Cochrane databases. Two independent researchers conducted the literature selection and data extraction. Evaluation of the quality of the reports was performed using the Cochrane Collaboration tool for assessing the risk of bias (ROB 2.0). The data analysis was conducted according to the PRISMA guidelines using Review Manager 5.3. Two RCT studies were included in this meta-analysis. Surgery for involutional entropion was performed on a total of 109 eyes. Everting sutures (ES) were used on 57 eyes and lateral tarsal strips (LTS) or combined procedures (LTS + ES) were performed on 52 eyes. At the end of the follow-up periods, involutional entropion recurred in 18 eyes (31.6%) in the ES group and three eyes (5.8%) in the LTS +/- ES group. Analysis of the risk ratio showed that the LTS +/- ES method significantly lowered the recurrence rate compared to using ES only (P = 0.007). Performing LTS +/- ES effectively lowered the recurrence rate of involutional entropion compared to ES alone. However, some patients cannot tolerate more invasive corrections such as LTS. Therefore, sequential procedures, in which ES is performed first and then when entropion recurs LTS +/- ES is performed, or another methods depending upon the degree of HL may be used.


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Entropion is an eyelid malposition where the eyelid margin and eyelashes are turned toward the eyeball. 53 Entropion is divided into four types, cicatricial, congenital, acute spastic, and involutional [1]. 54 Involutional entropion, also known as senile entropion, is most commonly observed in general 55 ophthalmic practice and increases in incidence with age [2,3]. Also, the incidence of entropion in 56 Asians is higher than in non-Asians [4]. Patients with involutional entropion complain of dry eye 57 syndrome, superficial punctate keratopathy, chronic blepharitis, and chronic conjunctivitis [2].  surgical therapies such as the use of lubricating ointment, eyelid taping, and botulinum toxin injections 59 are used for the treatment of involutional entropion, but most are temporary treatments while the patient 60 awaits eyelid surgery, which is the definitive treatment [1,5]. The causative factors of involutional 61 entropion are 1) vertical laxity of the lower eyelid, 2) horizontal laxity of the lower eyelid, and 3) 62 overriding of the preseptal orbicularis oculi muscle (OOM) [6,7]. 63 Various surgical methods have been attempted to correct each causative factor of involutional entropion. 64 The methods to correct vertical laxity of the lower eyelid include everting sutures (ES), the Quickert 65 procedure, the Weis procedure, the Jones procedure, the Hotz procedure, lower eyelid retractor 66 advancement, and Bick's procedure. Lateral tarsal strips (LTS) and lateral wedge resection are used to 67 correct horizontal laxity of the lower eyelid and OOM transposition is a method of correcting overriding 68 of the pre-septal OOM. In addition, procedures combining these methods, such as ES with LTS or lower 69 eyelid retractor advancement with LTS, are also performed [5]. We performed a meta-analysis of 70 randomized controlled trial (RCT) results of the recurrence and complication rates after procedures 71 conducted to correct vertical laxity only, horizontal laxity only, or both in patients with involutional 72 entropion. In addition, we summarized all RCTs performed for involutional entropion and the results.  follow-up loss was more than 10% and analysis of the participant characteristics was not presented, the 110 domain of "missing outcome data" was evaluated as "some concerns." Although it was not described 111 in the abstracts and full texts, the domain of "measurement of the outcome" was evaluated as high risk 112 if it was thought that the assessors knew the participants' aligned interventions in advance. The overall 113 ROB for each trial is presented in Table 1. The ROB for each domain analyzed using Review Manager    The outcome data were analyzed for recurrence and complication rates using Review Manager 5.3. In 126 this meta-analysis, the random-effects model and the Mantel-Haenszel method were used because 127 heterogeneity was suspected. The surgical methods used in each trial were not the same. eyes. The smallest sample size was 26 eyes, the largest sample size was 29 eyes, and the median sample 143 size was 27 eyes. The follow-up periods in the trials were 12 months and 18 months.

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None of the follow-up points in the two trials coincided with each other (Tables 2 and 3).   there was no mention of blinding of the participants, surgeons, and assessors, and it seems likely that 165 they knew about the intervention assignments. The recurrence rate was compared at the end of the study follow-up points of each trial using Review 169 Manager 5.3 (Fig 4). At the end of the study follow-up points, 18 eyes (31.6%) in the ES group and 170 three eyes (5.8%) in the LTS +/-ES group experienced recurrences. The risk ratio for recurrence 171 between the ES group and the LTS +/-ES group was 4.37, and the recurrence rate in the LTS +/-ES 172 group was significantly lower than that in the ES group (95% confidence interval: 1.51 to 12.64 P = 173 0.007). Recurrences in the two trials showed low heterogeneity with I 2 = 0%.  was no statistically significant difference in the success rate between the two groups, the use of silk 215 significantly reduced the cost of surgery. Therefore, when selecting suture material for involutional 216 entropion surgery, it is better to use a thinner absorbable material, but the cost of surgery should be 217 considered in a country with low socioeconomic status. The recurrence rates were compared and were not statistically significant between the two groups.  the ES+LTS group (9.5 mm) were not significantly different from each other.

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That is, rather than performing LTS or LTS+ES for all involutional entropion cases, to lower the 272 recurrence rate, horizontal laxity should be evaluated first and the appropriate surgical method should 273 be selected accordingly. This is because there is an advantage of ES only, such as in cases where the 274 horizontal laxity is not severe or in patients whose conditions cannot tolerate more invasive horizontal 275 laxity correction, such as by LST. Consideration can be given to using sequential methods where ES is 276 performed first and then when the entropion recurs, horizontal laxity correction only or a combined 277 procedure is performed. Also, another method, such as ES for low horizontal laxity and LTS or LTS+ES 278 for higher horizontal laxity, dependent upon the degree of horizontal laxity may be considered.

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In the two RCT studies selected for this meta-analysis, there was no mention of blinding, and all were 280 assessed as high risk of bias in quality assessment. It is more difficult to conceal group allocations in 281 surgical intervention RCTs than medication assignments in drug RCTs, but more rigorously designed

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RCT studies are required to obtain more reliable results. In addition, although the characteristics of We gratefully acknowledge the help of Harrisco for providing editing services for this paper.