Towards optimal management of lower eyelid malpositions: A systematic review of treatment effectiveness and safety

Sbitan, Lana; Tanous, Haneen; Jardak, Mira Nawfal; Camargo, Cristina Pires

doi:10.1016/j.clinsp.2024.100547

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Review articles • Clinics 80 • 2025 • https://doi.org/10.1016/j.clinsp.2024.100547 linkcopy

Towards optimal management of lower eyelid malpositions: A systematic review of treatment effectiveness and safety

Authorship SCIMAGO INSTITUTIONS RANKINGS

Lower eyelid malposition, a commonly encountered eyelid disorder, is often linked to discomfort, visual disturbances, and cosmetic concerns. Various treatment modalities have been employed to address these conditions, but their effectiveness and safety remain subjects of debate. This systematic review, aiming to compare and evaluate these treatments, produced a comprehensive analysis of diverse approaches to managing lower eyelid malposition. The search encompassed electronic databases, clinical trial registries, and relevant journals from inception to September 2023. Fifteen studies meeting the inclusion criteria, involving 709 patients (855 eyelids), were reviewed, comprising 12 randomized controlled trials and 3 ongoing trials. We assessed the quality of each included study using the Cochrane Risk-of-Bias tool for randomized trials (RoB v2). We analyzed success rates, recurrence rates, adverse events, and patient satisfaction. Results revealed that modifications to the conventional Lateral Tarsal Strip exhibited high success rates and low recurrence rates. Other treatments, including Everting Sutures, Retraction Pelication, and Orbicularis Muscle Shortening, showed promise in specific cases. Complications, generally mild and manageable, were reported across all modalities, with patients expressing overall satisfaction. The systematic review highlights the effectiveness and safety of various surgical interventions for lower eyelid malposition, offering durable outcomes and minimal recurrence. Tailoring treatments based on patient characteristics and anatomical variations is crucial. Further research is warranted to refine indications for each treatment option in this evolving field.

Keywords:
Ectropion; Entropion; Eyelid diseases; Oculoplastic procedures; Ophthalmic plastic surgery

Study ID	Intervention	Control	Outcome Measures	Outcomes								Follow-up duration
				Intervention Success		Recurrence		Adverse Events		Patient Satisfaction
				Intervention	Control	Intervention	Control	Intervention	Control	Intervention	Control
Olver et al. 1998¹	Donor scleral graft interposition without adjuvant antimetabolites	Partial tenotomy of the Anterior Lower Eyelid Retractors (ALER), capsulopalpebral fascia, and inferior tarsal muscle, with a single preoperative application of adjuvant 5-fluoro-uracil or mitomycin C	Lower margin reflex distance (MRD): distance (in mm) from the central corneal light reflex to the lower eyelid margin.	Significant lower MRD reduction (mean 1.8 mm; p < 0.001) and improved eyelid contour at 1, 3, 6 months post-surgery. Lower SS significantly reduced at 1, 3, 6 months after surgery (p < 0.001).	Significant lower MRD reduction at 1-month post-surgery (p = 0.006), not sustained at 3 and 6 months (p = 0.16 and 0.10). Significant lower SS reduction at 1-month post-surgery (p < 0.001), not sustained at 3 and 6 months (p = 0.12 and 0.22). No significant differences between patients treated with adjuvant 5-fluo-rouracil or mitomycin C.	None of the patients required surgery for recurrence.	3 patients (4 eyelids) required surgery for recurrent retraction; all received mitomycin C. 4 patients (5 eyelids) required surgery for recurrent central sag in the eyelid contour.	Results were satisfactory in all patients.	Results were satisfactory only in 5 patients (6 eyelids).	None reported.	Unilateral corneal epithelial erosion (1 patient). Temporary adhesion of lower eyelid to bulbar conjunctiva (1 patient).	7.8 months Fixed intervals (1-week and at 1, 3, 6, 9, 12, and 18 months) after surgery.
López-García et al. 2017²	Modified tarsal strip technique (Suture placement modified for entropion and ectropion)	Conventional lateral tarsal strip	Lower scleral show (SS): distance from the inferior limbus to the lower eyelid margin. Horizontal lid laxity (HLL) measured by pinch test, orbicularis muscle function and hypertrophy, lower eyelid retractors function.	All ectropion patients achieved successful surgical outcomes. 48 of 50 entropion eyelids had successful surgical outcomes (96%). Orbicularis hypertrophy (8 eyelids). Statistically significant HLL and orbicularis muscle function compared to the control group (p < 0.05).	Mean HLL in entropion eyelids = 5.8; in ectropion patients = 5.8. Orbicularis hypertrophy (12 eyelids) Lower eyelid retractors’ dysfunction noted in 22 eyelids.	2 out of 94 eyelids (4%) showed recurrence. (entropion)	9 out of 90 eyelids showed recurrence (17.4% entropion and 2.3% ectropion)	No difference in patient perception was found between groups. Subjective perception significantly improved after treatment (p = 0.001).	No difference in postoperative complications between groups. Moderate to severe lower lid hematomas were observed in 10 eyelids. Ectropion overcorrection (9 eyelids). Entropion overcorrection (8 eyelids).	64.8 months. Fixed intervals (1, 10, 30 days, 6, 12 months, 2, 3, 4, 5, 6 years) post-surgery.

Study ID	Country	Study design	Sample Size (number of eyelids)			Age (mean ’years’)			Gender (Females ’F’\|Males ’M’)
Study ID	Country	Study design	Total	Intervention	Control	Total	Intervention	Control	Total	Intervention	Control
Olver et al. 1998¹	UK	RCT	25 (35)	13 (20)	12 (15)	57	54	59	20F\|5M	9F\|4M	11F\|1M
Altieri et al. 2003²	Italy	RCT	43 (43)	13 (13)	Group 2: 16 (16) Group 3: 14 (14)	75.7	70.9	Group 2: 78.7 Group 3: 71.8	31F\|12M	8F\|5M	Group 2: 14F\|2M Group 3: 11F\|3M
Altieri et al. 2004³	Italy	RCT	69 (69)	33 (33)	36 (36)	74.8	77.5	70.3	62^a (39F\| 23M)	15F\|13M	24F\|10M
Scheepers et al. 2010⁴	UK	RCT	63 (63) 55 (55)^a	26 (26)	29 (29)	77	78	77	28F\|27M	13F\|13M	15F\|14M
Xu, 2015⁵	China	RCT	82 (126)	41 (63)	41 (63)	67.3	68.8	67.7	26F\|56M	11F\|30M	15F\|26M
López-García et al. 2017⁶	Spain	RCT	135 (184) 110^a	(94 eyelids)	(90 eyelids)	NA	71.2	67.4	93F\|91M (eyelids)	NA	NA
Goel et al. 2017⁷	India	RCT	30 (30)	15 (15)	15 (15)	Range (55-80 years)	69.33	70.53	11F\|19M	NA	NA
Meduri et al. 2018⁸	Italy	RCT	8 (16)	4 (8)	4 (8)	69.5	71	NA	NA	NA	NA
Nakos et al. 2019⁹	Greece	RCT	45 (54)	(28 eyelids)	(26 eyelids)	72.69	72	72.8	28F\|26M (eyelids)	15F\|13M (eyelids)	13F\|13M (eyelids)
Dulz et al. 2019¹⁰	Germany	RCT	52 (66) 49 (63)^a	(30 eyelids)	(36 eyelids)	73	65.4	67.2	NA	NA	NA
Yuan, 2020¹¹	China	RCT	79 (91)	41 (46)	38 (45)	73.1	73.2	72.9	39F\|40M	20F\|21M	19F\|19M
Khan et al. 2021¹²	Pakistan	RCT	78 (78)	39 (39)	39 (39)	Range (55‒ 80 years)	64.62	64.56	23F\|55M	NA	NA

^a
Excluding patients lost to follow-up.
¹
Olver JM, Rose GE, Khaw PT, Collin JR. Correction of lower eyelid retraction in thyroid eye disease: a randomised controlled trial of retractor tenotomy with adjuvant antimetabolite versus scleral graft. Br J Ophthalmol. 1998;82(2):174–80.
²
Altieri M, Iester M, Harman F, Bertagno R, Capris P, Venzano D, et al. Comparison of three techniques for repair of involutional lower lid entropion: a three-year follow-up study. Ophthalmol J Int Ophtalmol Int J Ophthalmol Z Augenheilkd. 2003;217(4):265–72.
³
Altieri M, Kingston AEH, Bertagno R, Altieri G. Modified retractor plication technique in lower lid entropion repair: a 4-year follow-up study. Can J Ophthalmol J Can Ophtalmol. 2004;39(6):650–5.
⁴
Scheepers MA, Singh R, Ng J, Zuercher D, Gibson A, Bunce C, et al. A randomized controlled trial comparing everting sutures with everting sutures and a lateral tarsal strip for involutional entropion. Ophthalmology. 2010;117(2):352–5.
⁵
Xu QL. Clinical efficacy comparison of flabby skin excision combined orbicularis oculi muscle shortening surgery in patients with senile entropion. Int Eye Sci. 2015;15:1277–9.
⁶
López-García JS, García-Lozano I, Giménez-Vallejo C, Jiménez B, Sánchez Á, de Juan IE. Modified lateral tarsal strip for involutional entropion and ectropion surgery. Graefes Arch Clin Exp Ophthalmol Albrecht Von Graefes Arch Klin Exp Ophthalmol. 2017;255(3):619–25.
⁷
Goel R, Sanoria A, Kumar S, Arya D, Nagpal S, Rathie N. Comparison of Polypropylene Sling with Combined Transconjunctival Retractor Plication and Lateral Tarsal Strip for Correction of Involutional Lower Eye Lid Ectropion. Open Ophthalmol J. 2017;11:285–97.
⁸
Meduri A, Inferrera L, Oliverio GW, Tumminello G, Rechichi M, Mazzotta C, et al. The Use of a Double Suture and Conjunctival Cuts in the Lateral Tarsal Strip: A New Approach to Involutional Ectropion. J Craniofac Surg. 2018;29(8):2312–5.
⁹
Nakos EA, Boboridis KG, Kakavouti-Doudou AA, Almaliotis DD, Sioulis CE, Karampatakis VE. Randomized Controlled Trial Comparing Everting Sutures with a Lateral Tarsal Strip for Involutional Lower Eyelid Entropion. Ophthalmol Ther. 2019;8(3):397–406.
¹⁰
Dulz S, Green S, Mehlan J, Schüttauf F, Keserü M. A comparison of the lateral tarsal strip with everting sutures and the Quickert procedure for involutional entropion. Acta Ophthalmol (Copenh). 2019;97(6):e933–6.
¹¹
Yuan W. Treatment of degenerative entropion with lower eyelid muscle reduction and lateral tarsal plate fixation. Int Eye Sci. 2020;2181–4.
¹²
Khan FA, Hyder MF, Khan Niazi SP, Mirza UT. Comparison of the Recurrence Rate of Entropion via Subciliary Route and Transconjunctival Route in Combined Lateral Tarsal Strip with Retractor Advancement Procedure for Involutional Entropion Correction. J Coll Physicians Surg ‒ Pak JCPSP. 2021;30(4):429–33.

Study ID	Intervention	Control	Outcome Measures	Outcomes								Follow-up duration
				Intervention Success		Recurrence		Adverse Events		Patient Satisfaction
				Intervention	Control	Intervention	Control	Intervention	Control	Intervention	Control
Goel et al. 2017¹	Transconjunctival retractor plication with lateral tarsal strip	Polypropylene sling	Success is defined as no epiphora and lid laxity of 4 mm or less at 12-month follow-up. Eyelid laxity was assessed through pinch test, lateral distraction test for medial canthal tendon laxity, lateral canthal tendon laxity, inferior lid retractor laxity, and position of puncta on upgaze and primary gaze. Ectropion graded using Moe and Linder scale.	Success rate: 14/ 15 eyelids (93.33%). No statistically significant difference in success rates between groups (p = 0.271).	Success rate: 13/ 15 eyelids (87%)	NA	NA	NA	NA	None reported. Complication occurrences between the two groups showed no statistically significant difference (p = 0.072).	Lateral ectropion observed on the 1st postoperative day, lasting ten days. Subsequently, a return to initial preoperative laxity confirmed at the 4th-week follow-up (1 eyelid). Grade 1 lateral entropion (inner margin inturned) developed at the 5th-month follow-up (1 eyelid).	12 months
Meduri et al. 2018²	Modified lateral tarsal strip	Conventional lateral tarsal strip	Success is defined as relief of lid laxity. HLL by pinch test.	Mean HLL: 3.5 mm. Statistically significant difference was observed between intervention and control groups (p < 0.05).	Mean HLL = 5.7 mm	None observed	None observed	NA	NA	None reported	None reported	18 months Fixed intervals (1, 6, 12, 18 months) postintervention.

Study ID	Intervention	Control	Outcome Measures	Outcomes								Follow-up duration
				Intervention Success		Recurrence		Adverse Events		Patient Satisfaction
				Intervention	Control	Intervention	Control	Intervention	Control	Intervention	Control
Clinical trials focused on Entropion Treatment using Everting Sutures (ES)
Altieri et al. 2003¹	Retractor plication and partial resection of pretarsal orbicularis (a modified technique)	Group 2: Everting sutures.	HLL: pinch test.	Statistically significant difference in preoperative and postoperative LLE and HLL measurements (p < 0.05)	Group 2: No significant difference between preoperative and postoperative HLL (p > 0.05) Significant difference in preoperative and postoperative LLE measurements (p < 0.05)	2/9 patients had recurrence (22.2%)	Group 2: 4/13 patients had recurrence.	NA	NA	NA	NA	36 months Fixed intervals (1, 6 months, 1, 2 and 3 years) post-operatively. (32 patients)
		Group 3: Fox Procedure (horizontal tightening of lid at lower tarsal border)	Lateral tarsal strip (LLE): measure vertical excursion in millimeters of the lower lid margin center between extreme upgaze and downgaze.		Group 3: No significant difference in preoperative and postoperative measurements of LLE and HLL (p > 0.05)		Group 3: 3/10 patients had recurrence.
							Statistically significant difference in recurrence rates between Group 2 and Group 3 (p < 0.05).
Scheepers et al. 2010²	Everting suture and horizontal eyelid shortening using lateral tarsal strip procedure.	Everting suture	HLL: pinch test.	Mean HLL: 9.5 mm. No statistically significant difference between intervention and control groups (p < 0.005).	Mean HLL: 9.6 mm.	0/26 patients had recurrence (0%). Statistically significant difference between intervention and control groups (p = 0.024).	6/29 patients had recurrence (21%).	None reported.	Suture-related granuloma (2 patients).	NA	NA	18 months Fixed intervals (3 weeks, 6, 12 and 18 months) post-operatively (55 patients)
Nakos et al. 2019³	Quickert everting sutures	Lateral tarsal strip	Success: Full anatomical restoration of eyelid position and symptom resolution. National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) was used to assess function and symptoms.	Statistically significant difference: LTS procedure alone more effective than ES technique at 12-month follow-up (p = 0.015).	40 eyelids had recurrence across all follow-up visits.	8 eyelids had recurrence across all follow-up visits. The LTS group showed significantly lower recurrence rates compared to the ES group at both follow-ups, with statistical significance (p = 0.025 and 0.015).	None reported.	Abscess in lateral canthal area at 12 months, possibly from polyethylene fixation suture granuloma (1 patient).	NA	NA	36 months Fixed intervals (1 week, 6 and 12 months) post-operatively.
Dulz et al. 2019⁴	Lateral tarsal strip with Everting sutures	Quickert everting sutures	Success: Lower eyelid consistently contacts ocular surface in both relaxed and intentionally closed states, with no entropion or ectropion symptoms.	Success rate: 27/30 eyelids (93.10%). No statistically significant difference in surgical failure between intervention and control groups (p = 0.46).	Success rate: 33/36 (97.06%).	2/30 eyelids	1/36 eyelids	Postoperative secondary ectropion (1 patient)	Postoperative secondary ectropion (2 patients)	NA	NA	14 months Fixed Intervals (2 weeks, 8 and 14 months) post-operatively.
Clinical trials Focused on Entropion Treatment using Lateral Tarsal Strip (LTS)
Yuan 2020⁵	Lower eyelid constrictor muscle reduction with lateral tarsal strip	Lower eyelid constrictor muscle reduction	Short-term cure: 3 months post-surgery. Long-term cure: 24 months post-surgery. Measure positive rates of square pulling test and lower eyelid repositioning test.	Short-term cure rate: 100%. Long-term cure rate: 98%. No statistically significant difference in short-term cure rate (p = 0.495). Long-term cure rate in the intervention group was higher than in the control group (p = 0.030).	Short-term cure rate: 98%. Long-term cure rate: 84%.	NA	NA	None reported. The intervention group had fewer postoperative complications than the control group, with statistical significance (p = 0.026).	Postoperative complications rate = 11%. Eyelid ectropion (2 eyelids). Scleroderma (3 eyelids).	NA	NA	24 months Fixed Intervals (1, 7, 30 days and 3, 12, 24 months) post-operatively.
Khan et al. 2021⁶	Lateral tarsal strip procedure, combined with retractor advancement, through the subciliary approach	Lateral tarsal strip procedure, combined with retractor advancement, through the transconjunctival approach	Success: restoration of normal anatomical position of lid margin without inward turning of lid margin on eyelid closure.	NA	NA	Recurrence rate: 2.6%	Recurrence rate: 5.1% No statistically significant difference in entropion recurrence between transconjunctival and subciliary route repairs (p > 0.999).	Ectropion (2 patients), stitch abscess (1 patient), lateral canthal dystopia (2 patients), visible scar in the infraciliary region (3 patients).	Mild conjunctivochalasis (3 patients). Lateral canthal dystopia (1 patient).	NA	NA	12 months Fixed intervals (1, 3, 6 and 12 months) post-operatively.
Clinical trials focused on Entropion Treatment using either Retractor Plication (RP) or Orbicularis Muscle Shortening (OMS)
Altieri et al. 2004⁷	Modified retractor plication technique	Jones retractor plication technique	HLL: pinch test. Medial canthal tendon laxity	Mean HLL: 6.86 mm. Mean medial canthal tendon laxity at rest = 1.90 mm. Significantly less horizontal lid laxity and medial canthal tendon laxity in the modified technique group compared to the Jones technique group (p < 0.05).	Mean HLL: 7.30 mm. Mean medial canthal tendon laxity at rest: 1.25 mm.	2/28 patients had recurrence (7.1%) Statistically significant difference between intervention and control groups (p < 0.05).	5/34 patients had recurrence (14.7%).	NA	NA	NA	NA	48 months Fixed intervals (1, 6 months, 1 year, 2, 3 and 4 years) post-operatively. (62 patients)
Xu 2015⁸	Loose skin excision and shortening of the orbicularis muscle	Shortening of the orbicularis oculi muscle without excision of loose skin	Short-term cure: Following one month of treatment, normal eyelid and lacrimal point positions in open and closed-eye conditions, normal eyelashes, no epiphora or irritation symptoms, and avoiding touching the eye. Long-term cure: No irritation symptoms in the cornea and conjunctiva after a 1.5-year follow-up. Efficiency calculated as (cured eyes + normal eyes) / total eyes.	Short-term effective rate: 95.2%. Long-term cure rate: 82.5%. Statistically significant differences in short-term and long-term cure rates between intervention and control groups (p-value = 0.043, < 0.05) respectively.	The short-term effective rate: 77.8%. The long-term cure rate: 39.7%	7(11)/41 (63) patients had recurrence (17.5%).	16(25)/ 41(63) patients had recurrence (39.7%).	NA	NA	NA	NA	18 months

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[TFN1] ¹
Olver JM, Rose GE, Khaw PT, Collin JR. Correction of lower eyelid retraction in thyroid eye disease: a randomized controlled trial of retractor tenotomy with adjuvant antimetabolite versus scleral graft. Br J Ophthalmol. 1998;82(2):174-80.

[TFN2] ²
López-García JS, García-Lozano I, Giménez-Vallejo C, Jiménez B, Sánchez Á, de Juan IE. Modified lateral tarsal strip for involutional entropion and ectropion surgery. Graefes Arch Clin Exp Ophthalmol Albrecht Von Graefes Arch Klin Exp Ophthalmol. 2017;255(3):619-25.