Quickert Procedure

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The Quickert procedure employs Quickert sutures for the treatment of entropion. It is most often used in the setting of spastic entropion or early involutional entropion and was first described by Quickert and Rathbun in 1971. Quickert sutures tighten lower lid retractors, rotate the eyelid margin anteriorly, and induce fibrotic adhesion between the orbicularis and the lower eyelid retractors to prevent preventing overriding of the preseptal obicularis (1,2).

Advantages of this technique include its simplicity - which can easily be performed in-office with only local anesthesia - obviation of the need for skin incision, minor complications, and ability to continue anticoagulation treatments (1,3). However, the Quickert procedure alone has been associated with long-term recurrence of entropion and does not address horizontal laxity (3,4).

In practice, the term "Quickert sutures" may refer to double-armed full thickness everting sutures, placed in a manner similar to the Quickert procedure. As such, Quickert sutures may be employed as a surgical technique in several contexts, and have been reported as an addition to the lateral tarsal strip and inverted T procedures for lower lid entropion.

Video from AAO: http://one.aao.org/basic-skills/entropion-ectropion-quickert-sutures

Indications[edit | edit source]

Acute entropion

Spastic entropion

Early involutional entropion

Congenital epiblepharon

Procedure[edit | edit source]

One aim of Quickert sutures is to induce fibrosis and adhesion between the orbicularis and lower lid retractors (2). Therefore, chromic gut, nylon, and silk have been used as suture materials (5). However, silk and nylon induce epithelial cell ingrowth along the suture tract (6). Accordingly, most studies examining Quickert sutures use absorbable vicryl sutures, but a modified procedure with nonabsorbable nylon sutures has been reported (7).

(Modified from Quickert and Rathbun, 1971)

1. Infiltrate local anesthetic, subcutaneously and subconjunctivally along inferior border of tarsus

2. Pass one need of a double-armed 4-0, 5-0, or 6-0 suture through the inferior fornix, grasping the inferior retractors, traveling obliquely, through the muscle to exit through the skin of the lower lid at a level slightly higher than the entry level in the fornix side.

3. Pass the second needle of the double-armed suture through the fornix 3mm adjacent to the first entry point in a similar manner and exiting through skin at a higher site closer to the eyelid margin to invert the eyelid.

4. Tie the suture tightly on the skin

5. Place a total of two to three of these sutures in a similar manner in the lateral two-thirds of the eyelid

Outcomes and Complications[edit | edit source]

When used alone, the Quickert procedure corrects involutional entropion and has minimal complications, but is associated with long-term recurrence of entropion (3,4). Reported long-term recurrence rates range from 15% after a mean of 31 months to 49% within 2 years (3,4). Recurrence peaks at 6 months, and is associated with male gender and severe lower-eyelid laxity (4). Therefore, given the high rate of long-term recurrence, the Quickert procedure is controversial as a treatment of choice for entropion (4). However, reported complications directly related to the Quickert procedure were minimal among these studies, amounting to one patient (1.7%) with acute inflammatory reaction to sutures in Wright et al, 1999. Accordingly, the safety, simplicity, quickness, and overall patient satisfaction have been cited as reasons to consider the Quickert procedure for patients in whom these features would be valuable, or patients with higher operative risk (4).

Quickert sutures have been studied in combination with inverted T and lateral tarsal strip procedures to treat involutional entropion. When combined with these procedures that treat horizontal laxity, Quickert sutures purportedly confer the added benefit of tightening lower lid retractors. Notably, the addition of Quickert sutures to the inverted T and lateral tarsal strip procedures decreases the recurrence rate of entropion when compared to the Quickert procedure alone. In two case series examining lateral tarsal strip + quicker sutures, Ho et al, 2005, reported a 12% recurrence at 2 years, and Barnes et al (2004) reported 2% recurrence 9 months. These rates represent an improvement over the 15% and 49% long-term recurrence of Quickert sutures alone reported by Wright et al, 1999, and Jang et al, 2014, respectively. Moreover, in an RCT comparing Quickert sutures alone to Quickert sutures + lateral tarsal strip, combination surgery resulted in 0% recurrence compared to 21% recurrence with Quickert sutures alone (1). Additionally, in a case series examining the combination of a single Quickert suture with the inverted T procedure, no recurrences of entropion were found after a median follow-up of 49 months (10). None of these studies endorsed significant complications: Barnes et al, 2006, reported 4% suture granuloma and 2% lower lid ectropion, Ho et al, 2005, reported 2.7% suture granuloma, and Mauriello et al, 1997, reported 3.3% wound dehiscence and 1.7% granuloma.

These results suggest that the Quickert procedure alone is inadequate in providing long-term repair of involutional entropion, but may be an appropriate choice for patients in whom the simplicity, obviation of the need for skin incision, minor complications, and ability to continue anticoagulation treatments of the procedure are valuable. Quickert sutures may also be safely employed to augment the more invasive surgical treatments of entropion, such as the inverted T and lateral tarsal strip procedures.

References[edit | edit source]

1. Scheepers MA, R Sing, J Ng, D Zuercher, A Gibson, C Bunce, K Fong, M Michaelides, J Olver. A Randomized Controlled Trial Comparing Everting Sutures with Everting Sutures and a Lateral Tarsal Strip for Involutional Entropion. Ophthalmology. 2010; 117:352-355.

2. Quickert MH, E Rathbun. Suture Repair of Entropion. Archives of Ophthalmology. 1971; 85:304-305.

3.Wright M, D Bell, C Scott, B Leatherbarrow. Everting Suture Correction of Lower Lid Involutional Entropion. British Journal of Ophthalmology. 1999; 83:1060-1063.

4. Jang SY, SR Choi, JW Jang, SJ Kim, HS Choi. Long-term Surigcal Outcomes of Quickert Sutures for Involutional Lower Eyelid Entropion. Journal of Cranio-Maxillo-Facial Surgery. 2014; 42:1629-1631.

5. Gigantelli JW. Entropion. In Yanoff M and JS Duker (Eds.) Ophtalmology (4th edition). Elsevier, Inc. 2014. (pp 1278-1283.e1)..

6. Seiff SR, M Kim, EL Howes Jr. Histopathological Evaluation of Rotation Sutures for Involutional Entropion. British Journal of Ophthalmology. 1989; 73:628-632.

7. Zoccali G, G Orsini, M Giulaini. Entropion Correction Using a Modified Quickert Technique. Letter to the Editor. Graefe's Archive for Clinical and Experimental Ophthalmology. 2013; 251:2821-2822.

8. Ho SF, A Pherwani, SM Elsherbiny, T Reuser. Lateral Tarsal Strip and Quickert Sutures for Lower Eyelid Entropion. Ophthalmic Plastic and Reconstructive Surgery. 2005; 21:345-348.

9. Barnes JA, C Bunce, JM Olver. Simple Effective Surgery for Involutional Entropion Suitable for the General Ophthalmologist. Ophthalmology. 2006; 113:92-96.

10. Mauriello Jr JA, A Abdelsalam. Modified Corncrib (Inverted T) Procedure with Quickert Suture for Repair of Involutional Entropion. Ophthalmology. 1997; 104: 504-507.