Introduction
Entropion of the upper or lower eyelids causes pain and leads eventually to corneal scarring. The changes occur more rapidly if there is also a poor tear film.
Classification:
Involutional
Cicatricial
Congenital
If cicatricial changes are absent, look for the transverse ridge of muscle caused by the preseptal orbicularis muscle overriding pretarsal orbicularis in the lower lid in involutional entropion ( Sect. A ).
Congenital entropion ( Sect. C ) is rare. It is diagnosed by complete inturning of the lid margin and tarsal plate.
Epiblepharon in young children is common. The tarsal plate is in a normal position but a fold of skin and muscle, especially medially, cause the lashes to turn in. Epiblepharon usually requires no treatment but in Asian eyelids the added effect of an epicanthic fold may cause persistent entropion, especially in the lower lid, which requires surgical correction.
Involutional entropion
Choice of operation
Assess the horizontal laxity in the lower lid (see 3.16 ).
If it is minimal a simple suture repair ( 6.1 ) is effective but may be temporary, lasting about 18 months. A lasting correction is more certain with the Quickert procedure ( 6.3 ), which corrects more of the aetiological factors in involutional entropion, including any excess horizontal laxity. The Wies procedure ( 6.2 ) does not correct horizontal laxity and the recurrence rate is higher than with a Quickert procedure but lower than a simple suture repair.
If the entropion (or ectropion – see Ch. 7 ) is accompanied by significant horizontal laxity, assess the canthal tendons (see 3.17 ). If either is very lax it may need to be stabilised first.
If the medial canthal tendon is lax but the lower lid position is normal vertically, and the patient is asymptomatic, the medial canthal tendon need not be stabilised. However, if the lid margin is displaced inferiorly and the patient is symptomatic – usually with watering – then the medial canthal tendon should be stabilised or tightened with a suture via the conjunctiva ( 7.7 ) into the skin ( 7.15 ) or with a medial wedge excision ( 7.8 ).
If the lateral canthal tendon is lax but the canthus and lower lid are in a good position and the patient is asymptomatic no stabilisation is required. However, if the canthus is rounded or displaced medially or inferiorly and the patient is symptomatic the tendon should be tightened. In this situation a lateral tarsal strip ( 7.2 ) is usually adequate. Occasionally, repositioning of the whole lateral canthal tendon may be required ( 10.5s–w ).
If only mild or moderate laxity of the canthal tendons is present or if there is residual laxity after one or both have been stabilised, choose the Quickert procedure ( 6.3 ).
The Jones procedure ( 6.4 ) tightens the lower lid retractors. It may be used as a primary procedure for involutional entropion but it is mainly used for recurrent involutional entropion if there is no other obvious cause. Horizontal lower lid laxity may also need to be addressed.
6.1
Suture repair ( ) 
The suture repair of entropion can be effective, usually as a temporary measure, for any involutional entropion. It can also be used in Asian children or young adults with congenital epiblepharon or entropion.
Inject local anaesthetic subcutaneously and subconjunctivally. Place three double-armed 4/0 or 6/0 absorbable sutures through the full thickness of the lateral two-thirds of the lid. Each suture is passed obliquely from 1 to 2 mm inferior to the lower tarsal border to emerge 2 to 4 mm inferior to the lashes. If the entropion is very mild the sutures may be passed almost horizontally through the lid from immediately inferior to the tarsus to emerge in the skin at only a slightly higher level as the entry into the conjunctiva.
Overcorrection occurs if the sutures are placed too far down in the fornix or emerge too close to the lashes and are tied too tightly. If ectropion persists for more than a week one or more sutures should be removed.
6.2
Wies
This procedure is used if there is no excess horizontal lid laxity. This is unusual and the Quickert procedure ( 6.3 ) is generally preferred.
Inspect the lower edge of the incision. The layers from posterior to anterior are conjunctiva, lower lid retractors (which are seen as a white sheet of tissue, usually easily identified), orbicularis muscle and skin (see Figs 11.8a–c ).
Overcorrection may occur if the everting sutures are inserted too far down in the fornix or emerge too close to the lashes. It is also more likely if significant horizontal lid laxity has not been recognised. If overcorrection persists for more than a week remove one or more sutures. If there is no improvement assess horizontal laxity and consider lid shortening (see 14.1, 14.2 ).
6.3
Quickert ( ) 
Use this procedure in preference to the Wies procedure if there is any horizontal lid laxity.
Mark a vertical incision 5 to 6 mm long, at right angles to the lid margin, 5 mm medial to the lateral canthus. From the lower end, mark a horizontal incision medially, parallel to the lid margin as far as the inferior punctum and 4 to 5 mm from the lid margin. Extend the incision directly laterally (without following the curve of the lid margin) as far as the lateral canthus. Using scissors, and starting with the vertical line, cut full-thickness incisions. This creates two strips of lid margin which include the full height of the tarsal plate.
Inspect the lower edge of the horizontal incision and identify the lower lid retractors (see 6.2c ).
Place three double-armed 4/0 sutures through the conjunctiva and lower lid retractors as described previously ( 6.2d ).
Pass the three double-armed sutures through the orbicularis and skin to emerge 2 mm below the lashes as described previously ( 6.2e ).
Ask the patient to look down. Downward excursion of the lid confirms the attachment to the lower lid retractors.
Remove the skin sutures at 5 days, if necessary. Remove the everting sutures at 14 days if nonabsorbable sutures have been used. Otherwise, and if the lid is in a good position, the sutures can be left to absorb.
Overcorrection may occur if the everting sutures are inserted too far down in the fornix or emerge too close to the lashes. It is also more likely if significant horizontal lid laxity has not been recognised. If overcorrection persists for more than a week remove one or more sutures. If there is no improvement assess horizontal laxity and consider lid shortening (see Figs. 14.1, 14.2, 14.3 ).
6.4
Jones ( ) 
Deepen the incision by separating the bands of orbicularis muscle until the lower border of the tarsal plate (arrow) is exposed throughout its length. Inspect the lower edge of the incision. Immediately posterior to the (preseptal) orbicularis muscle is the orbital septum, which is attached to the lower lid retractors close to the inferior border of the tarsal plate.
Incise the septum transversely 2 to 3 mm below the inferior border of the tarsal plate and retract it and the fat downwards. The white sheet of tissue now visible is the lower lid retractor layer (arrow). It moves down with downgaze. The upper border of this layer should be attached to the inferior border of the tarsal plate but it may be detached and is then found a few millimetres inferiorly. When this occurs the conjunctiva is the only layer bridging the gap between the tarsal plate and the lower lid retractors. If the retractors are obviously detached simple reattachment to the inferior border of the tarsal plate with interrupted 6/0 absorbable sutures may be all that is needed to stabilise the tarsal plate. Usually, however, plication of the retractors is required ( 6.4e ).
If the retractors are found to be attached they will need to be tightened by plication. Pass a 4/0 suture through the centre of the lower skin edge, through the lower lid retractors about 8 mm inferior to the tarsus, through the inferior border of the tarsal plate and out through the upper skin edge. Tie with a temporary knot and ask the patient to look up and down and observe the effect. If the lid moves normally and the suture has not caused downward retraction of the lid margin, place two similar sutures medial and lateral to the central suture. If, however, the plication is too tight or too loose adjust the position of the lower bite in the lower lid retractors until the correct tension is achieved.
Overcorrection or marked retraction of the lower lid margin which persists for more than a week requires removal of one or more of the plicating sutures. Check also that there is no significant horizontal laxity requiring correction.
Involutional entropion
Choice of operation
Assess the horizontal laxity in the lower lid (see 3.16 ).
If it is minimal a simple suture repair ( 6.1 ) is effective but may be temporary, lasting about 18 months. A lasting correction is more certain with the Quickert procedure ( 6.3 ), which corrects more of the aetiological factors in involutional entropion, including any excess horizontal laxity. The Wies procedure ( 6.2 ) does not correct horizontal laxity and the recurrence rate is higher than with a Quickert procedure but lower than a simple suture repair.
If the entropion (or ectropion – see Ch. 7 ) is accompanied by significant horizontal laxity, assess the canthal tendons (see 3.17 ). If either is very lax it may need to be stabilised first.
If the medial canthal tendon is lax but the lower lid position is normal vertically, and the patient is asymptomatic, the medial canthal tendon need not be stabilised. However, if the lid margin is displaced inferiorly and the patient is symptomatic – usually with watering – then the medial canthal tendon should be stabilised or tightened with a suture via the conjunctiva ( 7.7 ) into the skin ( 7.15 ) or with a medial wedge excision ( 7.8 ).
If the lateral canthal tendon is lax but the canthus and lower lid are in a good position and the patient is asymptomatic no stabilisation is required. However, if the canthus is rounded or displaced medially or inferiorly and the patient is symptomatic the tendon should be tightened. In this situation a lateral tarsal strip ( 7.2 ) is usually adequate. Occasionally, repositioning of the whole lateral canthal tendon may be required ( 10.5s–w ).
If only mild or moderate laxity of the canthal tendons is present or if there is residual laxity after one or both have been stabilised, choose the Quickert procedure ( 6.3 ).
The Jones procedure ( 6.4 ) tightens the lower lid retractors. It may be used as a primary procedure for involutional entropion but it is mainly used for recurrent involutional entropion if there is no other obvious cause. Horizontal lower lid laxity may also need to be addressed.
6.1
Suture repair ( ) 
The suture repair of entropion can be effective, usually as a temporary measure, for any involutional entropion. It can also be used in Asian children or young adults with congenital epiblepharon or entropion.
Inject local anaesthetic subcutaneously and subconjunctivally. Place three double-armed 4/0 or 6/0 absorbable sutures through the full thickness of the lateral two-thirds of the lid. Each suture is passed obliquely from 1 to 2 mm inferior to the lower tarsal border to emerge 2 to 4 mm inferior to the lashes. If the entropion is very mild the sutures may be passed almost horizontally through the lid from immediately inferior to the tarsus to emerge in the skin at only a slightly higher level as the entry into the conjunctiva.
Overcorrection occurs if the sutures are placed too far down in the fornix or emerge too close to the lashes and are tied too tightly. If ectropion persists for more than a week one or more sutures should be removed.
6.2
Wies
This procedure is used if there is no excess horizontal lid laxity. This is unusual and the Quickert procedure ( 6.3 ) is generally preferred.
Inspect the lower edge of the incision. The layers from posterior to anterior are conjunctiva, lower lid retractors (which are seen as a white sheet of tissue, usually easily identified), orbicularis muscle and skin (see Figs 11.8a–c ).
Overcorrection may occur if the everting sutures are inserted too far down in the fornix or emerge too close to the lashes. It is also more likely if significant horizontal lid laxity has not been recognised. If overcorrection persists for more than a week remove one or more sutures. If there is no improvement assess horizontal laxity and consider lid shortening (see 14.1, 14.2 ).
6.3
Quickert ( ) 
Use this procedure in preference to the Wies procedure if there is any horizontal lid laxity.
Mark a vertical incision 5 to 6 mm long, at right angles to the lid margin, 5 mm medial to the lateral canthus. From the lower end, mark a horizontal incision medially, parallel to the lid margin as far as the inferior punctum and 4 to 5 mm from the lid margin. Extend the incision directly laterally (without following the curve of the lid margin) as far as the lateral canthus. Using scissors, and starting with the vertical line, cut full-thickness incisions. This creates two strips of lid margin which include the full height of the tarsal plate.
Inspect the lower edge of the horizontal incision and identify the lower lid retractors (see 6.2c ).
Place three double-armed 4/0 sutures through the conjunctiva and lower lid retractors as described previously ( 6.2d ).
Pass the three double-armed sutures through the orbicularis and skin to emerge 2 mm below the lashes as described previously ( 6.2e ).
Ask the patient to look down. Downward excursion of the lid confirms the attachment to the lower lid retractors.
Remove the skin sutures at 5 days, if necessary. Remove the everting sutures at 14 days if nonabsorbable sutures have been used. Otherwise, and if the lid is in a good position, the sutures can be left to absorb.
Overcorrection may occur if the everting sutures are inserted too far down in the fornix or emerge too close to the lashes. It is also more likely if significant horizontal lid laxity has not been recognised. If overcorrection persists for more than a week remove one or more sutures. If there is no improvement assess horizontal laxity and consider lid shortening (see Figs. 14.1, 14.2, 14.3 ).
6.4
Jones ( ) 
Make an incision through the skin, 4 mm below the lashes, from the punctum to the lateral canthus.
