Entropion




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


Although less common than involutional entropion, cicatricial entropion should be excluded early in the examination. Look for cicatricial changes in the conjunctiva. If present try to establish the cause before considering surgery ( Sect. B ).


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.



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.



6.1a


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.




Fig. 6.1a


Sutures pass from conjunctiva, below the tarsal plate, to the skin 2–4 mm below the lashes.



6.1b


Tie the sutures just tightly enough to produce a slight ectropion of the lid. Leave the sutures in place until they dissolve and fall out.




Fig. 6.1b


Sutures tied to produce slight ectropion.



6.1c,d


In an Asian eyelid, place the sutures in the medial two-thirds of the eyelid.




Fig. 6.1c


Persistent epiblepharon in a young Asian adult.



Fig. 6.1d


Insertion of sutures.



6.1e


Tie the sutures as depicted in Fig. 6.1b .




Fig. 6.1e


Three weeks following suture repair.



Complications and management


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.




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.




6.2a


Mark the skin incision 4 mm inferior to the lashes medially and 5 mm laterally, and incise the skin. With a lid guard in place make a stab incision through the full thickness of the lid at each end of the incision.





Fig. 6.2a


Full-thickness stab incision at each end of the skin incision.



6.2b


Pass one blade of sharp pointed scissors through both stab incisions and complete the full-thickness transverse incision.





Fig. 6.2b


Full-thickness incision completed with scissors.



6.2c


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 ).





Fig. 6.2c


Identification of the lower lid retractors.



Key diag. 6.2c



6.2d


Place three double-armed 4/0 or 6/0 absorbable sutures through the conjunctiva and lower lid retractor layer, 2 mm below the cut edge.





Fig. 6.2d


Double-armed 4/0 sutures placed through the conjunctiva and lower lid retractors.



6.2e


Pass the sutures into the orbicularis muscle anterior to the tarsal plate (arrow) in the upper wound edge to emerge in the skin 2 mm inferior to the lashes.





Fig. 6.2e


Sutures passed anterior to the tarsal plate to exit inferior to the lashes.



6.2f


Tie the sutures to achieve a slight ectropion of the lid. Close the skin with a 6/0 suture. Remove the skin sutures at 5 days and the everting sutures at 10 days, or earlier if there is a marked overcorrection.





Fig. 6.2f


Sutures tied to achieve slight ectropion.



Complications and management


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 ).






Fig. 6.2 post


Ten days after Wies operation with everting sutures still in place.



Quickert ( )


Use this procedure in preference to the Wies procedure if there is any horizontal lid laxity.



6.3a


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.




Fig. 6.3a


Incision marked.



6.3b


Overlap the marginal strips, with moderate tension only, to estimate how much to excise to correct the horizontal laxity.




Fig. 6.3b


Marginal strip of lid overlapped to estimate the amount of lid shortening.



6.3c


Excise the overlap from the medial strip.




Fig. 6.3c


Excess lid excised.



6.3d


Close the lid margin in the usual way ( 14.1, 14.2, 14.3 ).




Fig. 6.3d


Marginal strip of lid closed.



6.3e


Inspect the lower edge of the horizontal incision and identify the lower lid retractors (see 6.2c ).




Fig. 6.3e


Identifying conjunctiva/lower lid retractor layer.



6.3f


Place three double-armed 4/0 sutures through the conjunctiva and lower lid retractors as described previously ( 6.2d ).




Fig. 6.3f


Placing double-armed sutures through conjunctiva/lower lid retractors.



6.3g


Pass the three double-armed sutures through the orbicularis and skin to emerge 2 mm below the lashes as described previously ( 6.2e ).




Fig. 6.3g


Double-armed sutures passed anterior to the tarsal plate and through the skin inferior to the lashes.



6.3h


Tie the sutures to achieve a slight ectropion of the lid. If necessary, a small triangle of skin may be excised laterally, inferior to the wound, to avoid a dog-ear in the lower wound edge.




Fig. 6.3h


Double-armed sutures tied to correct the entropion.



6.3i


Close the skin with 6/0 or 7/0 sutures.




Fig. 6.3i


Transverse wound closed.



6.3j


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.




Fig. 6.3j


Lower lid depression in downgaze confirms retractor attachment.




Fig. 6.3 post A


One week following Quickert procedure.



Fig. 6.3 post B


Reattached lower lid retractors draw the eyelid down in down gaze.


Complications and management


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 ).




Jones ( )




6.4a


Make an incision through the skin, 4 mm below the lashes, from the punctum to the lateral canthus.




Fig. 6.4a


Incision 4 mm from lashes to expose lower border of tarsal plate and upper part of septum.



6.4b


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.




Fig. 6.4b


Skin and orbicularis muscle layer reflected to expose the tarsal plate ( arrow ).



6.4c


Carefully dissect the skin and muscle layer off the underlying septum which can be identified by the fat pad posterior to it.




Fig. 6.4c


Orbicularis muscle reflected down to expose the orbital septum and underlying fat pad.



Key diag. 6.4c



6.4d


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 ).




Fig. 6.4d


Orbital septum and fat pad reflected down to expose the lower lid retractors ( arrow ).



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.




Fig. 6.4e


Plicating sutures in place.



6.4f


When all the plicating sutures are in place tie them to close the incision. Further fine skin sutures may be added if necessary.


Remove the plicating sutures at 2 weeks.




Fig. 6.4f


Sutures tied.



Complications and management


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.




Fig. 6.4 pre


Recurrent entropion.



Fig. 6.4 post


Two months following Jones procedure.




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.



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.



6.1a


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.




Fig. 6.1a


Sutures pass from conjunctiva, below the tarsal plate, to the skin 2–4 mm below the lashes.



6.1b


Tie the sutures just tightly enough to produce a slight ectropion of the lid. Leave the sutures in place until they dissolve and fall out.




Fig. 6.1b


Sutures tied to produce slight ectropion.



6.1c,d


In an Asian eyelid, place the sutures in the medial two-thirds of the eyelid.




Fig. 6.1c


Persistent epiblepharon in a young Asian adult.



Fig. 6.1d


Insertion of sutures.



6.1e


Tie the sutures as depicted in Fig. 6.1b .




Fig. 6.1e


Three weeks following suture repair.



Complications and management


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.




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.




6.2a


Mark the skin incision 4 mm inferior to the lashes medially and 5 mm laterally, and incise the skin. With a lid guard in place make a stab incision through the full thickness of the lid at each end of the incision.





Fig. 6.2a


Full-thickness stab incision at each end of the skin incision.



6.2b


Pass one blade of sharp pointed scissors through both stab incisions and complete the full-thickness transverse incision.





Fig. 6.2b


Full-thickness incision completed with scissors.



6.2c


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 ).





Fig. 6.2c


Identification of the lower lid retractors.



Key diag. 6.2c



6.2d


Place three double-armed 4/0 or 6/0 absorbable sutures through the conjunctiva and lower lid retractor layer, 2 mm below the cut edge.





Fig. 6.2d


Double-armed 4/0 sutures placed through the conjunctiva and lower lid retractors.



6.2e


Pass the sutures into the orbicularis muscle anterior to the tarsal plate (arrow) in the upper wound edge to emerge in the skin 2 mm inferior to the lashes.





Fig. 6.2e


Sutures passed anterior to the tarsal plate to exit inferior to the lashes.



6.2f


Tie the sutures to achieve a slight ectropion of the lid. Close the skin with a 6/0 suture. Remove the skin sutures at 5 days and the everting sutures at 10 days, or earlier if there is a marked overcorrection.





Fig. 6.2f


Sutures tied to achieve slight ectropion.



Complications and management


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 ).






Fig. 6.2 post


Ten days after Wies operation with everting sutures still in place.



Quickert ( )


Use this procedure in preference to the Wies procedure if there is any horizontal lid laxity.



6.3a


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.




Fig. 6.3a


Incision marked.



6.3b


Overlap the marginal strips, with moderate tension only, to estimate how much to excise to correct the horizontal laxity.




Fig. 6.3b


Marginal strip of lid overlapped to estimate the amount of lid shortening.



6.3c


Excise the overlap from the medial strip.




Fig. 6.3c


Excess lid excised.



6.3d


Close the lid margin in the usual way ( 14.1, 14.2, 14.3 ).




Fig. 6.3d


Marginal strip of lid closed.



6.3e


Inspect the lower edge of the horizontal incision and identify the lower lid retractors (see 6.2c ).




Fig. 6.3e


Identifying conjunctiva/lower lid retractor layer.



6.3f


Place three double-armed 4/0 sutures through the conjunctiva and lower lid retractors as described previously ( 6.2d ).




Fig. 6.3f


Placing double-armed sutures through conjunctiva/lower lid retractors.



6.3g


Pass the three double-armed sutures through the orbicularis and skin to emerge 2 mm below the lashes as described previously ( 6.2e ).




Fig. 6.3g


Double-armed sutures passed anterior to the tarsal plate and through the skin inferior to the lashes.



6.3h


Tie the sutures to achieve a slight ectropion of the lid. If necessary, a small triangle of skin may be excised laterally, inferior to the wound, to avoid a dog-ear in the lower wound edge.




Fig. 6.3h


Double-armed sutures tied to correct the entropion.



6.3i


Close the skin with 6/0 or 7/0 sutures.




Fig. 6.3i


Transverse wound closed.



6.3j


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.




Fig. 6.3j


Lower lid depression in downgaze confirms retractor attachment.




Fig. 6.3 post A


One week following Quickert procedure.



Fig. 6.3 post B


Reattached lower lid retractors draw the eyelid down in down gaze.


Complications and management


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 ).




Jones ( )




6.4a


Make an incision through the skin, 4 mm below the lashes, from the punctum to the lateral canthus.


Sep 8, 2018 | Posted by in OPHTHALMOLOGY | Comments Off on Entropion
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