Oculoplastics

20 OCULOPLASTICS

Entropion

Shoib Myint

ICD-9: 374.00

THE DISEASE

Pathophysiology

Entropion or inversion of the eyelid margin can potentially lead to corneal opacification and subsequent damage leading to severe visual loss. It is one of the most common eyelid malpositions seen in clinical practice. The surgeon must become familiar with the different etiologies of this condition so that the proper treatment option can be selected. Although involutional entropion is the type most frequently seen in private practice, other etiologies include congenital, acute spastic, and cicatricial. Involutional is more common in the lower eyelid, while cicatricial is more common in the upper eyelid.

Etiology

Congenital entropion has been known to result from retractor dysgenesis, structural defects in the tarsal plate, and sometimes a shortening of the posterior lamella. Congenital entropion of the upper lid is composed of a tarsal kink that can be surgically corrected with a Wies procedure (transverse blepharotomy). This procedure is described in the cicatricial portion of this chapter.

Congenital entropion should not be confused with epiblepharon in which the pretarsal muscle and skin override the margin and can potentially cause irritation. The cilia in this case remain vertical. Unlike entropion, this condition can resolve spontaneously and is most commonly seen in Asian patients. If epiblepharon becomes a problem for the patient, the excess skin and pretarsal orbicularis can be removed with the skin being fixed to the lower edge of the tarsus. Involutional entropion is the most common form of entropion and occurs in the lower eyelid. It has been postulated that horizontal eyelid laxity, disinsertion or attenuation of the eyelid retractor muscles and capsulopalpebral fascia, overriding of the preseptal orbicularis muscle, and involutional enophthalmos can all cause this type of entropion to occur. Some believe that every involutional entropion has some horizontal component to it. Clinically, the disinsertion of the fascia can be seen as a white line below the inferior tarsal border indicating the leading edge of the detached capsulopalpebral fascia. Other clinical clues include deep inferior fornix, ptosis of the lower eyelid (higher than normal), and minimal movement of the lower eyelid on downward gaze.

Cicatricial entropion results in vertical contracture of the posterior lamella of the eyelid. It most commonly occurs in the upper eyelid and can result in irritation of the globe from cilia or keratinized lid margin. A number of factors can predispose one to this condition including autoimmune (cicatricial pemphigoid), inflammatory (Stevens Johnson’s syndrome), infectious (trachoma, herpes zoster), surgical (posterior ptosis procedure, enucleation), and traumatic (chemical and thermal burns). Certain glaucoma medications such as miotics have been known to cause cicatricial entropion. This type of entropion can be differentiated from involutional entropion by the digital eversion test. An abnormal margin position will be corrected to its normal anatomic position with a digital traction of the involutional eyelid but not the cicatricial eyelid. One should be careful not to violate the conjunctiva in severe autoimmune patients.

Acute spastic entropion usually occurs after intraocular surgery from an underlying mild involutional entropion. Chronic inflammatory eye conditions have also been known to be predisposing factors. Typically, the spasm of the orbicularis results in the preseptal orbicularis overriding the pretarsal orbicularis. This can be cyclic in nature which can be very annoying to the patient.

The Patient

Clinical Symptoms

All of these conditions can result in corneal irritation. If they are severe enough, it must be corrected surgically to prevent potential visual loss. Patients will most frequently complain of persistent tearing, foreign body sensation, and blurred vision, which can severely affect their activities of daily living (Fig. 20-1).

Figure 20-1. Entropion.

(Photo courtesy of Leonid Skorin Jr.)

Clinical Signs

Inward turning of eyelid and eyelashes
Horizontal lid laxity
Overriding preseptal orbicularis
Enophthalmos
Conjunctival injection
Keratopathy

Physical testing for horizontal eyelid laxity includes the eyelid distraction test and the snap-back test. To perform the eyelid distraction test, grasp the lower eyelid and pull away from the globe. If the distance between the globe and the eyelid is 10 mm or greater, significant eyelid laxity is present.

The patient should not blink during the snap-back test. The eyelid is pulled downward and released. If it takes more than 10 seconds for the eyelid to reapproximate to the globe, laxity is present.

The orbicularis override test is positive if there is superior migration of the preseptal orbicularis as the patient squeezes his or her eyes closed.

The Treatment

Congenital entropion does not improve spontaneously and must be corrected surgically by reattaching the capsulopalpebral fascia to the inferior border of the tarsus on the lower lid. This procedure is similar to that used to correct involutional entropion.

Treatment of involutional entropion is directed toward correcting two out of the three factors (disinsertion of the capsulopalpebral fascia and horizontal laxity). Some of the treatment measures include temporizing sutures, tightening of the horizontal lid, and reattachment of the capsulopalpebral fascia. Maximum benefit is often obtained from a combination of horizontal tightening with reattachment of the fascia. This will correct the disinsertion and horizontal components of the entropion. The three suture technique (Quickert) is a useful in-office procedure, which can temporarily correct the problem. The horizontal tightening procedure can be performed via the lateral tarsal strip or lateral canthal plication. It is important to understand that the reattachment of the capsulopalpebral fascia should be done in combination with either a lateral tarsal strip or plication to prevent recurrence. If done properly, this procedure rarely fails. If the entropion does recur, it is probably due to faulty attachment of the fascia to the inferior border of the tarsus.

The basic procedure to correct cicatricial entropion is the transverse blepharotomy described by Wies. This results in fracturing the tarsus with eversion of the margin. Overcorrection is achieved with slight ectropion to prevent inversion of the margin in the future. The skin is closed with 6-0 mild chromic suture.

Treatment options for acute spastic entropion include taping of the eyelid, cautery, botulinum toxin injection to the orbicularis, and various temporary suture techniques. However, because it is thought that an involutional component is present, a more permanent solution is to perform reattachment of the capsulopalpebral fascia along with horizontal tightening as described previously.

Trichiasis and Distichiasis

Geoffrey J. Gladstone

ICD-9: 374.05

THE DISEASE

Pathophysiology

Trichiasis is eyelashes that grow inward toward the eye. There is no actual entropion of the eyelid margin, and the eyelashes originate from a normal position. Distichiasis is inward-growing eyelashes that originate from a position posterior to the normal lashes. Typically, these originate from the meibomian gland orifices. Once again, the eyelid margin is not entropic. When subjected to chronic inflammation, a lash will grow from the meibomian gland orifice, producing distichiasis.

Etiology

Trichiasis can occur after eyelid trauma. It can be seen after surgical resection of eyelid margin tumors. Chronic inflammatory conditions such as ocular cicatricial pemphigoid, chronic blepharoconjunctivitis, and trachoma can also cause trichiasis. Trichiasis can occur with no apparent etiology.

Distichiasis can be congenital or acquired. Chronic blepharoconjunctivitis and other chronic inflammatory conditions can cause distichiasis. Distichiasis and trichiasis may be seen when eyelid tumors are present.

The Patient

Clinical Symptoms

The patient will usually complain of pain, irritation, and foreign body sensation. Epiphora will usually be present, and vision may be impaired.

Clinical Signs

On slit-lamp examination, misdirected lashes are visible. With distichiasis, the lashes can be seen emanating from the meibomian gland orifices, while with trichiasis, the lashes originate from a normal location.

The most significant signs are secondary to corneal and conjunctival abrasion from the misdirected lashes. A punctate or linear vertical keratopathy will usually be present. The distribution of the keratopathy will correspond to the location of the aberrant lashes.

Corneal ulceration can also occur. When present, this must be treated promptly and aggressively to prevent permanent vision loss.

A mucoid discharge is common, while a true infection is somewhat rare.

On eyelid eversion, a horizontal band of scar tissue known as Arlt’s line can be present if the trichiasis is secondary to trachoma.

The lower eyelid should be pulled downward and the patient asked to look upward. Horizontal banding within the conjunctiva is known as a symblepharon. This is indicative of ocular cicatricial pemphigoid until proven otherwise.

The number of misdirected lashes as well as their distribution is important when trying to determine the proper treatment for trichiasis or distichiasis. A diagram can be drawn showing the areas of misdirected lashes on each eyelid.

Demographics

Areas of southeast Asia and the Middle East have a significant incidence of trachoma. Patients from these areas should be evaluated for trachomatous eyelid changes.

Significant History

What country is the patient from?
Did the patient have any prolonged eye infection?

Ancillary Tests

Whenever symblepharon is present, a biopsy should be considered to rule out the possibility of ocular cicatricial pemphigoid. This is important because prior to any surgical intervention in patients with ocular cicatricial pemphigoid, treatment with steroids or immunosuppressive agents should be considered.

The Treatment

Treatment of trichiasis and distichiasis depends on the extent and distribution of the aberrant lashes. If the abnormal lashes are in an isolated area, certain treatments are reasonable, while different procedures are indicated when the condition involves large areas of the eyelid.

Epilation of abnormal lashes is a simple but temporary solution to the problem. Almost always the lashes will regrow. Early in their growth, the lashes will be short and stubby. These lashes will often cause more irritation than longer more flexible ones.

Cryoablation is another option when a limited distribution of abnormal lashes is present. With this technique, a double freeze, thaw cycle is applied to the involved area. Several treatments may be necessary to achieve complete removal of the lashes. When treating distichiasis, the normal, anteriorly placed lashes will be destroyed along with the abnormal ones. If large areas of the eyelid are involved, cryoablation should be avoided as it can cause scarring and an abnormally displaced eyelid margin.

If abnormal lashes are present in a small area, consideration should be given to excising the area as a pentagonal wedge. The defect is then closed with standard techniques as for eyelid margin lacerations. The amount of eyelid that can be removed and closed in this fashion is directly related to the amount of eyelid laxity that is present. With this or other surgical techniques, it is important to rule out or treat ocular cicatricial pemphigoid prior to surgical intervention.

When a more diffuse trichiasis is present, consideration should be given to performing a Wies procedure. With this technique, a full-thickness, horizontal incision is made 3.5 mm from the eyelid margin. The incision extends several millimeters medial and lateral to the area of abnormal lashes. Sutures are placed to rotate the eyelid margin away from the globe. An overcorrection of the margin is desired because the eyelid will rotate inward as it heals. The amount of overcorrection can be controlled by the suture placement. The more cicatrizing the condition, the more initial overcorrection is necessary.

With distichiasis, an almost unlimited number of surgical procedures have been described. This is the result of the extreme difficulty in successfully treating this condition. This limited prognosis should be communicated to the patient preoperatively. One useful technique involves the excision of the portion of the tarsus that contains the abnormal lash follicles. Using a posterior approach, the tarsus is excised from 0.5 to 2.5 mm from the eyelid margin. The area of excision encompasses the entire area of abnormal lashes. The abnormal follicles are completely removed. This leaves a defect in the tarsus that is filled by advancing the remaining tarsus into the defect. Even though the lash follicles have been removed, new lashes can grow from the remaining portions of the meibomian glands, leading to incomplete resolution of the problem. When effective, this procedure has the advantage of leaving the normal lashes in a normal position.

When the tarsal excision procedure has been ineffective, a Wies procedure should be considered. Although it is often efficacious, it has the disadvantage of bringing the normal lashes into an overrotated position. With this procedure, the distichiatic lashes must be brought into an overrotated position initially, but this overcorrection will generally resolve with time.

Ectropion

Geoffrey J. Gladstone

ICD-9: 374.10

THE DISEASE

Pathophysiology

Ectropion is an outward turning of the eyelid. It can have a variety of etiologies. These include involutional, cicatricial, mechanical, and tarsal. It is crucial to determine the actual etiology, as this will guide the treatment.

Etiology

Involutional ectropion is the most common condition encountered. A progressive laxity of the lateral and or medial canthal tendon occurs. This leads to a horizontal eyelid laxity. Commonly, epiphora will commence, leading to rubbing of the eyelid and further weakening of the canthal tendons.

Cicatricial ectropion is secondary to a vertical skin shortage. This can occur after excessive skin removal. Lower eyelid blepharoplasty, eyelid reconstruction after tumor removal, and other types of surgery can cause a vertical skin deficiency. Thermal and chemical burns as well as cicatrizing dermatological diseases such as herpes zoster and acne rosacea can also be causative. Excessive exposure to the sun is another important predisposing factor. Chronic inflammation such as seen with blepharitis is occasionally implicated. Cicatricial ectropion can occur whether horizontal eyelid laxity is present or not.

Mechanical ectropion is somewhat rare and is seen when a mass is present on the eyelid. The weight of the mass pulls the eyelid away from the globe, causing the ectropion. This can be seen in neurofibromatosis and with other lesions that are allowed to get unusually large. The greater the horizontal eyelid laxity, the more easily the mass will pull the lid outward.

Tarsal ectropion is a distinct type of ectropion where little horizontal eyelid laxity exists and the eyelid turns outward by being hinged at the inferior tarsal border. Detachment of the eyelid retractors and conjunctival inflammation is thought to play a role in causing this condition.

The Patient

Clinical Symptoms

The patient will typically complain of epiphora, ocular irritation, a foreign body sensation, pain, and possibly decreased vision.

Clinical Signs

An outward turning of the eyelid is always present (Fig. 20-2). This can vary from a very mild medial ectropion to a frank, diffuse ectropion. At times, the ectropion is only present in upgaze. The ectropion will typically involve the entire eyelid. In cases of tarsal ectropion, the lid will hug the globe up to the inferior tarsal border. At this point, the lid turns outward.

Figure 20-2. Ectropion.

(Photo courtesy of Leonid Skorin Jr.)

The conjunctiva will often be hyperemic and thickened. A mucoid discharge is frequently seen. In long-standing cases, keratinization of the conjunctiva can be present.

Keratopathy will often be present. In severe cases, corneal ulceration is seen and must be treated promptly.

Laxity of the medial and or lateral canthal tendon will often be present. Medial canthal tendon laxity is often overlooked, leading to unsuccessful surgery or recurrence of the ectropion. The lateral canthal angle is usually several millimeters medial to the lateral orbital rim. In many cases of ectropion, the angle will be medially displaced, indicating laxity of the lateral canthal tendon. A displacement of 10 mm is not uncommon when significant laxity is present. The medial canthal tendon can be evaluated by grasping the medial eyelid and pulling it laterally. Normally, the punctum will move 2 or 3 mm. If the punctum moves to the medial limbus of the eye or further laterally (when the eye is gazing directly ahead), significant laxity is present. In these cases, the medial canthal tendon should be surgically tightened.

Other indicators of eyelid laxity include the eyelid distraction test and the snap-back test. To perform the eyelid distraction test, grasp the lower eyelid and pull it away from the globe. If the distance between the globe and the eyelid is 10 mm or greater, significant eyelid laxity is present. Another excellent test is the snap-back test. The patient must not blink during this test. The eyelid is pulled downward and released. If it takes more than 10 seconds for the eyelid to reapproximate to the globe, laxity is present.

In tarsal ectropion, eyelid laxity is absent, while a severe ectropion is often seen. Conjunctival hyperemia and thickening are present.

A taut, wrinkle-free appearance to the lower eyelid skin can indicate solar damage and cicatricial change. Scar tissue from burns or previous surgery should be readily apparent.

Demographics

Demographics play a role in ectropion only with regard to sun exposure and surgery for skin carcinomas. Areas of the world with more sunshine and warmer climates will have an increased incidence of cicatricial ectropion secondary to solar damage and complications of reconstructive surgery for malignant skin carcinomas.

Significant History

Does the patient have a history of work- or recreation-associated excessive exposure to the sun?
Has there been previous cosmetic or reconstructive eyelid or facial surgery?
Is there a history of dermatological conditions that affected the eyelids?

The Treatment

The treatment of ectropion is very dependent on the etiology. If the treatment is not directed at the underlying cause, it will not be successful.

Involutional ectropion is repaired surgically by tightening the medial and or lateral canthal tendons. When both are repaired, the medial canthal tendon should be repaired first, as a much smaller tissue excision will be needed laterally.

When repairing the medial canthal tendon, it is important to tighten the posterior and not the anterior limb of the tendon. Tightening the anterior limb will correct the laxity of the eyelid but will produce a gap between the eyelid and the globe medially. When the posterior limb is tightened, the eyelid is pulled posteriorly as well as tightened horizontally, keeping the medial lid in contact with the globe. A small portion of conjunctiva is removed just inferior and medial to the punctum. A 6-0 permanent, monofilament suture is placed between the medial-most tarsus and the remnant of the posterior limb of the medial canthal tendon. The conjunctiva is closed with a 6-0 plain suture.

The lateral canthal tendon is repaired with a lateral tarsal strip procedure. With this surgery, the eyelid is shortened horizontally and its attachment to the lateral rim strengthened. A lateral canthotomy and inferior cantholysis are made. The lower eyelid is pulled laterally, and its point of overlap with the lateral rim is noted. Lateral to this, all the eyelid tissue is removed (including the eyelid margin) except for the tarsus. This lateral tarsal strip is shortened and a permanent 5-0 suture used to attach the tarsal strip to the periosteum of the lateral orbital rim.

Cicatricial ectropion is repaired in several ways. In many cases, a full-thickness skin graft is utilized to replace the vertical skin deficiency. The skin can be harvested from the upper eyelids, retro- or preauricular, supraclavicular, and other areas. The retroauricular area has many advantages. Incision placement will vary depending on the etiology of the condition. In all cases, an incision is made and the scarred skin widely undermined. Any subcutaneous scar tissue is excised. The eyelid must rest without tension in a normal position. A horizontal tightening is performed if significant laxity is present. A full-thickness skin graft is placed on the defect. This is sewn in place and covered with a cotton-Telfa bolster. Often, a Frost suture is used to hold the eyelid in a slightly elevated position for the first week. The bolster is removed after 1 week.

In certain cases, a midface lift will be sufficient to recruit skin and allow the eyelid to assume a normal position. This has the advantage of not requiring a skin graft and potentially giving a better cosmetic result.

Repair of mechanical ectropion in- volves removing the mass that is pulling the eyelid downward. This can be relatively simple or involve resection of a portion of the eyelid. Skin grafting, as was described for repair of cicatricial ectropion, may be necessary. Simple or complex eyelid reconstruction may be indicated as well.

Tarsal ectropion is a unique condition and can be difficult to repair. The eye should be treated with an antibiotic steroid ointment for a week prior to and after surgery. This will decrease the conjunctival inflammation that contributes to the outward rotation. An incision is made at the inferior tarsal border and carried through the lower eyelid retractors. Chromic mattress sutures are then used to grasp the conjunctiva and eyelid retractors, closing the internal incision and exiting on the skin surface inferior to the conjunctival incision. These sutures place the retractors in proper position and pull the skin superiorly. The sutures are not removed and form a scar barrier to rotation within the eyelid.

Floppy Eyelid Syndrome

John D. Siddens

ICD-9: 374.50—Degenerative disorder of eyelid, unspecified

ICD-9: 728.4—Laxity of ligament

ICD-9: 374.9—Unspecified disorder of eyelid

THE DISEASE