6 Entropion Repair
Summary
Entropion is an inverted malposition of the eyelid that, when left uncorrected by either surgical or nonsurgical means, can result in ocular surface irritation, infection, and even loss of vision. Entropion refers to the inward rolling of the eyelid margin. Its causes include involutional, spastic, cicatricial, and/or congenital factors. The etiology and severity of entropion determine the corrective approach. Correction of entropion ranges from eyelid taping or temporary sutures to incisional surgery. Adjunctive techniques include mitomycin C for advanced cicatricial disease and tarsal spacer grafts for markedly shortened posterior lamella. Beware of significant overcorrection that will induce ectropion.
6.1 Goals
To correctly understand the etiology and management of inwardly turned eyelids.
6.2 Advantages
Eyelid entropion can cause ocular surface irritation and predispose the eye to infections and corneal ulcers. If severe or longstanding, scarring of the cornea and loss of vision can occur. Return of the eyelid to its normal position, either by surgical or non-surgical means, resolves the ocular surface irritation that accompanies the malpositioned, inward-turned eyelid.
6.3 Expectations
Durable restoration of normal eyelid anatomy and physiology.
Determine the type of entropion to plan appropriate surgical correction.
Involutional entropion requires lower lid retractor reinsertion with horizontal tightening with a lateral tarsal strip procedure to add stability, durability, and prevent overcorrection. 1
Spastic and cicatricial entropion necessitate increasing surgical intervention depending on severity.
A small degree of intraoperative overcorrection results in an acceptable eyelid position.
6.4 Key Principles
Several types of entropion exist. The identification of its etiology and its corresponding anatomical defect determines the surgical correction of choice.
Involutional entropion occurs due to a combination of the weakening or dehiscence of the lower eyelid retractors, horizontal eyelid laxity, and orbicularis override. 1 , 2 Surgical lower eyelid retractor reinsertion coupled with a lateral tarsal strip operation address both retractor weakness and horizontal lid laxity. An initial subciliary skin incision may be used to induce scar formation that prevents overriding preseptal orbicularis oculi, while a transconjunctival dissection anterior to tarsus may be used to ablate or weaken the offending preseptal orbicularis oculi. Spastic entropion results from a sustained or recurrent spasm of the muscle of Riolan after a precipitating event such as recent eye surgery or eyelid inflammation, 2 , 3 and it likely shares the same mechanical factors as involutional entropion. 1 Eliminating the cause of the spasm often resolves the entropion. If this is not possible, Quickert sutures can be used to tighten the lower lid retractors and create scarring, which changes the eyelid vector and deters entropion. Cicatricial contraction of the posterior lamella—as seen with chemical or thermal injuries, autoimmune mucous membrane disorders like Stevens–Johnson Syndrome, ocular cicatricial pemphigoid, and trachoma—can also lead to entropion. Treatment may require lengthening the posterior lamella with or without a tarsotomy (or tarsal fracture) in mild cases, or lysis of any cicatrix with a posterior spacer graft in severe cases.
Congenital entropion arises from disinsertion of the lower lid retractor aponeurosis 4 and/or defects in the tarsal plate. 3 Repair is dependent on the anatomical defect, and is typically done by lower lid retractor reinsertion with or without horizontal tightening and/or posterior lamella grafting.
Prevailing surgical repairs are combination procedures that address the multiple anatomic abnormalities that produce entropion. Non-incisional repair includes the use of eyelid taping or a temporary suture. Common incisional options include reinsertion of the lower lid retractors with horizontal tightening of the lid and transverse tarsotomy (e.g., Weis procedure).
6.5 Indications
Symptomatic ocular surface irritation.
Keratopathy.
Corneal ulceration.
Corneal scarring.
Persistent infectious keratitis.
6.6 Contraindications
Acute flare of autoimmune or cicatricial lid disease.
6.7 Preoperative Preparation
Successful surgical repair of entropion requires appropriate identification of entropic vectors and their associated anatomic defects. Congenital entropion should be distinguished from epiblepharon and congenital distichiasis. Lower lid laxity should be quantified using snapback and distraction tests. Correction of involutional entropion is most successful when surgical repair includes horizontal eyelid tightening. 2 , 3 , 5 , 6 Autoimmune or inflammatory disease should be controlled, ideally with the help of the patient’s primary care physician or rheumatologist, with immunosuppressant medications prior to surgical repair.
6.8 Operative Technique
6.8.1 Transverse Everting Sutures (Quickert Suture, Three-Suture Technique)
This is classically used for lower lid entropion. Three, double-armed, dissolvable sutures are passed full-thickness from the conjunctival cul-de-sac in the center, lateral, and medial aspects of the lower lid (avoiding the medial punctum and nasolacrimal duct system) and externalized 1 to 2 mm below the lower lashes, and tied to create eversion of the eyelid margin (Fig. 6.1).
6.8.2 Lower Lid Retractor Reinsertion
External Approach
A traction suture is placed through the gray line of the lower lid. A subciliary skin incision is made through the skin from the lateral canthus to the medial punctum along the inferior border of tarsus, after which a skin muscle flap is created and dissected inferiorly toward the inferior orbital rim to expose the inferior orbital septum. The septum is entered and the underlying orbital fat is retracted to reveal the white fibrous band of the lower eyelid retractors. A combination of blunt and sharp dissection will free the retractors anteriorly from the orbital fat and posteriorly from the conjunctiva. The superior edge of the lower lid retractor is reattached to the anterior, inferior tarsal border using several interrupted buried sutures. The eyelid should be mildly overcorrected at this point. If horizontal lid tightening is required, attention should now be turned to completion of a horizontal tightening procedure, such as a lateral tarsal strip. (See below for details.) Skin incision(s) are closed with continuous running, dissolvable suture.
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