EntropionEntropion

Presentor: Dr.PrashantModerator: Dr.E.Ravindramohan

Eyelid Anatomy

Anterior lamella• Skin • Orbicularis muscle

Posterior lamella• Tarsal plate• conjunctiva

Eyelid Anatomy

• Upper lid retractors– Levator palpebrae

superioris– Whitnall’s ligament– Muller’s muscle

Eyelid Anatomy

• Lower lid retractors– Capsulopalpebral fascia– Lockwood’s ligament– Inferior tarsal muscle

Entropion

• Inward turning of eyelid margin against the eye.

• It may produce an ocular foreign body sensation, secondary blepharospasm, ocular discharge, epiphora, conjunctival metaplasia, superficial keratopathy, and corneal scarring.

Preoperative Assessment of Entropion

CAPSULOPALPEBRAL FASCIA LAXITY • Higher eyelid resting position in primary gaze • Increased passive vertical eyelid distraction • Increased depth of inferior conjunctival fornix HORIZONTAL EYELID LAXITY • Passive horizontal eyelid distraction RELATIVE ENOPHTHALMOS Exophthalmometry PRESEPTAL ORBICULARIS MUSCLE OVERRIDE POSTERIOR LAMELLAR SUPPORT • Height of tarsal plate • Presence of cicatrizing conjunctival disease• MARKED ORBITAL FAT PROLAPSE

DIFFERENTIAL DIAGNOSIS

• Epiblepharon– a horizontal fold of redundant

pretarsal skin and orbicularis muscle extends beyond the eyelid margin and compresses the eyelashes against the globe

– Common in asian races– More common; bilateral– frequently resolves with the

normal vertical growth of the facial bones

Distichiasis

• Refers to an accessory row of cilia arising from the meibomian gland orifices.

• Treatment modalities: mechanical epilation, electrolysis, radiofrequency ablation, laser photoablation, and cryotherapy to the posterior eyelid lamella.

Trichiasis

• characterized by posterior misdirection of lashes arising from normal sites of origin

Eyelid Retraction

• The retracted eyelid is pulled toward the orbital rim with the eyelashes which gets obscured by the resulting fold of eyelid skin, resembling entropion

Classification

• Congenital• Congenital Entropion• Epiblepharon

• Acquired• Involutional (senile)• Cicatricial

Entropion

• Congenital Entropion– Extremely rareEtiology: Both the anterior and posterior

attachments of the capsulopalpebral fascia are dysfunctional.

Horizontal tarsal kink syndrome

Suture Correction of epiblepharon (Quickert-Rathbun Sutures)

• Principle: To hold the two lamellae together• Indications:

1. Epiblepharon not resolving within 2 years2. Causing recurrent conjunctivitis

• Method: Pass the 3 double armed sutures from

below the lower border of tarsal plate and tie them on the skin over the skin of epiblepharon fold.

Correction of congenital entropion

Principle: An ellipse of skin and orbicularis is excised from below

the inferior punctum. The skin edges are sutured to the lower lid retractors and lower border of tarsus

Method: Suture the lower lid skin edges to the retracotrs and lower

border of tarsal plate with inturrupted absorbable sutures

Entropion

• Involutional (senile)• Pathophysiology– Upward migration of preseptal orbicularis over the

posterior lamellae– Laxity or dehiscence of eyelid retractors– Horizontal lid laxity

Etiology and management:

• Lamella dissociation: create a scar tissue between preseptal and pretarsal muscles

• Lower lid retractor weakness: tighten with everting sutures plication or shortning of retractors

• Horizontal lid laxity: shorten the lid tendons• Buckling of tarsal plate: everting sutures

sutures• Transverse sutures• Everting sutures

• Indications temporary cure

Lateral Tarsal Strip Procedure

• A lateral canthotomy• anterior and posterior lamellae must be separated.• The palpebral conjunctiva is disinserted from the inferior tarsal border • The redundant tissues of the strip are excised and the new lateral

border of tarsus is attached to periosteum at the lateral orbital tubercle with either two interrupted sutures

Weis procedure

• Full-thickness horizontal lid incision

Principle:1. The transvers lid split prevents upward movem

ent of preseptal orbicularis 2. The everting sutures shorten the retractors

Quickert procedure

– Combination of horizontal tightening and Weis procedure

– Principle:1. The transvers lid split prevents upward

movement of preseptal orbicularis 2. The everting sutures shorten the retractors3. Horizontal lid shortnening correctsexcees lid

laxity

Method:Vertical incisionHorizontal full thickness incision3 double armed absorbabale sutures through the

retractors Correct the lid laxity by suturing two flaps as in

normal lid repairSuture the wound.

Plication of Inferior Retractors (Jones type procedure)

Principle: Shortining of retractors to create a barrier to

the upward movement of preseptal muscleIndications: As primary procedure In recurrence of entropion Method:

Lower lid cicatricial entropion management

• Tarsal fracture• Posterior lamella graft• Gray line split and retractor repositioning

Principle: tarsus is fractured horizontally and hinged into eversion with everting sutures.

Tarsal fracture

Posterior lamella graft

• Principle Tarso conjunctiva is lengthened with a graft inserted

near lid margin to allow eversionIndications: Severe cicatricial entropion Entropion with lid retraction of more than 1.5 mm

below limbus Recurrence of entropion after tarsal fracture

procedure

Gray line split and retractor repositioning

Principle: The lid margin is split at grey line. The

lower lid retractors are attached to anterior lamella just below the lashes to forcibly evert the lid margin.

Upper lid entropion

Any conjunctival scarring can lead to upper lid entropion.

• Severity of entropion mild entropion: anterior lamella repostion• Thickness of tarsal plate thick tarsal plate: tarsal plate resection thin tarsal plate: lamella division+mucous membrane graft• Keratinisation of marginal tarsoconjunctiva rotation of terminal tarsus• Lid retraction mild:advance tarsoconjunctiva and free Muller’s muscle severe retraction: posterior lamella graft

Anterior lamella reposition

• Anterior lamella are sutured to tarsus at a higher level.

Tarsal wedge resection

• Anterior lamella reposition and lid margin split combined with excision of wedge of tarsal plate

• Indications: marked entropion with thick tarsal plate,no keratinization of marginal tarsoconjunctiva

Lamella division + mucous membrane graft

• Lid is split. posterior lamella advanced and held in position with sutures passed through lid. The raw anterior surface is covered with mucous membrane.

Rotation of terminal tarsus

Principle: The tarsus is cut and lower

portion rotated through 180* .The posterior lamella is advanced to make a new lid margin.

posterior lamella graft

• The tarsus is divided, the terminal fragment everted and a graft sutured between the terminal tarsal fragment and recessed conjunctiva and lid retractors.

COMPLICATIONS

• Overcorrection The patient should be evaluated for excessive advancement of the

capsulopalpebral fascia, attachment of the fascia too high on the anterior tarsal surface, uncorrected horizontal eyelid laxity, and incorporation of the orbital septum in the advancement or surgical closure.

• Hematoma• Eyelid Retraction Result of excessive horizontal tightening of the tarsus or excessive

vertical advancement of the capsulopalpebral fascia.• Exposure Keratopathy From exposed conjunctival sutures, lagophthalmos, and keratinized

hard palate grafts.

• Granuloma Formation • Symblepharon • Aponeurogenic ptosis• Eyelash loss and eyelid necrosis

• Thank you.