eyelid entropion

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Entropion is a common eyelid malposition in which the margin turns inward against the globe. It must be well differentiated from trichiasis (misdirection of eyelashes) and distichiasis (anomalous eyelashes row). If untreated, this condition can cause irritative symptoms like ocular discomfort, corneal abrasion, microbial keratitis, corneal vascularization, and visual loss. Lower eyelid entropion (usually involutional) is much more common than superior eyelid entropion (usually cicatricial).1

The most recognized classification of entropion includes four types: cicatricial, congenital, acute spastic, and involutional.1

CLINICAL ASPECTS AND PHYSIOPATHOLOGY

Cicatricial entropion is secondary to scaring of the conjunctiva and vertical shortening of the posterior lamella. It is often seen in trachoma, burns, Stevens-Johnson syndrome, trauma, and enophthalmic cavity. This type of entropion will not be discussed in this article.

Congenital entropion is commonly caused by epiblepharon, a condition where the pretarsal muscle and skin ride above the eyelid margin forming a horizontal fold and causing the eyelashes to assume a vertical position. Usually the cilia only touches the cornea in downgaze. It tends to disappear with the maturation of the face and the lashes rarely cause corneal abrasions. When complications occur, it is necessary to excise the excess skin and orbicularis just inferior to the eyelid margin. Some authors do not consider epiblepharon a true entropion since the eyelid margin is in a normal position (Figure 1).

True congenital eyelid margin inversion is rare (Figure 2). It almost never resolves spontaneously and tends to worsen with age. Developmental fac-tors leading to this condition include lower eyelid retractor dysgenesis, structural defects in tarsal plate, and shortening of the posterior lamella. Upper eyelid entropion is usually associated with abnormalities of the tarsal plate and requires surgical correction.2, 3

Spastic entropion is an acute condition produced by excessive contracture of the orbicularis muscle in response to some ocular irritation and/or inflam-mation.3 This condition occurs in patients with some degree of involutional changes at the periocular area. During forcible closure, sustained squeezing or squinting of the eyelids, the contraction of orbicu-laris forces the tarsal plate to roll inwards, leading

Seminars in Ophthalmology, 25(3), 52–58, 2010Copyright © 2010 Informa UK Ltd.ISSN: 0882-0538 print/ 1744-5205 onlineDOI: 10.3109/08820538.2010.488573

Eyelid Entropion

Mario Genilhu Bomfim Pereira, Murilo Alves Rodrigues, and Silvia Andrade Carvalho Rodrigues

Universidade Federal de Sao Paulo, Sao Paulo, Brazil

ABSTRACT

Entropion is a common eyelid malposition in which the margin turns inward against the globe. If untreated, this condition can cause irritative symptoms like ocular discomfort, corneal abra-sion, microbial keratitis, corneal vascularization, and visual loss. It may be classified as cicatricial, congenital, acute spastic and involutional. Involutional entropion is the most common type seen in general ophthalmic practice and its prevalence is increasing as the population ages. There are several treatment strategies including nonsurgical and surgical procedures. This paper describes the surgical techniques most commonly used to treat entropion: everting sutures (Quickert), transverse blepharotomy and marginal rotation (Weis procedure), orbicularis transfer technique, tarsal strip, and advancement of the lower lid retractors.

KEYwORDS: entropion; treatment; review

Correspondence: Silvia Andrade Carvalho Rodrigues, Rua Jor-nalista Djalma Andrade, 1071, Belvedere, Belo Horizonte, Minas Gerais, Brazil 30320-540. E-mail: [email protected]

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Eyelid Entropion 53


to entropion. The irritation caused by the eyelashes increases the muscle spasm and worsens the entropion. If untreated, spastic entropion may be an evolving stage towards permanent entropion. Benign essential blepharospasm is another important cause of spastic entropion.

Involutional entropion is the most common type seen in general ophthalmic practice and its prevalence is increasing as the population ages (Figure 3). The etiol-ogy is complex and has been hypothesized to be a com-bination of degenerative tissue changes: (a) horizontal and longitudinal lower eyelid laxity; (b) overriding of the preseptal orbicularis oculi muscle over the pretar-sal portion; (c) enophthalmos; and (d) degenerative changes of the tarsal plate.

Senile entropion is characterized by excessive horizontal length of the eyelid secondary to laxity of the medial and the lateral canthal tendons and to the stretching of the tarsus (Figure 4). The loss of tone or weakness of the orbicularis muscle contributes to the laxity.4 Other factors involved include overriding of

the preseptal orbicularis (detected by observation of the preseptal orbicularis, as the patient squeezes the eyes closed after the entropic eyelid has been placed in its normal position), involutional enophthalmos, and attenuation or desinsertion of eyelid retractors. Several clinical clues may be present to indicate desinsertion of the retractors: a deeper than usual inferior fornix, a higher than normal eyelid border, and little or no inferior movement of the lower eye-lid on downgaze.1,4 A white line several millimeters below the inferior tarsal border caused by the leading edge of the detached retractors can be observed dur-ing surgery.

The tarsal plate is composed of collagenous fibers with scattered elastic fibers intermingled with the mei-bomius glands. The main component of the fibroconec-tive tissue found in the tarsus of a young individual is collagenous fibers. The composition gradually changes towards containing more elastic fibers as the individual gets older. The fragmentation of the elastic fibers, sep-tal atrophy and tarsal thinning also contribute to the inversion of the eyelid.5

FIGURE 1 Epiblepharon.

FIGURE 2 Congenital eyelid entropion.

FIGURE 3 Involutional entropion.

FIGURE 4 Involutional entropion.

54 M. Genilhu Bomfim Pereira et al.


TREATMENT

There are several strategies to treat eyelid entropion. This review describes the most commonly used and those with the best results.

Nonsurgical Procedures

Entropion treatment may require clinical interven-tions that provide only temporary relief like vigor-ous use of topical lubricants and/or lid taping before surgery.

To perform the lid taping the inferior eyelid is set in place and a tape of approximately 6 millimeters of width and 40 millimeters long is fixed in the temporal part of the eyelid and in the skin over the temporal bone (Figure 5A, 5B).

Spastic entropion may be completely resolved without any surgery. The primary irritating fac-tor must be diagnosed and controlled. If necessary, treatment of the orbicularis with botulinum toxin will abolish cycle of irritation and spasm. Botulinum

toxin injection must precede surgical treatment in this case.

Everting Sutures (Quickert)

Over time, a large number of sutures to evert the eyelid margin have been described. The method described by Quirkert and Rathbun6 is well known and has excellent results.

The procedure is simple and fast and has a long-term recurrence rate of 15%.7 Anticoagulation treat-ment does not need to be halted. It is a good choice for spastic entropion and debilitated patients in whom a more extensive procedure cannot be performed.

A 5-0 double-armed catgut suture is placed through the eyelid from the conjunctiva deep within the infe-rior formix exiting through the skin 2 mm below the lash line (Figure 6A, 6B). The other end of the suture is passed in a similar manner 3 mm apart. The arms are then tied over a small bolster (Figure 6C). The tighter the suture, the greater the eversion. At the end of the procedure, the eyelid must show a small overcorrec-tion. Three or four sutures equally spaced are normally used, avoiding the nasal third of the lower lid where they may cause a punctal ectropion. If there is no infection the sutures are left in place for a minimum of 4 weeks. The sutures running through the full thick-ness of the lid tighten the inferior retractors and create inflammatory changes and scarring as they dissolve. The scar will act as a barrier to the upward movement of the orbicularis muscle.

Transverse Blepharotomy and Marginal Rotation (weis Procedure)8

After a protective lid plate is placed in the formix, a full thickness straight incision is made across the lid 4 mm from the margin. The incision extends along the

A B C

FIGURE 6 Quickert everting sutures.

A B

FIGURE 5 Lid taping.

Eyelid Entropion 55


length of the abnormal eyelid (this may involve the entire eyelid or only a sector).

The marginal rotation is made with three double-armed 6-0 silk sutures passed from the conjunctiva and tarsus of the proximal inferior wound. It also may be passed full-thickness from the skin to the conjunctiva. In either case, each arm of the suture is passed through the pretarsal orbicularis muscle and skin of the upper edge of wound and brought out anteriorly beneath the lash line (Figure 7A, 7B). Each suture is tied over a bolster. The tighter the suture, and the closer to the lid margin, more the eyelid margin will rotate. At the end of the surgery, a small overcorrection should be observed. If necessary, a horizontal lid shortening pro-cedure like tarsal-strip may also be performed.

Orbicularis Transfer Technique

Orbicularis transfer starts with a subciliary skin inci-sion extending from a point 3 mm lateral to the lachry-mal punctum to beyond the lateral canthus (Figure 8A, 8B). The skin along the length of the lid is retracted and the orbicularis muscle exposed. Scissors are used to make a small opening through the superior aspect of the orbicularis muscle and a second opening 7mm inferiorly (Figure 8C, 8D). A strip of orbicularis muscle measuring 7 X 25mm is dissected and elevated on mus-cle hooks (Figure 8E). The lateral area is transected and the strip elevated (Figure 8F). The medial part remains attached and is temporarily displaced.

The orbital septum is transected. The periosteum of the inferior orbital rim is identified. Both needles of a double-armed 4-0 chromic suture are passed through the end of the strip (Figure 8G, 8H) and then through the periorbita, just inside the inferior lateral orbital rim and tied (Figure 8I). The skin is closed with nylon 6-0.9

If the patient has horizontal laxity, tarsal-strip or another horizontal shortening procedure is performed (Figure 8J).

Tarsal Strip

The tarsal strip procedure was first described by Anderson in 1979.10 It is a simple technique that works for some types of entropion and ectropion, since it cor-rects the laxity of the eyelid.

The procedure can be performed under local anes-thesia. A subciliary incision is made from the lateral two fifths of the eyelid extending beyond the lateral canthus. The muscle is incised and spread to expose the periorbita and orbital margin. Lateral canthotomy (Figure 9.1) and inferior cantholysis (Figure 9.2) are completed in order to mobilize the lateral aspect of the eyelid for its advancement superiorly and laterally. The tarsal strip is made by excising the mucosa, cilia, orbicularis and skin at the lateral edge of the eyelid (Figure 9.3, 9.4, 9.5, 9.6). The length of the tarsal strip and the amount of it to be excised is now determined, depending on the laxity of the eyelid. At least 4 to 5 mm of bare tarsal strip is left intact for attachment of the lateral orbital rim. Residual mucosa on the posterior surface of the tarsus is excised to avoid burying epi-thelium when the tarsus is attached to the periorbita. A suture is made passing through the strip into the periorbita 2 to 4 millimeters within the orbital aspect of the zygoma, several millimeters above the level of the lateral commissure. 5-0 prolene, 4-0 polyglactin, or 5-0 mersilene can be used as a suture (Figure 9.7, 9.8). The lower eyelid tarsal attachment to the peri-orbita can be reinforced with one or two additional sutures. The lateral comissure is redefined using 5-0 plain suture.11 The orbicularis plane is closed using 5-0 PDS or 5-0 polyglactin. Skin is closed with 6-0 silk or 6-0 nylon.

Advancement of the Lower Lid Retractors

Jones12 described a technique modified by Schaeffer13 that consists of imbrications of the lower lid retrac-tors. This procedure conforms to the physiology and anatomy of the lower eyelid: (a) it does not involve the inner third of the lower lid; (b) it does not injure the adducting or pumping action of the orbicularis; (c) the lower lid retractors are shortened and thus strengthened; (d) the upper part of the preseptal orbicularis muscle is prevented from overriding the tarsus.

The procedure can be performed under local anes-thesia. The skin and superficial fascia are incised along

A B

FIGURE 7 Weis procedure.



the inferior border of the tarsus of the lower eyelid, starting at the junction of the inner and middle one third of the eyelid and extending laterally just beyond the lateral canthus following the contour of the lid margin. The lateral end of the incision is curved in one of the skin furrows and extends down diagonally for about 15 millimeters (Figure 10.1). The skin is dis-sected along the lower border of the incision from the orbicularis muscle to just above the orbital rim. Next, the orbicularis muscle is grasped centrally, just below the lower border of the tarsus and incised by

sharp dissection. Through this opening, scissors are passed into the suborbicular space dissecting it medi-ally and laterally. The orbicularis is cut horizontally at the lower border of the tarsus from the medial to the lateral side, separating the septal and tarsal orbicu-laris. The preseptal orbicularis is separated from the orbital septum over the entire length of the incision inferiorly for about 12 millimeters. The orbital fat is exposed and part of it is removed. A 4-0 plain gut suture is placed through the skin, then the retractors about 8 millimeters below the tarsus (Figure 10.2),

A

F

G

C

D

B

H

E

I J

FIGURE 8 Orbicularis transfer technique.

Eyelid Entropion 57


through the inferior border of the tarsus and then the superior border of the skin. 2-4 sutures must be added after the first one is adjusted to see if it is an over- or undercorrection. Remaining skin and/or orbicularis can be removed if necessary.

Congenital Entropion

A child with congenital entropion must be managed with frequent eye examinations and use of lubrication. If the corneal epithelium is intact, surgical treatment may be delayed. Since the major etiological factor in congenital lower eyelid entropion is the hypertrophy

of the orbicularis muscle and skin in the pretarsal area, the simplest method for treating is removing the abnormal tissue.14

A B

FIGURE 10 Advancement of the lower lid retractors.

C

F

D

H

A B

G

E

FIGURE 9 Tarsal strip.



FINAL COMMENTS

More than a hundred surgical procedures have been described to correct entropion but the success rate of most of them is far from perfect. An inflexible approach to treatment will result in an unacceptably high recurrence rate.

Before planning the surgical approach is neces-sary to identify the etiologic factors. Knowledge of lower eyelid anatomy and recognition of the basic physiopathology is essential.

REFERENCES

[1] American Academy of Opthalmology. Basic and Clinical Science Course Orbit, Eyelids and Lacrimal System. 1996-7, San Francisco: American Academy of Ophthalmology; 148–154.

[2] Katowitz WR, Katowitz JA. Congenital and developmen-tal eyelid abnormalities. Plast Reconstr Surg. 2009 Jul;124(1 Suppl):93e–105e.

[3] Levine MR, Toukhy E, Schaefer AJ. Entropion. In: Nessi FA, Lisman RD, Levine MR, eds. Smiths’s Ophthalmic Plastic and Reconstructive Surgery. Mosby, 1997;271–289.

[4] Soll D. Entropion and ectropion. In: Soll DB, Asbell RD, eds. Management of Complications in Ophthalmic Plastic Surgery. Birmingham, AL: Aesculapius Pub. Co., 1976;168–206.

[5] Marshall JA, Valenzuela AA, Strutton GM, Sullivan TJ. Anterior lamelar actinic changes as a factor in involutional eyelid malposition. Opthal Plast Reconstr Surg 2006; 22:192–194.

[6] Quickert MH, Rathbun E. Suture repair of entropion. Arch Ophthalmol. 1971; 85:304–305.

[7] Scheepers MA, Singh R, James N, Zuercher D, Gibson A, Catey B, Fong K, Michaelides M, Olver J. A randomized controlled trial comparing everting sutures with everting sutures and a lateral tarsal strip for involutional entropion. Ophthalmology. 2009;Oct 27.

[8] Wies FA. Spastic entropion. Trans Acad Ophthalmol Otolaryn-gol 1955;59:503–506.

[9] Della Rocca R. Entropion. In: Della Rocca R, ed. Ophthal-mic Plastic Surgery: Decision Making and Techniques. New York:McGraw-Hill, 2002;65–76.

[10] Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol. 1979;97(11):2192–2196.

[11] Bosniak, S, ed. Principles and Practice of Ophthalmic Plastic and Reconstructive Surgery. 1st ed. Philadelphia, PA: Saunders 1996;413–438.

[12] Jones LT, Reeh MV, Wobig JL. Senile entropion: a new con-cept for correction. Am J Ophthalmol 1972;72:327–329.

[13] Schaefer A. Involutional entropion. In: Smith BC et al. Oph-thalmic Plastic and Reconstructive surgery, vol. 1, St Louis: CV Mosby Co, 1987;546–555.

[14] Millman AL, Mannor GE, Putterman AM. Lid crease and capsulopalpebral fascia repair in congenital entropion and epiblepharon. Ophthalmic Surg. 1994 Mar;25(3):162– 165.

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