7. ENTROPION
• Inward rotation of the
eyelid margin.
• Early procedures of entropion correction can
be categorized as vertically shortening the anterior lamella, vertically
lengthening posterior lamella& controlling lamellar rotation.
• Anatomic approach started during mid 20th century.
• Lower lid retractor system- Deroetth & jones et al.
Orbicularis function- Dalgleish, smith& tse et al.
Tarsal plate& canthal tendon physiologies
-Benger and musch, shore, Liu and stasior.
Posterior lamellar substitutes/grafting-Silver& others.
9. INVOLUTIONAL ENTROPION:
Factors responsible for,
• Laxity, dehiscence or disinsertion of
lower lid retractors.
• Over riding of pre-septal orbicularis
segment over pre-tarsal
orbicularis segment.
• Horizontal lid laxity.
• Enophthalmos.
CICATRICIAL ENTROPION:
• Conditions causing contracture of conjunctiva.
• Chemical burn, surgical/accidental trauma, topical anti-glaucoma
medications, ocular cicatricial pemphigoid, trachoma,
SJS.
10. ACUTE SPASTIC ENTROPION:
• Seen in susceptible individuals with blepharospasm that are induced
by ocular irritation (blepharitis, dry eye etc.)
CONGENITAL ENTROPION:
• Rare.
• Different from epiblepharon
(horizontal fold of redundant pretarsal
skin &orbicularis muscle extend
beyond eyelid margin),
which presents with inverted tarsus.
• Cause- abnormal insertion of
lower lid retractor.
11. PATIENT ASSESSMENT:
• Pt. age, medical& drug history.
• Careful naked eye& slit lamp examination for etiology.
• Conjunctival exam for scarring, symblephara&
keratinization of posterior lamella.
PRE OPERATIVE ENTROPION ASSESSMENT:
o Assessment of capsulopalpebral fascia laxity
• Higher eyelid resting position in primary gaze,
• Increased passive vertical eyelid distraction,
• Increased depth of inferior conjunctival fornix,
• Presence of a white infra tarsal band.
o Assessment of horizontal eyelid laxity
o Assessment of relative enophthalmos
o Assessment of preseptal orbicularis override
o Assessment of posterior lamellar support
o Assessment of marked orbital fat prolapse
12. DIFFERENTIAL DIAGNOSIS:
EPIBLEPHARON
resolves with normal vertical growth of facial bones.
DISTICHIASIS
the result of meta differentiation of primary epithelial germ cells
originally intent upon meibomian gland development.
TRICHIASIS
the result from inflammatory disruption& scarring of
eyelash follicles.
13. MANAGEMENT:
NON-SURGICAL:
• Artificial tear drops, lubricating ointments
• Bandage contact lens
• Lower lid tapping
• Chemo denervation of orbicularis with botulinum toxin
• Toward specific invoking stimulus
(trichiasis, blepharitis, dry eye etc.)
14. SURGICAL MANAGEMENT:
Involutional- Quickert Rathbun everting suture,
- lower lid retractor advancement with lateral tarsal strip
procedure,
- lower lid retractor advancement with lower lid wedge
resection.
Cicatricial- Retractor advancement,
- Tarsal plate fracture,
- posterior lamellar grafting.
Congenital- Retractor advancement.
ANAESTHESIA
Entropion correction is an out patient procedure, performed
under local anesthesia.
A 1:1 dilution of 2% lidocaine with 1:100000 epinephrine &
0.75% bupivacaine combined with hyaluronidase provides
excellent anesthesia.
15. QUICKERT-RATHBUN EVERTING SUTURES
• Elderly patients with concommitent medical problems for
whom surgery is contraindicated.
• Patients who have bleeding diathesis or who take anti-coagulants.
• Unable to co-operate with surgery.
• Unable to lie in semi recumbent position for the duration surgery.
16. PROCEDURE:
• 3-4 double armed 5/0 vicryl suture passed
through eyelid from inferior fornix to
emerge 2mm just below the lash line.
• Sutures are tied tightly enough to produce
a minimal degree of ectropion.
• If eyelid is lax, suture should
instead be passed th’gh
eyelid from just below
the tarsus to emerge 2mm
below the lash line.
QUICKERT-RATHBUN SUTURES
18. LOWERLID RETRACTOR ADVANCEMENT:
• Usually this procedure is combined with either lateral
tarsal strip (LTS)procedure or wedge resection of lower lid.
• Lower lid advancement with LTS is a convenient operation as
no sutures needed to be removed post operatively.
• But should be avoided in pt. with marked upper lid laxity&
pt. with HTN who are unable to discontinue aspirin preoperatively.
In those pts., bleeding is much easier to control with
wedge resection of lower lid.
PROCEDURE
• A 4/0 silk traction suture is placed horizontally th’gh gray line of
lower lid centrally& fixated with head drape.
• Skin incision is made 3mm below eyelid margin extending from
just below inferior Punctum to lateral aspect of lower lid
• Colorado needle is used to dissect th’gh orbicularis, exposing
septum. Then muscle is dissected away from septum.
19. • Septum opened inferiorly with Westcott scissors exposing
pre aponeurotic fat & retractor identified beneath it.
• Retractor then carefully dissected from underlying conjunctiva.
• Pt. then instructed to look down& inferior pull of capsulopalpebral
fascia should be felt.
• 1mm strip of fascia removed shortening retractor vertically.
• 2-3 interrupted 5/0 vicryl sutures are used to re attach lower lid
retractor to inferior border of tarsus.
21. LATERAL TARSAL STRIP PROCEDURE
• Lateral canthotomy is performed using straight blunt tipped
scissors up to lateral orbital rim.
• Inferior crus of lateral canthal tendon is cut.
septum is also freed until eyelid becomes loose.
• Anterior & posterior lamellae are split along gray line.
• Lateral tarsal strip is formed by cutting along inf. Border of
tarsus. Lid margin also excised.
• Tarsal strip is drawn to lateral orbital margin& redundant portion
excised. Conjunctiva scrapped from tarsal strip.
Redundant anterior lamella excised.
• Double armed 5/0 vicryl suture on a ½ circle needle is passed
through periosteum of lateral orbital wall, leaving a loop.
• End of tarsal strip is passed th’gh the loop& needle passed from
under surface of tarsal strip exiting on anterior surface.
23. • As the suture is pulled& the loop is tightened, the lateral tarsal strip
Drawn against globe in a posterior direction.
• Single 7/0 vicryl suture is passed th’gh gray line at the edges of the
lateral aspect of the upper & lower lids reforming angle of the
lateral canthus.
• Lateral canthal skin wound is closed in layers.
25. LOWER LID WEDGE RESECTION
• Retractor dissection is carried out in the same manner& freed from
underlying conjunctiva.
• At the junction of lateral 1/3rd and medial 2/3rd lower lid
margin is incised vertically. Using straight iris scissors vertical cut
completed th’gh tarsus.
• Edges grasped& overlapped without undue tension. Redundant
eyelid is cut th’gh tarsus. Then scissors angulated at 45˚ to
complete wedge resection.
• Tarsus re approximated with interrupted 5/0 vicryl suture.
orbicularis also closed with same suture.
• Eyelid margin repaired with 6/0 silk suture& the ends are left long.
vertical skin wound also closed with 6/0 suture& lid margin
sutures are incorporated into them to prevent corneal rubbing.
27. TARSAL FRACTURE/TRANSVERSE TORSOTOMY
• 4/0 silk traction suture placed horizontally th’gh gray line centrally
and eyelid everted over a desmarres retractor.
• Horizontal incision is made th’gh the whole length of tarsus on
the posterior surface of eyelid just below its center down to the deep
surface of the orbicularis.
• 3-4 double armed 5/0 vicryl sutures passed th’gh tarsus just below
the incision& th’gh eyelid to emerge from the skin just below the
lash line.
• Sutures are tied to produce a moderate ectropion.
29. POSTERIOR LAMELLAR GRAFT
• Indicated for the pt with severe degree of cicatricial entropion
with marked eyelid retraction.
• Hard palate is preferred graft material.
• Tarsal plate fracture carried out like before& inferior margin of
tarsus is freed from eyelid retractors and orbital septum.
• Ensuing defect is measured & slightly oversized hard palate graft
is harvested. Graft carefully prepared by removing
excessive sub mucosal tissue.
• 3-4 double armed 5/0 vicryl suture passed in a partial thickness
fashion th’gh hard palate graft& passed th’gh full thickness of
eyelid. These are tied just below the lash line to evert eyelid
margin& maintain graft in apposition.
• Edges of the graft are sutured to anterior edge of the tarsus
superiorly& the recessed edges of the conjunctiva with 8/0 vicryl.
