ENTROPION

DR K HARIPRIYASSSIHMS

EYE LID ANATOMY

FUNCTIONS: Secrete pre-corneal tear film & its even distribution. Lacrimal pump mechanism. Eye lashes sweep air-borne particles. Constant voluntary& reflex eyelid movements.GROSS DIVISION:o Anterior lamella-skin, orbicularis oculi.o Posterior lamella-tarsus, conjunctiva.

STRUCTURES NEEDED FOR PROPER FUNCTION:

ORBICULARIS OCULI• Orbital, pre-septal, pre-tarsal parts.

ORBITAL SEPTUM• Fibrous multi-layered membrane, representing continuation of orbital facial system.• Distal fibers merge with levator aponeurosis & capsulo-palpebral fascia.

MAJOR EYELID RETRACTORS• Upper lid- levator palpebrae, Muller's muscle lower lid- capsulopalpebral fascia.• From superior transverse orbital ligament of witnell, LPS continues as levator aponeurosis& inserts near marginal tarsal border.

ORBICULARIS OCULI ORBITAL SEPTUM

• Capsulo-palpebral fascia starts from Lockwood's ligament& sheaths around inferior rectus/inferior oblique muscles. Fuses with orbital septum& inserts onto lower border of tarsus.

TARSAL PLATE• Dense fibrous tissue 1-1.5mm thick.• 25mm horizontal length, height- superior, 8-12mm inferior, 3.5-4mm.

CANTHAL TENDONS• Medial canthal tendon inserts via 3 limbs. Anterior-orbital process of maxillary bone, Posterior-posterior lacrimal crest, superior-orbital process of frontal bone.• Lateral canthal tendon fibrous strands extend posteriorly along lateral orbital wall& blends with lateral check ligament.

EYELID RETRACTORS

LEVATOR APONEUROSIS

CAPSULOPALPEBRAL FASCIA

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.

CLASSIFICATION:

• Involutional entropion• Cicatricial entropion• Acute spastic entropion • Congenital entropion.

SYMPTOMS AND SIGNS:

• Ocular foreign body sensation• Secondary blepharospasm• Ocular discharge• Conjunctival metaplasia• Superficial keratopathy• Corneal scarring.

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.

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.

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 laxityo Assessment of relative enophthalmoso Assessment of preseptal orbicularis overrideo Assessment of posterior lamellar supporto Assessment of marked orbital fat prolapse

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.

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.)

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.

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.

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

WEIS PROSEDURE JONES PROCEDURE

ORBICULARIS OVERRIDE PREVENTING PROCEDURES

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.

• 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.

LOWERLID RETRACTOR ADVANCEMENT

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.

LATERAL TARSAL STRIP PROCEDURE

PREPARING LTS

• 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.

LATERAL TARSAL STRIP PROCEDURE

TRIMMING LTS

SUTURING LTS TO PERIOSTEUM

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.

LOWERLID WEDGE RESECTION

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.

TARSAL FRACTURE/ TRANSVERSE TARSOTOMY

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.

BUTTRESSING OF POSTERIOR LAMELLA WITH HARD PALATE GRAFT

COMPLICATIONS OF ENTROPION CORRECTION:

Over correction, Hematoma, Eyelid retraction, Exposure keratopathy, Granuloma formation, Symblepharon.

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