17 Entropion and ectropion

Background

Entropion

Entropion is an eyelid malposition characterised by the inward turning of the lid margin, lashes and sometimes the external skin against the globe. Depending on the aetiology, acquired entropion can be classified as involutional, spastic or cicatricial. An involutional entropion is one of the commonest lower lid malpositions in the elderly population and is the most frequently corrected in clinical practice.1 There are no published prevalence data, but it is usually encountered in people older than 60 years, with an equal sex distribution.2 It is mainly caused by senile vertical lid laxity in the form of attenuation or dehiscence of the lower lid retractors and horizontal laxity in the form of canthal tendon elongation.3,4 The pathophysiological changes in eyelids with entropion are similar to those seen in ectropion. However, in entropion, hypertrophy of the orbicularis and Riolan muscles, septal atrophy and tarsal thinning allow overriding of the preseptal over the pretarsal muscle, resulting in inward rolling of the lid margin.2,5,6 Spastic entropion is considered an early form of involutional entropion with the same causative factors and cicatricial entropion is often due to scarring and contracture of the posterior lid lamella.

Patients may complain of a chronic foreign body sensation, redness, tearing and discharge. Constant rubbing of the eyelid margin against the ocular surface can cause a chronic conjunctivitis or corneal abrasions. Secondary corneal thinning, corneal ulceration and perforation may occur in untreated cases.7,8 Non-surgical temporary treatments include topical symptomatic support with antibiotic or lubricating ointments, taping the lid to the cheek or chemical denervation of the orbicularis muscle with botulinum toxin injections.9,10 Surgical correction is considered the only long-term treatment and over the years more than 80 procedures have been described addressing one or more of the causative factors.11 Horizontal lid laxity has been corrected by stabilising the preseptal orbicularis muscle to the lateral orbital rim with or without tightening of the lateral canthal tendon.12,13 Vertical lid laxity has been reduced by tightening the lower lid retractors, indirectly with the Wies procedure or directly with the Jones retractor plication procedure.11,14–16 Procedures such as Quickert

procedure or Jones retractor plication with a lateral canthal sling, address both vertical and horizontal lid laxity.17–19 The same principles apply in the management of spastic entropion.

Interventions used to correct a cicatricial entropion include tarsal fracture or posterior lid lamella lengthening with a mucous membrane graft combined with everting sutures.20,21

Ectropion

Ectropion refers to an eyelid malposition in which the lid is everted from its normal apposition to the globe. Acquired ectropion is classified as involutional, mechanical, cicatricial or paralytic. Although prevalence data do not exist, involutional ectropion is undoubtedly the commonest type seen in clinical practice. This tends to occur in older people due to horizontal eyelid and canthal ligament laxity, and attenuation of the lower lid retractors. Another aetiological factor may be a larger than normal tarsal plate mechanically overcoming the normal or decreased tone of the preseptal/ pretarsal orbicularis muscle.22 Mechanical eversion of the lower lids can result from ill-fitting spectacles or lesions weighing down the eyelid. Cicatricial ectropion tends to be due to skin shortage or scarring of the anterior lamella of the eyelid, and paralytic ectropion is secondary to a facial nerve weakness.

Patients with a lower lid ectropion may experience ocular discomfort, recurrent conjunctivitis, epiphora and lagophthalmos (incomplete closure of the eyelids). Although topical therapies may help in mild cases, the eyelid malposition usually requires surgical correction. Many different procedures have been described to treat lower lid ectropion. Pentagonal wedge resections23 have been widely used to correct involutional ectropion for many years. The popularity of this procedure has declined recently as it may exacerbate medial and lateral canthal ligament laxity. A tarsal strip procedure has the advantage of shortening the lid laterally, followed by reattachment to the lateral orbital rim.24–26 Reinserting the lower eyelid retractors, either in isolation, or in conjunction with horizontal lid tightening, is another technique preferred by some ophthalmologists.27,28

Medial involutional ectropion can also be corrected by a number of different procedures. Excision of a diamond of

tarso-conjunctival tissue with inverting sutures,29 the “lazy-T” repair with a full thickness lid resection,30 plication of a lax medial canthal tendon31 or a medial tarsal strip procedure32 are all techniques in current use.

Interventions used for a cicatricial ectropion include a Z-plasty,33 or placement of a full thickness skin graft or flap.34 Correction of a paralytic ectropion may involve lid tightening but with additional medial canthoplasty. Autogenous fascia or synthetic devices can also be used in severe cases to create a supportive “sling” for the lid.35

Questions

What is the effect of the various interventions for involutional entropion?

What is the optimum technique for the surgical correction of involutional lower eyelid ectropion?

The evidence

We found one Cochrane review of interventions for involutional lower lid entropion that did not contain any trials.36 We did not find any randomised controlled trials where one intervention for either involutional entropion or ectropion has been compared to another method of treatment.

Comment

There are no available data from randomised trials to provide evidence for the most effective intervention for the correction of involutional entropion or ectropion. The large number of suggested surgical procedures for both eyelid malpositions, often addressing similar pathophysiological factors, may be interpreted as suggesting that the understanding of the disease process has been limited.

The current information available relating to the treatment of entropion and ectropion comes from nonrandomised studies. These vary significantly on key issues including methodology and follow up, such that the apparent success rate of each procedure is open to misinterpretation.37 Current clinical practice is probably formulated by surgeons’ understanding of the pathophysiological causative changes associated with involutional eyelid changes, along with results from personnel experience or uncontrolled retrospective case series studies.

Implications for practice

There are many non-randomised case series and retrospective studies that have reported on the number of

overcorrections and recurrences associated with different techniques. The studies suggest that for entropion the recurrence rate is higher when vertical lid laxity is corrected in isolation15 as compared to a combined technique that involves additional horizontal lid shortening.17,18,38 Other non-trial evidence suggests that inferior retractor plication may have a further beneficial role in achieving a satisfactory long-term outcome.39–41

Interpretation of these data should be considered with caution since these results have not been verified by randomised controlled trials.

Implications for research

There is a clear need for sufficiently large, high-quality randomised trials to establish the effectiveness of interventions for entropion and ectropion.

References

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