3Lower eyelid entropion

introduction

Lower eyelid entropion is an eyelid malposition in which the lower eyelid margin is turned inward against the globe. The keratinized skin of the eyelid margin and the eyelashes rub against the inferior cornea and bulbar conjunctiva, causing irritation. Patients with a lower lid entropion tend to seek medical attention early because of the troublesome symptoms. Lower lid entropion can be classified into four types.

classification

1.Involutional entropion

2.Cicatricial entropion

3.Acute spastic entropion

4.Congenital entropion

Involutional Entropion

The majority of entropia are involutional and therefore seen in older patients. In the lower eyelid, involutional changes typically result in either a lower lid entropion or ectropion, whereas in the upper eyelid the same changes result in ptosis. A combination of factors has been proposed to account for the eyelid malposition. These are:

1.Laxity, dehiscence, or disinsertion of the lower eyelid retractors (Fig. 3.1A)

2.Over-riding of the preseptal orbicularis oculi muscle over the pretarsal orbicularis oculi muscle

3.Horizontal eyelid laxity

4.Enophthalmos

Any surgical treatment should aim to address these factors with the exception of enophthalmos. Enophthalmos has not been shown to be a significant factor in the aetiology of involutional lower eyelid entropion. Laxity, dehiscence, or disinsertion of the lower eyelid retractors is the primary cause of involutional entropion. This lower eyelid retractor problem allows the inferior edge of the tarsus to rotate away from the globe. Horizontal eyelid laxity leads to instability of the eyelid. The preseptal orbicularis appears to force the lower eyelid margin inwards.

key point

Laxity of the eyelid retractors is the primary cause of involutional lower eyelid entropion

Cicatricial Entropion

Any condition that causes contracture of the conjunctiva can result in a cicatricial entropion (Fig. 3.2). Such conditions include chemical burns, surgical or accidental trauma, topical glaucoma medications, ocular cicatricial pemphigoid, trachoma, and

Stevens–Johnson syndrome. It may also be seen with the extrusion of an orbital floor implant through the inferior fornix.

Acute Spastic Entropion

This form of entropion is seen in susceptible individuals with blepharospasm that has been induced by ocular irritation. Although treatment of the underlying cause of ocular irritation may reverse the eyelid malposition, a permanent entropion may ensue which will require surgical intervention.

Congenital Entropion

Congenital lower eyelid entropion is a rare condition. It differs from congenital epiblepharon, a much more common condition, by the fact that the tarsus is inverted (Fig. 3.3). This eyelid malposition does not resolve spontaneously and requires surgical intervention to prevent corneal morbidity. It has been postulated that an abnormal insertion of the lower lid retractors is the underlying cause.

applied surgical anatomy

A thorough understanding of lower eyelid anatomy is essential to the surgical management of lower eyelid entropion (Fig. 3.4). For a more detailed description of the anatomy of the lower eyelid, refer to chapter 2.

The lower eyelid can be considered to consist of three lamellae:

●Anterior—skin and orbicularis oculi muscle

●Middle—orbital septum and inferior eyelid retractors

●Posterior—tarsus and conjunctiva

The lower eyelid tarsus is approximately 3 to 4 mm in height and 1 mm in thickness. The normal lower eyelid margin is flat, ending at right angles anteriorly and posteriorly. The most posterior aspect of the normal eyelid margin is the mucocutaneous junction where the mucosa of the palpebral conjunctiva ends and the keratinized skin of the eyelid margin begins. The meibomian gland orifices lie just anterior to the mucocutaneous junction. Anterior to the meibomian gland orifices lies the gray line. The gray line is used as a surgical landmark to separate the anterior and posterior lamellae of the eyelid. The eyelashes lie anterior to the gray line. These lie in one or two irregular rows in the lower eyelid and three or four irregular rows in the upper eyelid.

The tarsal conjunctiva is firmly adherent to the tarsus and cannot be dissected freely. The forniceal conjunctiva, in contrast, is very loosely attached to the underlying retractors. The lower eyelid skin crease is variable but usually situated approximately 4 to 5 mm below the eyelid margin. The lateral canthal angle normally sits approximately 2 mm higher than the medial canthal angle.

The lower eyelid retractor complex consists of an aponeurotic expansion from the inferior rectus muscle. This aponeurotic expansion, known as the capsulopalpebral fascia, extends anteriorly to envelop the inferior oblique muscle, where it

fuses with the inferior suspensory ligament (Lockwood’s ligament). The fascia also contains fibers which insert into the inferior margin of the tarsus, the preseptal orbicularis muscle at the level of the lower lid skin crease, and the inferior fornix. The fascia is also accompanied by some smooth muscle fibers. The retractors pull the lower eyelid inferiorly on down gaze acting synchronously with the inferior rectus muscle. Normal tension on the lower eyelid retractors is essential in the maintenance of a stable lower eyelid.

The orbital septum fuses with the fascia approximately 4 to 5 mm below the tarsus. The orbital septum extends from the arcus marginalis of the inferior orbital margin to the inferior border of the tarsus. Posterior to this lie the three lower lid fat pockets.

Figure 3.3 Congenital lower eyelid entropion.

The anatomy of the lower eyelid resembles that of the upper eyelid. Although the tarsus is much smaller, the capsulopalpebral fascia is analogous to the levator aponeurosis. The smooth muscle fibers accompanying this fascia are analogous to Müller’s muscle. Lockwood’s ligament is analogous to Whitnall’s ligament. The fat in the lower eyelid lies posterior to the septum but anterior to the capsulopalpebral fascia and is analogous to the upper lid preaponeurotic fat. There are three fat pads in the lower eyelid: medial, central, and lateral. These lie between the capsulopalpebral fascia and the orbital septum. The inferior oblique muscle lies between the medial and central fat pads. The central and lateral fat pads are separated by the arcuate expansion.

In the lower eyelid, an anastomotic arterial arcade runs in the orbicularis oculi muscle plane approximately 4 to 5 mm below the eyelid margin.

It is very helpful to consider the individual layers of the lower eyelid that are encountered during a surgical dissection. A full thickness horizontal incision made through the eyelid at a point 4 to 5 mm below the tarsus would pass through the following structures:

●Skin

●Orbicularis oculi muscle

●Orbital septum

●“Preaponeurotic” fat

●Lower eyelid retractors

●Conjunctiva

“Preaponeurotic” fat is often encountered a few millimeters inferior to this position, particularly in an elderly patient. The

orbital septum is very attenuated in this age group and should be opened more inferiorly to expose the fat. This ensures that the septum has been opened and released and the inferior retractors (the capsulopalpebral fascia) are correctly identified. This lies beneath the fat and above the conjunctiva.

The involutional entropion presents the trainee oculoplastic surgeon with the ideal opportunity to appreciate eyelid anatomy, to improve surgical skill in eyelid dissection, to perfect the use of the Colorado needle and bipolar cautery in achieving good hemostasis, to practice suturing, and to perfect patient communication during surgery under local anesthesia.

patient assessment

History

Patients who present with a lower eyelid entropion complain of irritation, photophobia, and a red eye. Occasionally they will complain of discharge. The patient may experience only intermittent symptoms and may show no physical abnormalities when they present. Such a history in an older patient should lead to the suspicion that an intermittent involutional entropion is the cause of the patient’s complaints. Some patients discover that the eyelid can be manually repositioned offering temporary relief from the symptoms. Others present with tape placed at the eyelid–cheek junction to prevent the re-occurrence of the entropion.

Patients with involutional entropion are frequently elderly with multiple medical problems. The patient’s age and medical and drug history must be taken into account when determining the appropriate management. Most elderly, infirm patients are better suited to the placement of simple lower lid everting

78

sutures in clinic. These are quick and simple to place, very effective, and easy to repeat in the event of a recurrence of the entropion. In the presence of significant lower eyelid laxity, transverse sutures can be used instead.

key point

Many patients presenting with an involutional lower eyelid entropion are elderly with systemic co-morbidities. Such patients are better suited to the placement of simple lower eyelid everting sutures.

Examination

The patient should undergo a careful naked eye and slit lamp examination to determine the etiology of the entropion, e.g., a corneal foreign body causing a spastic entropion, and to determine the most appropriate treatment. The conjunctiva is examined to exclude scarring, symblephara, or keratin on the posterior lamella (Fig. 3.5).

The lower lid is gently repositioned with a finger. If the eyelid remains in a normal position without blinking, the etiology is likely to be involutional rather than cicatricial, although more than one etiological factor may be present. If there is no entropion present, but the history suggests an intermittent episodic inversion of the eyelid, the patient should be asked to look down and to forcibly close the eyes. The patient should then be asked to slowly open the eyes and the eyelid should be carefully observed. An entropion may appear or the preseptal orbicularis muscle may be seen to roll upward (overriding of the preseptal orbicularis).

The eyelid margin should be observed in down gaze. Laxity, dehiscence, or disinsertion of the lower eyelid retractors is associated with a poor movement of the eyelid margin when the patient looks down. The eyelid margin is seen to ride above the inferior limbus.

The eyelid should be assessed for horizontal laxity. The eyelid should be drawn medially and laterally to determine the degree of medial and lateral canthal tendon laxity (the “distraction” test). It is unusual to have significant medial canthal tendon

OCULOPLASTIC SURGERY

laxity in lower lid entropion, and it is extremely rare for this to require surgical correction. This is in contrast to the situation with lower lid ectropion. The eyelid should be drawn away from the globe to determine the degree of laxity of the tarsus. It should only be possible to draw the eyelid approximately 2 to 3 mm from the globe. This is the “pinch” test (Fig. 3.6A and B). The eyelid is then drawn inferiorly and released. This is the “snap” test (Fig. 3.6C–E). The eyelid should return to lie in apposition to the globe without a blink. Failure to do so suggests significant eyelid laxity.

management

Medical Management

In the case of acute spastic entropion, the treatment is directed to the provoking stimulus, e.g., trichiasis, blepharitis, or a dry eye. Although a bandage contact lens or botulinum-toxin injections may improve symptoms temporarily, these are rarely justified. The use of lower lid tape can be advised for use in a primary care setting while the patient is waiting to be seen by an ophthalmologist.

Surgical Management

Involutional Entropion

Although over 100 procedures have been described for the surgical repair of lower eyelid involutional entropion, very few have withstood the test of time and the majority have been abandoned. This is mainly because these procedures have failed to address the underlying etiological factors responsible for the entropion.

Although a multitude of operations are still used by many different surgeons, only those procedures which are used in the author’s clinical practice are described:

1.Everting or transverse sutures

2.Lower lid retractor advancement with a lateral tarsal strip procedure

3.Lower lid retractor advancement with a lower lid wedge resection

These procedures are usually performed under local anesthesia, with or without sedation.

LOWER EYELID ENTROPION

Everting sutures are offered to all patients over the age of 70 years at the initial consultation, and are used exclusively for the following patients:

1.Elderly patients with concomitant medical problems for whom surgery is contraindicated

79

2.Patients who decline a more definitive surgical treatment

3.Patients who have a bleeding diathesis or who take anti-coagulants

4.Patients who are unable to cooperate with surgery

80

5.Patients who are unable to lie in a semi-recumbent position for the duration of surgery

6.Patients willing to undergo a trial of everting sutures.

Everting sutures have been commonly regarded as a temporary form of treatment, but many patients achieve a long-lasting or permanent result with the sutures alone. If the entropion recurs within a relatively short period of time, the patient is then offered a more definitive surgical procedure unless surgery is contraindicated. The sutures are very quick and simple to insert in a clinic setting and provide instant relief for the patient. It is also very easy to repeat such treatment as required. If the patient has significant eyelid laxity, transverse sutures are placed rather than everting sutures to avoid the possibility of causing a secondary ectropion. For some patients with lower lid laxity everting sutures can be combined with a lateral tarsal strip procedure.

key point

Lower lid everting sutures are very quick and simple to place, and have a high success rate. They can be used as the definitive treatment of a lower lid entropion in the older patient, or they can be used as a trial treatment before considering a more invasive procedure.

For all other patients, a lower eyelid retractor advancement is performed combined with either a lateral tarsal strip procedure or, less frequently, a lower eyelid wedge resection. Wherever appropriate these procedures can be combined with a debulking of the orbicularis oculi muscle. e.g., in a patient who has very marked orbicularis hypertrophy or overaction, or with a lower eyelid blepharoplasty, e.g., in a patient with marked fat pad prolapses.

key point

If a retractor advancement is not combined with a horizontal eyelid tightening procedure there is a great potential for recurrence of the entropion, even if the degree of lower eyelid laxity is not considered significant.

A lower eyelid retractor advancement combined with a lateral tarsal strip procedure is a very convenient operation for the patient, as no sutures need to be removed postoperatively. It is preferable to avoid the procedure, however, in the patient with marked upper eyelid laxity to avoid an upper eyelid overhang at the lateral canthus. It is also preferable to avoid this procedure in the obese, hypertensive patient who is unable to discontinue the use of aspirin preoperatively. In such patients, bleeding is much easier to control with a wedge resection of the lower lid. A lower eyelid retractor advancement combined with a lower lid wedge resection takes longer to perform and has the disadvantage that the

OCULOPLASTIC SURGERY

patient must return for suture removal 2 weeks following surgery. It is also associated with the risk of dehiscence of the wedge resection wound, notching of the eyelid margin or secondary trichiasis.

Everting Sutures

Surgical Procedure

1.Proxymethacaine drops are instilled into the inferior conjunctival fornix.

2.Two to three milliliters of 0.5% Bupivacaine with 1:200,000 units of adrenaline mixed 50:50 with 2% lidocaine with 1:80,000 units of adrenaline are injected immediately under the skin in the lower eyelid, avoiding bleeding from the orbicularis muscle and a hematoma.

3.Three or four double-armed 5/0 Vicryl sutures are passed through the eyelid from the inferior fornix to emerge 2 mm apart just below the lash line (Fig. 3.7A and B). The sutures are tied tightly enough to produce a minimal degree of ectropion (Fig. 3.8). If the eyelid is lax, the sutures should instead be passed through the eyelid from just below the tarsus to emerge 2 mm apart 2 to 3 mm below the lash line (transverse sutures) (Fig. 3.7C).

4.Antibiotic ointment is instilled into the eye.

Postoperative care. The patient is discharged with instructions to place topical antibiotic ointment in the eye and on the sutures externally three times a day for 2 weeks. Cool packs can be applied intermittently for 24 to 48 hours to reduce swelling. The sutures are removed in clinic 3 weeks postoperatively if still present. The patient can, however, be discharged from the clinic as the sutures will eventually dissolve over the course of 4 to 6 weeks.

Lower Lid Retractor Advancement with Lateral Tarsal Strip Procedure

Surgical procedure

Retractor advancement

1.Proxymethacaine drops are instilled into the inferior conjunctival fornix.

2.Two to three milliliters of 0.5% Bupivacaine with 1:200,000 units of adrenaline mixed 50:50 with 2% lidocaine with 1:80,000 units of adrenaline are injected immediately under the skin in the lower eyelid and at the lateral canthus, avoiding bleeding from the orbicularis muscle and a hematoma.

3.A 4/0 Silk traction suture is placed horizontally through the gray line of the lower eyelid centrally and fixated to the head drapes using a small curved artery clip.

4.A skin incision is then made 3 to 4 mm below the eyelid margin extending from just below the inferior punctum to the lateral aspect of the lower eyelid using a Colorado needle (Fig. 3.9A).

5.Hemostasis is obtained using bipolar cautery.

6.The Colorado needle is then used to dissect through the orbicularis oculi muscle exposing the orbital septum. The orbicularis muscle is then dissected away from the underlying orbital septum for 2 mm.

7.The septum is then opened inferiorly with the Colorado needle or Westcott scissors 6 to 8 mm below the eyelid margin, exposing the preaponeurotic fat (Fig. 3.9B).

8.The lower eyelid retractors are identified beneath the fat.

9.The tarsus is not specifically exposed

10.The retractors are then carefully dissected from the underlying conjunctiva 1 to 2 mm below the tarsus with Westcott scissors, avoiding the inferior tarsal vascular arcade (Fig. 3.9C).

11.The retractors are then held and the patient instructed to look down (Fig. 3.10). An inferior pull on the capsulopalpebral fascia should be felt.

12.A 1 mm strip of fascia is removed with Westcott scissors, shortening the retractors vertically.

13.Next, two to three interrupted 5/0 Vicryl sutures are used to reattach the lower lid retractors to the inferior border of the tarsus, avoiding the medial

aspect of the eyelid to avoid creating a medial punctal ectropion (Fig. 3.11). When these are tied, the lower eyelid should now have a minimal degree of central and lateral ectropion. If a tarsal strip procedure is not going to be used it is important to avoid creating more than a minimal degree of overcorrection. The traction suture is removed.

14.Next a lateral tarsal strip procedure is performed (see below). The eyelid should be tightened sufficiently to bring the eyelid in apposition with the globe.

Lateral tarsal strip procedure

1.A lateral canthotomy is performed using straight blunt-tipped scissors (Fig. 3.12A). The canthotomy is extended to the lateral orbital rim. (A Colorado needle can be used instead if available.)

2.The lower eyelid is then lifted in a superotemporal direction and the inferior crus of the lateral canthal tendon is cut using blunt-tipped Westcott scissors (Fig. 3.12B and C).

3.The septum is also freed with the Westcott scissors until the eyelid becomes loose. Care is taken to avoid excessive bleeding using bipolar cautery. It is easier to perform the initial steps of this procedure sitting at the head of the patient. It is then preferable to move to the side of the patient to complete the remainder of the procedure.

4.Once the lower eyelid has been freed of its canthal attachments, the anterior and posterior lamellae are split along the gray line using Westcott scissors (Fig. 3.12D). This is aided by holding the skin and orbicularis muscle taut at the lateral end of the eyelid with Paufique forceps.

5.The lateral tarsal strip is then formed by cutting along the inferior border of the tarsus (Fig. 3.13A). Next, the eyelid margin is excised (Fig. 3.13B).

6.The tarsal strip is then drawn to the lateral orbital margin to determine the extent of any redundant tarsal strip. This is then excised.

7.The tarsal strip is then positioned over the handle of a Paufique forceps with the conjunctival side exposed and the conjunctiva scraped from the tarsal strip using a no. 15 blade (Fig. 3.13C and D). Alternatively this can be achieved by the gentle application of bipolar cautery using a sweeping motion.

8.The redundant anterior lamella is excised with the Westcott scissors (Fig. 3.14A and B).

9.Next, a double-armed 5/0 Vicryl suture on a 1/2-circle needle is passed through the periosteum of the lateral orbital wall, the needles each being passed from inside the orbital rim exiting at the rim, leaving a loop (Fig. 3.14C).

10.The end of the tarsal strip is passed through the loop. The needle is then reverse mounted and passed from the under surface of the tarsal strip exiting on the anterior surface lateral to the loop.

This is repeated with the second needle. As the suture is pulled, the loop is then tightened, drawing the tarsal strip in a posterior direction against the globe (Fig. 3.14D and E).

11. The suture is then tied avoiding excessive tension.

buried followed by interrupted 7/0 Vicryl sutures to the skin wound.

14.Antibiotic ointment is instilled into the eye, and if there has been much oozing, a compressive dressing can be applied.

and lower eyelids reforming the angle of the lateral commissure.

13.The subciliary wound is closed with interrupted 7/0 Vicryl sutures. The lateral canthal wound is then closed using 1 or 2 7/0 Vicryl sutures subcutaneously ensuring that the 5/0 Vicryl suture is

tions to place topical antibiotic ointment along the lower eyelid and lateral canthal wound three times a day for 2 weeks. If a dressing was applied, this is removed the following day. The patient should be instructed to sleep with the head elevated for 2 weeks. Cool packs can be applied intermittently for 24 to 48 hours to reduce swelling. Any residual sutures can be

removed in clinic 2 to 3 weeks postoperatively if still present. The patient can, however, be discharged following the surgery as the sutures will eventually dissolve over the course of 3 to 4 weeks.

Lower Lid Retractor Advancement with Lower Lid Wedge Resection

Surgical procedure

1.Proxymethacaine drops are instilled into the inferior conjunctival fornix.

2.Two to three milliliters of 0.5% Bupivacaine with 1:200,000 units of adrenaline mixed 50:50 with 2% lidocaine with 1:80,000 units of adrenaline are injected immediately under the skin in the

lower eyelid avoiding bleeding from the orbicularis muscle and a hematoma.

3.The retractor dissection proceeds in the same manner as described above to the point at which the lower lid retractors have been dissected from the underlying conjunctiva.

4.Next the lower lid margin is incised vertically for 2 mm at the junction of the lateral third with the medial two-thirds of the eyelid using a no. 15 Bard Parker blade (Fig. 3.15A and B).

5.Straight iris scissors are then used to complete a vertical cut through the tarsus.

6.The edges of the eyelid wounds are then grasped with Paufique forceps and overlapped without undue tension.

86

7.The redundant eyelid to be removed is marked with gentian violet.

8.The eyelid margin is again incised with a no. 15 Bard Parker blade and straight iris scissors are then used to complete a vertical cut through the tarsus.

9.The scissors are then angulated at 45° to complete the wedge resection.

OCULOPLASTIC SURGERY

10.Hemostasis is obtained with bipolar cautery.

11.The tarsus is repaired using interrupted 5/0 Vicryl sutures ensuring that the sutures do not pass through the tarsal conjunctiva.

12.The first Vicryl suture is passed just below the lid margin and is tied with a single throw to ensure that the eyelid margin is correctly aligned. If this is not the case the suture is removed and replaced.

LOWER EYELID ENTROPION

13.The Vicryl suture is then pulled up and fixated to the head drapes with a curved artery clip. This makes it easier to place the remaining tarsal sutures.

14.The rest of the tarsus is reapproximated using interrupted 5/0 Vicryl sutures.

15.The orbicularis muscle below the tarsus is also reapproximated using interrupted 5/0 Vicryl sutures.

16.Next the superior Vicryl suture is tied.

87

17.The eyelid margin is repaired with 2 6/0 Silk sutures passed along the lash line and along the line of the meibomian gland orifices (see also Fig. 10.10C and D) in a vertical mattress fashion.

18.The silk sutures are tied creating a slight eversion of the eyelid margin wound edges. The ends are left long.

19.Next a 1 mm strip of eyelid retractor fascia is removed with Westcott scissors, shortening the retractors vertically.

LOWER EYELID ENTROPION

20.Next two to three interrupted 5/0 Vicryl sutures are used to reattach the lower lid retractors to the inferior border of the tarsus, avoiding the medial aspect of the eyelid to avoid creating a medial punctal ectropion. When these sutures are tied, the lower eyelid should be in apposition to the globe without any ectropion.

21.The subciliary skin wound is then closed using interrupted 7/0 Vicryl sutures although the remaining 6/0 Silk suture can also be used.

22.The vertical skin incision is closed with the same sutures.

23.The eyelid margin silk sutures are moistened with saline and laid over the lower lid skin. These are then incorporated into the vertical skin closure sutures to ensure that the silk suture is kept away from the cornea postoperatively.

24.A compressive dressing is applied.

Postoperative care. The patient is discharged with instructions to place topical antibiotic ointment along the lower eyelid wound three times a day for 2 weeks. The compressive dressing is removed after 24 to 48 hours. The patient should be instructed to sleep with the head elevated for 2 weeks. Cool packs can be applied intermittently for 24 to 48 hours to reduce swelling. The sutures are removed in clinic 2 weeks postoperatively.

Complications

These procedures have an extremely low recurrence rate and minimal morbidity in the hands of an experienced oculoplastic surgeon. The many potential complications of these procedures can be avoided by careful patient selection, by a good knowledge of surgical anatomy, and by attention to appropriate hemostasis and meticulous surgical technique:

1.Granuloma

2.Wound dehiscence

3.Hematoma

4.Infection

5.Ectropion

6.Lateral canthal discomfort

7.Overlapping of the upper eyelid

8.Eyelid notch

9.Trichiasis

10.Corneal ulcer

11.Recurrence of entropion

12.Lateral canthal angle deformity

A lateral canthal granuloma following a lateral tarsal strip procedure is seen when a permanent suture has been used to fixate the tarsal strip e.g., an Ethibond suture, and this has not been completely buried. This problem is very rarely seen when a dissolvable suture, e.g., a Vicryl suture, is used instead.

Before performing a wedge resection the surgeon should determine the precise amount of eyelid, which can be safely sacrificed without leaving the wound under tension. If the eyelid wound is under too much tension or if the sutures are tied too tightly causing strangulation of the wound edges, the wound is more likely to dehisce.

A hematoma or excessive postoperative edema places the wound at risk of breakdown. These are avoided by the preoperative

89

management of hypertension, the avoidance of antiplatelet agents, meticulous dissection, and careful use of bipolar cautery, and by the postoperative use of a compressive dressing.

A notch and trichiasis are avoided by meticulous attention to the apposition of the wound edges and the use of vertical mattress sutures through the eyelid margin. A corneal ulcer is avoided by careful placement of the eyelid margin sutures.

Great care needs to be taken over the placement of the periorbital fixation suture in the lateral tarsal strip procedure. This should engage the periorbita just inside the lateral orbital wall at the junction with the upper eyelid to avoid anterior displacement of the eyelid from the globe and lateral canthal dystopia. If the upper eyelid is very lax, there may be an unsightly overlap of the upper eyelid over the lower eyelid if the lateral tarsal strip is over tightened. The patient should be warned preoperatively that the lateral canthal area will be sore and lumpy to touch for the first few weeks following surgery until the suture dissolves. The suture causes a local periostitis and a sensitive wound.

Cicatricial Entropion

The choice of surgical procedure for the management of a lower lid cicatricial ectropion is dictated by the severity of the entropion and eyelid retraction and by the underlying cause. In the case of a cicatricial entropion caused by ocular cicatricial pemphigoid, surgery should be confined to the anterior lamella wherever possible to avoid exacerbating the conjunctival disease.

The surgical procedures that may be used are:

1.Retractor advancement

2.Tarsal fracture

3.Posterior lamellar graft

Retractor Advancement

This procedure is particularly useful for patients with active conjunctival disease or ocular cicatricial pemphigoid. A retractor advancement is used alone without any horizontal eyelid shortening. The retractor advancement can be repeated if the entropion recurs.

Surgical procedure. This is as described above.

Postoperative management. This is as described above.

Tarsal Fracture

This procedure is indicated for patients with a mild cicatricial entropion with a minor degree of lower lid retraction.

Surgical procedure

1.Proxymethacaine drops are instilled into the inferior conjunctival fornix.

2.Two to three milliliters of 0.5% Bupivacaine with 1:200,000 units of adrenaline mixed 50:50 with 2% lidocaine with 1:80,000 units of adrenaline are injected immediately under the skin in the lower eyelid avoiding bleeding from the orbicularis muscle and a hematoma. A small quantity of the local anesthetic solution is also injected subconjunctivally just below the tarsus.

3.A 4/0 Silk traction suture is placed horizontally through the gray line of the lower eyelid centrally and the eyelid is everted over a Desmarres retractor.

90

4.A horizontal incision is made through the whole length of the tarsus on the posterior surface of the eyelid just below its center down to the deep surface of the orbicularis muscle (Fig. 3.16A).

5.Three or four double-armed 5/0 Vicryl sutures are passed through the tarsus just below the incision and through the eyelid to emerge through the skin just below the lash line (Fig. 3.16B). These sutures are tied to produce a moderate ectropion (Fig. 3.16C and D).

Postoperative care. The patient is discharged with instructions to instill topical antibiotic ointment into the eye three

OCULOPLASTIC SURGERY

times a day for 2 weeks. The patient should be instructed to sleep with the head elevated for 2 weeks. Cool packs can be applied intermittently for 24 to 48 hours to reduce swelling. The sutures are removed in clinic 3 weeks postoperatively.

Posterior Lamellar Graft

A posterior lamellar graft is indicated for the patient with a more severe degree of cicatricial entropion with more marked eyelid retraction. A hard palate graft is preferred. The procedure is usually performed under general anesthesia although in carefully selected patients it can be performed under local anesthesia with sedation.

LOWER EYELID ENTROPION

Surgical procedure

1.Two to three milliliters of 0.5% Bupivacaine with 1:200,000 units of adrenaline mixed 50:50 with 2% lidocaine with 1:80,000 units of adrenaline are injected immediately under the skin in the lower eyelid avoiding bleeding from the orbicularis muscle and a hematoma. A small quantity of the local anesthetic solution is also injected subconjunctivally just below the tarsus.

2.A 4/0 Black silk traction suture is placed horizontally through the gray line of the lower eyelid centrally and the eyelid is everted over a Desmarres retractor.

3.A horizontal incision is made through the whole length of the tarsus on the posterior surface just below its center down to the deep surface of the orbicularis with a no. 15 blade.

4.The inferior margin of the tarsus is freed from the eyelid retractors and the orbital septum using blunttipped Westcott scissors.

5.The ensuing defect is measured and a slightly oversized hard palate graft is harvested.

6.The hard palate graft is carefully prepared by removing any uneven or excessive submucosal tissue with Westcott scissors.

7.Three or four double-armed 5/0 Vicryl sutures are passed in a partial thickness fashion through the hard palate graft and passed through the full thickness of the eyelid. These are tied just below the lash line to evert the eyelid margin and to maintain the graft in apposition to its bed.

8.The edges of the graft are sutured to the cut edge of the tarsus superiorly and the recessed edges of the conjunctiva inferiorly with interrupted 8/0 Vicryl sutures ensuring that the sutures are buried to avoid corneal irritation or a corneal abrasion.

9.Topical antibiotic ointment is applied to the eye and eyelids and a compressive dressing applied.

Postoperative management. The patient is discharged on an oral broad-spectrum antibiotic for 1 week. The patient should be reviewed 5 days postoperatively when the dressing is removed and the eyelids meticulously cleaned. Topical

91

antibiotic ointment should be instilled in the eye three times a day for 2 weeks. Cool packs can be applied intermittently for 24 to 48 hours to reduce swelling. The patient should be instructed to sleep with the head elevated for 2 weeks. The 5/0 Vicryl sutures are removed 2 weeks postoperatively.

Complications

1.Corneal abrasion

2.Corneal ulcer

3.Hematoma

4.Necrosis of the hard palate graft

5.Infection

6.Recurrence of the entropion

These potential complications can be largely avoided. The cornea should be protected intraoperatively, and adequate and frequent lubrication should be applied. If the potential development of a suture abrasion is a concern, a bandage contact lens can be used. The graft should be firmly attached to its bed to prevent a hematoma from collecting beneath it. A hematoma or movement of the graft can lead to graft failure.

Congenital Entropion

A congenital entropion is managed under general anesthesia

(Fig. 3.17).

Retractor Advancement

Surgical procedure

1.Two to three milliliters of 0.25% Bupivacaine are injected immediately under the skin in the lower eyelid avoiding bleeding from the orbicularis muscle and a hematoma.

2.A 4/0 Silk traction suture is placed horizontally through the gray line of the lower eyelid centrally and fixated to the head drapes using a small artery clip.

3.A skin incision is then made immediately below the lashes, as in a cosmetic lower lid blepharoplasty, extending from just below the inferior punctum to the lateral aspect of the lower eyelid using a Colorado needle.

4.Hemostasis is obtained using bipolar cautery.

5.The Colorado needle is then used to dissect through the orbicularis oculi muscle exposing

the orbital septum. The orbicularis muscle is then dissected away from the underlying orbital septum for 4 to 5 mm.

6.The septum is then opened inferiorly with the Colorado needle or Westcott scissors 5 to 6 mm below the eyelid margin, exposing the preaponeurotic fat.

7.The lower eyelid retractors are identified beneath the fat. The retractors may be found to be disinserted from their attachment to the tarsus.

8.The tarsus is not specifically exposed

9.The retractors are then carefully dissected from the underlying conjunctiva 2 to3 mm below the tarsus with Westcott scissors, avoiding the inferior tarsal vascular arcade.

10.No shortening of the retractors is required.

11.Next, two to three interrupted 5/0 Vicryl sutures are used to reattach the lower lid retractors to the inferior border of the tarsus, avoiding the medial aspect of the eyelid to avoid creating a medial punctal ectropion (Fig. 3.18A). When these are tied, the lower eyelid should not have any degree of ectropion.

12.A very conservative resection of a strip of skin and orbicularis muscle may be required (Fig. 3.18B). No eyelid shortening is normally required.

13.The skin is closed with interrupted 7/0 Vicryl Rapide sutures.

Figure 3.19 A congenital epiblepharon.

Postoperative care. No dressings are required. The parent is advised to clean the wound three times a day with cotton wool moistened with sterile saline or cooled boiled water and to apply topical antibiotic ointment three times a day until all the sutures have dropped out spontaneously. This usually takes 2 to 3 weeks.

Congenital Epiblepharon

A congenital epiblepharon is an excess fold of skin and orbicularis muscle in the medial aspect of the lower eyelid (Fig. 3.19). Epiblepharon can cause the eyelashes to invert against the globe, and can be unilateral or bilateral. The management of this condition should be conservative, as spontaneous

LOWER EYELID ENTROPION

improvement typically occurs with age, and eyelashes in an infant tend to be very soft. If, however, the child suffers from tearing, photophobia, and discomfort with corneal abrasions caused by the lashes, surgical intervention is warranted. The procedure is performed under general anesthesia.

Surgical procedure

1.One to two milliliters of 0.25% Bupivacaine are injected immediately under the skin in the lower eyelid avoiding bleeding from the orbicularis muscle and a hematoma.

2.A 4/0 Silk traction suture is placed horizontally through the gray line of the lower eyelid centrally and fixated to the head drapes using a small curved artery clip.

3.A skin incision is then made immediately below the lashes, extending from just below the inferior punctum to the junction of the lateral third with the medial two-thirds of the eyelid using a Colorado needle.

4.Hemostasis is obtained using bipolar cautery.

5.The Colorado needle is then used to dissect a 4 to 5 mm skin-muscle flap from the orbital septum.

6.The traction suture is released and reapplied with very gentle tension.

7.The skin–muscle flap is draped over the eyelid margin and the excess skin and muscle is very carefully excised with Westcott scissors, taking great care not to excise too much tissue.

8.If the eyelid margin is still inverted the eyelid retractors can be dissected free, advanced, and sutured to the lower border of the tarsal plate with a single 6/0 Vicryl suture until the eyelid margin is normally positioned.

9.The skin edges are then reapproximated with interrupted 7/0 Vicryl Rapide.

93

Postoperative management. This is as described above for congenital entropion.

further reading

1. Albert DM, Lucarelli MJ: Entropion. In: Clinical Atlas of Procedures in Ophthalmic Surgery, Chicago, MI: AMA Press, 2004: 257−60.

2. American Academy of Ophthalmology. Basic and Clinical Science Course: Orbit, Eyelids, and Lacrimal System, section 7.. San Francisco, CA: The American Academy of Ophthalmology, 2006/7: 201–5.

3. Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol 1979; 97: 2192–6.

4. Dutton JJ. Atlas of clinical and surgical orbital anatomy. Philadelphia, PA: WB Saunders, 1994.

5. Goldberg, et al. Entropion Repair. In: Wobig JL, Dailey RA, eds. Oculoplastic Facial Plastic Surgery: Face, Lacrimal System, and Orbit. New York, NY: Thieme, 2004: 91–7.

6.Hawes MJ, Dortzbach RK. The microscopic anatomy of the lower eyelid retractors. Arch Ophthalmol 1982; 100: 1313–18.

7. Jones LT, Rech MJ, Wobig JL. Senile entropion: a new concept for correction. Am J Ophthalmol 1972; 74: 327–9.

8. Katowitz JA, Heher KL, Hollsten DA: Involutional entropion. In: Levine MR, ed. Manual of Oculoplastic Surgery, 3rd edn. Boston, MA: Butterworth-Heinemann, 2003: 137–44.

9. Kersten RC, Kleiner FP, Kulwin DR. Tarsotomy for the treatment of cicatricial entropion with trichiasis. Arch Ophthalmol 1992; 110: 714.

10. Martin RT, Nunery WR, Tanenbaum M. Entropion, trichiasis, and distichiasis. In: McCord CD, Tanenbaum M, Nunery WR, eds. Oculoplastic Surgery, 3rd edn. New York, NY: Raven Press, 1995: 221–48.

11. Nerad JA, Carter KD, Alford MA. Entropion. In: Rapid Diagnosis in Ophthalmology—Oculoplastic and Reconstructive Surgery Philadelphia, PA: Mosby Elsevier, 2008: 92–5.

12. Penne RB. Entropion. In: Color Atlas & Synopsis of Clinical Ophthalmology: Oculoplastics. New York, NY: McGraw-Hill, 2003: 56–61.

13. Wesley RE. Cicatricial entropion. In: Levine MR, ed. Manual of Oculoplastic Surgery, 2nd edn. Boston, MA: Butterworth-Heinemann, 1996: 129–34.

14. Wesley RE. Cicatricial entropion. In: Levine MR, ed. Manual of Oculoplastic Surgery, 3rd edn. Boston, MA: Butterworth-Heinemann, 2003: 145–50.

15. Wright M, Bell D, Scott C, Leatherbarrow B. Everting suture correction of lower lid involutional entropion. Br J Ophthalmol 1999; 83: 1060–3.