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8.4 Temporary Lower Lid Involutional Entropion Management 77
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patient blinks. If it does not, ask the patient to squeeze their eyes tightly shut to
see whether this triggers entropion recurrence.
8.4 Temporary Lower Lid Involutional Entropion
Management
8.4.1 Taping
Teach the patient to apply a strip of adhesive tape to the lower lid skin, just below
the lashes, to pull the skin downwards towards the cheek. This additional pull
on the lid margin may temporarily control the entropion while the patient awaits
surgery.
8.4.2 Botulinum Toxin
A single subcutaneous injection of botulinum toxin (10 units of Dysport®or 2.5
®
units of Botox
) to the pre-tarsal orbicularis at the junction of the lateral 1/3
and medial 2/3 of the lid temporarily paralyses the lower lid orbicularis and may
control a spastic entropion for several weeks (Fig. 8.3). It is not a permanent
solution but a useful temporising treatment of the spastic component while surgical
correction is being arranged. Paradoxically, it can make it harder to persuade a
patient of the need for surgical correction once their symptoms have temporarily
abated.
Dysport®10 units or
Botox® 2.5 units
1/3
2/3
Fig. 8.3 Botulinum toxin entropion relief. Paralyse the pretarsal orbicularis with a subcutaneous
injection of botulinum toxin
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8.4.3 Everting (Quickert) Sutures
Absorbable 6/0 sutures placed obliquely through the lid, from the conjunctival
surface just below the tarsal plate to emerge on the skin just below the lashes
(Fig. 8.4), will temporarily stop the orbicularis from overriding and may tighten
the lower lid retractors and so prevent the entropion from occurring. In my hands
the effectiveness of everting sutures is short lived, lasting only as long as the
sutures themselves. I consider them to be a temporizing manoeuvre. However,
some authors have reported longer lasting success (78% at 18 months) [1].
a
b
Fig. 8.4 Quickert everting sutures. a. Insert three double armed absorbable sutures transconjuncti-
vally from the lower fornix to exit the skin 3–4 mm below the lash line. b. The tied sutures transfer
the lower lid retractor pull to the anterior lamella and create a barrier to orbicularis overriding
8.6 Lateral Lid Margin Resection and Modified Bick Repair (Fig. 8.7) 79
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8.5 ‘Permanent’ Surgical Correction of Involutional
Entropion
8.5.1 Principle
Surgical correction of lower lid involutional entropion requires:
1. tightening of a lax lid margin,
2. reinsertion of dehisced lower lid retractors into the anterior lamella, and
3. preventing the pre-septal orbicularis from overriding pre-tarsally.
‘Permanent’ is used loosely in this context as the aging that caused the involutional
entropion is not stopped by surgery. In my experience, effective surgery prevents
entropion recurrence for a minimum of 5 years and usually much longer. If your
corrections fail sooner review your surgical technique.
The above three factors are all corrected by the well described Quickert ‘four
snip’ entropion correction procedure [2] (Fig. 8.5). The shortening of the lid margin can be performed more elegantly at the lateral canthus using a Bick resection/
repair, and the retractor plication under direct vision can be performed without
breaching the conjunctiva as described below (Fig. 8.6). I describe these two components separately although you will perform both together for most entropion
corrections.
8.5.2 The Lid Shortening Rule
As a rule of thumb, shortening a lid margin by less than 5 mm verges on homeopathy. In contrast, never shorten by more than 15 mm because you will have missed
a canthal tendon dehiscence which must be corrected first.
8.6 Lateral Lid Margin Resection and Modified Bick Repair
(Fig. 8.7)
8.6.1 Principle and Considerations
Relative lid/globe laxity is a usual pre-requisite for involutional entropion to occur.
The simplest surgical remedy is to shorten the lid margin. Only undertake shortening once you have confirmed the integrity of the medial and lateral canthal
attachments. Address any dehiscence of these before attempting to shorten the lid.
Combine lid shortening with a retractor plication.
8.6.2 Case Selection
Involutional entropion without canthal tendon laxity.
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a b
c d
e
Fig. 8.5 Quickert entropion correction. a. Pull the lid down to correct the entropion. b.Markand
incise a horizontal incision 4–5 mm below the lash line and a vertical incision from the lid margin to
meet it. c. Overlap the resulting lid margin flaps and mark and excise the excess. d Insert 3 double
armed sutures transconjunctivally to pick up the lower lid retractors. Then repair the lid margin.
e Bring the retractor sutures out through the orbicularis and skin 2 mm below the lash line. f Tie
the retractor sutures tightly and close the horizontal skin wound
f
8.6.3 Steps
1. Load two double ended 6/0 absorbable sutures onto locking needle holders and
prepare them for instant use.
2. Grab the full-thickness lid margin laterally with Adson’s forceps and place
the lateral canthus on stretch by pulling the lid medially. Detach the lower lid
margin from the lateral canthus by cutting infero-laterally at 45° from the lateral
canthus for approximately 5–8 mm with Steven’s tenotomy scissors (Fig. 8.7b).
8.6 Lateral Lid Margin Resection and Modified Bick Repair (Fig. 8.7) 81
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a b
5 mm
c d
e
Fig. 8.6 Entropion correction. a Incise the skin and orbicularis. b Find and tag the lower lid retrac-
tors with 3 double armed absorbable sutures. c Shorten the lid margin laterally. d Repair the lateral
defect to tighten the lid margin. e Bring the retractor sutures out through the skin edges. f Tie the
sutures to simultaneously close the skin, plicate the retractors and create a barrier to orbicularis
overriding. Consider adding a continuous skin suture between the retractor suture knots
f
Note: Cut slowly to crush the vessels and reduce bleeding.
3. Without delay (before the bleeding starts) grab the exposed cut lateral canthal
tendon with toothed forceps (St Martins) and insert the first of the two pre-
mounted double armed 6/0 sutures as close to the canthus as possible. Before
letting go, insert the second arm of the suture 1 mm below the first. Confirm
a strong purchase by tugging the suture ends firmly. There should be no give.
Clip the pair of suture ends together with a bulldog clipboard (Fig. 8.7c).
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a b
c
d
e f
g h
i j
Fig. 8.7 Bick resection. a Pull the lid down to correct entropion and mark incision at the lateral
canthus. b Cut the full thickness of the lid infero-laterally to detach it from the canthus. c Preplace two lateral canthal tendon absorbable sutures. d Overlap the cut edges to mark the excess
lid margin. e Excise the excess lid margin. f Reattach the tarsal plate with the preplaced sutures.
g Insert a margin closing 7/0 absorbable horizontal mattress suture. h Tighten and tie the tarsal
plate sutures. i Tighten and tie the lid margin suture to bury the knot. j Close the orbicularis and
skin
8.6 Lateral Lid Margin Resection and Modified Bick Repair (Fig. 8.7) 83
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Note: An assistant is required to spread the canthal tissues apart to improve
visualization.
4. Place the second 6/0 suture 2 mm below the first in a similar fashion and again
confirm strong fixation. If there is any ‘give’ replace the suture more deeply.
Clip both ends together.
5. Ask an assistant to pull the upper of the two lateral canthal tendon sutures
medially to put the lateral canthus on medial stretch. Grasping the cut lateral
edge of the lid margin with toothed Adson’s forceps, pull it laterally to overlap
the taut lateral canthus until the lid margin is straight and mark the extent of
the overlap with a surgical marking pen (Fig. 8.7d). Measure this overlap. It is
normally between 7 to 15 mm. In the unlikely event that it is less, there was
either no lid margin laxity or the lid was not being pulled firmly enough. If
greater than 15 mm, undiagnosed medial canthal laxity is present and needs
to be treated before continuing.
6. Excise the excess lid margin as a triangle or pentagon, with tenotomy scissors
(Fig. 8.7e).
7. Insert the two pairs of pre-placed LCT 6/0 sutures in sequence through the
cut edge of the tarsal plate, starting with the uppermost (Fig. 8.7f). Insert
them from behind, trans-conjunctively, through the full thickness of the tarsal
plate, exiting through its anterior surface and bring them out of the wound
edge. Avoid engaging the orbicularis or skin. Place each subsequent suture
about 1 mm below the previous one. Clip the corresponding pairs of sutures
together again, temporarily. This results in the shortened lid being reattached
by the two horizontal mattress sutures.
8. Before tying the above sutures, place a single ended 7/0 absorbable suture in
the lid margin as a horizontal mattress (Fig. 8.7g). This time insert the suture
through the orbicularis to exit the skin through the lash line, 1–2 mm from the
wound edge.
9. Then, with the same needle, re-enter the lid through the meibomian orifice line
and exit through the cut tarsal plate edge just above the top, already placed,
6/0 suture bite (taking care not to inadvertently engage it with your needle).
10. Now enter the lateral canthal wound with the same needle, engage the upper
lid tarsal plate, and bring the needle out through the meibomian orifice line
1–2 mm from the lateral canthus.
11. Re-enter the upper lid lash line and exit the wound through orbicularis to
complete this lid margin mattress suture. Clip its two ends together.
12. Now that you have placed the sutures under direct vision, pull the ends of the
lower of the two 6/0 sutures laterally (Fig. 8.7h). Use their pulley action to
pull the lid margin laterally towards the LCT to close the posterior lamella.
Tie the suture with no less than three throws and cut the ends no shorter that
2 mm (to prevent spontaneous unravelling).
13. Tighten, tie and cut the upper 6/0 suture similarly.
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14. Tie the 7/0 pre-placed margin suture (Fig. 8.7i). This will align the lid margin
at the lateral canthus. Cut the ends flush with the skin so that the knot becomes
buried and does not irritate.
15. Close the remaining anterior lamellar defect with two or three horizontal
mattress 7/0 absorbable sutures through the skin and orbicularis (Fig. 8.7j).
8.6.4 Notes
•
The tightened lid margin may slip below the globe appearing retracted. This is
usually only temporary and resolves within a couple of weeks.
•
In Bick’s original procedure the lid margin is crushed before cutting to reduce
bleeding. This advantage is gained at the expense of clear visualization of the
epithelial surfaces and makes an accurate two lamellar repair more difficult.
•
For entropion repair, the lid margin shortening is usually combined with a
retractor plication (Fig. 8.8). Pre-place the retractor sutures before performing the lid margin resection but do not bring them through the skin until the lid
shortening is complete to avoid horizontal misalignment.
8.7 Lower Lid Retractor Plication (Fig. 8.8)
8.7.1 Principle and Considerations
In humans lower lid retraction in down gaze is achieved by a fibrous connection
between the inferior rectus muscle and the eyelid. It is known as the capsulopalpebral head or aponeurosis of the inferior rectus (the lower lid has no distinct
retractor muscle analogue to the upper lid levator palpaebri superioris). A secondary effect of the retractor is to stabilize the lower edge of the tarsal plate.
Laxity of this retractor, through stretching, dehiscence, or relative laxity from
enophthalmos, may render the eyelid margin unstable. Dehiscence of only the
anterior lamellar attachment allows the pull of the posterior lamellar attachment
to pull the lid margin inwards. Surgically re-attaching the retractor to the anterior
lamella works dynamically pulling the lid margin outwards each time the retractors
pull.
Additionally, anterior approach retractor plication prevents orbicularis overriding by creating a surgical barrier scar that separates the pre-tarsal from the
pre-septal orbicularis (a passive mechanism). Always combine plication with a
concurrent lid margin tightening unless you have a strong reason not to [3].
8.7 Lower Lid Retractor Plication (Fig. 8.8)85
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a
c
White line
Retractor aponeurosis
Septum & Pre-apo fat
b
5 mm
d
e f
g h
Fig. 8.8 Lower lid retractor plication. a Pull the lid down to unroll any margin entropion. b Keep-
ing the skin on a downward stretch, incise the skin and orbicularis horizontally 5 mm below the
lash line. c Bluntly dissect the septum and fat pad infero-posteriorly to reveal the retractor aponeu-
rosis. d Grab the aponeurosis fold (‘white line’) and insert a suture centrally. e Place two more
white line sutures. f For each suture bring one end out through the upper and the other through the
lower edge orbicularis and skin. g Tie the white line sutures tightly. h Close the skin between the
retractor sutures and cut them flush with the lid margin
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8.7.2 Case Selection
Involutional entropion if combined with a lid tightening.
8.7.3 Steps
1. Place the lower lid skin on a gentle downward stretch (Fig. 8.8a) and make
a horizontal incision through the lower lid skin and orbicularis approximately
5 mm below the lash line (Fig. 8.8b).
2. Bluntly separate the deeper tissues downwards, retracting and pushing the
orbital septum and underlying fat pad posteriorly with a cotton bud while
stretching the lid margin upwards. This reveals a whitish sheet of tissue and
often a ‘white line’ where the aponeurosis reflects on itself (Fig. 8.8c).
3. Grab the ‘white line’ with toothed forceps centrally (in the mid-pupillary
line) and tag it with a double armed 6/0 absorbable suture (e.g., polygalactin)
(Fig. 8.8d).
4. While asking the patient to look up with both eyes open, take up any slack in
the suture and hold it under gentle tension between the thumb and forefinger.
Then ask the patient to look downward as far as possible. You should feel a
tug on the suture, positively confirming that it is anchored in the retractors. If
you do not feel a tug, try again, but this time instruct the patient to follow your
other hand in a downward arc, to ensure that you elicit full down gaze. If there
is still no pull, then the suture is not anchored in the retractors, and you need
to replace it following further dissection.
5. Place two similar sutures, one on either side at about 5 mm from the central
suture. Keep each pair of suture ends together with a bulldog clip until all three
are placed (Fig. 8.8e).
6. At this point perform full thickness lid margin shortening if necessary (see Bick
repair above).
7. At the end of the operation (after any lid margin resection) pass one end of
each pair of retractor placation sutures through the superior and inferior skin
edges respectively (Fig. 8.8f).
8. Tie them across the wound. They both close the wound and create a skin crease
which deepens when the patient looks downward. Do not cut the suture ends at
this stage but clip them together again (Fig. 8.8g).
9. Finally, close the skin incision further with a continuous absorbable 7/0 suture,
placing a bite between each of the retractor sutures and a knot at either end
(Fig. 8.8h). Cut the retractor sutures flush with the lid margin. This leaves their
ends long enough to grasp easily should a suture need early removal.
Note: In the unlikely event that you discover an overcorrection the next day (a lid
margin ectropion) remove the retractor suture(s) which appears to be responsible.
You may do this safely as the continuous skin suture will prevent the wound from
re-opening.
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