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66 6 Eyelid Malposition
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6.4 Assessment
Note the following:
1. The lid margin appearance, contour, lash and meibomian orifice orientation,
and the symmetry between the two eyes.
2. The eyelid movement in various gaze positions.
3. The strength of forced eyelid closure.
4. The presence of masses or tethering.
5. Internal or external scarring.
6.5 Significance
Eyelid malpositions affect function and appearance. With upper lid ptosis the lid
margin can occlude the visual axis and impair vision. With lesser degrees of ptosis, the affected eye appears smaller, attracting unwelcome attention. Conversely,
eyelid retraction increases corneal exposure, giving rise to discomfort and a staring
look. Always ask yourself whether you are observing true ptosis or contralateral
lid retraction. The latter can cause a pseudo ptosis thanks to Hering’s law of equal
innervation.
Entropion allows lash and skin keratin contact with the cornea causing irritation and potentially corneal ulceration and scarring. Ectropion, on the other hand,
causes little discomfort or risk to vision. Instead, increased watering, and redness
and crusting of the exposed conjunctival lid surface are the commonest complaints.
6.6 Causation
Aging is by far the commonest cause of eyelid malposition in temperate climates.
It leads to weakening of connective tissues and deflation of the mid face and orbit
resulting in relative eyelid laxity against the now enophthalmic eye as already
mentioned.
The exact mechanism of individual malpositions is still debated. Why for
example are the signs of involutional ptosis, contact lens wear related ptosis,
and Horner’s ptosis identical (normal levator function, raised skin crease and no
‘hang-up in downgaze)? Might Müller’s muscle failure be a common denominator? Apparent medial canthal tendon laxity could be a consequence of deflation,
dehiscence, or weakening of the posterior pull of Horner’s muscle.
6.7 Don’t Strip! 67
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6.7 Don’t Strip!
Eyelid tightening is an integral part of most entropion and ectropion correction.
If the canthal tendons are intact, it involves resection of part of the lid margin.
This may be carried out anywhere along the lid margin. Performing the resection
at the lateral canthus gives the best functional and aesthetic outcomes. There are
two ways of performing this: the lateral tarsal strip (LTS) (Fig. 6.3b) and the Bick
resection (BR) (Fig. 6.3c). They both achieve a similar initial outcome (Fig. 6.3d),
but the more complex LTS risks damaging the lateral canthal tendon and has a
higher complication rate [2], so avoid it.
Lateral canthopexy involves using a suture to suspend the lid from the lateral
orbital rim periosteum. It is used by some to temporarily tighten a lid e.g., after a
lower lid blepharoplasty. However, as minimal permanent scarring is induced, this
procedure soon fails through suture migration.
Note: Originally, the ‘lateral canthal sling’ operation was developed to correct
lateral canthal tendon weakness. Since being rebranded as the LTS it has become
the most popular lateral lid shortening procedure. This is unfortunate because the
LTS relies on burying a strip of the tarsal plate. The tarsal plate stretches, losing
effectiveness, and burying the meibomian glands it contains may cause granulomas.
a b
c d
Fig. 6.3 Lateral lid shortening options. a Full thickness, oblique, lateral canthal incision. b Lateral
tarsal strip (fashioned from the excess lid margin). c Lateral lid margin resection. d Result of both
looks similar. However, the LTS stretches with time
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6.8 Take Home Message
•
Eyelid position is determined by the sum of all the active and passive forces
acting on it.
References
1. Beigi B, Kashkouli MB, Shaw A, Murthy R (2008) Fornix fat prolapse as a sign for involutional
entropion. Ophthalmology 115(9):1608–1612
2. Vahdani K, Rebecca F, Garrott H, Thaller V (2018) Lateral tarsal strip versus Bick’s procedure
in correction of eyelid malposition. Eye 32. https://doi.org/10.1038/s41433-018-0048-9
Ingrowing Eyelashes
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Fig. 7.1 Epilation
Inwardly growing eyelashes are not only uncomfortable but can cause corneal
ulcers. The commonest cause is lid margin or conjunctival scarring which misdirects lash growth. We call this trichiasis (normal lashes growing in an abnormal
direction).
Rarely, individuals are born with an extra row of lashes growing from an
abnormal position such as from the meibomian glands. This is termed distichiasis.
Metaplastic lashes are abnormal lashes growing from an abnormal position as
a result of chronic inflammation.
7
7.1 Assessment
1. Is there a recognised reason for the lash line distortion, such as previous
trauma?
2. Establish whether the lid margin is correctly orientated by noting the position
of the meibomian orifice line. An entropion of the lid margin causes symptoms
similar to trichiasis but is treated differently.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
V. Th a l l e r, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_7
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70 7 I ngrowing Eyelashes
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3. Look for conjunctival scarring as the cause (cicatricial lash entropion). Unex-
plained symblepharon (abnormal connection between the palpaebral and bulbar
conjunctiva) is a red flag for cicatricial pemphigoid. It is best seen by pulling
the lid away from the eye and looking for conjunctival tethering.
4. Look for rounding of the posterior lid margin (seen in chronic staphylococcal
lid margin disease).
5. Check whether the lashes are being pushed inwards by an overhanging skin
fold. This might require a blepharoplasty.
6. Note the position and number of lashes involved.
7.2 Treatment Options
7.2.1 Epilation (Fig. 7.1)
Pulling the lashes out is worth trying on the first occasion if only a few lashes
are involved. Review the patient after 8 weeks to check whether the lashes have
regrown. Do not use epilation as a long-term treatment.
Note: If you fail to epilate the eyelash bulb the broken lash will regrow as sharp
stubble which is more dangerous for the cornea than a long bendy lash.
7.2.2 Electrolysis to the Lash Root
Passing a small electric current through the root can permanently destroy individual lashes if administered correctly. Because the lash roots are not visible it can be
difficult to be certain that you have positioned the electrolysis needle tip correctly
alongside the root. Overtreatment risks causing lid margin scarring and distortion
which can lead to further trichiasis of adjacent lashes. Therefore, use the lowest
current that causes bubbling for the shortest time that allows you to lift the lash out
without pulling. There is approximately a 50% treatment failure per lash treated
so warn the patient that the treatment may have to be repeated. For this reason,
reserve electrolysis for the treatment of isolated lashes.
7.2.3 Localized Full Thickness Lid Margin Resection
This is the most effective way of treating a clump of in turning lashes. It does
not leave a visible gap in the lash line but carries the risk of causing a lid margin
notch if not performed well.
7.3 Take Home Message 71
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7.2.4 Localized ‘en bloc’ Lash Resection
Resecting only the lash bearing anterior lamella is an effective and less invasive
alternative to full thickness resection but leaves a denuded lash free section on the
lid margin which patients may find less acceptable.
7.2.5 Lash Cryotherapy
This is very effective and avoids surgery. Use only a proprietary, calibrated, trichiasis cryoprobe, applying a double freeze/thaw cycle. The freeze timing is cryoprobe
dependent e.g., for the Cryo II Collins Trichiasis Pencil (Keeler) use two freeze
cycles each lasting for 25 s in the upper lid and for 20 s in the lower lid. Protect
the eye with an insulating shield as you do so. Cryotherapy destroys all the lash
roots treated. However, it also causes skin depigmentation, lid margin atrophy, and
occasionally full thickness lid margin necrosis (especially if the lid vascularity has
been compromised by previous surgery).
7.2.6 Anterior Lamellar Repositioning
This is the most effective and aesthetically acceptable treatment for trichiasis
involving 1/3 or more of the lid margin. (See Chap. 8).
7.3 Take Home Message
•
Repeated epilation is not a good long-term trichiasis treatment strategy.
Entropion
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8.1 Overview
•
Types of entropion
•
Entropion assessment
•
Lower lid involutional entropion:
temporary management and
permanent correction.
The lower lid is inherently less stable about its long axis than the upper lid, as
explained in Chap. 6. It flips inwards on minimal provocation giving rise to entropion. By contrast, upper lid margin entropion requires a sustained strong force,
such as that caused by conjunctival scarring, to cause margin entropion.
8
8.2 Types of Entropion
8.2.1 Congenital Entropion
Entropion present at birth is uncommon.
Lower lid entropion often resolves spontaneously as the mid-face develops.
Therefore, monitor a child who is happy and does not have a red eye or photophobia. By contrast, prompt surgical entropion correction is necessary for an unhappy,
photophobic child with a red eye watery eye. Excise a narrow horizontal strip
of skin and orbicularis from below the lash line, avoiding the lash roots. Form a
skin crease by including a bite of the inferior tarsal plate edge in the skin closing
sutures (Hotz repair Fig. 8.1).
Rarely, congenital entropion may be part of the ocular fibrosis syndrome
(associated with strabismus due to extraocular muscle fibrosis).
The tarsal kink syndrome is a rare form of upper lid entropion occurring when
the lid becomes folded in on itself in utero. Unnecessarily complex procedures have
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
V. Th a l l e r, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_8
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a b
c d
Fig. 8.1 Hotz repair for congenital lower lid entropion. a Lower lid congenital entropion. b Evert
the lower lid margin by pulling down and mark a narrow skin ellipse that avoids the lash roots (3–
4 mm below the lashes). Excise the marked ellipse of skin with the underlying orbicularis. c Place
3 or 4 absorbable 6/0 sutures across the defect ensuring that each includes a bite of the lower tarsal
plate edge. d Tie the sutures to close the wound and create a skin crease to prevent future orbicularis
overriding
a b
Fig. 8.2 Tarsal kink everting sutures. a Congenital tarsal kink is a rare condition in which the
upper tarsal plate is folded on itself at birth. b Place three absorbable everting sutures to permanently cure the problem
been described to treat it. Simply inserting temporary absorbable transcutaneous
lid everting sutures between the superior and inferior edges of the tarsal plate
effects a permanent cure (Fig. 8.2).
8.2.2 Involutional (Age Related) Entropion
Age is the commonest cause of lower lid entropion in temperate climates, consequently the focus of this chapter. A similar type of entropion can occur in younger
patients as the result of persistent eye rubbing.
8.2 Types of Entropion 75
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The factors requiring surgical correction are:
1. the relative laxity of the eyelid against the eye (lid-globe disparity),
2. lower lid retractor laxity or imbalance, and
3. the overriding of the pre-septal orbicularis to a pre-tarsal position.
Spastic entropion is a subset of involutional entropion. Corneal irritation provokes
reflex orbicularis contraction, which leads to in-turning of an unstable lid margin.
The irritation caused by the entropion perpetuates the squeezing and hence also
the entropion.
8.2.3 Cicatricial Entropion
The term ‘cicatricial’ implies scarring related. Any condition that causes conjunctival or sub-conjunctival shrinkage will pull the lid margin inwards. Either one or
both lids may be affected. The following are the most common causes.
8.2.3.1 Trachoma
Trachoma is a chronic infectious conjunctivitis caused by chlamydia trachomatis.
It causes progressive conjunctival scarring which leads to cicatricial entropion. The
entropion, in turn, leads to secondary corneal scarring and eventually to blindness.
It is endemic in parts of Africa, South America, Asia, and Australia, and is the
commonest cause of preventable blindness worldwide.
8.2.3.2 Chronic Staphylococcal Lid Margin Disease
This is the most common cause of cicatricial entropion in temperate climates. It
causes initial rounding of the normally angled posterior lid margin followed by
in turning of the meibomian orifice openings and then progressive lash/corneal
contact (Trichiasis).
8.2.3.3 Ocular Cicatricial Pemphigoid
Ocular cicatricial pemphigoid is a rare auto-immune condition giving rise to
recurrent conjunctival inflammation which results in scarring and shrinkage. It is
ultimately a blinding condition if not managed by effective immunosuppression.
The onset is insidious, and sadly it is often diagnosed too late. Unless you specifically look for it you will miss the diagnosis. Regard unexplained symblepharon
(abnormal attachment between the bulbar and tarsal conjunctiva) as cicatricial
pemphigoid until proved otherwise. Diagnostic conjunctival biopsy is advocated,
but it only has a 50% sensitivity. Conjunctiva breaching surgery accelerates the
condition, and any surgery, including biopsy, should be delayed until the patient
is effectively immunosuppressed. In my opinion the diagnosis remains a clinical
one.
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8.3 Entropion Assessment/Examination
8.3.1 Lid Tone and Laxity
Grasp the lower lid skin, close to the lashes, between your thumb and forefinger
and pull it away from the eye. Note how far away from the cornea the margin
moves. Then let go and note how quickly and completely it returns to a normal
position (the ‘snap back’ test). Alternatively perform the ‘snap back’ test by pulling
the lower lid down to the orbital rim with your thumb or finger and observe the
speed of its return when released.
Apparent lid laxity may result from age associated enophthalmos. The backward displacement of the globe through loss of orbital fat means that the eye is no
longer pressing as firmly against the lid from behind.
Actual lid lengthening occurs through a combination of aging and chronic eye
rubbing.
Finally, the canthal tendons, which anchor the lid to the orbital rim, may have
weakened or dehisced (see below).
8.3.2 Medial Canthal Tendon and Lateral Canthal Tendon
Integrity
Grasp the lower lid close to the lashes, between your thumb and forefinger and pull
it laterally, away from the medial canthus while observing the movement of the
lower lid punctum relative to the corneo-scleral limbus. Any movement past the
medial limbus (in straight ahead gaze) suggests significant medial canthal tendon
laxity.
Repeat this manoeuvre again but this time pulling the lid medially while observing the movement of the lateral canthus. A significant drift of the lateral canthus
medially towards the lateral limbus suggests lateral canthal tendon dehiscence.
8.3.3 Conjunctival Scarring/Symblepharon
Evert the lids to examine the conjunctival surface with a slit lamp. Note any subconjunctival scarring. This is best seen using green illumination. Scarring may be
a sign of previous surgery, trauma, trachoma, or of an on-going process such as
cicatricial pemphigoid. Check particularly for any conjunctival fornix shrinkage or
localized bands (symblepharon) between the lid and the globe. Do this by pulling
the lid away from the eye and asking the patient to look in the opposite direction.
8.3.4 Orbicularis Over-Riding
Correct the lower lid entropion by pulling downward on the skin to restore the lid
margin to its correct orientation. Observe whether the entropion returns when the
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