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EntropionEntropion
Presentor: Dr.PrashantModerator: Dr.E.Ravindramohan
Eyelid Anatomy
Anterior lamella• Skin • Orbicularis muscle
Posterior lamella• Tarsal plate• conjunctiva
Eyelid Anatomy
• Upper lid retractors– Levator palpebrae
superioris– Whitnall’s ligament– Muller’s muscle
Eyelid Anatomy
• Lower lid retractors– Capsulopalpebral fascia– Lockwood’s ligament– Inferior tarsal muscle
Entropion
• Inward turning of eyelid margin against the eye.
• It may produce an ocular foreign body sensation, secondary blepharospasm, ocular discharge, epiphora, conjunctival metaplasia, superficial keratopathy, and corneal scarring.
Preoperative Assessment of Entropion
CAPSULOPALPEBRAL FASCIA LAXITY • Higher eyelid resting position in primary gaze • Increased passive vertical eyelid distraction • Increased depth of inferior conjunctival fornix HORIZONTAL EYELID LAXITY • Passive horizontal eyelid distraction RELATIVE ENOPHTHALMOS Exophthalmometry PRESEPTAL ORBICULARIS MUSCLE OVERRIDE POSTERIOR LAMELLAR SUPPORT • Height of tarsal plate • Presence of cicatrizing conjunctival disease• MARKED ORBITAL FAT PROLAPSE
DIFFERENTIAL DIAGNOSIS
• Epiblepharon– a horizontal fold of redundant
pretarsal skin and orbicularis muscle extends beyond the eyelid margin and compresses the eyelashes against the globe
– Common in asian races– More common; bilateral– frequently resolves with the
normal vertical growth of the facial bones
Distichiasis
• Refers to an accessory row of cilia arising from the meibomian gland orifices.
• Treatment modalities: mechanical epilation, electrolysis, radiofrequency ablation, laser photoablation, and cryotherapy to the posterior eyelid lamella.
Trichiasis
• characterized by posterior misdirection of lashes arising from normal sites of origin
Eyelid Retraction
• The retracted eyelid is pulled toward the orbital rim with the eyelashes which gets obscured by the resulting fold of eyelid skin, resembling entropion
Classification
• Congenital• Congenital Entropion• Epiblepharon
• Acquired• Involutional (senile)• Cicatricial
Entropion
• Congenital Entropion– Extremely rareEtiology: Both the anterior and posterior
attachments of the capsulopalpebral fascia are dysfunctional.
Horizontal tarsal kink syndrome
Suture Correction of epiblepharon (Quickert-Rathbun Sutures)
• Principle: To hold the two lamellae together• Indications:
1. Epiblepharon not resolving within 2 years2. Causing recurrent conjunctivitis
• Method: Pass the 3 double armed sutures from
below the lower border of tarsal plate and tie them on the skin over the skin of epiblepharon fold.
Correction of congenital entropion
Principle: An ellipse of skin and orbicularis is excised from below
the inferior punctum. The skin edges are sutured to the lower lid retractors and lower border of tarsus
Method: Suture the lower lid skin edges to the retracotrs and lower
border of tarsal plate with inturrupted absorbable sutures
Entropion
• Involutional (senile)• Pathophysiology– Upward migration of preseptal orbicularis over the
posterior lamellae– Laxity or dehiscence of eyelid retractors– Horizontal lid laxity
Etiology and management:
• Lamella dissociation: create a scar tissue between preseptal and pretarsal muscles
• Lower lid retractor weakness: tighten with everting sutures plication or shortning of retractors
• Horizontal lid laxity: shorten the lid tendons• Buckling of tarsal plate: everting sutures
sutures• Transverse sutures• Everting sutures
• Indications temporary cure
Lateral Tarsal Strip Procedure
• A lateral canthotomy• anterior and posterior lamellae must be separated.• The palpebral conjunctiva is disinserted from the inferior tarsal border • The redundant tissues of the strip are excised and the new lateral
border of tarsus is attached to periosteum at the lateral orbital tubercle with either two interrupted sutures
Weis procedure
• Full-thickness horizontal lid incision
Principle:1. The transvers lid split prevents upward movem
ent of preseptal orbicularis 2. The everting sutures shorten the retractors
Quickert procedure
– Combination of horizontal tightening and Weis procedure
– Principle:1. The transvers lid split prevents upward
movement of preseptal orbicularis 2. The everting sutures shorten the retractors3. Horizontal lid shortnening correctsexcees lid
laxity
Method:Vertical incisionHorizontal full thickness incision3 double armed absorbabale sutures through the
retractors Correct the lid laxity by suturing two flaps as in
normal lid repairSuture the wound.
Plication of Inferior Retractors (Jones type procedure)
Principle: Shortining of retractors to create a barrier to
the upward movement of preseptal muscleIndications: As primary procedure In recurrence of entropion Method:
Lower lid cicatricial entropion management
• Tarsal fracture• Posterior lamella graft• Gray line split and retractor repositioning
Principle: tarsus is fractured horizontally and hinged into eversion with everting sutures.
Tarsal fracture
Posterior lamella graft
• Principle Tarso conjunctiva is lengthened with a graft inserted
near lid margin to allow eversionIndications: Severe cicatricial entropion Entropion with lid retraction of more than 1.5 mm
below limbus Recurrence of entropion after tarsal fracture
procedure
Gray line split and retractor repositioning
Principle: The lid margin is split at grey line. The
lower lid retractors are attached to anterior lamella just below the lashes to forcibly evert the lid margin.
Upper lid entropion
Any conjunctival scarring can lead to upper lid entropion.
• Severity of entropion mild entropion: anterior lamella repostion• Thickness of tarsal plate thick tarsal plate: tarsal plate resection thin tarsal plate: lamella division+mucous membrane graft• Keratinisation of marginal tarsoconjunctiva rotation of terminal tarsus• Lid retraction mild:advance tarsoconjunctiva and free Muller’s muscle severe retraction: posterior lamella graft
Anterior lamella reposition
• Anterior lamella are sutured to tarsus at a higher level.
Tarsal wedge resection
• Anterior lamella reposition and lid margin split combined with excision of wedge of tarsal plate
• Indications: marked entropion with thick tarsal plate,no keratinization of marginal tarsoconjunctiva
Lamella division + mucous membrane graft
• Lid is split. posterior lamella advanced and held in position with sutures passed through lid. The raw anterior surface is covered with mucous membrane.
Rotation of terminal tarsus
Principle: The tarsus is cut and lower
portion rotated through 180* .The posterior lamella is advanced to make a new lid margin.
posterior lamella graft
• The tarsus is divided, the terminal fragment everted and a graft sutured between the terminal tarsal fragment and recessed conjunctiva and lid retractors.
COMPLICATIONS
• Overcorrection The patient should be evaluated for excessive advancement of the
capsulopalpebral fascia, attachment of the fascia too high on the anterior tarsal surface, uncorrected horizontal eyelid laxity, and incorporation of the orbital septum in the advancement or surgical closure.
• Hematoma• Eyelid Retraction Result of excessive horizontal tightening of the tarsus or excessive
vertical advancement of the capsulopalpebral fascia.• Exposure Keratopathy From exposed conjunctival sutures, lagophthalmos, and keratinized
hard palate grafts.
• Granuloma Formation • Symblepharon • Aponeurogenic ptosis• Eyelash loss and eyelid necrosis
• Thank you.