Chapter 1 Repair of Involutional Ectropion and Entropion

Core Messages

■ Vertical deviation of the orbicularismuscleplaysthemostimportantroleinentropionandectropionformation.

■ The orbicularis muscle is controlled bytranslamellar connections between thelower lidretractorsand theanterior la-mella.

■ In ectropion, retractor laxity causesan absence of the angle at the lacrimalpunctum.

■ Inentropion,retractorlaxityproducesalossofthelidcrease.

■ Ectropionandentropioncanbecorrect-edbytransconjunctivaladvancementoftheretractorswithoutexcisionoftissue.

■ Horizontal lid laxity also requires cor-rection.

1.1 IntroductionTheoppositeconditionsofectropionandentro-pionarecausedbyasimilarpathogenesisandcanbetreatedwithsimilarprinciples.Therefore,theyarepresentedinthischapterastwovariationsofthesameentity.Thetraditionalconceptofinvert-ingsurgeryforectropionorevertingsurgeryforentropion does not take into account that themost adequate procedure should simply aim torepair involutionalpathologyand try torestore

normalanatomy.Bothectropionandentropioncanbe treatedby transpositionof the lower lidretractors,withoutexcisionoftissueorrotatingsutures. Retractor surgery has been introducedmorewidelyoverthelast20years[2,4,6,7].Thischapter is an attempt to analyze why the back-ward-directedvectoroftheretractorscaneffec-tively correct vertical deviations, even thoughthismayappearparadoxicalatfirstsight.Manymodificationsofretractormanipulationsarepos-sible.Themodifiedtechniquesdescribedinthischapterhaveprovedtheirvalueover20yearsinagreatnumberofpatients.

1.2 Surgical Anatomy of the Lower Lid

Lowerlidsurgeryrequiresaprofoundknowledgeofpalpebralandorbitalanatomy.Abasicknowl-edge can be obtained from anatomical studiesof anatomical drawings and from anatomicalspecimens. As the tissues look very differentduring surgery, it isnecessary togivenames tosome peroperative observations that are notlistedinanatomicaltextbooks.Bloodlesssurgeryachievedwiththecarbondioxidelaserprovidesafarbetterdifferentiationofthestructures.Thelaseriscombinedwithhydrodissectionbyinject-ing an anesthetic solution under the layer andthus making the structures more visible below.Thefollowinganatomicalobservationshavebeenselectedaccordingtotheirsurgicalrelevancetolowerlidsurgery.

Repair of Involutional Ectropion and Entropion: Transconjunctival Surgery of the Lower Lid RetractorsMarkus J. Pfeiffer

Chapter 1

1

2 Repair of Involutional Ectropion and Entropion: Transconjunctival Surgery of the Lower Lid Retractors

11.2.1 Lower Lid Position

and the Intercanthal LineThe lower lid position has to be evaluated inassociation with the spherical surface of theglobe. The lower lid tends to follow the inter-canthalline,theshortestlinethatcanbedrawnontheglobesurfacefromthemedialtothelat-eralcanthalattachments.Notethatmediallyatthe lacrimal punctum, the intercanthal line isdirected backward close to the globe’s surfacetojointheposteriorlimbofthemedialcanthaltendon, while the lid margin forms an angleparallel to the anterior limb (Fig.1.1). Medialectropionisequivalenttothelossofthemedialangle (Fig.1.2). In ideal and stable conditions,theintercanthallineofthelowerlidisidenticaltoanequatoriallinedrawnthroughthemedialandlateralcanthus.Inthiscase,thetensionofthe pretarsal orbicularis muscle will keep thelidmargininthisposition.Incasesofalowlat-eralcanthus,theintercanthallineislowerthantheequatorial line,creatingatendencytowardanevenmoreinferiorpositionofthelowerlidand developing scleral show or even a lateralectropion(Fig.1.3).Theeffectofthelowlateralcanthus can be demonstrated using the modelofarubberbandaroundaping-pongball.Iftherubberbandismovedawaydownwardfromtheequator,ittendstoslipoff.Incasesofalowlat-eralcanthusorofexophthalmos, the intercan-thal line is lower than the equatorial line andthelidcannotberaisedbyanytighteningpro-cedures.Inthesecases,thepositionofthelateralcanthushastobemovedupwardortheexoph-thalmoshastobecorrectedbeforeanyfurthersurgerycanbeconsidered.

1.2.2 Posterior Lamella of the Lower Lid

The posterior lid lamella is an essential struc-ture, because it provides a mucous interface,thefornix.Theconjunctivalliningofthefornixallows independent movements of the eyeballand the eyelid. Vertical incisions into the for-nix should be avoided because scarring mayproducean inhibitionof themovementof the

tarsal and bulbar conjunctiva. We recommendhorizontalincisionstoexposethetarsalmuscleand the lower lid retractors. The lower lid re-tractors (fascia capsulopalpebralis) are formedbyashellshapedfasciathatcoverstheinferiorhemisphereoftheglobe.Mediallyandlaterallythefiberscontinueintothecanthaltendons.Thelateralfusionwiththecanthaltendonisobviouswhenweperformalateraltarsalstripprocedureand have to dissect the lateral retractors to beable to elevate the lid laterally. The medial fu-sionoftheretractorsandtheposteriorlimbofthemedialcanthaltendonisfoundbetweentheinferiorlacrimalpunctumandthecaruncle.Thevectorofthesefibersisdirectedposteriorlyandisessentialfortheproperpositionofthelacri-malpunctum.

1.2.3 Anterior Lamella of the Lower Lid

Thepretarsalandpreseptalskin is the thinnestof the body. Chronic epiphora induces skin ir-ritationandshrinking.Anylossofskinsurfacemust be ruled out. A certain skin redundancyisnotonlynormal,butnecessary topermitanelevationofthelowerlidabovetheleveloftheintercanthalline.Thisextraelevationcanbeob-served in forced closure, when the contractedpreseptalorbicularismuscleslidesbelowthein-ferioredgeofthetarsusandliftsthetarsusoverthe intercanthal line. The orbicularis muscleplays an important role in the pathogenesis ofectropionandentropion.Inbothconditionstheorbicularismusclelosesitscontrolovertheposi-tionoftheposteriorlamellabyanupwarddislo-cation inentropionoradownwarddislocationinectropion.

1.2.4 Relationship Between the Anterior and Posterior Lamellae

Therelationshipbetweenthetwolowerlidlamel-lae is most important for the pathomechanismof involutional ectropion and entropion. In thetarsalarea,thelayersoftheanteriorandthepos-

Fig. 1.1 Theintercanthalline(red line)runsclosetotheglobe’ssurfacefromthelateralcanthustothelacrimalpunctum,whereitcontinuesintotheposteriorlimbofthemedialcanthalten-doncreatingananglewiththelidmargin(yellow line)

Fig. 1.3 Inidealandstableconditions,theintercanthallineofthelowerlidisidenticaltoanequatoriallinedrawnthroughthemedialandlateralcanthus.Inthiscase,thetensionofthepret-arsalorbicularismusclewillkeepthelidmargininthisposition.Incasesofalowlateralcanthus,theintercanthallineislowerthantheequatorialline.Increasinghorizontaltensionwillcauselowerlidretraction.

Fig. 1.2 Medialectropionisequivalenttothelossoftheangleatthelacrimalpunctumcausedbythelaxityoftheposteriormedialfixation

1.2 Surgical Anatomy of the Lower Lid 3


1terior lamellae areunitedbycloseattachments.Thus,thepretarsalorbicularismuscleactslikeabeltonthetarsus.Involutionalchangesinducealaxityoftheseattachmentsandenablethemuscletobecomedetached.Intheseptalareabothlamel-laeareseparated.Ifbothlamellaearedisectedbya transconjunctival approach, the pre-retractorspace,wherereticularadhesionsconnect to theanteriorlamella,isexposed.Thesetranslamellarfibrous insertions are important for the controlofthepreseptalmuscleandtheformationofthelower lidcrease.An involutional laxityof thesetranslamellarfiberswillallowthepretarsalmus-cle toglideupwardand isconsidered tobe themainmechanismofentropionformation.

1.2.5 Lower Lid CreaseThe lower lid crease forms between the tarsalundtheseptalarea.Itispresentinthemajorityofyoungerindividualsandtendstodisappearintheagingeyelid.Unliketheupperlidcrease,thelower lidcrease isaesthetically lessappreciated.Theformationofa lower lidcrease is,however,animportantsignofafunctioningposteriorat-tachmentoftheorbicularismuscleandoffersthebestprotectionfromentropion.Thetranslamel-larfibersofthelowerlidretractorsinsertintothepreseptalorbicularismuscle.Entropionrepairismuch more effective and lasting if this transla-mellarconnectionisrestored.

1.2.6 Orbital Septum and the Orbitomalar Septum

Involutionalchangesnotonlycauselidlaxityinhorizontal, vertical, and anteroposterior direc-tions,butalsoinduceaweakeningoftheorbitalseptumandadisplacementoforbitalfatanteri-orly.Orbital fatprotrusioncontributestoafur-ther separationof the lamellaeanddetachmentof theorbicularismuscle fromtheposterior la-mella[1]creatinganadditional factorofectro-pion or entropion formation. The malar areaof themidface is suspendedby theorbitomalarseptumconnectingtheinferiororbitalrimwiththemalar fatpad.The laxityof theorbitomalar

septumcausesdroopingofthemalarfatpadanddownwardtractionoftheanteriorlamellaofthelowerlid.Forthisreason,wealwaystakeadvan-tageofthelateralcanthoplastyincisionforasi-multaneoussectionandsuperolateraltransposi-tionoftheorbitomalarseptum.

1.2.7 Lid Margin Shape and the Lid Margin Angle at the Lacrimal Punctum

Lower lid function is closely related to thecor-rect position of the lid margin. Deviations ofonly1mmcancause functionalproblems suchaspunctaleversionortrichiasis.Thestabilityofthetarsusdeterminesthepositionofthemuco-cutaneous junctionat the interioredgeand thelash line at the exterior edge of the lid margin.Deformitiesofthelidmargin’sshapearesignsofcomplicatedentropionandectropionandhavetobeaddressedwithadditionalprocedures.

Summary for the Clinician

■ The lower lid position depends on theintercanthalline.

■ Translamellar connections between theanterior and posterior lamellae are re-sponsible for the control of the orbicu-larisfibers.

■ The presence of a lower lid crease is asign of a functioning retractor attach-menttotheanteriorlamella.

■ Mediallyandlaterallytheretractorfiberscontinueintothecanthaltendons.

1.3 Preoperative Evaluation and Surgical Planning

Thisisthemostimportantstepofthetreatment,becauseanincompleteevaluationorinadequateplanning cannot be compensated by the bestsurgical performance. The following importantdetails should be checked before planning theprocedure.

1.3.1 Evaluation of the Intercanthal Line

Checktheshortestlinebetweenthemedialandthe lateral canthus on the globe and comparethislinewiththeequatoriallinebetweenthetwocanthi.Takeintoaccountthatahorizontalshort-eningofthelowerlidbyatarsalstripprocedureorfullthicknessexcisionwilllowerthelidiftheequatorial line is higher than the intercanthalline. An elevation of the lateral canthus shouldbeplannedtoraisetheintercanthallineuptotheleveloftheequatorialline(Fig.1.4).

1.3.2 Evaluation of the anterior and posterior Surface

Checktheconjunctivalsurfaceandtheskinsur-face carefully. A minimal deficit of only 1mmmaybesufficientforsurgicalfailure.Planthere-placementofskinormucousmembranebygraftsanddonot relyon the lessobvious skindeficitwhen thepatient is ina supinepositionon theoperatingtable.

1.3.3 Evaluation of the Three Vectors Influencing Lid Function

Checkthelidmotilityforlaxityorrestrictioninthree directions (vertical, horizontal, and sagit-tal). The simple snap-back test is only the firststepinchecking lid laxity.Thelower lidshould

beexaminedbypushingitupwardoverthelim-bustoruleoutverticalretractionandbylateralandmedialstretchingtotesttheconditionofthecanthalfixations.Thesagittalvector(antero-pos-teriorortranslamellarattachments)canbeeval-uatedbycheckingwhetherornotthelidcreaseispresent.

1.3.4 Evaluation of the Lid Margin and the Punctum

Check the shape of the lid margin with the slitlamp. Deformation of the lid margin tends tooccur in longstanding chronic ectropion andentropion. The “classic” rectangular shape ofthemarginisdeformedtoa“gothic”archinen-tropion or to a “roman” arch in ectropion. Lidmargin deformities contribute to complicatedectropion or entropion. They can be correctedwithadditional“shaping”proceduresorlamellarrepositioningsurgery.


■ Exclude the following signs of compli-cated ectropion and entropion, becausetheyrequireadditionalsurgery:

■ Inferiorpositionofthelateralcanthusoralowintercanthalline.

■ Deficit of skin surface or conjunctivalsurface.

■ Deformityofthelidmargin.

Fig. 1.4 Sectionofthelidmar-gin.Thenormal“classic”rect-angularshapeofthemarginisdeformedintoa“gothic”archincomplicatedentropionorintoa“roman”archincomplicatedec-tropion.Lidmargindeformitiescanbecorrectedwithadditional“shaping”proceduresorlamellarrepositioningsurgery

1.3 Preoperative Evaluation and Surgical Planning 5


11.4 Surgical Technique

for Ectropion RepairThefollowingtechniqueavoidsexcisionoftissue.Thecorrectionisobtainedbyseparation,trans-position,andfixationofthelidlamellae.

1.4.1 Principle of Retractor FixationThe action of the retractors is composed of a“backward” and a “downward” vector. In thecenterof the lower lidbothvectorsareequiva-lent. Near the lacrimal punctum, the backwardvector is dominant and is useful for correct-ing medial ectropion by pulling the lid marginbackward in thedirectionof theposterior limbofthemedialcanthaltendon.Theadvancementoftheretractorsformstheposteriorcomponent.Aloneitwouldbeinsufficient,becauseitonlyap-proximatesthelowerborderofthetarsalplateto

the globe. Therefore, a second anterior compo-nentisneededtolifttheanteriorlamella(orbi-cularismuscle)upward inan invertingmanner(Fig.1.5).

1.4.2 Access to the Medial Retractors

Theconjunctivalincisionbeginsclosetothecar-uncleandendslaterally3–4mmbelowthelacri-malpunctum,nearthemedialedgeofthetarsalplate.Thisincisionwillexposesomefibersofthetarsalmuscle. If the inferior lipof theconjunc-tival incision is pushed downward, the whitishlayeroftheretractorsisexposedunderneath.Theretractorsaretranssectedhorizontallyparalleltotheconjunctival incision.Thus,thepreretractorspace is opened and the orbital septum can beseen.Theretractorsaremobilizedbluntlyback-wardanddownwardwithacottontip(Fig.1.6).

Fig. 1.5 aTheposteriorcom-ponentoftheretractorfixationadvancestheretractors(green)tothetarsus(yellow).bTheanteriorcomponentliftstheanteriorlamella(orbicularismuscle,red)upward,andthetwocomponentshaveaninvertingeffect

Fig. 1.6 Theconjunctivalinci-sionbeginsclosetothecaruncleandendslaterally3–4mmbelowthelacrimalpunctum,nearthemedialedgeofthetarsalplate.Theretractorsaretranssectedhorizontallyparalleltothecon-junctivalincision

1.4.3 Access to the Central Retractors

Incasesofpronouncedmedialandcentralectro-pion, theretractorexposurehastobeextendedhorizontally over the entire lower lid. The con-junctival incision runs from the caruncle later-ally, parallel to the tarsus, and 2mm below theinferiorborder.Theinferiorlipoftheconjuncti-valincisionispushedbluntlydownwardtogetherwith the tarsal muscle to expose the retractors,which are transsected horizontally. Thus, thepre-retractorspaceisexposed,showingthetypi-calreticularadhesionsbetweentheposteriorandanteriorlamella.Thesereticularadhesionscanbeseparatedbybluntdissectiondowntotheorbitalseptum.

1.4.4 Exposure of the Inferior Tarsal Border

Inordertoplacetheretractoradvancementsu-tures,theinferiortarsalborderhastobeexposedat the site where the bite is planned. In medialectropionasinglesutureisplacedatthemedialandinferiorborderofthetarsus,approximately2mmlateralfromthelacrimalpunctum.Inpro-nouncedcentralectropiontwoadditionalsuturesareplacedat thebordersof thecentral thirdofthelid.Somecautionisneedednottoinjurethevasculararcadeatthelowertarsalborder.

1.4.5 Suture TechniqueTheposteriorcomponentofthesutureadvancestheretractorstothemedialinferiorborderofthetarsal plate. A double-armed 6-0 nylon suturewithasmallhalfcircleneedleisusedtograspfirsttheretractorsandthentheinferiortarsalborder(Fig.1.7).Medially,theretractorscanbecaughtjustbelowthepunctumif theposterior limbofthemedialcanthaltendonisintact.Ifthemedialcanthalfixationisinsufficient,theretractorsaregraspedhalfwaybetweenthepunctumandthecaruncletoimprovethemedialposteriorattach-ment (Fig.1.8). According to the laxity of theretractors, the suturehas tobepassed inat theappropriate level to create sufficient support oftheposteriorcomponentandtoavoidexcessivetightness. The adjustment of retractor advance-mentismuchlessdifficultthantheadvancementoftheaponeurosisinptosissurgery.Itisrecom-mendedtobeginwithminimalormoderatead-vancementandonlychangetofurtheradvance-ment if the effect is insufficient. The anteriorcomponentofthesutureisequallyasimportantas the posterior component. After having beenpassedthroughtheinferiorborderofthetarsus(Fig.1.9), the suture runs downward to lift thepreseptal orbicularis muscle fibers. Small hori-zontal skin incisions are necessary to grasp theneedlesovertheanteriorsurfaceofthepreseptalorbicularismuscle,wherethesuture is tiedandthe knot buried under the skin. This crane-like

Fig. 1.7 Theposteriorcompo-nentofthesutureadvancestheretractorstothemedialinferiorborderofthetarsalplate.Theanteriorcomponentliftstheorbicularismuscleupward

1.4 Surgical Technique for Ectropion Repair 7

� Repair of Involutional Ectropion and Entropion: Transconjunctival Surgery of the Lower Lid Retractors

1

Fig. 1.8 Theconjunctivalincisionrunsfromthecaruncletothemedialinferiorborderofthetarsus.Themediallowerlidretractorsareexposedandgraspedhalfwaybetweenthecaruncleandthelacrimalpunctumwitha6-0nonresorbablesuture.

Fig. 1.9 Thethin forceps liftsup theposteriorcomponentof the suture, that runs fromthe retractors to theinferioredgeofthetarsalplate.Theanteriorcomponentofthesamesutureispasseddownwardtoperforatetheorbicularismusclebeforeitistiedonitsanteriorsurface(shownbythethickerforceps).

mechanism of the suture provides an upwarddirected vector and a lifting of the anterior la-mellatowardthelidmarginwithverticaleffect.Thesuturesarenotremoved(Figs.1.10,1.11).

1.4.6 Correction of Horizontal Laxity

Mostcasesofinvolutionalectropionwillalsore-quireahorizontaltighteningproceduretocorrectlid laxity. In patients with a low lateral canthusandalowintercanthalline,thelateraltarsalstripprocedure can be combined with repositioningofthelateralcanthusatahigherlevelandalift-ing of the entire anterior lamella. The standardlateral tarsal strip procedure can be performed

directly after retractor surgery without produc-inganytissueloss[2,3].


■ The posterior component of the sutureapproximatesthetarsustotheglobe.

■ The anterior component of the sutureliftstheorbicularismuscleupward.

■ The medial fixation near the lacrimalpunctum is the most important step,because it provides medial canthalfixation.

■ Inpronouncedectropionadditionalsu-turesareplacedlateraltothepunctum.

Fig. 1.10 Preoperativeectropionwithamoderatedeficitofmedialeyelidskinandmoderatelidmargindeformity.

Fig. 1.11 Tendayspostop-eratively,aftermedialretractorfixationandalateraltarsalstripprocedure.Themedialskindeficithadtobecorrectedbyafreeskingraft.

1.4 Surgical Technique for Ectropion Repair �


11.5 Surgical Technique

for Entropion RepairAs in the ectropion repair procedure describedabove,thefollowingtechniquefortreatingentro-pionavoidsexcisionof tissue.Thecorrection isobtainedby separation, transposition, andfixa-tionofthelidlamellae.

1.5.1 Principle of Retractor FixationThe “backward” and “downward” vector of theretractoractioncanbeused toattachandcon-troloverridingorbicularismusclefibersininvo-lutionalentropion.Asagittaltranslamellarcon-nectionoftheposteriorandanteriorlidlamellaeiscreated.TheprinciplewasdescribedbyWies50years ago. His technique created a transla-mellar scar by a simple, horizontal, full-thick-nesstranssectioninthe lidcrease level[9].Thetranslamellar connection reforms the naturalattachmentsoftheretractorfibersintotheorbi-cularismuscletoformthelowerlidskincrease(Fig.1.12).

1.5.2 Access to the Lower Lid Retractors

The horizontal conjunctival incision is placed2mm below the inferior border of the tarsus.The inferior lip of the conjunctival incision ispushedbluntlydownward,togetherwiththetar-sal muscle, to expose the retractors, which aretranssected horizontally. Thus, the preretractorspace is exposed, showing the typical reticularadhesionsbetweentheposteriorandanteriorla-mellae.Theposterioraspectofthepreseptalor-bicularismuscleisexposed.Ifablepharoplastyisplannedinthesamesession,thereticularadhe-sionscanbeseparatedbybluntdissectiondown-wardtoopentheorbitalseptum.

1.5.3 Suture TechniqueTwobraided5-0nylonsutureswitha3/5circleneedle are passed through the retractors at themedialandthecentralthirdofthelid.Twosmall

horizontal skin incisions are placed over theupperpreseptalmuscle,wherethenewlidcreaseis tobecreated.Thesuturesarepasseddirectlyfrom the posterior position through the orbi-cularismuscleandappearanteriorlyintheskinincisions where they are tied and buried undertheskin.Thesuturesarenotremoved(Figs.1.13,1.14).


■ Translamellarretractoradvancementre-stores physiologic attachments betweentheanteriorandtheposteriorlamellae.

■ Lidcreaseformationaftersutureplace-mentisasignthatthepreseptalorbicu-laris muscle is prevented from slidingupward.

■ Horizontalshorteningcanbeperformedinthesamesession.

1.6 Repair of Complicated Cases and Complications of Retractor Surgery

1.6.1 Complicated Involutional Ectropion

Complicated involutional ectropion developsafter longstanding chronic ectropion with sec-ondary deformation of eyelid tissue. Chronicepiphoracauseschronicskineczemaandshrink-ingof the skin. It canbestbecorrectedby freeskingraftinginthesubciliaryarea.Longstandingeversion of the lid also causes keratinization ofthetarsoconjunctivawithdeformationofthelidmargin.Thesecaseswillneedadditional“shap-ing”proceduresorcomplete separationandre-positioningof theanteriorandposterior lamel-lae.

1.6.2 Complicated Involutional Entropion

After longstanding chronic involutional entro-pion, the lid margin can suffer a “gothic arch”

Fig 1.12 Mostcasesofinvolu-tionalectropionandentropionwillalsoneedahorizontaltight-eningproceduretocorrectlidlaxity.Incasesoflowlateralcan-thusandlowintercanthalline,thelateraltarsalstripprocedurecanbecombinedwithreposi-tioningofthelateralcanthustoahigherlevel

Fig 1.13 aThe“backward”and“downward”vectoroftheretractoraction(green)canbeusedtoattachoverridingorbicularismusclefibers(red)ininvolutionalentropion.bAsagittaltranslamellarconnectionoftheposteriorandanteriorlidlamellaeiscreatedtoattachtheorbicularismuscleandtorestorethelowerlidcrease

Fig. 1.14 Thehorizontalcon-junctivalincisionisplaced2mmbelowtheinferiorborderofthetarsus.Theinferiorlipoftheconjunctivalincisionispushedbluntlydownwardtogetherwiththetarsalmuscletoexposetheretractors,whicharetrans-sectedhorizontallyandadvancedtowardtheanteriorlamellawithpenetratingsuturesthataretiedsubcutaneouslyoverthepresep-talorbicularismuscle

1.6 Repair of Complicated Cases and Complications of Retractor Surgery 11


1deformitywherethelashlineisdisplacedtotheapexandtheinnerandouteredgesofthemarginare absent. In mild cases, the condition can becorrected by additional shaping of the lid mar-gin.Withthehighfrequencyneedle,asulcuscanbecreatedposterior to the lash line in theareaof conjunctivalization. If the retractor suturesare placed at a higher pretarsal level of the or-bicularismuscle,theyactinamorepronouncedeverting manner and can be used to open thesulcus.Inseverecases,completeseparationandrepositioningoftheanteriorandposteriorlamel-laearenecessary.

1.6.3 Complications of Retractor Surgery

Under-correction of entropion or ectropion isprobableafterretractorsurgerywithoutcorrec-tion of the horizontal laxity. The lateral tarsalstripprocedurecan,however,beperformedatalaterstage.Under-correctioncanalsooccurafterincorrect placement of the retractor sutures. Inthesecases,repeatsuturingshouldbeplannedasearlyaspossible.Resultsafterectropionsurgerycanappearover-correctedwhenthe lash line isdirectedupwardoreveninward,duethedefor-mityofthelidmargin.Wehaveoftenobservedaspontaneousnormalizationofthelashlineorien-tationafterafewweeks.Ifthisdoesnotoccur,wecansplitthelidmarginatthegraylineinordertoevertthelashline.Inentropionsurgeryexcessivetighteningoftheretractorscancausearetractionoreversion.Toavoidseverelidretraction,there-tractorshavetobereleasedasearlyaspossible.


■ Identifycomplicatedcasesbecausetheywillneedadditionalsurgery.

■ Trytoavoidexcisionoftissue.■ Donotexaggeratethetighteningorad-

vancement.■ Try to restoreanormalflexible tone to

thethreevectorsoffixation.

References1. BeigiB(2001)Orbicularisoculimusclestripping

andtarsalfixationforrecurrententropion.Orbit20(2):101–105

2. Collin JRO (2005) Manual of systematic eye-lid surgery. Butterworth Heinemann/Elsevier,Amsterdam

3. CorinS,VeloudiosA,HarveyJT(1991)Amodifi-cationofthelateraltarsalstripprocedurewithre-sectionoforbicularismuscleforentropionrepair.OphthalmicSurg22:606–608

4. Dresner SC, Karesh JW (1993) Transcon-junctival entropion repair. Arch Ophthalmol111:1144–1148

5. Khan SJ, Meyer DR (2002) Transconjunctivallowereyelid involutionalentropionrepair: long-term follow-up and efficacy. Ophthalmology109:2112–2117

6. PfeifferMJ(2004)InvolutivesUnterlidektropium:Chirurgische Therapie. Ophthalmochirurgie16:89–96

7. PfeifferMJ(2005)InvolutivesUnterlidentropion:Chirurgische Therapie. Ophthalmochirurgie17:23–28

8. QuickertMH,RathburnJE(1971)Suturerepairofentropion.ArchOphthalmol85:304–305

9. WiesFA(1954)Surgicaltreatmentofentropion.JIntCollSurg21:758–760

Documents

Chapter 1 Repair of Involutional Ectropion and Entropion