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Ectropion and entropion

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Ectropion and entropion

Ectropion and entropionDr. Nitish NarangAnatomy of eyelids:-SKIN- thin,stretches with age & there is usually excess available for a full thickness skin graft.ORBICULARIS MUSCLE:-

UPPER EYELID ANATOMY:-

LOWER EYLID ANATOMY:-

ECTROPION- It is an outward turning of the eyelid margin .

TYPES:- 1)Congenital 2) Involutional 3) Paralytic 4) Cicatricial 5) Mechanical *Involutinal ectropion is more common, while congenital ectropion is very rare.

SymptomsLower lid ectropion -> Inferior punctum displaced away from globe -> Epiphora/ Excoriation of skin around lid.Chronic conjunctivitis -> Irritation/ discomfort.

Lagophthalmos & corneal exposure.Lid laxity & loss of orbicularis tone eliminates the lacrimal pump mechanismFLACCID CANALICULAR SYNDROME.KERATINISATION of exposed conjunctiva

7Signs:Lid margin is outrolled and depending on outrolling ectropion can be classified as under:Grade I only punctum is evertedGrade II lid margin is everted and palpebral conjunctiva is visibleGrade III fornix is also visibleCase work upSNAP BACK TEST:-Pull the lower lid down and away from globe for several seconds and wait. Without the patient blinking, note the length of time required before the lower lid returns to its original position; the lid, in fact, may not return to its original position at all. MILD takes some time MODERATE goes back slowly without blink SEVERE doesnot go back even after a blink

MEDIAL CANTHAL LAXITY TEST:-Pull the lower lid laterally away from the medial canthus and measure displacement of medial punctum; the greater the distance measured, the greater the laxity.Normally, the displacement should only be 0-1 mm.

The medial canthal laxity test is graded from 0-IV, with a grade of 0 indicating normal laxity and a grade of IV indicating severe laxity.LATERAL CANTHAL LAXITY TEST:-Pull the lower lid medially away from the lateral canthus and measure displacement of the lateral canthal corner; the greater the distance measured, the greater the laxity.Normally, the displacement should only be 0-2 mm.

The lateral canthal laxity test is graded from 0-IV, with a grade of 0 indicating normal laxity and a grade of IV indicating severe laxity.Schirmer's test: to rule out dry eye.Fluorescein test of cornea: to assess the corneal damage.Slit lamp examinationAssessment of Bells phenomenon.Examination of 7th cranial/facial nerve.

Medical therapy

Provide medical therapy if surgical therapy is not warranted or not possible.Symptomatic therapy with artificial tear ointment or drops;Lower lid taping. If there is chronic dacryocystitis, performing a dacryocystorhinostomy alone or in combination with an ectropion procedure may produce better results than treating the ectropion alone.If the conjunctiva is markedly keratinized, use a lubricating ointment or mild steroid ointment several days or weeks prior to ectropion repair. Corneal epithelial defects and prior herpes simplex infection are relative contraindications to use of steroid-containing ointments.

Instruct patients with tearing and incipient ectropion or early punctal ectropion to wipe the eyelids in a direction up and in (toward the nose) to avoid worsening medial ectropion.

With cicatricial ectropion following trauma or lid surgery, digital massage may help stretch the scar. If not, consider steroid injection into the scar.

External paste-on upper lid weights are available and are useful for patients who have seventh nerve palsy. Lid weights can be approximately matched for different skin colours. A double-sided tape is used to apply the lid weight. Removing the lid weight at night may avoid irritation of the lid skin. External lid weights are not a good option in patients with upper lid dermatochalasis or poor manual dexterity.

Congenital ectropion:-Occurs as an isolated finding.Associated with blepharophimosis syndrome or icthyosis.Caused by vertical insufficiency of the anterior lamellae of the eyelid if severe can cause chronic epiphora and exposure keratitis.Topical lubrication and short term patching of both eyes is required.If severe and symptomatic it is treated surgically with horizontal tightening of lateral canthal tendon and vertical lengthening of the anterior lamellae using a full thickness sutures.Congenital eyelid eversion- complete eversion of the upper eyelids seen occasionally. Possible causes include inclusion conjunctivitis , anterior lamellar inflammation or shortage or Down syndrome.

ICHTHYOSIS WITH ECTROPIONTOTAL LID EVERSION

TREATMENT:Hotz-type operation the skin edges are sutured to lower lid retractors and lower border of tarsus.Indication: Frank lower lid ectropion with inversion of lid margin in a child who is persistently photophobic and gets recurrent attacks of conjunctivitis which dont resolve in first 2 years of lifeMethodPick excess skin and orbicularis, mark this as ellipse in medial part of eyelid, excise the ellipse.Suture the lower lid skin edges to retractor and lower border of the tarsal plate with interrupted 6-0 absorbable sutures. Do the procedure bilaterally

INVOLUTIONAL ECTROPION:- This is the most common form.Affects the lower lid of elderly patients Causes epiphora and in long standing cases the tarsal conjunctiva may become chronically inflammed ,thickened and keratinized .

INVOLUTIONAL ECTROPIONPathogenesis:-Horizontal lid laxity- caused by age related stretching of the tarsus and palpebral ligaments .Medial canthal tendon laxity lateral canthal tendon laxity .Disinsertion of lower lid retractors .

HORIZONTAL LID SHORTENING BY FULL-THICKNESS WEDGE EXCISION:-If horizontal lid laxity exists without significant lateral canthal or medial canthal tendon laxity.Preferred site is lateral 1/3rd It is useful if the lateral canthal angle contour and position are normal.First full thickness lid incision is made at right angle to the lid margin, extending to the lower border of tarsal plate. Tarsal plate edges are approximated using 2-3 long acting 6-0 absorbable sutures.Additional 6-0 marginal sutures are passed through the gray line and lash line and tied the ends are left long.

KUHNT-SYMANOWSKI PROCEDURE( Horizontal lid shortening & blepharoplasty):-A subciliary incision is cut through skin 2 mm below the lashes, from the inferior punctum to the lateral canthal angle. At the lateral canthus the incision is continued obliquely downward in a natural skin crease for a distance of 10mm and the skin flap is undermined to the level of the orbital rim.Rest surgery is same as previously describedIndication- generalised horizontal lid laxity with excess skin.

EXCISION OF DIAMOND OF TARSOCONJUNCTIVAProbe is passed into the inferior canaliculus.A diamond-shaped segment of tarsus and conjunctiva is resected directly below the punctum, 2mm from lid margin.One arm of a 6-0 absorbable suture is passed through the superior apex of the diamond from the conjunctival surface to emerge within the wound.The other end of the suture is passed through the conjunctiva and lower lid retractors at the inferior apex of the diamond and again emerges within the wound.As the suture is tied, the medial lid margin and punctum are rotated inward. Indication- ectropion of the lower lacrimal punctum without significant horizontal lid laxity.

Medial Diamond Excision Plus Horizontal Lid Shortening (BRYON SMITHS Lazy-T)

A full-thickness incision uptil lower tarsal edge is made through the lid margin 4 mm lateral to the punctum.Redundant lid excised as a full-thickness pentagon lateral to the first incision. This is repaired first followed by closure of diamond.Indication treatment of choice for medial ectropion with punctal eversion associated with predominantly medial horizontal lid laxity.

Plication of anteror limb of medial canthal tendonAIM: Is to give support to the medial canthal tendon. A wire probe is placed into the inferior canaliculus to mark its precise location.A horizontal skin incision is made below the canaliculus, starting at the medial canthus and extending to below the inferior punctum.A 5-0 nonabsorbable suture is passed through the medial edge of the tarsal plate and then through the anterior limb of the medial canthal tendon.The suture is tightened sufficiently to stabilize the canthal angle in its normal position. INDICATION mild medial canthal tendon laxity.

Medial canthal tendon plication-posterior limbThe posterior limb of the medial canthal tendon is reformed by suturing the medial end of the lower tarsal plate to the periosteum of the medial orbital wall.

INDICATION- a mild medial involutional or paralytic ectropion with a relatively anterior positioned punctum associated with some medial canthal tendon laxity affecting the posterior limb more than the anterior limb,i.e.it should not be possible to pull the lid very far laterally.Medial canthal resectionThis is the procedure of choice when marked medial canthal tendon laxity is present that results in dystopia of the medial canthal angle at rest.A vertical full-thickness cut is made through the lower lid just lateral to the caruncle to include the canthal tendon and canaliculusThe conjunctival incision is continued onto the bulbar surface, posterior to the plica.This plane is followed back along the medial orbital wall with blunt-ended scissors until the posterior lacrimal crest is encountered.2 half-circle needles of a 5-0 nonabsorbable sutures are passed through the periosteum of the posterior lacrimal crest, one at the level of the medial canthal tendon and one 2 mm higher on the medial orbital wall.Appropriate amount of lid is resected.The two ends of the fixation suture are passed throug

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