ECTROPION AND ENTROPION

Dr. Nitish Narang

ANATOMY 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.

SYMPTOMS

Lower 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 mechanism—FLACCID CANALICULAR

SYNDROME.

KERATINISATION of exposed conjunctiva

SIGNS:

Lid margin is outrolled and depending on outrolling

ectropion can be classified as under:

- Grade I –only punctum is everted

- Grade II –lid margin is everted and palpebral

conjunctiva is visible

- Grade III –fornix is also visible

CASE WORK UP

SNAP 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 examination

Assessment of Bell’s 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

ECTROPION

TOTAL 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 don’t resolve in first 2 years of

life

METHOD

Pick 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 ECTROPION

PATHOGENESIS:-

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 canthalangle.

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 described

Indication- generalised horizontal lid laxity with excess skin.

EXCISION OF DIAMOND OF TARSOCONJUNCTIVA

Probe 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 ectropionwith punctal eversion associated with predominantly medial horizontal lid laxity.

PLICATION OF ANTEROR LIMB OF MEDIAL

CANTHAL TENDON

AIM: 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 LIMB

The 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 RESECTION

This 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 canaliculus

The 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 through the cut edge of the tarsal plate. The fixation suture is tied to reform the medial canthalangle.

INDICATION- This is the procedure of choice when marked medial canthal tendon laxity is present that results in dystopia of the medial canthal angle at rest.

• Overriding of preseptal overpretarsal orbicularis during lidclosure

• Weakness of lower lid retractors

• Horizontal lid laxity

• Canthal tendon laxity

TREATMENT

LID EVERTING SUTURES:-

Transverse sutures are placed through the lid to

prevent the upward movement of the preseptal

muscle. Everting sutures are placed more obliquely

through the lid to shorten the lower lid retractors &

transfer their pull to the upper border of the tarsus.

INDICATIONS:- temporary cure(upto 18 months).

Quick ,easy & repeatable procedure especially in

geriatric group can be done bedside.

TREATMENT

SUTURES: To correct the lamella dislocation as

a) Transverse suture to prevent upward movement of

preseptal muscle.

b) Everting sutures to tighten the lower lid retractors

and evert lid margins.

Indication:

a) Temporary cure for geriatric, during wait for

definitive surgery.

b) Transverse suture when patient forcibly closes lid

and there is an element of spasm.

LID EVERTING SUTURES

WEISS PROCEDURE:- TRANSVERSE LID SPLIT

& EVERTING SUTURES

The lid is split transeversely to create a fibrous

tissue scar barrier which prevents the upward

movement of the preseptal muscle combined with

the mechanism of the lid everting sutures which

shorten the lower lid retractors and transfer their

pull to upper border of the tarsus

INDICATIONS:- long term cure(>18months) with

little horizontal lid laxity

Horizontal incision 4mm below lash line.

Perforate the lid with sharp pointed scissors at medial and lateral ends of skin incision.

Cut horizontally through the whole lid along the line of incision.

Identify lower lid retractors.

Pass 3, 4-0 absorbable sutures through conjunctiva, lid retractors, tarsal plate coming out through 1mm below lash line.

Close the skin with suture

Tie a double armed sutures under tension, just to evert lid margin

QUICKERT PROCEDURE:-TRANSVERSE LID SPLIT +

EVERTING SUTURES + HORIZONTAL LID

SHORTENING

Horizontal lid shortening corrects the excess lid

laxity & prevents the lid turning in or out along with

mechanisms of the other 2 procedures.

INDICATIONS:- long term cure of an entropion with

excess horizontal lid laxity assessed by pulling the

lid away from the globe.

QUICKERT PROCEDURE:-TRANSVERSE LID SPLIT +

EVERTING SUTURES + HORIZONTAL LID

SHORTENING

JONES PROCEDURE:-PLICATION OF LOWER LID

RETRACTORS

The lower lid retractors are exposed via a skin

approach,shortened,and the sutures used to create

a barrier to the upward movement of the preseptal

muscle

INDICATIONS:- recurrence after transverse lid split,

everting sutures & lid shortening procedure.

Make horizontal skin incision at

the lower border of tarsal plate.

Separate the pretarsal and

preseptal muscles to expose the

inferior edge of the tarsal plate.

Divide the inferior orbital septum,

the orbital fat lie anterior to lower

lid retractors.

Pass a 4 ‘0’ absorbable suture

through the skin in centre of the

lid, through lower lid retractors

about 8mm below the tarsus,

through the lower border of the

tarsal plate, and out through the

upper skin edge.

Tighten this suture and tie it with a

slip knot

CICATRICIAL ENTROPION

Caused by severe scarring of the palpebral

conjunctiva, which pulls the upper or lower lid

margin towards the globe.

Cicatrizing conjunctivitis, trachoma, trauma

chemical injuries, Stevens-Johnson syndrome.

POST TRACHOMA SCAR

POST LIME INJURY

TREATMENT

TARSAL FRACTURE:- the tarsus is fractured

horizontally & hinged into eversion with everting

sutures.

POSTERIOR LAMELLAR GRAFT:-

The tarso-conjunctiva is lengthened with a graft

inserted near the lid margin to allow eversion.

INDICATIONS:- severe Cicatricial entropion;

entropion with lid retraction of more than about

1.5mm below the limbus

Recurrence of entropion after tarsal fracture

procedure

UPPER LID ENTROPION- ANTERIOR LAMELLAR

REPOSITION

The anterior lamella of skin & muscle is

repositioned & sutured to the tarsus at a higher

level & also sutured to the aponeurosis with the

skin closure sutures.

INDICATIONS:- mild upper lid entropion.

UPPER LID ENTROPION- ANTERIOR LAMELLAR

REPOSITION

TARSAL WEDGE RESECTION

An anterior lamellar reposition & lid margin split is

combined with the excision of a wedge of tarsal

plate.

INDICATIONS:- marked upper lid entropion with a

thickened tarsus, no keratinisation of the marginal

tarso-conjunctiva & with eyelids able to meet on

forced lid closure.

LAMELLAR DIVISION +/- MUCOUS MEMBRANE

GRAFT

The lid is split into an anterior lamella & posterior

lamella. The posterior lamella is advanced & held in

position with sutures passed through the lid. The

raw anterior tarsal surface can be allowed to

granulate but heals quicker if covered with a

mucous membrane graft.

INDICATIONS: marked upper lid entropion with a

thin tarsus

TRABUT PROCEDURE:-ROTATION OF

TERMINAL TARSUS

The tarsus is cut & the lower portion rotated

through 180°. The posterior lamella is advanced to

make a new lid margin.

INDICATIONS:- upper lid entropion with metaplastic

changes involving the lower posterior tarsal surface

which is in contact with the cornea.

POSTERIOR LAMELLAR GRAFT:-

The tarsus is divided , the terminal fragment

everted & a graft sutured between the everted

terminal tarsal fragment & the recessed conjunctiva

& lid retractors.

INDICATIONS:- entropion associated with severe

lid retraction such that the lid margins will not meet

on forced lid closure.

TARSAL EXCISION

The tarsus is excised & the conjunctiva & lid

retractors are recessed & held wit sutures passed

through the lid. The raw posterior lid surface rapidly

becomes conjuntivalised.

INDICATIONS:- entropion associated with severe

lid retraction & a small scarred tarsus when a

corneal graft is not planned

AURICULAR CARTILAGE GRAFT

To lengthen the posterior lamella of the upper or

lower lid when rigidity is required but the lid margin

is intact.

For reconstruction of the lid margin a graft of tarsal

plate or nasal septal cartilage with its attached

mucosa is preferable

SPASTIC ENTROPION

Due to increased muscular tone, the lower lid

orbicularis shifts superiorly “overriding” the inferior

tarsal border.

Trauma, lid surgery or inflammation.

Sometimes seen in association with

blepharospasm.

TREATMENT

The irritation/entropion cycle is to be broken.

Taping of the inturned eyelid to evert the

margin,cautery, or various suture techniques afford

temporary relief for most patients

But usually involutional changes are present in the

eyelid so additional surgical repair may be needed.

Botulinum type A(botox) can be used to paralyze

the overriding preseptal orbicularis muscle.

COMPLICATIONS

Persistent entropion – minimized with good

preoperative planning

Overcorrection- for cictricial entropion immediately

post operative, patient should be overcorrected

Eyelid retraction- result of excessive horizontal

tightening of the tarsus or excessive advancement

of the capsulopalpebral fascia.

Hematoma

Keratopathy- from conjunctival

sutures/lagopththalmos(severe lid

retraction)/posterior lamellar graft

Symblepharon- as a result of injury to bulbar

conjunctiva in posterior lamella manipulation.

Granuloma formation.

Ptosis- injury to levator nerve fibres,eyelid necrosis.

Eye lash loss & eyelid necrosis- due to damage to

marginal vascular arcade.

SYSTEM FOR ACQUIRED ECTROPION

SYSTEM FOR ACQUIRED LOWER LID ENTROPION

SYSTEM FOR ACQUIRED UPPER LID ENTROPION

REFERENCES

J.R.O.COLLIN – a manual of systematic eyelid surgery

AMERICAN ACADEMY OF OPHTHLMOLOGY

JACK KANSKI & BRAD BOWLING – clinical

ophthalmology

MYRON YANOFF & DUKER

THE YALE GUIDE OF OPHTHALMIC SURGERY