Entropion repair by posterior tarsotomy







Table 31.1

Indications for surgery









Cicatricial entropion with lashes abrading cornea
Posterior lamellar scarring with transverse cicatricial bands
Corneal erosions and foreign body sensation secondary to entropion


Table 31.2

Preoperative evaluation













Assess posterior lamella with eyelid eversion; look for transverse horizontal bands
Assess eyelid laxity
Quantify horizontal length of eyelid involvement
Prior eyelid, facial surgery or trauma
Any history of infections, chemotherapy, topical medication use, oral ulceration


Introduction


Cicatricial entropion caused by posterior lamellar contraction has many causes. Infectious, inflammatory, medication-induced, and autoimmune are the most common etiologies. Prior to definitive surgical repair, systemic medical control of the underlying disease is paramount. Foreign body sensation, irritation, and redness occur as the posterior aspect of the eyelid margin rotates inward. Corneal involvement with epithelial defects arises as the lashes begin to abrade the ocular surface.


For mild cicatricial entropion, anterior lamellar repositioning will typically suffice. For moderate to severe cicatricial entropion, the posterior tarsotomy is particularly effective and simply means to rotate the eyelid margin and reduce the cicatricial forces causing inversion. For severe cicatricial entropion, placement of a posterior lamellar graft such as autologous hard palate may be required.


The posterior tarsotomy differs from the Wies procedure ( Chapter 30 ) in that only the tarsus is incised. A full thickness tarsal incision is made 1.5 mm from the eyelid margin within the horizontal transverse bands of the tarsus on the upper eyelid. On the lower eyelid, the incision is made 1 mm from the eyelid margin. Blunt and sharp dissection then allows the eyelid to rotate with placement of everting sutures. The tarsotomy can be tailored to the degree of horizontal involvement and it can be performed segmentally if desired. Slight overcorrection is desired, as a mild degree of inversion will gradually occur postoperatively.




Surgical Technique





Figures 31.1A and 31.1B


Placement of traction suture

Adequate exposure of the posterior tarsal surface is critical for success of the tarsotomy procedure. Difficulty in this exposure is also amplified by the cicatricial changes in the tarsal plate. A 6-0 silk suture with a G-7 needle is placed at the gray line at three equidistant points to facilitate traction ( Figure 31.1A ). The suture bites should be placed sufficiently deep within the eyelid to prevent cheese-wiring during the eyelid eversion. Then, using a large chalazion clamp, the instrument is pivoted on the upper eyelid crease and the long ends of the silk suture are wrapped about the clamp’s tension screw ( Figure 31.1B ). The tension screw should be tightened before wrapping the sutures around the threads, otherwise the silk will be cut as the tension screw is tightened. With gentle eversion of the clamp, the inferior and posterior edge of the tarsal plate should be readily exposed.

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May 16, 2019 | Posted by in Reconstructive surgery | Comments Off on Entropion repair by posterior tarsotomy
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