Entropion repair by transconjunctival approach







Table 29.1

Indications for surgery











Lower eyelid entropion
Inversion of the eyelid margin
Punctate epithelial erosions of the cornea
Epiphora and foreign body sensation secondary to ectropion


Table 29.2

Preoperative evaluation















Lower eyelid snap back test
Lower eyelid distraction test
Manual eversion of eyelid
Assess orbicularis tone – is there a spastic component?
Assess for posterior lamellar shortage or symblepharon
Prior eyelid, facial surgery or trauma


Introduction


Inward rotation of the eyelid margin or entropion causes symptoms as the lashes and keratinized epidermis rub on the ocular surface. Symptoms include tearing, foreign body sensation, ocular irritation, and redness. Normally, the Meibomian gland orifices are visible as the most posterior aspect of the eyelid margin, just anterior to the ocular surface. The first noticeable sign is when this landmark begins to rotate posteriorly and become masked. With foreign body sensation, orbicularis spasm may occur, worsening the entropion.


Classic causes of involutional entropion are: lower eyelid laxity, attenuation disinsertion of the lower eyelid retractors, and overriding of the preseptal orbicularis. Enophthalmos can be an additional risk factor, although this condition can be seen in patients with normal globe position and even exophthalmic globes.


Clinical examination of the entropic eyelid should focus on several findings. Eyelid laxity should be assessed with the eyelid distraction test (Figure 9.3, Chapter 9 ). Cicatricial changes in the posterior lamellar can cause contraction and symblepharon, and may be the primary cause of eyelid eversion. If cicatricial entropion is present, posterior lamellar grafting or rotational sutures may be necessary ( Chapters 30 and 31 ). Occult cutaneous malignancy such a squamous cell carcinoma of the conjunctiva should also be ruled out. Manual eversion of the entropic eyelid should be possible and taping of the eyelid should allow temporary relief. Orbicularis override can be visible as an elevated horizontal ridge of preseptal orbicularis. Severe spasm also may be amenable to neurotoxin injection as a temporizing measure.


Over 100 operations have been described to correct entropion. In our experience the best surgical correction of involutional entropion addresses each individual component causing the condition. The transconjunctival route is our preferred approach. First, a small strip of overriding preseptal orbicularis muscle is excised. Second, the lower eyelid retractors must be reinserted. Finally, horizontal shortening of the lax eyelid is performed.




Surgical Technique





Figure 29.1


Lateral canthotomy and cantholysis

The transconjunctival approach is well suited for lower eyelid involutional entropion. The transcutaneous approach may also be considered, but this involves a potentially visible incision postoperatively. The procedure begins with a lateral canthotomy and inferior cantholysis to provide access to the lower eyelid.

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May 16, 2019 | Posted by in Reconstructive surgery | Comments Off on Entropion repair by transconjunctival approach
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