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.