Eyelid malpositions: Entropion and ectropion

Published on 08/03/2015 by admin

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Last modified 08/03/2015

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CHAPTER 46 Eyelid malpositions

Entropion and ectropion

Chapter outline

See Video image

Introduction

Intact eyelids cover the eye completely while closed and the lid margins stay in direct contact with the globe while opened1. The lid margin’s contact line to the ocular surface is of vital importance to the integrity of the ocular surface. Dysfunction of lid motility and position can lead to symptoms varying from mild discomfort and dry eye to severe corneal ulceration and sight-threatening ocular surface disease. It is therefore most important to address lid malposition with the appropriate surgical therapy24. (Further suggested reading).

Entropion is a condition in which the lid margin is turned inward onto the ocular surface, while ectropion by definition is the contrary, describing a lid margin that turns outward, leading to exposure of tarsal conjunctiva (Figs 46.1 and 46.2).

Operation techniques

Both entropion and ectropion are more common in the lower eyelid; upper and lower eyelids are addressed separately in this section.

Lower lid ectropion

Ectropion occurs either as a result of aging changes to skin, muscle, or connective fibers, loss of muscle tone due to the lack of innervation as in seventh nerve palsy, or as a result of scar formation in the anterior lamella of the lid. Surgical repair aims either at restoring horizontal tightness at the medial or lateral canthal tendon and the lid margin itself or at reconstructing the anterior lamella. If the underlying cause of a neurological deficit cannot be addressed, the lid must be either elevated or horizontally tightened or both.

(Tarso)conjunctival excision, inverting sutures, and horizontal lid shortening (lazy T procedure)

If the canthal tendons are tight and the eversion is mainly in the medial third of the lid, inverting the lid margin by excising a part of the conjunctiva and shortening the lid horizontally will correct the malposition. The resulting incision lines after closure forms a T that lies lazily on its side, hence the name6.

Technique (Fig. 46.3 A,B)

A diamond-shaped excision is made with a one third longer horizontal axis at about 2–3 mm exactly below the lower punctum. A probe is entered into the canaliculus and the excision is tarso-conjunctival but care is taken not to damage the tearway. A double armed 6-0 silk suture is introduced at the upper border, picking up the conjunctiva and just the border of the tarsus. Both arms are then passed through the lower edge of the conjunctival wound, picking up the lid retractors and then brought out through the skin at about 1 cm below the punctum. The needles are passed through a silicone bolster and kept loose for later tightening. A full thickness vertical cut through the lid margin is made at about 3 mm lateral to the punctum. The amount of lid that needs to be resected is defined by pulling the lid medially. The lid is then shortened by a standard pentagonal excision and the wound closed by interrupted 6-0 silk sutures: two intermarginal sutures and three to four sutures through skin and tarsus are used to close the wound just like in any tarsal wedge resection. The ends of each suture are tied into the knot below in order to prevent the sutures irritating the cornea.

The inverting suture is tied to just invert the lid margin to the globe. A little overcorrection is acceptable. Sutures can be removed at 10 days, the inverting suture at 14 days.