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February 2016 Ophthalmic Pearls PDF
February 2016 Ophthalmic Pearls PDF
OPHTHALMIC PEARLS
I
nvolutional entropion is a trouble details of recent mechanical 1A
some eyelid malposition commonly manipulation of the eyelids
encountered in elderly patients, with with lid specula should be
a prevalence reported as high as 2.1% part of the routine entropion
in those aged 60 years and older.1 The workup.
condition is characterized by progres Interestingly, involutional
sive inward rotation of the lower eyelid entropion and ectropion
margin, causing progressive irritation share clinically and histo
of the ocular surface. Although conserv logically defining features, 1B
ative treatment with ocular lubricants, including retractor disinser
taping, or botulinum toxin injections tion, horizontal lid laxity,
can produce temporary relief, surgical and migration of the orbicu
intervention is required to definitively laris. In comparison, entro
restore anatomic positioning. pic lower eyelids were found
to have more significant
Etiology capsulopalpebral fascia dis INVOLUTIONAL ENTROPION. (1A) Ocular irritation
The pathogenesis of involutional en insertion than their ectropic is apparent in affected left eye. (1B) Improvement
tropion is multifactorial. Contributing counterparts, while ectropic after surgical repair with lateral tarsal strip and
factors include progressive horizontal lids had more pronounced lower lid reinsertion.
laxity of the tarsus and canthal ten horizontal lid laxity.
dons, disinsertion of the lower eyelid Other types of entropion. Other causing the cilia and the eyelid mar
retractors, and an overriding preseptal types of entropion have different etiol gin to come in direct contact with the
orbicularis. General fat atrophy with ogies; they are classified as cicatricial, globe.4
enophthalmos and increased appo congenital, or spastic. Spastic entropion develops in
sitional pressures during forced lid Cicatricial entropion is caused by response to acute ocular irritation
closure likely also play a role; however, scarring of the conjunctiva and relative or inflammation. It often occurs in
comparison with age-matched controls shortening of the posterior lamella. patients with underlying involutional
by means of Hertel exophthalmometry This is the result of chronic auto eyelid changes and is further exacerbat
measurements yielded no statistically immune, infectious, inflammatory, ed by the corneal irritation caused by
significant difference.2 thermal, or traumatic insult. the entropion.5
Development of involutional Congenital entropion is a rare
Christopher Lo, MD, and Ionnas Glavas, MD, FACS
EYENET MAGAZINE • 35
Diagnosis
Differential diagnosis. Entropion More Surgical Details
should be differentiated from epibleph
For more detailed coverage of the entropion repair
aron (overriding pretarsal muscle),
procedures discussed in this article, consult the Acad-
trichiasis (misdirection of eyelashes
emy’s Basic Techniques of Ophthalmic Surgery, 2nd
without entropion), and distichiasis
ed., published in 2015. Available in print and eBook
(anomalous growth of eyelashes).
formats, it presents step-by-step instruction and in-
Characteristics of involutional
formative illustrations for 81 surgical procedures—and
entropion. Diagnosis can be made
gives you access to 175 video vignettes on key points.
by identification of involution of the
Visit www.aao.org/store for further information.
eyelid and lash margin on slit-lamp ex
amination. Diminished tarsal integrity
can be detected by the lid snapback test
or the lid distraction test. is a fast, minimally invasive, low-cost include overcorrection with ectropion,
Inferior capsulopalpebral fascia technique to temporarily reinsert lower in addition to the mild retraction and
weakness, a defining anatomical defect lid retractors. granulomas that are also reported from
in involutional entropion, can be In this procedure, a double-armed repair with the external approach.
demonstrated by reverse ptosis of the absorbable suture is inserted into the Recurrence is slightly more frequent
lower eyelid, deep inferior fornix, or conjunctival fornix below the lower with the internal transconjunctival
diminished lower eyelid excursion on border of the tarsus to recruit the approach, although the difference is not
far downgaze. With lower lid excursion, lower retractors. The suture is directed statistically significant.8 Conservative
the presence of a visible white line in below the tarsal plate, and then upward retractor reinsertion without correction
the inferior cul-de-sac represents a to emerge inferior to the lash line to of horizontal laxity can have recurrence
complete retractor disinsertion. achieve lid eversion. rates as high as 17%; however, concur
The use of Quickert sutures as a rent horizontal canthal shortening can
Conservative Management primary procedure for entropion is greatly reduce recurrence rates.9
Artificial tears, lubricant eye ointment, controversial, however, because of high Lateral canthal tightening. Surgical
and contact lenses can be used to recurrence rates. Male sex, severe lower procedures for tightening lower eyelid
protect the ocular surface from the me eyelid laxity, and Asian race are risk laxity include full-thickness partial
chanical trauma caused by rotated cilia. factors for failure of the repair with lower eyelid resection and lateral tarsal
Lubrication will decrease a secondary Quickert sutures.7 In addition to recur strip procedure. Full-thickness lower
spastic component of the entropion. rence, other complications can include eyelid resections require a wedge resec
Tape can be placed parallel to the bruising, granuloma, and trichiasis. tion and tarsal repair.
lower eyelid margin with horizontal Reinsertion of lower lid retractors. In the lateral tarsal strip procedure,
tension to decrease horizontal tarsal Exploration and reinsertion of the after the surgeon performs a lateral
laxity and allow for eversion of the lid lower lid retractor can be performed canthotomy and inferior cantholysis,
margin. Care must be taken to avoid through a direct external incision or an the tarsus is isolated from the anterior
excessive lid eversion, lagophthalmos, internal transconjunctival approach. and posterior lamella to create a de-epi
or exposure keratopathy. In addition to In external repair, a subciliary thelialized strip of tarsus. The tarsus is
cosmetic concerns, excessive taping can cutaneous incision is made. After the shortened and then reattached to the
cause severe skin irritation. orbital septum is bluntly dissected, the periosteum of the lateral orbital rim.
Although thermal cautery has been lower eyelid retractors are identified The lateral tarsal strip procedure
used to induce shortening of inferior and reattached to the anterior inferior restores physiologic lower eyelid Illustration from Basic Techniques of Ophthalmic Surgery; AAO, © 2015
lid retractors and orbicularis, it is rarely tarsal edge with interrupted absorbable tension without causing eyelid margin
a successful permanent solution. sutures. The skin is then closed over the notching or weakness, which can occur
Botulinum toxin injections have repair. Reported complications include after a full-thickness lower eyelid re
been shown to be a safe and effective mild eyelid retraction and pyogenic section. In addition to recurrence, rare
temporizing mechanism for patients granuloma. complications of the lateral tarsal strip
with an overriding preseptal orbicu The internal approach involves a procedure include chemosis, self-limit
laris. However, the condition recurs transconjunctival incision below the ing granuloma, and persistent trichiasis
within 8 to 26 weeks, and repeated inferior tarsal border. A conjunctival without entropion.
injections are needed to maintain the flap is elevated until the lower eyelid Combined everting sutures and
therapeutic effect.6 retractors are identified. The retrac lateral canthal tightening. Combined
tors are reattached to the anterior Quickert and lateral canthal tightening
Surgical Treatment inferior border of the tarsus, and the procedures have been gaining populari
Everting sutures. The Quickert pro conjunctiva is approximated over the ty because of their decreased recurrence
cedure involves everting sutures and repair. Complications of internal repair rates and low risk of complication.
36 • F E B R U A R Y 2016
A small amount of preseptal or
bicularis can be removed in patients Advance Quality
who have significant override that
exacerbates the entropion. Reinserting of Care With
the capsulopalpebral fascia, tightening
the tarsus, and trimming the orbicu
Your Academy
laris addresses all 3 etiologic factors Member Benefits
for involutional entropion. Despite
significant improvements, recurrence
rates in literature range from 0% (mean
follow-up, 18 months) to 9.4% (mean
follow-up, 24 months).10 Varying
degrees of residual horizontal lid laxity
may contribute to differences in recur
rence rates.
Conclusions
Understanding the anatomy, patho
physiology, and etiologic factors is
crucial in diagnosis and management
of involutional entropion. Patient age,
general health, and preferences must be
considered in deciding between more
and less invasive management modal
ities. Many surgical procedures have
been described in the literature, with
varying recurrence rates. Everting su
tures and lateral tarsal strip combined
with preseptal orbicularis modification
restore lower eyelid anatomy with good
surgical result.
EYENET MAGAZINE • 37