ENTROPION

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ENTROPION

• Prepared by
• Khairul Anwar Limat
• Nazri Ahmad
• Salaamy Mat Kassim
• Ophthalmology Department
• 4th Year Zagazig University

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What is Entropion?

• Entropion is a medical condition in which the
  eyelid (usually the lower lid) folds inward. It
  is very uncomfortable, as the eyelashes rub
  against the cornea constantly

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Etiology of Entropion

• Spastic Entropion
• Cicatricial Entropion
• Senile Entropion
• Congenital Entropion
• Infantile Entropion

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Symptoms

• Redness and pain around the eye
• Sensitivity to light and wind
• Sagging skin around the eye
• Excessive tears
• Decreased vision, especially if the cornea is
  damaged

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1.Spastic Ectropion

• Spastic closure of the eyelids allows the
  orbicularis oculi muscle to overwhelm the
  oppositional action of the lower eyelid
  retractors, resulting in an inturning of the
  eyelid margin and further irritation of the
  ocular surface from the inturned eyelashes.
• Occurs when spasm of Muscle of Riolan (due to
  irritation) and lack of support of lid by the
  globe.

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• Treatment of spastic entropion may be of
• Removal of cause of irritation firstly.
• Canthoplasty
• Skin and muscle operation by excision of parts of
  skin and orbicularis muscle.
• Wheelers operation.
• Ocular lubrication and tear preparations are
  helpful for protecting the ocular surface.
• Small amounts of botulinum toxin (BOTOX)
  (approximately 5 U) are quite effective for the
  treatment of spastic entropion by weakening the
  pretarsal orbicularis oculi muscle.

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2.Cicatricial Entropion

• Occurs due to cicatrization of palpebral
  conjunctiva.
• These patients usually will display scar tissue
  of the conjunctiva, usually a result of trauma,
  chemical burns, Stevens-Johnson syndrome, ocular
  cicatricial pemphigoid (OCP), infections, or
  local response to topical medication.
• Examination of the tarsus and palpebral
  conjunctiva usually will point to the diagnosis
  in these cases.

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• Procedures for the repair of cicatricial
  entropion
• Depending on the degree of scarring and
  entropion, the etiology of the cicatricial
  changes, and the status of the tarsal plate.
• Mild cases can be treated with a transverse
  blepharotomy with marginal rotation (Wies
  procedure).
• More extensive scarring may require oral mucous
  membrane (eg, buccal mucosa) or cadaveric dermis
  (eg, Alloderm) grafts.

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• Snellens Operation may be done in upper lid
  entropion.
• Websters operation may be done in lower lid
  entropion.
• Temporizing Quickert-Rathbun sutures are
  effective for many cases of spastic entropion.
• Full-thickness eyelid sutures (usually gut
  suture) from the inferior fornix anteriorly
  toward the lashes are used to torque the eyelid
  margin away from the globe. Tissue reaction to
  the gut suture helps to create a cicatrix in the
  eyelid that maintains the eyelid in the everted
  position.

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• Cicatricial entropion of upper lid.

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• There is scar tissue involving tarsal conjunctiva.

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3.Senile Entropion

• Also known as involutional entropion.
• The patient may exhibit horizontal laxity of the
  medial and/or lateral canthal tendons.
• Vertical lid laxity due to weak lower lid
  retractor.
• Patients usually have an involution of the
  posterior eyelid retractors, with the eyelid
  inturning in much the same manner as with spastic
  entropion.
• Involution of the soft tissues of the orbit,
  particularly the orbital fat, may lead to
  involutional enophthalmos, which in turn can lead
  to unstable eyelid position with entropion.

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• Treatment of senile entropion
• It may require repair of the horizontal laxity
  via medial and/or lateral canthal tightening.
• Transmarginal rotation(Weis)
• Plication of lower lid retractors(Jones)
• Tucking of palpebral ligaments
• A small amount of the pretarsal orbicularis oculi
  can be resected concurrently to prevent further
  overriding of the tarsus

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• Involutional entropion. Note overriding
  orbicularis oculi muscle, eyelid margin
  entropion, and relative enophthalmos with deep
  superior sulcus.

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• Involutional entropion. Correction of entropion
  with eyelid retractor reattachment and lateral
  canthopexy.

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4. Congenital Entropion

• The congenital form of entropion is very rare. It
  may arise due to a number of underlying
  developmental abnormalities, usually in the lower
  eyelid. Facial nerve paralysis in the pediatric
  population has been shown to be associated with
  lower lid entropion.
• Dysgenesis of the lower eyelid retractors may be
  present creating instability in the eyelid with
  consequent entropion, or a paucity of tissue may
  be present vertically in the posterior lamella of
  the eyelid.
• Occur with microphthalmos.

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5.Infantile Entropion

• Occurs in plump children due to subcutaneous fat.
  It is self limiting.

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Differential Diagnosis

• 1-Trichiasis Presence of more than 4
  mal-directed lashes rubbing against the
  conjunctiva.
• 2-Distichiasis Congenital Trichiasis
• 3-Trachoma Infective Keratoconjunctivitis
  caused by Chlamydia Trachomatis.

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Medical Care of Entropion

• Medical therapy may be warranted for patients who
  decline surgery and as a temporizing maneuver in
  patients who may improve spontaneously.
• Ocular lubrication and tear preparations are
  helpful for protecting the ocular surface.
• Eyelid hygiene, antibiotics, and corticosteroids
  are useful.
• Small amounts of botulinum toxin (BOTOX)
  (approximately 5 U) are quite effective for the
  treatment of spastic entropion by weakening the
  pretarsal orbicularis oculi muscle.
• Patients with cicatricial entropion secondary to
  ocular cicatricial pemphigoid may benefit from
  systemic chemotherapy, usually dapsone.

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Follow Up after Surgery

• Complications
• Any surgical procedure can have immediate or
  delayed complications.
• Immediate complications include hemorrhage,
  infection, wound dehiscence, graft failure (donor
  and recipient sites), corneal injury, and
  recurrence of the entropion, as well as
  consecutive ectropion.
• Hemorrhage is treated with cauterization of the
  bleeding points, and infection is managed with
  antibiotics directed at culture-specific
  organisms.
• Wound dehiscence may require immediate surgical
  repair if extensive or conservative management if
  mild.
• Maintain grafts by stenting the grafted site for
  the purpose of graft immobilization.
• Graft failure may require debridement with
  delayed re-operation.
• Donor site complications, particularly bleeding,
  are managed with appropriate packing material.
• Consecutive ectropion may occur and may respond
  to conservative observation during the healing
  period with late secondary repair.

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