4. Eyelid Anatomy
• Lower lid retractors
– Capsulopalpebral fascia
– Lockwood’s ligament
– Inferior tarsal muscle
5. Entropion
• Inward turning of eyelid margin
against the eye.
• It may produce an ocular foreign
body sensation, secondary
blepharospasm, ocular
discharge, epiphora,
conjunctival metaplasia,
superficial keratopathy, and
corneal scarring.
6. Preoperative Assessment of Entropion
CAPSULOPALPEBRAL FASCIA LAXITY
• Higher eyelid resting position in primary gaze
• Increased passive vertical eyelid distraction
• Increased depth of inferior conjunctival fornix
HORIZONTAL EYELID LAXITY
• Passive horizontal eyelid distraction
RELATIVE ENOPHTHALMOS
Exophthalmometry
PRESEPTAL ORBICULARIS MUSCLE OVERRIDE
POSTERIOR LAMELLAR SUPPORT
• Height of tarsal plate
• Presence of cicatrizing conjunctival disease
• MARKED ORBITAL FAT PROLAPSE
7. DIFFERENTIAL DIAGNOSIS
• Epiblepharon
– a horizontal fold of redundant
pretarsal skin and orbicularis
muscle extends beyond the
eyelid margin and compresses
the eyelashes against the globe
– Common in asian races
– More common; bilateral
– frequently resolves with the
normal vertical growth of the
facial bones
8. Distichiasis
• Refers to an accessory row
of cilia arising from the
meibomian gland orifices.
• Treatment modalities:
mechanical epilation,
electrolysis, radiofrequency
ablation, laser
photoablation, and
cryotherapy to the
posterior eyelid lamella.
10. Eyelid Retraction
• The retracted eyelid is pulled toward the orbital rim with the
eyelashes which gets obscured by the resulting fold of eyelid
skin, resembling entropion
12. Entropion
• Congenital Entropion
– Extremely rare
Etiology:
Both the anterior and posterior
attachments of the capsulopalpebral
fascia are dysfunctional.
Horizontal tarsal kink syndrome
13.
14. Suture Correction of epiblepharon (QuickertRathbun Sutures)
• Principle:
To hold the two lamellae together
• Indications:
1.
2.
Epiblepharon not resolving within 2 years
Causing recurrent conjunctivitis
• Method:
Pass the 3 double armed sutures from
below the lower border of tarsal plate
and tie them on the skin over the skin of
epiblepharon fold.
15. Correction of congenital entropion
Principle:
An ellipse of skin and orbicularis is excised from below
the inferior punctum. The skin edges are sutured to the
lower lid retractors and lower border of tarsus
Method:
Suture the lower lid skin edges to the retracotrs and
lower border of tarsal plate with inturrupted absorbable
sutures
16. Entropion
• Involutional (senile)
• Pathophysiology
– Upward migration of preseptal orbicularis over the
posterior lamellae
– Laxity or dehiscence of eyelid retractors
– Horizontal lid laxity
17. Etiology and management:
•
•
•
•
Lamella dissociation: create a scar tissue between preseptal and pretarsal
muscles
Lower lid retractor weakness: tighten with everting sutures plication or
shortning of retractors
Horizontal lid laxity: shorten the lid tendons
Buckling of tarsal plate: everting sutures
19. Lateral Tarsal Strip Procedure
•
•
•
•
A lateral canthotomy
anterior and posterior lamellae must be separated.
The palpebral conjunctiva is disinserted from the inferior tarsal border
The redundant tissues of the strip are excised and the new lateral
border of tarsus is attached to periosteum at the lateral orbital tubercle
with either two interrupted sutures
20. Weis procedure
• Full-thickness horizontal lid incision
Principle:
1. The transvers lid split prevents upward movement of pre
2. The everting sutures shorten the retractors
21. Quickert procedure
– Combination of horizontal tightening and Weis
procedure
– Principle:
1.
2.
3.
The transvers lid split prevents upward
movement of preseptal orbicularis
The everting sutures shorten the retractors
Horizontal lid shortnening correctsexcees lid
laxity
Method:
Vertical incision
Horizontal full thickness incision
3 double armed absorbabale sutures through the
retractors
Correct the lid laxity by suturing two flaps as in
normal lid repair
Suture the wound.
22. Plication of Inferior Retractors (Jones type procedure)
Principle:
Shortining of retractors to create a barrier to
the upward movement of preseptal muscle
Indications:
As primary procedure
In recurrence of entropion
Method:
23. Lower lid cicatricial entropion
management
• Tarsal fracture
• Posterior lamella graft
• Gray line split and retractor repositioning
25. Posterior lamella graft
• Principle
Tarso conjunctiva is lengthened with a graft inserted
near lid margin to allow eversion
Indications:
Severe cicatricial entropion
Entropion with lid retraction of more than 1.5 mm
below limbus
Recurrence of entropion after tarsal fracture
procedure
26. Gray line split and retractor repositioning
Principle:
The lid margin is split at grey line. The
lower lid retractors are attached to anterior
lamella just below the lashes to forcibly evert
the lid margin.
27. Upper lid entropion
Any conjunctival scarring can lead to upper lid entropion.
•
•
•
•
Severity of entropion
mild entropion: anterior lamella repostion
Thickness of tarsal plate
thick tarsal plate: tarsal plate resection
thin tarsal plate: lamella division+mucous membrane graft
Keratinisation of marginal tarsoconjunctiva
rotation of terminal tarsus
Lid retraction
mild:advance tarsoconjunctiva and free Muller’s muscle
severe retraction: posterior lamella graft
29. Tarsal wedge resection
• Anterior lamella reposition
and lid margin split combined
with excision of wedge of
tarsal plate
• Indications: marked
entropion with thick tarsal
plate,no keratinization of
marginal tarsoconjunctiva
30. Lamella division + mucous membrane graft
• Lid is split. posterior
lamella advanced and
held in position with
sutures passed through
lid. The raw anterior
surface is covered with
mucous membrane.
31. Rotation of terminal tarsus
Principle:
The tarsus is cut and lower
portion rotated through 180*
.The posterior lamella is
advanced to make a new lid
margin.
32. posterior lamella graft
• The tarsus is divided, the terminal fragment
everted and a graft sutured between the
terminal tarsal fragment and recessed
conjunctiva and lid retractors.
33. COMPLICATIONS
•
•
•
•
Overcorrection
The patient should be evaluated for excessive advancement of the
capsulopalpebral fascia, attachment of the fascia too high on the anterior
tarsal surface, uncorrected horizontal eyelid laxity, and incorporation of
the orbital septum in the advancement or surgical closure.
Hematoma
Eyelid Retraction
Result of excessive horizontal tightening of the tarsus or excessive
vertical advancement of the capsulopalpebral fascia.
Exposure Keratopathy
From exposed conjunctival sutures, lagophthalmos, and keratinized
hard palate grafts.
