1. Entropion refers to inward rolling and rotation of the eyelid margin toward the eyeball. There are several types including congenital, cicatricial, senile/involutional, and mechanical. 2. Senile/involutional entropion is the most common type and affects only the lower eyelid in older people. It is caused by horizontal laxity of the eyelid due to weakening of the orbicularis muscle and vertical lid instability due to weakening of the lower eyelid retractors. 3. Surgical techniques for correcting senile entropion include transverse everting sutures, Wies operation, and Jones plication. The Wies

1. ENTROPION
ANOMALIES IN THE POSITION OF LID MARGINS
Dr. Vinit Kumar ( SCEH, Lahan )
( Class for O.A. 2nd year )

2. Anatomy of eyelid GROSS ANATOMY
• These are mobile tissue curtains placed in front of the eyeballs .
• Eyelid protecting the eyes from injuries and excessive light.
• These also perform an important function of spreading the tear film over the cornea and
conjunctiva & also help in drainage of tears by lacrimal pump system .

3. • Parts of eyelid : two parts 1. orbital & 2. tarsal part
• Position of lids. When the eye is open, the upper lid covers about one-sixth of the
cornea and the lower lid just touches the limbus. (the lateral canthus is about 2
mm higher than the medial canthus )
• Palpebral aperture. It is the elliptical space between the upper and the lower lid.
it measures about 10–11 mm vertically in the centre and about 28–30 mm
horizontally .

4. Eyelid structure from anterior to posterior
• The grey line (which marks junction of skin and conjunctiva) divides the intermarginal
strip into an anterior strip bearing 2–3 rows of lashes & a posterior strip on which
openings of meibomian glands are arranged in a row .
• 1. Skin
• 2. Subcutaneous areolar tissue
• 3. Layer of striated muscle : consist orbicularis muscle ( facial nerve). It is divided in to orbital,
palpebral (pretarsal and preseptal parts) & lacrimal part . The upper lid also contains levator palpebrae
superioris muscle (LPS = 3red CN / oculomotor)
• 4. Submuscular areolar tissue
• 5. Fibrous layer ( tarsal plate & septum orbital )
• 6. Layer of non-striated muscle fibres 7. Conjunctiva

5. Glands of eyelids , blood supply & nerve supply
• 1. Meibomian glands ( tarsal gland) : 30–40 in the upper lid & about 20–30 in the
lower lid . These are modified sebaceous glands .
• 2. Glands of Zeis
• 3. Glands of Moll
• 4. Accessory lacrimal glands of Wolfring
• BLOOD SUPPLY : MAA marginal arterial arcades which lie in the submuscular plane
• NERVE SUPPLY : Motor nerves are facial (orbicularis oculi), oculomotor (which
supplies LPS muscle ) & sympathetic fibres (which supply the Muller’s muscle).
• Sensory nerve supply is derived from branches of the trigeminal nerve such as
lacrimal, supraorbital & supratrochlear nerves for upper lid .

8. ENTROPION : Entropion refers to inward rolling and rotation of the
lid margin toward globe. ( trichiasis : misdirected eyelashes / cilia)

9. Etiological types
• 1. Congenital entropion.
• It is a rare condition seen since birth. Seen more commonly in lower than upper
eyelid.
• ■ Lower eyelid congenital entropion is caused by improper development of the
lower lid retractors.
• ■ Upper eyelid congenital entropion is usually secondary to mechanical effects of
microphthalmos.
• 2. Cicatricial entropion . It is a common variety usually involving the upper lid. It is
caused by cicatricial contraction of the palpebral conjunctiva, with or without
associated distortion of the tarsal plate.
• Common causes are trachoma, membranous conjunctivitis, chemical burns ,S-J
syndrome.

10. • 3. Senile (involutional) entropion. It is common occurrence and affects only the
lower lid in elder people .
• Etiological factors : Horizontal laxity of the lid due to weakening of orbicularis
muscle. Vertical lid instability due to weakening of lower eyelid retractors .
• Over-riding of pretarsal orbicularis. Degeneration of palpebral connective
tissue separates the orbicularis muscle fibres and thus allowes preseptal fibres to
over-ride the pretarsal fibres and thus tipping the lid margin inwards .
• Laxity of orbital septum along with prolapse of orbital fat into the lower lid
also contribute to inward rolling of lid margin .

11. Etiopathogenesis of entroion in old age
• 4. Mechanical entropion. It occurs due to lack of support provided by the globe to the
lids. Therefore, it may occur in patients with phthisis bulbi, enophthalmos & after
enucleation or evisceration
operation .

12. Clinical features ( symptoms - & signs )
• These include foreign body sensation, irritation, lacrimation and photophobia.

13. • Signs are as follows:
• 1. Inturning of lid margins. On examination, lid margin is found inturned. Depending
upon the degree of inturning, it can be divided into three grades:
• • Grade I entropion, only the posterior lid border is inrolled,
• • Grade II entropion, includes inturning up to the inter-marginal strip
• • Grade III entropion, in which the whole lid margin including the anterior border
is inturned .

15. • 2. Signs of causative disease, e.g., scarring of palpebral conjunctiva in cicatricial
entropion, and horizontal lid laxity in involutional entropion may be seen.
• 3. Signs of complications include recurrent corneal abrasions, superficial corneal
opacities, corneal vascularization and even corneal ulceration .

16. Treatment
• 1. Congenital entropion may resolve with time without need of any intervention
or may require excision of a strip of skin and muscle with plastic reconstruction
of the lid crease (Hotz procedure).

17. Congenital entropion (Hot’z procedure) : spindle /ellipse shape skin & tarsal tissue excision done & suture tighten.

18. Cicatricial entropion
• 2. Cicatricial entropion. It is treated by a plastic operation, which is based on any
of the following basic principles:
• • Altering the direction of lashes
• • Transplanting the lashes or
• • Straightening the distorted tarsus.

19. Senile /involutional entropion Surgical techniques are :
• Transverse everting suture.
• These offer temporary cure (upto 18 months) & are thus indicated in very old
patients. The transverse sutures are applied through full thickness of the lids to
prevent over-riding of the preseptal muscles

20. Old age senile entropion we generally do transverse lid everting suture
(recurrence rate is high >70%)

21. Surgical techniques employed for correcting cicatricial entropion are :
• i. Anterior lamellar resection.
• It is the simplest operation employed to correct mild degree of entropion. In this
operation, an elliptical strip of skin and orbicularis muscle is resected 3 mm away
from the lid margin

22. • ii. Tarsal wedge resection :
• It corrects moderate degree of entropion associated with atrophic tarsus. In this
operation, in addition to the elliptical resection of skin and muscle, a wedge of
tarsal plate is also removed

23. iii. Transposition of tarsoconjunctival wedge. (Modified Ketssey’s operation)
• This is indicated to treat mild to moderate amount of cicatricial entropion. It
basically involves tarsal fracture & eversion of distal tarsus.
• A horizontal incision is made along the whole length of sulcus subtarsalis (2–3 mm
above the lid margin) involving conjunctiva and tarsal plate . The lower piece of
tarsal plate is undermined up to lid margin.

24. • Mattress sutures are then passed from the upper cut end of the tarsal plate to
emerge on the skin 1 mm above the lid margin .
• When sutures are tied the entropion is corrected by transposition of
tarsoconjunctival wedge .

26. Upper eyelid entropion surgery

27. iv. Posterior lamellar graft.
• Indications of this operation include severe entropion with upper eyelid retraction.
• In this operation, the deficient or keratinized conjunctiva & the scarred &
contracted tarsus are replaced by a composite posterior lamellar graft.
• Tarsus may be replaced by preserved sclera or ear cartilage or hard palate alongwith
conjunctival or
• mucous membrane graft

28. Senile entropion : Wies operation .Transverse lid split & everting sutures
• This operation is indicated for long term cure in patients with little horizontal laxity.
• In this operation, an incision involving skin, orbicularis & tarsal plate is given 3 mm
below the lid margin, along the whole length of the eyelid.
• Mattress sutures are then passed through the lower cut end of the tarsus to emerge
on the skin, 1 mm below the lid margin & are tied firmly .

29. WIES OPERATION :
• The entropion is corrected by prevention of over-riding of preseptal muscle by the
horizontal fibrous scar tissue barrier & transferring of the pull of lid retractors to the
upper border of tarsus by the everting sutures

30. Plication of lower lid retractors (Jones plication / operation).
• It is indicated in severe cases or when recurrence occure after other surgery .
• In this procedure the lower lid retractors are exposed via horizontal skin incision at
the lower border of the tarsal plate, shortened & the sutures are used to create a
barrier to prevent over-riding of the preseptal muscle

31. Jones plication ( entropion Sx)

32. Quickert procedure : for recurrent cases of entropion
• Indication : patients :having associated marked horizontal lid laxity .
• This operation consists of transverse lid split to create barrier for over-riding of
preseptal muscle, everting sutures to transfer pull of lower lid retractors to upper
border of tarsus & horizontal lid shortening to correct the laxity .
• Thus Quickert procedure combines horizontal lid shortening with Weis procedure.

33. Quickert surgery for entropion (refractory cases)

34. CONSUMABLES & SURGICAL INSTRUMENTS
• GLOVES , SYRINGES, NEEDLE, DRAPES
• SUTURE MATERIAL ( 6-0 absorbable vicrly suture / 5-0 mersilk for skin suture) also 4-
0 mersilk suture for transverse everting lid suture .
• Wire speculum
• Entropion clamp / locking clamp
• Bar parker 15 no. surgical blade or cresent knife for skin incision
• Eye ointment / 5% or 2.5% povidone iodine solution / betadine
• Pain killer / NSAiDs
• Cautry ( mono or bipolar )

35. HOME WORK
1. What is entropion ? What are the types of entropion ?
2. Draw a labelled diadgram of lower eyelid & upper eyelid anatomy with different
layers of eyelid ?
3. What are the signs & symptoms of entropion ? Classify entropion grade wise ?
4. what are investigation we will do before entropion surgery ?
5. What is management both surgical & medical ?
6. Gold standard surgical technique for senile / involutional entropion explain in brief ?
7. What is etio pathogenesis of senile & congenital entropion ?

36. ThankYou