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Entropion

  1. 1. ENTROPION DR K HARIPRIYA SSSIHMS
  2. 2. EYE LID ANATOMY FUNCTIONS:  Secrete pre-corneal tear film & its even distribution.  Lacrimal pump mechanism.  Eye lashes sweep air-borne particles.  Constant voluntary& reflex eyelid movements. GROSS DIVISION: o Anterior lamella-skin, orbicularis oculi. o Posterior lamella-tarsus, conjunctiva.
  3. 3. STRUCTURES NEEDED FOR PROPER FUNCTION:  ORBICULARIS OCULI • Orbital, pre-septal, pre-tarsal parts.  ORBITAL SEPTUM • Fibrous multi-layered membrane, representing continuation of orbital facial system. • Distal fibers merge with levator aponeurosis & capsulo-palpebral fascia.  MAJOR EYELID RETRACTORS • Upper lid- levator palpebrae, Muller's muscle lower lid- capsulopalpebral fascia. • From superior transverse orbital ligament of witnell, LPS continues as levator aponeurosis& inserts near marginal tarsal border.
  4. 4. ORBICULARIS OCULI ORBITAL SEPTUM
  5. 5. • Capsulo-palpebral fascia starts from Lockwood's ligament& sheaths around inferior rectus/inferior oblique muscles. Fuses with orbital septum& inserts onto lower border of tarsus.  TARSAL PLATE • Dense fibrous tissue 1-1.5mm thick. • 25mm horizontal length, height- superior, 8-12mm inferior, 3.5-4mm.  CANTHAL TENDONS • Medial canthal tendon inserts via 3 limbs. Anterior-orbital process of maxillary bone, Posterior-posterior lacrimal crest, superior-orbital process of frontal bone. • Lateral canthal tendon fibrous strands extend posteriorly along lateral orbital wall& blends with lateral check ligament.
  6. 6. EYELID RETRACTORS LEVATOR APONEUROSIS CAPSULOPALPEBRAL FASCIA
  7. 7. ENTROPION • Inward rotation of the eyelid margin. • Early procedures of entropion correction can be categorized as vertically shortening the anterior lamella, vertically lengthening posterior lamella& controlling lamellar rotation. • Anatomic approach started during mid 20th century. • Lower lid retractor system- Deroetth & jones et al. Orbicularis function- Dalgleish, smith& tse et al. Tarsal plate& canthal tendon physiologies -Benger and musch, shore, Liu and stasior. Posterior lamellar substitutes/grafting-Silver& others.
  8. 8. CLASSIFICATION: • Involutional entropion • Cicatricial entropion • Acute spastic entropion • Congenital entropion. SYMPTOMS AND SIGNS: • Ocular foreign body sensation • Secondary blepharospasm • Ocular discharge • Conjunctival metaplasia • Superficial keratopathy • Corneal scarring.
  9. 9.  INVOLUTIONAL ENTROPION: Factors responsible for, • Laxity, dehiscence or disinsertion of lower lid retractors. • Over riding of pre-septal orbicularis segment over pre-tarsal orbicularis segment. • Horizontal lid laxity. • Enophthalmos.  CICATRICIAL ENTROPION: • Conditions causing contracture of conjunctiva. • Chemical burn, surgical/accidental trauma, topical anti-glaucoma medications, ocular cicatricial pemphigoid, trachoma, SJS.
  10. 10.  ACUTE SPASTIC ENTROPION: • Seen in susceptible individuals with blepharospasm that are induced by ocular irritation (blepharitis, dry eye etc.)  CONGENITAL ENTROPION: • Rare. • Different from epiblepharon (horizontal fold of redundant pretarsal skin &orbicularis muscle extend beyond eyelid margin), which presents with inverted tarsus. • Cause- abnormal insertion of lower lid retractor.
  11. 11. PATIENT ASSESSMENT: • Pt. age, medical& drug history. • Careful naked eye& slit lamp examination for etiology. • Conjunctival exam for scarring, symblephara& keratinization of posterior lamella. PRE OPERATIVE ENTROPION ASSESSMENT: o Assessment of capsulopalpebral fascia laxity • Higher eyelid resting position in primary gaze, • Increased passive vertical eyelid distraction, • Increased depth of inferior conjunctival fornix, • Presence of a white infra tarsal band. o Assessment of horizontal eyelid laxity o Assessment of relative enophthalmos o Assessment of preseptal orbicularis override o Assessment of posterior lamellar support o Assessment of marked orbital fat prolapse
  12. 12. DIFFERENTIAL DIAGNOSIS:  EPIBLEPHARON resolves with normal vertical growth of facial bones.  DISTICHIASIS the result of meta differentiation of primary epithelial germ cells originally intent upon meibomian gland development.  TRICHIASIS the result from inflammatory disruption& scarring of eyelash follicles.
  13. 13. MANAGEMENT: NON-SURGICAL: • Artificial tear drops, lubricating ointments • Bandage contact lens • Lower lid tapping • Chemo denervation of orbicularis with botulinum toxin • Toward specific invoking stimulus (trichiasis, blepharitis, dry eye etc.)
  14. 14. SURGICAL MANAGEMENT:  Involutional- Quickert Rathbun everting suture, - lower lid retractor advancement with lateral tarsal strip procedure, - lower lid retractor advancement with lower lid wedge resection.  Cicatricial- Retractor advancement, - Tarsal plate fracture, - posterior lamellar grafting.  Congenital- Retractor advancement. ANAESTHESIA  Entropion correction is an out patient procedure, performed under local anesthesia.  A 1:1 dilution of 2% lidocaine with 1:100000 epinephrine & 0.75% bupivacaine combined with hyaluronidase provides excellent anesthesia.
  15. 15. QUICKERT-RATHBUN EVERTING SUTURES • Elderly patients with concommitent medical problems for whom surgery is contraindicated. • Patients who have bleeding diathesis or who take anti-coagulants. • Unable to co-operate with surgery. • Unable to lie in semi recumbent position for the duration surgery.
  16. 16. PROCEDURE: • 3-4 double armed 5/0 vicryl suture passed through eyelid from inferior fornix to emerge 2mm just below the lash line. • Sutures are tied tightly enough to produce a minimal degree of ectropion. • If eyelid is lax, suture should instead be passed th’gh eyelid from just below the tarsus to emerge 2mm below the lash line. QUICKERT-RATHBUN SUTURES
  17. 17. WEIS PROSEDURE JONES PROCEDURE ORBICULARIS OVERRIDE PREVENTING PROCEDURES
  18. 18. LOWERLID RETRACTOR ADVANCEMENT: • Usually this procedure is combined with either lateral tarsal strip (LTS)procedure or wedge resection of lower lid. • Lower lid advancement with LTS is a convenient operation as no sutures needed to be removed post operatively. • But should be avoided in pt. with marked upper lid laxity& pt. with HTN who are unable to discontinue aspirin preoperatively. In those pts., bleeding is much easier to control with wedge resection of lower lid. PROCEDURE • A 4/0 silk traction suture is placed horizontally th’gh gray line of lower lid centrally& fixated with head drape. • Skin incision is made 3mm below eyelid margin extending from just below inferior Punctum to lateral aspect of lower lid • Colorado needle is used to dissect th’gh orbicularis, exposing septum. Then muscle is dissected away from septum.
  19. 19. • Septum opened inferiorly with Westcott scissors exposing pre aponeurotic fat & retractor identified beneath it. • Retractor then carefully dissected from underlying conjunctiva. • Pt. then instructed to look down& inferior pull of capsulopalpebral fascia should be felt. • 1mm strip of fascia removed shortening retractor vertically. • 2-3 interrupted 5/0 vicryl sutures are used to re attach lower lid retractor to inferior border of tarsus.
  20. 20. LOWERLID RETRACTOR ADVANCEMENT
  21. 21. LATERAL TARSAL STRIP PROCEDURE • Lateral canthotomy is performed using straight blunt tipped scissors up to lateral orbital rim. • Inferior crus of lateral canthal tendon is cut. septum is also freed until eyelid becomes loose. • Anterior & posterior lamellae are split along gray line. • Lateral tarsal strip is formed by cutting along inf. Border of tarsus. Lid margin also excised. • Tarsal strip is drawn to lateral orbital margin& redundant portion excised. Conjunctiva scrapped from tarsal strip. Redundant anterior lamella excised. • Double armed 5/0 vicryl suture on a ½ circle needle is passed through periosteum of lateral orbital wall, leaving a loop. • End of tarsal strip is passed th’gh the loop& needle passed from under surface of tarsal strip exiting on anterior surface.
  22. 22. LATERAL TARSAL STRIP PROCEDURE PREPARING LTS
  23. 23. • As the suture is pulled& the loop is tightened, the lateral tarsal strip Drawn against globe in a posterior direction. • Single 7/0 vicryl suture is passed th’gh gray line at the edges of the lateral aspect of the upper & lower lids reforming angle of the lateral canthus. • Lateral canthal skin wound is closed in layers.
  24. 24. LATERAL TARSAL STRIP PROCEDURE TRIMMING LTS SUTURING LTS TO PERIOSTEUM
  25. 25. LOWER LID WEDGE RESECTION • Retractor dissection is carried out in the same manner& freed from underlying conjunctiva. • At the junction of lateral 1/3rd and medial 2/3rd lower lid margin is incised vertically. Using straight iris scissors vertical cut completed th’gh tarsus. • Edges grasped& overlapped without undue tension. Redundant eyelid is cut th’gh tarsus. Then scissors angulated at 45˚ to complete wedge resection. • Tarsus re approximated with interrupted 5/0 vicryl suture. orbicularis also closed with same suture. • Eyelid margin repaired with 6/0 silk suture& the ends are left long. vertical skin wound also closed with 6/0 suture& lid margin sutures are incorporated into them to prevent corneal rubbing.
  26. 26. LOWERLID WEDGE RESECTION
  27. 27. TARSAL FRACTURE/TRANSVERSE TORSOTOMY • 4/0 silk traction suture placed horizontally th’gh gray line centrally and eyelid everted over a desmarres retractor. • Horizontal incision is made th’gh the whole length of tarsus on the posterior surface of eyelid just below its center down to the deep surface of the orbicularis. • 3-4 double armed 5/0 vicryl sutures passed th’gh tarsus just below the incision& th’gh eyelid to emerge from the skin just below the lash line. • Sutures are tied to produce a moderate ectropion.
  28. 28. TARSAL FRACTURE/ TRANSVERSE TARSOTOMY
  29. 29. POSTERIOR LAMELLAR GRAFT • Indicated for the pt with severe degree of cicatricial entropion with marked eyelid retraction. • Hard palate is preferred graft material. • Tarsal plate fracture carried out like before& inferior margin of tarsus is freed from eyelid retractors and orbital septum. • Ensuing defect is measured & slightly oversized hard palate graft is harvested. Graft carefully prepared by removing excessive sub mucosal tissue. • 3-4 double armed 5/0 vicryl suture passed in a partial thickness fashion th’gh hard palate graft& passed th’gh full thickness of eyelid. These are tied just below the lash line to evert eyelid margin& maintain graft in apposition. • Edges of the graft are sutured to anterior edge of the tarsus superiorly& the recessed edges of the conjunctiva with 8/0 vicryl.
  30. 30. BUTTRESSING OF POSTERIOR LAMELLA WITH HARD PALATE GRAFT
  31. 31. COMPLICATIONS OF ENTROPION CORRECTION:  Over correction,  Hematoma,  Eyelid retraction,  Exposure keratopathy,  Granuloma formation,  Symblepharon.
  32. 32. Thank you

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