Entropion and Ectropion Repair

Ectropion and entropion are common maladies of the eyelid margin that can directly affect ocular function and patient comfort; surgical repair is commonly performed.[1]

Ectropion (out-turning of the eyelid) can present with keratoconjunctivopathy, infection, and dermatitis, among other signs and symptoms. Tearing is a common presentation, whether the punctum is everted (resulting in a tear outflow problem) or not (as in reflex tearing from irritation and exposure keratoconjunctivopathy). Combined-mechanism tearing is not unusual in these cases.[1]

Ectropion is classified into the following categories on the basis of etiology[2] :

• Congenital ectropion - This is due to a developmental vertical foreshortening of anterior lamellar tissue, resulting in eversion of the lid margin

• Cicatricial ectropion - This results from vertical foreshortening caused by acquired scarring or inflammation and may coexist with involutional horizontal lengthening of the lid margin due to chronic vertical traction; treatment in these cases is directed at lengthening the lid vertically with midface lifting or skin grafts or flaps; concomitant repair of any horizontal component is similar to repair of involutional ectropion

• Mechanical ectropion - This is due to a mass effect on the eyelid (eg, from a tumor), which pulls the lid margin away from the globe; it is managed through treatment of the underlying causative factor (eg, tumor excision)

• Involutional ectropion - This is due to horizontal laxity of the eyelid, leading to stretching of the lid or dehiscence of its attachments at the medial or lateral canthus, with resultant out-turning of the lid margin

Of these, involutional ectropion (see the images below) is the type most commonly seen in clinical practice.[2]

Entropion (in-turning of the eyelid) presents as an irritated eye with foreign-body sensation caused by inwardly rotated eyelashes and eyelid skin. The eye is red from keratoconjunctivopathy. Affected individuals often devise home remedies, such as taping the lid down to the cheek to rotate it away from the globe for comfort.[3]

Like ectropion, entropion is classified into distinct categories on the basis of etiology, as follows[3] :

• Congenital entropion - Commonly affecting the lower lids, this is a roll of pretarsal skin that abuts the lashes and rotates them inward; it is quite common in persons of Asian descent and usually resolves as the face matures; if it does not, excision of the skin roll with suture closure is used as a remedy, with minimal scarring and little aesthetic downside

• Cicatricial entropion - This results from scarring of the palpebral conjunctival or tarsoconjunctival tissue, leading to inward rotation of the lid margin; worldwide, trachoma is the most common cause, with others including chemical burns, cicatrizing diseases, and trauma; treatment involves addressing the underlying problem with immunosuppression (in the case of ongoing cicatrizing disease) or scar release and grafting; suture rotation repair of the lid margin, with or without lid fracturing techniques, may be appropriate for less severe forms of the disease or cases where the availability of supplies and practitioners is limited

• Involutional entropion - This results from a triad of conditions, (1) dehiscence of the lower-lid retractors from the inferior tarsal border, (2) horizontal lid laxity, and (3) relative enophthalmos of the globe; the effect of relative enophthalmos is best appreciated by having the patient lie in the supine position, which typically elicits the transient entropion as the globe sinks into the eye socket

The management of involutional entropion (see the images below) is described in detail in this article.

Finally, some patients develop a forme fruste of involutional entropion that is attributable to early changes from the triad described above. Spastic entropion can result in ocular irritation, which is compounded by an overactive pretarsal orbicularis oculi. The vicious circle of spasms and entropion can often be broken by taping the lid away from the globe, placing bandage contact lenses, or injecting botulinum toxin into the pretarsal orbicularis oculi. Some of these patients eventually need surgical repair of the involutional entropion.

Indications

Common indications for ectropion repair include the following:

• Documented ectropion with chronic eye irritation despite topical lubrication

• Exposure keratopathy

• Chronic keratoconjunctivopathy

• Tearing related to outflow (punctal ectropion or tear pump dysfunction)

• Tearing related to reflex (chronic irritation)

• Chronic dermatitis from tear irritation of periocular skin

Common indications for entropion repair include the following:

• Keratoconjunctivopathy due to lash/skin-globe touch

• Ocular irritation

Contraindications

Contraindications to surgical repair of either entropion or ectropion are usually based on the medical condition of the affected patient.

Uncontrolled systemic hypertension, diabetes, vascular disease, or cardiac disease, as well as systemic anticoagulation (eg, with aspirin, clopidogrel, or warfarin), may be contraindications. These issues should be discussed with the primary physician before surgery so that the risk-benefit profile for intervention can be weighed against that for observation.

In patients with cicatrizing conjunctival diseases, surgical intervention should be approached cautiously. An autoimmune or inflammatory component should prompt consultation with the patient's rheumatologist or primary physician so that immunosuppressant medications can be managed and optimized before the surgical repair, which may exacerbate the underlying condition.

Technical Considerations

The success of entropion or ectropion repair depends on good surgical technique.

Best practices

Measures that will help optimize surgical repair of these conditions include the following:

• Opt for dissolvable sutures near the lid margin and canthi; if removable sutures are used, consider blue polypropylene, because silk and nylon can blend in and be confused with the normal eyelashes

• To avoid globe injuries, always pass full-thickness eyelid sutures away from the globe; free needles are useful if double-armed suture is unavailable

• To avoid having to work in a tight space, always pass full-thickness lid sutures before horizontally tightening the eyelid

• Consider low-dose botulinum toxin as a temporizing measure to provide comfort in patients with spastic entropion[4]

• "Measure twice and cut once" when deciding on the amount of horizontal tissue to excise; overresection can lead to dehiscence, canthal angle dystopia, and narrowed horizontal palpebral fissures

• Consider nightly eye shields in the postoperative period to avoid patient rubbing and possible wound dehiscence

• Consider reverse Quickert sutures for residual ectropion after horizontal tightening to allow additional lid margin inward rotation; these are full-thickness sutures similar to Quickert sutures, but they enter just below the inferior tarsal border and exit more inferiorly on the skin surface of the lower eyelid[5]

• Consider a medial spindle procedure for residual punctal ectropion in tearing patients; this entails removal of a wedge of posterior lamellar tissue inferior and lateral to the punctum, which is then closed primarily, resulting in an inward rotation of the lid margin and punctum[6]

• Consider softening the mild to moderate cicatricial component of ectropion with corticosteroid-containing ophthalmic ointments applied to the skin; this measure may obviate the need for skin grafts altogether or limit the size of the skin graft required

• If the effect of ectropion is unclear, use the tape test to tighten the lid horizontally and gauge the effect on the patient's symptoms[7]

• If entropion is difficult to appreciate in the examination chair with the patient seated upright, place him or her in the supine position to see if this elicits the entropion

Equipment

The equipment necessary for entropion and ectropion repair includes an operating table with head extension. Overhead or headlight illumination is required. No magnification is generally required, although some surgeons prefer loupe magnification. Stainless steel instruments and a bipolar cautery are sufficient.

Instruments include the following:

• Forceps with teeth (eg, 0.3 mm/0.5 mm)

• Wescott-type spring scissors or small straight/curved scissors

• Bard-Parker blade (No. 15)

• Bipolar or monopolar cautery

• Castroviejo or small Webster-type needle driver

• Small rake or 2-pronged retractor

• Cotton tip applicators, 4 × 4 sponges

• Cotton bolsters

The suture material varies according to the preferences of the individual practitioner. The authors’ preferences are as follows (not all of these sutures will be used for every case):

• Polyglactin (4-0) on a P-3 needle

• Double-armed chromic suture (4-0)

• Fast-absorbing gut suture (6-0)

• Polypropylene suture (6-0)

Patient Preparation

Appropriate anesthesia and proper positioning are important for surgical repair of ectropion and entropion.

Anesthesia

Surgical repair of entropion and ectropion can generally be performed with local anesthesia, with or without intravenous (IV) sedation. A topical anesthetic (eg, proparacaine eye drops) applied to the affected eye(s) is used during repair of involutional ectropion or ectropion.

Infiltrative anesthesia (1-2% lidocaine with 1:100,000 epinephrine) is administered subconjunctivally, with the needle directed away from the eye and entering just below the inferior tarsal border of the lower lid laterally. The injected anesthetic spreads in a subconjunctival plane across the lower lid. A second injection is placed in the subcutaneous tissues of the lateral canthus and lower eyelid, with additional anesthetic infiltrated down to the lateral canthal rim in the vicinity of the lateral orbital tubercle.

Nerve blocks are generally unnecessary, although an infraorbital block can be achieved by directing the needle in the subconjunctival space toward the face of the maxilla in the same vertical plane as the pupil in primary gaze. Zygomaticofacial blocks may be employed as needed. These 2 nerve blocks may be helpful when broad undermining for scar release and skin graft placement is considered.

Positioning

The authors' preference is to place the patient in the supine position on an operating table with a head extension. A pillow or some other support is always placed under the patient's knees to remove tension from the patient’s lower back. The entire body and head should be level and parallel to the floor. Because the operating time for these procedures is short, compression devices for deep venous thrombosis (DVT) prophylaxis generally are not needed.

Approach Considerations

The surgical techniques employed to treat ectropion and entropion generally have a number of steps in common. Because both procedures have a step in which the component of horizontal laxity is addressed, this step will be described first.

Involutional Ectropion Repair

For a large percentage of ectropion cases, the initially described step of horizontal tightening is all that is required to accomplish repair.

Horizontal tightening

A lateral canthotomy is performed by making a 6- to 8-mm incision through the lateral canthal angle (see the image below). The length of this incision may vary; for eyelids with extreme horizontal laxity, it can be lengthened to anticipate a larger amount of skin and orbicularis oculi redundancy at the conclusion of the horizontal tightening.[8]

Inferior cantholysis is performed with a scissors (see the image below). It is not necessary to lyse every fiber of the inferior canthal tendon crus; cantholysis should be just sufficient to permit adequate lateral pulling of the lid for the purposes of tightening. Overly zealous dissection will cause more bleeding from an already tight operative space without adding much to the procedure's efficacy. Hemostasis should be obtained with a monopolar or bipolar cautery.

The now-disinserted lower lid is split into anterior and posterior lamellae along the grey line of the eyelid, yielding a skin muscle flap anteriorly and a flap comprising the tarsoconjunctival and postseptal tissues posteriorly. How far the lid is split laterally depends on the degree of horizontal laxity. This step should be performed in cautious advancing increments in a lateral-to-medial direction to avoid overtightening of the lid.

The palpebral conjunctiva and the lower-lid retractors are then cut and disinserted from the inferior border of the tarsus from lateral to medial for the appropriate distance (see the image below). This disinsertion is required in most instances of horizontal tightening. If only a small tuck of the lateral canthal tendon is required, medial dissection is minimal.

A prepared strip of tarsus is visualized, then rotated laterally to allow the surgeon to judge the amount of redundant tissue to excise. The area to be excised is marked or scored to prevent overresection or underresection.

The part of the strip to be attached at the lateral orbital tubercle is then debrided of conjunctival epithelium by shaving with a No. 15 Bard-Parker blade. The lid margin epithelium is similarly removed with either sharp scissors or a monopolar cautery. These 2 maneuvers avoid burying epithelial tissues. The excess horizontal tendinous and tarsal tissue is then cut along the marked borders.

A 4-0 polyglactin suture is passed though the prepared strip of tarsus (see the image below); a single pass from anterior to posterior is usually sufficient. The needle is then repositioned on the needle driver and passed through the periosteum at the level of the lateral orbital tubercle. This is a somewhat deep suture pass, and visualization of the needle is difficult. Passage is aided be the use of the semicircular P-2 needle, which requires minimal rotation of the needle tip and hub and reduces the risk of inadvertent soft tissue (and globe) injury.

After a solid purchase of periosteum is obtained, the sutures ends are overlapped so that the effect of tightening can be observed. If the newly created lateral insertion is too high or too low, the suture should be removed and replaced. The same is true if the insertion is too deep in the orbit or too superficial. Once a satisfactory insertion is achieved, the suture is tied down with multiple square knots (see the image below).

If anterior lamellar tissue excess is evident at this juncture, conservative marking and construction of a dog-ear excision can be performed.

The lateral canthal angle is then repaired with either a 6-0 polypropylene suture or a dissolvable suture of 6-0 fast-absorbing gut. The suture should pass just inferior to the lower-lid lash line of the new canthal angle and should exit at the eyelid margin. The suture is then directed through the lid margin of the upper lid, exiting just superior to the lash line. Multiple square knots are used for fixation. The canthotomy and the area of dog-ear excision are closed with the same suture material (see the images below).

A medial spindle procedure may be considered for residual punctal ectropion in tearing patients (see the images below).

Involutional Entropion Repair

In the authors’ experience, repair of involutional entropion usually proceeds similarly to repair of involutional ectropion with respect to the horizontal laxity component of the disorder. Many options are available for repair of the vertical component (dehiscence of lower-lid retractors); the authors have found that both lower-lid retractor reinsertion and full-thickness sutures work well.

Horizontal lid tightening and lower-lid retractor reinsertion

Before the horizontal procedure described above, a marking pen is used to outline an infraciliary incision extending from the punctum laterally into a lateral canthal skin fold. A full-thickness skin incision is then made with a No. 15 Bard-Parker blade along the marking (see the image below).

A skin muscle flap is then elevated across the horizontal width of the incision in the sub–orbicularis oculi fascial plane. The flap is elevated inferiorly until the underlying orbital septum is visualized, along with the whitish postseptal lower-lid retractor aponeurosis. The orbital septum is then opened across the width of the eyelid (see the image below), and the edges of the lower-lid retractors are grasped with a toothed forceps and rotated superiorly to the inferior edge of the tarsus.

Sutures of 6-0 polypropylene are used to secure the superior edge of the retractors to the inferior border of the tarsus (see the images below). The lid may be slightly ectropic at this juncture; this state will be addressed subsequently by means of horizontal tightening.

From this point, the repair proceeds as for the horizontal tightening operation described above (see the images below). The lower-lid infraciliary incision is closed with a continuous suture of 6-0 polypropylene or 6-0 fast-absorbing gut.

Horizontal lid tightening and full-thickness eyelid sutures

The lower-lid retractors can be reinserted by means of either an open method, as described above, or a closed method that uses the Quickert suture technique.[9] The guiding aim of the closed technique is the same as that of the open technique—namely, repositioning of the disinserted lower-lid retractors at the level of the inferior border of the tarsus. The chromic suture appears to cause enough inflammation to create a new cicatricial attachment to the area of the inferior tarsal border.[10]

The operation proceeds as for the horizontal laxity repair described above (see the images below). Before the 4-0 polyglactin suture is tied down at the lateral rim, full-thickness sutures are passed.

Three sets of double-armed 4-0 chromic suture are passed: 1 in the nasal third of the lower lid, 1 in the central lower lid, and 1 in the lateral lower third. The first suture enters from the palpebral conjunctival surface deep in the lower fornix (and through the visible edge of the whitish retractor aponeurosis, if this is visualized). The suture is then directed anteriorly and superiorly, exiting a few millimeters below the lash line. The second arm is directed adjacent to and approximately 3-5 mm from the first pass.

All 3 sets of sutures are passed in this manner. The double-armed sutures are then tied over the skin under moderate tension (slight ectropion may be seen) or over cotton bolsters. The authors prefer the latter to prevent "cheese-wiring" and the occasional formation of suture abscesses. The operation then continues with the horizontal tightening procedure, as described above (see the images below).

Complications of Repair

Complications of ectropion or entropion repair include the following:

• Consecutive entropion or ectropion[11] - Consecutive entropion after ectropion repair or consecutive ectropion after entropion repair can occur; these complications should be managed with early massage or targeted suture removal, but surgical revision is occasionally required if they persist

• Hemorrhage - Meticulous hemostasis should be maintained throughout the procedure to avoid the possibility of a hematoma that may compromise surgical success or adequate wound healing or, more important, lead to visual loss due to orbital compartment syndrome

• Infection - Infection is rare after eyelid surgery but not impossible; appropriate prophylactic antibiotic regimens (systemic or topical) should be considered, and any postoperative infection should be managed with wound culture and sensitivity assessment, administration of broad-spectrum antibiotics, and surgical drainage of any abscess sites

• Loss of vision - This devastating complication can occur after any periocular surgical procedure; the best approach is proactive; globe injuries, hemorrhage, and corneal compromise may require outside consultation

• Wound dehiscence - Wound dehiscence may result from metabolic abnormalities, infection, or mechanical disruption; postoperative instructions should include general wound care recommendations to avoid these possibilities

• Recurrence - If entropion or ectropion recurs, further surgical intervention may be necessary; alteration of the surgical technique may be necessary to prevent additional recurrences

• Scarring - Scarring is part and parcel of any operation but, fortunately, tends to be insignificant after entropion and ectropion repair; massage, topical ophthalmic corticosteroid ointment, and triamcinolone injections may be helpful