Entropion Lower Eyelid Reconstruction Treatment & Management

If surgical therapy is unwarranted or impossible, patients with lower lid entropion should be treated medically. Symptomatic therapy can be achieved using artificial tear ointment or drops. Moisture shields are also helpful. Additionally, the lower lid can be taped down slightly, everting the lid and lashes from the eye using specially designed or normal skin tape.

For temporary spastic entropion (eg, from postoperative ocular surgery), botulinum toxin (BOTOX®) injections to the lower lid can be considered. The author usually administers 3 injections of 5 units BOTOX® laterally, centrally, and medially. Effects usually start in 2 days and last 3-6 months. If the inciting event disappears, BOTOX® injections can be a permanent cure.

The same BOTOX® therapy can also be a useful adjunct in reoperations or surgical treatments, especially in patients in whom orbicularis tone is 3-4 or higher.

The correct surgical treatment of entropion depends on etiology. ^[5] Horizontal lid laxity is often observed with entropion and can usually be corrected with a lateral tarsal strip procedure. ^{[6, 7]}

Entropion often requires reinsertion of lower lid retractors. Augmentation of posterior lamellae (along with excision of any cicatrix) is required for cicatricial entropion and can be helpful in reoperations after simpler procedures have failed.

The author recommends using a corneal protector during oculoplastic procedures. The surgeon must be wary of the remote possibility of flash burns whenever oxygen is on the surgical field. Failure to use a corneal protector may transform an elective lid repair into a much more complicated problem.

Patient comfort should be ensured during surgery. Since most cases of ectropion involve the lower lid, supplemental infraorbital nerve block is a useful adjunct to direct injection and subconjunctival injection.

Suture repair - Everting sutures

The author does not advocate this temporary repair method. Double-armed chromic sutures are passed through the fornix near the orbital rim, emerging at the skin surface just under the lash line. Even though this procedure often is not useful alone, it can be a useful adjunct to another procedure (eg, lateral tarsal strip).

A study by Jang et al found that of 69 patients with involutional entropion who were treated with Quickert sutures, 34 of them (49.3%) experienced a recurrence within a 2-year follow-up period. ^[8]

The lower lid diamond

This is a useful technique (described here ^[9] ) with a higher success rate than everting sutures and is particularly suitable for patients for whom rapid surgery is needed or a lateral canthotomy is best avoided.

Congenital entropion

The surgeon should try to differentiate this extremely rare condition from epiblepharon, which is much more common. Epiblepharon is corrected easily with an elliptical orbicularis-skin excision and interrupted 6-0 gut skin closure.

Lateral tarsal strip

Horizontal lid laxity is a component of most entropion cases, especially involutional entropion. Whenever feasible, the author prefers a lateral canthal-tightening procedure. Surgery at the lateral canthus avoids the possibility of lid notching with noncanthal procedures and decreases the risk of trichiasis. The most common variation of lateral canthal tightening is the lateral tarsal strip procedure. ^[10]

The lateral canthus can be clamped prior to canthotomy; then perform inferior cantholysis with Westcott scissors. The lower lid should then be freely mobile. Excess lid skin can be draped over the lateral canthus. Excise an appropriate triangle of full-thickness lid.

Approximately 3 mm of the lateral lid then is split at the gray line with sharp Westcott scissors or a No-15 blade. Trim away meibomian orifices of the lateral strip. Scrape the lateral conjunctiva to avoid epithelial inclusion cysts.

To secure the lateral strip of tarsus to the periosteum, 2 sutures (or a single horizontal mattress suture) can be placed approximately 4-5 mm posterior to the lateral orbital rim near the Whitnall tubercle (at or above the level of the inferior pupil). Suitable sutures with small semicircular needles include 5-0 Vicryl on a P2 needle or 4-0 Prolene on a PS-5 needle. Retracting the upper lid supertemporally and placing a cotton-tipped applicator at the lateral canthus to palpate the inner lateral orbital rim may help.

Before tying the suture, remove the corneal shield. The orbicularis layer can be closed with 6-0 Vicryl, and the skin can be closed with 6-0 plain gut. A stitch through the lateral-most gray line of the upper and lower lateral lid helps keep the lateral canthus sharp.

If the patient requires topical drops (eg, glaucoma therapy) postoperatively, do not retract the lower lid for the first month during drop instillation.

Patients often complain of prolonged discomfort at the lateral canthus following this procedure.

Severe entropion with retractor disinsertion

This complete inversion of the lower lid occurs when the capsulopalpebral fascia is disinserted from the inferior tarsal border. In addition to horizontal lid tightening, reinsert the retractors (ideally from a skin approach).

A double-armed 5-0 chromic suture can be used to reattach the capsulopalpebral fascia to the inferior tarsus in running fashion.

Spastic entropion

A tarsal strip procedure often is helpful. Only 0-2 mm of the lateral lower lid may have to be excised. In patients with extreme spastic ectropion, surgery can be augmented with preoperative or postoperative BOTOX® injections.

Cicatricial entropion

An enhanced tarsal strip (ie, tarsal strip with a posterior lamellas spacer graft) may help correct some degree of cicatricial ectropion. Spacer grafts may be obtained from the upper lid (tarsus), roof of the mouth (hard palate), nasal septal cartilage, buccal mucosa, or banked sclera. A superior traction suture decreases risk of recurrent cicatrix postoperatively. All these areas can and have been used; the best area is likely the one that is most similar to the existing tissue, ie, the tarsoconjunctival plate from the upper lid. ^[11]

For lid sutures, the author prefers an antibiotic steroid combination (eg, Maxitrol [neomycin, polymyxin, bacitracin]) administered three times per day. Applying cold compresses to the eyelids every 15 minutes (as tolerated) while awake decreases bruising and swelling. Frozen peas in a plastic bag are a useful alternative to traditional cloth compresses.

The author generally does not prescribe narcotics postoperatively. The patient is asked to use oral acetaminophen 325-650 mg every 4 hours as needed. Patients are asked to avoid aspirin-containing products.

Patients are usually reviewed on the first postoperative day, then 5-7 days later for suture removal.

Complications are primarily related to corneal damage and can involve corneal breakdown, ulcer formation, epiphora, and pain. Surgical complications may include bleeding, hematoma, infection, wound dehiscence, pain, and poor positioning of the tarsal strip.

Entropion surgery often has a poorer outcome than ectropion surgery and more recurrences. Frequency of surgical failure can be greatly reduced by carefully looking at the etiology of the entropion. Augmentation with BOTOX® for overacting orbicularis, augmentation with a spacer graft for patients with short posterior lamellae, and reinsertion of inferior retractors all can be helpful, either singly or in combination. ^{[12, 13]}