Manual Provocation Test for Intermittent Involutional Entropion

CLINICAL SCIENCE

Rahul S. Tonk, MD, MBA, and Dale R. Meyer, MD, FACS

ntropion is an eyelid malposition characterized by inward Purpose: To describe the manual provocation test (MPT), a novel Erotation of the eyelid margin and eyelashes toward the test for intermittent involutional entropion of the lower eyelid. ocular surface. It can be associated with various degrees of ﬂ Methods: Retrospective review of patients with intermittent visual morbidity, including in ammation of the conjunctiva, corneal abrasions, microbial keratitis, corneal vascularization, entropion who presented with ocular irritation and documented 1–3 inward eyelid rotation by them or their referring physicians, but and vision loss. Entropion can be divided into 4 main types who had no apparent entropion at the time of initial consultation. according to the cause: congenital, involutional, spastic, and Results of the MPT were recorded for this group, and then cicatricial. Involutional entropion is the most common type seen evaluated prospectively in an age-matched comparison group of in general ophthalmic practice, and has been reported to occur in approximately 2% of the elderly population. Its prevalence is patients presenting for blepharoplasty who had no history of 2,4 entropion. The essential steps of the MPT are as follows. Step 1: projected to increase as the population ages. The pathophys- the lower eyelid skin is grasped below the inferior border of the iology of lower eyelid involutional entropion has been well tarsal plate. Step 2: the lid is drawn anteriorly as with the eyelid described, and generally includes horizontal eyelid laxity, distraction test. Step 3: the patient is directed to forcefully close the retractor dehiscence, and overriding of the preseptal orbicularis oculi onto the pretarsal orbicularis. Surgical treatment is often eyelids. Step 4: the eyelid is released and the result is observed for 3,5–9 manifest entropion. required in symptomatic patients. Entropion can be manifest at all times or it can be Results: Thirteen eyelids in 12 patients with intermittent involu- intermittent, occurring at a variable frequency with intervals tional lower eyelid entropion were included in this study. Average of relatively normal (ie, not overtly malpositioned) eyelid patient age was 77.3 years (69.5 SD). The MPT elicited entropion in position. In cases where a patient’s history is not classic, this all 13 eyelids. Of the 12 patients, 9 elected to pursue surgery and, of can result in ocular surface irritation of uncertain etiology.10 these patients, all eyelids were successfully treated with subsequent We have developed a simple test to aid in the evaluation of improvement of symptoms. The MPT was thereafter negative in patients reported to have involutional entropion, but in whom these patients. None of the 20 patients in the blepharoplasty entropion is not manifest on examination. In this article, we comparison group (average age 71.6 years) demonstrated a positi- describe our experience with this test, which we refer to as the ve MPT. manual provocation test (MPT) for entropion, and compare it with known measures. Conclusions: The MPT can be a valuable and straightforward test in the clinical evaluation of patients with a history of intermittent entropion. METHODS Key Words: ocular surface, dry eye, entropion, intermittent A retrospective review was done for patients presenting entropion, ocular irritation with intermittent involutional lower eyelid entropion in the (Cornea 2016;35:510–512) practice of one of the authors (D.R.M.) between April 2013 and May 2014. Patients were included if they complained of ocular irritation and had entropion observed by their referring physician or by themselves at some point in the past, but no manifest entropion on initial consultation either at rest or Received for publication September 4, 2015; revision received November 13, upon squeezing their eyelids. Results of the test as described 2015; accepted December 12, 2015. Published online ahead of print herein were recorded along with data on patient age, gender, February 18, 2016. and surgical repair. From the Department of Ophthalmology, Lions Eye Institute, Albany Medical Results of the MPT were then prospectively evaluated College, Albany, NY. The authors have no funding or conﬂicts of interest to disclose. in a nonrandomized comparison group of 20 consecutive Supplemental digital content is available for this article. Direct URL citations patients presenting for blepharoplasty. This group was appear in the printed text and are provided in the HTML and PDF conveniently chosen to evaluate this test in a similar age versions of this article on the journal’s Web site (www.corneajrnl.com). group without a history or evidence of entropion. Statistical Reprints: Rahul S. Tonk, MD, MBA, Department of Ophthalmology, Lions Eye Institute, Albany Medical College, 1220 New Scotland Ave, Suite evaluation using t test was performed to compare the mean 302, Slingerlands, NY 12159 (e-mail: [email protected]). age of these 2 groups. This study was approved by the Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. Institutional Review Board of Albany Medical Center.

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MPT Description these patients was thereafter negative. Of the 20 patients in The test essentially involves the 4 steps described the age-matched blepharoplasty comparison group, none had below and as shown in Fig. 1 (see Video, Supplemental a positive MPT. The average age of the blepharoplasty Digital Content 1, http://links.lww.com/ICO/A386, for group, 71.6 years (611.5 SD, range 56–98 years), was not a demonstration). significantly different from that of the intermittent entropion group (P =0.15). Step 1 The lower eyelid skin is grasped between the thumb and forefinger within the “preseptal zone” (inferior border of DISCUSSION the tarsal plate to the inferior orbital rim) (Fig. 1A). The evaluation of intermittent involutional entropion involves a thorough history and physical examination that Step 2 includes assessment of eyelid position, typically with some The eyelid is drawn anteriorly away from the globe as attempt to provoke or induce entropion if it is not overtly with the eyelid distraction test,3 and a general assessment of present, as well as evaluation of any coexistent ocular eyelid laxity can be made (Fig. 1B). surface disorder. Horizontal lower eyelid laxity, per se, can be detected by simple eyelid distraction and Step 3 snapback tests.3,11 The former is generally considered The patient is directed to forcefully close the eyelids suggestive of eyelid laxity if the lower eyelid can be pulled (Fig. 1C). more than 6 mm from the globe, and the latter if the eyelid is slow to return to its resting position after being Step 4 pulled inferiorly. The eyelid is released and the result is observed for A handful of measures have been previously described development of manifest entropion (Fig. 1D). to help “uncover” entropion in patients with a history of The test may be repeated, if desired, after returning the observed entropion who nevertheless present without overt eyelid to the noninverted position. in-turning of the eyelid margin at consultation, representing so-called intermittent entropion. Entropion may become manifest after the patient voluntarily and forcefully closes RESULTS (squeezes) the eyelids, which can elicit superior override of A total of 13 eyelids in 12 consecutive patients the preseptal onto the pretarsal orbicularis.1,3,10,12 For patients presenting with a history of intermittent involutional lower who cannot follow commands, Kashani et al12 have described eyelid entropion were evaluated using the MPT reported in instillation of topical ophthalmic anesthetic to produce ocular this study. Of these 12 patients, 5 (41.7%) were male and 7 irritation and subsequent orbicularis contraction, a technique (58.3%) were female. Average patient age was 77.3 years they refer to as the tetracaine provocation test. Faria-e-Sousa (69.5 SD) with a range of 57 to 90 years. The MPT et al10 describe another maneuver that they refer to as the test described above elicited entropion in all 13 eyelids. Of the of induced entropion (“TIE”). Essentially, the TIE involves 12 patients, 9 elected to pursue a previously described topically anesthetizing the eye, manually lifting/rolling lower surgery involving transconjunctival lower eyelid retractor eyelid skin over the tarsal edge, and spreading the resultant plication combined with horizontal tightening.8,9 All these inverted eyelid flat against the eyeball. The test is considered patients had resolution of their ocular discomfort after positive if the induced entropion remains stable for at surgery.TheMPTthathadbeenusedtoelicitentropionin least 3 minutes.

FIGURE 1. The MPT for intermittent entropion. A, The patient has no apparent entropion on initial examination. B, The lower eyelid is grasped within the “preseptal zone” and pulled anteriorly away from the globe. C, The patient forcefully squeezes the eyelids. D, After release, the patient demonstrates manifest lower eyelid entropion.

Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Tonk and Meyer Cornea Volume 35, Number 4, April 2016

In the present article, we describe what we term the REFERENCES manual provocation test, which, in this series, was able 1. Pereira MG, Rodrigues MA, Rodrigues SA. Eyelid entropion. Semin to elicit entropion in 13 eyelids of 12 patients with a history of Ophthalmol. 2010;25:52–58. 2. Boboridis KG, Bunce C. Interventions for involutional lower lid ocular irritation and intermittent entropion, but no manifest entropion. Cochrane Database Syst Rev. 2011;CD002221. entropion on examination either at rest or with eyelid 3. Skuta GL, Cantor LB, Cioffi GA, et al. American Academy of squeezing alone. In contrast to the tetracaine provocation test Ophthalmology Basic Clinical Science Course: Orbit, Eyelids, and or TIE, the MPT does not require topical anesthesia or more Lacrimal System. Vol. 7. San Francisco, CA: American Academy of – intensive eyelid manipulation. A key advantage is that the Ophthalmology; 2013:194 199. 4. Damasceno RW, Osaki MH, Dantas PE, et al. Involutional entropion and MPT is a natural extension of the eyelid distraction test, ectropion of the lower eyelid: prevalence and associated risk factors in which is an accepted technique for assessment of eyelid the elderly population. Ophthal Plast Reconstr Surg. 2011;27:317–320. laxity. Once the lower eyelid is anteriorly distracted, the MPT 5. Jones LT. The anatomy of the lower eyelid and its relation to the cause simply involves asking the patient to forcibly close the and cure of entropion. Am J Ophthalmol. 1960;49:29–36. 6. Rougraff PM, Tse DT, Johnson TE, et al. Involutional entropion repair eyelids, and then releasing the lower lid to determine if with fornix sutures and lateral tarsal strip procedure. Ophthal Plast manifest entropion can be elicited. Once documented, Reconstr Surg. 2001;17:281–287. appropriate consideration can be given to further medical 7. Scheepers MA, Singh R, Ng J, et al. A randomized controlled trial and/or surgical treatment. comparing everting sutures with everting sutures and a lateral tarsal strip – The limitations of our study should be considered, for involutional entropion. Ophthalmology. 2010;117:352 355. 8. Khan SJ, Meyer DR. Transconjunctival lower eyelid involutional including its retrospective nature and modest sample size. entropion repair: long-term follow-up and efficacy. Ophthalmology. While we have described some of the differences between 2002;109:2112–2117. tests for intermittent involutional entropion, the absolute 9. Barrett RV, Meyer DR. The modified Bick quick strip procedure for superiority of one test over another cannot be claimed. surgical treatment of eyelid malposition. Ophthal Plast Reconstr Surg. 2012;28:294–299. Further, although the MPT elicited entropion in all the 10. Faria-e-sousa SJ, Gomes Vieira MP, Silva JV. Uncovering intermittent patients we evaluated in our intermittent entropion study entropion. Clin Ophthalmol. 2013;7:385–388. group, and none in our comparison group of similar age 11. Michels KS, Czyz CN, Cahill KV, et al. Age-matched, case-controlled patients, the sensitivity and specificity of this test might vary comparison of clinical indicators for development of entropion and ectropion. J Ophthalmol. 2014;2014:231487. with a larger number of patients. That said, we feel that the 12. Kashani S, Friebel J, Sadiq A, et al. Re: the Tetracaine Provocation Test MPT can be a valuable adjunct in the clinical evaluation of (TPT) for inducing early involutional entropion. Ophthal Plast Reconstr patients with this condition. Surg. 2006;22:406–407.