Diagnosis and Management of Involutional Entropion

nvolutional entropion is a trouble details of recent mechanical 1A some eyelid malposition commonly manipulation of the eyelids Iencountered in elderly patients, with with lid specula should be a prevalence reported as high as 2.1% part of the routine entropion in those aged 60 years and older.1 The workup. condition is characterized by progres Interestingly, involutional sive inward rotation of the lower eyelid entropion and ectropion margin, causing progressive irritation share clinically and histo of the ocular surface. Although conserv logically defining features, 1B ative treatment with ocular lubricants, including retractor disinser taping, or botulinum toxin injections tion, horizontal lid laxity, can produce temporary relief, surgical and migration of the orbicu intervention is required to definitively laris. In comparison, entro restore anatomic positioning. pic lower eyelids were found to have more significant Etiology capsulopalpebral fascia dis INVOLUTIONAL ENTROPION. (1A) Ocular irritation The pathogenesis of involutional en insertion than their ectropic is apparent in affected left eye. (1B) Improvement tropion is multifactorial. Contributing counterparts, while ectropic after surgical repair with lateral tarsal strip and factors include progressive horizontal lids had more pronounced lower lid reinsertion. laxity of the tarsus and canthal ten horizontal lid laxity. dons, disinsertion of the lower eyelid Other types of entropion. Other causing the cilia and the eyelid mar retractors, and an overriding preseptal types of entropion have different etiol gin to come in direct contact with the orbicularis. General fat atrophy with ogies; they are classified as cicatricial, globe.4 enophthalmos and increased appo congenital, or spastic. Spastic entropion develops in sitional pressures during forced lid Cicatricial entropion is caused by response to acute ocular irritation closure likely also play a role; however, scarring of the conjunctiva and relative or inflammation. It often occurs in comparison with age-matched controls shortening of the posterior lamella. patients with underlying involutional by means of Hertel exophthalmometry This is the result of chronic auto eyelid changes and is further exacerbat measurements yielded no statistically immune, infectious, inflammatory, ed by the corneal irritation caused by significant difference.2 thermal, or traumatic insult. the entropion.5 Development of involutional Congenital entropion is a rare entropion is generally attributed to condition characterized by shortened Signs and Symptoms age-related decreases in collagen tensile posterior lamella, capsulopalpebral fas Symptoms—such as blurry vision, strength, although there are reports of cia dysgenesis, and structural weakness severe discomfort, foreign body sensa iatrogenic disinsertion of capsulopal of the tarsal fascia. An unusual form of tion, redness, itching, burning, exces pebral fascia during routine cataract congenital entropion includes a tarsal sive tearing, and discharge—are caused surgery.3 Thus, a thorough history with kink, in which the upper tarsus is bent, by cilia and keratin rubbing against an unprotected globe. This may result in a persistent epithelial defect, corneal BY CHRISTOPHER LO, MD, AND IOANNIS GLAVAS, MD, FACS. EDITED BY ulceration, and in the worst cases, globe

Christopher Lo, MD, and Ionnas Glavas, MD, FACS MD, and Ionnas Glavas, MD, Lo, Christopher SHARON FEKRAT, MD, AND INGRID U. SCOTT, MD, MPH perforation.

EYENET MAGAZINE • 35 Diagnosis Differential diagnosis.Entropion More Surgical Details should be differentiated from epibleph For more detailed coverage of the entropion repair aron (overriding pretarsal muscle), procedures discussed in this article, consult the Acad- trichiasis (misdirection of eyelashes emy’s Basic Techniques of Ophthalmic Surgery, 2nd without entropion), and distichiasis ed., published in 2015. Available in print and eBook (anomalous growth of eyelashes). formats, it presents step-by-step instruction and in- Characteristics of involutional formative illustrations for 81 surgical procedures—and entropion. Diagnosis can be made gives you access to 175 video vignettes on key points. by identification of involution of the Visit www.aao.org/store for further information. eyelid and lash margin on slit-lamp ex amination. Diminished tarsal integrity can be detected by the lid snapback test or the lid distraction test. is a fast, minimally invasive, low-cost include overcorrection with ectropion, Inferior capsulopalpebral fascia technique to temporarily reinsert lower in addition to the mild retraction and weakness, a defining anatomical defect lid retractors. granulomas that are also reported from in involutional entropion, can be In this procedure, a double-armed repair with the external approach. demonstrated by reverse ptosis of the absorbable suture is inserted into the Recurrence is slightly more frequent lower eyelid, deep inferior fornix, or conjunctival fornix below the lower with the internal transconjunctival diminished lower eyelid excursion on border of the tarsus to recruit the approach, although the difference is not far downgaze. With lower lid excursion, lower retractors. The suture is directed statistically significant.8 Conservative the presence of a visible white line in below the tarsal plate, and then upward retractor reinsertion without correction the inferior cul-de-sac represents a to emerge inferior to the lash line to of horizontal laxity can have recurrence complete retractor disinsertion. achieve lid eversion. rates as high as 17%; however, concur The use of Quickert sutures as a rent horizontal canthal shortening can Conservative Management primary procedure for entropion is greatly reduce recurrence rates.9 Artificial tears, lubricant eye ointment, controversial, however, because of high Lateral canthal tightening. Surgical and contact lenses can be used to recurrence rates. Male sex, severe lower procedures for tightening lower eyelid protect the ocular surface from the me eyelid laxity, and Asian race are risk laxity include full-thickness partial chanical trauma caused by rotated cilia. factors for failure of the repair with lower eyelid resection and lateral tarsal Lubrication will decrease a secondary Quickert sutures.7 In addition to recur strip procedure. Full-thickness lower spastic component of the entropion. rence, other complications can include eyelid resections require a wedge resec Tape can be placed parallel to the bruising, granuloma, and trichiasis. tion and tarsal repair. lower eyelid margin with horizontal Reinsertion of lower lid retractors. In the lateral tarsal strip procedure, tension to decrease horizontal tarsal Exploration and reinsertion of the after the surgeon performs a lateral laxity and allow for eversion of the lid lower lid retractor can be performed canthotomy and inferior cantholysis, margin. Care must be taken to avoid through a direct external incision or an the tarsus is isolated from the anterior excessive lid eversion, lagophthalmos, internal transconjunctival approach. and posterior lamella to create a de-epi or exposure keratopathy. In addition to In external repair, a subciliary thelialized strip of tarsus. The tarsus is cosmetic concerns, excessive taping can cutaneous incision is made. After the shortened and then reattached to the cause severe skin irritation. orbital septum is bluntly dissected, the periosteum of the lateral orbital rim. Although thermal cautery has been lower eyelid retractors are identified The lateral tarsal strip procedure used to induce shortening of inferior and reattached to the anterior inferior restores physiologic lower eyelid lid retractors and orbicularis, it is rarely tarsal edge with interrupted absorbable tension without causing eyelid margin a successful permanent solution. sutures. The skin is then closed over the notching or weakness, which can occur © 2015 ; AAO, Botulinum toxin injections have repair. Reported complications include after a full-thickness lower eyelid re been shown to be a safe and effective mild eyelid retraction and pyogenic section. In addition to recurrence, rare temporizing mechanism for patients granuloma. complications of the lateral tarsal strip with an overriding preseptal orbicu The internal approach involves a procedure include chemosis, self-limit laris. However, the condition recurs transconjunctival incision below the ing granuloma, and persistent trichiasis within 8 to 26 weeks, and repeated inferior tarsal border. A conjunctival without entropion. injections are needed to maintain the flap is elevated until the lower eyelid Combined everting sutures and therapeutic effect.6 retractors are identified. The retrac lateral canthal tightening. Combined tors are reattached to the anterior Quickert and lateral canthal tightening Ophthalmic Surgery of Basic Techniques Surgical Treatment inferior border of the tarsus, and the procedures have been gaining populari Everting sutures. The Quickert pro conjunctiva is approximated over the ty because of their decreased recurrence

cedure involves everting sutures and repair. Complications of internal repair rates and low risk of complication. from Illustration

36 • FEBRUARY 2016 A small amount of preseptal or bicularis can be removed in patients Advance Quality who have significant override that exacerbates the entropion. Reinserting of Care With the capsulopalpebral fascia, tightening Your Academy the tarsus, and trimming the orbicu laris addresses all 3 etiologic factors Member Benefits for involutional entropion. Despite significant improvements, recurrence rates in literature range from 0% (mean follow-up, 18 months) to 9.4% (mean follow-up, 24 months).10 Varying degrees of residual horizontal lid laxity may contribute to differences in recur rence rates.

Conclusions Understanding the anatomy, patho physiology, and etiologic factors is crucial in diagnosis and management of involutional entropion. Patient age, general health, and preferences must be considered in deciding between more and less invasive management modal ities. Many surgical procedures have been described in the literature, with varying recurrence rates. Everting su tures and lateral tarsal strip combined with preseptal orbicularis modification restore lower eyelid anatomy with good surgical result.

1 Damasceno RW et al. Ophthal Plast Reconstr Surg. 2011;27(5):317-320. 2 Kersten RC et al. Ophthal Plast Reconstr Surg. 1997;13(3):195-198. 3 Hurwitz JJ et al. Ophthal Plast Reconstr Surg. 1990;6(1):25-27. 4 Dailey RA et al. Ophthal Plast Reconstr Surg. With your American Academy of Ophthalmology membership, take advantage 1999;15(5):360-362. of hundreds of face-to-face and online learning and networking opportunities 5 Wies FA. Trans Am Acad Ophthalmol Otolaryn- that include: gol. 1955;59(4):503-506. • Access to the Academy’s IRIS® Registry (Intelligent Research in Sight) 6 Deka A, Saikia SP. Orbit. 2011;30(1):40-42. 7 Jang SY et al. J Craniomaxillofac Surg. 2014; • Access to the Academy’s Ophthalmic News and Education 42(8):1629-1631. (ONE®) Network 8 Ben Simon GJ et al. Am J Ophthalmol. 2005; • Complimentary registration for AAO 2016, Oct. 15 – 18 in Chicago 139(3):482-487. • Biographical information in the Academy’s online listing of 9 Boboridis K et al. Ophthalmology. 2000;107(5): practicing ophthalmologists 959-961. • Subscription to Ophthalmology®, the journal of the American 10 Scheepers MA et al. Ophthalmology. 2010; Academy of Ophthalmology; and online access to nine other journals 117(2):352-355. • Subscription to EyeNet® Magazine, the Academy’s top-ranked monthly magazine Dr. Lo is an ophthalmology resident, and Dr. Visit www.aao.org/member-services/benefits for a complete list. Glavas is a clinical assistant professor of ophthal mology; both are at NYU School of Medicine If you haven’t paid your 2016 dues, submit your payment today for Department of Ophthalmology in New York, N.Y. uninterrupted access to these exclusive benefits. Relevant financial disclosures: None.

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