Transconjunctival Entropion Repair Steven C. Dresner, MD, James W. Karesh, MD

lower-eyelid entropion has three underlying correctable causes: eyelid laxity, over- riding of the orbicularis oculi muscle, and attenuation of the lower-eyelid retractors. We de- scribe a new technique for correcting this problem. A transconjunctival approach is used to Involutionaladvance or fortify the lower-eyelid retractors. The orbicularis oculi muscle can also be addressed through this approach. Combining this technique with lateral canthal resuspension anatomically cor- rects the entropion by addressing all three correctable causes. Transconjunctival blepharoplasty can also be performed in conjunction with this technique. Twenty-three eyelids of 18 patients successfully underwent this procedure. Six patients underwent simultaneous transconjunctival blepharoplasty. Follow-up ranged between 9 and 18 months. There were no postoperative recurrences, overcorrections, or lower\x=req-\ eyelid retraction. This approach yields a stable and definitive repair of involutional entropion with excellent postoperative cosmesis. (Arch Ophthalmol. 1993;111:1144-1148)

Many procedures have been described for SURGICAL TECHNIQUE correcting involutional entropion.1"11 The development of these techniques has been The lower eyelid is anesthetized through based on an understanding of the various the inferior fomix with an injection of ap¬ correctable pathophysiologic processes un¬ proximately 2 mL of 1 % xylocaine hydro¬ derlying this condition: (1) horizontal eye¬ chloride with a 1:100 000 dilution of epi¬ lid laxity, (2) overriding of the preseptal nephrine. A 1- to 2-mL bolus of this same orbicularis oculi muscle, and (3) attenua¬ solution is instilled into the lateral can- tion of the lower-eyelid retractors. Invo¬ thus down to the periosteum. A protective lutional enophthalmos may also play a role eyelid plate is used over the globe during in the cause of involutional entropion; how¬ the dissection. ever, this factor cannot be safely or easily A lateral canthotomy is performed with managed.1 Definitive surgical correction of a straight tenotomy scissors (Figure 1, top involutional entropion needs to address all left). The inferior crus of the lateral can- three of the correctable causes. We have thai tendon is then incised (Figure 1, top developed a new technique to repair this right). A small retractor is placed in the condition that corrects these anatomic ab¬ lateral canthal incision. Beginning at the normalities and provides increased cosme¬ lateral canthus and extending just lateral sis through a transconjunctival approach. to the punctum, an incision is made with a cutting unipolar cautery just below the lower tarsal border through the conjunc¬ tiva and lower-eyelid retractors (Figure 1, From the Division Plastic and Department of Ophthalmology, of Ophthalmic bottom left). Little is en¬ Reconstructive Surgery, The Jules Stein Eye Institute, UCLA School Medicine, bleeding usually of countered in this bloodless Los Angeles, Calif (Dr Dresner); the Krieger Eye Institute, Sinai Hospital of Baltimore relatively plane. (Md) (Dr Karesh); and The Wilmer Ophthalmological Institute, The Johns Hopkins The orbital septum and the orbicularis oc¬ University, Baltimore (Dr Karesh). uli muscle are not violated during the dis-

Downloaded from www.archophthalmol.com at SCELC - City of Hope National Medical Center, on April 23, 2012 Figure 1. Top left, A lateral canthotomy is performed with a straight tenotomy scissors. Top right, The inferior crus of the lateral cantbal tendon is incised. Bottom left, An incision is made with a unipolar cutting cautery just below the tarsal border through the conjunctiva and lower-eyelid retractors. Bottom right, A cutting cautery is used to excise a strip of orbicularis muscle along the full length of the incision. section. The conjunctiva and lower- entropion is unilateral, a limited fat the conjunctiva with the cutting cau¬ eyelid retractors are elevated and excision or none at all can be per¬ tery to create a free edge (Figure 2, separated from the anterior eyelid formed to ensure symmetry with the top left). This free edge is then re¬ lamella and orbicularis muscle. The other eyelid. inserted into the inferior and ante¬ surgical plane is carried inferiorly to¬ The lower tarsal border is then rior tarsal border with two buried 5-0 ward the inferior orbital rim be¬ pulled upward, everting the eyelid. Cut¬ polygalactin sutures (Figure 2, top tween the lower-eyelid retractors and ting cautery is used to excise a strip right). Reattaching the retractors to the fat pads. Downward traction on of orbicularis oculi muscle below the the anterior surface of the tarsus ap¬ the lower eyelid with either a rake tarsus along the full length of the in¬ preciably everts the eyelid margin. No or a small Desmarres retractor is used cision (Figure 1, bottom right). Since closure of the conjunctiva is neces¬ for improving exposure. the orbital septum fuses with the lower- sary since the conjunctiva readily re- Once the fat pads are identified, eyelid retractors approximately 5 mm attaches to the inferior tarsal border. a transconjunctival blepharoplasty can below the tarsal border, excision of The eyelid is then horizontally be performed when necessary. Gen¬ the orbicularis oculi in this area can shortened to correct all eyelid laxity tle pressure on the globe or upward be performed without violating the body and a tarsal strip is formed as a sub¬ traction on the lower-retractors is help¬ of the orbital septum. The lower-eyelid stitute lateral canthal tendon. The nee¬ ful for demonstrating the three lower- retractors are firmly adherent to the dle tip of the electrocautery unit is used eyelid fat compartments. The fine con¬ conjunctiva and immediately poste¬ to create this strip by dissecting the nective tissues covering the fat pads rior to the fat compartments. If there tarsus of the lateral eyelid from the an¬ can be incised with the cutting cau¬ is any uncertainty about their location, terior eyelid lamella and removing the tery. Each fat pad is excised with the the patient can be asked to look up¬ eyelid margin and epithelium from it. needle tip of the cutting cautery with¬ ward and downward to identify the Shortening of the strip before its re¬ out clamping. Small vessels in the fat edge of the retractors. attachment to the lateral orbital rim are cauterized when seen. When the The retractors are separated from periosteum prevents the formation of

Downloaded from www.archophthalmol.com at SCELC - City of Hope National Medical Center, on April 23, 2012 a lateral subcutaneous lump after clo¬ pion (Figure 4) and in one patient COMMENT sure of the skin (Figure 2, bottom left). with unilateral entropion. Patients with The tarsal strip is reinserted into the cicatricial entropion were excluded from Most authors agree that there are three lateral orbital rim with two 4-0 poly¬ this study. elements responsible for involu¬ galactin sutures. The canthotomy in¬ All patients underwent horizon¬ tional entropion: lower-eyelid lax¬ cision can then be closed in standard tal eyelid shortening and lateral can- ity, attenuation of the lower-eyelid fashion (Figure 2, bottom right). thai resuspension as well as reinser¬ retractors, and overriding of the or¬ tion ofthe lower-eyelid retractors. Post¬ bicularis oculi muscle.12"15 There¬ RESULTS operative follow-up ranged from 9 to fore, a definitive procedure should 18 months. During this period there address all three of these elements. Transconjunctival entropion repair was were no entropion recurrences. No pa¬ The eyelids should be shortened hor¬ performed successfully on 23 eyelids tient had postoperative eyelid retrac¬ izontally; the lower-eyelid retractors of 18 patients with involutional en¬ tion or scierai show, and there were should be fortified or reinserted; and tropion (Figure 3). There were six no overcorrections. One patient had the orbicularis oculi muscle should men (33%) and 12 women (67%) rang¬ a postoperative stitch abscess, which be attended to, either weakening it ing in age from 63 to 94 years. The resolved with antibiotic treatment and or creating a scar barrier under the mean age was 78 years. Five patients removal of the suture. Postoperative tarsus to prevent overriding of the (28%) had bilateral entropion repair ecchymosis was minimal and gener¬ preseptal portion. and 13 (72%) had unilateral repair. ally resolved in 2 weeks. The conjunc¬ In the evolution of entropion re¬ Ofthe 13 unilateral repairs, nine (69%) tival incisions were all fused in the first pair, many techniques have been de¬ involved the right eyelid and four (31%) week after surgery, and persistent con¬ scribed. In general, some failed to ad¬ the left. Transconjunctival blepharo- junctival edema was not a problem. dress any of the causative factors plasties were performed concomitantly No patients had postoperative corneal underlying involutional entropion. in five patients with bilateral entro- stippling or epithelial defects. Most, however, corrected only one

Figure 2. Top left, The retractors are separated from the conjunctiva with the cutting cautery to create a free edge. The tip of the cautery points to the lower-eyelid retractors. Top right, The lower-eyelid retractors are reinserted to the inferior anterior tarsal surface with two buried 5-0 polygalactin sutures. Bottom left, A horizontal eyelid shortening and eyelid resuspension through tarsal strip formation is then performed to tighten the eyelids. A small portion of tarsus extends from the horizontally shortened eyelid before its reattachment to periosteum of the inner aspect of the lateral orbital rim. Bottom right, The skin incision is then closed in standard fashion.

Downloaded from www.archophthalmol.com at SCELC - City of Hope National Medical Center, on April 23, 2012 Figure 3. Left, Preoperative appearance of a patient with entropion of the right lower eyelid. Right, Postoperative appearance 6 weeks after transconjunctival entropion repair. or two of these factors. Ziegler2 de¬ lid laxity or abnormalities of the lower- effectively and permanently performed. scribed a technique using cautery to eyelid retractors. In addition, it did not correct atten¬ create a scar between the anterior and Quickert and Rathbun7 described uation of the lower-eyelid retractors. posterior lamellae of the eyelid to re¬ a suture technique to create scarring Jones et al8 described dysfunction of pair entropion. Since this technique similar to that created by the Wies pro¬ the lower-eyelid retractors in involu¬ does not address any of the caus¬ cedure. This was modified by Rain- tional entropion and advocated tuck¬ ative factors, it has a high failure rate.16 in17 to include deeper cul-de-sac su¬ ing or resecting the abnormal retrac¬ Wies6 attempted to create a more tures to imbricate the lower-eyelid re¬ tors. Dryden et al10 described reattach- permanent scar between the anterior tractors. Both of these techniques can ing the retractors directly to the inferior and posterior lamellae of the eyelid be helpful to temporize before a de¬ tarsus in a similar fashion. with a full-thickness blepharotomy finitive procedure can be performed. Carroll and Allen1 have described combined with rotation sutures. This Neither achieves a high degree of per¬ a combined technique of retractor re¬ technique prevented overriding of the manent correction since horizontal eye¬ insertion and eyelid shortening that preseptal orbicularis oculi muscle but lid laxity is not addressed. To over¬ requires a full-thickness blepharotomy. did not address eyelid laxity or the come this problem, Bick18 described Wesley and Collins20 have also pre¬ lower-eyelid retractors. However, it a technique of full-thickness eyelid sented a combined technique oflower- is helpful in certain cases of cicatri- shortening. While this corrected one eyelid retractor repair with horizon¬ cial entropion. Frequent overcorrec¬ underlying cause of entropion, it left tal eyelid shortening. A modification tions and poor cosmesis limit its use¬ abnormalities of the orbicularis oculi ofthis technique has also been described fulness today. To prevent overriding muscle and eyelid retractors untouched. by Nowinski.21 All these techniques of the preseptal orbicularis oculi mus¬ Leone19 described a technique of provide long-term success and address cle, Wheeler3 transposed a strap of this transconjunctival tarsectomy and or- the three important elements causing muscle from the infratarsal area to the biculectomy to correct entropion. This entropion: lower-eyelid laxity, retrac¬ orbital rim. While this corrected the technique excised central tarsus in¬ tor attenuation, and overriding orbic¬ problemwith the orbicularis oculi mus¬ stead ofcorrecting the eyelid laxity at ularis oculi muscle. However, these cle, it did not address horizontal eye- the lateral canthus, where it is most techniques require a subciliary inci-

Figure 4. Left, Preoperative appearance of a patient with bilateral lower-eyelid entropion. Right, Postoperative appearance 6 weeks after bilateral transconjunctival entropion repair and bilateral transconjunctival blepharoplasty.

Downloaded from www.archophthalmol.com at SCELC - City of Hope National Medical Center, on April 23, 2012 sion. In our experience, overcorrec- averts iatrogenic retractor disinsertion, Monica Blvd, Suite 101, Santa Mon¬ tion and postoperative eyelid retrac¬ and is superior cosmetically to the skin ica, CA 90404 (Dr Dresner). tion with the anterior subciliary ap¬ approach. can be problematic and Nonetheless, it must be proach yield pointed REFERENCES less than satisfactory cosmetic results. out that there is some advantage to the It is interesting to note that in cutaneous for entropion re¬ approach 1. Carroll RP, Allen SE. Combined procedure for It a more all the patients described by Wesley pair. may be possible to create repair of involutional entropion. Ophthal Plast Re- and Collins,20 the capsulopalpebral significant anterior lamellar scar with constr Surg. 1991;7:123-127. fascia was noted to be disinserted on a skin incision and skin-muscle 2. Ziegler SL. Galvanocautery puncture in ectro- flap, pion and entropion. JAMA. 1909;53:183-186. This anatomic an of successful en¬ surgical exploration. important aspect 3. Wheeler JM. Spastic entropion corrected by or- defect was not corroborated in our tropion surgery. However, this must bicularis transplantation. Trans Am Ophthalmol study and has not been confirmed be weighed against the significant prob¬ Soc. 1938;36:157-162. 4. Sisler HA. A biomechanical and physical ap- in of of retraction a cuta¬ pathologic evaluation other pa¬ lems eyelid and proach to corrective surgery for senile entro- tients with entropion.22 Indeed, in neous scar associated with this approach. pion. Ann Ophthalmol. 1973;5:483-484. SA. none of the patients on in In addition, based on the successful and 5. Fox Relief of senile entropion. Arch Oph- operated thalmol. 1951;46:424-431. our study were the lower-eyelid re¬ stable results achieved using a transcon¬ 6. Wies FA. Spastic entropion. 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Senile en- cia and the orbital septum fuse into scar formation in a cicatricial tropion: pathogenesis and treatment. Arch Oph- resulting thalmol. 1978;96:1883-1885. a single layer, approximately 5 mm entropion. However, this did not oc¬ 11. Schaefer AJ. Lateral canthal tendon tuck. Oph- below the tarsal border. Since their pa¬ cur in any of our patients and has not thalmology. 1979;86:1879-1882. tients showed no definitive fasciai been shown to occur in other reports 12. Hsu WM, Liu D. A new approach to the correc- 23 tion of involutional entropion by pretarsal orbic- disinsertion, they speculated that its of transconjunctival surgery.23 ularis oculi muscle fixation. Am J Ophthalmol. occurrence may be iatrogenic. Although Our procedure addresses all the 1985;100:802-805. the exact role of the re¬ correctable factors of for a 13. Siegel RJ. Involutional entropion: a simple and sta- lower-eyelid entropion ble repair. Plast Reconstr Surg. 1988;82:42-47. tractors in the pathogenesis of entro¬ definitive and lasting repair. The re¬ 14. Schaefer AJ. Variation in the pathophysiology of pion is still not well defined, Hawes tractors can be strengthened or directly involutional entropion and its treatment. Oph- and Dortzbach22 did agree that reattached to the inferior anterior tar¬ thalmic Surg. 1983;14:653-655. laxity 15. Collin JRO, Rathbun JE. Involutional entropion: or attenuation of the lower retractors sus via a near-bloodless field. The anat¬ a review with evaluation of a procedure. Arch is partially responsible for the devel¬ omy of the lower eyelid leaves an ap¬ Ophthalmol. 1978;96:1058-1064. 16. Hornblass Bercovici Smith B. Senile opment of entropion. This fasciai proximate 5-mm area below the tar¬ A, E, en- layer tropion. Ophthalmic Surg. 1977;8:47-57. inserts on the an¬ sus both posterior and where the orbicularis oculi muscle 17. Rainin EA. Senile entropion. Arch Ophthalmol. terior tarsal surfaces and the base of can be excised without violating the 1979;97:928-930. 18. Bick MW. the tarsus. The posterior tarsal inser¬ of the orbital septum. This ex¬ Surgical management of orbital tarsal body disparity. Arch Ophthalmol. 1966;75:386-389. tion is particularly firm and extends one cision creates the scar barrier to pre¬ 19. Leone CR. Internal tarsus-orbicularis resection third of the distance up the tarsus.22 vent overriding of the orbicularis oc¬ for senile spastic entropion. Ann Ophthalmol. 1975; Therefore, attenuation of the anterior uli muscle. Eyelid laxity is then repaired 7:1004-1006. 20. Wesley RE, Collins JW. Combined procedure for se- insertion at the a portion of this with retention anatomically lateral canthus, nile entropion. Ophthalmic Surg. 1983;14:401-405. of the posterior portion theoretically modification ofthe procedure described 21. Nowinski TS. Orbicularis oculi muscle extirpa- may be a factor in the de¬ Anderson and Gordy.26 tion in a combined procedure for involutional en- contributory by tropion. Ophthalmology. 1991;98:1250-1256. Future ana¬ velopment of entropion. The transconjunctival entropion 22. Hawes MJ, Dortzbach RK. The microscopic anat- tomic studies may further elucidate this. repair is also useful in bilateral cases omy of the lower eyelid retractors. Arch Oph- surgery has when is desired. It pro¬ thalmol. 1982;100:1313-1318. Transconjunctival blepharoplasty 23. McCord CD Jr, Moses JL. Exposure of the in- been sur¬ a used successfully for orbital vides excellent cosmesis without sub¬ ferior orbit with fornix incision and lateral can- gery, blowout fracture repair, and lower ciliary incision and removes the "bags" thotomy. Ophthalmic Surg. 1979;10:53-63. This has been without scierai show and 24. Tenzel RR, Miller GR. Orbital blow-out fracture blepharoplasty. approach subsequent repair, conjunctival approach. 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