Entropion is a common involutional lid malposition that in addition to causing discomfort, can cause lasting damage to the cornea. This webinar will review the underlying anatomy, causes of involutional entropion and equip the viewer with strategies for surgical repair.
Lecturer: Dr. Tamara Fountain, Professor of Ophthalmology, Rush University Medical Center, Chicago, USA
DR FOUNTAIN: Good morning, everyone. It’s really my honor and pleasure to present for the next hour or so my lecture called: Rub You the Wrong Way: The Management of Entropion. And I want to thank Cybersight and Orbis for the opportunity to be talking with you today. My name is Tamara Fountain, and I’m a Professor of ophthalmology at Rush University in Chicago. What we’ll be covering today is: I’ll answer the question: What is entropion? What problems does entropion cause? We’ll go over the various types of entropion. I will discuss the various treatments of entropion. And also give you some strategies when initial treatments don’t work, and we’ll finish up with questions and answers. What is entropion? Well, it’s defined as a lid malposition, in which the lid margin and its lashes are rotated against the globe surface. As you can see here in this picture. What entropion isn’t is: Trichiasis. Now, even though entropion, by definition, rolls the margin in, and almost always along with the lashes, just because there are lashes touching the eye does not mean that entropion is present. As you can see here, in some cases, lashes can touch the eye because they’re misdirected or there is an extra row of them in the posterior margin that can also touch the globe. And it’s important to make this distinction, because the treatment for trichiasis in almost all cases will be very different than the treatment for entropion, which is what we’ll be covering today. Also, what isn’t entropion is: Epiblepharon, either of the upper lid, as in slide left, or the lower lid. An epiblepharon is a natural condition in which a fold of skin and underlying orbicularis forces the lashes against the globe. In general, we do not see marginal rotation in situations like these. Which means that it’s not technically entropion. But it can cause some of the same issues. Now I’d like my first polling question, please. For the audience: Which of the following is not a factor in the development of entropion? Periocular photoaging, horizontal lid laxity, ocular surface inflammation, or involutional enophthalmos. And the results of the poll show most people voting for ocular surface inflammation. And right behind, periocular photoaging. So periocular photoaging typically will cause tightening and perhaps contracture of the periocular skin, particularly the skin of the lower lids and the cheeks. And this type of anterior lamellar contraction will generally lead to the lid being pulled outwards, or ectropion. However, horizontal lid laxity is probably the primary underlying anatomic factor in the development of entropion. Ocular surface inflammation also, because it’s the interior lamella — the posterior lamella that’s affected can cause a type of cicatricial entropion. And finally, involutional enophthalmos or the tendency for there to be orbital volume loss as people age also causes the eye to recess, relative to the lids, and promote possible entropion. So the correct answer for this question is A. Periocular photoaging. Next slide. So the different types of entropion include congenital, which is extremely rare. In my 25 years of practicing, I have never seen a case. But the underlying factors are when babies are born with the same type of elements that lead to adult entropion. And that would be disinserted lower lid retractors, deficiency of the posterior lamella, kinking of the tarsal plate, and treatment for this is similar to that in adults, which starts with lubrication, taping, possible botulinum toxin to weaken the orbicularis muscles, and finally, surgery. Another type of entropion is cicatricial entropion. Where the posterior lamella is deficient in some way, through a variety of causes, which can include radiation damage, acute trauma, as in topical chemical burns or surgery, more often in my practice I see chronic inflammation that can be caused by things as varied as a constant use of glaucoma drops, trachoma infections, skin diseases like Stevens-Johnson, or ocular cicatricial pemphigoid, and other infections that include herpetic disease. No matter the underlying cause, the end result is fibrosis of the bulbar and palpebral conjunctiva, which causes shortening of the posterior lamella, and inward rotation of the eyelid margin, along with the lashes. This type of entropion is the most difficult to treat. There are a number of surgical options that I will detail later. And there is a significantly higher recurrence rate. Anywhere from 12% to 71% for treatments aimed at cicatricial entropion. Another type of entropion is referred to as spastic. This is typically intermittent. Commonly associated with focal muscle spasms. But it causes corneal irritation, and in many cases is considered a precursor to full involutional entropion. Involutional entropion is the final classification that I will talk about today. And I left it for last, because it by far is the most common type of entropion that I encounter in my practice. And the four underlying anatomic physiologic predisposing factors are: Horizontal lid laxity, recession of the lower lid retractors, overriding of the orbicularis muscle, particularly the pretarsal and preseptal orbicularis, and involutional enophthalmos, as you’ll see here in this picture of severe orbital volume loss and relative instability of the lids, as the result of the backwards movement of the eyeball. When I talk to patients about entropion, I commonly use an analogy of a tennis net. Even if a patient has never played tennis before, most of them are familiar with the tennis net, and that properly set up, it’s tightly strung across the court. And I explain to patients that if someone were to loosen the side of the tennis net, depending on which way the wind was blowing, the lid might flop into one side of the court or the other. And then I make an analogy to our eyelids, and that as we all age, our soft tissues can become lax, and the lower lid can become lax to the point where, depending on underlying anatomy, a lax lid might flop inwards, toward the eye, or away from the eye. Like this. So away, as in ectropion, or in, as in entropion, like a tennis net would flop one way or the other. A study out of the Ophthalmic Plastic Surgery and Reconstructive Surgery Journal in 2011 looked at 25,000 Brazilians, 60 years of age or older. And they studied the prevalence of lid malpositions. They found a 2% incidence of entropion and a 3% incidence of ectropion. So they found, in a very large cohort, a slightly increased incidence of ectropion over entropion. But interestingly, they found that ectropion patients, in general, had 2 millimeters greater axial projection. So going back to that tennis net analogy, it seems to be that people with more prominent globes, like this gentleman here in profile, may be more likely to have ectropion than a person with a more deep set eye, like this person. So what kinds of problems do our patients have, when they come to see us with entropion? Well, because the lashes — or at least the skin — is rubbing against the eye, this causes irritation and pain, commonly injection of the conjunctival surface, that leads to tearing and a mucousy discharge. Left untreated and over time, it can cause superficial corneal damage that can also progress to more permanent corneal damage, through stromal scarring. Weakening of the corneal surface can also predispose to infection. And of course, mucous discharge and tearing and corneal issues can all lead to blurred vision. So let’s move on into various treatments. I find in my practice that most people — the vast majority of people — at least present with unilateral symptoms. A careful history may reveal an underlying reason for the unilaterality, and it may have to do with the use of glaucoma drops in the past or present. A prior infection. A tendency for eye rubbing, in which case the dominant side may be rubbed more frequently and more vigorously. Something as relatively innocuous as sleep position can also contribute. This in general, involutional entropion, is a disease of aging. And so people who are habitual lifetime sleepers on one side, if you ask the question, you’ll commonly find or reveal a history of one-sided sleep patterns. And I reassure my patients that it’s very difficult to change one’s sleep position, and that generally speaking, even with surgery, that their lid will be able to withstand the sleeping forces. So I usually find that I’m not trying to convince people to change their sleep position. I say that the surgery should correct this. And should hold with your continued sleep position. Some of the tests that we can use as part of our workup for patients we suspect or diagnose with entropion is this distraction test. Which is where you grasp the lower lid and pull away from the globe. Everybody’s lid will pull away somewhat. But we generally feel a cutoff of 1 centimeter is within normal limits. If you can distract a lid forward away from the globe more than 1 centimeter, then we consider that general laxity. Snap back is another test we can perform. In which case we pull the lid away from the globe and then let go. And we observe what happens. In a normal situation, the lid will snap back and reoppose the globe without any action on your part, except simply releasing your finger. People who have lid laxity, however, will find that the lid will not quite snap back to the globe until the patient blinks. So we call this a positive snap back test, when the lid does not automatically, on its own, preblink, reoppose itself to the globe. Generally, people will have a global laxity of the eyelid, but it’s important to know whether their medial canthal tendon is particularly affected. Because it may impact the way you tighten the lid. And the way to demonstrate that would be to distract the lid laterally. For most normal patients, distraction laterally will not be able to pull the punctum past the level of the medial limbus. If you’re able to pull the punctum, as in this case, past the medial limbus, then the medial canthal tendon is at least one source of the laxity, and may need to be addressed separately, in addition to the other parameters that cause the entropion. In mild cases or intermittent spastic-type cases, many times simple lubrication will be enough to manage very mild and early symptoms. And the lubrication can take the form of over-the-counter drops, as well as ointments. Because ointments tend to blur vision, patients like those at nighttime, when they’re about to go to bed. People who wear contact lenses for refractive reasons automatically have a little bit of a bandage, because their contact lenses will prevent mechanical abrasion of the lid margin and the lashes against the globe. In some cases where surgery is not desirable or not possible, then patients can be fit with a non-refractive or bandage contact lens. In situations like the use of a contact lens, however, we obviously do not recommend full-time overnight 24-hour a day use of contact lenses. So at some point, the patient will still be vulnerable at the times of the day when the contact lenses are not in the eye. Some patients have figured out on their own, even before they come see me, that mechanical distraction is a highly effective workaround for this eyelid malposition. And people can use any type of tape. Here is a type of surgical tape that’s used — applied to the skin of the eye, and then pulled downward. This can stabilize the lid enough, in cases of very mild involutional entropion, that we will see the lid stabilize, and not roll inwards. I had a patient once who presented to me. On her form, her consultant form, it listed entropion. But when she showed up in my office, she looked like this. And I thought to myself: Hm. Maybe she’s got a spastic entropion. Because she certainly doesn’t have entropion on examination right now. But if you see very closely, she has applied a piece of flesh-colored tape, that even initially eluded my gaze. And she fooled me, because she was, in effect, distracting her lid with this almost invisible tape. When I asked her to remove the tape, and then to close her eyes very tightly, that was when her entropion became manifest. And I think that the tape is… You know, people get dermatitis from chronic use of taping. But it is actually very effective, at least as a temporizing measure. And patients can apply it themselves, or a family member can help. So here is our second audience poll question. Suture rotation, sometimes referred to as Quickert suture, of the eyelid margin addresses which physical component of involutional entropion? Orbicularis weakness, lower lid retractor recession, posterior lamellar shortening, or involutional enophthalmos. And the most common answer is lower lid retractor recession. And that is correct. These are all four contributors to entropion. But the rotational sutures address just one of these aspects. And that’s the lower lid retractor recession. And the way this happens here, in a schematic diagram, shows that sutures are introduced in a double armed fashion. You can also introduce a single armed suture, if that’s all you have. You just have to enter the skin first. But a horizontal mattress suture is effectively run from the inferior fornix out through the skin, just beneath the lashes. So it’s an inferior to superior trajectory of the suture. And by tying this tightly, it advances the retractors and everts the eyelid. This is a patient of mine who presented with, again, almost always unilateral right lower lid entropion. He was headed off on a long vacation, and couldn’t make time for surgery. So we decided to do suture rotation on him. I use a 4-0 double armed chromic suture.
DR FOUNTAIN: And I inject 2% lidocaine into the subcutaneous tissues beneath the eyelashes. In an infraciliary fashion. As well as the conjunctival palpebral tissues. I am backhanding the suture in this situation. And I’m going deep in the fornix, in a lateral position, and I’m using my finger to help position the eyelid, so that my needle is retrieved from just beneath the lashes. So I’ve gone from deep to — or inferior, in this case, to superior. I take the other limb of this double armed chromic 4-0 suture, and I move about 3 millimeters away from the previous exit, and I retrieve that needle as well. I then tie this with three half-throws. And you can watch very closely here, as I cinch this suture down. You can see how the lid margin everts. So a second throw here. And I’ve placed one lateral suture. Now, typically I will place three sutures across the lid for suture rotation, roughly dividing the lid into quarters. And you can see here again with the placement of the central second suture nice eversion of the eyelid margin. And the third suture was placed, and here you can see the nice eversion of the eyelid edge. And so you see here in the immediate postoperative phase that there’s a slight overcorrection, which is something always to shoot for, because just as you all saw, this procedure addresses one of the four components of involutional entropion. And that’s the reason why it’s not quite as powerful and has a higher recurrence rate. But in this case, it gave him just the eversion he needed to take his vacation and enjoy his time away, while we scheduled his surgery. And you can see here before pictures on the left, and after about one week, the sutures are dissolved, and the lid has maintained its nice everted position. And again, no overcorrection. I’ve never been able to overcorrect with suture rotation. But if you shoot for that initially, then you should have a more durable result. Orbicularis resection will address the overlying — excuse me — the overriding orbicularis component. And I’ve used it here on a case that is partially due to a little bit of an epiblepharon-type rotation of the lid margin. And so it was very mild, and the lashes barely abraded the corneal surface, and so I was able to get away with addressing just the overriding orbicularis for this particular case. And finally, the real workhorse of our entropion surgical repair is horizontal lid tightening. And we can tighten the lid laterally, which is normally what I do, except for cases as we saw in the test of medial canthal tendon laxity. If there is significant medial canthal tendon laxity, then aggressive lateral horizontal tightening will pull that punctum way out of position. So I choose to tighten medially with a full thickness wedge resection in cases of medial canthal tendon laxity. And the horizontal laxity can be addressed starting with a lateral canthotomy. And I thank my colleague and dear friend Jeremiah Tao for these pictures. And then an inferior cantholysis to free up the lower lid edge. As you can see here, I can distract that lower lid cut margin away from the globe after the inferior cantholysis. I then overlap the lid to see how much I want to remove, and therefore shorten the eyelid. And then I will tag that cut edge of eyelid. I like to use a 5-0 vicryl suture on a very large PS2 needle, which helps me to retrieve the suture from the lateral orbital tubercle. And then we resuspend that shortened cut edge of the lower lid to the lateral orbital tubercle. As in the case — as with any type of lateral tarsal strip or other type of lateral canthal shortening. And it’s important, as we all know, to get the placement of this lateral orbital rim suture posteriorly, so that the lid, once reapproximated, will continue to follow the natural curvature of the globe, and not leave any space between the lid and the bulbar conjunctiva. And then you can reform the canthal angle with a cerclage, 6-0 plain gut suture. And this slide here just happens to show somebody who had a lower lid tightening in conjunction with an upper lid blepharoplasty. So our third polling question: Surgical entropion repair can typically address all but which of the following causes of involutional entropion? Horizontal lid laxity. Lower lid retractor recession. Overriding orbicularis. Or involutional enophthalmos. And most of you voted for involutional enophthalmos, and that is the correct answer. I have just taken you through the steps of the procedure. And we will look now at a video that I have created that takes us through the steps. So involutional enophthalmos is the one physical parameter that we generally do not address when we’re doing surgical entropion repair. But it doesn’t mean that our patients who have involutional entropion cannot be helped with a standard surgical approach. It’s just that that surgical approach doesn’t specifically address the involutional enophthalmos that causes and contributes to that. So putting it all together… Here’s a video of a patient of mine, with involutional enophthalmos… Excuse me. Involutional entropion. And I’ll add here that some patients — and I think this patient had a little bit of it too — some patients can have primarily involutional enophthalmos with known sort of lid laxity. But there’s also a mild or moderate cicatricial component. And that’s a patient who the margin is continued to be rolled in, even when you distract the lid from the eye. So I always advise patients when I see that they do have a component of cicatricial entropion, along with their lid laxity, that their recurrence rate might still be a little bit higher than normal, but I still fully expect statistically speaking for them to have a successful result, even with those standard involutional entropion, as we’re seeing here. So I’ve made my infraciliary incision. And I am now trimming a little bit of orbicularis. Not aggressively. But just a little bit of pretarsal orbicularis to relatively weaken the orbicularis, to help with the stabilization of the eyelid. I have used the vicryl suture that I plan to use to reapproximate the lid. I’ve used that as a traction suture. And now that I’ve done the orbicularis resection, I am now doing the advancement of the lower lid retractors. I’m essentially doing the Quickert sutures that we saw before. But because we’re doing an open technique now, incorporating the — addressing the lid laxity, I’m going to take advantage of the open infraciliary wound to retrieve my needles through that incision. And you see here that I’m taking the bite through the superior aspect of the infraciliary incision, just beneath the lashes. Now, I will show you in a few moments one of the consequences of taking that superior lip. And why sometimes we might even go a little bit inferior, and not quite so high and close to the upper lid margin. I am placing my three — and sometimes with this type of approach, I will use two of the sutures. I’m relying primarily on my horizontal tightening for the effect. And I can get away with using two mattress sutures for the advancement of the lid retractors. And when I use just two sutures, I place them in a way to roughly divide the lid into thirds. So we’ve completed our orbicularis resection. We’ve completed the advancement of the lower lid retractors. And now I am performing the canthotomy and inferior cantholysis, where I can now release that lid. I’m overlapping. And dividing with a triangular full thickness resection. And now I am tagging that cut end of the tarsus, and actually, at this point, I’m putting my canthal reformation suture in, through the lower lid border to the upper lid, and then I have already reapproximated that cut edge to the lateral orbital tubercle. And now I am simply closing my infraciliary incision with a 6-0 running plain gut suture. And I continue that, to close the limited canthotomy as well. Now, I did edit that video. But I find that I can perform this procedure usually on patients in an office setting, in about 15 minutes. So it’s a very amenable procedure for an office-based setting, and it’s a very quick procedure. And this is that patient, before and after that surgery. Here’s another of my patients with right lower lid entropion, before and after. And you can see from the side here the improved position of the eyelid. And you can see how much better a patient will feel when those lashes are away from their globe. So this is a very powerful and effective procedure for almost all cases of involutional entropion, even those that have a mild cicatricial component, because it addresses three of the four underlying physiologic — pathophysiologic mechanisms that underlie the development of entropion. I am going to share with you now just how powerful a procedure this is, with one of my patients who I did such a good job everting the eyelid that I gave him a consecutive ectropion. So we went from entropion to an ectropion. And I looked back at this case and realized that I probably advanced the lower lid retractors too aggressively. And this is an example of what I was referring to before. When you take the full thickness sutures through that superior lip, it can really rotate the tarsal margin away, as it did in this case. So I learned from this case that it’s probably just as effective to advance those lower lid retractors not right beneath the lashes, but maybe 3 or 4 millimeters below that. Or in the case of a full open procedure, taking the sutures through the inferior lip, instead of the superior lip. Also, if you advance the retractors so much that the lid becomes a little bit loose, as time goes on, that little bit of laxity, recurrent laxity, combined with the advancement of the retractors, can cause the lid to evert, as it did in this patient as well. But here, it was delayed. It wasn’t immediate. And I attributed this overcorrection to a loosening of the lid. And I simply retightened the lid at the lateral canthal angle, to address this overcorrection. So if you have a patient who returns after surgery, and you see entropion again, it pays to reassess the physiologic issues. If a patient returns with recurrent entropion, is it because they have horizontal laxity? Is it because the orbicularis is overriding again? Or might it be because the lower lid retractors have become recessed? So when you address the different physiologic parameters, it might help guide you on how to address a recurrent situation. And when this has happened to me, I usually will just retighten the lid. If I don’t think that my retractors need to be advanced anymore. Again, as you saw before, overadvancement of the retractors can cause an ectropion. Whereas tightening doesn’t cause an ectropion. So I will usually just retighten the lid at the lateral canthal angle, if I have a recurrence of entropion, after this type of open repair. Our fourth question. It is fairly easy to reliably correct cicatricial entropion, given the number of possible surgical options available. True or false? All right. So this was closer than I expected. And it might have been by the way I worded the question. But I think if we all think about our surgical remedies for various ophthalmic conditions, if you think about a condition that has multiple surgical solutions, it’s normally because none of them is really super effective in and of itself. And so the answer here is false. Especially with cicatricial entropion. The reason why we have so many options is because many of them are associated with a high recurrence rate. And we have to remember the underlying causes of cicatricial entropion are sometimes chronic disorders. And so as much as possible, our objectives in treating cicatricial entropion should be focused on controlling the underlying condition. Whether that’s herpetic infection or unrelenting ocular cicatricial pemphigoid, or use of glaucoma drops, et cetera. For very mild cases of cicatricial entropion, you might try skin resection. But for upper lid or lower lid severe or moderate cicatricial entropion, there are a number of options that we have. And I’ll take a moment to say that you might have noticed that all of the discussion and all of the patient examples that I have given for involutional entropion have involved the lower lid. I have never in my 25 years of practice seen involutional entropion of the upper lid. So I think it’s safe for me to say that if you see a patient with entropion of their upper lid, almost always there is going to be at least a cicatricial component. If not… That will be the entire underlying physiologic reason why you would see entropion in the upper lid. And so treating cicatricial entropion can involve sliding the anterior lamella away from the globe, relative to the posterior lamella, through lid split procedures. It can involve tarsal fractures, to again try to increase the leverage of lid margin rotation. It can be a blepharotomy, again, to increase the ability for rotational sutures to be more effective. And in severe cases, it may require the placement of additional posterior lamella, where it is deficient. In other words, a mucous membrane graft, that either involves some stiff material, as in a hard palate graft, or simple soft tissue, as in from the buccal mucosa. But these are very difficult and challenging cases, because of the high recurrence rate. And the chronicity of the underlying condition, which caused the cicatricial entropion in the first place. I have in some cases had to simply resect and remove all the lash follicles in the patient to relieve them from the burden of corneal touch in recalcitrant stubborn cases of cicatricial entropion. So as we conclude, my take-home messages are that: Entropion is one of the most common lid malpositions that we see in an ophthalmic practice. The underlying reasons are multifactorial. And there are many ways to skin the cat, which is a saying here in America, meaning that there are different ways of approaching this, particularly when it comes to cicatricial entropion. But even for involutional entropion, we have the options of lubrication, mechanical distraction, suture rotation, and also surgical tightening. But relief from entropion is such a satisfying procedure, and it will create some of our happiest patients. Our final audience response question: Repair of involutional entropion is one of the most valuable skill sets for any ophthalmic surgeon. True or false? And this is sort of a trick question. It’s a subjective question that I happen to feel — given the joy and relief that I’ve given my patients over the years — that this is one of the most satisfying procedures that I perform in my practice. Because of the improvement that it gives my patients. And so finally… What have we covered today? We covered: What is entropion? We talked about the problems that entropion causes for our patients. We discussed the various types of entropion, as well as the treatment of entropion. And I gave you some strategies for when initial treatments don’t work. So in summary, entropion repair for most involutional cases involves horizontal tightening, retractor advancement, and orbicularis resection. You can temporize with Quickert sutures, and sometimes get quite long lasting results in that procedure, if that’s the only procedure you can do at the time. And again, in my opinion, is one of the most satisfying procedures that we perform. So I think now we have some time for the questions that you may have. And again, I want to thank Orbis and Cybersight for inviting me to be part of this wonderful educational series, and I am humbled and honored to be speaking to so many of my colleagues across the globe. Thank you again very much.
DR FOUNTAIN: Well, I’ll just read a couple of questions here. From Andi Pratiwi. For cicatricial entropion with symblepharon, which of the graft is the most commonly used and gives the best results? So when I have had situations like this, symblepharon — normally I don’t find that the symblepharon typically involves the tarsus of the lid. But I will evaluate the patient to see how robust their tarsus is. Some of these conditions can really cause a significant amount of tarsal atrophy. If I don’t think I need the structural rigidity of a tarsal substitute, if I’m just looking for mucous membrane to replace a deficient posterior lamella, I will go to the buccal surfaces. You can go on the inside of the cheek. Or commonly just evert the lower lip. It gives you a nice surface there. When you harvest that graft, it’s obviously a difficult graft for the patient to deal with, over the next few days or even weeks, sometimes. And in fact, they will complain much more about that donor graft site than they will about the surgical site. But I find that the buccal mucosa or the gingival mucosa is a great source for that. If I need the rigidity to replace the tarsus, then I will go with a hard palate graft in that situation. The next question here is: In a residivant involutional entropion, what kind of surgical technique do you recommend? So yes, just like I said during the talk itself that when I get a recurrence, most of the time I can pinpoint a recurrence of horizontal laxity. And I tell patients that the verbs “lift” and “tighten” are never something we can expect the human body to sustain over time. And that we always expect a certain amount of tightening to loosen over time. And so because we know that horizontal laxity is by far the largest contributor to the development of entropion, recurrent entropion in most cases is the result of a return of that laxity. So I will simply retighten. If I feel like there is a lateral canthal tendon dehiscence, I may not need to shorten the eyelid. I just need to reapproximate the lateral canthal angle to the lateral orbital tubercle. So I will make that assessment as I evaluate the patient on their physical exam. Next question. My treatment of choice for senile upper lid entropion. And so the way that’s described as “senile”, that’s the same type of entropion that I call “involutional”. Here in the states, anyway, the word “senile” has a connotation that’s negative. So over the years — when I first started, we called it senile entropion, senile ptosis, senile — a lot of things. But we’re sensitive, at least in the United States, to that term. I know what you’re talking about. I’ll say that during my talk, involutional is what I would have referred to as senile. And again, Rajiv KS, you may have seen involutional upper lid entropion. I have not seen that. So again, if it is truly involutional, then tightening the lid and maybe advancement of the upper lid retractors in this case… But I would be very careful to evaluate that patient for signs of cicatricial change. Because I feel that in the upper lid, that it’s just very uncommon to see an entropion. Now, we know that people with very floppy upper lids — they don’t develop entropion. They will just sometimes get eversion of the eyelid overnight in what we call the floppy eyelid syndrome. But I have never seen, in a floppy eyelid patient, upper lid entropion. We know that that patient’s got significant laxity. So again, I would be just more critical of that physical exam on the upper lid, to make sure indeed that there is no cicatricial component. The next question I see here is: Commonest causes of pediatric entropion. You can have congenital. That’s certainly known and written about. I have myself never been referred a baby born with entropion. But in the pediatric population, most of the patients that I’ve seen in my practice really have epiblepharon. Maybe occasionally some cicatricial change, maybe from a viral illness. Nasolacrimal duct obstruction and chronic eye rubbing and infections can sometimes cause posterior lamella deficiency. So I don’t see a lot of pediatric entropion. So it’s hard for me to say what the commonest causes are. But those are some of the causes that I’ve seen. Next question is: In significant cicatricial component, have you done mucous membrane graft? Absolutely. That is ultimately the go-to procedure for addressing cicatricial entropion. Next, can you please address the treatment for excessive conjunctival scarring in the inferior fornix after inferior oblique surgery? Excessive conjunctival scarring, again, will be a deficiency of your posterior lamella. In which case, if it’s mild, you may be able to get away with different eversion techniques, as described for the involutional entropion. But at some point, you may have to be looking at some sort of a mucous membrane graft. Next question is: Do you use botulinum toxin for entropion treatment? I personally do not. But I think that it would be a very acceptable option for people — particularly with intermittent entropion or spastic entropion. Someone who doesn’t want to even have Quickert sutures done. I think — at least in my hands, the use of Botox, whether it’s for lid retraction or strabismus or muscle relaxing, as in entropion, it’s not as fine an instrument. I can’t control it as much as I could a directed surgical intervention. But I think it’s a very reasonable — and can be highly effective as a treatment. It’s just that it’s a little bit hit or miss, in that you may overcorrect, you may undercorrect, et cetera. And I think as long as the patient understands that, that I wouldn’t have any hesitation at giving a try to Botox. Because in the end, even if it doesn’t work or causes some collateral paralysis to a muscle we hadn’t intended it to do, it’s going to wear off. I always tell patients: The negative effects of Botox will wear off, just as soon as the positive effects. So you have little to lose with that. Next question is: Can you tell cryotherapy and… Let’s see. I think the person might be asking about the use of cryotherapy and entropion. Cryotherapy is an accepted treatment for trichiasis. And we know that entropion involves lashes against the globe. But normally entropion is more broad and affects more of the eyelid than just a small segment. But cryotherapy is an effective treatment for destroying lashes that abrade the globe. But cryotherapy can also cause some fibrosis and trauma to the surrounding tissues. Which in some cases can exacerbate the condition that brought the patient to you in the first place. So cryotherapy is great for focal trichiasis. But one has to be aware of the cicatricial damage that it can cause, and perhaps worsening of the entropion. Next question I see is: Can I use PGA or PSD suture for everting the eyelid? You can use whatever suture you like. I like it to be at least a little bit heftier. I wouldn’t use a 6-0 suture. I would use a 5-0 or a 4-0. You can use braided suture, like vicryl. Although it’s going to be a little bit more inflammatory. I usually just let them stay in. If you use a non-absorbable suture, like a silk suture, you can absolutely remove that after a week or two. So whatever suture you have — if it’s double armed, it just makes the passage easier. But if all you have is a single armed suture, you just have to backtrack. You go from the skin underneath the lashes, retrieve it from the fornix, and be careful, because by definition, you’re going to be pointing the needle towards the globe, so put a corneal protector on. Reverse direction, go from the fornix out, and you’ve got your mattress suture, even with a single armed suture. So any suture you like. I prefer 4-0 or 5-0. Let’s see. Can Quickert suture have a long term result? Yes, it can. That patient that I showed the video of — he never returned to me for surgical treatment. It held for him. So absolutely. I think there’s no harm in trying Quickert sutures as an initial procedure. What can we do for upper lid entropion with distichiasis? So a second row of lashes. And so the second row of lashes normally comes posteriorly from the meibomian gland orifices. So we know that they’re pluripotential cells, they can undergo transformation, and kick out a lash, instead of sebaceous oily material. So in a situation with a second row posteriorly, my objective would be aimed at removing that posterior lash section altogether. So I would probably split the lid along the margin, into an anterior and a posterior lamella. And then I would — in block — cut out the follicles of that posterior distichiatic lash row. And hopefully that will do it, if there is no cicatricial rotation of the lid margin, and it’s just a second row of lashes. That should help. You can also — oh, never mind. Next question here. Can we retract the lower lid recession? Is it possible as a good result? Yes. I think the question is: Can we advance the lower lid retractors? And absolutely. That’s how you would — that’s what the sutures do. If we’ve overdone things, if that’s the question, if we need to recess an overly advanced retractor — yes, that can be done as well. You would just have to divide — I would think you would divide — I’ve never done this, but you would divide the retractors probably on the conjunctival surface, just beneath the tarsal plate. And dissect away, so that those retractors fall away from their original attachment. And I think just recessing them and letting the recessed area heal in by secondary intention would be all that’s needed. But I suppose taken to an extreme, one might need a spacer graft, if a significant degree of recession of overadvanced retractors is needed. I hope I understood that question correctly. Let’s see. Is a Weis procedure recommended? Oh my gosh. I have forgotten what a Weis procedure is. I could Google it real quick. But… I apologize. I know that is a procedure, and I forgot exactly what the Weis procedure is. Let’s see. May I ask: What did you do to correct the post-op ectropion from overcorrecting the entropion? So in that case, the first patient that I showed… He was so upset with me that he left and went to one of my friendly competitors across town. So I did not get a chance to redeem myself with him. But if I had, I would have disinserted the lower lid retractors and allow them to fall back, just like I just described. The second patient — I retightened him. Because I realized that I hadn’t overadvanced the retractors. Or the lid had simply gotten loose again. Through no fault of my own, I don’t think. But I just retightened that lid. I’ve gotten some really nice comments and some thank yous here. Thank you all very much for these nice comments. Tarsal plate rotation. Does it have a long term result? When we perform tarsal plate rotation and resection? Can we supply TPR on lower lid entropion? Tarsal plate rotation I think is a type of tarsal… You can do a tarsal fracture. Or a blepharotomy. And so these procedures in my hands, anyway, are directed at cicatricial entropions. And I say “can have a long-term result”. I think in the ideal situation. But as I mentioned before, you have a really high recurrence rate for all types of cicatricial entropion, despite our best efforts. What sutures from experience would be the best for Quickert sutures? And… So I sort of answered this already. For Quickert sutures, I have never been able to overcorrect anybody. So I don’t think you have to worry at all about overcorrecting with Quickert sutures, because it’s just not that powerful a procedure. I suppose never say never. But again, my choice of suture is a 4-0 chromic. It’s thick enough that gives me a lot of rotation. It lasts long enough that I get the nice cicatrix that will maintain the lid position, even after the suture is dissolved. And it’s well tolerated without a significant amount of inflammation. But if you’ve got a nylon suture, a prolene suture, those are fine. You just have to remove them. And if I were to remove them, I would probably leave them in at least two to three weeks, if the patient tolerated that. All right. And I’m looking at the clock. And I notice we’re coming in on one hour. And I’m seeing mostly thank yous and not any more questions. So I am going to take the liberty here of closing the questions. And again, thanking everybody across the globe who was with me today, here from my office in Chicago. And a thank you once again to Orbis and to Cybersight, and I wish you all a wonderful day and week with your practice and with your families. Thank you very much.