Lecture: Turning In and Turning Out: Management of Entropion and Ectropion

During this live webinar, we will discuss the management of entropion and ectropion. At the conclusion of this lecture, attendees should be able to: (1) identify the anatomic factors that cause both entropion and ectropion, (2) understand the clinical features caused by entropion and ectropion, and (3) select the most appropriate surgical treatment for entropion or ectropion based on the clinical situation. (Level: Beginner)

Lecturer: Dr. Tamara Fountain, Ophthalmologist, Rush University Medical Center, USA

Transcript

DR. FOUNTAIN: Hello. Good morning, at least it’s morning here in Chicago, Illinois. My name is Tamara Fountain. And I have the distinct honor and pleasure of presenting today’s lecture on behalf of Cybersight. I do oculoplastics here in Chicago. I have a private practice and I’m also on faculty at Rush University. And I recently did a trip with Orbis on the flying I-hospital to Zambia. Thank you to Lawrence Sica and Andrew Chen who have been wonderful preparing for today. Thank you to all of you who registered. We had over 700 people register for the course from all continents except Antarctica, it’s a pleasure to be you today. And I’m gonna be talking about entropion and ectropion. And I’ll now share my screen.
The management of entropion and ectropion. We’ll start with some pre-test questions. The first question: Suture rotation, also known as Quickert suture of the eyelid margin addresses which physical — of involutional entropion? lower lid retractor recession? Horizontal lid laxity, overriding orbicularis oculi or involutional enophthalmos? Our next question. And there are the result there is. So, we had about a third for the lower rid retractor recession. But horizontal laxity, overriding orbicularis. Okay. Our next question. It is usually easy to consistently and reliably correct cicatricial entropion given the number of possible surgical options: True or false? And we’ll have the results. Okay. And our third and final question: What is the common finding in both involutional ectropion and entropion? A, overriding orbicularis, B, recession of the lower rid retractor, C horizontal lid laxity, or D, cicatricial skin changes? Okay. Terrific. All right. So, at the end of today’s lecture, it is my hope that the attendees will be able to identify the anatomic factors that cause both entropion and ectropion. Understand the clinical features caused by entropion and ectropion. Select the most appropriate surgical treatment of entropion or ectropion based on the clinical situation. Let’s start with a question: What is entropion? Entropion is a malposition where the lid margin and the lashes are rotated inward against the ocular surface.
It is different from trichiasis or epiblepharon in that in these situations the lid margin is in its normal anatomic position. But in the case of trichiasis, you can have extra eyelashes in a second row or misdirected lashes from the normal anterior position that move backwards. In the slide left, we have extra lashes on the pose tear your margin, some call this distichiasis, going from the orifices. And in the case of epiblepharon, we have the normal lid margin, but this overriding orbital muscle push the lashes against the eye. The eyelashes are against the eye. What is ectropion? This is the malposition where the lid margin and lashes are rotated away from the ocular surface. And again, rotation is a key element of ectropion. We should be able to see the palpebral conjunctiva if a patient has ectropion. And that’s in distinction to lid retraction where the lid margin is an inferior location relative to normal. However, it is not rotated away from the globe. You do not see any pink palpebral conjunctiva. There are four factors that contribute to what I call involutional, some might refer to it as senile. But it’s the type of entropion you see as people get older. And these four factors that contribute to the lower lid entropion are horizontal lid laxity, the lid gets loose. The second one is the orbicularis can override the lid margin. Number three, there is recession of the lower lid retractors, the analogs to the ptosis — excuse me, to the levator muscle, those are recessed. Sort of like a ptosis of the lower lid, if you will. And the fourth contributor to involutional entropion is the enophthalmos, the deep set eye and as they lose the orbital volume. The eye moves posterior to the lids, and event if the lids were quote, unquote, tight when it moves posteriorly, the lid can no longer hug the eyeball as much as is used to. When we are talking about ectropion, however, there are really two major factors for involutional ectropion of the ectropion that we see. We see horizontal lid laxity and we see a relatively prominent eye. There’s no ectropion here, this is a lid retraction, but this is a prominent eye, as I described. For those of you who have ever watched a tennis match, you know that the net in tennis is tightly strung across the court. If you were to go to this little mechanism here and loosen the tennis net, depending on which way the wind was blowing, this net might flop into one side of the court or it might flop into the other side of the court. And eyelids are similar. If we think of the eyelids as the tennis net that’s normally tight up against the eye when the lid gets loose, it can flop in toward the eye or it can flop away from the eye in a similar fashion. So, horizontal lid tightening is the one common factor that contributes to both entropion and ectropion. Which is why some manner of horizontal lid tightening here via a lateral tarsal strip, is a common theme in surgery for both involutional and involutional ectropion and entropion. So, surgery for the entropion of aging. Here we have a gentleman, and on one side he has relative laxity of the lid. We can see the bowing of the lid here. And he developed entropion. When he squeezed his eye shut real tight, this rolled up against the eye. He was going away on vacation and couldn’t undergo surgery. And so, I did something that temporized it. Which is the placement of three full thickness what we call Quickert sutures. They’re horizontal mattress sutures. They’re two needles, it’s a double arm suture up one is brought through the fornix and emerges from the skin in a superior location just above the lashes. The other arm is pass the in the same fashion. When it’s tied snuggly, it helps to evert, or roll that eye margin away. And here is a surgery showing that I used a forearmed 00 suture. Done in the exam chair, done right in the clinic. You do not need to take the patient to the operating room for this. I anesthetized below the lashes, but also conjunctively, since that’s where I’ll be putting the suture. And this shows a surgeon’s view from the head of the table on the right eye. I am back-handing this 4-0 suture deep in the fornix and I’m trying to manipulate the lid in such a way that I retrieve that suture, the needle, just below the lashes. I then take the other arm and I will displace this 4 or 5 millimeters from where I entered on the first arm of the suture. I grab the needle here as well. And then we’ll tie this. It’s very subtle, but as I tie this down, watch how the lid margin just moves a little bit away from the eye. And you can see there under tightness there how the lid everts just a little bit. Now, do I recognize that just the injection of the local anesthetic will cure — at least temporarily — entropion, and make it look less noticeable. So, here I’m tying down the central suture and you can see how that lid rotates a little bit away from the eye. And I just leave these cut short and let them dissolve on their own over the ensuing three or four days. And so, three have been placed. And you can see how stable the eyelid is at that point. This is the gentleman with a picture right at the end of the operation where you see the one, two, three full-thickness sutures. We see a little bit of overcorrection. Not only do we not have the lid inward toward the eye, but it’s actually over-corrected a little bit. And I always shoot for a little bit of overcorrection because it never stays that way. He came back to see me after his vacation for his surgical procedure, but the lid was still holding its own and still stable at that point. So, I never ended up having to do surgery on this gentleman. The Quickert sutures, which do have a higher reoccurrence rate, but in many cases, these may be all that you need.
Moving on to surgical repair, commonly I will approach this because I want to address the lid laxity, I want to address the overriding orbicularis and I want to look at the recessed lid retractors. The one cause of entropion that I cannot address is the sunken eye. So, the infraciliary incision is made, and do the orbiculectomy, and suture advancement of the lower rid retractor, and lateral canthotomy and then shorten with a strip at the top, or a modified Bick procedure, the lateral aspect of the lid is cut away and that new edge, that cut edge, is approximated to the lateral orbital tubercle. That’s the lateral shortening through the modified Bick procedure. A suture, and I typically use a 4-0Vicryl surgery and I cut the edge, and to the periorbita, and it’s important to tag it periorbita in order for the lid to hold tightly in the new position. This is a short video showing my approach to the surgical treatment of the entropion of aging, or involutional entropion. And you can see here how the lid rolls in. And I am injecting at the lateral canthal angle, again, I use 2% lidocaine with 1 to 1,000% epinephrine. This is a 25-gauge needle. I’m doing this one in a hospital setting with some sedation. Although these can absolutely be done in a clinic setting with straight local. I have the traction suture in place and I have made an infraciliary incision. From the inferior, or lower lip of that incision, I am trimming just a little bit of the orbicularis. I want to decrease its relative strength, especially in the pre-tarsal area. Because that robust orbicularis tends to make the lid roll in. So, if we as surgeons can trim some of that orbicularis, then that will give us a mechanical advantage. And I try with the intraciliary incision to not remove the orbicularis on the upper lip of the incision, but on the lower lip. Now you’ll see a familiar placement, again, of a mattress — double armed mattress suture. But in this case, I’m taking advantage of the fact that I have an open wound and therefore, I can retrieve these sutures within the wound and not have them externalized. Here I am using a double armed Vicryl which I typically would not use a longer-acting braided inflammatory suture on the skin. So, I do take advantage of the fact that these knots will be buried in my infraciliary incision to utilize the Vicryl because it will last longer. Here I’m in the fornix and superior just beneath the lashes. I also grab a little bit of the orbicularis in the superior lid. And this can actually be so strong that you can overcorrect. And I think I’ve got a slide to show you how robust that is later on. But when these are tied, you can see just as we did in the gentleman who only had the sutures done, how that lid margin everts. I cut those short and then we’re going to do our lateral. Sometimes I’ll do the lateral canthotomy or and the inferior cantholysis at the binning. Now I’m doing the inferior cantholysis. Overestimating how much of the lateral margin I want to move. That’s the modified Bick. And I tag the edge and re-proximate that to the lateral orbital tubercle. And this is reforming the angle in a cerclage fashion. And I use the same 6-0 gut suture to close the infraciliary incision. With this operation that takes 10 to 15 minutes, I have addressed three of the four reasons people develop involutional entropion. I have addressed the horizontal laxity, I have addressed the overriding orbicularis, and I have addressed the recessed lower lid retractors. And that’s why the surgical approach is so powerful because you’re able to address so many of the factors that lead to this condition in the first place. And here are pre-op and post op pictures of that patient shown in the video.
Here is an example of a gentleman who I did that procedure on and he was so everted that I actually overcorrected him. And part of what happened in this case is he became a little bit loose at the lateral canthal angle, again. And this is a great example of how that horizontal laxity is a component of both entropion and ectropion. Because when the lid got loose because I had addressed the other two elements of entropion, that laxity resulted in an ectropion. So, the way I addressed this overcorrection is I removed a little more of the lid here, shortening it, and re-approximated it to the lateral orbital tubercle. Reestablishing that tightness. So, when we see ectropion in an older individual, again, part of what we’re seeing is a laxity. So, at least some of what we want to do with addressing lower lid involutional ectropion is also tightening. So, the same either lateral tarsal strip or the modified Bick procedure is used. But we can tighten not only at the lateral canthal angle, but we can also tighten in the middle of the lid using a full-thickness wedge resection underneath an infraciliary incision. We can also tighten the lid more towards the medial aspect and in many cases this is what I will use when a patient has a significant amount of medial ectropion that also involves the punctum as you see in this gentleman. There’s something called a lazy T procedure that combines inward rotation of the palpebral conjunctiva through a resection here in a diamond state. When you straddle the punctum with the conjunctival removal, it will help to pull this forward. When you combine that through horizontal tightening made through a full-thickness wedge resection right next to this, that wound, the horizontal closure of the palpebral conjunctiva and the vertical closure of the lid margin, when those are together, it makes a T on its side. And that’s the reason why we call this a lazy-T procedure. Because we combine the vertical limb of the T, which is horizontal in this case here, with the vertical full thickness resection which is the cross bar. But it’s on its side and that’s why we call it “Lazy.” So, this is a great way of both shortening the eyelid and addressing the medial ectropion that involves the punctum.
Cicatricial ectropion is caused by a shortening of the posterior lamella. When we have injury or prior surgery that shorten the posterior lamellae, the conjunctiva, it’s pulled in towards the eye. And that force is much greater than the floppiness. And therefore, it typically requires more in the way of a robust surgery. We more commonly see cicatricial ectropion of the upper lid. I would go as far to say if someone has entropion of their upper lid, it is going to be cicatricial in nature. It is almost — it’s almost impossible to have laxity of the upper lid that leads to entropion. On most eyes if you have entropion of the upper lid, it’s got a cicatricial component. And you can see here the scarring of the upper lid which then shortens the posterior lamellae and pulls the lid margin and its lashes in towards the eye. Cicatricial ectropion, conversely, is caused by a shortening of the anterior lamellae, or the skin. Again, either through inflammation, injury, burns, or previous surgery. And you can see it in the lower lids here. And you can see it in the upper lid here. The treatment of the cicatricial form of entropion or ectropion often involves replacing the deficient lamellae. So, in the case of entropion, we are talking about some sort of a mucous membrane graft to the posterior lamellae to give the extra area that is necessary. For cicatricial ectropion, we are usually talking about some sort of a skin graft. Or sometimes we can leave things to heal by granulation. But almost always we’re using some sort of a skin graft to give back the deficient anterior lamellae that’s causing the pulling away of the lid in the first place. Cicatricial entropion is fairly common and it is a real challenge to us as surgeons. Many different approaches have been described. Normally when you have a lot of different approaches to a surgical challenge, it means that not any one of them is normally perfect. So, this — this tells us — the fact that there are so many approaches to cicatricial entropion, it tells us it’s a challenge. And there’s not one super-good one. But I find in general that in my handle that the anterior lamellae recession is the most durable in my hands. And that’s depicted here in this slide. The anterior lamellae, or skin and muscle, is separated from the posterior lamellae. And then the anterior lamellae is recessed relative to the posterior lamellae along with the lashes. For good measure, I’ll commonly cut out the lashes as well. Here’s an example here at the bottom. Again, of the anterior lamellae recessions. The lid is split into anterior and posterior lamellae. And the anterior lamellae advanced relative to the posterior lamellae and they’re no longer in a globe, in a recessed position. No matter which choices that we have I have to explain to all patients that recurrence is pretty common in treating this very challenging disease.
This is a Cybersight video that was shot of a case that I did last October on the fly eye hospital. And this I’m demonstrating the anterior lamellae recession on a patient. So, the patient is under some sedation. We have a corneal protector in place. It’s very difficult to even evert the lid. Note that the lashes are short and stubby. Because the patient had been managed with serial epilation. The lashes were simply pulled to try to relieve some of the discomfort of the lashes against they. That’s why they’re so short. So, here I am making an incision posterior to the lashes. So, I am trying to isolate the lashes which are in the anterior portion of the lid lamellae. So, I am separating the anterior lamellae, which is the skin and orbicularis measure from the tarsal, the glands and the palpebral conjunctiva. And I use a 15-blade here which in my hands is more efficient than using a scissor. It can be a little tedious here. But once we are a little deeper into the tissue, we’ll start to get our bearings here. Once I’ve separated a little bit, I find it very help to feel place a traction suture through that slightly separated posterior lamellae. So, that is a full thickness through the tarsus. And with that traction suture in place, it make this is dissection a little bit easier. Now what we’re seeing — starting to see, anyway — is the face of the tarsal plate. Again, I am trying to separate the orbicularis in the skin and the lash follicles, hopefully, from the posterior layer. And now that we’ve got the traction suture in, it’s just a little more visible. You’ll notice here that there are a couple of lash follicles that are still in this posterior layer. And in fact, I did learn from my hosts and in Zambia that this patient did have a few recurrent lashes that grew through a few weeks after this operation. So, again, it’s not 100% in many cases. But it’s an improvement that we can offer to patients. So, now I have separated — or actually, my host has separated the anterior lamellae. And we are just continuing on so that we can release both laterally and medially enough so that we can really — so, now we’re making a little bit of an incision here. And I am resecting all of the lash follicles. Now, this is not controversial, but not everybody does this. But my reasoning is that many — almost all of these patients have been plucking their eyelashes for relief for months, if not years. They’re not attached to these lashes. And it — because of the high recurrence rate, I feel that once we’re in here doing this operation, as many of the lash follicles that we can remove, it just gives the patient a higher chance of recovery. And even despite what you’ve seen us do here, which is resect in block the inferior anterior lamellae that includes the lash follicles and go after the couple of lash follicles that we missed that were posterior coming through the tarsal plate. Now we have this open tarsal plate and we’re cauterizing a little bit of the bleeders here. But we’re going to leave this tarsal plate exposed. Some people might consider doing a graft over this area. I think it’s simpler. And just as easy for the patient to leave this bare and this will then granulate on its own. But to help maintain the recessed position, I will typically sew down here the recessed anterior lamellae to the posterior lamellae using a 6-0 chromic on plain gut suture. And you can do this in a running fashion. And at the conclusion of the case, after we’ve reattached that anterior lamellae in a more recessed position, we see here that we no longer have any lashes against the — in this case — corneal protector. And this will heal very well. The traction suture. You can actually leave it in place and tape it down on the cheek for a little while just to maintain that distraction.
So, in summary, the surgical approach to entropion, which is non-cicatricial of the type, and address three of the four causes. Address the horizontal lid laxity through lid tightening. You can use a lateral tarsal strip or retro section. We’re going to address the overriding orbicularis with a resection of some of the orbicularis. And address the recession of the lower lid retractors through an advancement of the lower lid retractors. It’s hard to treat, multiple are described, including mucous membrane retracting. There were a number of questions submitted in advance of today’s course asking about cicatricial ectropion. This is a patient which the pictures sent to me. This was not a typical, this was a burn situation that caused burn and cicatricial change across the face. Leading to ectropion on the right lower lid as well as the left upper lid. Honestly, a patient can be managed with lower lid ectropion if the patient is able to keep the lid lubricated. It is very difficult for a patient to manage severe cicatricial ectropion simply because the — the roll of the upper lid is so much more important to ocular health than the lower lid. So, it’s very difficult to — for a patient to manage and that’s why this patient underwent a graft to — with the plastic surgeons in Zambia to give a little bit more room for that upper lid to close. And this was a young child with ichthyosis. And these are challenging cases because we don’t have a good course of grafted skin — or skin to graft — very little in the way of surface area on people with ichthyosis is suitable for grafting. In some cases, we may have to resort to releasing the cicatrix to let it go against the globe and have a temporary and allow that open recessed area to granulate on its own if we don’t have a source of good skin graft material and we need to do something for lid closure. But these are extremely challenging cases.
The summary of a surgical approach to ectropion that’s non-cicatricial is to address the horizontal laxity through again a lateral tarsal strip or wedge resection. We address punctal ectropion through the inverting sutures. And we can also place sutures, which I didn’t demonstrate, but we can place sutures opposite to the palpable sutures, they go closer to the margin and emerge from the skin more inferiorly. This helps to invert the lid as well. Some people may also utilize a limited lateral tarsorrhaphy to support the lid by hitching it to the upper lid. Cicatricial disease is treated with replacement of the lamellae which is sufficient in that type of ectropion. And generally speaking, patients are able to tolerate involutional ectropion, especially if it’s the lower lid, better than they can with entropion. With ectropion, you get exposure and a little bit of drying of the eye. But you at least do not have the lashes up against the globe and the cornea. Which makes — which makes entropion so difficult for patients to tolerate and makes it more of a surgical urgency for us as surgeons. So, we are going now to the post-test questions. And we’ll see what you think based on what we’ve heard thus far. Number one: Suture rotation, or as we say, Quickert suture — of the eyelid margin addresses which physical component of involutional entropion. Lower lid retractor recession, horizontal lid laxity, overriding orbicularis oculi, or involutional enophthalmos. All of these address entropion, but the Quickert sutures address which one of these? And because of the way the sutures are placed, they’re placed deep in the fornix and emerge from the — beneath the lashes. They advance the lower lid retractors. And so, they primarily address lower lid retractor recession. Number two: It is usually easy to consistently and reliably correct cicatricial entropion given the number of possible surgical options available. True or false? Exactly. Exactly. This is a significant challenge to all of us as surgeons and usually when you have a lot of choices in an operation, it means that none of them is entirely terrific. But it doesn’t mean that we — that we can’t offer patients improvement. But we just have to be, I think, transparent and honest with the patient about the challenge of this disease and it might be that more than one operation may be needed. Number three. What is the common finding in both involutional ectropion and entropion? Overriding orbicularis, recession of the lower lid retractors, horizontal lid laxity, or cicatricial skin changes? Fantastic. That is exactly right. Just like the tennis net analogy, when lids get loose relatively with age or with frank paralysis, that is, then we can see the lid, depending on the underlying anatomy or maybe some very mild cicatricial forces. We can see any lid that becomes loose become unstable and roll toward the eye or away from the eye. Fantastic job, everyone. We have now about 20 minutes for some questions and I am going to go to some of the questions that were submitted from many of you — and I appreciate you asking ahead of time. I think we have answered many of them here. Many people asked what caused entropion and ectropion. Someone asked here, does ectropion occur mainly in old age? We see it commonly in people who have gotten older and their lids have gotten loose because we know that’s one of the reasons why. But for cicatricial ectropion, which usually is a — related to some sort of insult or injury to the skin, which can come at any age, and certainly with congenital ectropion from things like ichthyosis, we can certainly see it across the spectrum of ages. Someone asked if there were effects of entropion and ectropion to other body or organs? I’m not aware of any association. The — the ocular — the ocular issues related to entropion and ectropion are significant, but to my knowledge there aren’t any systemic related issues. Here’s a question: How can an optometrist help in the management of entropion and ectropion? So, we can manage especially mild cases of entropion and ectropion where it might be, for instance, intermittent or spastic entropion or mild ectropion with lubrication. Even if lashes do contact the cornea on a lower lid involutional entropion, the reason why they’re uncomfortable is because they can scratch the cornea, the lashes can. But if we are really diligent about lubricating the eye, then it will decrease the friction of the lashes against the eye. And some patients can be temporized or managed with mild cases of entropion with simple lid lubrication. People who have ectropion do very well with lubrication also. Part of ectropion which makes it, I think, uncomfortable — not necessarily for the patient, but for everybody who looks at the patient — is they don’t really like seeing that exposed palpebral conjunctiva. That little pink strip. Many people will be asking them about it saying, hey, what’s wrong with your eye? And because I explain to patients that when the lid pulls away from the eye and flops away from the globe, the part of the eye that is normally covered by the lid and the part of the lid that’s normally against the eye, they want to be wet. They’re both mucous membranes. They are bulbar conjunctiva and palpebral conjunctiva and they’re normally right up against each other. With ectropion, they separate. And we have the moist mucous membranes that are exposed to the air and they don’t like it. And so, lubricating with ointment overnight. I love ointment overnight for mild ectropion or even significant ectropion to keep the palpebral conjunctiva surface, that exposed pink part of the lid lubricated as well as the eye. Because if we can keep those two mucous membranes moist, then it will be happy. It will still be pink in color, but it won’t be quite as inflamed. And so, for patients who come in and they’re really not bothered, they don’t have a lot of dryness, their cornea is in good shape from mild involutional ectropion, I will say, listen. We can probably manage you without any surgery at all. Just with some lubrication. So, for all of us — not just optometrists — but us as surgeons, we don’t have to do surgery sometimes on some of these patients. Let’s see… how do you prep patients better post-op period? Particularly the appearance. The treatment for involutional entropion, you’ll have a line of stitches beneath the lashes. I close with a 6-0 plain gut, those sutures are hard to see in most patients. I tell the patient, you won’t really see too much what I did surgically. The lids are closing over your eye. I will prepare them for a great deal of bruising and swelling. The 4-0Vicryl or whatever you’re using to shorten the horizontal lid margin to the lateral orbital tubercle, whatever suture you’re using if it’s an inflammatory or dissolvable stitch, it’s going to great a little bit of inflammation. It’s usually a big knot, a big wide 4-0 suture also. I find that knot — it’s buried, we don’t see it, but the patient will commonly feel that for many weeks. Long after the bruising and swell having gone. They will talk about how it’s sore in that corner. Particularly if they are closing their eyes real tight or when we all sneeze, we tend to close our eyes real tight and they’ll feel the lid pulling on that approximated area. And that can be uncomfortable. So, I just prepare them for the fact that they’re gonna be a little sore in that corner for several weeks until that stitch finally dissolved.
Is there a way to parentheses senile ectropion? So, we — as we all age, everything gets loose. And, boy, if I could figure out a way of keeping things from loosening up as we get older, then I will probably get to retire a little early. To my knowledge, there isn’t too much we can do to prevent or hold off in some patients the development of senile ectropion or what we call involutional entropion. Is this conditional — condition congenital? We can see congenital entropion. I think I might have seen one case in my entire career. Congenital ectropion, however, is more common. Ichthyosis and certain types of chromosomal abnormalities can lead to deficiency and almost like a of the lid and ectropion. Yes, we can see children born with these lid malpositions. Discuss the treatment of lower eyelid refraction and ectropion correction after transcutaneous blepharoplasty. So, it is up to us as surgeons to make sure for an upper lid blepharoplasty that we never are removing so much skin that the patient cannot close their eyes. That is something that is completely within our control is to gauge how much skin we’re removing. And when you make your marks for an upper lid blepharoplasty, I like to just pinch those two, the upper and lower lymph my proposed incision. I like to pinch those two together, simulating the effect of removing that skin and I observe the eye, the lid, and I make sure that in pinching those together I have not pulled the lid off of the eye. Now, lower lid transcutaneous blepharoplasty your there are sometimes things we can’t control, we can have septal and scarring that pull it down. We can also remove too much skin on the lower lid as well. Again, it’s up to us to make sure that we don’t do that. When you are dealing with an ectropion or lid retraction after transcutaneous blepharoplasty, we have had scarring in the lamellae or we have removed too much skin, that’s most common. And depending on the degree of the lid retraction or ectropion, we may need to do a skin graft to replace the too much skin that was removed. We may be able to get away with developing a large sort of mid-face flap and combining a mid-facelift to help to support that tethered lower lid. And maybe a temporary tarsorrhaphy as well. Let’s see here…
Prognosis — oh, should we do a tarsal split for every entropion with — I didn’t go into the treatments of cicatricial, but we can do a horizontal incision through the tarsal plate to basically develop some leverage by dividing it. It’s almost like scoring it. Like you can — you can break — you can break a bar of chocolate easily if the chocolate is scored in the middle when you — when you bend it, it will break where it’s weakest. And that’s kind of what we do — or can do — on the tarsal plate. We can expose the tarsal plate and make a scoring incision so that it’s a little bit easier than placing the everting suture to — it makes the suture rotation a little more strong because we have weakened the tarsal plate by scoring it. And that’s another method of addressing cicatricial entropion. We can also cut the distal or the lid margin area of the tarsus and literally fold that back on itself, including the — or excuse me — the anterior lamellae including the lashes. And we can fold that back on itself as well to relatively recess the anterior lamellae relative to the posterior lamellae. Does the entropion of trachoma differ from other entropions? The entropion from trachoma is a type of cicatricial entropion. And, you know, I don’t think there’s anything histologically different. If you were to do a pathological analysis of a lid that’s been scared from trichoma. Obviously if it’s active infection, you’ll see the evidence of the microbes. But with just — the infection is gone, but you are left with the cicatrization, I’m not aware of any histological difference. And certainly will the treatment is no different than a cicatricial entropion caused by ocular surface inflammation or prior surgery. Again, we’re looking at a deficiency of lamellae in any situation. In it’s the deficiency in the — in this case, the mucous membrane. The mucous membrane needs to be addressed in severe cicatricial entropion. All right. I see that we have some questions in the Q&A. So, I’m gonna pull those up here. All right. Thank you. I’m seeing a lot of nice comments here. Let’s see, I’m a general ophthalmologist in oculoplastics work in Uganda, we have entropion secondary to acid burns, accidents, and the biggest challenge, especially with acid burns is graft/skin or mucosal failure. With my experience, what would I advise would be the best way to tackle this post-surgical effectively especially in the limited resource like mine. Thank you for this wonderful question. Thank you, doctor. So, the question basically comes down to cicatricial in and ectropion secondary to acid burns. We’re talking about damage to both the internal and external lamellae. For skin grafts, generally the face is pretty well-vascularized. And I have found in the rare circumstance that I lose a graft, that it will still act as a good tissue dressing for secondary intention or granulation healing underneath. So, I’ll explain to the patient that this darkening graft, which is gonna turn black and fall off eventually, I’m gonna leave it alone because it is acting like a band aid while the patient heals their abrasion underneath. It looks terrible while it’s going through this process. But once it falls off, we get this nice skin underneath. One thing that I will do — I try to do — on my skin grafts — is to, wherever I harvest them from. I love to go from behind the ear. if that’s not been taken already. It’s an area that doesn’t have sun exposure. It doesn’t have hair. And it’s pretty virgin. But it’s a little thicker than the lid skin. And remember, the skin graft is gonna get all of its nourishment, initially, from the donor site vascular bed. The thinner that graft is, the easier it will be to sustain it with that underlying blood supply. And so, once you harvest the skin graft, I like to take a — a Westcott scissors, it’s easiest for me to use that. I turn the graft upside down on my hand, I’m looking at the deep surface of the graft, the skin is on my hand. I take the scissors and thin the graft, you want it as thin as possible. Skin and dermis, no fat underneath there. Make it as thin as possible. And then once you sew that in place, there are a couple ways you can do that. You do not want that skin graft to become separated from its underlying bed because it went then get that blood supply. So, you want to keep them opposed to each other. You can do that through a full thickness stitch that goes through the skin graft as well as the donor bed so they’re stuck next to each other. You can also make little — we call them little tiny pie cuts in that graft that allow any oozing of blood from the donor site to allow that to egress. Because any accumulation of blood between the skin graft and the donor site will, again, threaten the revascularization of that skin graft. You can also — I think I had a picture in the lecture — you can also put a bolster or some sort of a pressure bandage on the patient, on that skin graft for six or seven days or so. So, if you have nothing else, you can just put a couple of eye pads and a bandage around or sticky tape to again press — you don’t want any accumulation of blood in between your skin graft and your recipient bed. And that might increase the yield on your skin grafts. If you find you’re getting a lot of failure from that. And keeping it covered with that pressure bandage will also help to keep it from being contaminated from environmental dust or whatever.
And again, even if it fails, you at least are buying yourself time for that to granulate and protect that granulation tissue. Failed mucous membrane grafts are a little bit more difficult. Sometimes you simply have to try to overcorrect. Maybe put a traction suture on to keep that graft on, stretched — sometimes it doesn’t fail as much as it contracts and you lose that benefit of adding — of adding your layer because it shorts and it contracts on itself. So, I might consider adding a traction suture as well during the healing process for that. Here’s a question: For your Quickert suture, do you aim for an area below the tarsus or go for the fornix? I go for the fornix. The deeper that you can go, the more advancement you can affect from that. So, deep in the fornix and just beneath the lashes. Question: Other procedures for involutional entropion? I really don’t. Because the Quickert sutures and the horizontal tightening, orbitotomy, it’s easier to treat involutional. Is it possible for one to have both entropion and ectropion on the same eye. Absolutely. And I have seen that before. A portion of one eyelid rolled in and the other portion rolled out. And I’m trying to remember how I addressed that. I don’t remember. But I have seen that. Or you can have a person who has got an entropion on one lid and an ectropion on the other. So, absolutely, I’ve seen that before. If yes, which do you manage first and why? As I said before, anything that involves the upper lid is normally harder to tolerate for the patient. And so, my focus would be on stabilizing the upper lid if that’s one of the lids that’s involved. Otherwise, I don’t think it really matter which is order you it in. What kind of lubrication in these cases? Ointments or drops? I think you can use both. Ointments — I don’t quite understand that. I think maybe if you mean drops. Ointments or drops, either one is fine. Drops are easier to use during the day because they don’t blur a person’s vision. What success have you had in surgical management of congenital horizontal kink? I must nit, I’m not familiar if that means something else, I’m sorry. But congenital ectropion, depending on the cause if it’s part of a genetic syndrome and I’ve got good skin supply, I can address that with the skin. It’s a pretty straightforward approach no matter the age of the patient. If you have change that’s significant, you’ve got to find some replacement for the lamellae that’s deficient. Whether it’s entropion or ectropion. Let’s see… we see ALR usually in the management of upper lid entropion. Is that also used for lower lid? Ah, anterior lamellae recession. Lower lid cicatricial entropion. And I haven’t used it for the lower lid. It might be because the tarsal plate is just so much shorter in the lower lid that I usually can overcome cicatricial entropion in other ways without having to do a lamellae resection in that situation. So, I would answer that that way. Well, everybody, we are coming up on the top of the hour and I want to be respectful for all of your time all across the world who are tuned in. Again, I want to thank Orbis and Cybersight for the support of this wonderful educational platform. It has been my honor to address you today. And thank you all for tuning in. I know for some people it’s the middle of the night or the middle of your patient day. So, we appreciate your participation. Everybody have a wonderful weekend and happy March.

3 thoughts on “Lecture: Turning In and Turning Out: Management of Entropion and Ectropion”

  1. Hello all,

    Dr. Fountain wanted to spotlight and share her answers to two important questions for this webinar. Please feel free to review them as you watch this webinar:

    • Q1: which kind of lubrication is used by optometrist to maintain the disease?
    It does not need to be medicated. It can be bland, ophthalmic ointment that doesn’t need a prescription. Like you would use for dry eye. Especially since it will need to be used indefinitely for comfort, the less medicine in the ointment, the better. Think of it like chap stick for dry lips.

    • Q2: can you use single arm?
    Absolutely!! I thank you for this question as I should have discussed this and will try to remember to do so in future if I give this lecture again. With a single arm, you will enter the skin beneath the lashes, retrieve the needle from the fornix then pass it back through the fornix and then retrieve next to the entry point just beneath the lashes. It’s EASIER to do with double arm, but can absolutely be done with single arm. You must be careful going from skin to fornix not to puncture the eye. Try using a corneal protector for this pass.

    Reply

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