Entropion. Focus

Transcription

1 Entropion Focus Dr. Gangadhara Sundar DO, FRCSEd, FAMS Dr. Ashok Kumar Grover MD, MNAMS, FRCS, FIMSA, FICO Dr. Poonam Jain MS Dr. Anita Sethi MD, DNB, FRCS (UK) Dr. Vikas Menon DNB, FLVPEI Entropion is a condition in which eyelid turns inward. This causes the eyelashes or the eyelid margin to rub against the eyeball and results in irritation, watering, redness, keratitis and corneal perforation. It may occur at any age but occurs primarily as a result of advancing age. Entropion can be classified into congenital, involutional, ciciatrical and acute spastic. Congenital entropion occurs when there is hypertrophy of the anterior lamella. Usually the milder forms resolve by themselves with time. Involutional entropion is an age-related condition caused by the laxity of tarsus, its medial and lateral canthal tendons, lower lid retractors, along with the over-riding of the orbicularis oculi muscle. Cicatricial entropion occurs due to scarring and shortening of the posterior lamella due to chemical injury, infection or stevens johnson syndrome. Medical therapy in the form of lid taping and lubricants is used as a temporary measure. Multiple surgical techniques have been described for the management of entropion depending upon its etiology. Management of involutional entropion require tightening or reattachment of lower lid retractors along with repair of the horizontal laxity via medial and/or lateral canthal tightening. Surgical procedure for cicatricial entropion depend on the degree of scarring and the severity of entropion, the etiology of the cicatricial changes, and the status of the tarsal plate. Mild or moderate cases can be treated with a wedge resection or transverse blepharotomy with marginal rotation (Wies procedure). More extensive scarring may require mucous membrane graft (eg, buccal mucosa). Dr. Gangadhara Sundar (GS): DO, FRCSEd, FAMS, Assistant Professor & Senior Consultant, Orbit & Oculofacial Surgery, Department of Ophthalmology, National University Health System, Singapore. Dr. Ashok Kumar Grover (AKG): MD, MNAMS, FRCS, FIMSA, FICO, Chairman & Senior Consultant, Department of Ophthalmology, Sir Ganga Ram Hospital, & CEO, Vision Eye Centres, West Patel Nagar and Siri Fort Road, New Delhi Dr. Poonam Jain (PJ): MS (Ophthalmology), Consultant, Oculoplasty Services, Sant Parmanand Hospital and Narang Eye Institute, New Delhi Dr. Anita Sethi (AS): MD DNB FRCS (UK), Senior Consultant & Head of Ophthalmology, Artemis Health Institute, Gurgaon, India, NOVA Medical Centres, New Delhi Dr. Vikas Menon (VM): DNB, FLVPEI, Consultant, Ophthalmic Plastic and Aesthetic Surgery, Orbit and Ocular Oncology, Centre For Sight, New Delhi. Dr. Shaloo Bageja (SB): DNB, Consultant, Department of Ophthalmology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi Q.1: What are the types of entropion encountered in your practice? Can you summarize? Involutional > Cicatricial > Spastic. AKG: The most common type of entropion encountered in my practice is involutional entropion. Ten years ago, the most common type was cicatricial entropion. This change in trend is due to a dramatic decrease in the incidence of trachoma. Cicatricial entropion seen today is more often due to Stevens Johnson Syndrome. Occasionally, congenital entropion is also encountered. Depending on the etiology, entropion can be classified as congenital, cicatricial, involutional and spastic. Involutional entropion involving the lower lid and cicatricial entropion of the upper eyelid due to trachomatous scarring are the most common types of entropion encountered in my practice. Types of entropion commonly seen in my practice are 1. senile: commonest 2. cicatriceal: less common in urban areas with decreasing incidence of trachoma, traumatic, esp following chemical injuries and also following Steven Johnsons syndrome. 15

2 3. Congenital VM: Common types of entropion encountered are involutional entropion of the lower lid and upper lid cicatricial entropion. Q.2: How do you differentiate between congenital entropion and epiblepharon? Epiblepharon is fairly common in our population. The absolute in-turning of the eyelid margin itself is the differentiating criterion for entropion cf. epiblepharon. AKG: Epiblepharon is characterized by an extra fold of skin (medially) and inward rotation of the eyelid margin compressing the lashes against the globe, while this is not present in congenital entropion. Epiblepharon Steps of Congenital Entropion Surgery In epiblepharon, there is a fold of skin which overlaps the lid margin and pushes the lashes inwards against the cornea, but the lid margin itself is normally aligned with the globe. If you pull down this fold of skin, the lashes turn out but the margin of the lid remains in apposition to the globe. The direction of the eyelashes is also different. They are directed straight up and lie flat against the cornea, more visible in downgaze, and mostly in the medial two thirds of the lower eyelid. VM: Congenital Entropion is very rare. It may occur in the upper or lower lids. In these cases, spasm of orbicularis is usually very prominent. It is also useful to look for any component of horizontal tarsal kink in these children. Congenital Entropion Epiblepharon, however is a more common condition and on careful examination, one can see a redundant horizontal skin fold running across the lower lid margin which mechanically pushes the cilia to point inwards. In congenital entropion, the entire lid margin and lashes turn inward. The lid crease is absent. When skin is pulled down, the lid margin also pulls away from the globe. It is a rare entity and requires surgical correction. Q.3: How to treat epiblepharon? In our patients if they fail maximal lubrication or inability to lubricate, they undergo a modified Hotz procedure under GA. 16 DOS Times - Vol. 16, No. 8, February, 2011

3 AKG: Epiblepharon is generally noted in young children/ infancy and may spontaneously resolve with growth of facial structures. Involvement is usually bilateral, asymptomatic and requires no specific treatment. When it causes irritation and keratopathy, surgical management may be needed. The surgery involves removal of a horizontal strip of excess skin and pretarsal orbicularis muscle with a deeper anchorage to the tarsal plate. Epiblepharon is most often seen in chubby children and corrects itself as the face grows, generally by 1 to 2 years of age. Therefore in most of the cases, nothing needs to be done. When it does not resolve or is symptomatic causing significant punctate keratopathy, epiphora or photophobia, surgical correction is required. An ellipse of skin and a strip of orbicularis muscle is excised from the medial two thirds of the lower lid. The wound is closed by taking suture bites through the skin edge, orbicularis taking a bite through the tarsus at its lower edge coming out through the other edge of orbicularis and skin, quite similar to the way we pass lid crease formation sutures in ptosis surgery. VM: Epiblepharon resolves spontaneously, mostly by 3 years of age. Surgery is performed if there is significant corneal staining or the child is very photophobic. The procedure involves excising the excessive fold of skin and muscle. Q.4: What is your pre-op evaluation method to determine the etiology in a case of entropion? Clinical examination, absence of cicatricial features, predisposing ocular surface disorder. AKG: Involutional entropion is generally noted in individuals of older age group with horizontal laxity of the eyelids associated with a hump on lower eyelid due to overriding of preseptal orbicularis over the pretarsal part. It is often associated with absence of the downward excursion of the eyelid in downgaze due to weakness of the lower lid retractors. Cicatrical entropion is seen in patients with variable amount of tarsoconjunctival lamellar scarring. The digital eversion test can be done to distinguish cicatricial entropion from involutional entropion. Digital eyelid traction is applied to return the eyelid to a normal anatomic position. This corrects the abnormal margin position in involutional entropion but not in cicatricial entropion. Entropion is multifactorial in origin. The preop evaluation is directed towards identifying each factor that is contributing to its development in a particular patient so that the most suitable surgical procedure is selected. We evaluate the age of the patient, history of trauma, position of lid margin, laxity of lid tissues, presence of trichiatic lashes and corneal status. VM: The diagnosis of entropion is usually straightforward. The goal of eyelid examination is to determine the type of entropion. First thing is to assess if the entropion is cicatricial. Usually the scarring of conjunctiva and tarsus is obvious. Also, there is more resistance on turning the inverted lid to its normal position. If it is not cicatricial, the entropion is involutional. Q.5: How do you assess a patient of involutional entropion? Looking for all contributing factors, lower lid laxity (medial and lateral), lower eyelid retraction, hypertrophy or overaction of the preseptal orbicularis oculi, degree of keratopathy, underlying intraocular conditions like visually significant cataract, fitness for surgery under LA. AKG: In a patient with involutional entropion, diminished lower eyelid excursion in down gaze is often present, indicating weakness of lower lid retractors. Also, ptosis of the lower eyelid (higher than normal lower eyelid) of the affected eye is seen. The horizontal eyelid distraction test may be done. This is done by pulling the lid away from the globe and observing the subsequent return of the eyelid to the resting position. Measurements of greater than 6mm between the eyelid margin and the corneal surface with the eye in primary gaze are considered abnormal. Involutional Entropion Pinch Test To assess laxity 17

4 Another method is the snap back test in which downward traction is applied to the lid and then released. The lid should return to its normal postion against the globe promptly, without the aid of a blink. In involutional entropion, the lid hangs down below its normal position until a blink returns it to its normal position. This includes assessment of horizontal lid laxity by performing lid snapback and lid distraction tests, assessment of vertical lid laxity due to lower lid retractor disinsertion by presence of higher eyelid position in primary gaze and a deep inferior conjunctival fornix and assessment of preseptal orbicularis muscle override by observing its movement after a blink or forceful closure. In the snapback test, downward traction is applied to the lid and then released. A normal lid returns to its normal position against the globe promptly but in involutional entropion the lid continues to hang down until a blink. Lid distraction test is performed by pulling the central lid away from the eye. If it can be pulled more than 6 mm away from the globe, lid laxity is present. The clinical examination should include evaluation of the laxity and lengthening of the eyelids. The Distraction test determines the amount of lengthening & laxity present. The position and strength of the medial and lateral canthal tendons needs to be assessed as well as the level of the lid margin. VM: In involutional entropion, the lid can be turned easily to its normal position and it remains there for a blink or two. If the entropion is not obvious at the time of examination, the patient should be asked to squeeze the lids, this usually makes the entropion manifest. There are some other subtle signs as well; the lower eyelid often rides above the inferior limbus and there may be a white line seen in the inferior fornix signifying disinsertion of retractors. Any associated lower lid laxity also needs to be assessed using the eyelid distraction and snap tests. Q.6: We attribute lid laxity as an etiologic factor in involutional entropion. Can you explain why some eyes develop entropion and others ectropion with increasing age? The amount of laxity present in our population is fairly less compared to Caucasian populations. Also the threshold to seek attention is higher and I hypothesise the mild to moderate ectropion cases seldom present to us. Entropion with keratopathy is far more symptomatic, esp in a population who have visually significant cataracts as well. AKG: The exact mechanism why some patients develop ectropion while others would have involutional entropion is not clear. However, laxity of lower lid retractors could be a factor in causing entropion while tight lower lid retractors in the presence of laxity of canthal tendons is likely to lead to ectropion. Aging causes laxity of the canthal tendons and the tarsal plate, as well as dehiscence or laxity of the lower lid VM: retractors. The activity of the orbicularis muscle determines whether the lid sags outward, producing ectropion or rolls inward, causing entropion. Hypertrophy of the preseptal and pretarsal orbicularis and its spasm causes overriding of tarsus with inward turning of the lid margin. Conversely, patients with ectropion have atrophy of the orbicularis muscle with loss of tone. Besides this, patients with enophthalmos are predisposed to entropion and patients with ectropion commonly have prominent eyes. Since horizontal lid laxity is an etiological factor in both, lid tightening and shortening by lateral tarsal strip procedure is performed for correction of both, entropion as well as ectropion. The position of the lower lid is dependant on the tone of the muscles, (Orbicularis & lower lid retractors) and the strength of the tarsal sling, (the tarsal plate with its attachment to the canthal tendons). If there is weakness of the lower lid retractors and the orbicularis, with relative strength of the tarsal sling there will be Entropion with the lid margin turning in. If there is weakness of the tarsal sling and the orbicularis with relative preservation of the lower lid retractors, the lid margin and sometimes the whole lid will fall away from the globe resulting in ectropion. Occasionally, both may co-exist. One should not overlook the role of lower eye lid retractors in maintaining the lid stability. The retractors pull the lower margin of tarsus inferiorly and posteriorly. This keeps the eyelid margin in normal position. Entropion tends to develop if lower eyelid laxity is associated with laxity or disinsertion of the lower lid retractors. Q.7: Please outline the treatment protocol that you follow in a case of lower lid involutional entropion? Is Jones procedure your treatment of choice? Generally some form of eyelid tightening and reattachment of the lower eyelid retractors. I have moved away from lateral tarsal strip to more upper eyelid crease approach suture canthoplasty (open or closed technique). Also, I use Jones Procedure Tightening of Inferior lid retractors 18 DOS Times - Vol. 16, No. 8, February, 2011

5 only a single small incision approach to the LL retractor with 6-0 vicryl central stitch. AKG: Treatment of involutional entropion is essentially surgical. In patients of lower lid involutional entropion without lid laxity, Jones procedure is my preferred technique. In patients with lid laxity, I prefer to combine Jones procedure with lateral tarsal strip procedure. My treatment protocol depends upon the principal causative factor. If no lid laxity is present at all, then I perform the Jones procedure in which the lower lid retractors are reattached to the tarsus. Horizontal lid laxity is present in majority of the cases for which I perform the lateral tarsal strip procedure. I mostly combine it with removal of a strip of redundant skin and preseptal orbicularis through a skin incision which is closed by passing continuous sutures. This creates a fibrous barrier between the skin and deeper eyelid structures preventing the preseptal muscle override and at the same time produces a nice, subtle lid crease. I combine both, the lateral tarsal strip and the Jones procedure in cases where lid laxity is present along with evidence of disinsertion of retractors. The treatment of lower lid involutional entropion is surgical. Taping and lubricants may be used temporarily if the patient is unfit for surgery. I prefer to routinely perform the modified Jones procedure, reattachment of the lower lid retractors and dehised orbital septum to the lower edge of the tarsus. I often combine it with a lid shortening procedure such as Bick s procedure (removal of a triangular section of the lower lid) or lateral canthal sling to support the sagging canthal tendon. VM: Yes, Jones procedure is my preferred surgery for involutional entropion of the lower lid. Q.8: In case of involutional entropion with eyelid laxity what do you prefer LTS alone or combine it with Jones procedure? How do you assess? Please note response for Q7. AKG: In patients of involutional entropion with lid laxity, I prefer to combine Jones procedure with lateral tarsal strip. The decision depends on the amount of lid laxity and lengthening present as determined by the pinch test or distraction method. VM: I prefer to combine Jones procedure with Lateral Tarsal Strip wherever there is significant laxity of the lower lid. Q.9: Do you ever combine involution entropion correction and blepharoplasty? In which cases? Please elaborate. Yes, when the steatoblepharon is significant and there is redundancy of the lower eyelid skin, an external transcutaneous blepharoplasty approach is preferred. Also, when bilateral procedures are being considered. AKG: I generally do not combine involutional entropion correction with blepharoplasty. However, skin is usually Lateral Tarsal Strip shortened in combination with Jones surgery, as the standard procedure. I always perform the retractor reinsertion through a subciliary, blepharoplasty incision instead of the classical lower incision described in Jones procedure. The skin muscle flap is raised in the same way and the rest of the exposure is also same as in transcutaneous blepharoplasty. I remove excess redundant skin as well but since most of these patients in fact have enophthalmic eyes caused by fat resorption rather than a fat prolapsed, fat pad removal is generally not required. In the upper lid, I frequently combine blepharoplasty with entropion correction especially in those who have had a previous surgery done somewhere and present with notching. There is hardly any tarsal support as much of it has been excised while attempting a wedge resection. I perform a blepharoplasty to shorten the anterior lamella, do anterior lamellar repositioning with or without lid split. While closing the skin incision I take two to three bites of the suture through the tarsus to form a lid crease, thus achieving a satisfactory, aesthetically pleasing result. I don t do it very often. Cases with prominent prolapse of fat and obviously dehised septums may be candidates. Often patients of senile entropion may be very old and on blood thinners, one needs to be careful while excising fat during blepharoplasty as there may be bleeding. VM: Involutional entropion can be combined with excision of excessive redundant lower lid skin and prolapsing orbital fat through a common subciliary incision. Q.10: Have you encountered overcorrection in patient of involutional entropion? What are the causes? How do you manage them? Yes, but occasionally esp when the LL retractor is tied tight and not just reattached. Also, when 3 horizontal mattress sutures are used instead of one, esp when lower eyelid tightening is not done or has given way. 19

6 AKG: Yes, I did have cases where there was an ectropion in the early postoperative period. Overcorrection in a patient with involutional entropion is generally seen in cases where intraoperative tightening of the lower lid retractors is excessive. It is important to titrate the amount of retractor tightening intraoperatively. VM: In the initial postoperative phase, overcorrection can be managed by lid massage and release of sutures. In later stages, the patient may have to be taken up for resurgery. If the lower lid retractors are attached too high onto the anterior surface of the tarsus in the retractor reinsertion procedure, overcorrection will result. They should be attached to the inferior border of the tarsus. If the orbital septum is incorporated in the surgical closure, then also a consecutive ectropion can occur. Uncorrected horizontal lid laxity can also result in overcorrection as also excessive excision of skin or pretarsal orbicularis instead of preseptal. Do not aim for an overcorrection on the OT table in case of lower lid entropion in contrast to upper lid entropion correction by marginal rotation procedure where some degree of overcorrection is desirable. Management of overcorrection is surgical, by using an appropriate technique depending on the case. There may be over-correction, especially if associated lengthening has not been tackled. It is best to prevent it. At the time of surgery while tightening the sutures, the margin should be just turned out, there is no need to over-correct. If over-correction has occurred, Lateral canthal sling may correct the problem. Overcorrection is usually caused by unaddressed lid laxity or tight plicating sutures. Management aims to correct the horizontal lid laxity by performing some form of lid tightening procedure like Lateral Tarsal Strip. If the cause is tight placating sutures, I consider an early release of these sutures. Q.11: How do you plan a patient how have keloidal tendencies? Patients seldom develop keloids from incisions in the upper and lower eyelid. The occasional hypertrophic scar is encountered in the medial canthus only, esp in the young er patients and almost never in the elderly. Of course the tendency to hypertrophic scars may be observed by looking at their BCG scars and any additional body scar they may have. AKG: In a patient with keloidal tendencies, the corrective surgery can be planned via the conjunctival approach or an everting suture may be used. I have not encountered keloid formations after entropion correction. Not so common, probably use less cautery. VM: Although keloids are rare in the periocular area, patients who have such tendencies are usually very apprehensive for undergoing any kind of surgery. In these cases, I usually try using Botox as a non surgical measure to relieve lower lid entropion. Lid everting sutures are also helpful in these cases. In a situation where keloid or hypertrophic scar has already formed, I inject 5 FU and sometimes triamcinolone in the scar tissue to flatten it. Q.12: How do you select the appropriate surgical procedure in a case of cicatricial entropion of the upper eyelid? As undercorrection and regression is the norm, I almost always aim for over correction. For mild cases, terminal tarsal rotation with a blepharoplasty may be necessary. For moderate to severe cases, posterior lamellar augmentation with blepharoplasty and browlift often minimizes recurrences. AKG: Surgical procedures to correct cicatricial entropion depend on the severity of the entropion, extent of tarsal thickening and whether previous surgical procedures have been carried out. In cases of mild to moderate entropion with thickened tarsus, I prefer to do a wedge resection. In patients with moderate or severe entropion, where tarsus is not so thick, I plan a tarsal Fracture. In patients with moderate to severe Cicatricial Entropion Marginal dissection with mucous membrane grafting 20 DOS Times - Vol. 16, No. 8, February, 2011

7 Tarsal Fracture entropion, where tarsus may have been lost due to previous surgical procedures, marginal dissection with mucous membrane grafting (Van Mellingen s procedure) is often the choice. The appropriate procedure is selected depending on the degree of entropion, keratinisation and distortion of the lid margin and eyelashes and analysis of posterior lamellar shortening and scarring. We can either recess the anterior lamella or lengthen the posterior lamella or ever the abnormal lid margin. If entropion is severe and there is a thickened tarsal plate, then Tarsal fracture works well. If the tarsal plate is fibrosed & there is also excess skin fold, skin approach wedge resection is the procedure of choice. If there is gross shortening of the posterior lamina then grafting may be required. VM: For cases with mild to moderate degree of cicatrisation, I prefer tarsal wedge resection or the tarsal fracture procedure. However, in very severe or recurrent cases, I prefer to do a posterior lamellar grafting procedure to lengthen the posterior lamella. Q.13: What is your procedure of choice for cicatrical entropion? As stated above. AKG: Tarsal Fracture is the procedure which works well in most cases and in most hands. In mild to moderate entropion of the upper lid with little distortion of other eyelid structures and in resurgery cases, I perform anterior lamellar repositioning along with blepharoplasty as discussed above. In mild to moderate entropion with margin distortion and trichiasis when tarsus is intact and of reasonably good quality, Tarsal fracture with marginal rotation gives good result in both the upper or lower lid. I perform transverse tarsotomy after everting the lid instead of a full thickness blepharotomy because the aesthetic result is better with no cutaneous scarring. Also, it is possible to titrate the degree of marginal rotation required by controlling suture placement and tightness. Tarsotomy should be made at least 3mm below the lid margin to avoid the marginal vascular arcade. In severe cicatricial entropion with marked contracture of the tarsus and conjunctiva, a graft has to be placed to lengthen and support the posterior lamella. I find that skin approach wedge resection is suitable in most cases. VM: Same as Q 12. Q.14: For managing cicatricial entropion, what material is your choice for the spacergraft? Hard palate mucosal graft. AKG: The material of choice for spacer graft, in a case of cicatricial entropion is donor sclera. However, usual precautions to prevent transmission of viral diseases are necessary. I use buccal mucous membrane graft. I have no personal experience of using amniotic membrane. Mucous membrane graft (oral mucosa). VM: Buccal mucous membrane. Q.15: What is your experience of using amniotic membrane in the management of cicatricial entropion? Only for extensive 4 fornix contraction with severe keratopathy. AKG: I generally do not use amniotic membrane in the management of cicatricial entropion and prefer mucosa. This is because amniotic membrane is a substrate graft rather than a substitute graft which may not work well in presence of extensive cicatrisation. VM: Amniotic Membrane can be used in a lid split procedure with anterior lamellar repositioning. It helps the bare tarsus 21

8 to epithelialize rapidly and improves the result of surgery. As a posterior lamellar spacer material in severe cicatricial entropion, I prefer to use mucous membrane rather than amniotic membrane. Q.16: How do you manage spastic entropion? (do you use Botox? what dose?) How frequently you use this in your practice in senile entropion. As a temporizing measure and also for patients who are medically unfit for anesthesia (even LA). AKG: Management of the underlying condition generally helps in the treatment of spastic entropion. I generally do not use botox in treatment of senile entropion. Botox works very well in correcting spastic entropion. I have also used Botox in some involutional entropion cases with significant preseptal muscle override when the patient is not willing for surgery or is bedridden and not fit for surgery. Inject 2.5 units of Botox at 2 or 3 places below the lower lid margin. Inject directly into the muscle by pinching it taking care not to go deep, specially medially as it may cause inferior oblique muscle paresis and lead to diplopia. VM: Spastic entropion can be managed by lid everting sutures or Botox. I use 5 to 10 Units of Botox for treating spastic entropion. The disadvantage in using botox is that it may take around 4 to 7 days for its effect to appear, so in situations where we need an immediate treatment for spastic entropion, lid everting sutures may be more beneficial. However, it is not my treatment of choice for senile entropion, where I prefer surgery. In senile entropion, I use Botox only for cases that are not willing for surgery or unfit because of some systemic condition. DOS Correspondent Shaloo Bageja DNB 22 DOS Times - Vol. 16, No. 8, February, 2011