ENTROPION

It is inturning of the lid margin.
Types
1. Congenital entropion. It is a rare condition seen
since birth. It may be associated with microphthalmos.
2. Cicatricial entropion (Fig. 14.17). It is a common
variety usually involving the upper lid. It is caused
by cicatricial contraction of the palpebral conjunctiva,
with or without associated distortion of the tarsal
plate.
Common causes are trachoma, membranous
conjunctivitis, chemical burns, pemphigus and
Stevens-Johnson syndrome.
3. Spastic entropion. It occurs due to spasm of the
orbicularis muscle in patients with chronic irritative
corneal conditions or after tight ocular bandaging. It
commonly occurs in old people and usually involves
the lower lid.
4. Senile (involutional) entropion. It is a common
variety and only affects the lower lid in elderly people
(Fig. 14.18). The etiological factors which contribute
for its development are : (i) weakening or dehiscence
of capsulopalpebral fascia (lower lid retractor);
(ii) degeneration of palpebral connective tissue
separating the orbicularis muscle fibres and thus
allowing pre-septal fibres to override the pretarsal
fibres; and (iii) horizontal laxity of the lid.
5. Mechanical entropion. It occurs due to lack of
support provided by the globe to the lids. Therefore,
it may occur in patients with phthisis bulbi,
enophthalmos and after enucleation or evisceration
operation.
Clinical picture
Symptoms occur due to rubbing of cilia against the
cornea and conjunctiva and are thus similar to
trichiasis. These include foreign body sensation,
irritation, lacrimation and photophobia.
Signs. On examination, lid margin is found inturned.
Depending upon the degree of inturning it can be
divided into three grades. In grade I, only the
posterior lid border is inrolled. Grade II entropion,
includes inturning up to the inter-marginal strip while
in grade III the whole lid margin including the anterior
border is inturned.
Complications. These are similar to trichiasis.
Treatment
1. Congenital entropion requires plastic reconstruction
of the lid crease.
2. Spastic entropion. (i) Treat the cause of blepharospasm
e.g. remove the bandage (if applied) or treat
the associated condition of cornea. (ii) Adhesive
plaster pull on the lower lid may help during acute
spasm. (iii) Injection of botulinum toxins in the
orbicularis muscle is advocated to relieve the spasm.
(iv) Surgical treatment similar to involutional (senile)
entropion may be undertaken if the spasm is not
relieved by above methods.
3. Cicatricial entropion. It is treated by a plastic
operation, which is based on any of the following
basic principles : (i) Altering the direction of lashes,
(ii) Transplanting the lashes, (iii) Straightening the
distorted tarsus.
Surgical techniques employed for correcting
cicatricial entropion are as follows:
i. Resection of skin and muscle. It is the simplest
operation employed to correct mild degree of
entropion. In this operation an elliptical strip of
skin and orbicularis muscle is resected 3 mm
away from the lid margin.
ii. Resection of skin, muscle and tarsus: It corrects
moderate degree of entropion associated with
atrophic tarsus. In this operation, in addition to
the elliptical resection of skin and muscle, a
wedge of tarsal plate is also removed (Fig. 14.19A).
iii. Modified Burrow’s operation. It is performed
from the conjunctival side after everting the lid.
A horizontal incision is made along the whole
length of the eyelid, involving conjunctiva and
tarsal plate (but not the skin), in the region of
sulcus subtarsalis (2-3 mm above the lid margin).
The temporal end of the strip is incised by a full
thickness vertical incision. Pad and bandage is
applied in such a way that the edge of lid is kept
everted till healing occurs. After healing, the
lashes are directed away from the eye.
iv. Jaesche-Arlt’s operation (Fig. 14.19B): The lid is
split along the grey line up to a depth of
3-4 mm, from outer canthus to just lateral to the
punctum. Then a 4 mm wide crescentric strip of
skin is removed from 3 mm above the lid margin.
After suturing the skin incision, the lash line will
be transplanted high. The gap created at the level
of grey line may be filled by a mucosal graft taken
from the lip.
v. Modified Ketssey’s operation (Transposition of
tarsoconjunctival wedge) (Fig.14.20): A horizontal
incision is made along the whole length of sulcus
subtarsalis (2-3 mm above the lid margin)
involving conjunctiva and tarsal plate. The lower
piece of tarsal plate is undermined up to lid
Fig. 14.19. Operations for cicatricial entropion: A, skin,
muscle and tarsal wedge resection; B, Jaesche-Arlt’s
operation. Fig. 14.20. Modified Ketssey’s operation.
margin. Mattress sutures are then passed from
the upper cut end of the tarsal plate to emerge on
the skin 1 mm above the lid margin. When sutures
are tied the entropion is corrected by transposition
of tarsoconjunctival wedge.
4. Senile entropion. Commonly used surgical
techniques are as follows:
i. Modified Wheeler’s operation: A base down
triangular piece of tarsal plate and conjunctiva is
resected along with double breasting of the
orbicularis oculi muscle (Fig. 14.21).
ii. Bick’s procedure with Reeh’s modification: It is
useful in patients with associated horizontal lid
laxity. In it a pentagonal full thickness resection
of the lid tissue is performed.
iii. Weiss operation. An incision involving skin,
orbicularis and tarsal plate is given 3 mm below
the lid margin, along the whole length of the
eyelid. Mattress sutures are then passed through
the lower cut end of the tarsus to emerge on the
skin, 1 mm below the lid margin. On tying the
sutures, the entropion is corrected by
transpositioning of the tarsus.
iv. Tucking of inferior lid retractors (Jones, Reeh
and Wobig operation): It is performed in severe
cases or when recurrence occurs after the above
described operations. In this operation the
inferior lid retractors are strengthened by
tucking or plication procedure