A Pinpoint Administration of Involutional Entropion

Kumari S, Kumari P, Agrawal A, Sunny D, Kumari N and Bharti AK

Published on: 1970-01-01

Abstract

The aim of the observations and study was to report the surgical outcome of mini-incisional correction method to treat involutional entropion Involutional entropion is a troublesome eyelid malposition commonly encountered in elderly above 55 year and older patients, with a prevalence reported as high as 2.1%. The condition is indicated by progressive inward rotation of the lower lid margin, causing progressive irritation of the ocular surface. Although conservative therapy with ocular lubrication, volving, or botulinum toxin injections can giverise to short-term relief, surgical interference is need to positively reimpose the anatomic state.

Keywords

Entropion; Pinpoint; surgical

Introduction

Pseudoptosis is a medical condition in which the lid of eye fold inward direction. This is very intolreable, as the eyelashes continually got rubbed against the cornea and got irritated. It is generally caused by genetic terms and very in frequently it may be congenital when an extra folds of skin grows with the lower lid. It can also generate pain of the eye. The upper or lower lid of eye can be intricated, and one or both eyes may be involve. When this occurs in both eyes, this is known as "bilateral pseudoptosis." Repeated cases of trachoma infection can cause discolouration of the inner lid of eye, which may cause pseudoptosis [1].

Figure 1: affects only the lower lid of eye.

The following forms are differentiated according to their origin:-

Congenital Entropion: usually the lower eyelid is affected.

Spastic Entropion: affects only the lower lid of eye.

Cicatricial Entropion: commonly the results of Post infectious or post-Traumatic tarsal contracture (such as Trachoma, burns and chemical injuries).

Classification

  • Involutional Entropion
  • Cicatricial Entropion
  • Acute Spastic Entropion
  • Congenital Entropion.

Symptoms and Signs

  • Ocular foreign body sensation
  • Secondary blepharospasm
  • Ocular discharge
  • Conjunctival metaplasia
  • Superficial keratopathy
  • Corneal Scarring 
    Figure 2: Normal aad Entropian Eye.

Involutional Entropion

Factors responsible for,

  • Laxity, dehiscence, or infusion of lower lid retractor.
  • Overriding of pre-septal orbicularis segment over pre-tarsal orbicularis segment.
  • Horizontal lid laxity.
  • Enophthalmos.

Cicatricial Entropion

  • Conditions causing contracture of conjunctiva
  • Chemical burn, surgical/accidental trauma, tropical anti-glaucoma medications, ocular cicatricial pemphigoid,Trachoma,SJS

Acute Spastic Entropion

Seen in susceptible individuals with blepharospasm that are induced by ocular irritation blepharitis, dry eye etc.

Congenital Entropion

  • RARE
  • Different from epiblepharon
  • horizontal fold of redundant pretarsal skin & orbicularis muscle extend beyond eyelid margin.
  • Which presents with inverted tarsus.

Cause

Unusual fusion of lower lid retractor.

Spastic Entropion

  • Due to increased muscular tone, the lower lid orbicularis shifts superiority overriding the inferior border of tarsal.
  • Trauma, lid surgery or inflammation
  • Occasionally associated with blepharospasm

Treatment and Management

Figure 3: Surgical anatomy of lower eyelid.

Congenital Ectropion

  • Full thickness skin graft

Involutional Ectropion

  • Medial Conjunctivoplasty
  • Horizontal lid shortening
  • Bryonsmith’s modified kuhnt
  • Szymanowsky operation

Surgical Management

Everting sutures: is a fast, minimally invasive, low-cost technique to temporarily reinsert lower lid retractors.Includes a double-armed easily absorbable suture is situated into the conjunctival fornix under the lower border of the tarsus to engage the lower retractors. The suture is pointed below the tarsal plate, and then upward to appear inferior to the lash line to reach lid eversion.That use this management for pseudoptosis is contentious, however, because of high reappearence rates. Male sex, severe lower eyelid laxity. In addition to reappearence, other complications may incorporate trichiasis, granuloma and bruising [2].

Reinsertion of lower lid retractor: Inspection and reinsertion of the lower lid retractors can be executed through a direct external incision or an internal transconjunctival point of view.

In external renovation

A subciliary cutaneous incision is made. After the orbital septum is openly dissected, the lowerlid of eye retractors are recognize and reattached to the anterior inferior tarsal edge with intersperse absorbable suture. The skin is then terminate over the repair. It Reports complication which include mild eyelid retraction and pyogenic granuloma [3].

 Internal approaches

Involve a transconjunctival incision below the inferior border of tarsal. A conjunctival flap is upraised until the lower lid of eye retractors are recognize. The retractor are attached to the anterior

Inferior border of the tarsus, and the conjunctiva nearer over the repair. Complications of internal repair include overcorrection with ectropion, in addition to the mild retraction and granulomas that are also reported from repair with the external approach.Reappearence is little bit more recurrent with the internal transconjunctival perspective, although the difference is not analytical significant.8 Conservative retractor reintegrating without correction of horizontal laxness can have recappearence rate as high as 18%; however, concurrent horizontal canthal shortedly reduce reappearance rate [4].

Lateral canthal tightening: Surgical procedure for tightening lower eyelid laxity including full-thickness partial lower eyelid sections and lateral tarsal strips procedure. Full-thickness lower eyelid section requires a wedge section and tarsal repair.In the lateral tarsal strip course of action, after the performance of surgeon a lateral canthotomy and inferior cantholysis, the tarsus is secluded from the anterior and posterior lamella to create a de-epithelialized strip of tarsus. The tarsus is shorten out and then reattaches to the periosteum of the lateral orbital rim. The lateral tarsal strip restores physiologic lower eyelid tension without causing eyelid margin incising or weakness, can occur after a full-thickness lower eyelid resection. , rare complications of the lateral tarsal strip procedure include persistent trichiasis, chemosis, and self-limiting granuloma, without pseudotopsis [5].

Lateral Canthal Tightening and Combined Everting Suture

Management have been obtaining popularity because of their rapid decreased in reappearance rates and low chance obstacles. A little amount of preseptal orbicularis can be removed in patients who have significant override that aggravates the pseudoptosis. Reinfusing the trimming, the orbicularis inscripted tightening the tarsus, and capsulopalpebral fascia, all 3 etiologic factors for involutional pseudoptosis. Despite remarkable improvements, reappearence rate in literature ranges from 2% (mean follow-up, 18 months) to 10.4% (mean follow-up, 24 months). Varying degrees of remaining horizontal lid laxity may donate difference in recurrence rates [6].

Conclusions

Understanding the anatomy, pathophysiology, and etiological factor is critical in diagnosis and management of involutional pseudoptosis. General health, & Patient age, and preferences may be contemplate in deciding between more or less invasive management modality. Many of the surgical procedures have been elabrated in the literature, with varying recurrence rate. Everting sutures and lateral tarsal strip added with preseptal orbicularis modification can restore lower eyelid anatomy with good surgical results.

References