Involutional lower eyelid entropion: causative factors and therapeutic management.

PURPOSE: To summarize proposed causative factors and the outcomes of surgical practices for involutional lower eyelid entropion. METHODS: We reviewed the literature on proposed causative factors and the outcomes of surgical practices for involutional lower eyelid entropion, searched on PubMed. RESULTS: Vertical and horizontal laxities of the lower eyelid, and overriding of the preseptal orbicularis oculi muscle onto the pretarsal orbicularis oculi muscle have been proposed as the major causes of involutional lower eyelid entropion. Treatment procedures have been developed over the years to address one or more of these causative factors. CONCLUSIONS: Various causative factors and treatment procedures have been advocated to explain and correct involutional lower eyelid entropion. The appropriate procedure is chosen according to the patient's condition, such as the presence of vertical laxity, horizontal laxity, and orbicularis oculi muscle overriding. A combination of these procedures to correct multiple factors further decreases the recurrence rate.

Association of Involutional Lower Eyelid Entropion with Reduced Upper Eyelid Position Relative to the Corneal Light Reflex: Quantification of Facial Asymmetry.

PURPOSE: To investigate the association between upper eyelid position relative to the corneal light reflex (MRD1) and to delineate an association between eyelid height and involutional lower eyelid entropion. METHODS: Retrospective study of patients presenting for entropion repair to an academic ophthalmic plastic surgery service. A total of 111 patients were included in the study; 95 had unilateral involutional lower eyelid entropion, and 16 had bilateral lower eyelid entropion. Patients with a history of previous eyelid surgery, trauma, upper eyelid entropion, or cicatricial changes were excluded from the study. RESULTS: Of the 95 patients with unilateral involutional lower eyelid entropion, 45 (47.4%) had a lesser MRD1 on the side ipsilateral to the involutional lower eyelid entropion. In this unilateral group, the mean MRD1 (± standard deviation) on the ipsilateral to the involutional lower eyelid entropion was 2.9 (±1.2) mm, while the mean MRD1 on the contralateral side was 3.3 (±1.0) mm. This difference was 0.4 mm and was statistically significant (p < 0.0001). Most patients with unilateral involutional entropion demonstrated a right-sided involutional lower eyelid entropion (56 of 95; 58.9%), although this finding was not statistically significant (p = 0.083). The frequency of true blepharoptosis (MRD1 ≤ 2.0 mm) was 24 of 95 (25.3%) in the unilateral involutional entropion group and was even higher in the bilateral involutional lower eyelid entropion group, with 7 of 16 (43.8%) patients exhibiting bilateral blepharoptosis. CONCLUSIONS: Patients presenting with involutional lower eyelid entropion tend to have a relatively reduced MRD1 on the ipsilateral (affected) side. When both lower eyelids are affected by involutional entropion, the reduced MRD1 tends to be more pronounced.

Manual Provocation Test for Intermittent Involutional Entropion.

PURPOSE: To describe the manual provocation test (MPT), a novel test for intermittent involutional entropion of the lower eyelid. METHODS: Retrospective review of patients with intermittent entropion who presented with ocular irritation and documented inward eyelid rotation by them or their referring physicians, but who had no apparent entropion at the time of initial consultation. Results of the MPT were recorded for this group, and then evaluated prospectively in an age-matched comparison group of patients presenting for blepharoplasty who had no history of entropion. The essential steps of the MPT are as follows. Step 1: the lower eyelid skin is grasped below the inferior border of the tarsal plate. Step 2: the lid is drawn anteriorly as with the eyelid distraction test. Step 3: the patient is directed to forcefully close the eyelids. Step 4: the eyelid is released and the result is observed for manifest entropion. RESULTS: Thirteen eyelids in 12 patients with intermittent involutional lower eyelid entropion were included in this study. Average patient age was 77.3 years (±9.5 SD). The MPT elicited entropion in all 13 eyelids. Of the 12 patients, 9 elected to pursue surgery and, of these patients, all eyelids were successfully treated with subsequent improvement of symptoms. The MPT was thereafter negative in these patients. None of the 20 patients in the blepharoplasty comparison group (average age 71.6 years) demonstrated a positive MPT. CONCLUSIONS: The MPT can be a valuable and straightforward test in the clinical evaluation of patients with a history of intermittent entropion.

The Versatile Lid Crease Approach to Upper Eyelid Margin Rotation.

Lid margin rotational procedures have been used to correct cicatricial trachomatous entropion since the 19(th) century. There are two basic types of surgeries used for lid margin rotation. The first type is based on through-and-through approach combining tarsotomy and the use of sutures on the anterior lamella. The second type of surgery was suggested by Trabut, who proposed a tarsal advancement by posterior approach. We demonstrate that using a lid crease incision combines the basic mechanisms of the anterior and posterior approaches and in addition, addresses a variety of lid problems commonly found in the aged population with cicatricial entropion. After tarsal plate exposure, a tarsotomy through conjunctiva is performed as described by Trabut. Then, instead of using external sutures secured by bolsters, internal absorbable sutures can be used to simultaneously advance the distal tarsal fragment and exert strong tension on the marginal orbicularis muscle. Sixty lids of 40 patients underwent surgery with a lid crease incision. The follow-up ranged from 1 to 12 months (mean 3.0 months ± 2.71). Forty percent of the patients (24 lids) had more than 3 months of follow-up. Adequate margin rotation was achieved in all lids but one that showed a medial eyelash touching the cornea.

Are You Missing an Entropion? The Test of Induced Entropion 2.

PURPOSE: Entropion is the inward turning of the eyelid. The most common type of entropion is involutional, a combination of eyelid laxity, lower eyelid retractor weakness, and orbicularis oculi override. Unfortunately, the condition can be intermittent and remain undiagnosed, leading to ocular surface damage. In suspected cases, clinicians can use provocation techniques to elicit the condition. These include the forced closure of the eyelids, the tetracaine provocation test, and the test of induced entropion (TIE). The authors present an alternative diagnostic test: the TIE-2. METHODS: The TIE-2 test is performed by asking the patient to look down while the examiner holds the upper eyelid open and high to prevent downward movement. The patient is then asked to close their eyelids as tightly as possible. An entropion will then be induced. To illustrate the technique, the authors present 2 patients seen in the oculoplastics clinic with symptoms and signs suggestive of intermittent entropion, in whom conventional provocation tests were unsuccessful. RESULTS: In both cases, conventional methods did not provoke an entropion. However, the TIE-2 test successfully induced an entropion, leading to the correct diagnosis and appropriate management. CONCLUSION: When there is suspicion of intermittent entropion that is not revealed with existing provocation tests, the TIE-2 is a simple and useful diagnostic tool.

Orbicularis oculi muscle transposition for repairing involutional lower eyelid entropion.

PURPOSE: To describe a simple technique for involutional entropion correction and to present the findings of a retrospective interventional case series study. METHODS: We studied a consecutive series of 414 patients (609 eyelids). Patients presenting with involutional entropion in the absence of lateral canthal tendon laxity underwent orbicularis oculi muscle (OOM) transposition from pretarsal position to corresponding preseptum without horizontal shortening or resection of the orbicularis muscle. RESULTS: Immediate resolution of entropion and associated ocular symptoms was achieved in 607 eyelids (99.67 %). An early postoperative complication was localized lid swelling that gradually subsided within one week. Over-correction occurred in six cases and resolved with pressure dressing, mostly one or two days post-operation. At final follow-up, a significant improvement in eyelid position was achieved in 579 eyelids (95.07 % ). There was mild recurrence of entropion in 30 eyelids (4.93 %). The mean follow-up was 6.84 months (range, 6-12 months). CONCLUSIONS: Orbicularis oculi muscle transposition is a reasonably successful procedure with a high success rate, and is particularly suitable for patients for whom there exits overriding of the preseptal OOM over the pretarsal OOM.

No histological evidence of orbicularis oculi muscle hypertrophy in congenital epiblepharon.

BACKGROUND: To analyse the microscopic anatomy of the orbicularis oculi muscle in patients with congenital epiblepharon and to determine whether hypertrophy of the orbicularis oculi muscle, which is considered as a possible cause of this eyelid malposition, exists. METHODS: Sixty-seven eyelids with congenital epiblepharon of 41 Japanese patients, as well as 30 control eyelids of 24 Japanese patients with other eyelid pathologies (upper eyelid: fourteen blepharoptosis, one trichiasis and two retractions; lower eyelid: five involutional entropions, one trichiasis and seven retractions) were analysed. These controls contained no orbicularis pathology such as cicatrization or orbitopathy. The muscle specimens were obtained from the central part of the pretarsal orbicularis oculi muscle during surgery. The specimens were stained with haematoxylin & eosin. Only specimens with cross-sectional areas that included large muscle fibres were selected. In each section, 10 muscle fibres were measured across their smallest diameter, thereby avoiding inaccurate measurements of muscle kinking occurring during the processing or by any obliquity of the plane of section. Measurements of the muscle fibre diameter were made with a digital measure. RESULTS: There were no significant differences in the average diameter of the muscle fibres between the patients with congenital epiblepharon and the control group. CONCLUSIONS: There was no evidence of orbicularis oculi muscle hypertrophy in congenital epiblepharon.

Ectropion and Entropion in Sub-Saharan Africa: How do we Differ?

Aims: To study the etiopathophysiology of ectropion and entropion in a sub-Saharan tertiary eye care center and examine how it differs from reports elsewhere. Methods and Materials: This was a retrospective audit of all consecutive patients who presented with ectropion or entropion to the oculoplastics clinic of a tertiary eye care unit. We reviewed the medical records of all such patients and data extracted include age; gender; etiopathology; and diagnosis. The primary oculoplastic disease was used in classifying the patients. The study period covered January 2008-June 2012. Results: A total of 53 patients were identified constituting 37.3 of all eyelid diseases. Thirty-three (62.3) were males. Forty-eight (90.6) had ectropion; 43(89.6) of which were cicatricial ectropion. Five (9.4) had entropion. The median age group affected was 30-39 years (26.4). There were no cases of congenital ectropion or entropion. The leading etiological factor was trauma in 36 cases (67.9); which was mostly due to road traffic accidents (50.9). Conclusions: This study highlights a difference in etiopathophysiology of ectropion and entropion in a sub-Saharan region when compared to reported data from developed countries. In Nigeria; ectropion (which is often cicatricial) is usually secondary to trauma whereas senile involution is the common cause in many developed countries. This finding has implications in appropriate planning and skill acquisition for surgical correction in this group of patients

Use of adhesive tape for temporary management of inturned upper eyelid eyelashes.

OBJECTIVE: To evaluate the efficacy of adhesive tape for temporary management of inturned upper eyelid eyelashes. METHODS: In a prospective, consecutive, comparative, nonrandomized, interventional case series, 50 patients (100 eyes) had inturned eyelashes with at least 1 of 3 symptoms: foreign body sensation, itchiness, and tearing. Transpore tape was applied to the right upper eyelid of each patient; the left eye was used as a control. A questionnaire was used to assess relief or persistence of the symptoms before, during, and after tape adhesion. RESULTS: Analysis of variance showed a significant difference between the study and control groups (P = .002). Tukey honestly significant difference analysis revealed a significant difference in symptoms before and during tape adhesion and a significant difference during and after tape adhesion. Symptoms in the control eye remained unchanged. CONCLUSION: Use of adhesive tape can be an effective temporary measure for relief of symptoms of inturned upper eyelid eyelashes.

Entropion-ectropion: the influence of axial globe length on lower eyelid malposition.

PURPOSE: To evaluate the effect of axial globe length and other biometry parameters on age-related lower eyelid malposition. METHODS: Consecutive patients with involutional lower eyelid malposition underwent preoperative biometry with Zeiss IOL Master and Hertel's exophthalmometer prior to surgery. Patients with other causes of eyelid malposition and thyroid eye disease were excluded. GraphPad InStat was used for t test and chi-square statistical analysis. RESULTS: Data on 57 eyelids of 52 Caucasian patients were collected. There were 28 ectropions and 29 entropions. The mean axial globe length in the ectropion group (23.5 mm, standard deviation ± 0.9) was significantly longer than in the entropion group (22.7 mm, standard deviation ± 1.03) (p = 0.008). There was significant sex predilection, with entropion more common in women and ectropion more common in men (p = 0.03). The mean axial globe projection in the ectropion group was 16.6 mm (standard deviation ± 2.4) and in the entropion group was 14.6 mm (standard deviation ± 2.7) (p = 0.002). There was no statistical difference in age, keratometry, amount of astigmatism, and cylinder axis. CONCLUSION: Involutional eyelid malposition directly correlates with axial globe length with the ectropion group having lengthier eyes compared with the entropion group. Hence, axial globe length could be an influential factor in the onset of involutional eyelid malposition.

Surgical correction of Hallermann-Streiff syndrome: a case report of esotropia, entropion, and blepharoptosis.

We report a case of surgical treatment for Hallermann-Streiff syndrome in a patient with ocular manifestations of esotropia, entropion, and blepharoptosis. A 54-year-old man visited Yeouido St. Mary's Hospital complaining of ocular discomfort due to cilia touching the corneas of both eyes for several years. He had a bird-like face, pinched nose, hypotrichosis of the scalp, mandibular hypoplasia with forward displacement of the temporomandibular joints, a small mouth, and proportional short stature. His ophthalmic features included sparse eyelashes and eyebrows, microphthalmia, nystagmus, lower lid entropion in the right eye, and upper lid entropion with blepharoptosis in both eyes. There was esodeviation of the eyeball of more than 100 prism diopters at near and distance, and there were limitations in ocular movement on lateral gaze. The capsulopalpebral fascia was repaired to treat the right lower lid entropion, but an additional Quickert suture was required to prevent recurrence. Blepharoplasty and levator palpebrae repair were performed for blepharoptosis and dermatochalasis. Three months after lid surgery, the right medial rectus muscle was recessed 7.5 mm, the left medial rectus was recessed 7.25 mm, and the left lateral rectus muscle was resected 8.0 mm.

Surgical Correction of Hallermann-Streiff Syndrome: A Case Report of Esotropia, Entropion, and Blepharoptosis

We report a case of surgical treatment for Hallermann-Streiff syndrome in a patient with ocular manifestations of esotropia, entropion, and blepharoptosis. A 54-year-old man visited Yeouido St. Mary's Hospital complaining of ocular discomfort due to cilia touching the corneas of both eyes for several years. He had a bird-like face, pinched nose, hypotrichosis of the scalp, mandibular hypoplasia with forward displacement of the temporomandibular joints, a small mouth, and proportional short stature. His ophthalmic features included sparse eyelashes and eyebrows, microphthalmia, nystagmus, lower lid entropion in the right eye, and upper lid entropion with blepharoptosis in both eyes. There was esodeviation of the eyeball of more than 100 prism diopters at near and distance, and there were limitations in ocular movement on lateral gaze. The capsulopalpebral fascia was repaired to treat the right lower lid entropion, but an additional Quickert suture was required to prevent recurrence. Blepharoplasty and levator palpebrae repair were performed for blepharoptosis and dermatochalasis. Three months after lid surgery, the right medial rectus muscle was recessed 7.5 mm, the left medial rectus was recessed 7.25 mm, and the left lateral rectus muscle was resected 8.0 mm.

Entropion-ectropion: the influence of axial globe projection on lower eyelid malposition.

PURPOSE: To evaluate the effect of axial globe projection on lower eyelid malposition with aging. METHODS: Consecutive patients presenting to 2 oculoplastic surgeons with lower eyelid and tarsal involutional ectropion or entropion underwent axial globe projection measurements with a Hertel exophthalmometer. RESULTS: Data on 36 eyelids of 31 white patients were collected. Axial globe projection in the ectropion group, mu = 19.9, was significantly greater than in the entropion group, mu = 16.1 (p = 0.000021). This held true even when the analysis was confined to the subgroup of male patients. CONCLUSION: Tarsal ectropion directly correlates with more prominent axial globe position, and patients with relatively enophthalmic eyes tend to develop entropion.

Conservative management of upper eyelid entropion.

The authors report for the first time two cases of upper eyelid entropion secondary to neonatal conjunctivitis that resolved spontaneously following the insertion of a bandage contact lens. Previous reports advocate early surgical intervention to correct the eyelid abnormality and prevent any permanent corneal scarring and visual loss.

Clinical evaluation of changes in cornea and tear film after surgery for trachomatous upper lid entropion.

PURPOSE: To determine the effect of entropion surgery on corneal health in terms of surface epithelium, tear film stability, change in curvature and vision. METHODS: Prospective study; included consecutive patients with trachomatous upper lid entropion undergoing corrective surgery. Corneal opacity and other conditions that reduced vision were recorded. Best-corrected visual acuity, corneal fluorescein staining, tear film break-up time, Schirmer I test, and keratometry were performed before and after surgery. Data were analysed using Student's t-test, chi(2) test, one-way ANOVA, one-sample t-test, and logistic and multiple regression. RESULTS: Thirty-six female and 15 male patients with an average age of 59.1+/-10.65 years were included. Lenticular and retinal causes resulted in blindness (P=0.008), and low vision (P=0.02), more often than entropion. At 90 days after surgery, vision improved by 0.55+/-1.48 lines (P=0.01). Superficial punctate staining of the cornea reduced by half over 1-15 days (average 6.96+/-4.99) after surgery, and completely in 1-90 days (average 26.15+/-17.49). Tear film break-up time (range: 3-20 s preoperatively) improved significantly after surgery (P=0.005) whereas Schirmer I (range: 10-35 mm preoperatively) and keratometry values showed insignificant change. CONCLUSIONS: Surgery for entropion results in healing of superficial keratopathy, improves tear film stability, and the realigned lid margin spreads tears evenly and efficiently, thus contributing to improved vision. These changes, taking place over 1-90 days, should be kept in mind when planning intraocular surgery, keratoplasty, or keratorefractive procedures after entropion correction.

Efficacy and complications of the transconjunctival entropion repair for lower eyelid involutional entropion.

PURPOSE: To evaluate the efficacy of the transconjunctival entropion repair (TCER) for lower eyelid involutional entropion. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: One hundred fifty-one eyelids in 120 patients who underwent TCER for involutional entropion over a 12-year period from February 1991 through January 2003. METHODS: Surgical technique addressed all 3 anatomic factors underlying the entropion and was performed through a transconjunctival incision. Lateral tarsal strip procedure addressed horizontal eyelid laxity, lower eyelid retractor reinsertion addressed retractor disinsertion, and excision of a strip of the preseptal orbicularis oculi addressed preseptal orbicularis override. MAIN OUTCOME MEASURES: Entropion resolution, entropion recurrence, postoperative eyelid retraction, and complication rate. RESULTS: Transconjunctival entropion repair resulted in resolution of entropion, with a success rate of 96.7% (146 of 151 eyelids); entropion recurrence rate was 3.3% (5 of 151 eyelids). No patient had postoperative eyelid retraction or scleral show, and there were no overcorrections or secondary ectropions in any of the 151 eyelids. Postoperative complications occurred in 6 of 151 eyelids (4.0%) of 6 of 120 patients (5.0%) and included stitch abscess (1 eyelid, 0.7%), lateral tarsal strip dehiscence (2 eyelids, 1.3%), lateral canthal dystopia (2 eyelids, 1.3%), and conjunctivochalasis (1 eyelid, 0.7%). CONCLUSIONS: The transconjunctival lower eyelid entropion repair is effective and safe with low recurrence and complication rates. The TCER circumvents the risk of lower eyelid retraction and overcorrections that may occur with the transcutaneous approach.

Correction of involutional entropion with suborbicularis septal and lateral canthal tightening.

BACKGROUND: Involutional entropion, or infolding of the margin of the eyelid, is a common eyelid malposition affecting the elderly that can lead to significant morbidity when not corrected. It is notable for both functional and cosmetic sequelae. Numerous surgical techniques have been described to correct this defect; however, because of its multifactorial pathophysiology, no single procedure has been entirely satisfactory. In this study, the authors present a simple and effective surgical procedure that addresses the salient pathophysiology and successfully corrects this defect with minimal morbidity or chance of recurrence. METHODS: Two hundred fifty-three patients (409 eyelids) with involutional entropion who underwent surgical repair from 1995 to 2004 were analyzed. All patients were symptomatic, ranging in age from 61 to 96 years (115 men and 138 women). All patients underwent lateral canthal lysis, suborbicularis and supraorbicularis undermining, canthoplasty, and lateral muscle suspension with septal tightening. RESULTS: All 409 eyelids with symptomatic involutional entropion were successfully corrected. All patients were satisfied with both the functional and cosmetic outcome and experienced a short recovery time. Objective examination revealed a marked improvement in static and dynamic lower eyelid position and alleviation of the herniated lateral orbital fat. There were no complications or entropion recurrences. CONCLUSIONS: Involutional entropion is frequently encountered in the elderly. Ideal treatment addresses horizontal lid laxity, improves vertical support, prevents preseptal orbicularis override, and reinserts the lower lid retractors. With the direct, easily executed and effective surgical procedure presented here, both functional and aesthetic improvements can be obtained. This procedure should be included among the techniques used by every surgeon who treats functional and cosmetic problems in the periocular region.

An infant case of Graves' disease with ophthalmopathy.

Graves' disease is a rare disorder in children, particularly in infants. Ocular manifestations of Graves' disease in children are even more rare and are mild compared to adults. We report a 3-year-old girl with Graves' ophthalmopathy who visited our clinic because of lacrimation. Her family had also noticed exophthalmos, goiter, irritability and increased appetite for more than 3 months. The ophthalmologist noted bilateral proptosis, eyelid erythema, lacrimation, entropion of the lower eyelid, and superficial keratitis. Her serum concentrations of free thyroxine and free triiodothyronine were high, and thyroid-stimulating hormone (TSH) was low. Serum samples were markedly positive for antibodies to TSH receptor (TRAb) and thyroid-stimulating antibody (TSAb). Although hyperthyroidism was controlled with propylthiouracil within 3 weeks, her eye signs did not improve. We administered methylprednisolone pulse therapy for ophthalmopathy, but the effect was limited and the lacrimation due to entropion and superficial keratitis persisted. Titers of both TRAb and TSAb decreased slightly and transiently with the pulse therapy. One year later, both titers remained high and eye signs did not improve any more though she was clinically euthyroid. This might indicate that both TRAb and TSAb levels correlate with the clinical course. Therefore, TRAb or TSAb might be good indicators of progress of Graves' ophthalmopathy. Ocular manifestations of Graves' disease should be followed closely with measurements of both TRAb and TSAb even in infant cases.