Oculoplastics
Surgical options for entropion

Certain types of eyelid conditions are more amenable to surgical intervention

Entropion
Source: Daljit Singh, M.D.

Ophthalmologists confronted with cases of inward turning lower eyelids—entropion—may not have to refer such patients to oculoplastic surgeons for corrective procedures. Instead, several temporary and permanent surgical options are available to treat the potentially serious condition.
The condition is found during routine eye exams among patients complaining of irritation or mucus discharge, or who have corneal infection, abrasions, or ulcers. Although several types of entropion can occur, the most frequent age-related iteration, called involutional entropion, occurs after weakening of the surrounding ligaments and musculature, specifically disinsertion of the lower lid retractors, over-riding of the orbicularis, and relative enophthalmos. Initial management with drops, lubricating ointments, and lid taping is often unsuccessful, said Mark Heimmel, M.D., Brick, N.J. Corrective surgical procedures aim to provide longer lasting amelioration of these problems.
One of the newer ways to address entropion is through sutures, such as the Quickert procedure. This in-office approach under local anesthesia utilizes 2-3 sutures placed 2-3 mm below and perpendicular to the lid margin to evert the eyelid. This approach is best suited for a patient who is either not bothered by their entropion or who is not healthy enough for an operating room-based procedure using general anesthesia, said Bobby Korn, M.D., Ph.D., assistant professor of ophthalmology, Division of Oculofacial Plastic and Reconstructive Surgery, University of California, San Diego. Until the patient recovers enough for more aggressive treatment, sutures will keep the lashes from rubbing against the eye and causing corneal abrasions or other problems. “It’s a way of treating the patient on the spot,” Dr. Korn said
The disadvantage of Quickert sutures is that they can have a high failure rate depending on the surgeon. Success rates for the sutures range from 30-80%, according to Dr Korn. “In general, the Quickert sutures are viewed as more of temporizing measures rather than more definitive measures,” Dr. Korn said.
But general ophthalmologists also can master longer-lasting treatments, such as the lateral tarsal strip procedure that shortens the eyelid laterally, fashions a new lateral canthal tendon from the lateral tarsus and sutures it to the lateral orbital rim. Another approach identifies the retractors and reattaches them to the tarsus.
Michael Migliori, M.D., chairman and program director, Division of Ophthalmology, Alpert School of Medicine, Brown University, Providence, R.I., uses these techniques in tandem to correct entropion and move the lid back into its normal position. “People try to do a lot of other things—take a wedge out of the lid, for example—and while those may work it rarely addresses the problem,” Dr. Migliori said. “So using a procedure that is a little more involved will give you a more stable result.”
Dr. Heimmel also prefers to treat the underlying etiologic factors of involutional entropion with a lateral tarsal strip procedure in conjunction with either reattachment of the lower eyelid retractors or everting sutures. He has achieved a success rate of “well over 90%” with these approaches.
A variety of surgical techniques have been developed and investigated to simplify surgery that addresses both the horizontal laxity and the detachment of the retractors. For example, some surgeons prefer approaching the underlying musculature and tendons through an incision in the lid and others approach from the conjunctival side.
“The approach may be different but they’re all addressing the same basic issue, which is those two factors as the most important,” Dr. Migliori said.
Dr. Korn agreed that such a combined approach is needed to address all of the underlying factors of eyelid laxity, overriding of the orbicularis oculi muscle, and attenuation of the lower-eyelid retractors.

Pearls increase success

Ophthalmologists who use a suture approach, Dr. Korn said, will have the most success by using the appropriate suture, such as a 4-0 chromic suture.
“You want to use a suture like that which causes inflammation and scarring so that the eyelid retractors will scar down in a more appropriate level to repair the entropion,” Dr. Korn said.
Dr. Heimmel emphasized the need for surgeons to individualize their surgical approach to each entropion patient. And when a surgeon moves beyond sutures to surgery that addresses the underlying problems in involutional entropion cases he suggests targeting for an initial overcorrection. Initial excessive lid tightness and eversion during the early post-op period will result in proper lid position later and lead to a lower rate of recurrence.
Dr. Korn said general ophthalmologist can perform lateral tarsal strip procedure in conjunction with reattachment of the lower eyelid retractors if they have proper training and education. Videos and books, including one Dr. Korn is publishing this year, can instruct surgeons on the proper techniques.
“General ophthalmologists can be trained to perform this procedure but tend to shy away from that,” Dr. Korn noted. “It really depends on the surgeon’s training.”
For Dr. Migliori, the most important surgical pearl is a thorough understanding of the anatomy involved in entropion.
“What you’re really doing is restoring the normal anatomy,” Dr. Migliori said. “You’re tightening the lid back where it belongs. You’re attaching the retractor back where it belongs. As long as you know the anatomy well enough to know where the retractors are supposed to be and that the lid follows the contour of the eye then you should be able to very easily repair that surgically.”

Editors’ note: Drs. Heimmel, Korn, and Migliori have no financial interests related to their comments.

Contact information

Heimmel: heimmel@yahoo.com
Korn: bkorn@ucsd.edu
Migliori: 401-444-6877