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Prepared by Khairul Anwar Limat Nazri Ahmad Salaamy Mat Kassim Ophthalmology Department 4th Year Zagazig University Entropion is a medical condition in which the eyelid (usually the lower lid) folds inward. It is very uncomfortable, as the eyelashes rub against the cornea constantly Spastic Entropion Cicatricial Entropion Senile Entropion Congenital Entropion Infantile Entropion Redness and pain around the eye Sensitivity to light and wind Sagging skin around the eye Excessive tears Decreased vision, especially if the cornea is damaged Spastic closure of the eyelids allows the orbicularis oculi muscle to overwhelm the oppositional action of the lower eyelid retractors, resulting in an inturning of the eyelid margin and further irritation of the ocular surface from the inturned eyelashes. Occurs when spasm of Muscle of Riolan (due to irritation) and lack of support of lid by the globe. Treatment of spastic entropion may be of: Removal of cause of irritation firstly. Canthoplasty Skin and muscle operation by excision of parts of skin and orbicularis muscle. Wheelers operation. Ocular lubrication and tear preparations are helpful for protecting the ocular surface. Small amounts of botulinum toxin (BOTOX) (approximately 5 U) are quite effective for the treatment of spastic entropion by weakening the pretarsal orbicularis oculi muscle. Occurs due to cicatrization of palpebral conjunctiva. These patients usually will display scar tissue of the conjunctiva, usually a result of trauma, chemical burns, Stevens-Johnson syndrome, ocular cicatricial pemphigoid (OCP), infections, or local response to topical medication. Examination of the tarsus and palpebral conjunctiva usually will point to the diagnosis in these cases. Procedures for the repair of cicatricial entropion Depending on the degree of scarring and entropion, the etiology of the cicatricial changes, and the status of the tarsal plate. Mild cases can be treated with a transverse blepharotomy with marginal rotation (Wies procedure). More extensive scarring may require oral mucous membrane (eg, buccal mucosa) or cadaveric dermis (eg, Alloderm) grafts. Snellens Operation may be done in upper lid entropion. Websters operation may be done in lower lid entropion. Temporizing Quickert-Rathbun sutures are effective for many cases of spastic entropion. Full-thickness eyelid sutures (usually gut suture) from the inferior fornix anteriorly toward the lashes are used to torque the eyelid margin away from the globe. Tissue reaction to the gut suture helps to create a cicatrix in the eyelid that maintains the eyelid in the everted position. Cicatricial entropion of upper lid. There is scar tissue involving tarsal conjunctiva. Also known as involutional entropion. The patient may exhibit horizontal laxity of the medial and/or lateral canthal tendons. Vertical lid laxity due to weak lower lid retractor. Patients usually have an involution of the posterior eyelid retractors, with the eyelid inturning in much the same manner as with spastic entropion. Involution of the soft tissues of the orbit, particularly the orbital fat, may lead to involutional enophthalmos, which in turn can lead to unstable eyelid position with entropion. Treatment of senile entropion: It may require repair of the horizontal laxity via medial and/or lateral canthal tightening. Transmarginal rotation(Weis) Plication of lower lid retractors(Jones) Tucking of palpebral ligaments A small amount of the pretarsal orbicularis oculi can be resected concurrently to prevent further overriding of the tarsus Involutional entropion. Note overriding orbicularis oculi muscle, eyelid margin entropion, and relative enophthalmos with deep superior sulcus. Involutional entropion. Correction of entropion with eyelid retractor reattachment and lateral canthopexy. The congenital form of entropion is very rare. It may arise due to a number of underlying developmental abnormalities, usually in the lower eyelid. Facial nerve paralysis in the pediatric population has been shown to be associated with lower lid entropion. Dysgenesis of the lower eyelid retractors may be present creating instability in the eyelid with consequent entropion, or a paucity of tissue may be present vertically in the posterior lamella of the eyelid. Occur with microphthalmos. Occurs in plump children due to subcutaneous fat. It is self limiting. 1-Trichiasis Presence of more than 4 mal- directed lashes rubbing against the conjunctiva. 2-Distichiasis Congenital Trichiasis 3-Trachoma Infective Keratoconjunctivitis caused by Chlamydia Trachomatis. Medical therapy may be warranted for patients who decline surgery and as a temporizing maneuver in patients who may improve spontaneously. Ocular lubrication and tear preparations are helpful for protecting the ocular surface. Eyelid hygiene, antibiotics, and corticosteroids are useful. Small amounts of botulinum toxin (BOTOX) (approximately 5 U) are quite effective for the treatment of spastic entropion by weakening the pretarsal orbicularis oculi muscle. Patients with cicatricial entropion secondary to ocular cicatricial pemphigoid may benefit from systemic chemotherapy, usually dapsone. Complications Any surgical procedure can have immediate or delayed complications. Immediate complications include hemorrhage, infection, wound dehiscence, graft failure (donor and recipient sites), corneal injury, and recurrence of the entropion, as well as consecutive ectropion. Hemorrhage is treat