Entropion is the medical term used to describe rolling inward of the lower eyelid and eyelashes towards the eye. The skin of the eyelid and the eyelashes rub against the cornea (the front part of the eye) and conjunctiva (the mucous membrane that protects the eye). This rubbing can lead to excessive tearing, crusting of the eyelid, mucous discharge, a feeling that something is in the eye, irritation of the cornea, and impaired vision.
Most cases of entropion are due to relaxation of the tissues of the eyelid as a result of aging. Some cases result from scarring of the inner surface of the eyelid caused by chemical and thermal burns, inflammatory diseases such as ocular pemphigoid, or allergic reactions. Rarely entropion can be present at birth if the eyelids do not form properly.
Entropion should be repaired surgically before the rubbing damages the cornea by causing infection and scarring. Prior to surgery, the eye can be protected by taping the lower lid down and using lubricating drops and ointment. In some cases, sutures can be placed through the lower eyelid until more definitive surgery can be performed.
The surgery to repair entropion is usually performed under local anesthesia as an outpatient. In most cases, Dr. Ebroon doctor will tighten the eyelid and its attachments. You may have a patch overnight and then will commonly use an antibiotic ointment for about a week. After your eyelids heal, your eye will feel comfortable and you will not longer have the risk of corneal scarring, infection, and loss of vision.
Ectropion is the medical term used to describe sagging and outward turning of the lower eyelid and eyelashes. The margin of the eyelid and the eyelashes evert (turn out). This rubbing can lead to excessive tearing, crusting of the eyelid, mucous discharge and irritation of the eye.
During blinking, the eyelids normally sweep across the surface of the cornea (Tearing occurs because the eyelids are not able to wipe the surface of the cornea properly to pump the tears into the tear duct).
Most cases of entropion are due to relaxation of the tissues of the eyelid as a result of aging. Some cases result from scarring of the eyelid caused by chemical and thermal burns, trauma, skin cancers, or previous eyelid surgery. Rarely ectropion can be present at birth if the eyelids do not form properly.
Ectropion should be repaired surgically before the rubbing damages the cornea by causing infection and scarring. Prior to surgery, the eye can be protected by taping the lower lid down and using lubricating drops and ointment. In some cases, sutures can be placed through the lower eyelid until more definitive surgery can be performed.
The surgery to repair entropion is usually performed under local anesthesia as an outpatient. In most cases, Dr. Ebroon will tighten the eyelid and its attachments. You may have a patch overnight and then will commonly use an antibiotic ointment for about a week. After your eyelids heal, your eye will feel comfortable and you will no longer have the risk of corneal scarring, infection, and loss of vision.
Cicatricial ectropion is the pulling of the upper or lower eyelid away from the eye because of scar formation or a shortage of the anterior lamella of the eyelid. The scarring process can involve the skin, subcutaneous tissue, muscle or septum. This can result in drying of the cornea (exposure keratopathy).
a) Cicatricial ectropion can occur as a result of aging skin changes, sun damage and chronic dermatitis. Mechanical injuries such as lacerations and burns - thermal, chemical and radiation can cause scarring resulting in ectropion. Eyelid surgery such as blepharoplasty or tumor removal can result in ectropion due to removal of too much skin. It can also be seen after ptosis surgery, entropion repair and orbital surgery ,such as blow-out fracture repair. Infections such as herpes zoster can cause contraction and ectropion of the eyelid.
b) Congenital ectropion is caused by shortage of skin such as seen in blepharophimosis syndrome, euryblepharon and congenital ichthyosis.
a) Initial treatment is directed to protect the cornea. Ophthalmic lubricating drops and ointments should be applied frequently. Moisture chambers attached to eyeglasses or the expa-bubble can be helpful. Room humidifiers may also help.
b) In the initial post operative stage such as following trauma repair or blepharoplasty, frequent digital message can be tried to relax the scar and stretch the skin. If this does not work small amounts of steroids (0.1 - 0.5cc) of Triamcinolone (Kenalog) 10mg/cc in a 1 cc syringe can be injected into the scar.
Early Surgical Management
It is best to wait at least six months following injuries for the scar to mature and soften before performing surgery. However, when the cornea is showing evidence of significant exposure keratopathy, it may be necessary to operate earlier. Particularly in the management of severe burns it may be necessary to protect the cornea. A tarsorrhaphy can be performed, but if it is pulled open, early grafting may be necessary.
1. Surgery with tissue rearrangement
A thin linear scar from trauma or lid surgery can be corrected by performing surgery with tissue rearrangement (V-Y or Z plasty) and excising the subcutaneous scar tissue.
2. Surgery with skin grafting
a) An incision is made in the skin near the lid margin or in the scar. All subcutaneous scar tissue is removed and the full extent of the defect is determined.
b) A Telfa template of the defect is made and placed on the donor site. The donor site for a full thickness skin graft in order of preference is the upper eyelid, beind the ear (retroauricular) or above the clavicle (supraclavicular).
c) The amount of skin is determined by drawing an ellipse around the telfa template. The area is infiltrated with Marcaine, Xylocaine with 1: 200,000 Epinephrine and Wydase. A thin full thickness skin graft is taken and subcutaneous tissue meticulously removed with a scissors.
d) The graft is cut to the appropriate size and shape to fill the full extent of the defect. It is sutured into position with 6 0 running nylon sutures. A xeroform stent is sutured into position using 4 0 nylon suture. The eyelid is placed in traction with frost sutures. The donor site is sutured with 5-0 or 6-0 nylon sutures.
e) The stent is removed in 5 or 6 days, the sutures in 10 days.
3. If there is associated horizontal laxity of the eyelid, a horizontal shortening is done in conjunction with the tissue rearrangment or skin grafting.
4. Tissue expansion - specially designed tissue expanders have been utilized to stretch the anterior lamella of the eyelid.
1. Garber PF. Lukash FN. Eyelid Reconstruction Using Temporary Tissue Expanders and Cartilage Grafts, Ophthalmic Plast & Reconst Surg 3(4): 253-257, 1987.
2. Soll DB. Entropion and Ectropion, in Soll D. Management of Complications in Ophthal Plast. Aescular)ius Publish. Co. Birmingham Alabama , 1976, pp. 125-205.
3. Victor WM. and Hurwitz JJ. Cicatricial Ectropion Following Blepharoplasty: Treatment by Tissue Expansion. Can J Ophthalmol 19: 317, 1984.
The facial nerve is the 7th of 12 cranial nerves. It emerges from the brain at the lower border of the pons between the olive and the inferior cerebellar peduncle. It runs laterally and forward to the internal auditory meatus where it enters the facial canal with the nervus intermedius. It leaves the cranium through the stylomastoid foramen where it divides into a larger (temporo-zygomatic) and smaller (cervico-facial) division which subdivides within the parotid gland into temporal, zygomatic, buccal, mandibular, and cervical branches. The upper zygomatic branch supplies the frontalis, upper lid orbicularis oculi, corregator supercilli and procerus. The lower zyqomatic branch supplies the lower lid orbicularis. The nervus intermedius gives off the greater petrosal nerve which carries parasympathetic secretary fibers to the lacrimal gland.
The facial nerve control the muscles of facial expression, including the frontalis muscle (raises the eyebrows), the orbicularis oculi muscle (closes the eyes), the zygomaticus muscles (raises the angle of the mouth), and the orbicularis oris muscle (closes the mouth). With paralysis or palsy of the nerve, the function of these muscles are weakened.
Facial nerve palsies may be congenital (Moebius' Syndrome) or acquired. Acquired causes include infection (Bell's Palsy), vascular lesions, tumors (Acoustic Neuroma, Parotid gland or temporal bone tumor) or trauma (birth, temporal bone fracture).
Facial nerve paralysis can be divided into two types:
A. Supranuclear lesions - Voluntary movements of the forehead and orbicularis oculi are only affected to a small degree because of bilateral cortical innervation. Emotional movements are unimpaired.
B. Peripheral lesions - The upper and lower facial muscles are equally affected in voluntary and emotional movements
Clinical Signs Patients with facial nerve palsy develop flattening of the entire face with loss of forehead wrinkles, infraorbital fold and nasolabial fold. Ocular findings include eyebrow drooping, elevation of the upper eyelid, ptosis and ectropion of the lower eyelid, epiphora, laqophthalmos (inability to close the eye), and exposure keratopathy (drying of the cornea).
Many patients can be managed medically with topical lubrication drops and ointment, moisture chambers, and taping the eyelids closed at bedtime. In addition, a Donaldson Patch (Keeler Instrument Co., Broomall , PA ) or suture tarsorraphy (closure of the eyelids with a suture) may be useful.
Surgery Surgical procudres can be divided into two groups: Passive and active
Passive Surgical Procedures
1. Lateral Tarsorraphy - Lateral closure of the eyelids will frequently suffice to narrow the palpebral fissure and decrease evaporation. Under local anesthesia a 5-6mm triangle of tarsus and conjunctiva is removed from the lateral aspect of the upper eyelid. A 5mm piece of tarsoconjunctiva is advanced from the lower eyelid and sutured into this defect. Lashes may be removed giving a new lateral canthus.
2. Lateral Tarsal Strip Procedure - This procedure involves tightening of the lower eyelid and is performed when the eyelid is very lax. The eyelid is shortened laterally and a new lateral canthal tendon is fashioned from the lateral tarsus and sutured to the lateral orbital rim.
Dynamic Surgical Procedure
1. Gold Weights - More animated closure of the eyelids can be obtained with placement of a gold weight. Between 0.6 & 1.6mg weight (Meddev Corp., P.O. Box 1352 Los Altos , CA 94023 ) is sutured into the pretarsal space of the upper eyelid through a lid crease incision using 6-0 prolene sutures. The appropriate weight is determined preoperatively by taping different weights to the upper eyelid while creating the least amount of ptosis. If there is associated laxity of the lower eyelid a lateral tarsal strip procedure is also performed. The weight acts by gravity to help close the eyelids during relaxation.
Gold weights used for implantation into the eyelid:
1. Neurotrophic Keratitis can accompany facial paralysis when surgery is performed for an acoustic neuroma because of associated involvement of the first division of the 5th cranial nerve (nerve sensation to the cornea). Patients have diminished sensation of the cornea (front surface of the eye) and cannot feel dryness or foreign bodies which can rub on the corneal surface. These eyes have a significant incidence of corneal ulceration.
a. Eyelid closure with suture tarsorrhaphy will be necessary for the ulcer to heal.
b. Subtotal medial and lateral tarsorrhaphy or canthoplasty with central opening may be necessary to protect the cornea.
References 1- Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol, Vol. 97:2192-2196, 1979.
2. Garber PF. Lateral canthoplasty, in Bosniak SL, Smith BC . Adv Ophthal Plas Reconstr Surg, Pergamon Press , New York , NY , 1983, pp. 245-256.
3. Jobe RP. A technique for lid loading in the management of lagophthalmos of facial paralysis. Plas Reconstr Surg 53: 29-32, 1974.