What is Entropion?
- Entropion is the inward turning of the eyelid margin, causing the eyelashes to rub against the cornea and conjunctiva.
- This condition can lead to discomfort, irritation, and in severe cases, corneal damage if left untreated.
What are the types of Entropion?
Entropion can be classified into five main types:
- 1. Congenital Entropion.
- 2. Cicatricial Entropion.
- 3. Spastic Entropion.
- 4. Senile Entropion. and
- 5. Mechanical Entropion.
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1. Congenital Entropion:
- Congenital entropion is a rare condition present from birth.
- It is often associated with other abnormalities such as microphthalmos—a developmental disorder where the eye is abnormally small.
2. Cicatricial Entropion:
- Cicatricial entropion is one of the more common forms, typically affecting the upper eyelid.
- It occurs due to scarring and contraction of the palpebral conjunctiva, which can distort the tarsal plate.
- Common causes include:
- Trachoma,
- Membranous conjunctivitis,
- Chemical burns,
- Stevens-Johnson syndrome.”
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3. Spastic Entropion:
- This type occurs due to spasms of the orbicularis oculi muscle, usually triggered by chronic irritative corneal conditions or tight ocular bandaging.
- Spastic entropion is most commonly seen in older patients and typically affects the lower eyelid.
4. Senile Entropion or Involutional Entropion:
- Senile entropion is one of the most common types and exclusively affects the lower eyelid in elderly individuals.
- Its development is linked to factors such as:
- Weakening or separation of the capsulopalpebral fascia (the lower lid retractor),
- Degeneration of palpebral connective tissue, allowing the pre-septal orbicularis fibers to override the pretarsal fibers, and
- Horizontal laxity of the eyelid.”
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5. Mechanical Entropion:
- Mechanical entropion occurs when the globe no longer provides adequate support to the eyelid.
- This can happen in conditions like:
- Phthisis bulbi (a shrunken, non-functional eye),
- Enophthalmos (recession of the eyeball within the orbit), and
- After surgeries like enucleation or evisceration.”
What are the Symptoms of Entropion?
1. Foreign body sensation:
- Misdirected eyelashes rub against the cornea and conjunctiva, creating a constant feeling of something being stuck in the eye.
- This is due to the abnormal mechanical interaction between the lashes and the sensitive ocular surface.
2. Irritation:
The friction caused by inward-facing lashes leads to persistent irritation of the ocular surface, stimulating nerve endings in the cornea and conjunctiva.
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3. Pain:
- Continuous rubbing of the lashes on the cornea, which is densely innervated, triggers pain sensations.
- The severity of pain increases with deeper abrasions or chronic inflammation.
4. Lacrimation (excessive tearing):
Reflex tearing occurs as a protective response by the lacrimal glands to wash away irritants caused by the lashes rubbing against the cornea or conjunctiva.
5. Photophobia (light sensitivity):
Corneal irritation and inflammation make the eye hypersensitive to light, as the affected nerves in the cornea amplify their response to stimuli.
What are the Signs of Entropion?
The key sign is an inturned eyelid margin. Depending on how severe the inward turning is, entropion can be classified into three grades.
In Grade I Entropion:
- In Grade I Entropion, the inward turning is minimal.
- Only the posterior lid border—the part of the eyelid closest to the eyeball—is rolled inward.
- Patients might experience mild irritation, but the damage is usually limited.”
In Grade II Entropion:
- In Grade II Entropion, the inturning progresses to include the inter-marginal strip.
- This is the area between the eyelid’s anterior and posterior borders.
- At this stage, symptoms like foreign body sensation, irritation, and tearing are more pronounced.
In Grade II Entropion:
- Grade III Entropion is the most severe form. Here, the entire eyelid margin, including the anterior border, is turned inward.
- This can lead to significant discomfort and increase the risk of corneal abrasions or infections.
“Identifying the grade of entropion is crucial because it determines the treatment approach. For mild cases, temporary solutions like lubrication or taping the eyelid may help. But in severe cases, surgical correction is often required to prevent complications.”
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What is the Treatment of Entropion?
1. Treatment for Congenital Entropion:
- For congenital entropion, which is rare and present from birth, the treatment involves plastic reconstruction of the eyelid crease.
- This procedure corrects the abnormal inward turning and restores normal eyelid function.
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2. Spastic Entropion
Spastic entropion, often caused by muscle spasms, is addressed in several steps.
Step 1:
First, the cause of the spasm is treated. For instance, removing a tight ocular bandage or managing corneal conditions can alleviate the issue.
Step 2:
For acute spasms, adhesive plaster can be applied to gently pull the lower eyelid outward.
Step 3:
Injection of botulinum toxin into the orbicularis muscle can be highly effective in relieving persistent spasms.
Step 4:
In severe cases, surgical treatments, similar to those used for senile entropion, are recommended.
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3. Cicatricial Entropion
- For cicatricial entropion, which is caused by scarring and contraction, plastic surgery is the treatment of choice.
- The surgical approach depends on the specific needs of the patient and can include:
- Altering the direction of the lashes.
- Transplanting the lashes to a new position.
- Straightening the distorted tarsus to restore proper alignment.
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4. Senile Entropion:
- Senile entropion, the most common type in older adults, is typically treated with surgical procedures.
- Let’s review the most commonly used techniques:
1. Modified Wheeler’s Operation
The Modified Wheeler’s Operation is a surgical procedure designed to address the inward turning of the eyelid by targeting the tarsal plate, conjunctiva, and orbicularis oculi muscle.
Procedure:
- A base-down triangular piece of the tarsal plate and conjunctiva is excised. This resection creates a structural adjustment to counteract the inward turning of the eyelid.
- Along with the excision, the orbicularis oculi muscle is double-breasted, meaning it is overlapped and sutured to reinforce the eyelid’s outward tension.
- This approach not only corrects the entropion but also helps stabilize the eyelid by reducing the inward pull of the orbicularis muscle.
Benefits:
- Effective in mild to moderate cases of senile entropion.
- Restores proper eyelid alignment and minimizes corneal irritation.
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2. Bick’s Procedure with Reeh’s Modification
The Bick’s Procedure with Reeh’s Modification is particularly useful in patients with horizontal lid laxity, a condition where the eyelid becomes loose and saggy.
Procedure:
- A pentagonal full-thickness resection of the lid tissue is performed. This means a five-sided piece of tissue, including all layers of the eyelid (skin, muscle, and tarsus), is removed.
- The resected edges are then sutured together, tightening the eyelid horizontally to correct the laxity.
Benefits:
- This technique addresses both the inward turning of the eyelid and the excessive horizontal laxity, making it a dual-purpose solution.
- Suitable for cases where horizontal laxity is a contributing factor to entropion.
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3. Weiss Operation
The Weiss Operation focuses on repositioning the tarsal plate to correct the entropion. This procedure is ideal for cases where the tarsal plate requires stabilization.
Procedure:
- An incision is made 3 mm below the lid margin, extending along the entire length of the eyelid. This incision includes the skin, orbicularis muscle, and tarsal plate.
- Mattress sutures are placed through the lower cut end of the tarsus and emerge on the skin, approximately 1 mm below the lid margin.
- When the sutures are tied, the lower edge of the tarsus is pulled upward and outward, effectively repositioning it and correcting the entropion.
Benefits:
- Provides a strong and stable correction by anchoring the tarsus in an optimal position.
- Minimizes the risk of recurrence by directly addressing the tarsal malposition.
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4. Tucking of Inferior Lid Retractors (Jones, Reeh, and Wobig Operation)
The Tucking of Inferior Lid Retractors is a more extensive procedure, typically reserved for severe cases of senile entropion or recurrences following other surgeries.
Procedure:
- The inferior lid retractors, which are responsible for maintaining the eyelid’s outward position, are identified.
- A tucking or plication technique is used to strengthen the retractors. This involves folding or shortening the retractor tissue to enhance its tension and function.
- The procedure restores the balance between the retractors and the orbicularis muscle, correcting the inward turning of the eyelid.
Benefits:
- Effective in severe or complex cases.
- Reduces the risk of recurrence by directly reinforcing the weakened retractors.
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