Approach to a patient with ectropion, entropion and symblepharon

1. APPROACH TO A CASE OF
ECTROPION, ENTROPION
AND SYMBLEPHARON
PRESENTER: DR. IDDI NDYABAWE
MODULATOR: DR. LUSOBYA REBECCA
DEPARTMENT OF OPHTHALMOLOGY
MAKERERE UNIVERSITY COLLEGE OF HEALTH SCIENCES

2. Introduction
• Normal position of sharp posterior border of inter-marginal strip is
essential-
• For integrity of the tear film and
• For maintenance of healthy ocular surface

3. .

4. .

5. Lower lid retractors

6. Lower lid retractors

7. Lower lid retractors

8. Lower lid retractors

9. .

10. • Demographic
• Chief complaints
• History: HOPC, PMH, PSH, POH, FSH
• General examination
• Ocular examination
• Provisional diagnosis
• Differential diagnosis
• Investigations
• Management

11. DEMOGRAPHY
• Age: senile/young… (Y=mass, cicatrization)
• Sex
• Address

12. Complaints
• Ectropion: watering, redness of lid margins and discharge

13. HOPC
• Patient presented with watering and redness of lid margins
• The patient also tells that lid margins are gradually turning outwards
and he is noticing it for last 6 months
• There is no diminution of vision.

14. History of past illness
• h/o any lid surgery
• Trauma
• h/o any bleeding dyasesia

15. General examination
• Gait
• Nutrition
• CVS
• RS
• CNS
• P/A

16. Ocular examination
• Vision:
-Distance
-Near
• Eyelid margin: puncta
• Conjuctiva: -Palbebral conjunctiva… (congested, conjunctivitis)
-Cornea
-Lens
-Iris

17. ECTROPION
• It is a common eyelid anomaly
affecting mainly the lower lid
• It means an outward turning or
outward rolling of the lid margin
• .

18. ANATOMY
• LOWER LID RETRACTORS:
• Sheet of fibrous tissue (capsulopalpebral fascia) arising:
• IR
• IO
• Suspensory ligament of Lockwood
• Inferior tarsal muscle
• Attach into tarsal plate

19. .

20. MEDIAL CANTHAL TENDON
• It is the tendon of INSERTION of the preseptal and pretarsal portions
of orbicularis oculi muscle
LATERAL CANTHAL TENDON
• It is the tendon of ORIGIN of the preseptal and pretarsal portions of
orbicularis oculi muscle

21. .

22. CLINICAL FEATURES
• Irritation
• Watering
• Erythema of lid margin
• .

23. CLINICAL EXAMINATION
• Lid laxity
• Pinch test/distraction test
• If lid can be pulled more than
6mm from globe then lid laxity is
present
• .

24. CLINICAL EXAMINATION
• Lid elasticity: snap test-
• Pull the lid away from the globe
and release it and note the
duration it takes to recover to its
normal position
• .

25. Medial canthal tendon (MCT) laxity
• Pull the lower lid laterally and
note the displacement of lower
puncta: if displaced beyond
nasal limbus then definite MCT
laxity exists
• .

26. Lateral canthal tendon test
• Horizontal palpebral aperture
shorted
• Distance between temporal
limbus and lateral canthal
tendon is decreased
• .

27. Inferior scleral show:
• . • .

28. Lacrimal system
• Due to long standing ectropion keratinization of puncta and
canaliculus can occur

29. CLINICAL EXAMINATION
• Identify the defects in various components of ther lower lid
• Look for eyelid closure – normal/abnormal
• Excess lid skin
• Laxity of LCT/MCT and its severity
• Any mass lesion in lid causing ectropion

30. Grades of ectropion
• Grade 1: Punctal eversion
• Grade 2: Eversion of sharp posterior lid margin
• Grade 3: Palpebral conjunctival exposure
• Grade 4: Exposure of the fornix

31. TYPES OF ECTROPION
• Involutional: Most common
• Cicatricial
• Paralytis
• Mechanical
• Congenital
• Spastic

32. INVOLUTIONAL ECTROPION
• Most common type, generally affects lower lid (LL laxity, lengthening
of tendons)

33. Surgical management of involutional
ectropion
• Mild to moderate ectropion mainly affecting lateral lid
• Full thickness pentagonal wedge resection of lid (Bick procedure)

34. Surgical management of involutional
ectropion
• Mild ectropion with excess of skin
• Smith modification of Kuhnt-Szymanowski procure [blepharoplasty
with a base up lateral triangle and excision of full thickness wedge of
lid beneath the blepharoplasty flap]

35. Surgeries
• Moderate ectropion – generalized or affecting lateral lid: lateral tarsal
strip

36. Surgeries
• Marked ectropion: double wedge resection with lateral tarsal strip

37. Involutional ectropion: medial aspect
• Only punctal eversion present and no lid laxity:
-Medial conjuctioplasty [Excision of a diamond of tarso conjunctiva]
(medial spindle procedure)
• When horizontal lid laxity is present but MCT is not lax: Lazy -T

38. Entropion
• Entropion is caused by:
• i) disparity in length and
• Ii) tone of anterior skin-muscle layer and
• Posterior tarso-conjunctival layer of the eyelid (inward rotation of
tarsus and eyelid margin)
• Natural course of entropion is progressive

39. Entropion
• It is the in rolling of the lid margin
• Types:
i) senile
ii) cicatricial
iii) spastic
iv) congenital

40. Grades of entropion
• Inward rolling of lid margin
• Grade 1: only posterior lid border is inturned
• Grade 2: in turning of inter-marginal strip
• Grade 3: whole lid margin including anterior border is inturned

41. Involutional ectropion
• This condition is due to old age, due to instability off lid structures
• Affects only the lower lid in elderly people
• There occurs:
• A. weakness of the posterior retractor of the lid
• B. laxity of medial and lateral canthal ligaments
• C. atrophy of orbital pad o fat leading to enophthalmos

42. Senile/involutional/atonic
• 1) stretching, dehiscence/disinsertion of lower lid retractors and
thinning of orbital septum – leading to decrease in vertical lid stability
• 2) horizontal laxity of whole lid due to lengthening of medial and
lateral palpebral ligaments and thinning of tarsal plate
• 3) upward gliding of the peripheral preseptal fibres of orbicularis oculi
of the lower lid
• 4) relative disparity between lid and globe (enophthalmos) (atrophy
of adipose)

43. Involutional entropion
• There occurs over-ridding of
preseptal orbicularis muscle over
pretarsal orbicularis, that leads
to forward rotation of lower
border of tarsal plate
• Seen in lower lids
• .

44. Involutional entropion
• .

45. Cicatricial entropion
• Common variety usually involving upper lid
• Caused by contraction of scar tissue of the palpebral conjunctiva
• In this case there is relative shortening of inner layer i.e tarso-
conjunctiva and inversion of lower lid margin

46. Cicatricial entropion
• Caused by scarring of palbebral conjunctiva by:
• Trachoma
• Trauma
• Chemical injuries (burns)
• Pemphigus
• SJS

47. Spastic entropion
• This condition is due to spasm of orbicularis in presence of
degeneration of the palpebral connective tissue separating orbicularis
fibres. The spasm is induced by local irritation in inflammatory and
traumatic conditions

48. What are the pathogenic mechanisms? How
do you test for them?
• Five classic mechanisms:
• Overriding of preseptal to pretarsal orbicularis oculi (test by closure of
eyelids)
• Horizontal lid laxity (test by pulling lid away from gobe and watching
lids ‘snap’ back)
• Weakness of lower lid retractors (test by downgaze to see position of
lower lid)
• Tarsal plate atrophy (test by palpation of tarsal plate)
• Atrophy or retrobulbar fat leading to relative enophthalmos

49. Symptoms of entropion
• Foreign body sensation
• Watering
• Redness
• Pain
• Photophobia
• These symptoms are due to rubbing of ocular surface by misdirected
eyelashes

50. Clinical picture
• Condition is found in elderly patients
• Tight bandaging cause spastic entropion (post-operative)
• Chronic conjunctivitis
• Keratitis
• Narrowness of palpebral aperture
• Seen in lower lids

51. Management of entropion
Depends on:
• Cause of entropion
• Severity of entropion
• Length of cure required
• Specific pathogenic mechanisms
• Conservative or surgical

52. Management of entropion
1. involutional entropion
• Temporary cure required – transverse lid everting sutures
• Long term cure required:
• No excess horizontal laxity – Weiss procedure (transverse lid split and
everting sutures)
• Excess horizontal laxity – Quickert’s procedure (Weiss procedure plus
horizontal lid shortening)
• Recurrence of entropion after Weiss or Quickert’s procedure – Jones
procedure (plication of lower lid retractors)

53. .

54. 2. Cicatricial entropion
• Management of trichiasis/distichiasis:
• Epilation
• Electrolysis
• Cryotherapy
• Lash excision
• Mild – anterior lamellar repositioning with lid split at gray line
• Moderate – anterior lamellar repositioning
• Severe – rotation of terminal tarso-conjunctiva and posterior lamellar graft
or advancement

55. 3. Congenital entropion
• Hotz procedure (tarsal fixation of pretarsal skin and orbicularis)
4. Acute spastic:
• Conservative (taping of lids, eyelid everting sutures, Botox injection).

56. Symblepharon
• Symblepharon is an adhesion between conjunctival surfaces.
• Causes:
• Inflammation
• Infection
• Trauma
• previous surgery.
• Treatment: Conjunctival Z-plasties are sometimes effective for localized contracted
linear adhesions when vertical lengthening of the involved tissue is the primary
objective.
• More extensive symblepharon formation requires a full-thickness conjunctival graft or
flap, a partial thickness buccal mucous membrane graft, or amniotic membrane graft.