Overview of Entropion Eyelid Reconstruction
Entropion is a condition where the eyelid turns inward towards the eye. This abnormal positioning is quite frequent and disrupts regular tear production and protection offered by the eyelid. As a result, the eyelashes might scratch the eye, potentially causing damage to the cornea (transparent front part of the eye) or the conjunctiva (the thin, transparent tissue that covers the front of the eye), which can lead to ongoing eye diseases. Entropion can affect one or both eyes, and either your upper or lower eyelids.
There are four types of entropion: congenital (present from birth), involutional (age-related), acute spastic (caused by muscle spasms), and cicatricial (caused by scarring). The most common cause of lower eyelid entropion is age-related, while in the upper eyelid, it’s most commonly caused by scarring.
The likelihood of developing entropion increases as you age. This is especially true for involutional entropion, which occurs due to weakening and laxity (looseness) of muscles and tendons around the eye with aging. This weakening allows the eyelid to fall out of its usual position.
Acute spastic entropion is primarily caused by infection, irritation, or inflammation. This condition is often seen after eye surgery, particularly in patients already showing age-related eyelid changes. Constant contraction of the muscle around the eye causes the eyelid to twist inward. This then leads to eye irritation due to the eyelashes rubbing against the cornea, which in turn worsens the condition.
Cicatricial entropion happens due to tarsoconjunctival contracture, which is a tightening of scar tissue in the eyelid. Any process that results in the formation of more scar tissue, particularly in the eyelid’s inner and middle layers, can make a person more likely to develop cicatricial entropion. Some common risk factors include prior burns, infection, inflammation, connective tissue disease, and trauma, including certain types of eye surgery.
Anatomy and Physiology of Entropion Eyelid Reconstruction
The eyelid has many layers. Listed from the outside to the innermost: skin, a type of muscle called the muscles of protraction and orbicularis oculi, a thin, tough membrane called the orbital septum, fatty tissue, another type of muscle called “muscles of retraction”, a tough plate called the tarsus, and the lining of the eyelid (conjunctivae). The skin of the eyelid is much thinner than the skin in other parts of the body. Problems in any of these layers can potentially cause eyelid disorders, including a condition called entropion, where the eyelid turns inward.
The eyelid is supplied by different nerves. The nerves supplying the top lid are known as the infratrochlear, supratrochlear, supraorbital, and lacrimal nerves which are part of the trigeminal nerve (specifically, the ophthalmic division – V1). The nerves that supply the lower eyelid are the infratrochlear and infraorbital nerves. These are part of the maxillary division of the trigeminal nerve (cranial nerve V division V2).
The upper and lower eyelids receive their blood from the lateral and medial palpebral arteries. These arteries originate from the lacrimal artery (for the side of the eyelid closest to the nose) and the ophthalmic artery (for the rest of the eyelid).
The lower eyelid is supported and maintained by the tarsus, orbicularis oculi (a muscle), lid retractors (muscles that help open the eyelid), and canthal tendons (tendons on the corners of the eyes). The canthal ligaments (tissue in the inside corners of the eyes) and tarsal plate (stiff tissue in the eyelid) give the eyelid its shape. Weakening of these structures can cause the lid to turn inwards. The upper eyelid is supported by the levator aponeurosis and Mueller muscle, which help to retract (open) the eyelid. As the tissues around the eye weaken with age or after injury, there is more space between the eye and eyelid, which can cause the eyelid to turn in, resulting in a condition known as entropion.
Why do People Need Entropion Eyelid Reconstruction
If you’re feeling like there’s something in your eye, experiencing eye pain, tearing up excessively, or finding your vision becoming blurry, you could be suffering from a condition called entropion. This happens when your eyelid, usually the lower one, flips inward. When this happens, your eyelashes rub against the eye, which causes discomfort and irritation. Those who show these signs during a doctor’s examination may need treatment to correct the issue, also known as entropion repair.
It’s best to have entropion repair done sooner rather than later, specifically before the eye experiences any serious injury or exposure due to the turned in eyelid. By treating this condition early, we can avoid serious complications, such as permanent vision loss.
For instance, if there are early signs of eye damage that can be fixed, like a corneal abrasion (think of it as a scratch on the eye’s surface), you should have the entropion repair as soon as possible. This is because reversible damage could become irreversible if not promptly treated.
Also, to prevent further damage while waiting for surgery, temporary solutions can be effective. These may include increasing lubrication in the eye with ointments or artificial tears, using a substance known as botulinum toxin via injection, stitching the eyelids partially together (tarsorrhaphy), or applying a quick suture technique called Quickert suturing. Your doctor could recommend these methods for temporary relief before surgery.
When a Person Should Avoid Entropion Eyelid Reconstruction
There are times when a procedure to fix entropion, a condition where the eyelid folds inward, isn’t the best choice for a patient. Some people might not be able to cope with the procedure. Also, if a person has an ongoing health issue like an autoimmune disorder or a connective tissue disease, it’s vital to manage these conditions well before any surgery is considered.
If the inflammation or infection in the area is not under control, it can make the situation worse. It can even increase the risk of complications during surgery and make the condition progress faster.
For those patients who unfortunately have lost all their vision in the affected eye, the urgency for this procedure might not be as high compared to those who still have some vision. However, even they could benefit from this surgery in terms of pain relief and control of other symptoms.
Equipment used for Entropion Eyelid Reconstruction
For the procedure, the doctor will need specific tools. These include a type of knife called Bard-Parker blade (No.15), a device called Castroviejo needle driver for holding and controlling sutures (medical thread used to close wounds), and scissors specifically made for eye surgery known as Westcott-Aldrich scissors. The doctor will also use a tool named Castroviejo 0.5 forceps which is used to hold or move tissues.
Additionally, either monopolar or bipolar cautery, a tool used to stop bleeding by heating the tissue, will be used. The doctor will use 4-0 silk suture, which is a type of medical thread, along with other types of this thread specifically known as 5-0 and 6-0 polyglactin (also known as Vicryl) suture.
For protection, a corneal shield, a type of protective cover for the eye, will be utilized. Lastly, antibiotic ophthalmic ointment, a type of eye medicine used to prevent infection, will be applied.
Who is needed to perform Entropion Eyelid Reconstruction?
Different types of doctors can fix the problem you’re having with your eye, which is called entropion. We have eye doctors (ophthalmologists), eye plastic surgeons (oculoplastic surgeons), face plastic surgeons (facial plastic surgeons), and general plastic surgeons. However, the skill level of the surgeon is key. If the surgeon has done a lot of entropion repairs before, there’s a greater chance your surgery will go well.
Preparing for Entropion Eyelid Reconstruction
Before opting for surgery, it’s important for the patient to undergo a proper check-up by an eye specialist or a surgery expert who knows about entropion evaluation and repair. This is to make sure the patient is fit and suitable for the procedure. The medical team will also explain to the patient about the pros and cons of having the surgery, along with other available treatment options. Any potential risks or complications will be thoroughly explained. The patient should feel free to ask any questions they might have about the procedure.
The operation can be done under general anesthesia, where the patient is completely unconscious, or with local or topical anesthesia, where only the area being operated on is numbed. In some cases, additional sedatives may be administered either intravenously (through a vein) or orally (by mouth) to help the patient relax. The choice of anesthesia will be based on the surgeon’s experience, and the patient’s comfort and preference.
How is Entropion Eyelid Reconstruction performed
There are two main methods to repair the condition called involutional entropion, an eyelid disorder where your eyelid and eyelashes turn inward. This can irritate the eye and cause discomfort.
Internal Approach with Tarsal Strip for Involutional Entropion Repair
In this method of repair, the doctor places a protective shield on the eye that needs treatment and sterilizes your face. Then, the doctor makes a small cut in the corner of your eye and separates the canthal tendon and inferior crus tissues responsible for keeping the shape and position of your eyelids. This allows the doctor to create a tarsal strip, which will be used to correct the placement of your eyelid.
The eye will be everted, meaning your eyelid will be turned outward for the doctor to work better. The doctor will also make another incision inside the lower eyelid and create a pathway towards your cheekbone, while carefully managing bleeding. This will expose the so-called retractors, tissues that help your lower eyelid to move.
The doctor will then stitch the lower eyelid area to allow it to heal up with a better shape and placement. The stitches will ensure that your eyelid aligns correctly with your eye. After these actions, the doctor will take a few more steps to secure the correct position of your eyelids, such as tightening the stitches and closing all incisions.
At the end of the procedure, you will receive an antibiotic ointment to prevent infections.
External Approach for Involutional Entropion Repair
In this method, the protective shield is again used on your eye and your face is sterilized. The doctor places a traction suture, which is a thread that pulls your skin in a specific direction, through your eyelid. A skin marker then helps the doctor to determine where the incision at the bottom of your tarsus (the dense tissue that forms the supporting structure of your eyelid) should be made.
The doctor continues to open a pathway down to your cheekbone by making a small incision in the skin. Once the lower lid retractors are revealed, the doctor utilizes stitches in the same way as in the first method, to ensure the proper shape and function of your eye. After these steps, the doctor stitches the incision together, removes the protective shield, and applies antibiotic ointment to the eye and all stitched sites to prevent infections.
Both methods aim to resolve the discomfort and eye irritation stemming from the inward rotation of your eyelid. The chosen method will depend on the severity of your condition and the doctor’s expertise.
Possible Complications of Entropion Eyelid Reconstruction
Fixing an entropion, which is when your eyelid mistakenly turns inward, can sometimes lead to complications. These issues can include bleeding, fixing the eyelid too little or too much, the lower eyelid being pulled back too far, developing an infection, separation of the wound edges, permanent scarring, damage to the clear front layer of the eye (known as the cornea), losing eyelashes (a condition called “milphosis”), and the edge of the eyelid dying (a process known as “necrosis”).
What Else Should I Know About Entropion Eyelid Reconstruction?
Entropion is a condition where your eyelid folds inward, which can harm the eye and cause discomfort. Doctors address this condition by performing a surgical procedure to realign the eyelid into its proper position. This helps prevent any damage to the eye and also reduces any related symptoms.
While you prepare for surgery and during recovery, your doctor will give you specific treatments to protect your eye and prevent any more damage to your cornea (the clear front surface of your eye). These may include ocular lubrication with ointments, artificial tears, or using contact lenses as an extra layer of protection for your eye. There are some temporary measures such as botulinum toxin (commonly known as Botox) injections or Quickert sutures (special stitches used to tighten the eyelid muscles), but keep in mind, these are only temporary fixes. The only permanent solution to fix entropion is having it surgically corrected.
