Entropion Repair Surgery - An Overview

Introduction

When an eyelid's edge turns inward, it rotates abnormally in the direction of the eyeball, a condition known as entropion. This is a rather common condition that interferes with the eyelid's regular functioning, compromising the tear film and the eye's protective functions. Since the eyelashes usually point in the direction of the eye, there is a chance that the cornea and conjunctiva will be harmed, which might cause long-term vision issues. Entropion can impact one or both eyes, affecting the lower or upper eyelids. It is more likely to develop in older adults. By realigning the eyelid, surgery corrects this issue. In this manner, it keeps the eye safe from injury and relieves the symptoms by preventing the eyelashes from irritating the eye.

What Are the Indications of Entropion Repair Surgery?

• Entropion can cause symptoms such as blurred vision, pain in the eye, excessive tears, and a foreign body sensation. Patients who exhibit symptoms of entropion during a clinical evaluation are candidates for entropion repair.

• More serious consequences, such as irreversible vision loss, may be avoided with early entropion correction before clinical indications of corneal exposure or damage appear. Reversible corneal changes, including abrasions, should be repaired as soon as possible since, if untreated, they could turn into irreversible changes.

• While waiting for surgery, patients with early, reversible corneal injury should also receive temporary care to stop more damage. Botulinum toxin injections, tarsorrhaphy (uniting the lower and upper eyelids in part or entirely to close an eye either fully or partially), Quickert suturing (procedure for correcting entropion), or enhanced ocular lubrication with ointments or artificial tears may benefit these patients.

What Are the Contraindications of Entropion Repair Surgery?

Patients who cannot tolerate the process are not candidates for entropion repair. Moreover, before considering a surgical repair, the best medical care must be provided for any underlying etiology, such as connective tissue illness or autoimmune disorders. Mismanagement of inflammation or infection aggravates the condition's prognosis, raises the possibility of complications, and speeds up its course. Reconstruction may not be an urgent need for patients whose visual loss is irreparable as it is for those whose vision is still somewhat intact. For pain reduction or other symptom control, entropion repair can still be necessary.

How Are the Patients Prepared Before Surgery?

• Before undergoing surgery, the patient should receive a proper examination, and an ophthalmologist or surgeon skilled in entropion diagnosis and repair should determine whether the patient is a good candidate for surgery. The patient needs to be informed about the possible side effects and advantages of the intervention, as well as any viable substitute treatments. Every potential issue needs to be addressed. Finally, all of the patient's inquiries need to be addressed.

• General anesthesia, topical and local anesthetic, and extra intravenous or oral sedatives may be used during the procedure. Patient preference and the experience of the surgeon determine the anesthetic modality.

• Equipment Needed for the Procedure: A No.15 Bard-Parker blade, a Castroviejo needle driver, Westcott-Aldrich scissors, Castroviejo 0.5 forceps, a corneal shield, antibiotic ophthalmic ointment, monopolar or bipolar cautery, 4-0 silk suture, 5-0 and 6-0 polyglactin (Vicryl) suture.

• Personnel: Surgeons with the necessary training, such as plastic surgeons, ophthalmologists, and oculoplastic surgeons, can carry out these procedures. Success in entropion repair depends on the surgeon's experience.

What Are the Surgical Techniques for Entropion Surgery?

• Internal Approach With Tarsal Strip for Involutional Entropion Repair:

  • The patient is prepared by covering the patient's eye with a sterile shield and covering the cornea with a shield.

  • The doctor will make an incision of three to four mm (millimeter) in the outer corner of the eye using a No. 15 Bard-Parker blade

  • The lateral canthal tendon and inferior crus will be disinserted (involves separating the tendon located at the outside corner of the eye and the lower portion of the eyelid).

  • A tarsal strip is created by cutting a strip of tissue with Westcott scissors and 0.5 forceps to treat the structure supporting the eyelid.

  • Hemostasis is maintained using cautery, a tool that burns or coagulates tissue and controls the bleeding. For gentle pulling, a 4-0 silk traction suture is used.

  • Below the inferior tarsal border, an incision is made in the conjunctiva (membrane that covers the inside of the eyelid).

  • Using Westcott scissors and 0.5 forceps, dissection is made toward the inferior orbital rim to reveal the lower lid retractors (to disclose the structures that support the lower eyelid, the tissues are carefully separated toward the bone structure beneath the eye using forceps and scissors).

  • Retractors from the conjunctiva are removed, and 6-0 Vicryl sutures are inserted to induce the proper lid eversion (the eyelid can be turned outward).

  • For lateral canthal angle (the outer corner of the eye) reconstruction, 5-0 Vicryl sutures are inserted and fastened.

  • Absorbable sutures are used to seal the skin incision and Vicryl (6 plain) is used to stitch the muscle surrounding the eye.

  • An ointment is applied to seal the wound and stop infection.

• External Approach for Involutional Entropion Repair:

  • The patient is prepared by covering the patient's eye with a sterile shield and covering the cornea with a shield.

  • Mark the incision at the inferior tarsus border (an orbital border that curves and a free, straight ciliary border that is next to the lash follicles), and place a 4-0 silk traction suture there (mark the incision site near the lower edge of the eyelid's supporting structure and position a silk thread for gentle pulling)

  • Cut a skin incision with the No. 15 Bard-Parker blade and proceed to dissect in the direction of the inferior orbital rim (use the No. 15 blade to make a slit in the skin, and then gently pull the tissues apart in the direction of the bone beneath the eye.

  • Lower lid retractors (fibrous tissue that begins in the inferior rectus muscle sheath splits as it surrounds the inferior oblique, and then merges with the inferior oblique sheath) are visible after opening the orbital septum, identifying the preaponeurotic fat, and dissecting (making a hole in the membrane around the eye, pinpointing a particular kind of fat, and revealing the mechanisms supporting the lower eyelid).

  • To cause proper lid eversion (expose the eye’s surface to check for foreign object detection), insert 6-0 Vicryl sutures via the tarsus and retractors (put the Vicryl sutures through the retractors and supporting structure to turn the eyelid outward).

  • After removing the corneal shield and applying antibiotic ointment, close the skin incision using 6-0 simple gut sutures (absorbable sutures).

What Is the Clinical Significance of Entropion Repair Surgery?

Restoring the eyelid to its correct anatomical alignment involves surgically repairing entropion. This thereby lessens related discomfort and shields the eye from harm. For a corneal injury to stop getting worse, perioperative medical care is essential. Contact lens protection, artificial tears, and ointments for lubricating the eyes are a few examples of this. While temporary relief can be achieved with Botulinum toxin or Quickert sutures, ultimate treatment requires surgical repair.

Conclusion

For those with this uncomfortable disease of the eyelids, entropion restoration surgery is a beneficial intervention. This procedure attempts to correct the inward movement of the lid, which should protect the eye from damage and improve the patient's quality of life. It also attempts to reduce pain. To find the best course of action that is customized to each patient's needs, speaking with a skilled ophthalmologist or oculoplastic surgeon is essential.