Orbit and ocular adnexae
Lid Malpositions
Unlock FRCOphth Part 2 Study Notes to access this content.
Get accessEntropion
Classification
- Involutional (due to increasing lid laxity)
- Cicatricial: often in associated with periocular skin disease or scarring
- Spastic
- Congenital (eg. epiblepharon)
Involutional entropion
Contributing factors
- Lower lid laxity
- Over-riding of the preseptal orbicularis over the pretarsal orbicularis
- Dehiscence of the lower lid retractors: these consist of capsulopalpebral fascia and the inferior tarsus muscle (analogous to Muller’s in the upper lid)
- Orbital fat atrophy
Management of involutional entropion
- Non-invasive measures: skin taping
- Everting sutures: may provide long-term correction and can be repeated
- Horizontal lid tightening: eg. with lateral tarsal strip
- Lower lid retractor reinsertion
- Combination of the above
Management of cicatricial entropion
- Medical control of associated disease eg. dermatitis
- Surgery must be approached cautiously in cases associated with cicatricial conjunctivitis eg. OCP
- Posterior lamellar lengthening eg. with tarsal fracture
- Release of scar tissue
Epiblepharon
-
Bilateral horizontal fold of skin running parallel to lower lid margin
-
Associated with dehiscence of the lower lid retractors and override of the pre-tarsal orbicularis by the pre-septal orbicularis
-
May cause pseudotrichaisis and corneal irritation
-
Improves with age
-
Surgery indicated for symptomatic corneal irritation
- Skin and orbicularis excision
Ectropion
Classification
- Involutional: eg. age-related lid laxity
- Cicatricial: eg. anterior lamellar shortening from scarring (including previous surgery such as excision of a skin lesion, or traumatic), SJS, periorbital dermatitis or ichythosis
- Paralytic: facial palsy
Presentation
- Epiphora
- Periocular skin irritation
- Discomfort
Hot Topic
Clinical tests in ectropion
- Lid distraction: normally the lower lid will not move more than 6mm from the globe
- Snap-back test: pull lid inferiorly and then release. It should spring back to the globe without the need to blink
- Medial canthal tendon laxity: lateral traction on the lid and observe how far the punctum can be pulled over. If it can be moved beyond the limbus, this implies medial canthal tendon laxity
Management
Conservative
- Observation
- Topical lubricants
- Topical treatments to skin eg. in cicatricial ectropion secondary to dermatitis
Surgical: depends on aetiology
- Involutional: horizontal lid tightening
- Lateral tarsal strip
- Kuhnt-Szymanowski procedure: wedge excision combined with a blepharoplasty
- Primarily medial ectropion can be managed with a diamond conjunctivoplasty (Medial spindle) or Lazy-T procedure
- Cicatricial: anterior lamellar lengthening
- eg. Skin grafts/flaps
- Paralytic: similar horizontal tightening procedures, but may also require management of exposure
- Medical canthoplasty
- Wedge resections
- LTS