CHAPTER

13 PALPEBRAL DEGENERATION

J C van der Meulen

CICATRICIAL ENTROPION AND ECTROPION

The eyelids are delicate structures. Normal closure will depend on a normal relationship of the tissues that make up the eyelids. If there are deficiencies in the inner or outer lamina, whether caused by cica­trization or contraction, function will fai l and either entropion or ectropion will result.

ENTROPION

Conjunctival shortage may be caused by various diseases such as pemphigoid, Stevens-Johnson syndrome, and trachoma. The first and second of these diseases are rare but their destructive effect is severe and medical treatment is always indicated.

By contrast trachoma is much more common. Both eyelids may be affected. The most significant characteristics of trachoma are: • Trichiasis. • Obstruction of the lacrimal ducts. • Inversion and rigidity of the eyelid rim. • Symblepharon.

In order to maintain the eyelashes in a normal position, there must be a balance of tissue tension between the two anatomical layers of the upper eyelid, namely the anterior skin and orbicularis muscle layer and, posteriorly, the tarsoconjunctivallayer. In cica­tricial entropion, the problem is caused by shortage in the height of the posterior layer.

219

When conjunctival shortage exists, normal closure of the eye­lids becomes impossible because the inner layer cannot keep pace with the outer layer. Activity of the orbicularis muscle will cause the pretarsal fibres to override the edges, resulting in entropion.

Surgery In cases of generalized deficiency of conjunctival lining, suppletion with buccal mucous membrane grafts inserted parallel to the margin of the eyelid will relieve the vertical shortage and restore balance between the inner and outer layers (13.1-13.3).

Unfortunately, in spite of various surgical procedures including scar resection and mucosal grafting or even cartilage insertion, recur­rence of entropion may still occur. Whether this is due to inadequate correction of the conjunctival shortage, to the lack of apposition

13.1 a Cicatricial entropion of right upper eyelid. b Correction by insertion of buccal graft parallel to

the eyelid rim . c Preoperative appearance. d Postoperative appearance.

PALPEBRAL DEGENERATION

tonus in the external lamina, or to a combination of both, is diffi­cult to determine.

In one particular case, this problem was solved by the use of opposing Z-plasties. This technique corrects the vertical shortness of both lamina without superimposing scars that could result in

®

@ ®

recurrence. Another mechanism of correction is the tightness of the horizontal limbs of the Z -plasties away from the lid margin. This tightening over a 'lesser circle' or 'higher latitude' of the globe results in a ' turning-out' of the lid margin and further correction of the entropion (13.4).

CD

· ..•.. -... ',·' .. (,'· ·' ' • . '. -. . ~

./, ( . . .

13.2a Cicatricial entropion of lower eyelid. b Correction by insertion of buccal graft. c Preoperative appearance - fronta l view. d Preoperative appearance - lateral view. e Postoperative appearance - frontal view. f Postoperative appearance - lateral view.

220

13.3 a Cicatricia l entropion of lower eyelid . Note rigidity of eyelid rim. b Conjunctival def ect to be closed. c Insertion of buccal graft. d Repositioning of eyelid skin.

CICATRlClAL ENTROPION AND ECTROPION

ECTROPION

Whereas conjunctival diseases are responsible for entropion, cuta­neous diseases sometimes produce ectropion. Deficiences of skin may develop in patients with acute herpes, psoriasis, and xeroderma pigmentosum. Even minima l eversion of the eyelid margin will expose the fornix to irritation and, once this process has become chronic, keratoconjunctivitis becomes manifest, producing even more eversion or ectropion of the eyelid margin.

®

.-····

221

Surgery Correction of ectropion is usually straightforward. Generous replacement of skin using a retro-auricular graft as second best choice is indicated (13.5 ). In spite of this, secondary corrections are not unusual (13.6). Keratoconjunctivitis is sometimes a complicat­ing factor, since the associated hypertrophy may prevent adequate repositioning of the rim. In such cases, resection of the inflamed lining together with a small wedge excision of the margin of the eyeli d near the lateral canthus will take care of the problem and restore the intimate contact of the eyelid with the global surface.

13.4 Double Z-plasties. a Design of cut aneous Z­plasty. b Design of t arsoconjunctival Z-plasty. c Transposition of tarsoconjunctiva l f lap. d Transposit ion of cut aneous f lap. (The author is g ratefu l t o his colleagues G. Tamir and D. Hauben from t he Beilson Med ical Centre in Tel Aviv, Israel for allowing him t o use th is procedure on t heir pat ient.)

13.5 a Cicatrici al ectropion caused by xeroderma pig mentosum. b Correction by insertion of fu ll-t hickness skin graft . (Note the persistent excess of hypertrophic conjunctiva­resection is indicated.)

13.6 a Cicatricial ectropion caused by skin disease. b Correction by insertion of full­thickness grafts, which are adequate on the left side but not quit e adequate on the right side, require secondary correction.

PALPEBRAL DEGENERATION

INVOLUTIONAL ENTROPION AND ECTROPION

The causative mechanisms of involutional entropion and ectropion are not understood, unlike the causative mechanisms already discus­sed. Indeed, how can one explain the paradox that rigidity and lax­ity or shortage and surplus of conjunctiva or skin may have similar effects on the position of the eyelid margin? And why do involu­tional entropion and ectropion almost exclusively affect the lower lid?

ENTROPION

Senile or involutional entropion may be observed in the upper or lower eyelid. In the upper eyelid, it is exceptionally rare (13.7). In

® @

@

222

the lower eyelid it is quite common. In these patients laxity may affect the tarsal plate, the orbital septum, the inferior retractors, the orbicularis muscle and its insertions, and the canthal tendons.

Horizontal laxity is seen when the margin of the eyelid is lifted from the globe. Vertical laxity, characterized by an excess of skin and conjunctiva, is observed when the margin of the eyelid is pulled upward. But why do these patients develop entropion?

The answer, according to this author, must be sought in the vary­ing degrees of laxity that occur. Sisler et al., comparing specimens from both categories, found more atrophy of the tarsal plate and orbital septum in patients with entropion. Jones attributed entro­pion to malfunction of the retractors. It is difficult to accept that these factors alone are capable of producing entropion.

However, if laxity of the tarsus and orbital septum occurs, it is logical to assume that this laxity will also affect the interface

13.7 a Extreme laxity of upper eyelid as a ra re cause of seni le entropion of upper eyelid . b Resection of triangular tarsa l segment. c Closure of conjunctival defect. d Reduction and redistribution of eyelid skin to increase apposition tension. (Reproduced f rom van der Meulen, JC. Radical correction of seni le entropiion and ectropion. Plast Reconstr Surg 1983;71(3):318-323.)

13.8 Correction of senile entropion . a Classica l subciliary incision. b Removal of a triangula r full-thickness wedge in the most lateral part of the eyelid, and of a cresent-shaped segment of conjunctiva in the deeper part of the forn ix. c The pedicled eyelid rim is reattached to the lateral canthus w ith a f ew interrupted sutures. dAfter reduction of the skin surplus and, if necessary, shortening of the o rbicularis, the incision is closed. (Reproduced f rom van der Meulen, JC. Radical correction of senil e ent ropiion and ectropion. Plast Reconstr Surg 1983;71 (3):3 18- 323.)

INVOLUTIONAL ENTROPION AND ECTROPION

between the orbicularis muscle on one side and the tarsal plate and orbital septum on the other, thus allowing for minimal changes in the relative positions of the inner and outer layer under the influ­ence of gravity. This process of differential 'sagging' will trigger the following vicious circle of events.

Once the inner layer shows a tendency to collapse, thereby exert­ing some downward pull on the eyelid margin, any activity of the orbicularis muscle will progressively alter the distribution of the ap­position tension over the eyelid and worsen the situation. Attempts to close the eye will cause shortening of the pretarsal muscle fibres. This shortening will tend to approximate the already lax canthal tendons, allowing for progressive collapse of the inner layer and fur­ther maldistribution of muscular tone.

The pretarsal fibres will override the superior edge of the weak tarsus and cause it to buckle, and entropion results.

Techniques of correction In the past, many techniques have been devised to correct entropi­on. One school of thought tries to prevent the effect of muscle action by the induction of scar tissue, by using a variety of trans palpebral suture techniques, by implanting a cartilaginous or fascial graft, or by transposing or imbricating the orbicularis muscle.

223

A second school reduces the horizontal laxity through a trian­gular excision of the tarsus or a triangular or rectangular excision of the margin of the eyelid.

A third school aims at correcting vertical laxity by various lid­shortening procedures. Still others have combined some of these ideas in a variety of ways.

In 1983, this author advocated a procedure that achieved verti­cal and horizontal lid reduction in combination with transposition or imbrication of orbicularis muscle (13.8) . This radical approach has a lways been extremely effective. The technique is as follows: 1. T he lower eyelid skin is first mobilized using a classical ble­

pharoplasty incision. 2. The orbicularis muscle is exposed and the margin of the eyelid

incised close to the lateral canthus. After gently p ulling the margin latera lly, the surgeon demarcates the excess and excis­es a wedge.

3. In conjunction with the triangular defect thus formed, a cres­cent-shaped segment of conjunctiva is removed from the deeper part of the inferior fornix.

4. The eyelid is reattached with a few inverted stitches and the orbicularis muscle is shortened or imbricated.

5. The skin incision is closed after resection of the excess skin (13.9).

13.9 Correction of senile entropion. a Senile entropion - frontal view. b Senile entropion -lateral view. c Horizontal and vertical laxity of the lower eyelid. d Mobilization of skin. e Removal of triangular segment in lateral part of the lower eyelid margin to correct horizontal laxity. f Removal of crescent-shaped segment in deeper part of the fornix to correct vertica l laxity. g Reattachment of the eyelid rim. h Postoperative result. (Reproduced from van der Meulen, JC. Radical correction of senile entropiion and ectropion. Plast Reconstr Surg 1983;71 (3): 318-323.)

PALPEBRAL DEGENERATION

ECTROPION

If a process of differential 'sagging' can be held responsible for entro­pion, it must also be able to cause ectropion. In patients with ectro­pion, however, it is the outer layer that collapses first. Sagging of the orbicularis muscle and the skin under the influence of gravity will decrease the apposition tonus over the superior part of the fornix in favour of the inferior part. Loss of muscular tone will cause the margin of the eyelid to lose contact with the eye. Tears then accu­mulate, and the conjunctiva becomes exposed and irritated.

®

@

224

H ypertrophy and keratoconjunctivitis develop, ca using eversion of the margin of the eyelid.

Attempts to close the eye tend to increase the downward shift of the muscle fi bres.

Correction While there are many procedures still in use for the correction of entropion, only one for the treatment of ectropion has proved its efficacy over time (13.10). This is the technique of Kuhnt and Zymanovski with some minor modifications.

13.10 Correction of senile ectropion. a Classical subciliary incision. b Removal of a triangular full thickness wedge in the most lateral part of the eyelid and of the inflamed conjunctiva and tarsus in t he upper part of the fornix. c The pedicl ed eyelid r im is reattached to the latera l canthus. d. The incision is closed after reduction of the skin surplus. (Reproduced from van der Meulen, JC. Radical correction of senile entropiion and ectropion. Plast Reconstr Surg 1983;71 (3):318- 323.)

13.11 a Correction of senile ectropion. b Removal of triangular segment in lateral part of lower eyelid rim. c Removal of inf lamed conjunctiva l segment. d Reattachment of the eyelid r im and closure of skin. (Reproduced from van der Meulen, JC. Rad ical correction of senile entropiion and ectropion. Plast Reconstr Surg 1983;71(3):318-323.)

INvOLUTIONAL ENTROPION AND ECfROPION

1. The lid is incised below the ci lia ry border in a manner resem­bling the classical blepharoplasty incision.

2. Skin and muscle are then separated, allowing reduction of any skin excess .

3. The horizontal laxity of the eyelid margin is corrected by removal of a wedge either in its most lateral part or more cen­trally.

4. The height of the lid is reduced by excision of excessive hyper­trophic keratinized conjunctiva.

5. The eyelid is reattached with a few inverted stitches, the orbic­ularis muscle is shortened or imbricated, and the skin incision is closed (13.11 ).

This procedure has been used successfully in a considerable number of patients with recurrent ectrop ion and sufficient lower eyelid skin (13.12}. Occasionally, repositioning of the margin of the eyelid reveals a shortage of skin that must be corrected with a full­thickness graft. However, correction of skin shortage only may prove to be sufficient (13.13).

13.12 a and b Symmetrical senile ectropions. c and d Long-term result of correction. (Reproduced from van der Meulen, JC. Radical correction of seni le entropiion and ectropion. Plast Reconstr Surg 1983;71(3}:318- 323.}

225

13.13 a Senile ectropion caused by shortage of skin. b Correction by insertion of skin grafts from the upper eyelids. c Preoperative view. d Postoperative.

PALPEBRAL DEGENERATION

BIBLIOGRAPHY

Bick MW. Surgical management of orbital tarsal disparity. Arch Ophthalmol 1966;75;386.

Butler JBV. A simple operation for entropion. Arch Ophthalmol1948;40:665. Dalgleish R, Smith JLS. Mechanics and histology of senile entropion. Br]

Ophtha/mo/1966;50;79. Fox SA. Ophthalmologic Plastic Surgery, 3rd edition. New York: Grune and

Stratton, 1963. Fox SA. Senile (atonic) entropion. Ann Ophthalmo/1976;8:167. von Graefe A. Bennerkungen zur Operation des Entropium und Ectropium.

Arch Ophtha/mo/1864;10;221. Jones LT. The anatomy of the lower lid and its relation to the cause and cure

of entropion. Am] Ophthalmo/1960;49:29. Elliot RA. Correction of senile entropion with fascia lara graft. Plast Reconstr

Surg 1962;29;698. Feldstein M. A method of surgical correction of entropion in aged persons. Eye

Ear Nose Throat Monthly 1960;39:730. Foulds WS. Surgical cure of senile emropion. Br] Ophthalmo/1961;45:678. Hargiss JL Inferior aponeurosis vs orbital septum tucking for senile entropion.

Arch Ophtha/mo/1973;89;210. Hill JC, Feldman F. Tissue barrier modifications of a Wheeler II operation for

entropion. Arch Ophthalmo/1967;78:621. Huang TT, Amaya E, Lewis SR. A histologic study of the lower tarsus and the

significance in the surgical management of an involutional (senile) entro­pion. Plast Reconstr Surg 1981;67:585.

]elk GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy ]G (ed). Plastic Surgery. Philadelphia: WB Saunders, 1990;1739-1742.

Jones LT, Reeh MJ, Tsujimura JK. Senile entropion. Am ] Ophthalmol 1963;55;463.

Jones LT. A new concept of the orbital fascia and rectus muscle sheaths and its surgical implications. Trans Am Acad Ophthalmol Otol1968;72:755.

Jones LT, Reeh MJ, Wobig JL Senile entropion: a new concept for correction. Am] Ophthalmo/1972;74;327.

Kemp EG, Collin JR. Surgical management of upper lid entropion. Br J Ophtha/mo/1986;70;575-579.

Kuhnt and Szymanovski: vide SA Fox. McCarthy JG. Introduction to plastic surgery. In: McCarthy JG, ed. Plastic

Surgery. Philadelphia: WB Saunders, 1990:61. Millman AL, Katzen LB. Cicatricial entropion: an analysis of its treatment with

transverse blepharotomy and marginal rotation. Ophthalmic Surg 1989;20;575-579.

Nasr AM. Eyelid complications in trachoma. I. Cicatricial entropion. Ophthalmic Surg 1989;20;800-807.

Schaefer AJ.lnvolurional entropion. In: Smith BC (ed). Ophthalmic Plastic and Reconstructive Surgery. StLouis: CV Mosby, 1987:546-555.

Sisler HA, Labay GR, Finlay JR. Senile ectropion: a comparative histopatho­logical study. Ann Ophtha/mo/1976;8;319.

Sheehan JE. Plastic Surgery of the Orbit. New York: MacMillan, 1927. Shorr N, Christenbury ]D. Tarsoconjunctival grafts for upper eyelid cicatri­

cial entropion. Ophthalmic Surg 1988;19:316-320. Smith B, Cherubini TD. Oculoplastic Surgery: A Compendium of Principles and

Techniques. StLouis: CV Mosby, 1970. Quickert MH, Rathbun E. Suture repair of entropion. Arch Ophthalmol

1971;85;304. Teichmann KD. Correction of severe upper eyelid entropion. Int Ophthalmol

1988;12;37-39. van der Meulen ]C. Radical correction of senile entropio and ectropion. Plas

Reconst Surg. 1983;71(3):318-323. Wheeler JM. The use of orbicularis palpebrum muscle in surgery of the eyelids.

Am J Su'g 1938;42;7. Wheeler JM. Spastic entropion correction by orbicularis transplantation. Am

J Ophtha/mo/1939;22A77. Wies FA. Spastic entropion. Trans Am A cad Ophthalmol Oto/1955;59:503.