1
ECTROPION and ENTROPION
ECTROPION

outward turning of the eyelid margin.

Presentation is usually from
1. epiphora
a. horizontal laxity or weak orbicularis produce poor lacrimal pump
b. punctum pulled away from lacus lacrimalis
2. ocular irritation
3. cosmesis.

Chronic exposure will lead to
a. punctal eversion and punctal phimosis
b. keratinization of conjunctiva
c. conjunctival hyperemia, and
d. finally exposure of the globe.
Pathophysiology

Position of the lower lid margin depends on:
1. the integrity of the tarsal plate
2. the ligamentous and tendinous attachments of the tarsus (tarsoligamentous sling)
3. the forces exerted on these structures by the overlying skin and orbicularis layers

Causal factors leading to ectropion include horizontal laxity of the eyelid (universal), dehiscence of the
lower eyelid retractors, vertical shortening of the anterior lamella of the eyelid, paralysis of the
orbicularis oculi muscle causing loss of eyelid muscular tone, and neoplasia within the lower eyelid
pulling or forcing the eyelid away from the globe.
CLASSIFICATION
A) CONGENITAL
B) ACQUIRED
1. Involutional
2. Mechanical
3. Cicatricial
2
4. Paralytic
Also classified according to position- punctal, medial, lateral, or tarsal (complete).
Congenital ectropion

Rare

Cause often is a vertical deficiency of the anterior lamella.

may be associated with blepharophimosis syndrome, microphthalmos, buphthalmos, orbital cysts, Down
syndrome, and ichthyosis

occasionally due to paralytic causes

Treatment: Horizontal lid tightening/shortening or Grafting of anterior lamella
Involutional Ectropion
 A major factor is horizontal lid laxity, usually due to age-related weakness (most patients are elderly) of
the canthal ligaments and pretarsal orbicularis.
 Eversion of the lid leads to conjunctival exposure and secondary inflammatory changes. The tarsus
thickens which mechanically worsens the ectropion.
 Disinsertion of the capsulopalpebral fascia may lead to severe tarsal ectropion
 generally a progression from eyelid laxity to punctal ectropion, medial ectropion, then generalized
ectropion.
Mechanical Ectropion
 Due to lesions (tumours or cysts) near the lid margin.
 May present as a lump in the lid.
 Treatment is by excision with resultant scar to be left as vertical as possible.
 If there is horizontal laxity, the lid is shortened at the same time.
Cicatricial Ectropion
 occurs secondary to scar contracture of the anterior lamella of the eyelid
 The lid margin is pulled away from the globe by a shortage of skin.
 Causes
1. trauma, burns
2. skin conditions – atopic dermatitis, acne rosacea, herpes zoster
3
3. iatrogenic - excessive skin excision (or laser) with blepharoplasty.
 To confirm the Dx, superiorly displace the lower lid margin. If the lower lid margin does not extend 2 mm
above the inferior limbus, then consider cicatricial ectropion.
 The problem may be localised to a particular scar or may affect the lid generally.
Paralytic Ectropion
 Due to VII nerve palsy.
 There is no skin shortage.
Management
Non Surgical
1. Lubrication and moisture shields
2. taping the lateral canthal skin supertemporally provides temporary relief, especially in patients with
new-onset seventh nerve palsy.
3. If the conjunctiva is markedly keratinized, use a lubricating ointment several days or weeks prior to
ectropion repair.
4. Instruct patients with tearing and incipient ectropion or early punctal ectropion to wipe the eyelids in
a direction up and in (toward the nose) to avoid worsening medial ectropion.
5. With cicatricial ectropion following trauma or lid surgery, digital massage may help stretch the scar.
If not, consider steroid injection into the scar.
Surgical
Depends on aetiology

Mild-to-moderate cases of medial ectropion may respond to a medial conjunctival spindle procedure.

Horizontal lid laxity often is seen with ectropion and usually can be corrected with a tightening procedure
of the tarsal ligamentous sling

Tarsal ectropion requires reinsertion of the lower lid retractors.

Augmentation of the anterior lamellae (along with excision of any cicatrix) is required for cicatricial
ectropion.

Mechanical ectropion requires excision of offending tumor
Congenital ptosis
4
Mild cases

corneal lubrication.

If it doesn’t work, consider placing lid margin sutures. A lateral tarsorrhaphy may be required if suture
techniques do not work, but be careful of iatrogenic amblyopia.
Severe cases

may need a skin flap or graft.
Medial/punctal ectropion

if tearing is mainly the problem, one-snip or two-snip inferior punctoplasty may be beneficial

medial canthal ligament plication – may result in occlusion of the canalicular system

medial conjunctival spindle procedure (excision of the medial conjunctiva and retractors)
o horizontal ellipse or diamond of conjunctiva and underlying lid retractors is excised inferior to
the punctum, approximately 3-4 mm high and 6-8 mm wide.

Byron Smith Lazy-T procedure
o a lower lid, full-thickness5-8mm
pentagonal wedge resection, 3-to 4-mm temporal to the
punctum
o resection of a medial triangle of conjunctiva and lower lid retractors (similar to medial
conjunctival spindle)
o may need medial canthal tendon plication if marked medial canthal laxity is present
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Involutional ectropion

wedge resections
1. pentagonal wedge
2. Kuhnt-Szymanowski procedure
o involves lid splitting and lateral wedge resection
o may be combined with a diamond shaped excision near the
medial punctum to correct punctal eversion.
o Ensure lateral canthal tendon is not dehisced
o Problem: tendency to create a more rounded lateral canthal
angle, which may result in lid notching, phimosis, and further
tension on the lateral canthal tendon without appropriate
reinforcement

Lateral canthal tightening procedures
1. lateral tarsal strip
o inferior lateral-cantholysis
o 3 mm of the lateral lid is then split at the gray line
o conjunctival margin of the lateral strip is then trimmed away.
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o Secure lateral strip to periosteum 4-5 mm posterior to the lateral orbital rim near the Whitnall
tubercle (at or above the level of the inferior pupil).
o Augmented tarsal strip - long (10-15 mm) strip, attached to the outer temporal orbital rim at a
point higher than that of a standard LTS. In order to pass the long strip high enough, a small
portion of the upper eyelid anterior lamella laterally was removed.
o Problem: lid shortening and the possibility of lateral canthus distortion.
o
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2. Dermal obiculare pennant canthopexy:
o avoids the problems with the lateral tarsal strip procedure by making a pennant-type incision in
the lateral canthal skin
o inferior retinaculum and tarsus are deepithelialized and placed through the lateral orbit to
reposition the canthus.
3.
Inferior retinacular lateral canthoplasty
o Division of inferior limb and reposition it several millimeters higher to the medial aspect of the
lateral orbital rim periosteum
4. Lateral retinacular canthoplasty
o Entire lateral canthis detached and reattached
5. Lateral canthopexy
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o lid is tightened and repositioned by passing a double-armed suture through the lateral canthus and
suturing to the medial aspect of the lateral orbital rim periosteum superiorly

reinsertion of capsulopalpebral fascia
o tarsal ectropion
o due to disinsertion of the capsulopalpebral fascia from the inferior tarsal border
o conjuctival approach
o Reinsert capsulopalpebral fascia to tarsus
o A spindle of redundant conjunctiva, no more than 3 mm in vertical height, can be excised if
necessary.

temporalis transfer
o For extreme, recurrent involutional or paralytic ectropion
o reserved for the most severe cases of ectropion with marked generalized periocular laxity or after
previous failed repair
o provides a viable lower lid sling as well as additional pretarsal muscle mass. As a secondary benefit it
may initiate myo-neurotinization of the atrophic orbicularis muscle.
Cicatritional ectropion
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
secondary to skin or muscle deficiency, and requires replacement of the missing elements for correction.

Simply tightening the eyelid will not adequately correct cicatricial ectropion.
Paralytic ectropion

Need to treat a combination of lagopthalmos and ectropion
o Most useful are lateral tarsal strip or wedge excisions
o consider use of fascial slings, midface lifting
o temporalis transfer if severe
Complex Ectropion (Lid Retraction)

Constriction of both inner and outer lamellae with constriction of supporting structures of the lid.

Eversion occurs only if outer lamella contracted more than inner.

Results from inflammation/oedema during leading to fusion of all lid structures with septum.

May occur following burns, trauma or post-operative haematoma.

Treatment principles are to release all scar tissue and introduce a rigid lid supporting element (insertion
of a strong middle lamella, such as nasal septal cartilage, to withstand any subsequent deforming forces).

Controversial whether new tissues must be imported or existing tissues supported.

Gruss et all advocate bipedicled orbicularis flap inset into subciliary incision with grafts to anterior
(FTSG) and posterior (scleral graft) lamellae.
1. infraciliary incision and lysis of adhesions
2. homologous free scleral graft for the posterior lamella
3. free retroauricular skin graft to the anterior lamella
4. bipedicle orbicularis flap mobilization and interposition between the free grafts.

If the lid has been stretched through scar contracture, a lid tightening procedure is required.
ENTROPION
is an inward turning of the eyelid margin so that the lashes make contact with the surface of the eye.
Problem: ocular surface irritation
result in corneal and conjunctival irritation, abrasion and scarring.

Trichiasis is where only the lashes are turned in, but the lid margin remains in the normal position.

Distichisis is an extra row of lashes which point inwards, but the lid margin is in the normal position.
CLASSIFICATION
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1.
2.
3.
4.
5.
Congenital
Acute Spastic entropion
Involutional
Cicatricial
Mechanical
LOWER LID RETRACTORS
1. FIBROUS – capsulopalpebral fascia. From the sheath of the inferior rectus muscle, extends a sheet of
fibrous tissue which splits to enclose the inferior oblique muscle and runs forward to the lower border of
the tarsal plate.
2. MUSCULAR - From this fibrous sheet some slips of smooth muscle arise and run forward to the inferior
border of the tarsal plate = Inferior tarsal muscle (Mullers muscle of lower lid.)
UPPER LID RETRACTORS
1. Fibrous - Aponeurosis of the levator muscle
2. Muscular - Superior tarsal (Muller’s) muscle
Dysfunction of lower lid retractors leads to entropion.
Dysfunction of upper lid retractors leads to ptosis.
LOWER LID ENTROPION
A. CONGENITAL ENTROPION

Rare.

Due to :
1) Dysgenesis of lower eyelid retractors
2) Structural defects in tarsal plate (tarsal kink syndrome)
3) Vertical shortage of posterior lamella
4) hypertrophy of marginal fibres of orbicularis oculi.
5) Epiblepharon

In-rolling of lid margin and lashes over superior tarsal edge

Due to lack of adhesion between lid retractors and anterior lamella

More common in Orientals

Usually bilateral
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

Involves the whole of the lower lid margin.

Initially progressive, but then tends to resolve spontaneously

Clinically, often associated spasm of orbicularis.
Treatment
1. conservative – most will resolve with age
2. taping

Surgery is indicated in children who have symptomatic entropion with
a) Persistently photophobia or
b) Recurrent attacks of conjunctivitis.

Surgical options
1. suture fixation (Snellen)
2. Excision of redundant tissue
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a. This involves the excision of an ellipse of infra-tarsal skin and underlying
hypertrophied pre-tarsal orbicularis. Lateral canthoplasty may also be
indicated. A better cosmetic result is obtained if both sides are done at the
same time.
B. MECHANICAL ENTROPION

Due to lack of lid support. Either due to a small or absent globe or caused by the backward pressure on
the ciliary margin by a fold of excess skin with epiblephron.

Surgical correction is by excision of infra-tarsal skin and hypertrophied pre-tarsal orbicularis with or
without lateral canthoplasty.
C. ACUTE SPASTIC ENTROPION

Spastic entropion occurs transiently in younger patients

Spastic closure of eyelids allow orbicularis to overwhelm the lower eyelid retractors

may herald the eventual development of involutional entropion. It is similar to involutional entropion
and has a similar pathophysiology.

Clinically, patients with a constant entropion present with an irritated, red eye.
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
Sometimes the entropion might be intermittent. If so it can be elicited by asking the patient to close their
eyes tightly. This causes the pre-septal orbicularis to override the pre-tarsal orbicularis, precipitating the
entropion.
D. CICATRICAL ENTROPION

Due to posterior lamella scarring and vertical shortage

Difficult eversion of lower lid differentiates this from involutional type

May follow trauma, burns, Stevens-Johnson syndrome, infections

Trichiasis may be associated, especially with the inflammatory causes.

Symblepharon (adhesions between lid and globe) or abnormal adhesions between palpebral and bulbar
conjunctiva may also occur with the above causes and may complicate entropion.

Treatment
o Early – massage
o Late

Triachiasis only - Marginal incision and wedge graft

Mild cases - Tarsal fracture and margin rotation
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Tenzel tarsal fracture for upper lid
Transverse tarsotomy (Kersten)

Severe - Posterior lamella grafting

Indicated when:
1. cicatricial entropion is severe, ie lid retraction more
than 1.5 mm below the limbus, or
2. recurrence of entropion after tarsal fracture.

Donor sites:

Nasal chondromucosa

Palatal mucoperichondrium

Buccal mucosa

Tarsoconjunctival composite graft

Cadaveric dermis (Alloderm)

Ensure that inflammation has settled prior to embarking on surgery

Distorted tarsus needs excision and replacement (usually with grafts)
E. INVOLUTIONAL ENTROPION

Occurs with advancing age.

Causes:
1) dehiscence or attenuation of the capsulopalpebral fascia, which allows the lower tarsal border to
rotate outward
2) horizontal lid laxity with or without laxity of the canthal tendons
3) overlapping of preseptal orbicularis muscle fibers up and onto the pretarsal orbicularis on the
tarsus, which makes the lid turn inward. The condition is self-perpetuating: as the tarsal plate rotates,
the pre-septal fibres are encouraged to move even further up towards the upper part of the tarsal plate.
This can even result in the formation of tight band that pushes the lid margin against the eye.
4) Atrophy of orbital fat – leads to enopthalmos, loss of support
5) Tarsal plate involutional changes:
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a) rotation (top moves in; bottom moves out - as above),
b) atrophy with loss of stiffness - allows the tarsal plate to bend.

Whether the lid turns in (entropion) or out (ectropion) depends on changes occurring in the orbicularis
oculi muscle, the lower lid retractors and the tarsal plate.

The treatment depends on the cause:
CAUSE
AIM
1. Orbicularis overriding
PROCEDURE
Prevent the overriding by creating a 1. Partial resection
scar tissue barrier between the pre- 2. Transverse sutures
2. Laxity of lower lid retractors
septal and pre-tarsal muscles.
3. Transverse lid split
Tighten the retractors.
1. Everting sutures
2. Plication of lid retractors
3. Involution of the tarsal plate
Transfer the pull of the retractors so 1. Everting sutures
that they evert the lid margin.
4. Horizontal lid laxity
Horizontally shorten the lid and/or 1. Shorten the lid
canthal tendons.
2. Canthopexy
SURGERY FOR INVOLUTIONAL LOWER LID ENTROPION
A. TEMPORARY CURE
Suture techniques
B. PERMANENT CURE
No excess lid laxity:
Recurrence:
Excess lid laxity:
Recurrence:
Transverse lid split and everting sutures.
Horizontal lid shortening.
Transverse lid split, everting sutures and horizontal lid shortening.
Plication of lid retractors.
1. Sutures

Suture provide a quick, easy but temporary solution (up to 18 months).

The procedure can be repeated if necessary.

Can be done at the bedside (eg in the geriatric patient).
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Everting sutures (Snellen/ Quickert-Rathbun)

Indicated for intermittent spastic entropion

Full thickness sutures from inferior fornix anteriorly towards the
lashes.

Tissue reaction to the suture (usually gut) helps to create a cicatrix to
maintain everted position are placed through the lid aiming to prevent the
upward movement of the pre-septal muscle.

Method: 4.0 CCG through the lateral two thirds of the lid from skin to
fornix and out again. The sutures should be tied tightly and removed after
10 to 14 days.
2. Transverse lid split and everting sutures (Wies-type procedure)

Indicated where a more permanent result is desirable (> 18 months).

Only indicated if minimal horizontal lid laxity.

The lid is split transversely to create a fibrous scar tissue barrier to prevent upward movement of the preseptal muscle.

Everting sutures, in addition, are used to shorten the lower lid retractors and transfer their pull to the
upper border of the tarsus.
Technique

Protect the globe.

A horizontal full thickness incision is made 4mm below the lash line
(corresponding to the lower border of the tarsal plate) and a little lower laterally.

Avoiding damage to the tarsal plate, the incision is carried through the whole lid
including the conjunctiva. Care must be taken to ensure that the skin and
conjunctiva are cut at the same level.
The lower lid retractors should be
identified as a layer of white fibrous tissue just anterior to the conjunctiva.

The everting sutures (4.0 CCG - double armed) are passed from the conjunctiva
about 2 mm below its cut surface through the lower lid retractors, across the lid
transection, anterior to the tarsal plate to emerge through the skin 1 to 2 mm
below the lash line. Starting with the lateral suture, these sutures are tied tight
enough to evert the lid margin. When tying the medial suture, avoid a punctal
ectropion.
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3. Transverse lid split, everting sutures and horizontal lid shortening (Quickert procedure)

Again this procedure is indicated where a ‘long term’ (> 18 months) cure is
desired.

If there is excess horizontal lid laxity this is the procedure of choice. This is
assessed by pulling the lid away from the globe.

The principle is the same as for the Wies-type procedure. The lid is shortened
so as to prevent it from moving either in or out due to its excess laxity.
Method:

Protect the globe.

vertical incision is made in the lid 5 mm from the lateral canthus. This incision
extends from the lid margin to the lower border of the tarsal plate. Make the
horizontal incision as for the Weis-type

Overlap the 2 flaps to assess the extent of the lid resection necessary to
overcome the excess horizontal laxity and resect this amount from the medial
flap.

If the medial punctum moves too far laterally, a plication of the medial canthal tendon may be indicated.
Everting sutures are placed as described above and the wounds are closed.
4. Plication of the lower lid retractors (Jones type procedure)

Recurrence after a Quickert procedure is likely due to weakness of the lower lid retractors (everting
sutures will not adequately tighten retractors if they are too lax or have become disinserted). Recurrence
after a Quickert procedure therefore needs to be corrected by a plication of the lower lid retractors.

The principle of this procedure is that the lower lid retractors are exposed and plicated and the sutures are
used to create a barrier to the pre-septal orbicularis muscle.
Method:

Protect the globe.

A horizontal incision is made at the lower border of the tarsal plate.

The pre-tarsal and pre-septal muscles are separated to expose the inferior edge of the tarsal plate. Deep to
the pre-septal muscles the inferior orbital septum is found and divided to reveal the orbital fat. The
orbital fat is retracted to expose the lower lid retractors.

A 4.0 CCG is passed through the lower skin edge in the centre of the wound, through the lower lid
retractors about 8 mm from the lower edge of the tarsal plate, through the lower border of the tarsal plate
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and out through the upper skin edge. Check the degree of correction before placing 1 or 2 sutures
medially and laterally. Excess skin and orbicularis muscle can be excised from the lower edge of the skin
incision if required.
UPPER LID ENTROPION
Upper lid entropion is due to conjunctival scarring. The constant factor is a shortage of the posterior lamella
(conjunctiva, tarsal plate and upper lid retractors) relative to the anterior lamella (skin/orbicularis muscle).
In 183 lids examined by Kemp and Collin (BJO, 70,575, 1986) the aetiology of upper lid entropion was:
Diagnosis
Number of Lids
Trachoma
73
Chronic blepharo-conjunctivitis
41
Erythema multiforme
14
Chemical / Radiant trauma
12
Post-operative (ptosis repair, tumour excisions)
9
Pemphigoid
7
Mechanical
7
Postnucleation socket syndrome
6
Herpes Zoster Ophthalmicus
5
Cicatricial vernal conjunctivitis
5
Dysthyroid
4
TOTAL
Factors of importance in the examination
1. Position of the meibomian gland orifices
183
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2. Conjunctivalisation of the lid margin
3. The position and direction of the lashes
4. Palpation and inspection of the tarsal plate
5. The presence or absence of keratin deposits on palpebral conjunctiva
The various effects of the cicatrisation influence the choice of operation:
I. Severity of entropion

If the entropion is mild, the lashes may not frankly abrade the cornea but the entropion can still be
recognised because of:
a) apparent posterior migration of the meibomian gland orifices
b) conjunctivalisation of the lid margin,
c) lashes touch the globe on upward gaze.

The treatment of mild entropion is anterior lamella repositioning.
II. Thickness of the tarsal plate

Some causes of scarring result in a thick tarsal plate, eg trachoma.

Other causes result in a thin tarsal plate, eg Stevens-Johnson syndrome.

If the tarsal plate is thick, entropion can be corrected by excision of a wedge, but not if it is thin.
Thick tarsal plate
trachoma
Rx: Tarsal wedge resection
Thin tarsal plate
Stevens-Johnson
Rx: Lamella division + mucous membrane graft
III. Keratinisation of the marginal tarso-conjunctiva

Scarring may result in metaplastic changes:
a) keratinisation,
b) aberrant fine hair formation.

If this occurs on the posterior surface of the lid near the lid margin, this area must be everted away from
the cornea by a rotation of the terminal tarsus.
IV. Lid Retraction

Any scarring causing upper lid entropion also shortens the posterior lid.

If this is mild, it can be corrected by releasing the conjunctiva from Muller’s muscle and any
subconjunctival scar tissue and advancing the posterior lamella of the lid. This, according to Collin,
should be part of any upper lid entropion operation.

If the lid retraction is severe, (ie the eyelids do not meet on forced lid closure), then:
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a) the posterior lamella must be released with a graft and the lid margin everted, or,
b) the scarred tarsus must be excised and the conjunctiva and lid retractors recessed.
Mild lid retraction
Free Muller’s muscle and advance tarso-conjunctiva
Severe lid retraction Posterior lamella graft or tarsal excision
SURGERY FOR UPPER LID ENTROPION
A. MILD
Anterior Lamella Repositioning
B. SEVERE
Thick Tarsus:
Tarsal wedge resection
Thin Tarsus:
Lamella division + mucous membrane graft
Keratinisation of Tarso-conjunctiva:
Rotation of terminal tarsus
Moderate Lid Retraction:
Posterior Lamella Advancement
Severe Lid Retraction:
Posterior Lamella Graft or Tarsal Excision
1. Anterior Lamella Repositioning

This is indicated for mild upper lid entropion.
An incision is made in the skin crease and the structures dissected off the anterior tarsal surface until the lash
roots are just visible. Repositioning sutures (6.0 long acting absorbable) are placed through the skin just
above the lashes, through the tarsal plate at a slightly higher level and out through the skin again about 2 mm
away from where they went in. The height of tarsal fixation controls the degree of lid eversion. If eversion
is inadequate (even after repositioning the suture), the lid margin can be split just anterior to the meibomian
glands to a depth of 1 to 2 mm. This split is left to granulate. After the repositioning sutures have been
placed, any excess of skin and muscle is excised and the anterior wound is closed. The long acting sutures
should be removed after 6 weeks if they have not fallen out on their own.
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2. Tarsal Wedge Resection

Indicated where there is marked upper lid entropion with a thickened
tarsus (as in trachoma).
There must be no keratinisation of the
marginal tarso-conjunctiva and the eyelids should meet on forced
eyelid closure.
Do a lid margin split. Make an incision in the upper lid crease and
undermine as above. Using a blade, cut a wedge out of the anterior
tarsus. Fibrous tissue and Muller’s muscle must be dissected of the
upper border of the tarsal plate and conjunctiva so that the tarsal plate
can be straightened. The tarsal wedge is closed with 6.0 long acting
absorbable sutures that exit through the skin near the lashes in such a
way as to evert the upper lid and to hold the lid margin split open. The
rest of the procedure is as for anterior lamella repositioning.
3. Lamella Division with or without Mucous Membrane Graft
Indicated where there is marked upper lid entropion with a thin tarsus. There must be no keratinisation of the
marginal tarso-conjunctiva and the eyelids should meet on forced eyelid closure.
The lid is split completely into anterior lamella and posterior lamella. The posterior lamella is advanced and
held in position by (4.0 CCG) sutures passed through the lid (upper fornix to prospective skin crease). The
lower border of the anterior lamella is sutured to the advanced posterior lamella. The exposed tarsal plate
can be left to granulate or can be grafted with thin (split or full thickness) mucous membrane graft.
4. Rotation of Terminal Tarsus (Trabut type procedure)
Indicated for upper lid entropion where there are metaplastic changes of that part of the upper lid that is in
contact with the cornea. This indicates a more severe degree of lid disturbance.
The lid is cut posteriorly just above the area of the metaplastic changes (2 to 3 mm from the margin).
Through this incision the anterior and posterior lamella are separated so as to allow the posterior lamella to
be advanced down. The lower (metaplastic) inner part of the lid is undermined and releasing incisions are
made medially and laterally so that this lower part can be rotated through 180 o. The advanced posterior
lamella is held in position by a suture (4.0 CCG) from the upper fornix to the site of the proposed skin crease.
The everted (metaplastic) part of the lid is held in place with interrupted 6.0 long-acting absorbable sutures
and the original incision becomes the new lid margin.
5. Posterior Lamella Graft
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Indicated when entropion is associated with severe upper lid retraction so that the lid margins do not meet on
forced lid closure. If a corneal graft is considered under these circumstances then a posterior lamella graft
must be done.
A posterior incision is made in whatever remains of the tarsal plate. The terminal tarsal fragment is freed and
everted and the upper tarsal fragment is also freed and separated from the anterior lamella. The gap thus
created is filled with graft:
a) cartilage
b) contralateral tarsus
c) sclera
d) mucous membrane.
Grafts of a stiff material are preferable (cartilage or contralateral tarsus).
6. Tarsal Excision
Indicated when entropion is associated with severe upper lid retraction and a small scarred tarsus when a
corneal graft is not planned.
The lid is split into anterior and posterior lamellae, the lid retractors and the conjunctiva are freed into the
upper fornix and the tarsal remnant is excised. The remaining conjunctiva and lid retractors are sutured to
the remnants of the upper lid.