|Year : 1960 | Volume
| Issue : 2 | Page : 42-46
Genesis of senile entropion and a simplified operation for its correction
Muslim University Institute of Ophthalmology, Aligarh, India
|Date of Web Publication||6-May-2008|
A D Grover
Muslim University Institute of Ophthalmology, Aligarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Grover A D. Genesis of senile entropion and a simplified operation for its correction. Indian J Ophthalmol 1960;8:42-6
Senile entropion is a common clinical entity. It is troublesome to the patient and annoying to the ophthalmologist, because minor measures arc usually ineffective and only operation can effect a permanent cure, though even this is not always certain.
Cicatrical entropion shows anatomical changes of the intermarginal surface and the tarsus, while senile entropion is the simple turning in of the unchanged lower tarsus. Most text books define senile entropion as a form of spastic entropion of the lower lid, or conversely the commonest form of the spastic entropion is described as occurring in the lower lid of elderly people. It is usually attributed to a spasm of the orbicularis muscle brought on by ocular irritation. For such a spasm to cause the entropion, it would have to be confined to the marginal fibres of the orbicularis (Muscle of Riolan) of the lower lid. It is hard to believe that such a remarkable selectivity is possible in a portion of a muscle. Obviously there must be other factors to explain the mechanism of senile entropion.
Under normal conditions the lower lid or rather its skeleton, the tarsus, is kept in the correct position by two forces, (i) the elasticity of the tarsoorbital fascia including the embedded inferior tarsal muscle, and (ii) the tone of the orbicularis oculi exerting equally distributed pressure upon the lid. [Figure - 1].
The tarsus normally lies snugly against the globe where it is held in place by the palpebral ligaments, whose attachment is well behind the anterior plane of the globe. The lower tarsal border is held in place by the tarso-orbital fascia and a fibrous slip from the inferior rectus muscle which assists in keeping the attached border in contact with the globe. [Figure - 1]. The muscle of Riolan is more developed in the lower lid than in the upper, and helps to keep the free border of the tarsus against the globe.
The orbicularis oculi plays an important role. Its normal distribution is maintained by connective tissue branching off between the bundles of muscle fibres. In normal lid closure the orbicularis elevates the lid margin, stretches the skin smoothly over the lower lid and applies direct pressure to the tarsal plate which thus maintains its normal snug relation to the globe. The muscle of Riolan and the fascial attachments keep the upper and the lower borders of the tarsus in place.
However, the aging process, by absorption of the orbital fat and general relaxation of the tissues causes a derangement of this normal mechanism. In senility there is slackening of all the palpebral connective tissue with the result that there is a drawing up and accumulation of the bundles or orbicularis muscle near the lid margin, creating a situation which predisposes towards entropion. Kirby (1953) has emphasized that flaccidity and elongation of all the fibrous and elastic elements of the lower lid occur with age, and that such changes are of great importance.
The loosening of the skin, the muscle, and the other tissues of the lower lid reduce the pressure on the attached tarsal border which loses its firm contact with the globe. The contraction of the orbicularis which is now accumulated at the lid margin, straightens the latter and forces it down, thus relaxing the inferior ligaments (Butler-1948). A straight axis is provided by the shortened upper border around which the already unbalanced tarsal plate rotates in a flaplike manner. The inadequate support of the enophthalmic globe facilitates the inturning of the lid margin and thus the senile entropion begins. It would seem, therefore, that the senile entropion is the result of a disturbance of the normal relationship of the structures caused by the degenerative processes of old age rather than by the muscle spasm.
It is only after prolonged corneal irritation caused by the inturned lashes that the spastic element becomes superimposed. That spastic entropion exists as a clinical entity is of course obvious. An acute form of this condition is seen in cases of ocular inflammation and after prolonged bandaging; it is found in young and old alike and is accompanied by blepharospasm, photophobia and lacrimation. It is usually amenable to conservative treatment, such as application of adhesive strips or collodion and disappears with subsidence of the causative factor.
However, in senile entropion the clinical picture is different. The condition is of gradual onset and often there is no history of previous inflammation, so whatever, irritation is present seems to be the result of the entropion and not the cause. Frequently, the eye is white and quiet, and the condition is detected when the patient is seen for some other ocular complaint.
| Treatment|| |
Many procedures have been suggested for the correction of senile entropion. The great list of the remedies indicates that none of them is fully effective. Recurrence of entropion often occurs after the use of temporary sutures, cautery, alchohol injection; skin, muscle and tarsus excision. Wheeler's (1938) transplantation of the orbicularis strip gives good results, but has the disadvantage of its being a comparatively lengthy operative procedure. Meek's (1940) modification of this operation does not appear to be advantageous in any way.
Schimek (1957) described a simple technique which consists of tightening a strip of the orbicularis by a permanently buried horizontal suture. The operation has the advantage of being a simple procedure involving minimum mutilation of the tissues. It can be done in cases in which other methods have failed, provided at least a bundle of the orbicularis muscle fibres is present. In case of recurrence after this operation, other methods can be adopted without difficulty.
Schimek (1957) operated ig cases of senile entropion by this technique with only 2 recurrences during the average follow-up of 22 months.
A local anaesthetic is injected along the lower lid and temporal to the outer canthus. An incision about i cm. long is made 3 mm. below the lash margin at the junction of the medial and the middle third of the lower lid. [Figure - 2]. The incision may be vertical or horizontal, the latter has the advantage that the wound heals quickly and the resulting scar does not become visible as it lies in the line of the lid folds. Another vertical incision i cm, long is made 2 cm. temporal and 0.5 cm. above the level of the outer canthus. The skin around the incision is undermined.
With a pair of toothed forceps a good sized bundle of the orbicularis is held. A long 4-0 silk suture on a needle is passed through the muscle and tied. [Figure - 2]. The needle is removed and both arms of the suture are now threaded on a long straight needle, which is inserted into the lower lid incision, passed sub-cutaneously across the lid and out of the temporal skin incision [Figure - 3]. Both arms of the stitch are thus taken out of the wound, one arm of the suture is threaded on a curved needle and passed through the orbicularis muscle and the temporal fascia [Figure - 4]. The suture is tied with sufficient tension to over-correct the entropion and produce an ectropion of mild degree. It is then cut, and allowed to retract into the wound. The skin incisions are closed by interrupted 6-0 black silk sutures. The skin stitches are removed on the fifth day while the sub-cutaneous one lies buried permanently.
The degree of the tightening of the orbicularis and thereby the entropion correction can be altered by varying the distance between the two incisions and the pressure of the buried suture. If greater effect is required the temporal incision should be placed more laterally and the suture must be tied more tightly. [Figure - 5].
The entropion is corrected by two factors
1. The tightening of the orbicularis muscle, which has accumulated at the upper lid margin.
2. The buried suture by supporting the lower half of the tarsus does not allow it to turn outwards and thus keeps it against the globe, restoring to some extent the original snug relationship. The scar tissues formed along the subcutaneous stitch is of further help in correcting the entropion.
| Result|| |
Fourteen eyes in eleven cases were operated and the results are summarized in [Table - 1]. All the cases were old people, mostly with enophthalmic eyes. No other operation had been done on any of these eyes previously. The immediate results were good in all the cases. [Figure - 6].
On follow-up there was only one partial recurrence in which the entropion re-appeared to a slight extent in the outer half of the lower lid, after a period of one month. In this case the temporal incision had been made at the level of the outer canthus and the eye was markedly enophthalmic. The recurrence may have occurred because the buried stitch was lifted up by the outer orbital margin and it did not retain its contact with the tarsus as far as its lateral end, a condition which is more marked in enophthalmic eyes. Such recurrences can he avoided by making the temporal incision higher and more laterally so that the oblique stitch will retain its contact with the tarsus as far as the outer end, even in markedly enophthalmic eyes.
One case complained of pain in the region of the temporal incision. A small tender swelling developed at the site of the incision (a stitch abscess), but it subsided readily with medical treatment. No other complication was encountered.
| Summary|| |
The role of degenerative changes of old age in the causation of the senile entropion is discussed. A simple technique for correction of entropion is described. By this method the orbicularis muscle is tightened and the lower border of the tarsus is given support by a permanently embedded suture. In this operation there is minimum mutilation of the tissues and the results are very encouraging.
| References|| |
Butler, J. B. V., 1948, A.M.A., Arch. Ophthal. 40, 665.
Kirby, D. B., 1953, (Am. J. Ophthal.) 36, 1372.
Meek, R. E., 1940, A.M.A., Arch. Ophthal. 24, 547.
Schimek, R. A., 1957, Am. J. Ophthal. 43, 245.
Wheeler, J. M., 1938, Tr. Am. Ophthal. Soc. 36, 157.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]
[Table - 1]