Eyelid protrusion: causes, symptoms, diagnosis, treatment

Entropion (syn. entropion) is a condition in which the edge of the eyelid and eyelashes are turned toward the eyeball. This leads to constant irritation of the eye, the formation of erosion and ulcers of the cornea, injection of conjunctival vessels, and lacrimation.

Pathogenesis

Age-related degeneration of elastic and fibrous tissues of the eyelid leads to the following processes.

• Horizontal laxity of the eyelids caused by stretching of the tendons of the angle of the eye and tarsal plate.
• Vertical instability of the eyelids caused by weakening, splitting, or avulsion of the tendon of the inferior retractors of the eyelid. Weakness of the latter is recognized by a decreased excursion of the lower eyelid on downward gaze.
• The superior part of the pretarsal portion of the orbicularis oculi muscle, during closure of the eyelids, tends to move the inferior border of the tarsal plate anterior to the eyeball and the superior border toward the eyeball, bending the eyelid inward.

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Forms

The following forms of inversion of the eyelids are distinguished: congenital, age-related, spastic, cicatricial.

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Congenital entropion

Congenital inversion of the eyelid is more often observed in representatives of the Mongoloid race and is a consequence of thickening of the skin and hypertrophy of the fibers of the orbicularis oculi muscle at the ciliary edge.

Inversion of the lower eyelid

The cause is a developmental defect of the aponeurosis of the lower retractor.

Symptoms of lower eyelid inversion: inward turning of the lower eyelid and eyelashes, absence of the edge of the eyelid; inversion should not be confused with epiblepharon.

Age-related entropion

Age-related entropion occurs due to stretching of the eyelid ligaments, atony of the lower eyelid retractor, instability of the tarsal plate. Age-related entropion is corrected by horizontal shortening of the outer eyelid ligament, retractor plastic surgery, resection of the skin-muscle flap, and a combination of these techniques. The prognosis is good.

In age-related inversion of the eyelids, the lower eyelid almost always inverts, since the upper eyelid has a wider plate and is more stable. Constant contact of the eyelashes with the cornea in patients with prolonged inversion of the eyelid (pseudo-trichiasis) can cause irritation, the appearance of punctate epithelial erosions of the cornea and, in severe cases, the formation of an ulcer and pannus.

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Spastic entropion

Spastic inversion is characterized by age-related stretching of the lower eyelid structures, which in age-related enophthalmos leads to instability of the lower eyelid. The fibers of the orbicularis oculi muscle gradually move toward the edge of the eyelid, and their hypertrophy occurs. The occurrence of such an inversion of the eyelid is provoked by blepharospasm. In case of spastic inversion of the eyelid, a combination of horizontal shortening of its external ligament is justified, and if necessary, the operation is supplemented by plastic surgery of the lower eyelid retractor and removal of the lower eyelid skin flap. Unlike age-related inversion, spastic inversion often recurs.

Cicatricial inversion of the eyelids

Cicatricial inversion is often the result of tarsal plate wrinkling after burns, injuries, radiation damage, surgeries, infections (trachoma), and allergic and toxic reactions (pemphigoid, Stevens-Johnson syndrome, Lyell's syndrome). Constant trauma to the eyeball by eyelashes causes constant lacrimation and irritation of the conjunctiva, leading to increased blepharospasm. To prevent corneal trauma, the eyelid is pulled down with a plaster for the time preceding surgery.

Treatment eyelid droop

Treatment of lower eyelid inversion involves removing a strip of skin and muscle and fixing the skin fold to the tarsal plate (Hotz technique).

Treatment of congenital entropion consists of a dosed crescentic resection of the skin and orbicularis oculi muscle, and if necessary, the resection can be supplemented by the application of eversion sutures. Congenital entropion often disappears within the first months of the child's life.

In case of cicatricial inversion, plastic surgery of the skin-muscle plate of the eyelid is required, often in combination with plastic surgery of the conjunctiva with a transplant of the patient’s own oral mucosa.

Conservative treatment is aimed at protecting the cornea from the traumatic effects of eyelashes. Bandage contact lenses are used.

Surgical treatment in mild cases is transverse tarsotomy with eyelid margin rotation. In severe cases, transplantation of missing or keratinized conjunctiva and replacement of the scarred and stretched tarsal plate with composite grafts are used.

Temporary treatment of age-related entropion includes the use of lubricants, fixation of the eyelid with a plaster, injection of CI botulinum toxin, protection with soft contact lenses. Surgical treatment is used mainly in cases of severe horizontal weakness of the eyelid.

1. Absence of horizontal weakness of the eyelids
   • transverse everting sutures that evert the eyelid provide temporary (up to several months) correction of entropion;
   • The Weis technique results in long-term remission. Its essence consists of horizontal dissection of the eyelids along the entire thickness and the imposition of everted sutures. The scar forms a barrier between the preseptal and pretarsal portions of the orbicularis oculi muscle, and the everted suture changes the tension of the lower eyelid retractors between the tarsal plate, skin and orbicularis muscle;
   • The Jones technique is used both as a primary treatment and for relapses. Tensioning the inferior eyelid retractors will create a barrier between the preseptal and pretarsal layers of the orbicularis muscle.
2. Horizontal eyelid weakness. It is necessary to perform a transverse eyelid dissection, everting sutures and horizontal eyelid shortening (Quicken technique). Severe weakness of the canthal tendon will be corrected.

Forecast

The prognosis is favorable.

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