CHAPTER I INTRODUCTION

Entropion is an inward rotation of the tarsus and eyelid margin. It may produce an ocular foreign body sensation, secondary blepharospasm, ocular discharge, epiphora, conjunctival metaplasia, superficial keratopathy, and corneal scarring. 1 The natural course of entropion is often progressive; its symptoms eventually become unremitting. Numerous corrective techniques for this anomaly are reported; many reflect the failure of earlier practitioners to appreciate this conditions pathophysiology. Multiple pathogenic factors, including tarsotendinous instability, capsulopalpebral fascia dysfunction, and preseptal orbicularis muscle override, may contribute to the anatomic basis of entropion. Surgical goals are to normalize eyelid function and appearance by determining the individual pathogenic factors present and addressing their direct surgical correction.1

CHAPTER II LITERATURES REVIEW

2.1. Anatomy of eyelids

The eyelids protect the eye from injury and excessive light by their closure The upper eyelid is larger and more mobile than the lower, and they meet each other at the medial and lateral angles. The palpebral fissure is the elliptical opening between the eyelids and is the entrance into the conjunctival sac.2

Figure 1. Cross section of the eyelids

The framework of the eyelids is formed by a fibrous sheet, the orbital septum. This is attached to the periosteum at the orbital margins. The orbital septum is thickened at the margins of the lids to form the superior and inferior tarsal plates. 2 The free lid margin is 25-30 mm long and about 2 mm wide. It is divided by the gray line (mucocutaneous junction) into anterior and posterior margins. A surgical incision through the gray line of the lid margin splits the lid into an anterior lamella of skin and orbicularis muscle and a posterior lamella of tarsal plate and palpebral conjunctiva.2

a. Anterior lamella of palpebra1,2 Skin3 The skin of the eyelids differs from skin on most other areas of the body in that it is thin, loose, and elastic and possesses few hair follicles and no subcutaneous fat. Orbicularis oculi muscle The function of the orbicularis oculi muscle is to close the lids. Its muscle fibers surround the palpebral fissure in concentric fashion and spread for a short distance around the orbital margin. Some fibers run onto the cheek and the forehead. The portion of the muscle that is in the lids is known as its pretarsal portion; the portion over the orbital septum is the preseptal portion. The segment outside the lid is called the orbital portion. The orbicularis oculi is supplied by the facial nerve. The submuscular areolar tissue that lies deep to the orbicularis oculi muscle communicates with the subaponeurotic layer of the scalp The anterior margin structures also involve eyelashes, glands of zeis, glands of moll. The eyelashes project from the margins of the eyelids, dont have erector pilli muscles and are arranged irregularly. The upper lashes are longer and more numerous than the lower lashes and turn upward; the lower lashes turn downward. The skin of the eyelids differs from skin on most other areas of the body in that it is thin, loose, and elastic and possesses few hair follicles and no subcutaneous fat. Glands of Zeis are small, modified sebaceous glands that open into the hair follicles at the base of the eyelashes. Glands of Moll are modified sweat glands that open in a row near the base of the eyelashes.
1,2

b. Posterior lamella of palpebra Tarsal plate

The lateral and medial angles and extensions of the tarsal plates are attached to the orbital margin by the lateral and medial palpebral ligaments. The upper and lower tarsal plates are also attached by a condensed, thin fascia to the upper and lower orbital margins. The tarsal glands are embedded in the posterior surface of the tarsal plates. Palpebral Conjunctiva The lids are lined posteriorly by a layer of mucous membrane, the palpebral conjunctiva, which adheres firmly to the tarsal plates. A surgical incision through the gray line of the lid margin (see below) splits the lid into an anterior lamella of skin and orbicularis muscle and a posterior lamella of tarsal plate and palpebral conjunct iva.

The posterior lid margin is in close contact with the globe, and along this margin are the small orifices of modified sebaceous glands (meibomian, or tarsal, glands). Pucta lacrimalis located at the medial end of the posterior margin of the lid, a small elevation with a central small opening can be seen on the upper and lower lids. The puncta serve to carry the tears down through the corresponding canaliculus to the lacrimal sac.

The palpebral fissure is the elliptic space between the two open lids. The fissure terminates at the medial and lateral canthi. The lateral canthus is about 0.5 cm from the lateral orbital rim and forms an acute angle. The medial canthus is more elliptic than the lateral canthus and surrounds the lacrimal lake. 1 Two structures are identified in the lacrimal lake: the lacrimal caruncle, a yellowish elevation of modified skin containing large modified sweat glands and sebaceous glands that open into follicles that contain fine hair ; and the plica semilunaris, a vestigial remnant of the third eyelid of lower animal species. 1 In the Asian population, a skin fold known as epicanthus passes from the medial termination of the upper lid to the medial termination of the lower lid, hiding the caruncle. Epicanthus may be present normally in young infants of all races and disappears with development of the nasal bridge but persists throughout life in Asians.
1

2.2. Entropion

2.2.1. Definition Entropion is an inward rotation of the tarsus and eyelid margin. May be involutional (spastic, senile), cicatricial, or congenital 1,2 Involutional entropion always affects the lower lid and is the result of a combination of laxity of the lower lid retractors, upward migration of the preseptal orbicularis muscle, and buckling of the upper tarsal border.3 Cicatricial entropion may involve the upper or lower lid and is the result of conjunctival and tarsal scar formation. It is most often found with chronic inflammatory diseases such as trachoma.3 Congenital entripion is rare and should not be confused with congenital epiblepharon, which usually afflicts Asians. In congenital entropion, the lid margin is rotated toward the cornea, whereas in epiblepharon, the pretarsal skin and muscle cause the lashes to rotate around the tarsal border.3

2.2.2. Epidemiology Involutional entropion is the most common and by definition occurs as a result of aging. The prevalence of involutional entropion was 2.1% (1.9% in men and 2.4% in women), slightly higher in women.

2.2.3. Etiology and Pathophysiology 3,4,5,6,7 The lower eyelid is acted upon in four directions away from the globe or outwards, towards the globe or inwards, superiorly and inferiorly. Forces which push the eyelid outward include gravity, the lower eyelid retractors, and the eyeball itself. Forces pulling the eyelid towards the eyeball include the canthal tendons and the orbicularis muscle. Forces elevating the eyelid include the orbicularis, while forces pulling the eyelid down include gravity and the lower eyelid retractors. Normal eyelid position is accomplished when these forces are in balance.

a. Congenital entropion Congenital entropion typically effects the upper eyelid and results from structural defects in the tarsal plate, shortened posterior lamellae (tarsal plate and conjunctiva), or eyelid retractor dysgenesis. The current hypothesized pathophysiology is that in congenital lower eyelid entropion both the anterior and posterior attachments of the capsulopalpebral fascia are dysfunctional. This accounts for the poorly formed lower lid skin crease in addition to the inward tarsal rotation in affected children. Hypertrophic changes in the skin and underlying orbicularis muscle in the medial part of the childs eyelid are common. Unlike epiblepharon, congenital entropion does not resolve spontaneously and requires prompt surgical intervention. A rare form of congenital upper eyelid entropion is known as the horizontal tarsal kink syndrome. In this condition, a fixed right-angled inward rotation of the tarsal margin causes apposition of the eyelid margin to the ocular surface and results in early and severe corneal complications. The cause of this variant remains speculative b. Involutional entropion Aging changes affect all the lid structures, and entropion results from a number of anatomic factors, including : increased horizontal lid laxity The causes of the excessive horizontal length of the eyelid, which is thought to be secondary to laxity of the medial and lateral canthal tendons, may be collagen degeneration and elastosis of the tarsal plate and canthal tendons attenuation or disinsertion of lower lid retractor overaction of the orbicularis muscle smaller than age average tarsal plate. tarsal plates may have a general tendency to atrophy or shrink with age. Entropion results from the mechanical effect of an atrophied or smaller than age-normal, partially

or fully disinserted, tarsal plate being overcome by the normal or increased tone of the preseptal/pretarsal orbicularis muscle c. Spastic entropion Spastic entropion occurs secondarily to neurologic, inflammatory or irritative processes of the eyelids. Blepharospasm and involutional changes following surgery are among the common sources. d. Cicatricial entropion Anything that causes a shortening or loss of the conjunctiva and posterior lamella of the eyelid can cause inward rotation of the eyelid margin and create a cicatricial entropion. It is often associated with trichiasis (misdirected eyelashes from anterior lamella), distichiasis (abnormal lashes originating from the meibomian gland orifices in the posterior lamella). In the more severe cases, it may also be associated with symblepharon (adhesion between conjunctival surfaces), ankyloblepharon (fusion of the eyelids by skin webs), and epidermalization (keratinization of the lid margin). Common conditions that may contribute to cicatricial entropion include previous eyelid surgery, chronic allergy, trauma, chemical burns, infection, trachoma, Stevens-Johnson syndrome, ocular cicatricial pemphigoid, radiation, Sjgrens syndrome, anophthalmia 2.2.4. Sign and Symtomps 1,3 a. Symtomps : persistent tearing, discharge, foreign body sensation, and blurred vision. In acute spastic symtomps may be periodic b. Sign: inward turning of eyelid and eyelashes, horizontal lid laxity (Snap-back test,eyelid distraction test); overriding preseptal orbicularis; enopthalmus; conjunctival injection; keratopathy. 2.2.5. Differential Diagnosis 1 a. Distichiasis Distichiasis refers to an accessory row of cilia arising from the meibomian gland orifices. It may occur in an autosomal dominant inheritance pattern. The tarsal plate in distichiasis manifests a normal position and orientation. It is the eyelash follicles that emerge from an abnormal position, the result of metadifferentiation of the primary epithelial germ cells originally intent upon meibomian gland development. The lashes are directed posteriorly toward the ocular surface and may not become symptomatic until about 5years of age b. Epiblepharon

In epiblepharon, a horizontal fold of redundant pretarsal skin and orbicularis muscle extends beyond the eyelid margin and compresses the eyelashes against the globe. The condition is usually bilateral, prevalent in Asian populations, and commonly involves the lower lid. Some patients demonstrate the clinical findings at all times, whereas others are symptomatic only in downgaze. Although both epiblepharon and congenital entropion result from lower eyelid retractor defects, their clinical presentation and course contrast sharply. Nearly 80% of children who show epiblepharon have no ocular complaints.The condition frequently resolves with the normal vertical growth of the facial bones c. Trichiasis an acquired condition in which cilia arising from their normal anterior lamellar position are misdirected toward the ocular surface. This usually results from inflammatory disruption and scarring of the eyelash follicles. The underlying inflammation may involve both eyelid lamellae and produce a coexistent entropion

2.2.6. Treatment Surgery is the best way to achieve long-lasting correction. Congenital entropion does not improve spontaneously and must be corrected surigicallny by reattaching the capsulopalpebral fascia to the inferior border of the tarsus on the lower lid. Treatment of involutional entropion is directed toward correcting the underlying pathophysiologic factors. Some of the treatment measures include full thickness marginal rotaion sutures, tightening of the horizontal lid and reattachment of the capsulopalpebral fascia. Basic procedure to correct cicatrical entropion is the transverse blepharotomy described by Wies, this result in fracturing the tarsus with eversion of the margin. Treatment option for acute spastic entropion include taping of the eyelid, cautery, botulinum toxin injection to the orbicularis oculi muscle and various suture techniques. Temporizing methods: lubricating oinment, antibiotic, soft bandage contact lens, taping the lower eyelid awat from the globe and epilation. 9

2.2.7. Complication Complications are primarily related to corneal damage and can involve corneal breakdown, ulcer formation, epiphora, and pain. Surgical complications may include bleeding, hematoma, infection, wound dehiscence, pain, and poor positioning of the tarsal strip.1,9

2.2.6. Prognosis Entropion surgery often has a poorer outcome than ectropion surgery and more recurrences. Frequency of surgical failure can be greatly reduced by carefully looking at the etiology of the entropion. Augmentation with botox injection for overacting orbicularis, augmentation with a spacer graft for patients with short posterior lamellae, and reinsertion of inferior retractors all can be helpful, either singly or in combination. 9

CHAPTER III CASE

3.1. Patients Identity Name : Ny. S Sex : Female Age : 53 years old Address : Kompleks Batara Indah I BK D/3 Job : Civil Servant Ethnic : Melayu Religion : Islam

3.2. Chief Complaint : eyelashes on lower eyelid of both eyes grow inward toward the eye

3.3. History of Disease : The patient complaint that her lower palpebrass eyelashes grow toward the eye surface on both eyes causing red eye, watery discharge and foreign body sensation. She has had this condition since she was young and often had her eyelashed removed. Years ago she visited an opthalmologist and was suggested to undergo a surgery for her condition but she refused. She came again to the opthalmologist because she was afraid that her condition would be worse and damage her eyes.

3.4. Family history : None of her family have the same complaint

3.5. Physical Assessment General condition : good Awareness Vital Signs: Heart Rate Respiration freq. Blood Pressure Temperature : 80x/minute : 18x/minute : 130/80 mmHg : 36,7oC : E4V5M6 (CM)

3.6. Ophthalmological status

3.7. Resume The patient complaint that her lower palpebrass eyelashes grow toward the eye surface on both eyes causing red eye, watery discharge and foreign body sensation. She has had this condition since she was young and often had her eyelashed removed. Years ago she visited an opthalmologist and was suggested to undergo a surgery for her condition but she refused. She came again to the opthalmologist because she was afraid that her condition would be worse and damage her eyes. None of her family have the same complaint

In the physical examination, patients blood pressure was 130/80 mmHg, prehypertension state, the pasient also have a history of hypertension. Visual acuity in OD : 6/60; OS: 6/12f. There was Internal rotation of lower tarsus and eyelid margin on both eyes. There were also mild conjungtival injection, watery discharge and multiple small yellow nodules on upper and lower palpebra conjungtiva . The cornea of both eyes are clear on loop examination. Iris and pupil look normal. Depth of COA of both eye are normal.

3.8. Diagnose Working Diagnose: OD : entropion, lithiasis OS : entropion, lithiasis

3.8. Plan for examination Slit lamp with flouroscens

3.9. Treatment Blepharoplasty Medicamentous: - cendoliters - kloramfenikol salep - vit. A - vit B6

3.10.Prognosis : OD/OS : dubia et bonam

CHAPTER IV DISCUSSION

A woman, 53 years old The patient complaint that her lower palpebrass eyelashes grow toward the eye surface on both eyes causing red eye, watery discharge and foreign body sensation. This condition had happened sinced she was young and she often had her eyelashes removed. In the physical examination . There was Internal rotation of lower tarsus and eyelid margin on both eye refer to the diagnosis of entropion . There were also some eyelashes grow in the posterior lamella and may be disthiasis . The multiple small yellow nodules found on upper and lower palpebra conjungtiva on both eye may be lithiasis. Because of chronic history, the patient has a high risk for corneal complication and need further examination on her cornea by flouroscens. Surgery is the best way to achieve long-lasting correction. Temporizing methods include lubricating oinment, antibiotic, soft bandage contact lens, taping the lower eyelid away from the globe and epilation

CHAPTER V CONCLUSION

The diagnosis of the patients is Entropion ocular dexter et sinister. The patient was suspected to have disthiasis and ocular lithiasis too on both eyes. The treatment of the patient include surgery epilation, and medicamentous

REFFERENCES
1

James W. Gigantelli. Entropion. In Yanoff & Duker: Ophthalmology, 3rd ed. Yanoff, M., et al. (Edt). China: Mosby. 2008

Sullivan, John H. Lids. In Vaughan & Asbury's General Ophthalmology, 17th Edition (Paul R.E and John P.W., edt.) 2007 The McGraw-Hill Companies

Pikinien, Raimonda. Eyelid malposition: lower lid entropion and ectropion. Medicina (Kaunas) 2006; 42(11)

Kocaoglu FA, Katircioglu YA, Tok OY, Pulat H, Ornek F. The histopathology of involutional ectropion and entropion. Can J Ophthalmol. 2009 Dec;44(6):677-9. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20029486

Damasceno RW, Osaki MH, Dantas PE, Belfort R Jr. Involutional ectropion and entropion: clinicopathologic correlation between horizontal eyelid laxity and eyelid extracellular matrix. Ophthal Plast Reconstr Surg. 2011 Sep-Oct;27(5):321-6. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21490515

Mounir Bashour and Harvey, J. Causes of Involutional Ectropion and Entropion-Age-Related Tarsal Changes Are the Key. Ophthalmic Plastic & Reconstructive Surgery: March 2000 - Volume 16 Issue 2 - pp 131-141. Available at: http://journals.lww.com/oprs/Abstract/2000/03000/Causes_of_Involutional_Ectropion_and.8.a spx

Bernardino, C. Robert. Approaches to the Malpositioned Lower Lid. 2008. Available at: http://www.revophth.com/content/d/plastic_pointers/c/23014/

Sowka, J.W., Andrew, S.G., Alan, G.K. Handbook of Ocular Disease Management. 2001 Jobson Publishing L.L.C. Available at: http://legacy.revoptom.com/handbook/SECT8a.HTM

Bashour, Mounir. Lower Eyelid Reconstruction, Entropion Treatment & Management. Available at http://emedicine.medscape.com/article/877281