A lower eyelid entropion is an eyelid malposition in which the lower eyelid margin is turned inwards against the globe causing discomfort from contact between the eyelashes and the surface of the eye. An entropion is usually involutional (age-related) and the majority are therefore seen in older patients. An upper eyelid entropion is seen very infrequently in the UK.
In the case of an acute spastic entropion, the treatment is directed to the provoking stimulus e.g. in growing eyelashes, blepharitis, dry eye. Although a bandage contact lens or botulinum toxin injections may improve symptoms temporarily, these are rarely justified. The use of lower lid tape can be advised for use in primary care while the patient is waiting to be seen by an ophthalmologist.
The surgical procedures that are commonly used to manage this eyelid problem are:
- Lower lid everting sutures
- Lower lid retractor advancement with a lateral tarsal strip procedure
These procedures are usually performed under local anaesthesia with or without mild sedation (“twilight anaesthesia”).
Everting sutures are offered to all older patients at the initial consultation and are used exclusively for the following patients:
- Elderly patients with concomitant medical problems for whom surgery is contraindicated
- Patients with a severe bleeding tendency e.g. patients taking warfarin
- Patients unable to co-operate with surgery
- Patients who are unable to lie in a semi-recumbent position e.g. due to breathing difficulties.
Everting sutures have been commonly regarded as a temporary form of treatment but many patients achieve a permanent result with the sutures alone. If the entropion recurs they are offered a repeat procedure or a more definitive surgical procedure. The sutures are very quick and simple to insert in a clinic setting and provide instant relief for the patient.
For all other patients, a lower eyelid retractor advancement combined with a lateral tarsal strip procedure is performed in the operating theatre. This is a very convenient operation for the patient as no sutures need to be removed. It does, however, leave a sore tender lumpy area at the outer corner of the lower eyelid for a few weeks before this settles.
These procedures can be performed under local anaesthesia on a day case basis. Most patients, however, prefer “twilight anaesthesia”.
You will visit the clinic to have a preoperative consultation. This usually lasts 30 minutes. You will be asked to complete a healthcare questionnaire, providing information about your current and past health, about any previous eye, eyelid or facial surgery or treatments including refractive surgery or laser eye surgery. We need to know if you have a past history of any eye problems e.g. dry eyes, or if you use contact lenses. We need to know about any allergies you may have, medications you are taking (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements), previous major surgery or illnesses, any past dermatology history and whether or not you smoke. You will have your blood pressure checked by the nurses at the clinic.
The nurses are also happy to answer any further questions and to show you the facilities at Face & Eye, including the operating theatre if it is not in use.
If you are unsure of the names of any medications, bring them with you.
You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure as long as these are not medically essential. You might need to check this with your GP. Any anti-inflammatory medicines e.g. Ibuprofen, Nurofen should be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. You will be given a leaflet advising you on what medications, foods, and vitamin supplements to avoid prior to surgery. Your blood pressure should also be under good control if you take medications for hypertension. This is very important.
Your vision in each eye will be measured. Your eyes will be examined carefully using a slit lamp (a special ophthalmic microscope). Your tear film status is determined and the back of the eyes (called the retina) is examined as well as the eyelids themselves. The rest of your face is then examined. Photographs of your face and eyelids will be taken before surgery so that the results of surgery can be compared with your original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.
Some insurance companies request copies of preoperative photographs.
The risks and potential complications of surgery should be considered but these need to be kept in perspective. Complications in the hands of a trained and experienced oculoplastic surgeon are very rare and all precautions are taken to minimize any risks.
What are the possible complications of entropion surgery?
Most complications of entropion surgery are amenable to successful treatment.
Complications from entropion surgery include:
- Blurred or double vision, lasting mainly for a few hours, and sometimes up to a day or two after surgery. This may occur for several reasons – ointment put in the eyes immediately after the operation, local anaesthetic used in the operation. If blurring persists for longer than 48 hours, it is important to inform your surgeon.
- Injury to the surface of the eyeball (a corneal abrasion) that causes persistent pain. If the pain lasts longer than a few hours after the operation, the surgeon must be informed. Such a problem is extremely rare in the hands of an oculoplastic surgeon. Such a problem is treated with antibiotic ointment. Sometimes a “bandage” contact lens needs to be used.
- Bleeding. A collection of blood around the eyelids or behind the eyeball, is called a haematoma. This can very rarely lead to loss of vision, including blindness. A haematoma usually needs to be drained in the operating theatre
- Infection. An infection following this surgery is extremely rare but it is important to follow postoperative wound care instructions to help to prevent such a problem. These should be given to you in writing for you to take home following surgery.
- Asymmetry. It is impossible for any surgeon to achieve perfect symmetry although an oculoplastic surgeon strives to achieve this. Tightening of the lower eyelid on one side can give an asymmetical pulled up look to the operated eyelid but this usually settles as the tissues relax over time.
- Overcorrection. This can result in an ectropion (an out-turning of the eyelid). This is usually mild and if this occurs it tends to settle with some supportive massage to the lower eyelid. Sometimes further surgery is required to correct this.
- Scarring or thickening of a skin graft if this is required. Most eyelid wounds heal with scars that are barely perceptible although full maturation of the wounds can take some months. Poor scarring can follow infection or wound disruption but this is very rare. Poor scars can be treated with steroid injections or with the application of silicone gels e.g. Kelocote. Rarely, scars need to be revised surgically.
- Eyelid lumps. Lumps can very occasionally occur as a reaction to sutures used to close the wounds. These usually resolve with time but occasionally steroid injections are required. A tender lump can appear after ectropion surgery at the outer corner of the eyelids near the bony rim of the eye socket. This usually settles after a few weeks.
- Reoperation. Further surgery within the first few weeks to address any asymmetries may be required. This should be borne in mind. There are a number of factors beyond a surgeon’s control, which can have an impact on postoperative progress e.g. postoperative swelling affecting one side more than the other, which in turn can necessitate re-intervention.
After surgery, the eye is initially covered with pressure dressings for approximately half an hour to reduce postoperative swelling and the wounds are treated with antibiotic ointment. The dressing is then removed and replaced with cool packs. Activity is restricted for 2 weeks to prevent bleeding.
You will be asked to clean the eyelids very gently using clean cotton wool and Normasol (sterile saline) or cooled boiled water and repeat the application of antibiotic ointment (usually Chloramphenicol or Soframycin) to the wounds 3 times a day for 2 weeks. The sutures used are dissolvable but are usually removed in clinic after 2 weeks.
A realistic period of recovery must be expected. Postoperative bruising usually takes at least 2-3 weeks to subside completely. Swelling takes much longer. Most of the swelling disappears after 3-4 weeks but this can vary considerably from patient to patient as does the extent of the swelling. The final result is not seen for at least 3-4 months. This should be taken into consideration when scheduling the operation. You should arrange this surgery after holiday periods or important professional or social events and not before so that you are available for postoperative review and just in case any surgical adjustments are required.
You are advised to sleep with the head raised approximately 30 degrees. It is preferable to raise the head of the bed if possible.
Contact lenses should not be worn for a few weeks following this type of surgery.