Age-Matched, Case-Controlled Comparison of Clinical Indicators for Development of Entropion and Ectropion

Journal of Ophthalmology, Mar 2014

Purpose. To analyze the clinical findings associated with involutional entropion and ectropion and compare them to each other and to age-matched controls. Methods. Prospective, age-matched cohort study involving 30 lids with involutional entropion, 30 lids with involutional ectropion, and 52 age-matched control lids. Results. The statistically significant differences associated with both the entropion and ectropion groups compared to the control group were presence of a retractor dehiscence, presence of a “white line,” occurrence of orbital fat prolapse in the cul-de-sac, decreased lower lid excursion, increased lid laxity by the snapback test, and an increased lower lid distraction. Entropion also differed from the control group with an increased lid crease height and decreased lateral canthal excursion. Statistically significant differences associated with entropion compared to ectropion were presence of a retractor dehiscence, decreased lateral canthal excursion, and less laxity in the snapback test. Conclusion. Entropic and ectropic lids demonstrate clinically and statistically significant anatomical and functional differences from normal, age-matched lids. Many clinical findings associated with entropion are also present in ectropion. Entropion is more likely to develop with a pronounced retractor deficiency. Ectropion is more likely to develop with diminished elasticity as measured by the snapback test.

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Age-Matched, Case-Controlled Comparison of Clinical Indicators for Development of Entropion and Ectropion

Age-Matched, Case-Controlled Comparison of Clinical Indicators for Development of Entropion and Ectropion Kevin S. Michels,1,2 Craig N. Czyz,1,2 Kenneth V. Cahill,2 Jill A. Foster,1,2 John A. Burns,2 and Kelly R. Everman2 1Division of Ophthalmology, Section Oculofacial Plastic and Reconstructive Surgery, Ohio University/Doctor’s Hospital, 50 Old Village Road, Columbus, OH 43228, USA 2Department of Ophthalmology, Oral and Maxillofacial Surgery, Grant Medical Center, 111 S. Grant Avenue, Columbus, OH 43215, USA Received 1 August 2013; Accepted 27 January 2014; Published 5 March 2014 Academic Editor: Edward Manche Copyright © 2014 Kevin S. Michels et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Purpose. To analyze the clinical findings associated with involutional entropion and ectropion and compare them to each other and to age-matched controls. Methods. Prospective, age-matched cohort study involving 30 lids with involutional entropion, 30 lids with involutional ectropion, and 52 age-matched control lids. Results. The statistically significant differences associated with both the entropion and ectropion groups compared to the control group were presence of a retractor dehiscence, presence of a “white line,” occurrence of orbital fat prolapse in the cul-de-sac, decreased lower lid excursion, increased lid laxity by the snapback test, and an increased lower lid distraction. Entropion also differed from the control group with an increased lid crease height and decreased lateral canthal excursion. Statistically significant differences associated with entropion compared to ectropion were presence of a retractor dehiscence, decreased lateral canthal excursion, and less laxity in the snapback test. Conclusion. Entropic and ectropic lids demonstrate clinically and statistically significant anatomical and functional differences from normal, age-matched lids. Many clinical findings associated with entropion are also present in ectropion. Entropion is more likely to develop with a pronounced retractor deficiency. Ectropion is more likely to develop with diminished elasticity as measured by the snapback test. 1. Introduction Multiple anatomical defects are believed to contribute to involutional entropion, and numerous surgical techniques have been described to correct them. The three anatomic factors most consistently described in the literature as requiring attention are lower lid retractor disinsertion, horizontal lid laxity, and orbicularis oculi muscle override [1–11]. Horizontal lid laxity, diminished orbicularis tone, and lower lid retractor disinsertion have all been implicated in the development of involutional ectropion [12–15]. The anatomic and histologic features of lower eyelid malposition have been described by numerous authors. Lower lid anatomy, including the lower lid retractors, was investigated by Jones who theorized that laxity of the retractors would allow the inferior border of tarsus to rotate outward [2]. He described lower lid retractor plication and advancement as a surgical treatment for entropion [3]. Jones [2] also postulated that lower lid retractor laxity was analogous to a levator aponeurosis dehiscence. Collin and Rathbun [16] histologically studied patients with entropion versus normal eyelids evaluating the lower lid retractors. In the entropion specimens, they found that the lower lid retractors and orbital septum only came to within 3.5 mm of the inferior border of the tarsus versus 1.5 to 2.5 mm in normal lids [16]. Additionally, a larger amount of orbital fat was present in the entropion specimens compared to the normal lids indicating a retractor dehiscence [16]. The tarsal plate has been shown to invert in entropion where the lower border rotates superiorly and anteriorly 16 degrees and the upper border rotates inward 63 degrees [17]. In some patients, the junction of the inferior border of the tarsus with the lower lid retractors has an acute angulation as compared to a normal eyelid. With inferior distraction of the eyelid, an abnormal cul-de-sac develops below the inferior tarsal border forming a “V” shaped appearance (Figures 1 and 2). We believe this indicates the presence of a retractor dehiscence or disinsertion. Additionally, the presence of a “white line” representing the retracted edge of the disinserted lower lid retractors under the palpebral conjunctiva may be visible and is referred to as a complete retractor disinsertion [18]. Figure 1: Patient with entropion of the right lower eyelid. Blue arrow demonstrates retractor dehiscence with “V” shaped junction between the retractors and the inferior border of the tarsus. Green arrow demonstrates the “white line.” Black bar indicates area of orbital fat prolapse. Figure 2: Age-matched control lower eyelid. Blue arrow points t (...truncated)


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Kevin S. Michels, Craig N. Czyz, Kenneth V. Cahill, Jill A. Foster, John A. Burns, Kelly R. Everman. Age-Matched, Case-Controlled Comparison of Clinical Indicators for Development of Entropion and Ectropion, Journal of Ophthalmology, 2014, 2014, DOI: 10.1155/2014/231487