In the second article of this two part series, Dr Chuah Chin Tek discusses malposition of the eyelids- Entropion and Ectropion
Inturned Eyelids – Entropion
Entropion is a condition where the eyelid margin turns inwards to cause the lashes, and the margin, to rub against the eyes. It can occur both in the lower eyelids, or less commonly affect the upper eyelids.
The condition is caused mainly by involutional/ ageing changes affecting the eyelid tissues, or as a result of scarring/cicatricial changes affecting the back portion of the eyelids. Congenital entropion is a less common subtype caused by an excess of skin or the muscle around the eyelids, the orbicularis oculi.
Patients present with tearing, ocular irritation and redness or even with frequent discharge from the eyes. If not addressed, the constant rubbing can lead to a breakdown in the surface of the cornea, resulting in abrasions, or worse, corneal ulcers.
In many instances, as the condition is prevalent among the elderly who also have problems of cataract, entropion needs to be treated before such patients undergo cataract extraction procedures because a clean ocular surface is a necessary pre-requisite to reduce the risk of eye infection following cataract extraction.
Treatment consists of measures to address the root causes of the problem, for example, tightening of the
lower lid tendons or repair of the muscle that has been weakened due to age (the inferior retractor). The procedure is done under regional anaesthesia (similar to local anaesthesia except that the anaesthesia involves a wider region), almost always as a day surgery procedure.
Downtime is about a week, whereupon the sutures are removed and the patients can go back to bathing the region around the eyes.
Photos showing entropion cases
The results two weeks after operation to treat entropion, involving horizontal lid tightening for horizontal lid laxity
Epiblepharon
This is a common condition especially among Oriental children. The end result is the same as with entropion, i.e. lashes rubbing against the cornea, but the condition is actually the result of the muscle and the skin covering the eyelid (tarsal plate) overriding the eyelid margin, thereby pushing the eyelashes inwards, and not because the eyelid margin is turned inwards.
Fortunately, as the face matures and generally, elongates, this condition resolves spontaneously. Surgery is only indicated if the condition is so severe that the lashes rub against the cornea, thereby potentially developing a corneal ulcer.
Out-turned Eyelids-Ectropion
Ectropion is rarer compared to entropion. It is also caused frequently by loosening of the tendon of the lower eyelids, akin to a tennis net that is loose.
Patients present with irritation and discomfort, due to the exposure of the tarsal conjunctiva, and often look dramatically different (as the accompanying patient photos illustrate).
Treatment is directed again at the root causes of the condition with a similar downtime as entropion surgery.
This 61-year-old man was working in the restaurant business when he lost his job because the customers complained that he looked “unhygienic”. Two months after operation, his appearance has improved to an extent that he has regained his confidence – he wrote to the doctor thanking him and said the operation has given him hope to resume working at a restaurant.
Lumps and Bumps of the Eyelids
While most lesions of the eyelids are benign, it is nevertheless important not to miss the occasional malignancy. It is also important to understand the pathophysiology of the infective conditions so as to minimize future recurrence.
Stye/chalazion
At some point in our lives, we most certainly have had one of these lesions as they are one of the commonest problems affecting the eyelids, albeit a painful experience. When the infection is acute, it is a stye; but with time, the infected lesion undergoes granulomatous transformation to become a chalazion.
The condition can affect the > 20 oil glands lining the lid margin, or the oil gland situated with our eyelid hair follicles. When detected early and proper treatment instituted, one might be able to avoid having have a doctor incise and drain the lesions when the gland openings becomes irreversibly clogged. Patients can also do hot compresses with a warm towel which in many instances, will encourage the pus to spontaneously expel itself.
Stye
Photo copyright: Dr Chuah Chin Tek
Tumours of the Eyelids
Malignant tumours involving the eyelids may sometimes mimic benign lesions. Thus it is important to note that there are some signs that would alert one to the likelihood of a malignancy. They include a rapid increase in size, bleeding or ulceration.
Basal cell carcinoma is the most common eyelid malignancy, with very good outcomes following resection (see pictures showing the examples of basal cell carcinoma in Chinese patients).
Photo copyright: Dr Chuah Chin Tek
The left photo shows a naevus (benign tumour) on the right eyelid, while the right photo shows a case of basal cell carcinoma (malignant tumour); basal cell carcinoma may mimic cysts and other benign lesions
Photo copyright: Dr Chuah Chin Tek
These photos demonstrate the effects of treating basal cell carcinoma, two months after treatment, featuring full thickness wedge resection and reconstruction
Before After
Conclusion
This two-part article attempts to introduce patients to the more common oculoplastic conditions in our local context. These conditions, when dealt with in the appropriate manner, often yield highly satisfactory results.
Dr Chuah Chin Tek, medical director of The Eye & Aesthetics Clinic and Consultant at Mount Elizabeth Medical Centre, has been in practice for 17 years. He graduated MBBS (Singapore), and was admitted to the specialist register after his ophthalmology training. He sub-specialised in ophthalmic plastic and reconstructive surgery, having trained under the top oculoplastic surgeons in Singapore for two years and secured the prestigious Higher Manpower Development Plan Award to hone his skills in advanced oculoplastics surgery and management of complications of blepharoplasty in Salt Lake City, USA. Dr Chuah also holds a diploma in aesthetic medicine from the American Academy of Aesthetic Medicine and is currently practicing in Suntec City and Mount Elizabeth.