For the most benign form of entropion where there is incompetence of the lid retractors, all that is required are everting sutures. These can be 4/0 catgut double-armed sutures. It is possible to gain a similar
effect using 6/0 gauge sutures. Three sutures per lid are average (Figure 4.6). Care must be taken that the most medial suture is not over tightened as this may well cause punctal ectropion, creating epiphora where none existed before. Excessive secondary ectropion causing excessive exposure of the conjunctiva allows secondary keratinisation of the epithelium.
The ideal position post operatively is a lid margin which approximates the cornea. The sutures should create a deep crease on downgaze indicating that the lid retractors have been re-attached to the anterior lamella. Everting sutures, although used alone, can also be part of more elaborate procedures. If they are used alone the effect can only be guaranteed for about eighteen months to two years. Should the lid display not only incompetence of lid retractors but laxity at canthal ligaments or even distortion of the tarsal plate, then further surgery is required concentrating on these main areas. Distortion of the tarsal plate will require either direct shortening or dissection of excessive fibrosis. Laxity of the canthal ligaments requires some form of support or excision and shortening of the tissue, particularly at the junction between canthal ligament and tarsal plate. Care must be taken not to excessively shorten the lid or canthal ligaments, as this will prevent the lid from rising to its normal level and may well create a degree of overexposure of the inferior corneal limbus. Specific procedures that incorporate these principles for the lower lid are as follows:
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