Ophthalmologists, oculoplastic surgeons, facial plastic surgeons, and plastic surgeons are all qualified to perform these repairs.

The patient should have been properly examined before surgical intervention and deemed appropriate for surgery by an ophthalmologist or surgeon trained in oculoplastic procedures. The patient needs to be educated about the associated risks and benefits of the intervention, including alternative therapies available. All possible complications should be discussed. Lastly, all questions from the patient should be answered.

Internal Approach with Tarsal Strip for Involutional Entropion Repair

The patient is prepped and draped in the usual sterile, full-face preparation. A corneal shield is placed in the affected eye. A No. 15 Bard-Parker blade is used to make a 3 mm to 4 mm incision in the lateral canthal angle. The lateral canthal tendon and inferior crus are then disinserted. A tarsal strip is then created using Westcott scissors and 0.5 forceps. Hemostasis is maintained with cautery. A 4-0 silk traction suture is placed through the lash line or grey line of the lower lid. The lid is then everted. An incision in the conjunctiva below the inferior tarsal border from the lateral canthus (immediately lateral to the punctum) is made. Dissection is continued toward the inferior orbital rim with a 0.5 forceps and Westcott scissors. The orbital fat is dissected to expose the lower lid retractors while maintaining hemostasis. The retractors are then dissected free from the conjunctiva. A 6-0 Vicryl suture is passed through the inferior, anterior portion of the tarsus. It is then passed through the lower lid retractors beneath the conjunctiva toward the globe, advancing them onto the anterior, inferior tarsus. Sutures are then placed across the lower lid. The sutures induce appropriate eversion of the eyelid without displacing the puncta. Additionally, a 5-0 Vicryl suture is passed in a whipstitch fashion through the anterior and posterior tarsus of the lid. The suture is then passed through the periosteum at the lateral orbital rim. The suture is temporally tightened to assess the lid position. Once appropriate. A buried, interrupted 6-0 Vicryl suture is passed from gray line to gray line, upper to lower lid, to reform the lateral canthal angle. The 5-0 Vicryl suture is tied down. The orbicularis is closed with a 6-0 Vicryl in a buried, interrupted method. The skin incision is closed using simple, interrupted 6-0 plain gut sutures. Antibiotic ophthalmic ointment should be applied to the eye and all suture sites.

External Approach for Involutional Entropion Repair

The patient is prepped and draped in the usual sterile, full-face preparation. A corneal shield is placed in the affected eye. Attention is turned to the affected lower lid. A 4-0 silk traction suture is placed through the lash line or grey line of the affected lid. A surgical marking pen is used to mark an incision at the inferior border of the tarsus from the puncta to the lateral canthus. A #15 Bard-Parker blade is used to make a skin incision at the marking. The assistant then elevates the inferior portion of the incision with a lacrimal rake while caudally tractioning the cheek tissue. Dissection is continued toward the inferior orbital rim using 0.5 forceps and Westcott scissors. The orbital septum is opened, and the preaponeurotic fat identified. The fat is dissected to expose the lower lid retractors. Hemostasis is maintained with cautery. The retractors are then dissected free from the conjunctiva for 5-10mm. A 6-0 Vicryl suture is passed through the inferior, anterior portion of the tarsus. It is then passed in a buried fashion through the lower lid retractors advancing them onto the inferior tarsus. Three to four such sutures are placed an equidistance across the affected lower eyelid. This should cause appropriate eversion of the eyelid without displacing the puncta from the proper position. The skin incision is then closed using simple, interrupted 6-0 plain gut sutures. The corneal shield is then removed from the affected eye.  The antibiotic ophthalmic ointment is instilled into the eye and on all suture sites.

Complications include the following: hemorrhage, overcorrection, lower lid retraction, under correction, infection, wound dehiscence, scarring, corneal injury, milphosis, and eyelid margin necrosis.[8][9][10]

The clinical significance is to restore the eyelid to its proper anatomical alignment. This, in turn, protects the eye from injury and reduces associated symptoms. Management can include ocular lubrication with ointments, artificial tears, or ocular protection with contact lenses. Botulinum toxins or Quickert sutures can temporarily provide relief, but only surgical treatment provides definitive treatment.

Patients with entropion may first present to the nurse practitioner or primary care provider. Since entropion is a progressive disorder with the potential of causing injury to the cornea, it is important to refer these patients to an oculoplastic surgeon or an ophthalmologist. There are several techniques for repairing entropion, and skill and experience are required. Complications of the surgery include hemorrhage, overcorrection, lower lid retraction, under correction, infection, wound dehiscence, scarring, corneal injury, milphosis, and eyelid margin necrosis. Operating room and ophthalmology nurses assist in care and provide patient education. The outcomes for most patients are good, but a number of patients do require revision or touch-ups, and cosmesis is not always perfect.[11][12]