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ENTROPION
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FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH SUMATERA UTARA MEDAN 2013
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Dengan menyebut nama Allah Yang Maha Pengasih Maha Penyayang.

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I. TUJUAN INSTRUKSIONAL UMUM


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Setelah Proses Belajar Mengajar mahasiswa mampu menegakkan diagnosa entropion dengan melakukan anamnese dan pemeriksaan sederhana yang akan dipelajari selama masa perkuliahan dengan baik dan benar .
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II. TUJUAN INSTRUKSIONAL KHUSUS


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Setelah Proses Belajar Mengajar mahasiswa mampu mengetahui tanda dan gejala , faktor resiko, prinsip pengobatan, komplikasi, dan mengkonsulkan secara garis besar dengan baik dan benar kasus-kasus entropion sesuai dengan kompetensinya
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ENTROPION
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It is inturning of the lid margin.

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CLASSIFICATION
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1. Congenital entropion. 2. Cicatricial entropion. 3. Spastic entropion. 4. Senile (involutional) entropion. 5. Mechanical entropion.

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CLASSIFICATION
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1. Congenital entropion. It is a rare condition seen since birth. It may be associated with microphthalmos. 2. Cicatricial entropion. It is a common variety usually involving the upper lid. It is caused by cicatricial contraction of the palpebral conjunctiva, with or without associated distortion of the tarsal plate. Common causes are trachoma, membranous conjunctivitis, chemical burns, pemphigus and Stevens-Johnson syndrome.
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CLASSIFICATION
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3. Spastic entropion. It occurs due to spasm of the orbicularis muscle in patients with chronic irritative corneal conditions or after tight ocular bandaging. It commonly occurs in old people and usually involves the lower lid. 4. Senile (involutional) entropion. It is a common variety and only affects the lower lid in elderly people . The etiological factors which contribute for its development are : (i) weakening or dehiscence of capsulopalpebral fascia (lower lid retractor); (ii) degeneration of palpebral connective tissue separating the orbicularis muscle fibres and thus allowing pre-septal fibres to override the pretarsal fibres; and (iii) horizontal laxity of the lid.
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CLASSIFICATION
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5. Mechanical entropion. It occurs due to lack of support provided by the globe to the lids. Therefore, it may occur in patients with phthisis bulbi, enophthalmos and after enucleation or evisceration operation.

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CLINICAL PICTURE
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Symptoms occur due to rubbing of cilia against the cornea and conjunctiva and are thus similar to trichiasis. These include foreign body sensation, irritation, lacrimation and photophobia. Signs. On examination, lid margin is found inturned. Depending upon the degree of inturning it can be divided into three grades. Grade I : only the posterior lid border is inrolled. Grade II : includes inturning up to the inter-marginal strip Grade III : whole lid margin including the anterior border is inturned.
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TREATMENT
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1. Congenital entropion requires plastic reconstruction of the lid crease 2. Spastic entropion. (i) Treat the cause of blepharospasm e.g. remove the bandage (if applied) or treat the associated condition of cornea. (ii) Adhesive plaster pull on the lower lid may help during acute spasm. (iii) Injection of botulinum toxins in the orbicularis muscle is advocated to relieve the spasm. (iv) Surgical treatment similar to involutional (senile) entropion may be undertaken if the spasm is not relieved by above methods.
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TREATMENT
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3. Cicatricial entropion. It is treated by a plastic operation, which is based on any of the following basic principles : (i) Altering the direction of lashes, (ii) Transplanting the lashes, (iii) Straightening the distorted tarsus. Surgical techniques employed for correcting cicatricial entropion are as follows: i. Resection of skin and muscle. It is the simplest operation employed to correct mild degree of entropion. In this operation an elliptical strip of skin and orbicularis muscle is resected 3 mm away from the lid margin.

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TREATMENT
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ii. Resection of skin, muscle and tarsus: It corrects moderate degree of entropion associated with atrophic tarsus. In this operation, in addition to the elliptical resection of skin and muscle, a wedge of tarsal plate is also removed (Fig. 14.19A). iii. Modified Burrows operation. It is performed from the conjunctival side after everting the lid. A horizontal incision is made along the whole length of the eyelid, involving conjunctiva and tarsal plate (but not the skin), in the region of sulcus subtarsalis (2-3 mm above the lid margin). The temporal end of the strip is incised by a full thickness vertical incision. Pad and bandage is applied in such a way that the edge of lid is kept everted till healing occurs. After healing, the lashes are directed away from the eye.

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TREATMENT
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iv. Jaesche-Arlts operation (Fig. 14.19B): The lid is split along the grey line up to a depth of 3-4 mm, from outer canthus to just lateral to the punctum. Then a 4 mm wide crescentric strip of skin is removed from 3 mm above the lid margin. After suturing the skin incision, the lash line will be transplanted high. The gap created at the level of grey line may be filled by a mucosal graft taken from the lip. v. Modified Ketsseys operation (Transposition of tarsoconjunctival wedge) (Fig.14.20): A horizontal incision is made along the whole length of sulcus subtarsalis (2-3 mm above the lid margin) involving conjunctiva and tarsal plate. The lower piece of tarsal plate is undermined up to lid margin. Mattress sutures are then passed from the upper cut end of the tarsal plate to emerge on the skin 1 mm above the lid margin. When sutures are tied the entropion is corrected by transposition of tarsoconjunctival wedge.

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TREATMENT
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4. Senile entropion. Commonly used surgical techniques are as follows: i. Modified Wheelers operation: A base down triangular piece of tarsal plate and conjunctiva is resected along with double breasting of the orbicularis oculi muscle ii. Bicks procedure with Reehs modification: It is useful in patients with associated horizontal lid laxity. In it a pentagonal full thickness resection of the lid tissue is performed. iii. Weiss operation. An incision involving skin, orbicularis and tarsal plate is given 3 mm below the lid margin, along the whole length of the eyelid. Mattress sutures are then passed through the lower cut end of the tarsus to emerge on the skin, 1 mm below the lid margin. On tying the sutures, the entropion is corrected by transpositioning of the tarsus

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CICATRICIAL ENTROPION
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SENILE ENTROPION
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REFERENCES
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American Academy of Ophthalmology, External Disease and Cornea, Section 8, 2011-2012 Khurana AK, Comprehensive Ophthalmology, Fourth Edition , New Delhi, New Age Internasional (p) Limited Publisher, 2007. Vaughan & Asbury's : General Ophthalmology 17th Edition , Mc Graw- Hills Companies , May 2007

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Segala puji bagi Allah, Tuhan semesta alam.

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