Entropion

Involutional (Age-Related) Entropion

• Horizontal lid laxity: Attenuation of medial and lateral canthal tendons with age
• Lower lid retractor dehiscence: Disinsertion of capsulopalpebral fascia from tarsal plate
• Orbicularis override: Preseptal orbicularis muscle overrides pretarsal muscle
• Enophthalmos: Loss of orbital volume reducing posterior globe support
• Most common type: Accounts for 85-90% of entropion cases

Spastic Entropion

• Acute orbicularis spasm: Triggered by ocular irritation or inflammation
• Underlying lid laxity: Pre-existing involutional changes
• Precipitating factors: Blepharitis, dry eye, conjunctivitis, recent eye surgery
• Self-perpetuating cycle: Lid inversion causes irritation, which worsens spasm

Cicatricial Entropion

• Trachoma: Most common cause worldwide; chronic Chlamydia trachomatis infection
• Ocular cicatricial pemphigoid: Autoimmune conjunctival scarring
• Stevens-Johnson syndrome: Severe mucocutaneous reaction with scarring
• Chemical burns: Acid or alkali injury to conjunctiva
• Chronic blepharitis: Posterior lamella shortening from inflammation
• Trauma or surgery: Conjunctival scarring from injury or procedures

Congenital Entropion

• Rare condition: Present at birth, more common in Asian populations
• Vertical tarsal kink: Abnormal tarsal plate folding
• Hypertrophic orbicularis: Excessive muscle bulk
• Epiblepharon overlap: Often confused with epiblepharon

Mechanical Entropion

• Enucleation: Loss of globe causing lid malposition
• Phthisis bulbi: Shrunken, atrophic eye
• Microphthalmos: Congenitally small eye

Involutional Entropion Mechanism

Three essential anatomical defects must be present:

1. Horizontal lid laxity: Elongation of canthal tendons allows lid instability
2. Lower lid retractor dehiscence: Separation of capsulopalpebral fascia from inferior tarsal border reduces downward pull on lid margin
3. Orbicularis override: Preseptal orbicularis muscle migrates upward and overrides pretarsal muscle, rotating lid margin inward

Contributing factors include enophthalmos (loss of orbital fat), which reduces posterior support for the globe, and loss of skin elasticity allowing anterior lamella redundancy.

Spastic Entropion Mechanism

• Acute orbicularis spasm: Ocular irritation triggers reflex muscle contraction
• Pre-existing laxity: Underlying involutional changes allow rotation
• Self-perpetuating: Inverted lashes irritate eye, causing more spasm
• Progression to chronic: May evolve into permanent involutional entropion

Cicatricial Entropion Mechanism

• Posterior lamella contraction: Scarring of conjunctiva and tarsus pulls lid margin inward
• Tarsal distortion: Fibrous tissue replaces normal tarsal architecture
• Fornix shortening: Loss of conjunctival depth limits lid mobility
• Progressive scarring: Chronic inflammation perpetuates contracture

Secondary Ocular Surface Changes

• Chronic mechanical trauma from misdirected lashes
• Corneal epithelial defects and erosions
• Conjunctival inflammation and keratinization
• Risk of infectious keratitis and corneal scarring
• Persistent irritation worsening orbicularis spasm

By Etiology

• Involutional (senile): Age-related changes; most common (85-90%)
• Spastic: Acute orbicularis spasm with underlying laxity
• Cicatricial: Secondary to conjunctival scarring
• Congenital: Present at birth; rare
• Mechanical: Loss of posterior globe support

By Anatomical Location

• Medial entropion: Affects inner third of eyelid
• Central (mid-lid) entropion: Middle segment involvement
• Lateral entropion: Outer third involvement
• Total entropion: Entire lower lid inverted

By Temporal Pattern

• Intermittent entropion: Occurs only with forceful lid closure or blinking
• Persistent entropion: Constant lid inversion in primary gaze

By Severity

Demographic Factors

• Advanced age: Prevalence increases significantly after age 60
• Asian ethnicity: Higher prevalence in East Asian populations
• Gender: Slight female predominance (related to longevity)

Anatomical Factors

• Deep-set eyes: Enophthalmos from orbital fat atrophy
• Lid laxity: Horizontal canthal tendon elongation
• Small palpebral aperture: Increases lid pressure on globe
• Prominent epicanthal folds: More common in Asian populations

Medical Conditions

• Chronic blepharitis: Posterior lid margin inflammation
• Dry eye disease: Ocular surface irritation triggering spasm
• Trachoma: Leading cause worldwide in endemic areas
• Ocular cicatricial pemphigoid: Autoimmune conjunctival scarring
• Stevens-Johnson syndrome: Severe mucosal scarring
• Thyroid eye disease: Orbital changes affecting lid position

Iatrogenic Factors

• Previous eye surgery: Conjunctival scarring from glaucoma or retinal surgery
• Enucleation or evisceration: Loss of globe support
• Radiation therapy: Periocular radiation causing tissue changes
• Chemical injury: Acid or alkali burns

Environmental Factors

• Trachoma endemic areas: Poor sanitation, crowding, limited access to water
• Sun exposure: Photoaging accelerating tissue degeneration
• Chronic eye rubbing: Mechanical trauma to lid structures

Eyelid Position Abnormalities

• Inward rotation of lid margin: Visible turning of lid edge toward globe
• Misdirected lashes: Eyelashes pointing toward and touching cornea
• Lid margin keratinization: Whitish appearance of inverted lid margin
• Intermittent vs. persistent: May be present only with blinking or constant

Lid Laxity Signs

• Positive snap-back test: Delayed return to normal position after manual displacement
• Positive distraction test: >8mm lid pull from globe
• Medial/lateral canthal laxity: Tendons displaced with gentle pressure
• Lower lid retractor dehiscence: Reduced inferior movement with downgaze

Corneal and Conjunctival Signs

• Inferior punctate keratopathy: Fluorescein staining in area of lash contact
• Corneal epithelial defects: Linear abrasions corresponding to lash position
• Corneal ulceration: In severe or chronic cases
• Corneal vascularization: Neovascularization in chronic cases
• Corneal scarring: Stromal opacification from chronic trauma
• Conjunctival injection: Hyperemia from chronic irritation
• Conjunctival scarring: In cicatricial entropion

Tear Film Abnormalities

• Reflex tearing: Increased tear production from irritation
• Epiphora: Overflow tearing onto cheek
• Mucoid discharge: String or crusting from chronic inflammation

Associated Findings

• Enophthalmos: Sunken eye appearance from orbital fat loss
• Dermatochalasis: Excess skin on upper or lower lids
• Chronic blepharitis: Lid margin inflammation and crusting
• Blepharospasm: Increased blinking or eye squeezing

Primary Symptoms

• Foreign body sensation: Most common complaint; persistent gritty or scratchy feeling
• Eye irritation: Burning, stinging, or sharp discomfort
• Excessive tearing (reflex epiphora): Constant wetness from corneal irritation
• Eye redness: Chronic conjunctival injection
• Photophobia: Light sensitivity from corneal involvement

Corneal-Related Symptoms

• Pain: Acute pain if corneal epithelial defect or ulcer present
• Blurred vision: From irregular tear film, epithelial defects, or scarring
• Fluctuating vision: Varies with blinking and tear film
• Decreased vision: If central corneal scarring develops

Chronic Symptoms

• Mucoid discharge: String or crusting, worse in morning
• Chronic discomfort: Persistent low-grade irritation
• Recurrent infections: Repeated episodes of conjunctivitis or keratitis
• Morning crusting: Lids stuck together upon awakening

Behavioral Symptoms

• Increased blinking: Reflex attempt to clear foreign body sensation
• Eye rubbing: Trying to relieve discomfort (worsens condition)
• Squinting: Protective mechanism against irritation
• Manual lid eversion: Patients may pull lid outward for temporary relief

Quality of Life Impact

• Sleep disturbance: Nocturnal symptoms and morning crusting
• Reading difficulty: Blurred or fluctuating vision
• Driving problems: Photophobia and visual disturbance
• Work impairment: Difficulty with tasks requiring clear vision

Corneal Complications

• Punctate keratopathy: Superficial corneal epithelial damage
• Corneal abrasions: Recurrent epithelial defects from lash trauma
• Corneal ulceration: Infectious or sterile ulcers; may be sight-threatening
• Bacterial keratitis: Secondary infection of damaged epithelium
• Corneal vascularization: Neovascularization in chronic cases
• Corneal scarring: Permanent stromal opacification; may affect vision
• Corneal perforation: Rare but catastrophic complication
• Irregular astigmatism: From corneal surface irregularity

Conjunctival Complications

• Chronic conjunctivitis: Persistent inflammation and injection
• Conjunctival scarring: Subepithelial fibrosis in chronic cases
• Papillary conjunctivitis: Giant papillae formation
• Symblepharon: Adhesion between bulbar and palpebral conjunctiva (cicatricial cases)

Visual Complications

• Decreased visual acuity: From central corneal scarring
• Permanent vision loss: In severe cases with corneal perforation or dense scarring
• Glare and halos: From irregular corneal surface
• Contrast sensitivity loss: From corneal changes

Surgical Complications

• Recurrence: Return of entropion after surgery (5–20% with combined retractor reinsertion approaches; up to 30–40% with everting sutures alone — see surgical options below)
• Overcorrection: Ectropion from excessive lid tightening
• Lid retraction: Abnormal lid position from vertical shortening
• Lagophthalmos: Incomplete lid closure
• Canthal dystopia: Abnormal canthal angle or position
• Granuloma formation: At suture sites
• Wound dehiscence: Suture breakdown
• Infection: Postoperative wound infection

Psychosocial Complications

• Quality of life reduction: Chronic discomfort affecting daily activities
• Depression or anxiety: From chronic symptoms and visual impairment
• Social withdrawal: Embarrassment from tearing and redness
• Occupational impact: Inability to work requiring good vision

Autoimmune Associations

• Ocular cicatricial pemphigoid: Chronic progressive autoimmune disease causing conjunctival scarring
• Stevens-Johnson syndrome: Severe mucocutaneous reaction to medications or infections
• Toxic epidermal necrolysis: Life-threatening skin condition
• Linear IgA disease: Autoimmune blistering disorder

Infectious Diseases

• Trachoma: Chlamydia trachomatis; leading infectious cause worldwide
• Herpes zoster ophthalmicus: Can cause cicatricial changes
• Chronic blepharitis: Staphylococcal or seborrheic

Dermatological Conditions

• Atopic dermatitis: Chronic eczema affecting periocular skin
• Rosacea: Can cause chronic lid margin inflammation
• Psoriasis: May affect eyelid skin

Endocrine Disorders

• Thyroid eye disease: Orbital changes may affect lid position

Trauma and Surgery

• Chemical burns: Acid or alkali injury causing conjunctival scarring
• Thermal burns: Heat injury to periocular tissues
• Previous ocular surgery: Glaucoma filtering surgery, retinal detachment repair
• Radiation therapy: Periocular radiation for malignancies

No Direct Systemic Complications

Entropion itself does not cause systemic health problems. However, it may be a manifestation of underlying systemic disease (autoimmune conditions, infections) that requires appropriate medical evaluation and management. Severe corneal complications may require systemic antibiotics or immunosuppression.

Clinical Diagnosis

Diagnosis is primarily clinical, based on characteristic examination findings:

• Visible lid inversion: Inward rotation of lid margin toward globe
• Misdirected lashes: Eyelashes contacting cornea or conjunctiva
• Corneal staining pattern: Fluorescein uptake corresponding to lash contact area
• Intermittent vs. constant: May require forced lid closure to elicit

Patient History

• Age and symptom onset
• Chief complaint: foreign body sensation, pain, tearing, redness
• Duration and progression of symptoms
• Previous eye conditions or surgeries
• History of trauma, burns, or infections
• Systemic diseases (autoimmune, dermatological)
• Travel to trachoma-endemic areas
• Previous treatments attempted

Physical Examination

Etiology Classification

Determine underlying cause to guide treatment:

• Involutional: Horizontal lid laxity, retractor dehiscence, enophthalmos
• Spastic: Acute onset with ocular irritation or inflammation
• Cicatricial: Conjunctival scarring, shortened fornices, tarsal distortion
• Congenital: Present from birth or early childhood
• Mechanical: Associated with enucleation, phthisis, or microphthalmos

Ancillary Testing

• Photography: Document lid position and severity for surgical planning
• Corneal topography: If irregular astigmatism suspected
• Conjunctival biopsy: If autoimmune disease suspected (cicatricial pemphigoid)
• Orbital imaging (CT/MRI): If enophthalmos or orbital pathology suspected

Diagnostic Criteria

Conservative (Non-Surgical) Management

Temporary measures for mild cases, spastic entropion, or when surgery is contraindicated:

Surgical Management

Definitive treatment for most cases. Choice of procedure depends on etiology and anatomical defects.

Surgical Considerations

• Anesthesia: Local with or without sedation for most procedures
• Bilateral surgery: Often performed if both eyes affected
• Combined procedures: Address multiple anatomical defects simultaneously
• Recovery time: 2-4 weeks for most procedures

Postoperative Care

• Ice compresses: First 48 hours to reduce swelling
• Head elevation: Sleep with head elevated for 1 week
• Topical antibiotic ointment: To incision sites 3-4 times daily
• Lubricating drops: Continue for ocular surface protection
• Activity restriction: Avoid heavy lifting, bending, straining for 2 weeks
• Suture removal: 1-2 weeks postoperatively (if non-absorbable)
• Follow-up: 1 week, 1 month, 3 months, 6 months

Management Algorithm

Natural History

• Progressive condition: Involutional entropion typically worsens over time without treatment
• Rarely self-resolves: Spastic entropion may improve if underlying cause treated
• Complications increase with duration: Risk of corneal damage rises with chronic untreated entropion
• Self-perpetuating cycle: Lid inversion causes irritation, worsening spasm and inversion

Surgical Outcomes

• High success rate: 90-95% with appropriate surgical technique (lateral tarsal strip + retractor reinsertion)
• Symptom resolution: Immediate relief from foreign body sensation and irritation
• Corneal healing: Epithelial defects typically heal within days postoperatively
• Recurrence rate: 5-15% for involutional entropion; higher for cicatricial (20-30%)
• Patient satisfaction: Excellent in majority of cases

Factors Affecting Prognosis

Long-Term Outcomes

• Durable correction: Most patients maintain good lid position long-term
• Quality of life improvement: Dramatic reduction in symptoms
• Visual outcomes: Excellent if treated before corneal scarring
• Revision surgery: May be needed in 5-15% of involutional cases
• Aging changes: Continued facial aging may cause recurrence after many years

Vision Prognosis

• Uncomplicated cases: Excellent visual prognosis with timely treatment
• Corneal abrasions without scarring: Full recovery expected
• Peripheral corneal scarring: Minimal visual impact
• Central corneal scarring: May result in permanent visual impairment
• Severe complications: Corneal perforation or dense scarring may require keratoplasty

Overall Prognosis

1. Epiblepharon

2. Trichiasis

• Definition: Misdirected lashes pointing toward cornea
• Difference from entropion: Lid margin position normal; only lashes misdirected
• Common causes: Chronic blepharitis, trachoma, trauma
• Management: Epilation, electrolysis, or surgery

3. Distichiasis

• Definition: Extra row of lashes growing from meibomian gland orifices
• Difference: Normal anterior lash row present; posterior row abnormal
• Can be congenital or acquired: After chronic blepharitis
• Management: Epilation, cryotherapy, or follicle destruction

4. Ectropion

• Definition: Outward eversion of eyelid margin
• Opposite of entropion: Lid turns away from globe vs. toward globe
• Symptoms: Tearing, exposure, but not foreign body sensation from lashes
• Management: Surgical correction addressing horizontal laxity

5. Pseudotrichiasis

• Definition: Normal lashes displaced toward cornea by cicatricial process
• Cause: Scarring from trauma, surgery, or inflammation
• Difference from entropion: Lid margin itself not inverted
• Management: Depends on underlying cause and severity

6. Blepharospasm

• Definition: Involuntary eyelid muscle spasm
• Presentation: Forceful lid closure; may cause transient entropion
• Difference: Primary problem is spasm, not lid malposition
• Management: Botulinum toxin injections

7. Floppy Eyelid Syndrome

• Definition: Extremely lax, rubbery eyelids that easily evert
• Relationship: May coexist with or predispose to entropion
• Key features: Upper lid involvement, association with sleep apnea
• Management: Treat sleep apnea; consider surgery for severe cases

Diagnostic Key Points