Eye Diseases > Eyelids
Epiblepharon
Evidence-based assessment and management of congenital eyelid malposition. Comprehensive guide covering etiology, pathogenesis, classification, diagnosis, and treatment protocols for optometry practice.
Figure: Comparison of normal eyelid anatomy (left) versus epiblepharon (right). In epiblepharon, a horizontal fold of redundant pretarsal skin and orbicularis muscle overrides the lower eyelid margin, causing the vertically oriented eyelashes to be redirected toward the cornea. Unlike entropion, the eyelid margin itself maintains normal position without inward rotation.
Epiblepharon is a congenital eyelid malposition characterized by a horizontal fold of redundant pretarsal skin and orbicularis oculi muscle that overrides the eyelid margin, causing normally oriented eyelashes to be directed toward the cornea and conjunctiva. Unlike entropion, the eyelid margin itself is not rotated inward; rather, the excess skin fold mechanically pushes the lashes against the ocular surface.
This condition is most commonly observed in the lower eyelids of East Asian children, with prevalence rates of approximately 40–60% in most cohort studies of East Asian pediatric populations; figures as high as 90% have been cited in select studies using broad diagnostic criteria and should be interpreted with caution. While many cases resolve spontaneously with facial growth and maturation, persistent cases may cause chronic ocular irritation, punctate keratopathy, and rarely, corneal scarring requiring surgical intervention.
Epiblepharon is clinically significant in optometric practice as it represents one of the most common causes of pediatric ocular surface irritation in Asian populations. Differentiation from other eyelash-cornea contact disorders (entropion, trichiasis, distichiasis) is essential for appropriate management planning.
Developmental Factors
- Congenital anatomical variant: Present from birth due to developmental characteristics of the periocular tissues
- Immature facial bone structure: Underdeveloped infraorbital rim and shallow orbit common in infants
- Excess pretarsal skin and orbicularis: Redundant tissue that typically regresses with facial maturation
Anatomical Factors
- Hypertrophic orbicularis muscle: Excessive pretarsal orbicularis overrides the eyelid margin
- Deficient lower eyelid retractors: Weak or poorly developed capsulopalpebral fascia
- Absent or poorly formed infraorbital fat: Inadequate support for lower eyelid tissues
- Prominent epicanthal folds: Often associated with epiblepharon in medial canthal region
Ethnic Predisposition
- Asian populations: Highest prevalence in East Asian, Southeast Asian, and Korean children
- Genetic factors: Familial clustering suggests hereditary component
- Facial morphology: Associated with characteristic Asian eyelid anatomy (absent or low superior palpebral fold, epicanthus)
Mechanical Mechanism
The pathogenesis of epiblepharon involves a complex interplay of anatomical factors:
- Pretarsal tissue redundancy: Excess horizontal fold of skin and orbicularis muscle overhangs the eyelid margin
- Mechanical override: The redundant fold pushes against the base of normally oriented eyelashes
- Lash misdirection: Vertical lashes are mechanically deflected inward to contact the ocular surface
- Dynamic component: Lid closure and blinking exacerbate lash-cornea contact
- Ocular surface trauma: Repetitive friction causes epithelial disruption and inflammatory response
Structural Deficiency
- Inferior rectus-capsulopalpebral fascia complex: Weak or absent attachments fail to maintain proper lid position
- Orbital septum laxity: Permits anterior displacement of orbital fat
- Orbicularis hypertrophy: Excessive pretarsal muscle mass overrides marginal structures
Age-Related Changes
Many cases of epiblepharon improve or resolve spontaneously due to:
- Maturation of facial bone structure (deepening of infraorbital rim)
- Development of subcutaneous fat in lower lid
- Tightening of eyelid retractors with growth
- Reduction in relative skin redundancy as face elongates
- Regression typically occurs by age 5-10 years
By Location
- Lower lid epiblepharon: Most common; typically involves medial or central segments
- Upper lid epiblepharon: Rare; occasionally seen in severe cases
- Medial epiblepharon: Affects inner third of lid; often associated with epicanthus
- Lateral epiblepharon: Less common; outer third involvement
- Total (panlid) epiblepharon: Entire lid length affected
By Severity
Grade 1 (Mild)
- Minimal skin fold present
- Lashes barely touch ocular surface
- No or minimal symptoms
- No corneal changes visible
Grade 2 (Moderate)
- Obvious pretarsal skin fold
- Multiple lashes in contact with cornea/conjunctiva
- Intermittent symptoms (tearing, irritation)
- Mild punctate epithelial erosions may be present
Grade 3 (Severe)
- Prominent skin fold with significant tissue redundancy
- Extensive lash-cornea contact across lid width
- Persistent symptoms affecting quality of life
- Corneal findings: punctate keratopathy, erosions, potential scarring
By Clinical Presentation
- Asymptomatic epiblepharon: Anatomical finding without symptoms or corneal involvement
- Symptomatic epiblepharon: Causes ocular irritation, tearing, or foreign body sensation
- Complicated epiblepharon: Associated with corneal damage (SPK, erosions, scarring)
Demographic Factors
- Ethnicity: East Asian descent (Korean, Japanese, Chinese, Southeast Asian)
- Age: Most common in infants and young children (birth to 10 years)
- Gender: Equal distribution between males and females
- Family history: Positive family history suggests hereditary predisposition
Anatomical Factors
- Epicanthal folds: Associated medial canthal anatomy
- Flat nasal bridge: Common in Asian facial structure
- Prominent cheeks: May contribute to lower lid tissue redundancy
- Shallow orbit: Less orbital depth in developing face
Persistence Risk Factors
Factors associated with failure to spontaneously resolve:
- Severe initial presentation (Grade 3)
- Persistence beyond age 7-10 years
- Total (panlid) involvement
- Associated significant epicanthus
- Corneal scarring or persistent keratopathy
Eyelid Findings
- Horizontal pretarsal skin fold: Redundant tissue overhanging the eyelid margin
- Vertically oriented lashes: Normal lash direction at base, turned inward by skin fold
- Normal eyelid margin position: No inward rotation (differentiates from entropion)
- Lash-globe contact: Multiple lashes touching cornea or bulbar conjunctiva
- Accentuation with downgaze: More prominent when looking down
- Associated epicanthal folds: Commonly present at medial canthus
Ocular Surface Signs
- Conjunctival injection: Mild to moderate hyperemia, especially inferior bulbar area
- Punctate epithelial erosions (PEE): Inferior cornea corresponding to lash contact zone
- Superficial punctate keratopathy (SPK): Fluorescein staining in distribution pattern
- Corneal epithelial defects: In severe or chronic cases
- Mucus strands: May be present in tear film
- Papillary conjunctivitis: Tarsal conjunctiva changes in chronic cases
Severe or Complicated Cases
- Corneal pannus: Vascularization at inferior limbus
- Corneal scarring: Subepithelial or stromal opacification (rare)
- Persistent epithelial defect: Non-healing erosion
- Astigmatism: Induced by chronic mechanical pressure (uncommon)
Common Symptoms
Many cases are asymptomatic, especially in mild grades. When symptomatic, patients or caregivers report:
- Excessive tearing (epiphora): Most common presenting complaint in children
- Eye rubbing: Child frequently rubs eyes, especially upon waking
- Foreign body sensation: Feeling of "something in the eye"
- Eye irritation: Non-specific ocular discomfort
- Photophobia: Light sensitivity, may indicate corneal involvement
- Mucoid discharge: Particularly in morning or after sleep
Aggravating Factors
- Downgaze activities: Symptoms worse when reading or looking down
- Windy conditions: Increased exposure exacerbates irritation
- Dry environments: Air conditioning, heating, low humidity
- Prolonged visual tasks: Reduced blink rate increases lash contact time
- Fatigue or crying: Eyelid edema may worsen lash malposition
Severe Cases
- Blepharospasm: Excessive squinting or lid closure
- Blurred vision: If corneal surface irregularity or scarring present
- Recurrent pain: Episodes of sharp discomfort with blinking
Pediatric Presentation
In infants and young children who cannot verbalize symptoms, caregivers may notice:
- Frequent eye rubbing or touching
- Wetness on cheeks from tearing
- Squinting or keeping eyes partially closed
- Fussiness or behavioral changes related to ocular discomfort
Ocular Surface Complications
- Chronic punctate keratopathy: Persistent corneal epithelial disruption
- Corneal erosions: Recurrent or persistent epithelial defects
- Corneal scarring: Subepithelial fibrosis or stromal opacity (rare but vision-threatening)
- Corneal neovascularization: Vascular pannus formation at inferior limbus
- Astigmatism: Irregular corneal surface from chronic mechanical trauma
- Conjunctival scarring: Chronic inflammation leading to fibrosis
Secondary Conditions
- Chronic blepharitis: Secondary lid margin inflammation
- Dry eye disease: Tear film instability from chronic irritation
- Allergic conjunctivitis: May be exacerbated by mechanical irritation
- Papillary conjunctivitis: Giant papillae on superior or inferior tarsal conjunctiva
Visual Complications
- Amblyopia: Rare; may occur if significant corneal scarring develops in critical period
- Reduced visual acuity: From irregular astigmatism or central corneal scarring
- Contrast sensitivity reduction: Due to corneal surface irregularity
Surgical Complications
When surgical correction is performed:
- Recurrence: Inadequate tissue excision or suture technique
- Undercorrection: Persistent mild lash contact
- Overcorrection: Ectropion or lagophthalmos from excessive skin excision
- Eyelid asymmetry: Contour irregularity or height mismatch
- Scarring: Hypertrophic scar or keloid formation (especially in predisposed individuals)
- Anesthetic complications: General anesthesia risks in pediatric patients
Psychosocial Impact
- Chronic discomfort: May affect quality of life and daily activities
- Cosmetic concern: Excessive tearing, red eyes, or asymmetry may cause self-consciousness
- Activity limitation: Avoidance of outdoor activities or sports due to symptoms
Epiblepharon is primarily an isolated anatomical variant without systemic associations. However, certain relationships warrant consideration:
Associated Conditions
- Blepharophimosis syndrome: Rare association with other eyelid anomalies (telecanthus, ptosis, epicanthus inversus)
- Down syndrome: Increased prevalence of epiblepharon in patients with trisomy 21
- Congenital syndromes: Occasionally observed in craniofacial dysmorphology syndromes
- Fetal alcohol syndrome: May present with epiblepharon as part of facial features
No Direct Systemic Complications
Epiblepharon itself does not cause systemic health problems. It is a localized eyelid condition that:
- Does not indicate underlying systemic disease (in isolated cases)
- Does not affect general health or development
- Does not predispose to systemic infections or inflammation
- Requires no systemic workup in typical presentations
Differential Consideration
In atypical presentations, consider evaluation for:
- Chromosomal abnormalities (if dysmorphic features present)
- Genetic syndromes (if family history or multiple anomalies)
- Neuromuscular disorders (if associated with other lid position abnormalities)
Clinical Diagnosis
Diagnosis is primarily clinical, based on characteristic examination findings:
- Horizontal pretarsal skin fold: Visible redundancy overriding eyelid margin
- Normal lid margin position: No inward rotation (key differentiator from entropion)
- Vertically oriented lashes: Misdirected toward globe by mechanical pressure of skin fold
- Lash-cornea contact: Observable contact between lashes and ocular surface
Patient History
- Age of onset (typically congenital, noted in infancy)
- Symptom duration and progression
- Specific complaints: tearing, irritation, photophobia, discharge
- Ethnic background (Asian descent common)
- Family history of similar condition
- Previous treatments attempted
Examination Techniques
External Examination
- Assess eyelid position in primary gaze and downgaze
- Evaluate extent of pretarsal skin fold (location, width)
- Observe lash orientation and globe contact
- Check for associated epicanthal folds
- Assess symmetry between eyes
Slit Lamp Biomicroscopy
- Eyelid margins: position, contour, no inward rotation
- Lashes: orientation, density, contact with cornea
- Conjunctiva: injection, papillae, scarring
- Cornea: fluorescein staining pattern, punctate erosions, scarring
- Tear film: breakup time, volume, debris
Fluorescein Staining
- Essential to document corneal involvement
- Pattern: typically inferior cornea corresponding to lash contact
- Severity grading: mild SPK to frank epithelial defects
- Photography for documentation recommended
Ancillary Testing
- Photography: Document lid position, lash contact, corneal findings for monitoring
- Corneal topography: If astigmatism suspected from chronic mechanical trauma
- Visual acuity: Assess for any vision impact (especially in severe or chronic cases)
- Refraction: Rule out refractive error, assess astigmatism
Diagnostic Criteria
Epiblepharon is diagnosed when:
- Horizontal fold of redundant pretarsal skin and orbicularis present
- Eyelid margin maintains normal position (not rotated inward)
- Eyelashes are vertically oriented but mechanically deflected toward globe
- Observable lash-cornea or lash-conjunctival contact
Imaging Findings
- Slit-lamp photography: document lash position in primary gaze and downgaze; fluorescein staining for inferior punctate epithelial erosions (PEE).
- Corneal topography: for lower corneal irregularity (elevated SRI/SAI) in cases with chronic mechanical trauma.
- Standardised photographs: in primary gaze with a ruler scale for serial comparison and surgical planning documentation.
Severity Grading
| Grade | Clinical Finding | Action |
|---|---|---|
| Grade 1 | Lashes do not touch cornea in primary gaze | Observe; lubricate |
| Grade 2 | Lashes touch cornea only in downgaze | Observe; lubricate; monitor |
| Grade 3 | Lashes contact cornea in primary gaze | Lubricate; refer for surgical planning |
| Grade 4 | Corneal staining (punctate epithelial erosions) | Urgent surgical referral |
| Grade 5 | Corneal scarring or pannus formation | Urgent surgical referral |
Singapore Optometry Scope Note: Optometrists can monitor epiblepharon and provide supportive care (ocular lubrication). Surgical intervention requires referral to pediatric ophthalmology or oculoplastics. Given the high rate of spontaneous resolution, conservative management is appropriate for most cases.
Conservative Management
Initial approach for most cases, given high rate of spontaneous resolution with growth:
Observation ("Watchful Waiting")
- Indication: Asymptomatic or mildly symptomatic cases without corneal damage
- Rationale: Many cases resolve by age 5-10 years with facial maturation
- Monitoring: Regular follow-up every 3-6 months to assess progression
- Education: Counsel parents on expected natural history and signs requiring intervention
Lubricating Eye Drops
- Purpose: Protect ocular surface, reduce friction, alleviate symptoms
- Options: Preservative-free artificial tears, lubricating gels
- Regimen: Apply 4-6 times daily, or as needed for symptom relief
- Nighttime: Lubricating ointment at bedtime for prolonged protection
Manual Lid Eversion
- Technique: Parent gently pulls lower lid down and outward to temporarily reposition lashes
- Timing: Perform several times daily, especially before activities
- Efficacy: Temporary relief only; not curative
- Limitation: Requires consistent compliance, difficult in young children
Surgical Management
Indicated when conservative measures fail and significant symptoms or corneal damage persist.
Indications for Surgery
- Persistent moderate to severe symptoms despite conservative management
- Corneal involvement: significant SPK, erosions, or scarring
- No improvement or worsening after age 5-7 years
- Patient/parent preference after informed discussion
- Vision-threatening complications (rare)
Modified Hotz Procedure (Most Common)
- Technique: Excision of redundant pretarsal skin and orbicularis muscle strip
- Suturing: Anchoring sutures secure skin to lower lid retractors (capsulopalpebral fascia)
- Goal: Reposition lashes away from globe, eliminate skin fold
- Success rate: 85-95% with appropriate patient selection
Alternative Surgical Techniques
- Wies procedure: Full-thickness lid margin splitting with rotation (for severe cases)
- Quickert sutures: Everting sutures without skin excision (lower success rate)
- Transcutaneous approach: Skin and muscle excision with eyelid retractor plication
Surgical Considerations
- Age for surgery: Typically deferred until age 3-5 years unless severe
- Anesthesia: General anesthesia required for pediatric patients
- Bilateral vs unilateral: Often bilateral surgery if both eyes affected
- Recovery: 1-2 weeks for edema/ecchymosis resolution, 4-6 weeks for final result
Postoperative Care
- Antibiotic ointment: Apply to incision site 3-4 times daily for 1 week
- Cool compresses: First 48 hours to reduce swelling
- Activity restriction: Avoid rubbing eyes, swimming, contact sports for 2 weeks
- Suture removal: Typically 5-7 days postoperatively (if non-absorbable sutures used)
- Follow-up: 1 week, 1 month, 3 months to assess healing and outcome
Management Algorithm
Suggested Approach:
- Assess severity: Grade 1-3 based on symptoms and corneal findings
- Grade 1 (Mild): Observation + lubricants, monitor every 6 months
- Grade 2 (Moderate): Intensive lubrication, educate on manual eversion, monitor every 3-6 months
- Grade 3 (Severe) or persistent Grade 2 beyond age 7: Consider surgical referral
- Corneal scarring or vision threat: Urgent surgical referral
Optometric Co-Management
- Monitor for spontaneous resolution with growth
- Document corneal involvement with fluorescein staining and photography
- Provide symptomatic relief with lubricants
- Educate parents on natural history and when to consider surgery
- Refer to oculoplastic surgeon when surgical indications met
- Postoperative follow-up for healing assessment and complication monitoring
Natural History
- Spontaneous resolution: Occurs in majority of cases (60-90% by age 5-10 years)
- Mechanism of improvement: Facial growth, orbital rim deepening, subcutaneous fat development
- Peak resolution age: Most cases improve between ages 5-10 years
- Persistence beyond age 10: Unlikely to spontaneously resolve; consider surgery
Conservative Management Outcomes
- Asymptomatic cases: Excellent prognosis with observation alone
- Mild symptoms: Usually well-controlled with lubricants during growth period
- Moderate symptoms: May persist until surgical intervention or spontaneous resolution
- No long-term sequelae: If corneal damage minimal and resolves
Surgical Outcomes
- Success rate: 85-95% with modified Hotz procedure
- Symptom resolution: Most patients report significant improvement or complete relief
- Corneal healing: SPK and erosions typically resolve within weeks postoperatively
- Recurrence rate: 5-15%, usually due to inadequate tissue excision
- Cosmetic outcome: Generally excellent with minimal visible scarring
- Long-term satisfaction: High patient and parent satisfaction rates
Factors Affecting Prognosis
Favorable Prognostic Factors
- Mild severity (Grade 1-2)
- Young age at presentation (infancy to early childhood)
- Minimal or no corneal involvement
- Localized (not panlid) involvement
- Good response to conservative management
Unfavorable Prognostic Factors
- Severe presentation (Grade 3)
- Persistence beyond age 10 years
- Significant corneal scarring present
- Total (panlid) involvement
- Associated syndromes or systemic conditions
Visual Prognosis
- Uncomplicated cases: Excellent visual prognosis, no long-term vision impact
- Mild corneal involvement: Full recovery expected with treatment
- Corneal scarring: May result in reduced visual acuity or astigmatism; depends on location and density
- Amblyopia risk: Very low unless central corneal scarring develops in critical visual development period
Overall Prognosis
Excellent overall prognosis: The majority of epiblepharon cases are mild, asymptomatic, or minimally symptomatic and resolve spontaneously with facial growth. For persistent or severe cases, surgical correction provides high success rates with minimal complications. Vision-threatening outcomes are rare with appropriate monitoring and timely intervention.
Epiblepharon must be distinguished from other eyelid malpositions and lash disorders that cause lash-cornea contact:
1. Entropion
Epiblepharon
- Eyelid margin in normal position
- Pretarsal skin fold overrides margin
- Lashes vertically oriented at base
- Congenital, common in Asian children
- Often spontaneously resolves
Entropion
- Eyelid margin rotated inward
- Entire lid margin inverted
- Lashes directed inward from base
- Involutional (elderly) or cicatricial (scarring)
- Rarely spontaneously resolves
2. Trichiasis
- Definition: Misdirection of individual eyelashes toward cornea
- Difference: Normal lid position, isolated lash maldirection (not due to skin fold)
- Causes: Chronic blepharitis, trauma, chemical injury, cicatricial disease
- Distribution: Usually focal, involving few lashes
- Age: Can occur at any age; less common in children
3. Distichiasis
- Definition: Second row of eyelashes growing from meibomian gland orifices
- Difference: Congenital or acquired extra row of lashes (not maldirection by skin fold)
- Appearance: Double row of lashes visible along lid margin
- Lash characteristics: Posterior row lashes often finer, lighter in color
- Association: May be associated with lymphedema-distichiasis syndrome
4. Congenital Entropion
- Definition: Inward rotation of eyelid margin present from birth
- Difference: True lid margin inversion (vs. skin fold override in epiblepharon)
- Etiology: Tarsal hypoplasia, orbicularis override, retractor dehiscence
- Rarity: Much less common than epiblepharon in Asian populations
- Resolution: Less likely to spontaneously resolve compared to epiblepharon
5. Epiblepharon vs. Epicanthus
- Epicanthus: Vertical skin fold at medial canthus (does not cause lash-cornea contact)
- Often coexist: Epicanthus frequently present with epiblepharon
- Distinction: Epicanthus affects canthal appearance; epiblepharon affects lash position
6. Pseudoepiblepharon
- Definition: Apparent epiblepharon-like appearance without actual lash-cornea contact
- Causes: Facial edema, obesity, excessive lid tissue in infants
- Key difference: No actual corneal contact or irritation
- Management: Observation only; no treatment needed
Diagnostic Key Points
To differentiate epiblepharon:
- Examine eyelid margin position carefully (normal in epiblepharon)
- Look for horizontal pretarsal skin fold overriding margin
- Assess lash orientation at base (vertical in epiblepharon)
- Consider patient age and ethnicity (congenital, Asian predisposition)
- Document actual lash-cornea contact (must be present for true epiblepharon)
Spontaneous resolution occurs in up to 50% of Asian children by age 4–5 as facial fat redistribution reduces the skin fold. Watchful waiting with lubricating drops is appropriate for Grade 1–2 without corneal staining.
Epiblephron vs congenital entropion: in epiblephron, the lid margin itself is in the normal position — it is the skin/orbicularis fold that pushes otherwise normal lashes inward. In true entropion, the lid margin itself is rotated inward. This distinction drives different surgical approaches.
Corneal staining in primary gaze = surgery without further delay. Once fluorescein PEE is present with the eyes in the straight-ahead position, spontaneous resolution is unlikely and progressive corneal damage is at risk.
Always check for amblyopia in unilateral epiblephron, particularly when corneal staining or significant astigmatism is present. Amblyopia treatment is time-critical and takes priority over surgical correction scheduling.
Singapore Optometry Scope Note: Observation is appropriate for Grade 1–2 without corneal staining. Prescribe preservative-free lubricating drops for Grade 3–4 while awaiting ophthalmologist review. Document the severity grade at each visit with photographic evidence. Refer to a paediatric ophthalmologist for Grade 4–5, or any case not showing spontaneous improvement by age 4.
- Sundar G, Young SM, Tara S, et al. Epiblepharon in East Asian patients: the Singapore experience. Ophthalmology. 2010;117(1):184-189.
- Woo KI, Yi K, Kim YD. Surgical correction for lower lid epiblepharon in Asians. Br J Ophthalmol. 2000;84(12):1407-1410.
- Khwarg SI, Lee YJ. Epiblepharon of the lower eyelid: classification and association with astigmatism. Korean J Ophthalmol. 1997;11(2):111-117.
- Noda S, Hayasaka S, Setogawa T. Epiblepharon with inverted eyelashes in Japanese children. I. Incidence and symptoms. Br J Ophthalmol. 1989;73(2):126-127.
- Preechawai P, Amrith S, Wong I, Sundar G. Refractive changes in epiblepharon. Am J Ophthalmol. 2007;143(5):835-839.
- Tse DT, Anderson RL, Fratkin JD. Aponeurosis disinsertion in congenital entropion. Arch Ophthalmol. 1983;101(3):436-440.
- Levine MR. Epiblepharon and congenital entropion. In: Levine MR, ed. Manual of Oculoplastic Surgery. 4th ed. Slack Incorporated; 2010:133-138.
- Quickert MH, Rathbun E. Suture repair of entropion. Arch Ophthalmol. 1971;85(3):304-305.
- Johnson CC, Walton KA. Epiblepharon: an often overlooked diagnosis. Optom Vis Sci. 2012;89(5):e90-e93.
- Yan J, Zhang K, Wang X. Surgical management of epiblepharon in children: a systematic review and meta-analysis. J Pediatr Ophthalmol Strabismus. 2018;55(5):301-308.
- American Academy of Ophthalmology. Basic and Clinical Science Course, Section 7: Orbit, Eyelids, and Lacrimal System. San Francisco: American Academy of Ophthalmology; 2020-2021:186-188.
- Bartley GB, Nerad JA, Kersten RC, Hold R. Congenital entropion with intact lower eyelid retractor insertion. Am J Ophthalmol. 1991;112(4):437-441.
- Yoon JS, Lee SY. Long-term functional and cosmetic outcomes after epiblepharon surgery with modified Hotz procedure. Eye (Lond). 2015;29(3):350-356.
- Hiraoka T, Hoshi S, Okamoto Y, et al. Corneal iron ring associated with epiblepharon. Jpn J Ophthalmol. 2013;57(1):90-94.
- Bashour M, Harvey J. Causes of involutional ectropion and entropion – age-related tarsal changes are the key. Ophthalmic Plast Reconstr Surg. 2000;16(2):131-141.