Entropion
Oculoplasty
Key Points
- •Involutional entropion has THREE pathogenic factors - horizontal laxity, retractor dehiscence, and overriding orbicularis; surgery must address at least two
- •Cicatricial entropion from trachoma is the leading infectious cause of preventable blindness globally - WHO SAFE strategy (Surgery, Antibiotics, Face washing, Environmental improvement)
- •Quickert everting sutures are the quickest temporary fix - takes 5 minutes at the slit lamp, lasts 2–3 months
- •Always biopsy conjunctiva (with immunofluorescence) if cicatricial entropion without clear cause - OCP requires systemic immunosuppression, not just lid surgery
- •Differentiate: entropion (lid margin turns in) vs trichiasis (misdirected lashes, normal lid margin) vs distichiasis (extra row of lashes from meibomian gland orifices)
Entropion is inward turning (inversion) of the eyelid margin toward the globe, causing the lashes and keratinised lid skin to contact and abrade the ocular surface. It primarily affects the lower lid (involutional type) and can cause significant corneal damage from chronic mechanical irritation.
Involutional entropion is the most common type in Western countries - prevalence 2–3% in patients >60 years.
Cicatricial entropion is more common in developing countries (trachoma - leading infectious cause of blindness worldwide, WHO).
Lower lid affected much more commonly in involutional type.
Upper lid more commonly affected in cicatricial type (especially trachoma).
Female preponderance for involutional type.
Involutional (most common in developed world):
- Age-related changes: horizontal lid laxity + override of preseptal orbicularis over pretarsal orbicularis + lower lid retractor dehiscence → lid turns inward.
Cicatricial (most common in developing world):
- Trachoma (Chlamydia trachomatis - WHO grading TT = trachomatous trichiasis).
- Chemical/thermal burns.
- Stevens-Johnson syndrome (SJS), ocular cicatricial pemphigoid (OCP).
- Chronic allergic conjunctivitis (AKC, VKC - tarsal scarring).
- Post-surgical scarring (retinal detachment surgery, enucleation).
- Herpes zoster ophthalmicus.
Spastic/acute:
- Reflex blepharospasm from ocular surface irritation, post-operative inflammation.
Congenital:
- Rare. Epiblepharon (more common in Asian children) - skin fold and preseptal orbicularis override cause lashes to turn inward.
Involutional entropion - THREE factors (all must be present):
- Horizontal lid laxity (canthal tendon dehiscence).
- Vertical lid laxity (lower lid retractor dehiscence/disinsertion - LER + inferior tarsal muscle lose attachment to tarsal plate).
- Overriding preseptal orbicularis: preseptal portion rides up over pretarsal portion on eyelid closure → rotates lid margin inward.
Cicatricial entropion:
- Scarring of palpebral conjunctiva/tarsus → shortening of posterior lamella.
- Shortened posterior lamella pulls lid margin inward → lashes contact globe.
- Progressive in conditions like trachoma, OCP.
By aetiology:
- Involutional (senile) - lower lid; commonest in West
- Cicatricial - upper or lower lid; commonest globally (trachoma)
- Spastic/acute - temporary, from blepharospasm
- Congenital - rare; vs epiblepharon (common in Asians)
By lid:
- Lower lid entropion (involutional - most common)
- Upper lid entropion (cicatricial - trachoma, OCP, SJS)
Differentiate from trichiasis:
- Entropion: entire lid margin turns IN
- Trichiasis: individual lashes misdirected inward but lid margin position normal
- Distichiasis: extra row of lashes from meibomian gland orifices
- Advanced age (involutional).
- Trachoma (endemic areas - Africa, Middle East, South Asia).
- Ocular cicatricial pemphigoid (OCP), SJS/TEN.
- Chronic allergic eye disease (VKC, AKC).
- Previous ocular surgery (especially posterior segment).
- Herpes zoster ophthalmicus.
- Chronic blepharospasm.
- Asian ethnicity (epiblepharon).
Symptoms: foreign body sensation, tearing, pain, photophobia, red eye, decreased vision (if corneal involvement).
Signs:
- Inward rotation of lid margin → lashes and keratinised skin contact globe
- Conjunctival injection
- Corneal punctate erosions (SPK) from lash abrasion
- Corneal pannus, vascularisation, scarring (chronic)
- Corneal ulceration (in severe/neglected cases)
- Lash-cornea touch on slit lamp examination
Involutional: lower lid; may be intermittent initially (spastic component); worsens with forced closure.
Cicatricial: upper or lower lid; conjunctival scarring visible on lid eversion (shortening of fornix, symblepharon, Arlt's line in trachoma).
Spastic: acute onset following surgery or irritation; resolves with cause.
Epiblepharon: lash-corneal touch from skin fold, but lid margin position may be normal.
Clinical diagnosis.
- Slit lamp: confirm lid position, lash-cornea touch, corneal damage (fluorescein staining).
- Lid eversion: assess tarsal conjunctiva - scarring, papillae, follicles (trachoma grading).
- Snap-back test and lid distraction: assess horizontal laxity (involutional).
- Assessment of lower lid retractor function.
For cicatricial causes:
- Conjunctival biopsy: if OCP suspected (direct immunofluorescence - linear IgG, IgA, C3 at basement membrane).
- Chlamydia testing: PCR or Giemsa stain of conjunctival scrapings (trachoma).
- Blood tests: if autoimmune cause suspected (anti-basement membrane antibodies in OCP).
Trichiasis - misdirected lashes with NORMAL lid margin position. Common in trachoma but distinct from entropion.
Distichiasis - accessory row of lashes from meibomian gland openings; lid margin position normal.
Epiblepharon - skin/muscle fold pushes lashes inward; lid margin not truly inverted. Common in Asian children; usually resolves with facial growth.
Ectropion - lid turns OUTWARD (opposite direction).
Floppy eyelid syndrome - upper lid; lid everts easily during sleep.
Corneal abrasion and recurrent erosions.
Corneal ulceration → perforation (in severe trachoma/OCP).
Corneal scarring and vascularisation (pannus) → permanent visual loss.
Secondary bacterial keratitis (infection of abraded cornea).
Chronic pain and discomfort.
Trachomatous corneal opacity - leading cause of preventable blindness in endemic areas (WHO).
Amblyopia (congenital cases in children).
Temporary measures:
- Taping lid outward (Steri-strips).
- Bandage contact lens (corneal protection).
- Lubricating ointment.
- Botulinum toxin injection to orbicularis (spastic entropion).
- Everting sutures (Quickert sutures): 3 double-armed 4-0 chromic sutures passed through full thickness of lid to evert margin - lasts 2–3 months; useful as temporary measure or in frail patients.
Definitive surgery - involutional:
- Jones procedure (lower lid retractor reinsertion + horizontal lid shortening) - addresses both vertical and horizontal laxity.
- Wies procedure (transverse blepharotomy + everting sutures) - full-thickness horizontal incision 4 mm below lid margin, rotate lid margin outward.
- Lateral tarsal strip + lower lid retractor plication - combined approach for horizontal + vertical laxity.
- Quickert sutures alone: for elderly/unfit patients.
Definitive surgery - cicatricial:
- Posterior lamellar graft: mucous membrane graft (buccal/labial mucosa), or hard palate graft, or amniotic membrane to lengthen shortened posterior lamella.
- Tarsal rotation (posterior lamellar tarsal rotation / modified Trabut procedure): incision through posterior lamella above tarsal plate → rotate distal segment outward - commonly used for trachomatous entropion.
- Lid margin splitting with anterior lamellar repositioning.
Treat underlying cause:
- Trachoma: oral azithromycin 1 g single dose (SAFE strategy: Surgery, Antibiotics, Face washing, Environmental improvement).
- OCP: systemic immunosuppression (dapsone, methotrexate, cyclophosphamide).
- SJS: systemic management of acute episode.
Involutional: excellent surgical outcome (>90% success with Jones/Wies procedure).
Cicatricial: depends on underlying disease activity - surgery during active OCP/SJS may fail; must control inflammation first.
Trachoma: WHO SAFE strategy has dramatically reduced blindness in endemic areas.
Recurrence: 5–10% for involutional; higher for cicatricial if disease active.
Corneal scarring: if already present, visual recovery limited even after lid correction.
Clinical Pearls
1
Involutional entropion has THREE pathogenic factors - horizontal laxity, retractor dehiscence, and overriding orbicularis. Effective surgery must address at least two of these.
2
Everting sutures (Quickert) are the quickest temporary fix - takes 5 minutes at the slit lamp; buys 2–3 months until definitive surgery.
3
Trachomatous trichiasis (TT) - the WHO indication for surgery in trachoma. The SAFE strategy is: Surgery, Antibiotics, Face washing, Environmental improvement.
4
Always biopsy conjunctiva (with immunofluorescence) if cicatricial entropion without clear cause - OCP is a progressive disease that requires systemic immunosuppression, not just lid surgery.
5
Epiblepharon in Asian children is usually self-limiting - observe until age 5–6; surgery only if significant corneal damage (SPK in visual axis) persists.
6
In involutional entropion, forced eyelid closure may provoke the entropion - useful diagnostic manoeuvre when the lid appears normal at rest.
7
The Wies procedure (transverse blepharotomy) is particularly effective because the full-thickness incision creates a scar that acts as a new fulcrum, everting the distal lid margin.
8
Exam Trap: Involutional entropion has a spastic component - it may be intermittent and only manifest when the patient looks down and squeezes the lids. If the lid looks normal at rest, always provoke entropion by asking the patient to forcefully close their eyes.
9
Exam Trap: Cicatricial entropion of the upper lid must prompt identification of the underlying cause - trachoma, OCP, SJS, or chemical burns all cause posterior lamella scarring but require different treatments. Never operate without identifying and controlling the underlying disease.
10
Exam Trap: Differentiate congenital epiblepharon from true congenital entropion - epiblepharon has a horizontal skin/muscle fold pushing lashes inward but the lid margin itself is NOT inverted. Epiblepharon usually resolves spontaneously by age 5–6; true entropion requires surgery.
Oral-exam questions
- What are the THREE factors causing involutional entropion? - Horizontal lid laxity (canthal tendon dehiscence), lower lid retractor dehiscence (vertical laxity), and overriding preseptal orbicularis. All three contribute; surgery must address at least two.
- How do you differentiate entropion from trichiasis? - In entropion, the entire lid margin is inverted. In trichiasis, individual lashes are misdirected but the lid margin position is normal. This distinction is clinically important because the surgical approach differs.
- What is epiblepharon and how is it managed? - A horizontal fold of skin and preseptal orbicularis that pushes lashes against the cornea in Asian children. Lid margin is NOT truly inverted. Usually self-resolving by age 5–6; surgery only if significant SPK in the visual axis persists.
- What investigation is essential if cicatricial entropion has no obvious cause? - Conjunctival biopsy with direct immunofluorescence (DIF) - looking for linear IgG, IgA, C3 at the basement membrane zone, which is diagnostic of ocular cicatricial pemphigoid (OCP).
- How do Quickert everting sutures work? - 3 double-armed 4-0 chromic sutures are passed full-thickness through the lower lid and tied to evert the margin. The suture reaction creates temporary fibrosis that holds the lid everted for 2–3 months. Takes 5 minutes at the slit lamp.
- Why should you not operate on cicatricial entropion during active OCP? - Surgery during active disease will fail because ongoing inflammation and scarring will undo the surgical correction. Must achieve disease quiescence with systemic immunosuppression (dapsone, methotrexate) before lid surgery.
Mnemonics
THREE factors of involutional entropion
H - Horizontal lid laxity (canthal tendon dehiscence)
R - Retractor dehiscence (vertical laxity - LER disinsertion)
O - Overriding orbicularis (preseptal rides over pretarsal)
SAFE (WHO Trachoma Strategy)
S - Surgery (for trachomatous trichiasis)
A - Antibiotics (azithromycin 1 g single dose)
F - Face washing (hygiene, reduce transmission)
E - Environmental improvement (sanitation, water access)
Comparison Tables
Involutional vs Cicatricial Entropion - Key Differences
| Feature | Involutional Entropion | Cicatricial Entropion |
|---|---|---|
| Most common cause | Age-related lid changes | Trachoma (globally); OCP, SJS (West) |
| Lid affected | Lower lid | Upper lid (trachoma, OCP) or lower |
| Pathology | Horizontal laxity + retractor dehiscence + orbicularis override | Posterior lamella scarring/shortening |
| Conjunctival finding | Normal conjunctiva | Scarring: Arlt's line, symblepharon, fornix shortening |
| Onset | Intermittent initially, then constant | Progressive, constant |
| Surgery | Jones procedure / Wies procedure | Tarsal rotation / posterior lamellar graft |
| Recurrence | 5–10% | Higher if disease still active |
| Feature | Involutional Entropion | Cicatricial Entropion |
|---|---|---|
| Most common cause | Age-related lid changes | Trachoma (globally); OCP, SJS (West) |
| Lid affected | Lower lid | Upper lid (trachoma, OCP) or lower |
| Pathology | Horizontal laxity + retractor dehiscence + orbicularis override | Posterior lamella scarring/shortening |
| Conjunctival finding | Normal conjunctiva | Scarring: Arlt's line, symblepharon, fornix shortening |
| Onset | Intermittent initially, then constant | Progressive, constant |
| Surgery | Jones procedure / Wies procedure | Tarsal rotation / posterior lamellar graft |
| Recurrence | 5–10% | Higher if disease still active |
Entropion vs Trichiasis vs Distichiasis
| Feature | Entropion | Trichiasis | Distichiasis |
|---|---|---|---|
| Lid margin position | Inverted (turned IN) | Normal | Normal |
| Lash origin | Normal lash line (rotated inward) | Normal lash line (misdirected) | From meibomian gland orifices |
| Mechanism | Lid rotation | Lash misdirection (scarring) | Metaplasia of meibomian glands |
| Common cause | Involutional / trachoma | Trachoma, blepharitis | Congenital; lymphoedema-distichiasis |
| Treatment | Lid surgery (rotation/reinsertion) | Epilation, electrolysis, cryotherapy | Cryotherapy, lid splitting |
| Feature | Entropion | Trichiasis | Distichiasis |
|---|---|---|---|
| Lid margin position | Inverted (turned IN) | Normal | Normal |
| Lash origin | Normal lash line (rotated inward) | Normal lash line (misdirected) | From meibomian gland orifices |
| Mechanism | Lid rotation | Lash misdirection (scarring) | Metaplasia of meibomian glands |
| Common cause | Involutional / trachoma | Trachoma, blepharitis | Congenital; lymphoedema-distichiasis |
| Treatment | Lid surgery (rotation/reinsertion) | Epilation, electrolysis, cryotherapy | Cryotherapy, lid splitting |
Surgical Procedures for Involutional Entropion
| Procedure | What It Addresses | Technique | Durability |
|---|---|---|---|
| Quickert everting sutures | Temporary eversion | 3 full-thickness sutures | 2–3 months |
| Jones procedure | Retractor dehiscence + horizontal laxity | Retractor reinsertion + lid shortening | Long-term (>90%) |
| Wies procedure | Orbicularis override | Full-thickness blepharotomy 4 mm below margin | Long-term |
| LTS + retractor plication | Horizontal + vertical laxity | Combined approach | Long-term |
| Tarsal rotation (modified Trabut / PLTR) | Posterior lamella scarring (cicatricial) | Posterior lamellar incision, rotate tarsal plate | Variable - depends on disease activity |
| Procedure | What It Addresses | Technique | Durability |
|---|---|---|---|
| Quickert everting sutures | Temporary eversion | 3 full-thickness sutures | 2–3 months |
| Jones procedure | Retractor dehiscence + horizontal laxity | Retractor reinsertion + lid shortening | Long-term (>90%) |
| Wies procedure | Orbicularis override | Full-thickness blepharotomy 4 mm below margin | Long-term |
| LTS + retractor plication | Horizontal + vertical laxity | Combined approach | Long-term |
| Tarsal rotation (modified Trabut / PLTR) | Posterior lamella scarring (cicatricial) | Posterior lamellar incision, rotate tarsal plate | Variable - depends on disease activity |
Self-Assessment (5)
MCQ
A 70-year-old woman presents with intermittent foreign body sensation in the left eye that worsens with forced eyelid closure. On examination, the lower lid margin turns inward on forced closure, with lashes touching the cornea. What is the most likely diagnosis?
MCQ
What are the THREE pathogenic factors in involutional entropion?
MCQ
A patient from East Africa presents with upper lid entropion, corneal scarring, and Herbert pits at the superior limbus. What is the most likely underlying cause?
MCQ
What investigation should be performed if a patient has progressive cicatricial entropion with symblepharon formation and no clear history of trachoma, burns, or SJS?
MCQ
What is the WHO SAFE strategy for trachoma elimination?
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