Entropion (Eyelid Inversion)

Entropion is the inward rotation of the eyelid margin causing eyelashes and lid skin to contact and abrade the ocular surface. Four etiologic types are recognized: involutional (most common, attenuation/disinsertion of lower lid retractors, horizontal lid laxity, orbicularis override of eyelid margin), cicatricial (vertical shortening of posterior lamella from trachoma, Stevens-Johnson syndrome, ocular cicatricial pemphigoid, chemical burns, surgical scarring), spastic (acute reversible orbicularis spasm from ocular irritation or surgery), and congenital (rare, may be associated with epiblepharon or tarsal kink).

Clinical features include eyelid margin and lashes turning inward, foreign body sensation, photophobia, tearing, ocular redness, mucous discharge, blepharospasm, corneal punctate staining, abrasion, scarring, and even ulceration. Trichiasis (lashes rubbing cornea) and distichiasis (extra row of lashes from meibomian openings) may coexist. In cicatricial entropion, evidence of conjunctival fibrosis, symblepharon, and forniceal foreshortening is present.

Diagnostic evaluation includes slit-lamp examination of lid position and corneal staining, lid distraction and snap-back tests for involutional laxity, evaluation of orbicularis override, and conjunctival biopsy if cicatricial entropion is suspected (immunofluorescence for ocular cicatricial pemphigoid). Treatment options include temporizing lid taping or quickert sutures, definitive surgery with lateral tarsal strip and retractor reinsertion for involutional entropion, posterior lamellar grafting (mucous membrane, hard palate, amniotic membrane) for cicatricial entropion, botulinum toxin or quickert sutures for spastic entropion, and electrolysis, cryotherapy, or radiofrequency for trichiasis.