Irritation, foreign-body sensation, tearing, and redness.

(see Figure 6.3.1.)

Figure 6.3.1: Entropion.

Critical

Inward turning of the eyelid margin that pushes otherwise normal lashes onto the globe.

Other

SPK from eyelashes contacting the cornea, conjunctival injection. Corneal epithelial defect, thinning, and/or ulceration in severe cases.

• Involutional: Age-induced horizontal eyelid laxity, retractor disinsertion, and orbicularis override.

• Cicatricial: Conjunctival scarring in mucous membrane pemphigoid, Stevens–Johnson syndrome, posterior lamellar malignancies, chemical burns, trauma, trachoma, and others.

• Spastic: Sustained orbicularis contraction due to surgical trauma, ocular irritation, or blepharospasm.

• Congenital

1. History: Previous surgery, trauma, chemical burn, or infection (trachoma, herpes simplex, varicella zoster)?

2. Slit-lamp examination: Check for corneal involvement and conjunctival or eyelid scarring.

If blepharospasm is present, see 6.6, Benign Essential Blepharospasm.

1. Aggressive lubrication and antibiotic ointment (e.g., erythromycin or bacitracin q.i.d.).

2. Everting the eyelid margin away from the globe and taping it in place with lateral traction may be a temporizing measure.

3. A Quickert suture placed at the bedside or in the office can temporarily resolve the eyelid malposition by tightening the lower eyelid retractors and rotating the eyelid margin anteriorly. Neurotoxin therapy can also help temporize spastic entropion.

4. Surgery is often required for permanent correction. Surgical options should address the underlying etiology for entropion:

   • Involutional entropion: Horizontal laxity can be addressed with a lateral tarsal strip or similar procedure. This can be paired with retractor reinsertion. In some cases, judicious orbicularis myectomy or orbicular debulking can improve override of the orbicularis.

   • Cicatricial entropion: Should include medical control of the underlying condition if present. Lengthening of the posterior lamella with scar release and graft placement may be necessary. Graft options include hard palate, buccal mucosal membrane, or allografts.

   • Spastic entropion: Chemodenervation with botulinum toxin helps weaken the orbicularis muscle. Quickert sutures can help rotate the eyelid margin into the appropriate position.

   • Congenital entropion: Lubrication to limit mechanical trauma, taping of the lower eyelid, and chemodenervation with low-dose botulinum toxin can be considered. Surgical options are similar to the above for definitive treatment.

If the cornea is uninvolved, the condition does not require urgent attention or follow-up. If the cornea is significantly damaged, aggressive treatment is indicated (see 4.1, Superficial Punctate Keratopathy). Follow-up is determined by the severity of corneal involvement.