Entropion

What is Entropion?

Entropion is a common eyelid condition that occurs when the eyelid turns inwards towards the eye. It usually affects the lower eyelid, but may also affect the upper eyelid.

When the eyelid turns inwards, the eyelashes and eyelid skin rub against the surface of the eye causing friction, discomfort, and irritation of the ocular surface. If left untreated, erosions of the surface of the eye, the cornea, may develop. The clear cornea acts as a barrier to protect the inner eye from infections.

Entropion that is left untreated can cause damage to the cornea, leading to infections and eventually to sight loss.

Unfortunately, once entropion develops, surgery is usually required to resolve the problem although there are conservative measures which can hold it at bay if patients are not fit or motivated for surgery.

What Are The Signs And Symptoms Of Entropion?

Entropion can cause many uncomfortable symptoms in or around the eye. At first, the signs and symptoms may be intermittent but become more constant in time:

  • Foreign body sensation
  • Mild redness of the eye
  • Irritation and/or soreness
  • Watery eyes and excessive tearing
  • Eyelid crusting
  • Mucous discharge

If you have been diagnosed with entropion and you start to experience any of the following symptoms, immediate medical care should be sought:

  • Blurred vision
  • Sensitivity to light or wind
  • Eye redness that is rapidly getting worse
  • Pain in or around the eye

These can be signs and symptoms of damage to the cornea that can permanently damage your vision if left untreated.

What Are The Causes Of Entropion?

The most common cause of entropion is age-related changes to the structural support of the eyelids although there may occasionally be a combination of factors. At your appointment, your ophthalmologist will examine the eye and the eyelids to detect the cause. It’s important to determine the correct cause as the surgical treatment varies.

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Hover on image to see entropion example

Age related changes to the eyelids

As we get older, the ligaments and tendons which support the eyelid become lax which allows the eyelid to roll inwards causing an entropion (or outwards causing an ectropion). Age-related entropion is called involutional entropion and is experienced by around 2% of the UK elderly population.

Developmental anomalies

Very rarely, babies may be born with the eyelids turned inwards in a condition called congenital entropion.

Excessive squeezing

It's common for our eyes to become irritated, often as a result of dryness or inflammation. When this happens, it can cause the individual to excessively rub their eyelids or try to squeeze them shut. Rubbing the eyes leads to laxity of the eyelids which is a contributing factor to entropion. Excessive blinking and squeezing can also cause the eyelid muscles to spasm and turn inwards. An in-turned eyelid brought on in this way is called spastic entropion.

Eye Infections

Eye infections can lead to scarring of the lining of the eyes which mechanically pulls the eyelids inwards. Worldwide, the commonest infection to cause entropion is trachoma, but other causes of conjunctivitis including bacterial and viral infections may have the same effect.

Ocular burns and trauma

Trauma to the eye, including from chemical injury can also damage the lining of the eye, the conjunctiva. Contraction of the conjunctiva due to scarring causes the eyelids to roll inwards, causing an entropion. This is more complex to treat surgically.

Epiblepharon

Epiblepharon is commonly seen in Asian patients and occurs when a fold of skin overrides the eyelid margin pushing the lashes towards the ocular surface. This is different to an entropion when the eyelid margin is rolled inwards and your ophthalmologist will be able to differentiate between the two.

Medical Conditions

Rarely, autoimmune conditions such as pemphigoid may cause scarring of the conjunctiva leading to entropion. This may be treated with immunosuppression to stabilise the condition before proceeding with surgery.

What Are The Types Of Entropion?

There are four different types of entropion which are treated differently:



Involutional Entropion
Involutional or age-related entropion is by far the most common type of entropion and usually occurs from the age of around 60 onwards. As the eyelid tendons and ligaments become lax with age, they can turn inward causing the lashes to rub against the surface of the eye. Once involutional entropion has developed, it is a permanent condition that is best treated by eyelid surgery.

Acute Spastic Entropion
Spastic entropion is usually brought on by a problem with the ocular surface which causes the patient to squeeze their eyes shut, which turns the eyelid inwards. It is essential to see an ophthalmologist to diagnose and treat the cause of the spastic entropion.

Cicatricial Entropion
Cicatricial entropion is caused by scarring on the inner surface of the eyelid, the conjunctiva. This may result from several conditions such as viral conjunctivitis, blepharitis, shingles, and other various medical issues. The cause of the scarring must be diagnosed and treated before proceeding with surgery.

Congenital Entropion
Congenital entropion occurs when the lower lid margin has been turned inwards since birth and is the rarest type of entropion.



What Are The Complications Of Entropion?

If left untreated, entropion can lead to severe complications. The lashes rubbing against the eye may cause erosions of the cornea which may become infected. A corneal ulcer, or keratitis is a medical emergency and requires hourly antibiotic drops to treat the infection. In the most severe cases, the cornea may perforate or the contents of the eye may become infected in a condition called endophthalmitis with very poor outcomes. Even in less severe cases, there is often a degree of corneal scarring which blurs the vision.

 

What Is The Treatment For Entropion?

It is important to be assessed by an ophthalmologist to diagnose the cause of the entropion and treat any underlying disorders. The mainstay of treatment in entropion is surgical correction of the position of the eyelid. If the patient does not wish to undergo surgery, there are other treatments which may be effective for a limited time period and will often need to be repeated.

Conservative Treatments

Conservative therapies exist to provide temporary relief and prevent damage to the eye. However, surgical correction is usually required to amend entropion permanently.

  • Lubricants - all patients with entropion should use regular lubricating eye drops and ointments to reduce the effects of the lashes rubbing against the eye.
  • Skin tape - can be effective at pulling the lower eyelid away from the eye to provide temporary relief from the lashes rubbing against the eye. The skin around the eye is cleaned and dried before a strip of medical tape eg micropore is applied to the lower eyelid pulling the lid towards the cheek.
  • Bandage contact lenses - Your ophthalmologist may recommend using soft contact lenses to cover the cornea, preventing further damage and relieving symptoms.
  • Everting eyelid stitches - This quick procedure can be carried out with local anaesthesia. After your doctor has numbed the area around the eye, stitches are applied in several specific positions along the eyelid to turn it outward. This may last from a few months to several years but is not a permanent solution.
  • BoNT injections - Small injections of BoNT into the lower eyelid can weaken the muscles that are turning it inward. These injections are highly effective and will typically be administered prior to surgery. Although these injections can be used as an alternative to surgery, the procedure needs to be repeated every three months to remain effective.

Surgery

Surgery is the only treatment option that can permanently correct the eyelid position. This procedure involves the tightening and repositioning of the eyelid tissues. Age-related (involutional) entropion surgery involves tightening the lower eyelid and repositioning the lid muscles and tendons with stitches under the lower eyelid and / or on the outside corner of the eye. This is usually performed under local anaesthesia with sedation. The patient is awake but sleepy for the procedure and the area is numbed with a small injection into the lower eyelid. The whole procedure will usually take around 45 minutes per eyelid. The patient may spend around half a day in the clinic or hospital when allowing for preparation and aftercare times.

Entropion caused by scar tissue (cicatricial) is more complex to treat and may require a mucous membrane graft from your mouth. This is usually performed as a day case surgery under general anaesthesia.

Preparation for Surgery

At your appointment, your ophthalmologist will discuss your medication with you and you may be asked to stop some medication prior to surgery. It is important to tell your doctor if you take any anti-platelet or anti-coagulant medication such as aspirin, clopidogrel, warfarin, apixaban, edoxaban, rivaroxaban or dabigatran. Your doctor will advise you when to stop eating or drinking depending on your planned anaesthesia.

Post-Surgery Aftercare And Risks

Surgery will correct entropion almost immediately for most patients. There may be some short-term discomfort, as with any surgical procedure. It's completely normal to experience some bruising and swelling around the area that has been operated on after surgery but it will usually subside between one and two weeks. We aim to minimise any scarring by making incisions along the natural creases of eyelids. Stitches are usually removed at one to two weeks.After the procedure, patients will be advised to:

  • Use antibiotic ointment on the area for one week
  • Use cold compresses to reduce bruising and swelling
Post-surgical complications such as bleeding or infections are uncommon but are a risk after any operation. It's essential to follow advice on aftercare so the eyelid can heal properly. Once the eyelids have healed, the patient will feel noticeably much more comfortable. There should no longer be a risk of corneal scarring, infection, or sight loss.

Entropion Examples