Aetiology

Inward rotation of the tarsus and lid margin, causing the lashes to come into contact with the ocular surface

Most cases have a single aetiology but some are multi-factorial

Involutional (age-related)

• most common cause of entropion, affects lower lid (occurs in approx. 2% of the population over 60 and 11% of the population over 80)
• may be intermittent
• results from a combination of age related degenerations
  • horizontal lid laxity resulting from thinning and atrophy of the tarsus and the canthal tendons
  • weakness of the lower lid retractors
  • overriding of the preseptal over the pre-tarsal portion of the orbicularis oculi muscle, at the lid margin. This causes inward rotation of the tarsal plate on lid closure

Cicatricial

• severe scarring and contraction of the palpebral conjunctiva pulls the lid margin inwards (chronic blepharitis, ocular cicatricial pemphigoid, Stevens-Johnson syndrome, trachoma, chemical burns, post-operative complication)

Spastic

• caused by spastic contraction of the orbicularis muscle triggered by ocular irritation (including surgery) or due to essential blepharospasm. Usually resolves spontaneously once the cause has been removed

Congenital

• very rare entropion of the lower lid due to improper attachment of the retractor muscles to the inferior border of the tarsal plate

Predisposing factors

Age-related degenerative changes in the lid
Severe cicatrising disease affecting the tarsal conjunctiva
Ocular irritation or previous surgery

Symptoms of entropion

Foreign body sensation, irritation
Red, watery eye
Blurring of vision

Signs of entropion

Corneal and/or conjunctival epithelial disturbance from abrasion by the lashes (wide range of severity)
Localised conjunctival hyperaemia
Lid laxity (involutional entropion)
Conjunctival scarring (cicatricial entropion)
Absence of lower lid crease (congenital entropion)
Distraction test

• if lower lid can be pulled >8mm from globe, it is lax
• positive test indicates canthal tendon laxity

Snap-back test

• with finger, pull lower lid down towards inferior orbital margin
• release: lid should snap back
• lid slow to return to its normal position: indicates poor orbicularis tone

Test of Induced Entropion (TIE-2 test)

• ask patient to look down
• hold upper lid up as high as possible
• ask patient to close the eyes as tightly as possible
• The TIE-2 test is positive if this provokes an intermittent lower lid
  entropion

Differential diagnosis

Eyelid retraction (e.g. Graves’ disease):

• retracted upper or lower lid causes the lashes to be hidden by the resulting fold of lid skin, resembling entropion

Distichiasis:

• congenital additional row of lashes at the meibomian gland orifices

Trichiasis:

• lashes arise from normal position but are misdirected towards the cornea, secondary to inflammation

Dermatochalasis:

• degenerative condition, common in the elderly, leading to baggy appearance due to redundant lid skin and protrusion of orbital fat. Misdirection of lashes of upper lid may resemble entropion

Epiblepharon:

• congenital condition in which a fold of skin and muscle extends horizontally across the lid margin causing the lashes to be directed vertically. Orientation of tarsal plate normal. Usually asymptomatic and resolves with increasing age

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

Taping the lid to the skin of the cheek, so as to pull it away from the globe, can give temporary relief (particularly for involutional or spastic entropion)
Epilation of lashes can be done where the trichiasis is localised (eg in cicatricial entropion)
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Therapeutic (bandage) contact lens to protect cornea from lashes
(GRADE*: Level of evidence=low, Strength of recommendation=weak)

Ocular lubricants for tear deficiency/instability related symptoms (drops for use during the day, unmedicated ointment for use at bedtime)
NB Patients on long-term medication may develop sensitivity reactions which may be to active ingredients or to preservative systems (see Clinical Management Guideline on Conjunctivitis Medicamentosa). They should be switched to unpreserved preparations
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Management category

B1: Initial management (including drugs) followed by routine referral to ophthalmologist

A3: In the case of sight-threatening corneal involvement, and in congenital entropion, refer urgently (within one week) to ophthalmologist

Possible management by ophthalmologist

The choice of surgical procedure depends on the underlying cause(s)

Surgical intervention is indicated if any of the following are persistent:

• ocular irritation
• recurrent bacterial conjunctivitis
• reflex tear hypersecretion
• superficial keratopathy
• risk of ulceration and microbial keratitis

There is evidence that the combination of horizontal and vertical eyelid tightening is an effective treatment for involutional entropion

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (See www.gradeworkinggroup.org)

Sources of evidence

Boboridis KG, Bunce C. Interventions for involutional lower lid entropion. Cochrane Database Syst Rev. 2011;(12):CD002221

Hakim F, Phelps PO. Entropion and ectropion. Dis Mon. 2020;66(10):101039

Kennedy AJ, Chowdhury H, Athwal S, Garg A, Baddeley P. Are you missing an entropion? The Test of Induced Entropion 2. Ophthal Plast Reconstr Surg 2015;31/6:437-9

Milbratz-Moré GH, Pauli MP, Lohn CLB, Pereira FJ, GrumannAJ. Lower Eyelid Distraction Test: New Insights on the Reference Value. Ophthalmic Plast Reconstr Surg. 2019;35(6):574-577

Entropion
Version 8
Date of search 20.05.21
Date of revision 30.07.21
Date of publication 05.04.22
Date for review 19.05.23
© College of Optometrists