CLINICAL MANAGEMENT GUIDELINES

Entropion
Aetiology

Predisposing factors

Symptoms

Signs

Differential diagnosis

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 in some are multi-factorial
Involutional (age-related)
Most common cause of entropion, affects lower lid
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 (ocular cicatricial pemphigoid, Steven-Johnson
syndrome, trachoma, chemical burns)
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
Age-related degenerative changes in the lid
Severe cicatrising disease affecting the tarsal conjunctiva
Ocular irritation or previous surgery
Foreign body sensation, irritation
Red, watery eye
Blurring of vision
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)
Eyelid retraction (eg 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 and scarring of the lash
follicles
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

Entropion
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College of Optometrists

CLINICAL MANAGEMENT GUIDELINES

Entropion
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
Non pharmacological
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)
Therapeutic contact lens (hydrogel, silicone hydrogel, large diameter
corneal or scleral) to protect cornea from lashes
Pharmacological
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
Management Category B1: Initial management (including drugs) followed by routine referral
Congenital entropion does not resolve spontaneously and the potential
for severe corneal complications requires referral for prompt treatment
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
Evidence base

Authors conclusion: there are no randomised controlled trials to support

any intervention for lower lid entropion. Published case series indicate
that the combination of horizontal and vertical lower lid shortening in the
form of lateral canthal sling and Jones retractor plication give the most
favourable results.
(The Oxford 2011 Levels of Evidence = 4)

Entropion
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College of Optometrists