CLINICAL MANAGEMENT GUIDELINES

Entropion

Entropion Version 4 30.08.11

1 of 2 College of Optometrists

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 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

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

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

Signs 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)

Differential diagnosis 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

CLINICAL MANAGEMENT GUIDELINES

Entropion

Entropion Version 4 30.08.11

2 of 2 College of Optometrists

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)