4 Diagnosis and Treatment of

Entropion

CHAPTER OUTLINE Introduction 113 Etiology 118

Anatomic Considerations 114 Planning Treatment 119
The Normal Eyelid Margin 114 Treatment of Entropion 120
The Stable Lower Eyelid 115 Involutional Entropion 120
Involutional Entropion 116 Spastic Entropion 123
Spastic Entropion 116 Cicatricial Entropion 124
Cicatricial Entropion 117 Major Points 129
History 118 Suggested Reading 129
Physical Examination 118

VIDEOS ’ 4.1 Entropion Repair, Retractor Reinsertion, and Lateral Tarsal Strip
’ 4.2 Spastic Entropion Repair: Quickert Sutures
’ 4.3 Tarsal Fracture Procedure
’ 4.4 Cicatricial Entropion Mucous Membrane Graft
Visit Expert Consult (expertconsult.inkling.com) for videos on topics discussed throughout the text.

and spastic entropion types) or shortening of the posterior

Introduction lamellar tissues (seen with cicatricial and marginal entro-
Entropion of the eyelid occurs when the lid margin inverts or pion types). Lower eyelid entropion is most commonly invo-
turns against the eyeball (Figure 4.1). The keratinized skin lutional. The symptoms of irritation are intermittent, and
of the eyelid margin and eyelashes rub against the cornea lower eyelid horizontal laxity is seen. Upper eyelid entropion
and conjunctiva, causing irritation. Unlike with ectropion, is always cicatricial and is a source of constant irritation.
the irritation is troublesome enough so that most patients When you evert the lid, you see cicatricial changes.
seek medical treatment early. Entropion is common, but less Cicatricial forms of lower lid entropion do occur, so it is
common than ectropion of the lids. important to look for scarring of the posterior lamella in the
There are four types of entropion (Box 4.1). A congenital lower lid also. Spastic entropion occurs when the eye is irri-
form of entropion exists, but it is so rare that it is hardly tated and inflamed. Guarding of the inflamed eye, with
worth mentioning. some squeezing of the eyelid, initiates the entropion.
The anatomy of the lower eyelid is discussed as it relates Usually, some elements of laxity are also present. Marginal
to the causes of entropion in some detail. The two most entropion, a subtle form of eyelid inversion, is often per-
important causes of involutional entropion are horizontal ceived by the patient (and sometimes the inexperienced
lid laxity and disinsertion or laxity of the lower eyelid retrac- examiner) as an eyelash problem.
tors. As discussed in Chapter 3, any horizontal laxity of Involutional entropion is the most common type of entro-
the eyelid contributes to instability. Without the normal pion seen in the United States, so you should be familiar
tension of the lower eyelid retractors pulling the lower with its management. The aim of surgical treatment is to
edge of the tarsus inferiorly and posteriorly, the eyelid restore the normal tension of the lower lid retractors and to
may invert, pulling skin and lashes against the eye. The correct any coexisting horizontal lid laxity. The discussion
concepts of anterior and posterior lamellar shortening are includes the retractor reinsertion operation and the lateral tar-
also important in the discussion of entropion. Scarring of sal strip operation to correct involutional entropion. Learn
the posterior lamella, conjunctiva, and tarsus causes a cic- these operations well.
atricial entropion. Cicatricial entropion is less common than involutional
The history and physical examination show the etiology of entropion. Trachoma is the “textbook” cause of posterior
entropion to be either lax tissues (seen with involutional lamellar scarring that leads to cicatricial entropion.

113
114 4 • Diagnosis and Treatment of Entropion

Trachoma is rarely seen in the United States. The typical

trachoma patient with cicatricial entropion has severe con-
Anatomic Considerations
junctival scarring with the eyelid margin inverted, causing THE NORMAL EYELID MARGIN
skin and lashes to rub against the eye. Chemical, thermal,
and conjunctival diseases can cause a cicatricial entropion. Understanding exactly how the eyelid sits against the eye-
In reality, the patient with the most commonly seen type of ball is important for understanding cicatricial entropion.
cicatricial entropion has a mild form, called marginal entro- We take the eyelid margin for granted, but there is a very
pion. The eyelid margin is turned in slightly, bringing the specific relationship between the mucosal tissues on the
lashes against the eye. A considerable amount of time is back of the lid and the keratinized skin on the lid margin.
spent on marginal entropion in Chapter 5. The aim of treat- The next time you perform a slit lamp examination, start
ment of all forms of cicatricial entropion is to restore the to become familiar with this eyelid margin anatomy. The
normal length of the posterior lamella using either inci- normal eyelid margin is flat, ending at right angles anteri-
sional rotation of the margin or incision of the cicatrix and orly and posteriorly to form a long thin rectangle of tissue
replacement with a graft. The tarsal fracture operation is a (Figure 4.2). The most posterior aspect of the normal lid
great margin rotation procedure to add to your list of com- margin is the mucocutaneous junction. It is at this point
petencies for repair of marginal entropion or mild degrees of that the mucosa of the palpebral conjunctiva stops and
cicatricial entropion of the lower eyelid. The anterior lamel- the keratinized skin of the eyelid margin begins. Look at
lar advancement procedure is also an upper eyelid everting several normal patients to see this junction. The next
procedure that pulls the anterior lamella tighter. When the time you see a patient with cicatricial entropion, you may
entropion is too severe for incisional rotation, mucous mem- be able to appreciate the fact that the mucocutaneous
brane grafts are necessary. You should learn to recognize junction moves forward as the eyelid margin inverts
patients with severe entropion who need the more (Box 4.2).
advanced operations involving grafting. These grafts are Just anterior to the mucocutaneous junction are the mei-
not often needed, however. bomian gland orifices extending out from the tarsal plate. By
Spastic entropion is an unusual form of eyelid entropion. everting the eyelid during the slit lamp examination you
You occasionally see this form of entropion occurring with can see the faint vertical lines of the meibomian glands visi-
squeezing of the lids in association with ocular pain or ble in the tarsal plate. Anterior to the meibomian gland ori-
inflammation, often after eye surgery. Frequently, the fices is the gray line. Initially, this line was thought to result
entropion resolves as the postoperative discomfort disap- from the fusion of the anterior and posterior lamellae. In
pears. If corneal irritation is severe, treatment with Quickert reality, the gray line is a specialized muscle of the pretarsal
sutures returns the lid to its normal position. There are not orbicularis, known as the muscle of Riolan. The gray line is
many patients with spastic entropion. Quickert sutures are still used as a landmark to surgically separate the anterior
easy to learn, however, and are an easy solution for spastic and posterior lamellae of the eyelid in some procedures.
entropion when it occurs. Posterior to the gray line is the posterior lamella (the tarsus
and the conjunctiva). Anterior to the gray line is the
anterior lamella (the skin and muscle). The eyelashes arise

Orbicularis muscle

Tarsus

Figure 4.1 Bilateral lower eyelid entropion: eye irritation due to

involutional entropion. Note other involutional changes in this elderly Eyelash
patient: brow ptosis and blepharoptosis. and follicle

Mucocutaneous
Box 4.1 Types of Entropion junction
Gray line
Meibomian (Riolan's muscle)
’ Involutional orifice
’ Spastic
’ Cicatricial
’ Marginal Figure 4.2 Normal eyelid margin architecture. Note the position of
the gray line, meibomian glands, and mucocutaneous junction.
 4 • Diagnosis and Treatment of Entropion 115

Eyelashes
Box 4.2 Eyelid Margin Architecture
Gray line
’ Mucocutaneous junction Meibomian gland orifice
’ Meibomian gland orifices
’ Gray line Mucocutaneous
’ Eyelashes junction

anterior to the gray line, usually in one or two irregular

rows in the lower lid and three or four irregular rows in the
upper lid. The eyelash follicles originate on the surface of the
tarsal plate. Learn these subtle anatomic features of the eye-
lid. They are especially important when you are evaluating A
patients with mild cicatricial entropion or trichiasis. I
emphasize the changes that occur in the lid margin later in
this chapter and more completely in Chapter 5.

THE STABLE LOWER EYELID

Let’s go over the anatomic factors that are important for
understanding and treating entropion. Remind yourself of
the layers of the lower eyelid inferior to the tarsal plate (see
Figure 2.35). Starting at a point below the tarsus from ante-
rior to posterior, the layers of the eyelid are:
B
’ Skin
’ Orbicularis muscle
’ Septum
’ Preaponeurotic fat (the landmark for the lower lid
retractors)
’ Retractors
’ Conjunctiva

The lid margin remains normally apposed to the eye dur-

ing eye movements through a combination of forces holding
the lid in position. Watch the lid during the slit lamp exami-
nation as the eye moves up and down. The pretarsal eyelid C
and the eyelid margin move as a unit. Remember that the pre-
tarsal orbicularis is firmly adherent to the anterior surface of the
tarsus, creating a block of tissue. The mucocutaneous junction of Figure 4.3 Eyelid margin architecture. (A) Normal eyelid margin. The
lid margin is a flat platform with a sharp right-angled posterior edge.
the eyelid margin does not change its position relative to the eye- Normal landmarks (from posterior to anterior) are the mucocutaneous
ball as the eye rotates (Figure 4.3). This is one of many junction, meibomian gland orifices, gray line, and eyelashes.
aspects of our functional anatomy that we take for granted. (B) Abnormal eyelid margin. This eyelid (manually everted) shows
When you try to reconstruct a missing eyelid margin, you migration of the conjunctiva over the meibomian glands in the
central area. The mucocutaneous margin has migrated anteriorly, a
come to appreciate this even more! sure sign of long-standing entropion, usually cicatricial. A scar is
Several factors contribute to the stability of the lid. In gen- present pulling the eyelid margin inward. (C) Close-up view of same
eral, a tight lower eyelid, without horizontal lid laxity, is a eyelid. Notice that the mucocutaneous junction is now anterior to the
stable lid. Laxity predisposes the lower lid to either ectropion or meibomian glands. The gland openings appear as slits.
entropion, as we have seen in Chapter 3. Think about what
the lower eyelid retractors do. As the eye looks down, the
lower lid retractors pull the lower eyelid downward. If
the retractors did not work in synchrony with the eyeball,
the eyelid would block the pupil in downgaze. This synchro- pull of the inferior rectus muscle. This keeps the lower edge of
nous movement results from the connection of the capsulo- the tarsal plate tucked in against the eye with the eyelid mar-
palpebral fascia portion of the lower eyelid retractors with gin in the normal position. Normal tension on the lower eyelid
the inferior rectus muscle. retractors is essential for maintaining a stable eyelid and prevent-
The lower eyelid retractors also help to keep the eyelid mar- ing entropion (Box 4.3).
gin in normal position. The retractors pull the lower margin In the normal eyelid, the anterior and posterior lamellar
of the tarsus inferiorly and posteriorly, in the direction of the tissues superior to the tarsus have enough redundancy and
116 4 • Diagnosis and Treatment of Entropion

flexibility so that normal movement does not alter the posi- lid-tightening procedure, you notice that the patient’s
tion of the lid margin. There is no pull or cicatricial force eyes (and face) look younger.
turning the eyelid inward or outward.
SPASTIC ENTROPION
INVOLUTIONAL ENTROPION Spastic entropion occurs when the eyelids are held in a
Involutional entropion occurs only in the lower lid. Three closed or “guarded” position. The sustained squinting of the
anatomic factors play a role in involutional entropion: lower lid is the initiating force for the entropion. The most
common situation for this reflex blepharospasm is after sur-
’ Laxity of lower eyelid retractors gery, usually an anterior segment trauma repair or an
’ Horizontal lid laxity extensive posterior segment procedure. The spasm or
’ Overriding preseptal orbicularis muscle

Laxity of the lower lid retractors is the primary cause of invo-

lutional entropion (Figure 4.4). Lower lid horizontal laxity is
usually present, making the lid unstable. Laxity of the lower Inferior
lid retractors allows the inferior edge of the tarsus to rotate tarsal m.
away from the eye. This allows the lid margin to invert
(Figure 4.5). In many cases, the preseptal orbicularis muscle Suspensory ligament
actually seems to push the lower eyelid margin inward. of the fornix
Variations of Figure 4.4 are shown in all texts discussing
entropion. Make sure that you understand this figure. Later Inferior oblique m.
in this chapter you learn that you can often elicit involu-
tional entropion by having the patient squeeze the eyelids
Inferior rectus m. Orbicularis m.
closed tightly for a few seconds. This squeezing pushes the
preseptal and orbital orbicularis muscle upward, initiating
the inversion of the eyelid.
For many years, enophthalmos was considered to be an Orbital
etiologic factor in involutional entropion. This has been dis- septum
proven. The presence of enophthalmos has been shown to
be no different in age-matched patients with or without
entropion.
Capsulopalpebral fascia
As an aside, many older patients have the appearance
Lockwood's ligament
of small eyes. This is caused by a narrowing of the eyelid A
aperture both vertically and horizontally. As the retrac-
tors relax with age, the position of the lower eyelid ele-
vates a bit. This upside-down ptosis of the lower eyelid is
common in elderly patients with entropion. The upper
eyelid becomes somewhat ptotic. The horizontal length of
the palpebral aperture decreases, and the canthi become
rounded as the canthal tendons lengthen; this condition Inferior tarsal m.
is known as phimosis of the aperture. Look for this in Suspensory ligament Orbicularis m.
your elderly patients. It is an apparent, but unappreciated, of the fornix
feature of aging. When you lift the upper eyelids
and re-create the sharp lateral canthal angle with a Inferior oblique m.
Orbital
Inferior rectus m.
septum

Box 4.3 Factors Contributing to the Stability of

the Lower Eyelid
’ Appropriate horizontal tension of the lower lid so that the
eyelid is apposed to the eyeball
’ Lower lid retractors applying appropriate tension to the
inferior margin of the tarsus, pulling the lower edge of the Capsulopalpebral fascia
tarsus inferiorly and posteriorly and thus preventing the lid Lockwood's ligament
margin from turning inward toward the eye B
’ Synchronous movement of the inferior rectus and lower lid
retractors so that the eyelid moves downward as the eye Figure 4.4 (A) Normal lower eyelid anatomy. The retractors pull the
travels in downgaze lower margin of the tarsus inferiorly and posteriorly, stabilizing the
eyelid. (B) Involutional entropion: laxity of the lower lid retractors is
’ Balance between the anterior and posterior lamellar tension
the primary cause of involutional entropion.
 4 • Diagnosis and Treatment of Entropion 117

squeezing of the lid seems to push the lid margin against the ’ Surgical or accidental trauma
eye. This condition most often occurs in patients who have ’ Recurrent chalazia or blepharitis
predisposing factors to involutional entropion, such as hori- ’ Stevens Johnson syndrome
zontal laxity and lax lower lid retractors. The retractors can- ’ Trachoma
not hold the lid in a normal position against the forceful
overriding orbicularis pushing the lid margin inward. In most patients with cicatricial entropion, the conjunctival
scarring is easy to see and the etiology is obvious (Figure 4.7).
As I said earlier, all instances of upper lid entropion are cicatri-
CICATRICIAL ENTROPION cial. There is no upper lid involutional entropion.
Cicatricial entropion is caused by shortening of the posterior
lamella, which pulls the eyelid margin inward (Figure 4.6).
Cicatricial entropion is common throughout the world,
especially where trachoma is endemic. Cicatricial entropion
is less common than involutional entropion, but it is still
seen in the United States. Any problem that causes scarring Orbicularis
muscle
of the conjunctiva may cause a cicatricial entropion
(Box 4.4). Common causes include:
Meibomian
Tarsus
glands
’ Ocular cicatricial pemphigoid
’ Alkali or acid burns
Meibomian
orifice Eyelash
and follicle

Mucocutaneous
junction

Figure 4.6 Cicatricial entropion. Note that the posterior lamellar

shortening pulls the eyelid inward.

Box 4.4 Anatomic Factors Contributing to

Involutional Entropion
Figure 4.5 Involutional entropion. Lax lower eyelid retractors allow ’ Laxity of lower lid retractors
the lid margin to turn inward. ’ Horizontal lid laxity
’ Overriding preseptal orbicularis muscle

A B

Figure 4.7 Mild cicatricial entropion caused by the Stevens Johnson syndrome. (A) Note subtle inversion of eyelid margin. (B) Mild conjunctival
scarring and shortening of the fornix are present. The scarring pulls the lid margin inward, causing the cicatricial entropion.
118 4 • Diagnosis and Treatment of Entropion

Marginal Entropion determine the etiology of the entropion. Ask, Is the entropion
Patients with cicatricial entropion have eyelashes against cicatricial? With your finger, return the inverted lid to its
the eye. The problem is classified as entropion, not trichiasis, normal position. Is there resistance to placing the lid in the
because the eyelid margin is obviously inverted. Most normal position? See if it springs back to the inverted posi-
patients diagnosed with trichiasis have a subtle form of cica- tion when you release it. If cicatricial changes are present, it
tricial entropion known as marginal entropion. Slit lamp is not easy to return the lid to its normal position. After you
examination of these patients shows that the lid margin is release the lid, it returns to the inverted position. Reposition
no longer a flat platform with well-defined right-angled the lid and observe the eyelid margin during the slit lamp
anterior and posterior edges. The posterior angle of the lid examination to see where scar tissue might be causing the
margin has a slightly rolled appearance, with the mucocuta- lid to pull inward. Evaluate the conjunctiva and tarsal plate
neous junction being more anterior than normal. There for signs of shrinkage or scarring. You usually are able to
may be subtle scarring or inflammation of the posterior sur- see some obvious conjunctival scarring that is the cause of
face of the conjunctiva and tarsus. This subtle shortening the entropion (Figure 4.8).
brings the eyelashes against the cornea. The diagnosis and
management of marginal entropion is discussed in the next
chapter. This is an important concept, so do not ignore it.
If Not Cicatricial, the Entropion Must
Be Involutional
CHECKPOINT With involutional entropion, you can return the lid to the
normal position with your finger and it will remain there for
At this point you should: a blink or two. If the entropion does not recur within a few
blinks, ask the patient to squeeze the lids closed for a
• Understand the definition of entropion moment and the entropion often returns. If the history sug-
• Be able to recognize entropion in a patient gests episodic inversion of the eyelid but none is present at
• Know the normal anatomic appearance of the eyelid the time of the examination, ask the patient to squeeze the
margin as seen with the slit lamp (this is very important
lids tightly. Frequently, the entropion will appear
in understanding trichiasis)
(Figure 4.9). Watch the patient blink normally. In some
• Know the anatomic factors responsible for a stable patients, the preseptal orbicularis muscle rolls upward,
eyelid
starting to push the lid margin inward (so-called overriding
• Understand the anatomic factors responsible for preseptal orbicularis). In some cases, it seems that laying
• Involutional entropion the examination chair downward helps to elicit the entro-
• Cicatricial entropion pion with forced eyelid closure.
There is no clinically reliable diagnostic sign that shows
that the lower lid retractors are lax. Some texts describe a
white line of retractors that is visible through the palpebral
conjunctiva, signifying a disinsertion of the retractors.
History I have never been convinced that this sign is present. Often,
Patients with entropion complain of eye irritation. You may the lower eyelid rides above the lower limbus, suggesting
be able to identify the type of entropion based on the fea- some laxity of the lower eyelid retractors.
tures of the irritation. Intermittent symptoms suggest an invo-
lutional cause. The patient often recognizes that the eyelid is
inverting and causing the symptoms. Your patient may
have discovered that manual eversion of the eyelid tempo-
rarily improves the irritation. Occasionally, a patient comes
to the office with tape on the cheek to prevent the involu-
tional entropion. Constant symptoms of irritation suggest a
cicatricial cause. Manual repositioning of the lid does not offer
any relief because the lid immediately returns to its inverted
position on release. The patient with cicatricial entropion
may identify a specific onset of the entropion after an injury
or infection.

Physical Examination
ETIOLOGY
Is the Entropion Cicatricial?
The goal of the eyelid examination in the patient with entro-
pion is to determine the type of entropion and the most Figure 4.8 Cicatricial entropion. Note conjunctival scarring, caused by
appropriate treatment. First, look to see if the lid margin is a chemical burn in this patient, causing the entropion. Note upper
in the normal position. If the eyelid margin is inverted, the eyelashes turned against the cornea. The lower eyelid is being
manually everted to demonstrate inferior fornix scarring.
patient has entropion. Now ask yourself a few questions to
 4 • Diagnosis and Treatment of Entropion 119

Figure 4.10 Severe cicatricial entropion resulting from trachoma.

Note meibomian glands opening as slits on the back of the tarsus.

B
Box 4.5 Entropion Evaluation: Ask Yourself These
Questions

Is the entropion cicatricial?

’ Reposition the eyelid.
’ Is eversion difficult?

’ Does the lid return to the inverted position immediately?

If yes, it is probably cicatricial.

’ Look for scarring of the posterior lamella.
’ Determine the location and severity of the scarring.

’ Will a graft be necessary, or is a tarsal fracture operation enough?

If not cicatricial, then it must be involutional.

C ’ Reposition the eyelid.
’ Does the eyelid easily evert with your finger?

’ Does the eyelid remain in position?

Figure 4.9 Involutional entropion. (A) Patient complaining of
’ Does forceful lid closure cause the entropion to return?
intermittent right eye irritation. (B) Ask patient to squeeze eyes
closed. (C) Lower eyelid entropion precipitated by squeezing. ’ If yes, the entropion is involutional.

Is there lid laxity present?

’ Do eyelid distraction and eyelid snap tests.
’ Plan retractor reinsertion, usually with a lateral tarsal strip

PLANNING TREATMENT operation.

Involutional Entropion: Is There Associated Lower Lid

Laxity?
The typical patient with lower lid involutional entropion is minimal or extensive? The easiest way to evaluate the degree of
elderly and has associated horizontal lower eyelid laxity. scarring is to identify the position of the meibomian gland
Once you have established that the entropion is involu- orifices. Start evaluating the position of the meibomian
tional, check for horizontal lid laxity using the eyelid distrac- glands in the least inverted part of the lid and follow them to
tion and eyelid snap tests (explained in Chapter 3). Although the most inverted part. With severe cicatricial entropion,
the mainstay of surgical correction of lower lid involutional the meibomian glands open on the posterior surface of the
entropion is to tighten the lower lid retractors, any horizon- tarsus (Figure 4.10). With subtle cicatricial entropion, visuali-
tal lid laxity should be corrected, as well. zation of the line of meibomian gland orifices and the relationship
to the mucocutaneous junction is especially important. You
Cicatricial Entropion: Characterize the Scar Tissue often see that the mucocutaneous junction is near, or some-
If the entropion is cicatricial, the scarring is usually obvious. times anterior, to the meibomian glands.
The goal of the repair of cicatricial entropion is to restore The diagnosis of entropion is usually straightforward.
the posterior lamella to its normal length. Think about Identifying the cause becomes easy with experience. Once
how this might be done as you are assessing the scar tissue. you have identified the type of entropion, selection of the
Is the scarring localized or widespread? Is the contracture appropriate treatment follows (Box 4.5).
120 4 • Diagnosis and Treatment of Entropion

subciliary incision. The landmark for the lower lid retractors is

Treatment of Entropion the preaponeurotic fat. The fat is dissected off the anterior sur-
face of the retractors. The posterior surface of the retractors
INVOLUTIONAL ENTROPION is dissected free from the underlying conjunctiva for a
As discussed above, involutional entropion is associated few millimeters. The retractors are pulled superiorly and
with: sutured to the inferior tarsal margin. A slight eversion of the
lid margin is recommended. This slight intraoperative over-
’ Horizontal lower lid laxity correction usually resolves postoperatively. Using a lateral
’ Laxity of lower lid retractors tarsal strip operation in combination with the retractor reinser-
’ Overriding preseptal orbicularis tion operation eliminates overcorrection from a practical point of
view.
The ideal operation to repair involutional entropion To perform a retractor reinsertion operation, you:
should correct as many of these etiologic factors as possible.
The retractor reinsertion operation is the procedure of choice ’ Make a subciliary incision
for correction of lower lid involutional entropion. Tightening of ’ Identify the lower lid retractors
the lower lid retractors pulls the inferior edge of the tarsus ’ Dissect the retractors off the conjunctiva
inferiorly, providing a powerful eversion of the lid margin. ’ Advance the lower lid retractors onto the tarsus
The retractor reinsertion operation is so powerful that over- ’ Add a lateral tarsal strip operation if necessary
correction of the entropion is possible when lid laxity is pres- ’ Close the skin
ent. Overcorrection can actually cause the lid to be everted
postoperatively (Figure 4.11). Performing a lateral tarsal The steps of the retractor reinsertion operation are:
strip operation in addition to the retractor reinsertion proce-
dure adds stability to the eyelid and prevents an overcorrec- 1. Prep the patient.
tion. I use the lateral tarsal strip procedure for nearly all A. Instill topical anesthetic.
patients with lower lid involutional entropion. The preseptal B. Mark for the subciliary incision.
orbicularis muscle is prevented from overriding superiorly C. Inject local anesthetic containing epinephrine into
on the tarsus by the subciliary incision scar. Enophthalmos the lower lid fornix and anteriorly under the skin
is no longer considered an etiologic factor, so we do not (Figure 4.12A).
need to worry about that. 2. Make a subciliary incision.
A. Stabilize the lower lid with a 4-0 silk traction suture
The Retractor Reinsertion Operation (Ethicon no. 783 P-3 cutting needle) and clamp to
The goal of the retractor reinsertion operation is to correct the drape. As you get more experience, you find
the laxity of the lower lid retractors. During this proce- that the traction suture is not necessary for many
dure, the retractors are identified and advanced onto the procedures, but for the retractor reinsertion, I use it
lower lid tarsus. This provides a greater inferior and poste- routinely.
rior pull on the inferior edge of the tarsal plate and an B. Cut along the mark with a no. 15 blade or
eversion of the lid margin. Colorado microdissection needle through the skin
The lower lid anatomy is similar to the upper lid anatomy. (see Figure 4.12B).
Let’s preview the steps of the retractor reinsertion operation. C. Use a Colorado microdissection needle (or Westcott
The lower lid retractors are approached through a lower lid scissors) to cut the orbicularis muscle. Usually, the
subciliary incision is superior to the inferior edge of
the tarsus.
D. After cutting into the pretarsal orbicularis muscle,
stay anterior to the septum, if possible, and dissect
inferiorly toward the inferior orbital rim (see
Figure 4.12).
3. Identify the lower lid retractors.
A. Remember that the preaponeurotic fat is the
landmark for the lower lid retractors. Open the
orbital septum to find the preaponeurotic fat. In
many older patients, the fat is retracted and difficult
to see. Frequently, the white layer of the retractors
is visible before the fat is seen. If you are not sure
that these are the retractors, have the patient look
way up and way down to see if the retractors move.
Do not expect the lower lid retractors to move as
much as the levator aponeurosis in the upper lid
(Figure 4.13A).
4. Dissect the retractors off the conjunctiva.
Figure 4.11 Postoperative ectropion after retractor reinsertion. Note A. After you have identified the retractors, use
that a lateral tarsal strip was done on the right side but not on the Westcott scissors to free the fat from the anterior
left side.
surface of the retractors (see Figure 4.12D).
 4 • Diagnosis and Treatment of Entropion 121

A B

C D

F
E

Figure 4.12 Retractor reinsertion operations. (A) Mark a subciliary incision and inject local anesthetic. (B) Place a 4-0 silk traction suture. Make a skin
incision with a Colorado needle or no. 15 blade. (C) Dissect a skin muscle flap inferiorly. (D) Open the orbital septum to find the preaponeurotic fat.
Use the Westcott scissors to dissect the fat off the anterior surface of the lower lid retractors. (E) Dissect the lower lid retractors off the conjunctiva.
(F) Advance the lower eyelid retractors onto the tarsus. (G) Lateral view of the lower lid retractors reattached. (H) Close the skin with absorbable
sutures. Note that a lateral tarsal strip procedure has been performed.
Continued
122 4 • Diagnosis and Treatment of Entropion

H
G

Figure 4.12 continued.

A B

Figure 4.13 Retractor reinsertion operation. (A) Five to ten mm of the lower lid retractors has been freed up from the underlying conjunctiva. Note
the preaponeurotic fat anterior to the lower lid retractors. (B) The retractors have been advanced onto the tarsus.

B. Next, free up the posterior aspect of the retractors and the retractors. It is helpful to inject some
from the underlying conjunctiva (see Figure 4.12E). local anesthesia posteriorly to “hydro-dissect” the
C. Start a few millimeters below the inferior edge of the conjunctiva off the lower eyelid retractors.
tarsus. Cutting through the retractors causes some (1). It is not possible or necessary to separate the
bleeding. Dissect a plane between the conjunctiva retractors into the voluntary and involuntary
 4 • Diagnosis and Treatment of Entropion 123

parts. The full thickness of the retractors

should be advanced as a whole. Box 4.6 The Retractor Reinsertion Operation
(2). If you buttonhole the conjunctiva, it is not a ’ Instill local anesthetic with epinephrine.
problem. ’ Use 4-0 silk traction suture to stabilize the lower lid margin.
D. Free up a few millimeters of the retractors (see ’ Make a subciliary incision.
Figure 4.13A). ’ Identify the retractors.
E. Note that most patients do not have a disinsertion ’ Dissect the preaponeurotic fat off the retractors.
of the retractors. You have to create an edge of ’ Dissect an edge of retractors off the conjunctiva.
retractors to reattach onto the tarsus. ’ Make a lateral tarsal strip and reattach to the rim.
5. A lateral tarsal strip operation is almost always ’ Advance the retractors onto the tarsus using 5-0 Vicryl sutures
necessary. (Ethicon J493 P-3 needle or J571 5-0 Vicryl S-14 needle).
A. If there is associated lower lid laxity, I usually ’ Close the skin.
perform the lateral tarsal strip operation after the
retractors are isolated and before they are advanced.
The lateral tarsal strip procedure is performed in the
same way as in any ectropion repair. When the lid entropion. The exact mechanical factors are poorly under-
is tightened appropriately, you see the lid well stood but are probably the same as those causing involu-
apposed to the globe. tional entropion. If the cause of the underlying spasm can
6. Advance the lower lid retractors onto the tarsus. be eliminated, the spastic entropion resolves. If it is not pos-
A. Reattach the edge of the retractors to the inferior sible to eliminate the irritation, a cycle of spasm, irritation,
margin of the tarsus using three interrupted 5-0 and more spasm follows. A quick solution to spastic entro-
Vicryl sutures on a spatula needle (Ethicon 5-0 pion is the use of Quickert sutures.
Vicryl J493 P-3 needle or J571 S-14 needle) (see Quickert sutures are used to mechanically tighten the
Figures 4.12F and 4.13B). lower lid retractors without any skin incision. After adminis-
B. Release the traction suture. You see immediately tration of local anesthetic, double-armed sutures are passed
that the lid margin may be turned outward very full thickness through the lid, entering the conjunctiva poste-
slightly. If the retractors do not seem tight enough, riorly low in the fornix and exiting on the anterior surface of
advance them a bit more. It is ideal to have a small the lid just inferior to the lashes. Medial, central, and lateral
amount of overcorrection (see Figure 4.12G). double-armed sutures are placed. The sutures are tied to give
C. If you are not going to add a lateral tarsal strip a slight overcorrection. The sutures are not removed but are
operation to the procedure, be careful not to left to dissolve over 7 to 10 days. In theory, the sutures pli-
overcorrect much. cate the retractors, making them stronger. The scar tissue
7. Close the skin. that forms as the sutures dissolve holds the retractors in posi-
A. Close the subciliary skin incision with a running 5- tion. A scar forms where the sutures leave the skin, creating
0 or 6-0 mild chromic suture (see Figure 4.12H). a barrier to the overriding preseptal orbicularis.
You can use 6-0 Prolene, but most of these patients The steps of the Quickert suture procedure are:
are elderly and there is no visible scar if you use
chromic sutures. 1. Instill local anesthesia.
B. During the skin closure, combine the canthotomy A. Instill topical anesthetic, and inject local anesthetic
with the subciliary incision closure, re-forming the with epinephrine in the conjunctival fornix and
lateral canthal angle. the skin.
8. Provide postoperative care. Instill topical antibiotic 2. Pass double-armed sutures from the fornix
ointment. through the lid to emerge under the lashes.
A. Load a double-armed 4-0 chromic (Ethicon 793,
The retractor reinsertion operation is a very powerful pro- G-3 needle double-armed) suture back-handed.
cedure. Recurrence of entropion is rare, because the proce- B. Pass each arm of the suture through the lid from
dure addresses all the factors contributing to entropion. deep in the conjunctival fornix, passing anteriorly
Adding the lateral tarsal strip procedure corrects the etio- and superiorly to emerge from the skin just inferior
logic factor of lid laxity and prevents overcorrection to the eyelashes (Figure 4.14A). Repeat, placing
(Box 4.6). The subciliary incision and scar likely prevent the medial, central, and lateral sutures in position (see
preseptal orbicularis from overriding. Although the retrac- Figure 4.14B).
tor reinsertion can be performed from the conjunctival side, 3. Tie the sutures.
this anterior adhesion is not corrected, so I prefer the ante- A. Tie the sutures on the skin, creating a slight
rior approach. eversion of the eyelid margin. Remember that you
will not be correcting any horizontal lid laxity if it is
present, so be conservative with the overcorrection
SPASTIC ENTROPION (Box 4.7).
Quickert Sutures A few surgeons use Quickert sutures as a primary method
Spastic entropion occurs when the lids are held in a guarded of repair for all instances of involutional entropion. In many
position (protective blepharospasm) in response to eye pain patients, this technique provides a long-term cure for the
or inflammation. The constant spasm of the lids causes an entropion. However, any lower lid laxity is not addressed,
124 4 • Diagnosis and Treatment of Entropion

A B

Figure 4.14 The Quickert suture repair of entropion. (A) Everting sutures in position, tightening lower lid retractors, lateral view. (B) Everting sutures
in position, front view.

lengthening of the posterior lamella are necessary using

Box 4.7 Quickert Sutures Operation mucous membrane grafts.
The tarsal fracture operation is very successful for
’ Instill topical and local anesthetic.
’ Load a double-armed 4-0 chromic suture (Ethicon no. 793, G-3
patients with mild lower lid cicatricial changes. The more
needle) back-handed. advanced procedures have variable results, and secondary
’ Pass the arms of the suture through the lid from deep in the procedures are often required.
conjunctival fornix, passing anteriorly and superiorly to
emerge from the skin just below the eyelashes.
’ Repeat so that there are medial, central, and lateral sutures in
Mild Cicatricial Entropion of the Lower Eyelid: The
position. Tarsal Fracture Operation
’ Tie the sutures so that there is a slight overcorrection. Do not The tarsal fracture operation lengthens and reorients the
aggressively overcorrect, especially at the medial suture; scarred posterior lamella by a small amount. A horizontal
holding back prevents long-term ectropion.
incision across the lower tarsus is made. The lid is then
“fractured” or bent out. The surgical wound spreads apart.
The wound is stabilized in an open position with double-
armed 6-0 Vicryl sutures (Figure 4.15). Keep in mind that
and the advancement of the retractors is not as secure. In this procedure is only good for mild cicatricial entropion
theory, recurrence is more likely to occur. The main indica- because the posterior lamella is lengthened only minimally.
tion for Quickert sutures is spastic entropion, in which the The tarsal fracture operation is most often used in the lower
irritation is likely to resolve, or the rare situation for which a eyelid. If you have a patient with mild entropion of the
retractor reinsertion operation is not practical in debilitated upper eyelid, the tarsal fracture operation can be used, but
patients. For those patients, Quickert sutures can be per- you must be careful to place the conjunctival pass of the
formed at the bedside or in the examination chair. suture in the fracture wound to avoid sutures rubbing
against the cornea (a bandage soft contact lens is appropri-
ate). The tarsal fracture operation is discussed in more detail
CICATRICIAL ENTROPION
in Chapter 5.
Cicatricial entropion is treated by lengthening of the poste-
rior lamella. If the posterior lamellar shortening is mild, as
with marginal entropion of the lower eyelid, the tarsal frac-
Mild to Moderate Cicatricial Entropion of the Upper
ture operation (also called a tarsotomy) is used. This proce- Eyelid: Anterior Lamellar Advancement
dure can also be used for mild cases of contracture in the In mild cases of upper eyelid entropion, the pretarsal skin
upper eyelid; however, your patient needs to wear a soft and muscle can be advanced using a skin crease incision.
contact lens for a few weeks after surgery to avoid the irrita- Make a skin crease incision and dissect the pretarsal orbicu-
tion of the cut tarsus. For upper eyelid cases where the con- laris off the tarsus to about 2 mm above the eyelid margin.
tracture is worse but not severe, you can advance the You often see eyelash roots at this point. Use double-armed
anterior lamella from the skin crease inferiorly. If the cica- 6-0 Vicryl sutures placed high on the tarsus and passed
tricial changes are severe, lysis of the scar tissue and more inferiorly through the anterior lamella. As these
 4 • Diagnosis and Treatment of Entropion 125

Figure 4.15 Tarsal fracture operation. (A) Pass a traction suture. Evert the eyelid. Make a horizontal incision full thickness through the posterior
surface of the tarsus. The Colorado needle is useful for minimizing bleeding. (B) Pass double-armed 6-0 Vicryl sutures below the inferior margin of
the tarsus to emerge immediately inferior to the eyelashes, lateral view. (C) Pass and tie three or four double-armed sutures. (D) Leave the lid
margin in a slightly everted position, lateral view.

sutures are tied, the superior traction on the anterior

lamella counters the preexisting pathologic posterior lamel- Moderate or Severe Cicatricial Entropion: Mucous
lar shortening. Because both the anterior and posterior Membrane Grafting
lamellae are shortened at the conclusion of this procedure, Moderate or severe shortening of the posterior lamella can-
some eyelid retraction may occur. This procedure can be not be repaired with excision of the scar tissue alone.
combined with a tarsal fracture procedure to produce more Mucous membrane grafts must be placed to prevent the
eversion. As you dissect inferiorly on the tarsal plate, stop scarring of the posterior lamella from returning. Correction
prior to the tarsal fracture incision. Place the inverting of the entropion starts with lysis of the scarred conjunctiva
sutures as usual (Figure 4.16). so that the lid margin can return to its normal position.
126 4 • Diagnosis and Treatment of Entropion

A B

C D

Figure 4.16 Anterior lamellar advancement. (A) Mild cicatricial entropion of upper eyelid. (B) Skin crease incision and dissection to lash roots.
(C) Advancement of anterior lamella using a lamellar pass of a double-armed 6-0 Vicryl suture into the superior third of tarsus, passing out through
the inferior third of the anterior lamella. (D) As the sutures are tied, the eyelid inversion is corrected. A slight overcorrection is recommended.
(E) Usually, three sutures are passed. The skin crease is closed.
 4 • Diagnosis and Treatment of Entropion 127

After the scar has been released, mucous membrane is sewn recessed position. In some cases, the eyelid skin is eventu-
over the defect (Figures 4.17 and 4.18). ally pulled inward and a further operation may be
Mucous membrane can be harvested from the side of the necessary.
mouth, buccal mucosa, or labial mucosa of the lower lip. Keep in mind that patients with severe cicatricial entro-
Buccal mucosa wounds can be closed primarily, whereas pion no longer have normal ocular lubrication, Often, the
labial mucosal donor sites must undergo granulation. Using lacrimal ductules are scarred closed. The accessory lacrimal
the operating microscope to sew the graft in place is much glands are destroyed. The damaged eyelids do not have a
easier than using surgical loupes. Stabilizing the graft with normal quick blink and may have lagophthalmos. Some
TISSEEL glue as in pterygium surgery is helpful to maintain patients require stem cell transplantation and corneal
the graft position. A contact lens and eye patch are used transplantation following eyelid reconstruction. Most
postoperatively. patients benefit from these operations, but you should
Anterior lamellar eyelash excision can be used in patients not create high expectations for a normal-appearing or
with moderate degrees of cicatricial entropion of the upper comfortable eye. Lubrication is required forever in most
eyelid if a somewhat ptotic eyelid exists. This procedure is cases.
easier to do and heals more comfortably than the tarsal More advanced forms of cicatricial entropion are diffi-
fracture type of procedure. The patient has to agree to lose cult to treat. Reoperations are often required. Despite
all the eyelashes completely, however. Under local anes- repositioning of the lid margin and eyelashes, many
thesia, you can split the eyelid at the gray line and excise patients still complain of eye irritation because of the poor
the inferior 2 to 3 mm of anterior lamella containing the lubrication. Often, the lacrimal ductules are scarred
eyelash follicles. Suture the remaining anterior lamellar closed. The accessory lacrimal glands are destroyed. The
edge to the tarsus with vertical mattress sutures in a damaged eyelids do not have a normal complete quick

Figure 4.17 Mucous membrane grafting to lengthen the posterior lamella in cicatricial entropion (see Figure 4.18). (A) Cut the scar tissue using a
horizontal incision through the posterior surface of the tarsus to return the eyelid margin to normal position. This creates a posterior lamellar defect.
(B) Repair the posterior lamellar defect using a mucous membrane graft to prevent contracture.
128 4 • Diagnosis and Treatment of Entropion

A B

Figure 4.18 Mucous membrane graft to repair severe cicatricial entropion, caused by trachoma in this patient (see Figure 4.10). (A) Mucous
membrane graft sewn in position, lengthening the posterior lamella. (B) Following healing, the eyelid margin is no longer inverted. A thin line of
the graft is visible.

A B

Figure 4.19 Severe cicatricial entropion due to Stevens Johnson syndrome. (A) This young lady had undergone many eyelid and anterior segment
procedures. Preoperatively, she could see only hand motions and could not open her eyes due to severe photophobia. (B) After right upper and
lower eyelid reconstruction with mucous membrane grafting, stem cell transplantation, and penetrating keratoplasty, she was able to see 20/80
with relatively comfortable eyes. She had not seen the faces of her friends and family for several years. She continues to require frequent lubrication
and immunosuppressive therapy.

blink and may have lagophthalmos. Some patients require complete anatomic and functional rehabilitation to
stem cell transplantation and corneal transplantation fol- patients with moderate or severe cicatricial entropion
lowing eyelid reconstruction. Most patients benefit from (Figure 4.19). Lubrication will be required forever in most
these operations. Do not be overly optimistic and promise cases.
 4 • Diagnosis and Treatment of Entropion 129

For mild to moderate upper eyelid entropion, excision of the ante-

CHECKPOINT
rior lamella containing the eyelash follicles is an alternative to rota-
tion procedures. This procedure shortens the anterior lamella to
You should be able to: match the posterior lamellar length and removes all eyelashes.
• Describe the typical presentation of Treatment of moderate or severe cicatricial entropion requires lysis
• A patient with involutional entropion of the scar tissue and mucous membrane grafts to lengthen the pos-
• A patient with cicatricial entropion terior lamella.
• How do the history and physical examination for
cicatricial entropion differ from those for involutional
entropion?
• Remember the questions to ask yourself in the Suggested Reading
physical examination (e.g., can the lid be everted Albert DM, Lucarelli MJ. Entropion. Clinical atlas of procedures in ophthal-
easily) mic surgery. Chicago: AMA Press,; 2004:257 260.
• State by memory the steps of the retractor reinsertion Allen RC. Oculoplastic surgery techniques (videos). EyeRounds.org.
operation University of Iowa Department of Ophthalmology and Visual Sciences,
• State by memory the steps of the Quickert suture University of Iowa Carver College of Medicine, Iowa City, IA. Available
at: http://www.eyerounds.org/video/plastics/index.htm. (Well-done,
procedure quick video review of surgical procedures.)
• Understand the principles of repair of cicatricial American Academy of Ophthalmology. Basic and clinical science course:
entropion and when a graft might be needed orbit, eyelids, and lacrimal system. San Francisco: The American
Academy of Ophthalmology, 2017, sect. 7, pp. 201 205.
Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol.
1979;97:2192 2196.
Barber K, Dabbs T. Morphologic observations on patients with presumed
trichiasis. Br J Ophthalmol. 1988;72:17 22.
Major Points Collin JR, Rathbun JE. Involutional entropion: a review with evaluation
of a procedure. Arch Ophthalmol. 1978;96(6):1058 1064.
Dutton JJ. Entropion. Atlas of ophthalmic surgery. vol. 2. St. Louis: Mosby
Entropion of the eyelid occurs when the lid margin inverts or turns Year Book; 1992:114 143.
against the eyeball. There are four main types of entropion: Goldberg RA, Kim JW, Shorr N, et al. Surgery of the lower eyelid.
’ Involutional In: Wobig JL, Dailey RA, eds. Oculofacial plastic surgery: face, lacrimal
’
system, and orbit. New York: Thieme; 2004:91 97.
Spastic Jones LT, Reeh MJ, Wobig JL. Senile entropion: a new concept for correc-
’ Cicatricial tion. Am J Ophthalmol. 1972;74(2):327 329.
’ Marginal Katowitz JA, Heher KL, Hollsten DA. Involutional entropion. In: Levine
Factors contributing to lower lid involutional entropion include: MR, ed. Manual of oculoplastic surgery. 3rd ed. Boston: Butterworth-
Heinemann; 2003:137 144.
’ Laxity of lower lid retractors Kersten RC, Kleiner FP, Kulwin DR. Tarsotomy for the treatment of cica-
’ Horizontal lid laxity tricial entropion with trichiasis. Arch Ophthalmol. 1992;110:714.
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Shortening of the posterior lamella causes cicatricial entropion. surgery. 3rd ed. New York: Raven Press; 1995:221 248.
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’ The retractor reinsertion operation Nerad JA. Eyelid malpositions. In: Linberg JV, ed. Contemporary issues in
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Treatment of mild cicatricial entropion uses incisions with sutures Nerad JA, Carter KD, Alford MA. Entropion. Rapid diagnosis in ophthalmol-
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Penne RB. Entropion. Color atlas and synopsis of clinical ophthalmology:
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’ For mild upper lid entropion, the terminal tarsal rotation Wesley RE. Cicatricial entropion. In: Levine MR, ed. Manual of oculoplastic
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you use this, be sure to bury the sutures to protect the cornea; a
bandage contact lens may be required for a few weeks)