Entropion Clinical Presentation
- Author: Christopher DeBacker, MD; Chief Editor: Hampton Roy, Sr, MD more...
The first order of business when assessing the patient with entropion is to determine the etiology and place it into an appropriate classification.
Dysgenesis of the lower eyelid retractors may be present creating instability in the eyelid with consequent entropion, or a paucity of tissue may be present vertically in the posterior lamella of the eyelid. Structural defects in the tarsal plate also may result in a tarsal kink syndrome, with entropion in the upper eyelid.
Acute spastic entropion
Spastic closure of the eyelids allows the orbicularis oculi muscle to overwhelm the oppositional action of the lower eyelid retractors, resulting in an inturning of the eyelid margin and further irritation of the ocular surface from the inturned eyelashes. Most of these patients often have an involutional component as well.
The patient may exhibit horizontal laxity of the medial and/or lateral canthal tendons.
The snap test is a useful diagnostic maneuver. The eyelid margin is pulled away from the globe, with poor resultant snap back to the globe surface. Make sure the patient does not blink the lid back. If entropion is suspected but not elicited when the patient is in an upright position, lay the patient in a supine position and have him or her squeeze the eyelids closed. This will often manifest the entropion by allowing the orbital soft tissues to settle posteriorly, allowing the eyelid to turn inward. Patients usually have an involution of the posterior eyelid retractors, with the eyelid inturning in much the same manner as with spastic entropion. Involution of the soft tissues of the orbit, particularly the orbital fat, may lead to involutional enophthalmos, which in turn can lead to unstable eyelid position with entropion.
These patients usually will display scar tissue of the conjunctiva, usually a result of trauma, chemical burns, Stevens-Johnson syndrome, ocular cicatricial pemphigoid (OCP), infections, or local response to topical medication. Digital eversion of the eyelid margin is difficult in cases of cicatricial entropion, whereas it is quite easy in cases of involutional entropion. Examination of the tarsus and palpebral conjunctiva usually will point to the diagnosis in these cases. See the image below.
Entropion can be divided into the following classes: congenital, acute spastic, involutional, and cicatricial.
The congenital form of entropion is very rare. It may arise due to a number of underlying developmental abnormalities, usually in the lower eyelid. Facial nerve paralysis in the pediatric population has been shown to be associated with lower lid entropion.
Acute spastic entropion usually occurs as a result of ocular irritation, which may be due to infectious, inflammatory, or traumatic (eg, surgical) processes.
Involutional entropion usually is due to a constellation of problems.
Cicatricial entropion occurs as a result of scarification of the palpebral conjunctiva, with consequent inward rotation of the eyelid margin.
Other diagnostic considerations
Entropion must be distinguished from a number of other conditions that may simulate entropion.
Epiblepharon is a congenital condition in which the pretarsal orbicularis muscle and the skin covering the eyelid override the eyelid margin and push the eyelashes vertically or inwards. The eyelid margin in these cases actually is in a normal position. This condition most commonly is seen in the lower eyelids and is more common in Asians. Compared to congenital entropion, epiblepharon usually resolves spontaneously as the face matures.
Eyelid retraction also may simulate entropion in both the upper and lower eyelids. However, the eyelid margins in these cases display a normal apposition to the globe.
Trichiasis and distichiasis are conditions in which misdirected eyelashes are directed toward the globe. While trichiasis may coexist with entropion, particularly in cicatricial cases, it is a distinct entity and requires its own treatment approach.
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