- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Medical therapy may be warranted for patients who decline surgery and as a temporizing maneuver in patients who may improve spontaneously.3
- Ocular lubrication and tear preparations are helpful for protecting the ocular surface and also may break the cycle in patients with spastic entropion due to dry eye syndrome.
- Eyelid hygiene, antibiotics, and corticosteroids are useful for the treatment of blepharitis, which may cause spastic entropion.
- Small amounts of botulinum toxin (BOTOX®) (approximately 5 U) are quite effective for the treatment of spastic entropion by weakening the pretarsal orbicularis oculi muscle.
- Patients with cicatricial entropion secondary to ocular cicatricial pemphigoid may benefit from systemic chemotherapy, usually dapsone.
Surgical Care
Multiple surgical procedures have been described for the management of entropion.4,5,6 The procedure chosen must be appropriate for the class of entropion being treated.
Involutional entropion. Correction of entropion with eyelid retractor reattachment and lateral canthopexy.
The most common procedures utilized in the management are as follows:
- Temporizing Quickert-Rathbun sutures7
- They are effective for many cases of spastic entropion, as well as for some cases of involutional entropion in which the patient refuses or is medically unable to undergo more definitive procedures.
- Full-thickness eyelid sutures (usually gut suture) from the inferior fornix anteriorly toward the lashes are used to torque the eyelid margin away from the globe. Tissue reaction to the gut suture helps to create a cicatrix in the eyelid that maintains the eyelid in the everted position.
- Repair of involutional entropion
- It may require repair of the horizontal laxity via medial and/or lateral canthal tightening.
- The vertical component is best repaired by vertically shortening or reattaching the lower eyelid retractors to the inferior border of the tarsus via a lower eyelid transcutaneous approach.
- A small amount of the pretarsal orbicularis oculi can be resected concurrently to prevent further overriding of the tarsus.
- Procedures for the repair of cicatricial entropion
- They will depend on the degree of scarring and entropion, the etiology of the cicatricial changes, and the status of the tarsal plate.
- Mild cases can be treated with a transverse blepharotomy with marginal rotation (Wies procedure).
- More extensive scarring may require oral mucous membrane (eg, buccal mucosa) or cadaveric dermis (eg, Alloderm) grafts.
- It is important that the inflammatory process is in a quiescent state in OCP patients prior to any procedure that violates the conjunctiva. Any manipulation of the conjunctiva in these patients may cause a recurrence of inflammation with failure of the procedure.
- Assess the status of the tarsal plate in all cases of cicatricial entropion. If it is distorted, place a facsimile of tarsus following excision of the distorted portions of the tarsal plate. Materials such as autologous tarsus, hard palate grafts, and chondromucosal grafts have been used successfully for this purpose.
Consultations
Consultation with an internist or a hematologist is recommended for OCP patients requiring immunosuppressive medications, as well as for systemic evaluation to rule out other autoimmune diseases.
Medication
Topical, local, and systemic medications may be useful in the management of various forms of entropion.
Ocular lubricants
Topical ocular lubricants may be necessary to increase patient comfort and to diminish abrasive conjunctivopathy and keratopathy.
Artificial tears
Preservative-free artificial tears are preferred to avoid preservative-associated ocular reactions.
Adult
1-2 gtt into eye(s) prn
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Hyperemia, photophobia, stickiness of eyelashes, ocular discomfort or irritation may occur
Immunosuppressive agents
These medications have been shown to effectively diminish the autoinflammatory reaction associated with ocular cicatricial pemphigoid.
Dapsone (Avlosulfon)
Bactericidal and bacteriostatic against mycobacteria; mechanism of action is similar to that of sulfonamides where competitive antagonists of PABA prevent formation of folic acid, inhibiting bacterial growth.
Adult
100 mg/d PO
Pediatric
Not established
May inhibit anti-inflammatory effects of clofazimine; hematologic reactions may increase with folic acid antagonists, eg, pyrimethamine (monitor for agranulocytosis during the second and third months of therapy); probenecid increases dapsone toxicity; trimethoprim with dapsone may increase toxicity of both drugs; due to increased in renal clearance, dapsone levels may significantly decrease when administered concurrently with rifampin
Documented hypersensitivity; known G-6-PD deficiency
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Perform weekly blood counts (first month); then perform WBC counts monthly (6 mo); then semi-annually; discontinue if significant reduction in platelets, leukocytes, or hematopoiesis is seen
Caution in methemoglobin reductase deficiency, G-6-PD deficiency (patients receiving >200 mg/d), or hemoglobin M due to high risk for hemolysis and Heinz body formation; caution in patients exposed to other agents or conditions (eg, infection, diabetic ketosis) capable of producing hemolysis
Peripheral neuropathy can occur (rare)
Phototoxicity may occur when exposed to UV light
Neuromuscular transmission blocking agents
Weakening or paralyzing the orbicularis muscle of the lower eyelid helps in preventing the inturning of the lower eyelid in cases of spastic and involutional entropion.
Botulinum toxin type A (BOTOX®)
Temporarily paralyzes the muscles by inhibiting acetylcholine release. Duration of effectiveness usually is 3-4 mo.
Adult
5-10 U injected into orbicularis muscle
Pediatric
Not established
Aminoglycosides or drugs that interfere with neuromuscular transmission may potentiate effects of botulinum toxin
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Injection should not be too superficial such that the orbicularis muscle is not affected or too deeply such that the inferior oblique muscle is weakened; do not exceed recommended dosages and frequencies of administration; presence of antibodies to botulinum toxin type A may reduce effects of therapy
More on Entropion |
| Overview: Entropion |
| Differential Diagnoses & Workup: Entropion |
 Treatment & Medication: Entropion |
| Follow-up: Entropion |
| Multimedia: Entropion |
| References |
| Further Reading |
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References
Awan MA, Chadha V, Gonzalez P, Diaper CJ, Cauchi P, Kemp EG. Small tarsal plates causing recurrent lower lid entropion in a young adult. Eye. Feb 6 2009;[Medline].
Pasco NY, Kikkawa DO, Korn BS, Punja KG, Jones MC. Facial nerve paralysis: an unrecognized cause of lower eyelid entropion in the pediatric population. Ophthal Plast Reconstr Surg. Mar-Apr 2007;23(2):126-9. [Medline].
Maycock NJ, Sahu DN, Mota PM, Gaston H, Hodgkins PR. Conservative management of upper eyelid entropion. J Pediatr Ophthalmol Strabismus. Nov-Dec 2008;45(6):377-8. [Medline].
Gu J, Wang Z, Sun M, Yuan J, Chen J. Posterior lamellar eyelid reconstruction with acellular dermis allograft in severe cicatricial entropion. Ann Plast Surg. Mar 2009;62(3):268-74. [Medline].
Swamy BN, Benger R, Taylor S. Cicatricial entropion repair with hard palate mucous membrane graft: surgical technique and outcomes. Clin Experiment Ophthalmol. May 2008;36(4):348-52. [Medline].
Hintschich C. Correction of entropion and ectropion. Dev Ophthalmol. 2008;41:85-102. [Medline].
Ho SF, Pherwani A, Elsherbiny SM, Reuser T. Lateral tarsal strip and quickert sutures for lower eyelid entropion. Ophthal Plast Reconstr Surg. Sep 2005;21(5):345-8. [Medline].
Bartley GB, Kay PP. Posterior lamellar eyelid reconstruction with a hard palate mucosal graft. Am J Ophthalmol. Jun 15 1989;107(6):609-12. [Medline].
Cheung D, Sandramouli S. Consecutive ectropion after the Wies procedure. Ophthal Plast Reconstr Surg. Jan 2004;20(1):64-8. [Medline].
Christiansen G, Mohney BG, Baratz KH, Bradley EA. Botulinum toxin for the treatment of congenital entropion. Am J Ophthalmol. Jul 2004;138(1):153-5. [Medline].
Dortzbach RK, McGetrick JJ. Involutional entropion of the lower eyelid. Ophthalmic Plast Reconstr Surg. 1983;2:257-267.
Khan SJ, Meyer DR. Transconjunctival lower eyelid involutional entropion repair: long-term follow-up and efficacy. Ophthalmology. Nov 2002;109(11):2112-7. [Medline].
McCord CD Jr, Chen WP. Tarsal polishing and mucous membrane grafting for cicatricial entropion, trichiasis and epidermalization. Ophthalmic Surg. Dec 1983;14(12):1021-5. [Medline].
Millman AL, Katzen LB, Putterman AM. Cicatricial entropion: an analysis of its treatment with transverse blepharotomy and marginal rotation. Ophthalmic Surg. Aug 1989;20(8):575-9. [Medline].
Quickert MH, Rathbun E. Suture repair of entropion. Arch Ophthalmol. Mar 1971;85(3):304-5. [Medline].
Further Reading
Related eMedicine topics
Lower Eyelid Reconstruction, Ectropion
Blepharoplasty, Lower Lid Ectropion Surgery
Corneal Abrasion
Corneal Laceration
Corneal Edema, Postoperative
Keywords
entropion, involutional entropion, cicatricial entropion, acute spastic entropion, congenital entropion, eyelid entropion, eyelid inversion, eyelid margin inversion, ocular irritation, eyelid retraction, corneal abrasions
