What is the recommended management for entropion of the eyelid?

Management of Entropion

Surgical repair is the definitive treatment for entropion when conservative measures fail to control symptoms or when corneal damage is present. 1

Initial Conservative Management

Start with conservative measures for symptomatic relief while planning definitive surgical correction:

• Ocular lubrication is essential for all entropion patients to prevent corneal damage from the inward-turning eyelid margin 2, 1
• Use preservative-free artificial tears frequently throughout the day (may require administration as often as every 30 minutes in severe cases) 2
• Apply petrolatum-based ointments at bedtime to maintain overnight corneal protection 2
• Consider lipid-containing eye drops if meibomian gland dysfunction coexists 2

Critical caveat: Conservative therapy provides only temporary relief and is primarily used for preoperative stabilization or when surgery is not immediately feasible 3. Symptoms will recur when treatment is discontinued 2.

Indications for Surgical Intervention

Surgery should be performed when:

• Conservative treatment with artificial tears and lubricating ointments fails to control symptoms (eye pain, foreign body sensation, irritation) 1, 4
• Objective corneal damage is documented on slit-lamp examination, including:
  • Superficial punctate keratitis 1
  • Corneal abrasion 1, 4
  • Corneal ulceration 1, 4
  • Corneal scarring or vascularization 1, 4
• Severe acute presentation with corneal infiltrate, ulcer, or imminent perforation (requires urgent surgical intervention) 1

Documentation requirements before surgery: Trial period of conservative management, slit-lamp examination findings showing presence or absence of corneal epithelial damage, and clinical notes demonstrating persistent symptoms despite appropriate conservative measures 1.

Surgical Approach by Entropion Type

Involutional Entropion (Most Common Type)

This is the most prevalent form, increasing with population aging 4. It results from three pathological mechanisms: eyelid laxity, lower lid retractor weakness, and orbicularis oculi override 4, 3, 5.

Surgical options include:

• Everting sutures (Quickert technique): Minimal invasive, non-incision procedure with 87.88% success rate, completed in 10 minutes, and highly cost-effective 6. This is appropriate for straightforward involutional cases.
• Transverse blepharotomy with marginal rotation (Wies procedure): Addresses the underlying anatomical defects 4, 3
• Lower lid retractor advancement: Corrects retractor weakness 4
• Tarsal strip procedure: Addresses horizontal lid laxity 4
• Orbicularis transfer technique: Manages orbicularis override 4

Important surgical consideration: Avoid overcorrection, which can cause iatrogenic ectropion 3.

Cicatricial Entropion

This type results from persistent inflammation or injuries (e.g., Stevens-Johnson Syndrome, chemical injury) 2, 3.

Surgical management:

• Anterior lamellar recession (ALR) with mucous membrane graft (MMG): For severe segmental cicatricial entropion, this technique achieves 100% anatomical success at final follow-up (mean 14.8 months) with 87.5% improvement in ocular surface symptoms 7
• Success rates: 90% in Stevens-Johnson Syndrome, 80% in chemical injury 7
• Free mucosa grafts may be necessary for extensive cicatricial changes 3
• This eyelash-sparing technique avoids cosmetic concerns 7

Congenital Entropion

Observation is appropriate initially, as congenital entropion typically resolves spontaneously within the first 12 months of life 3. Surgery is not needed immediately unless corneal damage develops.

Spastic Inflammatory Entropion

Treat the underlying inflammation first—the entropion will resolve with successful treatment of the inflammatory condition 3.

Diagnostic Pearls for Intermittent Entropion

When entropion is suspected but not visible on examination:

• Perform provocation testing to elicit intermittent entropion 5
• Test of Induced Entropion-2 (TIE-2): Ask patient to look down while holding upper eyelid open and high, then have patient close eyelids tightly—this successfully induces entropion when conventional tests fail 5
• Other provocation techniques include forced eyelid closure and tetracaine provocation test 5

Monitoring for Complications

Untreated entropion leads to serious sequelae:

• Progressive corneal damage from chronic eyelash abrasion (trichiasis) 2, 4
• Microbial keratitis 4
• Corneal vascularization and scarring 4
• Visual loss 4, 3
• In cicatricial cases: symblepharon formation, punctal stenosis, progressive conjunctival shrinkage 2

Recurrence rates: Approximately 15% of cases may recur within 18 months, requiring repeat intervention 6. Residual trichiasis can be managed with repeat ALR with MMG or eyelash resection 7.