2d:I[856015,["/_next/static/immutable/chunks/1xzisbplk9czp.js","/_next/static/immutable/chunks/3j2i1faptc_-9.js","/_next/static/immutable/chunks/0fma7nlq6immz.js","/_next/static/immutable/chunks/08tq8rmv423j5.js","/_next/static/immutable/chunks/1chr5wkk3j58k.js","/_next/static/immutable/chunks/37kmmh_zm4dov.js","/_next/static/immutable/chunks/311zvdjfxff-f.js","/_next/static/immutable/chunks/1a_hqhrsle_n_.js"],"default"] 2e:T5191,

Summary Table

Category	Details
Risk Factors	Elderly patients (>60 years), prior trachoma, ocular cicatricial pemphigoid, Stevens-Johnson syndrome, chemical or thermal burns, prior eyelid surgery or trauma, chronic blepharitis
Etiology	Horizontal lid laxity with lower lid retractor disinsertion (involutional), conjunctival scarring (cicatricial), orbicularis spasm from irritation (spastic), congenital tarsal plate maldevelopment
Patient Presentation	Foreign body sensation, persistent tearing (epiphora), red eye, photophobia, blurred vision, sensation of "lashes poking the eye"
Classic Physical Exam	Inward rotation of the eyelid margin (most often the lower lid), eyelashes rubbing against the globe, conjunctival injection, punctate corneal staining with fluorescein, possible corneal ulcer
Key Diagnostic Results	Clinical diagnosis on slit-lamp examination; fluorescein staining shows corneal abrasion or pannus; positive snap-back and lid distraction tests indicate involutional laxity
Management	Temporizing: lubricating drops, lid taping, bandage contact lens, botulinum toxin. Definitive: surgical correction (Quickert sutures, lateral tarsal strip, retractor reinsertion, tarsal fracture/grafting for cicatricial)
Keywords	"Inward turning eyelid," "lashes rubbing the cornea," "elderly patient with chronic tearing," "history of trachoma," "snap-back test," "trichiasis from entropion"

1. Pathophysiology

Entropion is the inward inversion of the eyelid margin so that the lashes and keratinized skin contact the cornea and conjunctiva. The mechanism differs across the four classifications, but the end result is mechanical trauma to the ocular surface, producing the patient's symptoms.

In involutional (senile) entropion, three age-related changes converge: horizontal eyelid laxity (loss of canthal tendon tone), disinsertion or attenuation of the lower eyelid retractors, and override of the preseptal orbicularis muscle over the pretarsal orbicularis. When the orbicularis contracts during blinking, the upper portion of the muscle rolls over the lower portion and flips the tarsal plate inward. Coexisting enophthalmos from orbital fat atrophy removes the posterior support that normally keeps the lid apposed to the globe.

In cicatricial entropion, scar tissue on the posterior lamella (tarsoconjunctival surface) contracts and pulls the lid margin posteriorly toward the globe. This is the dominant mechanism in trachoma worldwide, and is also seen in ocular cicatricial pemphigoid, Stevens-Johnson syndrome, chemical burns, and prior surgery.

In spastic entropion, sustained orbicularis contraction from ocular irritation (postoperative inflammation, conjunctivitis) overrides normal lid position. It often resolves once the underlying irritant is treated, but it can become involutional if laxity already exists.

In congenital entropion, the tarsal plate is malformed or the lower lid retractors fail to attach properly, producing a true rolled-in lid. This is distinct from epiblepharon, in which the lid position is normal but a horizontal skin fold pushes the lashes against the globe (commonly seen in East Asian children and frequently self-resolving).

The downstream sequence is consistent: lashes contact the cornea, producing reflex tearing, foreign body sensation, and corneal epithelial defects. Untreated, this progresses to corneal ulceration, neovascularization (pannus), scarring, and vision loss, which is the chief reason entropion is treated rather than observed.

2. Classification and Clinical Manifestation

Type	Population	Mechanism	Distinguishing Features
Involutional (Senile)	Elderly, most common form in developed countries	Lid laxity + retractor disinsertion + orbicularis override + enophthalmos	Lower lid affected; intermittent at first, then constant; positive snap-back test
Cicatricial	Any age; trachoma-endemic regions, autoimmune, post-burn	Posterior lamellar scarring shortens conjunctiva	Upper or lower lid; visible conjunctival scarring; symblepharon may be present
Spastic	Post-surgical or post-inflammatory eye	Orbicularis spasm from irritation	Acute onset; resolves when irritation treated
Congenital	Neonates and infants	Tarsal plate malformation, retractor dysgenesis	Present from birth; true lid inversion (differs from epiblepharon)

3. Diagnostic Workup

Test	Purpose	Finding
Slit-lamp examination	Best initial test; confirms lid position and ocular surface damage	Inward lid rotation, lashes touching globe, conjunctival injection
Fluorescein staining	Detects corneal epithelial damage	Punctate keratopathy, abrasion, or ulcer
Snap-back test	Assesses lower lid laxity (involutional)	Lid fails to return promptly to globe after pulling down
Lid distraction test	Quantifies horizontal laxity	Lid pulls more than 6 to 8 mm from globe
Eversion of upper lid	Examines posterior lamella for cicatricial causes	Tarsal scarring, symblepharon, keratinization
Conjunctival biopsy	Reserved for suspected cicatricial pemphigoid	Linear IgG/IgA at basement membrane on immunofluorescence

Entropion is a clinical diagnosis made at the slit lamp. The best initial step is direct inspection of the eyelid margin in primary gaze followed by forceful blinking, because mild involutional entropion may only manifest with orbicularis contraction. Fluorescein staining is mandatory in every suspected case because the most consequential complication, corneal ulceration, must be identified before definitive repair is planned.

The snap-back test is performed by pulling the lower lid downward and releasing it without allowing the patient to blink. A normal lid snaps back immediately; in involutional entropion the lid returns slowly or only after a blink. The distraction test measures how far the lid can be pulled anteriorly from the globe, with greater than 6 to 8 mm indicating clinically meaningful laxity.

When the upper lid is involved, or when the patient has a history compatible with autoimmune or infectious scarring, the upper tarsal conjunctiva must be everted to look for the diagnostic features of trachoma (Arlt's line, Herbert's pits) or cicatricial pemphigoid (subepithelial fibrosis, symblepharon, fornix shortening). Conjunctival biopsy with immunofluorescence is the confirmatory test for ocular cicatricial pemphigoid and is the only way to distinguish it reliably from other scarring conjunctivitides.

4. Management and Treatment

Stage	Intervention	Indication
Ocular surface protection	Preservative-free artificial tears every 2 to 4 hours; lubricating ointment at bedtime	All patients pending definitive treatment
Lid taping	Horizontal tape pulling the lower lid skin downward and laterally	Temporary measure while awaiting surgery
Bandage contact lens	Soft therapeutic lens	Corneal abrasion or ulcer protection
Botulinum toxin injection	2.5 to 5 units into the pretarsal orbicularis	Spastic entropion or temporary control (3 to 4 months)
Quickert sutures	Three transverse everting sutures	Temporary or low-risk surgical option, useful in frail patients
Lateral tarsal strip + retractor reinsertion	Definitive procedure for involutional entropion	First-line definitive surgery
Tarsal fracture or mucous membrane graft	Posterior lamellar lengthening	Cicatricial entropion
Treatment of underlying disease	Systemic immunosuppression (cicatricial pemphigoid), topical/systemic antibiotics (trachoma)	Cicatricial cases

Acute stabilization focuses on protecting the cornea. Preservative-free artificial tears are dosed every 2 to 4 hours during the day, with a lubricating ointment such as carboxymethylcellulose or paraffin at bedtime. If a corneal abrasion or early ulcer is present, a bandage soft contact lens is placed and prophylactic topical antibiotics (moxifloxacin 0.5% four times daily, or ofloxacin 0.3% four times daily) are added until the epithelium heals. Lid taping, with adhesive strips drawing the lid skin inferolaterally toward the cheek, can immediately reverse the inversion as a bridge to surgery.

Botulinum toxin type A, injected at 2.5 to 5 units into the pretarsal orbicularis, paralyzes the overriding muscle and corrects the lid position for roughly 3 to 4 months. It is the treatment of choice for spastic entropion and is useful for patients who are poor surgical candidates.

Definitive management is surgical in involutional and cicatricial cases. For involutional entropion, the lateral tarsal strip combined with lower eyelid retractor reinsertion addresses both horizontal laxity and the disinserted retractors and is the standard definitive procedure. Quickert sutures, three full-thickness everting sutures placed through the lower fornix and out through the skin, provide a quick repair under local anesthesia and are favored in elderly or medically frail patients, although recurrence rates are higher.

Cicatricial entropion requires posterior lamellar lengthening. Options include tarsal fracture (tarsotomy with anterior rotation) for milder cases and mucous membrane grafting (typically buccal mucosa or hard palate) for advanced posterior lamellar shortening. Critically, cicatricial entropion is never treated with anterior lamellar tightening alone; doing so worsens the inversion. In autoimmune disease, systemic immunosuppression must be initiated before surgery because operating on inflamed tissue accelerates scarring. Dapsone, methotrexate, mycophenolate, or rituximab are used depending on severity for ocular cicatricial pemphigoid.

The next best step in any patient presenting with suspected entropion and ocular pain is slit-lamp examination with fluorescein staining to rule out corneal ulceration, because identifying an ulcer changes the immediate management to include a bandage contact lens and topical antibiotics before surgical referral.

5. Differential Diagnosis and Distractors

Differential	Why It's Similar	Key Discriminator
Ectropion	Same population (elderly), red eye, tearing	Lid margin turns outward, exposing palpebral conjunctiva; tearing is from punctal eversion, not lash trauma
Trichiasis	Lashes rub the cornea producing the same symptoms	Lid margin is in normal position; only the lashes are misdirected. Common after trachoma without full entropion
Distichiasis	Lashes touching cornea	Accessory row of lashes emerging from the meibomian gland orifices; lid margin is anatomically normal
Epiblepharon	Lashes against cornea in a child	Lid margin is in normal position; a horizontal pretarsal skin fold pushes lashes inward. Common in East Asian children, often resolves spontaneously
Floppy eyelid syndrome	Chronic irritation and lid laxity in adults	Upper lid everts spontaneously during sleep; associated with obstructive sleep apnea and obesity
Blepharitis	Red lid margin, foreign body sensation	Lid margin is anatomically normal; crusting at lash bases, meibomian gland dysfunction
Dry eye syndrome	Tearing, foreign body sensation, photophobia	No lid malposition; reduced Schirmer test and tear break-up time

6. Traps and High-Yield Pearls

The most common error is confusing entropion with trichiasis. Both produce the identical symptom of "lashes rubbing the eye," but the management is different. In entropion, the entire lid margin is rotated inward and the lid itself must be repositioned surgically. In isolated trichiasis, the lid margin is normal and the misdirected lashes are treated locally with epilation, electrolysis, or cryotherapy. Picking surgical lid repair for pure trichiasis, or simple lash removal for true entropion, is the test-writer's favorite trap.

A second high-yield pearl is the distinction between involutional and cicatricial entropion, because this drives the surgical plan. A vignette featuring an elderly patient with intermittent lid inversion, chronic tearing, and a positive snap-back test points to involutional disease and a lateral tarsal strip with retractor reinsertion. A vignette featuring a patient from a trachoma-endemic region, a history of Stevens-Johnson syndrome, or visible conjunctival scarring points to cicatricial disease and the answer becomes a posterior lamellar lengthening procedure, never simple horizontal tightening.

A third trap is forgetting fluorescein staining. Any patient with entropion and ocular pain or decreased vision needs the cornea examined for ulceration before definitive repair, and the question stem will often hide a corneal ulcer in the description ("greenish-yellow infiltrate," "hypopyon"). The next best step in that scenario is bandage contact lens with topical antibiotic coverage, not immediate surgery.

Finally, epiblepharon should never be repaired surgically as a first step in a young child. It typically resolves as facial bones mature, and conservative management with lubrication is correct unless persistent corneal damage develops past age 5 to 6.

The core competency tested is recognizing the mechanism behind a malpositioned eyelid, mapping that mechanism to the correct surgical approach, and protecting the cornea before doing anything else.

1e:["$","$L2d",null,{"article":{"id":"f4ccaa0a-0ce0-4d33-87fa-63e291913d26","title":"Entropion","content":"$2e","category":"Oftalmologi","created_at":"2026-05-01T14:24:32.773467+00:00","status":"published","subcategory":null},"questionCount":3,"sections":[{"id":"section-pathophysiology","num":"01","title":"Pathophysiology"},{"id":"section-classification-and-clinical-manifestation","num":"02","title":"Classification and Clinical Manifestation"},{"id":"section-diagnostic-workup","num":"03","title":"Diagnostic Workup"},{"id":"section-management-and-treatment","num":"04","title":"Management and Treatment"},{"id":"section-differential-diagnosis-and-distractors","num":"05","title":"Differential Diagnosis and Distractors"},{"id":"section-traps-and-high-yield-pearls","num":"06","title":"Traps and High-Yield Pearls"}],"hasSummaryTable":true}]