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CLINICAL MANAGEMENT GUIDELINES
Entropion
Aetiology
Predisposing factors
Symptoms
Signs
Differential diagnosis
Inward rotation of the tarsus and lid margin, causing the lashes to come
into contact with the ocular surface
Most cases have a single aetiology but in some are multi-factorial
Involutional (age-related)
Commonest cause of entropion, affects lower lid (occurs in approx. 2%
of the elderly population)
Results from a combination of age related degenerations
 horizontal lid laxity resulting from thinning and atrophy of the
tarsus and the canthal tendons
 weakness of the lower lid retractors
 overriding of the preseptal over the pre-tarsal portion of the
orbicularis oculi muscle, at the lid margin. This causes inward
rotation of the tarsal plate on lid closure
Cicatricial
Severe scarring and contraction of the palpebral conjunctiva pulls the lid
margin inwards (ocular cicatricial pemphigoid, Stevens-Johnson
syndrome, trachoma, chemical burns, post-operative complication)
Spastic
Caused by spastic contraction of the orbicularis muscle triggered by
ocular irritation (including surgery) or due to essential blepharospasm.
Usually resolves spontaneously once the cause has been removed
Congenital
Very rare entropion of the lower lid due to improper attachment of the
retractor muscles to the inferior border of the tarsal plate
Age-related degenerative changes in the lid
Severe cicatrising disease affecting the tarsal conjunctiva
Ocular irritation or previous surgery
Foreign body sensation, irritation
Red, watery eye
Blurring of vision
Corneal and/or conjunctival epithelial disturbance from abrasion by the
lashes (wide range of severity)
Localised conjunctival hyperaemia
Lid laxity (involutional entropion)
Conjunctival scarring (cicatricial entropion)
Absence of lower lid crease (congenital entropion)
Distraction test
 if lower lid can be pulled >6mm from globe, it is lax
 positive test indicates canthal tendon laxity
Snap-back test
 with finger, pull lower lid down towards inferior orbital margin
 release: lid should snap back
 positive test indicates poor orbicularis tone
Eyelid retraction (e.g. Graves’ disease):
 retracted upper or lower lid causes the lashes to be hidden by the
resulting fold of lid skin, resembling entropion
Distichiasis:
 congenital additional row of lashes at the meibomian gland
orifices
Trichiasis:
 lashes arise from normal position but are misdirected towards the
cornea, secondary to inflammation and scarring of the lash
Entropion
Version 5, Page 1 of 3
Date of search 23.03.15; Date of revision 27.05.15; Date of publication 06.08.15; Date for review 22.03.17
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Entropion
follicles
Dermatochalasis:
 degenerative condition, common in the elderly, leading to baggy
appearance due to redundant lid skin and protrusion of orbital fat.
Misdirection of lashes of upper lid may resemble entropion
Epiblepharon:
 congenital condition in which a fold of skin and muscle extends
horizontally across the lid margin causing the lashes to be
directed vertically. Orientation of tarsal plate normal. Usually
asymptomatic and resolves with increasing age
Management by Optometrist
Practitioners should recognise their limitations and where necessary seek further advice or refer
the patient elsewhere
Non pharmacological
Taping the lid to the skin of the cheek, so as to pull it away from the
globe, can give temporary relief (particularly for involutional or spastic
entropion)
Epilation of lashes can be done where the trichiasis is localised (eg in
cicatricial entropion)
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Therapeutic contact lens to protect cornea from lashes
(GRADE*: Level of evidence=low, Strength of recommendation=weak)
Pharmacological
Ocular lubricants for tear deficiency/instability related symptoms (drops
for use during the day, unmedicated ointment for use at bedtime)
NB Patients on long-term medication may develop sensitivity reactions
which may be to active ingredients or to preservative systems (see
Clinical Management Guideline on Conjunctivitis Medicamentosa). They
should be switched to unpreserved preparations
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Management Category
B1: Initial management (including drugs) followed by routine referral
Congenital entropion does not resolve spontaneously and the potential
for severe corneal complications requires referral for prompt treatment
Possible management by Ophthalmologist
The choice of surgical procedure depends on the underlying cause(s)
Surgical intervention is indicated if any of the following are persistent:
 ocular irritation
 recurrent bacterial conjunctivitis
 reflex tear hypersecretion
 superficial keratopathy
 risk of ulceration and microbial keratitis
There is evidence that the combination of horizontal and vertical eyelid
tightening is an effective treatment for entropion
Evidence base
*GRADE: Grading of Recommendations Assessment, Development and
Evaluation (see http://gradeworkinggroup.org/toolbox/index.htm)
Sources of evidence
Boboridis KG, Bunce C. Interventions for involutional lower lid entropion.
Entropion
Version 5, Page 2 of 3
Date of search 23.03.15; Date of revision 27.05.15; Date of publication 06.08.15; Date for review 22.03.17
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Entropion
Cochrane Database Syst Rev. 2011;(12):CD002221
Hintschich C. Correction of entropion and ectropion. Dev Ophthalmol.
2008;41:85-102
LAY SUMMARY
Entropion is a condition in which the edge of the eyelid (usually the lower lid) rolls inwards, so that the
eyelashes touch the surface of the eye. The commonest cause is loss of elasticity and muscle tone of the
eyelids which happens as part of the ageing process. It can also result if the eyelid is scarred following
inflammation or injury. In many countries of the world entropion occurs as a complication of repeated
infection by the trachoma agent (Chlamydia trachomatis).
The affected eye becomes irritable, red and watery, and vision may be blurred. The optometrist will be able
to see the effect of eyelashes rubbing on the eye surface and may be able to determine the cause.
Taping the edge of the eyelid to the skin of the cheek may give temporary relief, as may the removal of
lashes or the fitting of a bandage contact lens to protect the eye surface from contact with the eyelashes.
Patients may be helped by artificial tears and unmedicated ointments. These measures will not cure the
condition, so patients are often referred routinely to the ophthalmologist for consideration of surgery, usually
under local anaesthetic, which may solve the problem.
Entropion
Version 5, Page 3 of 3
Date of search 23.03.15; Date of revision 27.05.15; Date of publication 06.08.15; Date for review 22.03.17
© College of Optometrists