References and pictures- Collins Manual of Systematic Eyelid Surgery, Collins Color Atlas, Kanski, DOS articles Presented as DNB Resident at Sri Sankaradeva Nethralaya, Guwahati

1. ENTROPION
PRESENTER- Dr. Tanvi Gupta
Moderator- Dr. G.C. Kuri

2. Etiopathogenesis and management modalities of involutional entropion (4+6)
(Dec 2017)
Causes of cicatricial entropion. Common techniques for correction of
trachomatous upper lid correction (3+7)
(June 2017)
Discuss pre-operative assessment of entropion. Briefly discuss surgical options
for correction of involutional entropion. (3+7) Dec 2012, Dec 2014 (3+7), April
2016 (5+5)
Classification and management of various types of entropion (5+5) Dec 2016

5. - Inward turning of lid margin against the eye
- Redness, irritation, watering, keratitis, corneal
perforation
Entropion

6. Classification
1.Congenital- rare (due to hypertrophy of anterior lamella, mostly self limiting)
2. Acquired
a. Involutional (commonest)- mostly lower lid
b. Cicatricial- more common in upper lid
c. Acute spastic

7. 5 basic pathogenic mechanisms
Over-riding of pre-septal over pre-tarsal orbicularis oculi -> Anterior lamella
and pre-septal O.O. move upwards
Horizontal lid laxity -> The orbicularis with its medial and lateral canthal
tendons becomes lax
Weakness of lower lid retractors -> No longer control the inferior border of
tarsal plate
Tarsal plate atrophy (tested by palpation of tarsal plate)
Atrophy of retrobulbar fat/ fat resorption leading to relative enophthalmos

10. INVOLUTIONAL ENTROPION
Laxity of tarsus Laxity of medial and lateral canthal tendons Laxity of retractors Over-riding of pre-septal
over pre-tarsal orbicularis

13. Normally, the lower eyelid retractors maintain the lower eyelid margin in
proper orientation. However, attenuation of the eyelid retractors
(capsulopalpebral head of inferior rectus and inferior tarsal muscle) in the
lower eyelids allows the inferior border of the tarsus to ride forward and
superiorly, with the eyelid margin rotating inward
Enophthalmos- entropion, prominent eye- ectropion develops
Horizontal lid laxity common in both- Lateral tarsal strip can be done for
both
Posterior lamella shortening- inturning, anterior lid shortening- ectropion
Activity of orbicularis- orbicularis action> retractors entropion
Orbicularis lax- ectropion

14. Pre-op evaluation to determine etiology in case of entropion
Involutional entropion is generally noted in individuals of older age group with horizontal laxity of the eyelids
associated with a hump on lower eyelid due to overriding of preseptal orbicularis over the pretarsal part. It is
often
associated with absence of the downward excursion of the eyelid in downgaze due to weakness of the lower lid
retractors.
Cicatrical entropion is seen in patients with variable amount of tarsoconjunctival lamellar scarring. The digital
eversion test can be done to distinguish cicatricial entropion from involutional entropion. Digital eyelid traction is
applied to return the eyelid to a normal anatomic position. Th is corrects the abnormal margin position in involutional
entropion but not in cicatricial entropion.
Entropion is multifactorial in origin. Th e preop evaluation is directed towards identifying each factor that is contributing to its
development in a particular patient so that the most suitable surgical procedure is selected.
We evaluate the age of the patient, history of trauma, position of lid margin, laxity of lid tissues, presence of trichiatic lashes
and corneal status.
The diagnosis of entropion is usually straightforward. The goal of eyelid examination is to determine the type of entropion. First
thing is to assess if the entropion is cicatricial. Usually the scarring of conjunctiva and tarsus is obvious.
Also, there is more resistance on turning the inverted lid to its normal position. If it is not cicatricial, the entropion is
involutional.

15. Over-riding of pre-septal over pre-tarsal O.O.
If the entropion is not obvious at the time of examination, the patient should be asked to squeeze the lids/
forceful closure of lids, this usually makes the entropion manifest
After a forceful lid closure/blink -> entropion will manifest
Hump on lower eyelid due to over-riding of pre-septal over pre-tarsal O.O.

16. In the snapback test, downward traction is applied to the lid and then released. A normal lid returns to its
normal
position against the globe promptly but in involutional entropion the lid continues to hang down until a blink.
Lid distraction test is performed by pulling the central lid away from the eye. If it can be pulled more than 6
mm away
from the globe, lid laxity is present.

17. Lid distraction test – tests the amount of
lengthening and laxity present
Snap back test

19. There are some other subtle signs as well; the lower eyelid often rides above the inferior limbus and there
may be a white line seen in the inferior fornix signifying disinsertion of retractors
• deeper-than-normal inferior fornix
• reverse ptosis of the lower eyelid (lower eyelid margin sits higher than normal)
• little or no inferior movement of the lower eyelid on down gaze (diminished lower eyelid excursion)

20. Degree of keratopathy
Underlying intra-ocular conditions like visually significant cataract
Fitness for local anaesthesia

22. THANK YOU