This document discusses various eyelid malpositions including entropion, ectropion, ptosis, and trichiasis. Entropion is when the eyelid rolls inward causing eyelashes to rub the eye, potentially damaging the cornea. Ectropion is when the eyelid rolls outward. Causes, symptoms, evaluations, and treatments are described for each condition. Conservative treatments include taping, lubricants, and botulinum toxin injections. Surgical treatments aim to tighten or reposition the eyelid depending on the specific malposition and its underlying cause. Prompt treatment is important to prevent corneal complications.

1. By
Assistant Professor of Ophthalmology
Sohag University

2. Eyelid malposition is the abnormal positioning of the
eyelids due to various causes.
 Eyelid retraction: the upper eyelid is abnormally
high, or the lower eyelid is abnormally low.
 Ptosis: drooping of the upper
eyelid.
The most common forms are:

3.  Entropion: the eyelid turns inwards causing
the eyelashes to brush against the cornea.
 Ectropion: the lower eyelid turns
outwards.

4. • Entropion is a condition in which your
eyelid turns inward so that your eyelashes
and skin rub against the eye surface.
• It can cause corneal and conjunctival
damage leading to corneal stromal
abrasion, scarring, corneal thinning and
corneal neovascularization.
• In advanced cases, there is even a risk of
corneal ulcer and perforation hence
necessitating prompt management.

5. • Patients with entropion tend to present with complaints of foreign body sensation,
redness, tearing and discharge.
• Symptoms may be intermittent depending on etiology.
• Dry eye syndrome, and punctate epithelial erosions

6. • Horizontal lid laxity can be evaluated
with the snap back test.

7. • Resistance to traction and persistence of
entropion with horizontal lid traction
• Lower lid retractor function is
evaluated by measuring lower lid
excursion in downgaze.

8. Trichiasis:
• is a condition in which eyelashes grow in a
posterior direction toward the corneal surface. It
can present similar to entropion, but management
is different, as the problem is the direction of lash
growth and not a margin malposition.
Distichiasis:
is the growth of lashes from the meibomian gland
orifices.

9. Epiblepharon :
• is a horizontal fold of redundant skin and orbicularis at the eyelid margin causing the
lashes to be directed vertically or invert to a small degree.

10. Involutional Entropion
• Involutional entropion is the most common type
of entropion.
• Common in old age.
• Management should be directed at the specific
mechanical failures of horizontal and vertical lid
laxity, lower lid retractor weakness, and
orbicularis oculi override.

11. Conservative Treatment: application of a cyanoacrylate liquid bandage to evert the lid margin,
botulinum toxin injections to the preseptal orbicularis.
Surgical Treatment
Horizontal lid tightening
Rotational or everting Sutures Lateral Tarsal Strip

12. • Pre-existing lower eyelid laxity or irritation after ocular surgery can cause a muscle spasm
in the orbicularis oculi muscle, producing a transient pretarsal orbicularis override
leading to entropion.
• Ocular irritation from infection, inflammation, or traumatic causes.
Treatment:
• Injecting 80% alcohol into the
orbicularis oculi.
• Botulinum toxin injection to the
orbicularis and full thickness
eyelid sutures.

13. • It is characterized by tarsoconjunctival scarring and inward rotation of the mucocutaneous
junction, often associated with trichiasis and distichiaisis. Diseases that cause conjunctival
scarring are often associated with forniceal shortening and symblepharon formation.
Treatment:
• Tarsal fracture is a viable
surgical option that preserves
the lashes with acceptable
cosmesis.
• An external partial tarsectomy is
performed through a lid crease
incision.
• A full thickness tarsotomy is
then performed to direct the lid
margin away from the globe.

14. - Inward rotation of the lower or upper eyelid margin,
present at or shortly after birth.
- Proposed mechanisms of congenital lower eyelid entropion
o Vertical deficiency in the posterior eyelid lamella with or
without disinsertion of the lower eyelid retractor
muscles
o Horizontal laxity of the medial or lateral canthal tendons
o Facial nerve palsies
Treatment:
• Taping the lower lid, injecting low doses of
botulinum toxin into the orbicularis.
• Surgical therapy provides definitive treatment.

15. • Ectropion is an outward turning of the eyelid margin.
• Patients may experience symptoms due to ocular exposure and inadequate lubrication.

16. Types:
 Involutional ectropion is caused by increased
horizontal laxity of the lower eyelid and
disinsertion of the lower eyelid retractors.
 Cicatricial ectropion is caused by shortening of
the anterior lamella, which is comprised of the
skin and orbicularis muscle.

17.  Mechanical ectropion can occur when a
mass, such as a tumor, displaces the lower
eyelid margin.
 Paralytic ectropion is caused by
decreased orbicularis muscle tone
supporting the lower eyelid.

18. Facial nerve palsy: Eyelid laxity:

19. • Eyelid pathology: • Punctal ectropion:
 Ocular surface:
 Examine the cornea for epithelial changes secondary to exposure.

20. Management
• Definitive management is surgical. Medical management is temporizing but can
improve symptoms while awaiting surgery.
Medical therapy:
 Lubrication of the ocular surface
 Horizontal taping of the eyelid

21.  Lower eyelid laxity: the lower eyelid is
horizontally tightening by a lateral tarsal
strip.
 Lower eyelid retractor disinsertion: the
Jones procedure of reattaches retractors to
the tarsus.
 Cicatricial ectropion often requires
lengthening of the anterior lamella by a skin
graft.
 Paralytic ectropion requires horizontal
tightening and correction of punctal
ectropion.