Entropion (in-turning eyelid)

An entropion is an in-turning eyelid margin. This can commonly affect the lower eyelid but the upper eyelid can occasionally turn inwards too.

In the lower eyelid an entropion occurs usually as a consequence of the natural ageing process. This is called an involutional entropion.The eyelid tissues gradually become lax and the so the lower eyelid becomes unstable. This combined with some weakening of the lower eyelid retractors can result in the eyelid turning inwards.

Entropion can also occur if there is scarring or shortage of the inner lining of the eyelid (the palpebral conjunctiva). This is known as a cicatricial entropion and can be caused by blepharitis (eyelid margin inflammation), infections, trauma or scarring diseases (such as ocular cicatricial pemphigoid).

An entropion can cause the following symptoms: 

• A sore, gritty or red eye (the eyelashes rub against the eyeball)
• A corneal ulcer or abscess (constant eyelash rubbing can lead to a corneal ulcer)
• A watering eye (as a consequence of irritation of the eye)
• Blurred vision - this can be due to the surface of the eye being irritated

Procedures 

Lower Eyelid Entropion Surgery

Entropion surgery is usually performed under local anaesthesia with or without conscious intravenous sedation (“twilight anaesthesia”).

Several techniques (or combination of techniques) can correct a lower eyelid entropion: 

• Everting sutures - in this simple procedure 2 or 3 stitches are passed form the inside of the eyelid to be tied just under the lashes on the outside of the eyelid. These dissolve over a few weeks. Everting sutures can improve the eyelid position for several months (or sometimes years). This has the advantage of taking only a few minutes to do in an outpatient setting but is considered a less definitive and relatively short-lasting procedure.
• Inferior retractor reinsertion (IRR): the lower eyelid retractors are important stabilisers of the eyelid and they can be tightened / reinserted via a skin incision just below the lashes (a subciliary incision).
• A lateral tarsal strip (LTS) is the commonest procedure used to tighten the eyelid. Tightening the eyelid can improve it’s stability and so help correct an entropion. A small skin incision is made in the outer corner of the eyelids (the lateral canthus) to tighten the lower lid against the outer bony rim of the eye socket.
• A lateral canthal resuspension (LCR) / canthopexy is an alternative method of tightening the lower eyelid. Tightening the eyelid can improve it’s stability and so help correct an entropion. An upper eyelid skin crease incision is made to tighten the lower eyelid against the outer bony rim of the eye socket. 

The most effective method to correct a lower eyelid entropion is to perform a combined lower eyelid tightening (LTS or LCR) and inferior retractor reinsertion (IRR).

Upper Eyelid Entropion Surgery

There are a number of surgical options to correct upper eyelid entropion and the choice of procedure will depend on the underlying cause.

If there only a few inturning lashes then electrolysis can help remove the offending lashes. This treatment is simple short procedure performed under local anaesthetic. It does sometimes require repeating 2 or 3 times. Surgical removal of these in-turning lashes can be considered if electrolysis does not help.

Many patients benefit from surgery to move the eyelash margin away from the eyeball by splitting the upper eyelid margin and moving the eyelash-bearing skin layer away from the eyelid margin (an anterior lamellar recession).

Other patients may need the upper eyelid margin rotated away from the eyeball (a tarsotomy or terminal tarsal rotation).

Risks and complications

In the hands of an experienced oculoplastic surgeon the risk of a serious complication is very low.

I will explain potential eyelid surgery complications in detail to you. You will be asked to sign a consent form to ensure that you fully understand the procedure you will undergo and any risks or potential complications which can include: 

• Blurred or impaired vision, including loss of eyesight (extremely rare)
• Corneal abrasion - this is a scratch to the surface of the eyeball that causes persistent pain. This is rare but can occur with any surgery on or near the eye and is treated with antibiotic ointment. Sometimes a “bandage” contact lens needs to be used
• Bleeding (haematoma) - This can very rarely lead to a loss of vision, including blindness. A haematoma usually needs to be drained in the operating theatre
• Infection-this is rare but it is important to follow post-operative wound care instructions to help to prevent such a problem
• Numbness and other changes in skin sensation
• Undercorrection (so the eyelid still turns inwards)
• Overcorrection (so the eyelid now turns outwards)
• Tender orbital rim - the outer bony rim of the eye socket can be tender for a few weeks after an eyelid tightening procedure
• Scarring. Most eyelid wounds heal very well with scars that are barely perceptible after a few months. However occasionally wounds can become thickened and may require attention with additional treatment such as steroid injections or, rarely, surgical revision to improve the scar
• Sutures may spontaneously surface through the skin, become visible or produce irritation that require removal
• Asymmetry. Tightening of the lower eyelid on one side can give pulled up tight look to the operated eyelid but this usually settles over time. It is very unusual for further surgery to be required to address this
• Donor site problems - any part of the body that is used to take a graft from has a small risk of infection, bleed & scarring. Usually these donor sites heal very well with no problems
• Acute glaucoma - this is sudden raised pressure and pain within the eye,  haloes around lights with blurring of vision, headache and vomiting. This can occur very rarely following eyelid surgery. Any such symptoms following surgery should be reported to your surgeon who can diagnose and treat this, should this occur
• Possibility of revision surgery if the outcome is not as expected

Be sure to ask questions:

It’s very important to ask any question you have about your proposed eyelid procedure. I’ll do my best to address any concern you may have.

When you go home

If you experience shortness of breath, chest pains, or unusual heart beats, seek medical attention immediately. Should any of these complications occur, you may require admission to hospital and additional treatment.

Your consultation

The success and safety of your eyelid surgery procedure depends very much on your complete candidness during your cosmetic eyelid surgery consultation. You'll be asked a number of questions about your health, desires and lifestyle.

Please be prepared to discuss:

• Why you want the surgery, your expectations and desired outcome
• Medical conditions, drug allergies and previous medical treatments
• Use of current medications, vitamins, herbal supplements, alcohol & tobacco
• Previous surgeries

The following will also take place at your consultation

• Evaluation of your general health and any pre-existing health conditions or risk factors
• An assessment of your vision and a thorough eye examination including a slit-lamp examination of the eye.
• Photographs for your medical record
• A discussion about treatment options
• Recommendations for treatment most appropriate for you
• Discussion about likely outcomes of eyelid surgery and risks or potential complications
• The type of anaesthesia that will be used (This is usually “Twilight anaesthesia” using local anaesthesia with intravenous sedation administered by a consultant anaesthetist. However, a full general anaesthetic can be arranged if you prefer this option)

After the consultation I will send you a letter summarising your concerns and desires relating to your appearance along with my assessment and advice to you regarding treatment options.

You will also receive a quote for your proposed surgery and have the opportunity to attend for a further consultation prior to proceeding should you wish to ask any further questions.

Arrange a consultation