A Case of Inturning Lashes

“Her eye is very scratchy and sore,” the daughter of my elderly patient says. “It’s been going on for close to six months. She is suffering with it.”

Where I should see an arc of lower lid lashes, I see a rolled skin edge, a soft line abutting a red irritated eye.

“Yes, I can see that,” I say before turning to my patient from outside the slit lamp. “I’m going to gently touch your eyelid.” My patient nods at me.

I place my fingertip below her eye, pressing down on the skin of her upper cheek. The lower lid distracts easily, pulling down away from the eye. Lashes unscroll from where they are curled, buried in against the eye. The inner surface of her eyelid shows an inflamed ruby-red conjunctiva, but thankfully no bands of symblepharon. I move my finger beside her eye, pressing next to her lateral canthus, distracting to the side. Her eyelid pulls sideways over her eye, moving more easily than it should. When I take my hand away, her lower lid sits normally, lashes curving down, no longer scratching. Where has her entropion gone?

“Blink please,” I ask.

On blinking, the lower lid lashes disappear again, tucking in against her eye, rubbing and abrading with every movement.

With a drop of fluorescein, her lower cornea lights up in a spread of confluent speckles, green-yellow dots shining bright when I dial in the cobalt blue filter.

“You have an entropion,” I say. “Surgical repair is usually successful, and we can plan that within the next few weeks.”

Entropion repair is a procedure that effectively removes pain and discomfort for these patients. Often, as the appearance of an entropion can be relatively subtle, their complaints of soreness and irritation can grumble on for a protracted period. Occasionally, the underlying cause of their discomfort remains unknown for years. Trauma from the lashes causes corneal irritation and ocular surface disease. A frank corneal abrasion can develop, risking microbial keratitis. Of the different presentations in the oculoplastic clinic, I aim to provide entropion repair within a short time frame. Early detection and repair of entropion reduces the risk of vision loss.

Assessment in the clinic guides the choice of type of repair procedure. The most common type of entropion is caused by age-related disinsertion of the lower lid retractors and horizontal laxity of the canthal tendons. The portion of the orbicularis muscle that overlies the orbital septum, the preseptal orbit, can spasm and override the pretarsal portion of the muscle, further curling in the lower lid.

In the clinic, looking inside the lower eyelid is mandatory. This is an essential step in ruling out other less common causes of entropion. Cicatricial eyelid disease features abnormal bands of connection between the bulbar and palpebral conjunctiva. Symblepharon develop for a wide variety of reasons including trauma, but autoimmune causes are important to detect. Inflammatory cicatrising disease can be acute or chronic and requires systemic immunosuppression to reduce the risk of progression and blindness.

Trichiasis or entropion

Confusion can arise, particularly for non-ophthalmologists, in distinguishing trichiasis from entropion. Referrals may label trichiasis as entropion and vice versa. Having an open mind when seeing the patient is helpful. Trichiasis can be difficult to detect, as the ingrowing hairs are usually tiny and barely visible. Despite their relatively inconsequential appearance, they cause sharp pain. Definitive management can be challenging, and often these patients have been getting by with frequent epilation performed by a sharp-eyed relative with a tweezer, or by regularly seeing an obliging optometrist. Long-term treatment involves ablation of the abnormal lashes, and recurrence rates can be disappointing. Techniques include electrolysis, cryotherapy, and argon thermal laser. Direct excision of the trichiatic lash roots can also be performed.

Entropion repair is an elegant procedure that involves correction of the underlying anatomic abnormalities. There are a variety of procedures described, and temporising methods can be used to treat the entropion during the wait before surgery. Taping the lower lid down is a simple method that works surprisingly well. Lower lid everting sutures can be placed prior to definitive repair also. Ultimately, repair will be required because the laxity persists and needs correction. Horizontal shortening of the lower lid and plication of the lower lid retractors, combined with orbicular stripping, are one good approach. Horizontal shortening can be achieved with a lateral wedge or lateral tarsal strip-type procedure. I usually plicate the retractors from a transcutaneous approach, and that helps to flip the lashes outwards. Finally, orbicularis can be trimmed out with Weskott scissors, reducing the spasm-related closure.

Like cataract surgery, entropion repair is a satisfying procedure to perform, as it provides a step change in quality of life for patients. If cataract coexists, manage the entropion first and wait until healing has taken place to allow an optimal ocular surface for the cataract procedure.

This is the fourth in a series of columns discussing conditions of the eyelids.

Clare Quigley MD is a Consultant Eye Surgeon in private practice in Progressive Vision, and in public practice in the Royal Victoria Eye and Ear Hospital and St James’s Hospital, Dublin.