Cicatricial entropion is caused by vertical tarsoconjunctival contracture and internal rotation of the eyelid margin, with resulting irritation of the globe from inturned cilia or the keratinized eyelid margin (Fig 12-7). Various conditions may lead to cicatricial entropion, including autoimmune (mucous membrane [ocular cicatricial] pemphigoid), inflammatory (Stevens-Johnson syndrome, Fig 12-8), infectious (trachoma, herpes zoster), surgical (enucleation, posterior approach ptosis correction, transconjunctival surgery), and traumatic (thermal or chemical burns, scarring) conditions. The long-term use of topical glaucoma medications, especially miotics and prostaglandins, may cause chronic conjunctivitis with vertical conjunctival shortening and secondary cicatricial entropion.
The patient’s history, along with a simple diagnostic test (digital eversion), usually distinguishes cicatricial entropion from involutional entropion. Attempting to return the eyelid to a normal anatomic position using digital traction will correct the abnormal margin position in involutional entropion but not in cicatricial entropion. In addition, inspection of the posterior lamella may reveal scarring of the tarsal conjunctiva in cases of cicatricial entropion.
Figure 12-7 Cicatricial entropion. A, Entropion of the right lower eyelid. B, Eyelid everted, showing conjunctival scarring and shortening of the fornix.
(Courtesy of Don O. Kikkawa, MD.)
Figure 12-8 Stevens-Johnson syndrome with conjunctival scarring and eyelid margin keratinization.
(Courtesy of Bobby S. Korn, MD, PhD.)
Successful management of cicatricial entropion depends on careful preoperative evaluation to determine the cause, severity, and prominent features in each patient. When the etiology is autoimmune or inflammatory disease, the prognosis is guarded because of frequent disease progression.
Cicatricial entropion usually requires surgery, but lubricating drops and ointments, barriers to symblepharon formation, and eyelash ablation with lash cautery are sometimes useful. Indeed, surgery is contraindicated during the acute phase of autoimmune diseases, and medical management of the inflammatory condition with topical and systemic medications is more appropriate until the disease stabilizes. When surgery is indicated, maximal inflammatory suppression is achieved with pulsed systemic anti-inflammatory medications (corticosteroids and immunosuppressive agents).
The tarsal fracture operation is useful in cases of mild to moderate cicatricial entropion (marginal entropion) of the upper or lower eyelid (Fig 12-9). In this situation, lashes abrade the cornea, and careful examination shows that the eyelid margin has lost its square edges and is rotated posteriorly. A posterior horizontal tarsal incision is made 2 mm distal to the eyelid margin. This incision through the full thickness of the tarsus allows the eyelid margin to be rotated away from the globe. The eyelid position is stabilized with everting sutures.
Figure 12-9 Tarsal fracture operation. A, Tarsotomy. B, Margin rotation for cicatricial entropion.
(Illustration by Mark Miller.)
For margin rotation to be effective, the tarsus should be intact and of reasonably good quality. In patients with severe cicatricial entropion, the involved tarsus is usually scarred and distorted and generally needs to be replaced. In the upper eyelid, tarsoconjunctival and other mucosal grafts are useful tarsal substitutes; in the lower eyelid, autogenous ear cartilage, preserved scleral grafts, and hard-palate mucosa have been used.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.