Etiology

• Eyelid condition common among Asian children
• Poor attachment of lower eyelid retractors to overlying orbicularis muscle and subcutaneous tissue
• Excess skin and orbicularis oculi muscle override onto the lid margin and direct the cilia towards the eye, often causing corneal irritation
• Lower eyelid pretarsal orbicularis muscle and skin push up and ride above lower lid margin to form horizontal fold
• Related to high body mass index in Korean children
• Korean study suggests acquired epiblepharon associated with thyroid associated ophthalmopathy in adults

Epidemiology

• More common in Asian and Hispanic children
• Occasionally seen in Caucasian children with a low nasal bridge
• More common in lower lids than upper lids
• Normally bilateral
• Associated with a "chubby cheek" at times
• Medial eyelid is often effected more than lateral
• Often associated with an epicanthal fold
• High prevalence of astigmatism with possibility for amblyopia

History

• Well tolerated in many patients and most are asymptomatic
• Ocular irritation or foreign body sensation
• Eye rubbing
• Especially in children
• Epiphora
• Photophobia
• Mucoid discharge
• Conjunctival erythema
• Decreased vision less common unless corneal breakdown/scarring

Clinical features

• Fold of skin with underlying orbicularis muscle overriding the eyelid margin and pushing cilia vertically along medial half to two-thirds of lower eyelid
• Cilia touching ocular surface, particularly in downgaze
• Punctate epithelial keratopathy may be present, typically inferomedial

Testing

• Slit-lamp biomicroscopic examination looking for lash to cornea touch and punctuate epithelial staining

Risk factors

• Asian or Hispanic ancestry
• Family history

Differential diagnosis

• Congenital entropion
• When the eyelid margin truly inverts
• Pronounced epicanthus inversus

Natural history

• Often lashes do not touch ocular surface.
• Children often tolerate mild lash to cornea touch.
• Tends to decrease with growth of the face and development of the nasal bridge
• Therapy should be guided by patient symptoms and corneal health.

Medical therapy

• Observation
• Ocular lubrication with tear drops daily
• To avoid amblyopia, do not treat a child aggressively with ointment.

Surgery

• If mechanical keratopathy occurs due to lash touch, might require surgical correction
• Mostly performed bilaterally
• Patient discomfort might be an indication for surgery.
• Many surgical techniques has been described, but most focus on tightening the lower lid retractors and excising an ellipse of skin and orbicularis oculi muscle.
• Small risk of cicatricial eyelid retraction or ectropion
• Tarsal fixation sutures and lash rotational sutures without an incision are also popular.
• 5-0 or 6-0 chromic full-thickness mattress sutures (similar to Quickert sutures) placed at the lower eyelid crease about 2–3 mm inferior to the lashes
• If a prominent epicanthal fold is present, excision or incision of the orbicularis and fibrous tissue beneath the fold might help prevent recurrence.
• Thermal cauterization of the tarsus and lower lid retractors without lash rotating sutures has been described.

Other management considerations

Botulinum toxin A and hyaluronic acid gels have recently been used in the management of epiblepharon, but surgery is the preferred treatment.

Unless there is symptomatic or significant corneal damage, conservative management is recommended.

• Inadequate lash rotation/recurrence
• Requires adequate excision of both skin and underlying orbicularis muscle.
• It also might require tarsal fixation suture or tightening of the lower lid retractors to minimize the chance of inadequate rotation or recurrence.
• This author advocates one of the above methods in conjunction with skin and orbicularis excision.
• Higher recurrence rate in upper eyelid epiblepharon in patients with Down's syndrome
• Asymmetry of incisions
• Care taken to create symmetric lower eyelid creases
• Cicatricial ectropion
• Due to hypertrophic scar, overcorrection is rare.
• Eyelid retraction: Treatment should be aimed at the etiology of retraction.
• Overzealous skin excision or skin cicatrix: Attempt conservative measures first.
• If surgery indicated, SOOF/cheek lift or full-thickness skin graft indicated; this is rare.
• Overtightening of lower lid retractors could lead to retraction.
• Loss of lashes if excessive cautery or dissection near follicles

Disease-related complications

• Punctuate epithelial keratopathy
• Conjunctival cytologic analysis indicates a decrease density in goblet cell in the nasal and temporal conjunctiva.

Patient instructions

• Follow-up as instructed
• Ocular lubrication

1. AAO, Basic and Clinical Science Course. Section 7: Orbit, Eyelids, and Lacrimal System, 2010-11.
2. AAO, Ophthalmology Monograph 8. Surgery of the Eyelid, Orbit, and Lacrimal System. Vol. 1. 1995:108.
3. Chang M, Lee TS, Yoo E, Baek S. Surgical correction for lower lid epiblepharon using thermal contraction of the tarsus and lower lid retractor without lash rotating sutures. Br J Ophthalmol. 2011 Dec; 95(12): 1675-8.
4. Chen CY, Nava-Castaneda A. Successful treatment of lower eyelid epiblepharon by injection of botulinum toxin A in patients under two years of age. Nepal J Ophthalmol. 2013 Jul; 5(10): 177-81.
5. Cinoo Kim, Young Joo Shin, Nam Ju Kim, Sang In Khwarg, Jeong-Min Hwang, Won Ryang Wee. Conjunctival epithelial changes induced by cilia in patients with epiblepharon or entropion. American Journal of Ophthalmology. 2007 Jul; Volume 144, Issue 4, Pages 564-569.
6. Gupta VP, Gupta R, Gupta P. Prognosis of upper eyelid epiblepharon in thyroid-associated ophthalmopathy of Koreans. Am J Ophthalmol. 2011 Jun; 151 (6): 1104.
7. Kim MS, Sa HS, Lee JY. Surgical correction of epiblepharon using an epicanthal weakening procedure with lash rotating sutures. Br J Ophthalmol. 2014 Jan; 98(1): 120-3.
8. Lee KM, Choung HK, Kim NJ, Lee MJ, Lee KW, Khwarg SI. Prognosis of upper eyelid epiblepharon repair in Down syndrome. Am J Ophthalmol. 2010 Oct; 150(4): 476-480.
9. Park SW, Khwarg SI, Kim N, Lee MJ, Choung HK. Acquired lower eyelid epiblepharon in thyroid-associated ophthalmopathy of Koreans. Ophthalmology. 2011 Oct; Volume 119, Issue 2, Pages 390-395.
10. Park SW, Kim N, Choung HK, Khwarg SI. Outcomes of various surgical procedures on acquired lower eyelid epiblepharon in thyroid associated ophthalmopathy. Korean J Ophthalmol. 2012 Oct; 26(5): 319-23.
11. Preechawi P, Amrith S, Wong I, Sundar G. Refractive changes in epiblepharon. American Journal of Ophthalmology. 2007 Jan; Volume 143, Issue 5, Pages 835-839.