Entropion, ectropion and trichiasis

The normal eyelid margin rests against the globe and spreads tears across the cornea with each blink. Entropion reverses its usual orientation, bringing lashes and lid skin against the eye. Ectropion pulls the margin away, exposing conjunctiva and disrupting the position of the lacrimal punctum. Trichiasis refers to one or more misdirected eyelashes and can occur with an otherwise correctly positioned lid. These distinctions matter because removing lashes will not correct a globally inverted lid, while lid-tightening surgery is not automatically required for a single abnormal follicle.

Age-related tissue changes are common causes of lower-lid malposition. Horizontal laxity, altered lower-lid retractor support and muscle imbalance can contribute to involutional entropion. Ectropion may follow loss of lid support, facial nerve weakness, scar contraction or the weight of a lesion. Previous surgery, trauma and inflammatory disease are therefore important parts of the history. A new focal mass or a progressively scarred conjunctiva needs its own diagnostic assessment rather than being classified simply as ageing.

Symptoms overlap with dry eye and conjunctivitis: grittiness, watering, redness and intermittent blur are common. Watering does not prove adequate surface lubrication. An everted punctum may no longer collect tears efficiently, while exposure stimulates reflex tear production. Repeated downward wiping can aggravate lower-lid laxity, so advise gentle dabbing. In entropion or trichiasis, discomfort may be particularly noticeable with blinking because lashes repeatedly scrape the epithelium. Persistent focal rubbing can produce an abrasion that becomes infected.

Examination should identify the mechanism and its effect on the eye. Observe the lid at rest and during blinking, assess whether it closes fully and inspect lash contact in different gaze positions. Test visual acuity and examine the cornea with fluorescein when appropriate. A mild-looking lid abnormality may have substantial consequences when tear function or corneal sensation is poor. Conversely, chronic laxity with a comfortable, protected cornea usually permits routine oculoplastic referral with interim measures and explicit safety-netting.

Preservative-free lubricants can reduce surface friction and exposure symptoms. An ointment may provide longer protection at night, although transient blur must be explained. Taping for entropion pulls the lower lid away from the cornea; taping for incomplete closure aims to close and protect the eye. These are different techniques and should be demonstrated by someone competent. Ensure that lashes, adhesive or an incorrectly positioned lid are not trapped against the cornea. A patient who cannot apply the method reliably needs practical assistance or a different protection plan.

Epilation with suitable magnification and fine forceps can relieve a small number of offending lashes. It is temporary because the follicle remains; lashes commonly regrow within four to six weeks. Recurrent trichiasis can be treated with follicle-directed procedures such as electrolysis or cryotherapy, selected according to the distribution and underlying cause. If entropion drives the lash contact, correcting the lid position is central. Bandage contact lenses are a specialist option requiring monitoring, not a reason to resume ordinary contact-lens wear over an injured cornea.

Definitive lid surgery is tailored to the anatomical problem and often uses local anaesthesia. Horizontal tightening, retractor adjustment or reconstruction of scarred tissue have different indications. Assess functional goals and the patient's ability to manage postoperative care, rather than judging success by appearance alone. Progressive cicatricial disease may require treatment of active inflammation before or alongside reconstruction. Continue monitoring corneal protection while waiting for surgery, because a booked operation does not make new pain or visual deterioration safe to defer.