Treatment of Entropion – A Modified Technique  
Qirat Qurban1, Zeeshan Kamil2, Muhammad Tanweer Hassan Khan3  
1-3LRBT Teaching Tertiary Care Hospital Korangi 2½, Karachi – Pakistan  
Purpose: To study the results of a modified technique of Entropion correction at a Tertiary care hospital.  
Study Design: Quasi experimental study.  
Place and Duration of Study: Layton Rahmatullah Benevolent Trust (LRBT), a tertiary care teaching Eye  
hospital, Korangi, Karachi, for a duration of six months, from January 2018 to June 2018.  
Material and Methods: Patients with senile entropion were included in the study. Patients with recurrent  
entropion, cicatricial entropion, chronic/acute ocular and adnexal infection were excluded. Three equally spaced  
double-armed 6–0 vicryl horizontal mattress sutures were used to close the skin and orbicularis muscle of the  
wound with a bite of the retractors in the center and a 5 mm silicone tube bolster place in the superior loop. Post-  
operative treatment of antibiotics, anti-inflammatory drugs and topical lubricant eye gel were given. Patients were  
examined on 11stpost operative day and then weekly interval for up to one month and thereafter every month for  
up to six months.  
Results: There were 40 eyes of 30 patients with ages ranging from 50 to 65 years. Twenty (66%) patients had  
unilateral repair and 10 (33%) had bilateral repair done. No recurrence was seen in 39 (97.5%) eyes at the end  
six months after surgery. Out of the 40 patients, only 2 (5%) patients complained of heaviness which went away  
eventually with the disintegration of the external tamponade.  
Conclusion: This modified technique of entropion repair using skin excision with retractor plication in the wound  
has a favorable outcome with minimum recurrences and complications.  
Key Words: Entropion, entropion repair, Wies procedure, external tamponade.  
How to Cite this Article: Qurban Q, Kamil Z, Khan MTH. Treatment of Entropion – A Modified Technique. Pak J  
Ophthalmol. 2020; 36 (3): 277-281.  
Doi: 10.36351/pjo.v36i3.1020  
(1.9%) and has a prevalence of 2.4% in whites and  
0.8% in blacks.1 Entropion is also more common in  
Entropion is of four types; congenital, acute spastic,  
involutional and cicatricial. It may occur unilaterally  
or bilaterally and tends to affect the lower eyelid more  
commonly than the upper eyelid. It is also found to be  
more prevalent among women (2.4%) than men  
Since, multiple anatomical defects are involved in  
causing entropion, numerous surgical techniques have  
been described to correct them, the most consistent  
anatomical factor discussed in the literature are  
horizontal eyelid laxity, lower eyelid retractor  
disinsertion and orbicularis oculi muscle override3.  
The horizontal eyelid stability of the lower lid is  
derived from the underlying orbicularis oculi, lower  
eyelid retractors, tarsus and canthal tendons. Laxity of  
these structures leads to the rotation of the lid margin.  
Analogous to the levator aponeurosis and Muller's  
muscle in the upper lid, the lower eyelid retractors  
Correspondence to: Dr. Qirat Qurban  
LRBT Teaching Tertiary Care Hospital  
Korangi 2½, Karachi, Pakistan  
Email: qirat_89@hotmail.com  
Received: March 16, 2020  
Accepted: May 4, 2020  
Revised: May 4, 2020  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 277-281  
Qirat Qurban, et al  
provide vertical stability and the capsulopapebral head  
of these retractors surrounds the inferior oblique  
muscle, forming part of the Lockwood ligament, and  
fuse with the septum at the inferior border of the tarsal  
plate. Since, most traction on the lid is provided by the  
posterior layer of the lower lid retractors, laxity of  
these vertical stabilizing structures causes the lid to  
rotate inward.The extent of laxity which contributes to  
entropion is accessed via a pinch test which was  
described by Nishimoto et al4. Asamura et al assessed  
the overriding of preseptal orbicularis muscle onto the  
pretarsal in Asian patients5.  
Diagnosis of senile entropion was made on the basis of  
clinical examination. History of previous surgery,  
trauma or skin disease was specifically sought.  
Patients were enquired about their occupation,  
previous recurrent conjunctivitis, history of ocular  
diseases and surgeries, use of topical ocular  
medication, diabetes and hypertension. Best corrected  
visual acuity (BCVA) was recorded after refraction.  
Local examination of the entropion included medial  
and lateral canthal tendon laxity as well as the extent  
of horizontal lid laxity. Slit lamp examination included  
thorough examination of the palpebral conjunctiva,  
tear film, inferior corneal surface irregularities, as well  
as flourescein staining of cornea. IOP measurement  
and fundus examination was carried out as part of the  
general ophthalmic examination. After examination,  
all the surgeries were performed under the microscope  
using local anesthesia by a single surgeon.  
Entropion is managed according to the specific  
etiology, which includes conservative medical  
management and surgical management. The aim of  
medical management is to counter the adverse effects  
of misdirected lashes causing ocular surface damage  
secondary to irritation and includes the use of  
lubricants, contact lenses and Botulinum toxin.  
Definitive treatment includes surgical management  
and temporary office based procedure such as Quickert  
sutures, in which the surgeon explores and repairs the  
After all aseptic measures, a skin incision was  
marked 3 mm inferior to the lashes. Local anesthesia  
was induced across the whole length of the eyelid.  
A lid guard was placed to protect the globe. The lower  
eyelid was stabilized with '4–0' silk traction suture and  
clamped to the guard and drape. A Partial-thickness  
incision was made and a 2-3 mm strip of skin,  
depending upon the laxity, was removed along the  
entire length of the lower lid. The inferior fat pad was  
exposed with blunt dissection behind the preseptal  
orbicularis oculi muscle. The lower eyelid retractors  
were identified as a visible white fibrous tissue layer  
between the inferior fat pad and the conjunctiva. Three  
equally spaced double-armed 6–0 vicryl horizontal  
mattress sutures were used to close the skin and  
orbicularis muscle of the wound with a bite of the  
retractors in the center. A 5 mm silicone tube was  
introduced through each of the 3 suture arms initially.  
At the end both arms of the sutures were at the same  
level and were tied to each other. These sutures acted  
as an external tamponade. These sutures absorbed over  
the course of 3 to 4 weeks and the tubes disintegrated,  
leaving a good cosmetic appearance.  
lower eyelid retractors via  
skin incision.  
Alternatively, transconjunctival approach can be done  
to support the inferior border of the tarsus.6 A little  
amount of pretarsal orbicularis oculi can be removed  
to prevent further overriding of the tarsus. If only  
horizontal eyelid laxity is involved, a medial or lateral  
canthal tightening procedure can be done. A lateral  
tarsal strip operation or wedge resection overcomes all  
three etiologic factors in involution entropion  
(horizontal lid laxity, attenuation or disinsertion of the  
eyelid retractors, and overriding by the preseptal  
orbicularis oculi muscle).  
We describe a modified surgical technique for  
senile Entropion done at a Tertiary care hospital.  
This Quasi experimental study was conducted at  
LRBT Tertiary Teaching Eye Hospital, Karachi, from  
January 2018 to June 2018. Thirty patients were  
enrolled in this study with age ranging from 50-65  
years (58.57 ± 2.1). Inclusion criteria were patients  
between 50 – 65 years of age attending hospital  
outpatient department with senile entropion. Exclusion  
criteria were recurrent entropion, cicatricial entropion,  
congenital entropion, chronic/acute ocular and adnexal  
infections. Informed consent was obtained from all the  
patients. A proforma was used to record information.  
Post-operative treatment comprised of systemic  
antibiotics and anti inflammatory drugs along with the  
topical lubricant eye gel at night. All the patients were  
examined on 1st post-operative day and then weekly  
interval for up to one month and thereafter every  
month for up to six months. Total duration of follow-  
up in this study was six months.  
Post-operative complication was observed in 2  
(5%) patients, which included heaviness of lid margin;  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 277-281  
Treatment of Entropion – A Modified Technique  
Fig. 2: Pre and postoperative appearance.  
which resolved spontaneously after disintegration of  
external tamponade. Data collection and recording was  
done using SPSS 21.  
period. One (2.5%) patient ended up with recurrence  
of previous disease, who was re-operated after three  
months of initial surgery. Only 2 (5%) patients  
complained of heaviness of lid margin until the  
external tamponade disintegrated.  
Forty eyes of thirty patients underwent lower lid  
entropion repair via a modified technique. Twenty  
(66%) patients had unilateral repair and ten (33%) had  
bilateral repair done. Most of the patients in this study  
were between 50 – 65 years of age. Mean age was  
58.57 ± 2.1 years. Twenty (66.6%) patients were male  
and ten (33%) were females. 39 (97.5%) eyes showed  
no recurrence (Figure 1) at the end of the follow-up  
Senile entropion is most commonly defined as a form  
of spastic entropion occurring in the lower eyelid of  
elderly people, attributed to the spasm of orbicularis  
muscle frequently causing significant ocular  
discomfort. The aim of entropion correction is directed  
towards the prevention of ocular irritation, recurrent  
bacterial conjunctivitis, reflex tear hyper secretion,  
superficial keratopathy and risk of ulceration and  
microbial keratitis7,8.  
Jones narrated lower eyelid retractor plication and  
advancement as a surgical treatment for entropion.  
Jones also suggested that lower eyelid retractor laxity  
was analogous to a levator aponeurosis dehiscence9.  
Collin and Rathbun studied patients with entropion  
versus normal eyelids evaluating the lower lid  
retractors on the basis of histology. In the specimens  
of entropion patients, they found that the lower lid  
retractors and orbital septum only came to within 3.5  
mm of the inferior border of the tarsus versus 1.5 to  
2.5 mm in normal lids10. Moreover, a larger amount of  
orbital fat was present in the entropion samples  
compared to the normal lids indicating a retractor  
dehiscence11. The tarsal plate has been shown to invert  
in entropion where the lower border rotates superiorly  
and anteriorly and the upper border rotates inward10. In  
a number of patients, the junction of the inferior  
border of the tarsus with the lower lid retractors has an  
acute angulation as compared to a normal eyelid.  
Fig. 1: Horizontal mattress sutures with silicone bolster superiorly.  
It was the physicians’ knowledge of the  
involutional pathophysiological and anatomical  
changes of the inward rotation of the lower lid margin,  
that was dictating the current clinical and surgical  
repair practice prior to the publication of high level  
evidence12. Various methods have been described for  
treating involutional entropion13,14,15. Wies, in 1954,  
introduced his procedure for vertical lid laxity but this  
resulted in over correction of 10% and recurrence of  
11% at the end of 6 months follow up.8 Carrol et al  
combined above procedure with horizontal shortening  
which resulted in almost no recurrence at follow up of  
33 months16. Some authors, such as Collin stated a  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 277-281  
Qirat Qurban, et al  
3.7% recurrence rate for the combined procedure17 and  
Rougraff observed a recurrence of 1.6% for indirect  
retractor attachment with everting sutures combined  
with the tarsal strip procedure18. Dryden reported  
recurrence rate of 2/12 patients who underwent  
correction of vertical lid laxity in the form of retractor  
plication with the Jones procedure19.  
Muhammad Tanweer Hassan Khan; Consultant  
Ophthalmologist: Concept, study design, Data  
Collection, final review.  
1. Damasceno RW, Osaki MH, Dantas PE, Belfort R.  
Involutional entropion and ectropion of the lower  
eyelid: prevalence and associated risk factors in the  
elderly population. Ophthalmic Plast Reconstr Surg.  
2011; 27 (5): 317-20.  
2. Carter SR, Chang J, Aguilar GL. Involutional  
entropion and ectropion of the Asian lower eyelid.  
Ophthal Plast Reconstr Surg. 2000; 16: 45–49.  
3. Marcus MM, Paul PO, Jimmy SML. Involutional  
entropion: Risk factors and surgical remedies Curr Opin  
Ophthalmol. 2015; 26 (5): 416–421.  
4. Nishimoto H, Takahashi Y, Kakizaki H. Relationship  
of horizontal lower eyelid laxity, involutional entropion  
occurrence, and age of Asian patients. Ophthal Plast  
Reconstr Surg. 2013; 29: 492–496.  
5. Asamura S, Kakizaki H, Shindou E, Itani Y, Isogai  
N. What is the best strategy for Asians with  
involutional entropion? J Craniofac Surg; 2014; 25:  
In this study, a modified surgical technique was  
performed for the repair of senile entropion which  
showed 2.5% recurrence at the end of follow up  
period, whereas, Sobky et al20 shows 7.1% recurrence  
rate. Baboridis et al21 mentioned recurrence rate of  
17%. Males were predominant over females in this  
study, whereas in several other studies by Baboridis,  
females were predominant. Damasceno et al showed  
that prevalence of females was 2.4% as compared to  
males, which was 1.9%22. On the contrary, Abdel  
Fatteh et al showed 20 male patients in comparison to  
6 female patients23. In this current study, no  
overcorrection was encountered whereas Sobky et al20  
ended up in 6.7% rate of overcorrection.  
6. Quickert MH, Rathbun E. Suture repair of entropion.  
Arch Ophthalmol. 1971; 85 (3): 304–305.  
7. Bergstrom R, Czyz CN. Entropion Eyelid  
Reconstruction. PMID: 29262117, 2018.  
8. Wies FA. Surgical treatment of entropion. J Int  
CollSurg. 1954; 21 (6): 758–760.  
Limitation of our study is that it was a small scale  
study and the follow up period was only six months.  
Larger sample size with longer duration of follow up  
will further prove the efficiency of this procedure.  
9. Jones LT, Reeh MJ, Tsujimura JK. Senile entropion.  
Am J Ophthalmol. 1963; 55 (3): 463–469.  
10. Collin JRO, Rathbun JE. Involutional entropion: a  
review with evaluation of a procedure. Arch of  
Ophthalmol 1978; 96(6): 1058–1064,  
11. Quickert MH. Malpositions of the eyelid. In: Modern  
Ophthalmology, A. Sorsby, Ed. Butterworths, London,  
UK, 1972; 2nd Edition: pp. 941–943.  
This modified technique of entropion repair using skin  
excision with retractor plication in the wound has a  
favorable outcome with minimum recurrences and  
12. Boboridis KG, Bunce C. Interventions for involutional  
lower lid entropion. Cochrane Database of Systematic  
Reviews 2011, Issue 12. Art. No.: CD002221.  
13. Cook T, Lucarelli MJ, Lemke BN, Dortzbach RK.  
Primary and secondary transconjunctival involutional  
entropion repair. Ophthalmology, 2001; 108: 989–993.  
14. Rainin E. Senile entropion. Arch Ophthalmol 1979; 97:  
Ethical Approval  
The study was approved by the Institutional review  
board/Ethical review board.  
Conflict of Interest  
Authors declared no conflict of interest  
15. Dryden R, Leibson J, Wobig J. Senile entropion.  
Pathogenesis and treatment. Arch Ophthalmol. 1978;  
96: 1883–1885.  
16. Caroll R, Allen SE. Combined procedure for repair of  
involutional entropion. Ophthal Plast Reconstr Surg.  
1991; 7: 273–277.  
Authors’ Designation and Contribution  
Qirat Qurban; Associate Professor: Concept, study  
design, Manuscript writing.  
Zeeshan Kamil: Senior Consultant Ophthalmologist:  
Concept, study design, Final review.  
17. Collin J. A manual of systemic eyelid surgery.  
Edinburgh: Churchill Livingstone; 1989: 7–26.  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 277-281  
Treatment of Entropion – A Modified Technique  
18. Rougraff P, Tse D, Johnson T, Feuer W. Involutional  
entropion repair with fornix sutures and lateral tarsal  
strip procedure. Ophth Plast Reconstr Surg. 2001; 17  
(4): 281–7.  
Ophthalmology, 1978; 96 (10): 1883–5.  
20. El-Sobky HMK, Mandour SS, Allam MMM. Wies  
procedure versus Jones procedure in the surgical  
correction of acquired lower eyelid involutional  
entropion, Menoufia Med J. 2017; 30 (2): 507-511.  
DOI: 10.4103/1110-2098.215452, 2017.  
19. Dryden RM, Leibsohn J, Wobig J. Senile entropion.  
21. Boboridis K, Bunce C, Rose GE. A comparative study  
of two procedures for repair of involutional lower lid  
entropion. Ophthalmology, 2000; 107: 959–961.  
22. Damasceno RW, Osaki MH, Dantas PE, Belfort  
clinicopathologic correlation between horizontal eyelid  
laxity and eyelid extracellular matrix. Ophthal Plast  
Reconstr Surg. 2011; 27: 321–326.  
23. Abdel Fattah ME, El-Sayed EMEH, Abdel Kader  
KSED, Abdel Badia SM. Wies operation with  
horizontal shortening versus retractor tightening with  
horizontal shortening for management of lower eyelid  
senile entropion. Discussed thesis in Zagazig  
University, Egypt 2007. Available from:  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 277-281