Cicatricial Entropion

Etiology

• Definition: inward rotation of the eyelid margin due to posterior lamellar abnormality, with direction of the lashes or keratinized lid margin against the ocular surface
• Rare congenital cases are not truly cicatricial.
• Upper eyelid entropion (tarsal kink syndrome): posterior tarsal plate demonstrates a full horizontal length inward “kink” of the tarsus that turns the lid margin inwards.
• Also seen in incomplete development/deficiency of the upper lid tarsal plate with an absent eyelid crease and overriding of the orbicularis muscle
• Acquired: Inflammatory or scarring processes cause shortening of the posterior lamella of the eyelid. The posterior shortening causes inward rotation of the eyelid margin with direction of the lashes or keratinized lid margin against the ocular surface.
• Conjunctival cicatrizing disorders (Stevens Johnson syndrome, ocular cicatricial pemphigoid, drug-induced pseudo-ocular cicatricial pemphigoid, sarcoidosis)
• Chemical burns
• Post-traumatic injuries from iatrogenic surgery (such as orbital floor fracture repair or lower lid blepharoplasty) or radiation therapy
• Infectious processes (trachoma, herpetic disease)
• Treatment with glaucoma medications and chemotherapy drugs
• Mechanical entropion due to mass lesions that secondarily invert the lid margin
• Can be neoplastic or inflammatory

Epidemiology

• Congenital: relatively uncommon
• Acquired: relatively uncommon in the US
• Trachoma: travel to endemic areas, exposure to infected individuals
• Stevens Johnson syndrome: exposure to inciting agent or medications
• Ocular cicatricial pemphigoid (OCP): OCP is a rare, bilateral mucosal cicatrizing autoimmune disease in older patients (> 55 years old), that has a chronic recurrent and relapsing course. Despite aggressive management, OCP can be progressive and blinding in severe cases. A subset of mucous membrane pemphigoid, it is thought to be due to a type II (antibody dependent) hypersensitivity response against the hemidesmosome-epithelial membrane complex in conjunctival basement membrane. Specific human leukocyte antigen (HLA) associations have been described including DR-2, DR-4, DQw7, HLA A2, HLA B8, HLA B49, and HLA B35.
• Drug-induced pseudo-ocular cicatricial pemphigoid: Onset of OCP has been observed after use of drugs such as systemic practolol, topical pilocarpine, epinephrine, phospholine iodide, and timolol. 

History

• Symptoms of ocular irritation, dryness, corneal damage, and visual compromise (more common and more severe with upper eyelid involvement than with lower eyelid involvement)
• History of an inflammatory or traumatic process such as
• Autoimmune (ocular mucous membrane pemphigoid or linear IgA bullous dermatosis, sarcoidosis) (Carruth, Ophthal Plast Reconstr Surg 2013)
• Inflammatory (Stevens Johnson syndrome)
• Infectious (trachoma, herpes zoster)
• Surgical (enucleation, upper eyelid conjunctival-Muller muscle resection (CMMR) ptosis repair)
• Traumatic (thermal or chemical burns, scarring)
• Glaucoma drugs
• History of eyelid neoplasm
• Can involve upper and/or lower eyelid, unlike involutional entropion, which typically involves lower eyelid
• Cicatricial entropion is typically progressive

Clinical features

• Upper-eyelid involvement can have similar signs and symptoms as lower-eyelid entropion.
• Inability to correct entropion by gentle downward manual traction (lower lid) or upward traction (upper lid)
• Conjunctival injection (Stage I), mechanical corneal abrasion, superficial keratitis, ulcer, corneal thinning, corneal scar/xerosis (Stage IV)
• Inferior scarring and shortening of the conjunctiva (Stage II) and/or deformation of tarsus
• Symblepharon (Stage III) or scar bands in the fornix or on the tarsal plate
• Chronic exposure with lagophthalmos can occur in cases of significant scarring that shortens the posterior lamella.
• Trichiasis can occur due to chronic inflammation, and can sometimes be the presenting sign of a conjunctival cicatrizing disorder.
• Dry eye can also be more severe due to the loss of accessory lacrimal glands.
• Large symblepharon adhesions can limit globe motility in certain gazes, resulting in diplopia.

Evaluation for establishing diagnosis

• Testing directed by history
• Immunofluorescence studies for mucous membrane pemphigoid, including IgG, C3, fibrinogen
• Conjunctival or eyelid biopsy: Linear staining for IgG and C3 in the epithelial basement membrane zone is consistent with OCP.
• 83% of OCP cases are correctly diagnosed with conjunctival biopsy. Remaining 17% with negative biopsy have clinical characteristics typical of CP that clinician proceeds with therapy despite negative biopsy (Thorne, Ophthalmology 2004).
• Cultures or PCR test for trachoma, herpes in cases that appear active
• Consider collaborative care with anterior segment or corneal specialist, rheumatologist if indicated

• Travel to endemic areas for trachoma
• Chemical exposure: Safety glasses should be used in susceptible work environments.
• History of trauma
• Use of topical drugs to treat glaucoma (topical pilocarpine, epinephrine, phospholine iodide, timolol)

• Involutional entropion
• Spastic entropion: Rule out irritative factors such as conjunctivitis, dry eye, infection, eyelash malposition.
• Trichiasis without entropion
• Misdirected lashes from chronic posterior blepharitis, eyelid margin scar (such as from prior lid margin surgical repair or trauma)
• Aberrant trichiatic lashes: can have history of Lumigan, Xalatan, Latisse use
• Distichiasis: eyelash abnormality, may be attributed to a genetic mutation, in which an abnormal lash exits from the duct of the meibomian gland at the eyelid margin; typically bilateral, affecting the upper or lower eyelid, with more than one eyelash often arising from a duct orifice
• Floppy eyelid syndrome (FES): Exam can demonstrate eyelash ptosis, loss of parallelism, thick velvety palpebral conjunctiva, profound horizontal laxity with easy eversion of the upper eyelid, keratopathy; may have associated history of sleep apnea, CPAP use, daytime somnolence, heavier body habitus, keratoconus, Down syndrome.

Natural history

Variable depending on etiology and activity of disease; surgical treatment should ideally be done when disease process has been controlled.

Medical therapy

• Aggressive lubrication, bandage contact lens
• Trachoma: Treat infectious etiology.
• Azithromycin, doxycycline, tetracycline — avoid latter in children less than 8 years old, pregnant women, and nursing mothers.
• Ocular cicatricial pemphigoid
• Treat blepharitis
• Lubrication with frequent artificial tears and ointment
• Bandage contact lens can provide temporary relief
• Topical steroids (judicious use with close monitoring of cornea)
• Systemic steroids
• Dapsone (progressive increase to 100–150 mg/d)
• Immunosuppressives (cyclophosphamide, methotrexate, azathioprine, mycophenolate mofetil, rituximab); often managed with rheumatologist
• Control of ocular inflammation, such as from OCP or other cicatrizing disorders, is necessary prior to surgery for optimal entropion repair.

Surgery

Mild cases with minimal tarsal abnormalities:

• Shortening of anterior lamella (skin muscle resection with epitarsal fixation) or anterior lamella repositioning via eyelid crease incision
• Margin rotation/marginal tarsotomy: useful for marginal cicatricial entropion
• Tarsal fracture: useful for tarsal kink and tarsal deformities. Not as effective for severe cicatricial entropion as margin might not be adequately rotated. Can be used as an initial procedure, with a success rate of about 74% (Ponbejara, J Med Assoc Thai 2011)
• After local anesthesia, a 4-0 silk traction suture is placed on the central eyelid margin
• Eyelid is everted over a Desmarres retractor
• A 15-blade scalpel is used to make a full thickness tarsal horizontal incision at least 4mm from the eyelid margin (to preserve the integrity of the lid contour)
• 5-0 double-armed polyglactin, or 4-0 double-armed chromic, sutures are passed horizontally through the superior tarsus edge, taking care to avoid passing through the posterior conjunctiva. The two suture arms are then passed, about 3–4 mm apart, through the muscle and subcutaneous tissues, to exit the skin 1–2 mm from the eyelash line. The sutures are tied over the skin, with 2–3 horizontal sutures placed in this fashion. By passing the needles in an oblique direction to exit closer to the eyelid margin, this results in an outward rotation of the margin.

Moderate to severe cases:

• Eyelash resection: removal of the lash follicles with scissors or cauterization to prevent regrowth can provide symptomatic relief
• In a retrospective chart review of patients with severe, recurrent or segmental cicatricial entropion, 90% of patients had functional success with no recurrent trichiasis during a mean follow up of 13 months (Wu, Ophthal Plast Reconstr Surg 2010)
• When combined with eyelid margin splitting at the gray line with a 15-blade scalpel, the anterior lamellar skin and lash follicles can be excised as a horizontal strip. The anterior lamella can then be recessed several millimeters away from the lid margin and sutured to the tarsus to prevent upper skin rotation over the lid margin and subsequent irritation.
• Surgical entropion repairs (i.e., Quickert sutures, transconjunctival entropion repair, Wheeler procedure, Wies procedure, tarsal fracture)
• Bleyen et al. (Br J Ophthalmol 2009) reported an 85% success rate using the Weis procedure (transverse blepharotomy and marginal rotation) on 126 upper and lower eyelids with cicatricial entropion. 13 eyelids developed complications, and 18 eyelids developed recurrences requiring additional surgery.
• More severe cases might require posterior lamellar lengthening procedures with spacer grafts (for shortened conjunctiva, fornix, and/or tarsus), tarsal modification, or a combination. These procedures typically combine marginal rotation techniques and super-advancement of the posterior lamella (or recession of the anterior lamella) such that bare tarsus is seen.
• Graft options include
• Mucous membrane
• Amniotic membrane
• Tarsal plate
• Hard palate
• Banked scleral graft (Tenzel, Arch Ophthalmol 1975)
• Acellular dermal grafts (human cadaveric, fetal bovine, porcine xenograft)

Mucous membrane grafting to eyelid margin:

• Indications: entropion due to posterior lamellar deficiency (cicatricial conjunctival processes), particularly when associated with keratinization or other irregularities of the lid margin (Dortzbach, Arch Ophthal 1971)
• Preprocedure evaluation: Evaluation of the severity of entropion, presence of keratinization of the lid margin, evaluation of buccal mucosa for potential donor site. Epidermized tarsal conjunctiva can be polished prior to addition of the mucous membrane graft (McCord, Ophthalmic Surg 1983).
• Technique (Leone, Ophthalmic Surg 1974):
• Inject local anesthesia
• Protective corneal shield may be placed on the ocular surface
• Eyelid margin is split into an anterior and posterior lamella using an 11- or 15-blade scalpel
• The anterior lamella (skin and orbicularis muscle) is recessed, or the posterior lamella super-advanced, about 5–7 mm
• The recessed anterior lamella is fixated with 5-0 or 6-0 sutures (Vicryl, chromic gut, or nonabsorbable) placed through the skin surface, then horizontally through partial-thickness tarsus (slightly further than the desired anterior lamella position to compensate for postoperatively migration), and back out through the skin 3–4 mm apart from the tail end. The sutures are tied over the skin or over bolsters. Several horizontal mattress sutures are needed to secure the anterior lamella in recessed position.
• This results in an anterior lamellar defect over bare tarsus, which can be covered with a graft. Buccal mucous membrane graft site can be harvested from the inner aspect of the cheek. Smaller grafts can be harvested from the inner lower lip mucosa.
• Care should be taken to avoid the opening of salivary Stenson duct; located opposite the second upper molar
• A slightly oversized elliptical graft is demarcated with a marking pen, and local anesthesia infiltrated. The full thickness mucosal graft is harvested with standard surgical instrumentation (i.e., 15-blade, Westcott or tenotomy scissors).
• Posterior surface of graft is thinned as needed
• Donor site closure, after adequate hemostasis, is often performed with 5-0 polyglactin or chromic suture in a running or running-locking fashion.
• Graft is sutured into position on bare tarsus up to the lid margin with 6-0 plain gut suture (or similar suture), with sutures positioned away from the ocular surface. Mild oversizing of the graft is optimal.
• Antibiotic ointment is applied, followed by a light pressure dressing (optional) for 24–48 hours, which minimizes bleeding under the graft that could compromise the outcome.
• Complications
• Intraoperative
• Bleeding/hematoma
• Damage to ocular/periocular/oral structures (i.e. Stensen duct)
• Ptosis
• Corneal abrasion
• Postoperative
• Infection
• Scarring
• Graft failure/necrosis (rare)
• Graft contraction with recurrence of symptoms
• Corneal abrasion
• Preventing and managing complications
• Prevention of complications
• Bleeding and hematoma are prevented by preoperative management (stopping blood thinners at the appropriate time), meticulous intraoperative hemostasis
• Unintended damage to healthy structures is prevented by appropriate surgical technique, as well as an intimate understanding of all relevant surgical anatomy
• Infection is minimized through aseptic technique, and topical postoperative antibiotics
• Graft failure/necrosis can be prevented by minimizing cautery to the graft and host site
• Oversizing the graft slightly is recommended to compensate for anticipated graft contraction during healing. Koreen et al. (Ophthal Plast Reconstr Surg 2009) reported that 4/21 eyelids that had buccal mucous membrane grafting for cicatricial entropion required repeat grafting for recurrent entropion due to graft shrinkage (3 eyelids) and graft dislocation (1 eyelid).
• 1–3 small openings placed through the central graft (using a scissors or blade) during surgery can allow for egress of possible fluid or blood under the graft
• Super-advancement of the posterior tarsal edge, or recession of the anterior lamella, can be considered to accommodate for some degree of postoperatively migration of the anterior lamella back towards the eyelid margin.
• Management of complications
• Postoperative bleeding and hematoma should be followed in mild to moderate cases.
• If hematoma is severe (risking graft viability), the incision can be partly opened, the hematoma drained, any active bleeding controlled, then resutured and patched.
• Infections are treated with topical and oral antibiotics.
• Corneal abrasions are treated with a bandage contact lens, lubrication, or topical antibiotics.
• Damage to Stenson duct requires referral to oral or ENT surgeon.
• Follow-up
• Follow-up about 1 week postoperatively
• Bolsters, if placed over the graft, can be removed at 5–10 days
• Ice packs are often avoided when grafts are placed because increased vasoconstriction can affect graft viability.
• Combination antibiotic/corticosteroid ointment is applied 2–3 times a day
• Artificial tear drops are recommended for irritation
• Pain is usually managed with acetaminophen or mild narcotic
• Warm compresses may be carefully used to keep the site clean; standard postoperative instructions regarding positioning and activity limitations for 1 week

Tarsal fracture, tarsectomy, and rotation procedure:

• Indications: Correction of tarsal kink entropion or mild-moderate tarsal scarring deformities
• Contraindications: Not as effective for severe cicatricial entropion as the margin cannot be adequately rotated, and procedure could result in significant vertical eyelid shortening if a posterior lamellar graft is not used to lengthen the tarsus
• Describe the technique (Fox, Am J Ophthalmol 1964; Seiff, Am J Ophthalmol 1999)
• Eyelid crease is marked with a surgical marking pen
• Protective corneal shield is placed on the ocular surface
• Dissection is made through the pretarsal orbicularis muscle down to expose the tarsal plate down to the lash line
• The area of tarsal cicatrix can sometimes be identified as a thick horizontal scar band within the tarsal plate
• At the level of the tarsal kink or scarring, a partial thickness tarsal trough, “gutter,” or triangular wedge cut is made in the tarsus for the length of the tarsus, using a 15-blade scalpel; the trough tarsectomy should not be full-thickness through tarsus
• Fox (AJO 1964) recommends creating the gutter by incising 2 horizontal tarsal incisions, with the inferior incision about 3 mm from the lash line, and the second placed 3 mm above the other, with the 2 incisions then beveled towards each other in the tarsus to meet before reaching conjunctiva. The base of the triangular trough cut is therefore about 3 mm wide in height, with the apex towards the conjunctiva.
• If tarsus is completely transected and conjunctiva inadvertently incised, the conjunctiva can be closed with fast-absorbing or plain gut suture
• Eyelid margin can be split at the gray line, dividing the skin and lashes from the tarsus, with a 15-blade scalpel to further rotate the lid margin.
• 6-0 absorbable or nonabsorbable sutures can be placed to close the tarsal trough, which rotates the lid anteriorly. Other authors have recommended double-armed 4-0 chromic gut suture passed horizontally through the superior tarsus and then through both edges of the tarsal trough, with the knots tied below the inferior edge.
• The lower skin-pretarsal orbicularis lamella is then elevated smoothly, and redundant tissue extending past the trough level excised to minimize mechanical weight exacerbating margin rotation
• The inferior tissue edge is sutured in an elevated position on the superior tarsus or levator aponeurosis to create additional outward margin eversion, using multiple transcutaneous 6-0 vicryl or prolene interrupted sutures
• Additional skin closure can be performed as needed between the rotation sutures.
• Preventing and managing complications
• Intraoperative
• Bleeding/hematoma can be prevented with meticulous hemostasis and avoidance of peripheral and marginal arcade arteries
• Damage to globe when creating tarsal trough can be prevented by excising partial thickness trough and utilizing a corneal shield
• Ptosis if levator aponeurosis is detached
• Postoperative
• Infection
• Scarring
• Recurrent entropion due to incomplete release or removal of tarsal cicatrix
• Recurrent retraction of the lower lid can be avoided by placing an adequate posterior lamellar spacer

Various grafts used in entropion repair:

• Types of acellular spacer grafts: Acellular grafts, typically composed of flexible collagen-dermal sheets from cadaveric acellular collagen matrix, have unique characteristics allowing increasing applications in oculoplastic surgery.
• Consistency, rigidity, and thickness can closely approximate the properties of the tarsus
• Basement membrane surface allows for conjunctival epithelial repopulation 3 to 5 weeks later
• Minimal inflammation is seen postoperatively
• Negligible risk of immunologic rejection
• AlloDerm allografts (Life Cell Corp, Branchburg NJ)
• Cadaveric acellular collagen matrix typically 0.3–1.8 mm thick
• With the use of thin 0.3- mm AlloDerm grafts, the contraction rate was found to be 57% compared to hard palate grafts 16% in a prospective trial of 14 patients undergoing lower eyelid surgery (Sullivan, Ophthal Plast Reconstr Surg 2003).
• A study using thick 1.8-mm AlloDerm grafts found their use to be superior to thin AlloDerm grafts, but comparable to hard palate grafts in the reconstruction of the posterior lamella in lower eyelid retraction (Taban, Arch Facial Plast Surg 2005).
• ENDURAGen grafts, implants and spacers (Porex Surgical, Newnan, GA)
• Porcine acellular collagen matrix typically 0.5–1-mm thick, that is slightly more rigid than other similar tissue products
• Used as an eyelid spacer graft, complications were reported in 10% of patients (13/129 eyelids) and were secondary to inadequate spacer size, infection, or excess graft (McCord, Plast Reconstr Surg 2008).
• ENDURAGen acellular grafts can stretch significantly less than AlloDerm grafts of the same size and thickness, a property that can be considered during surgical planning (Vural, Laryngoscope 2006).
• Placement in the lower eyelid should be below the existing tarsal plate and peripheral vascular arcade, and is typically sutured into the recipient site with 6-0 polyglactin or similar.
• Dermis fat grafts
• Dermis fat grafts (DFG) have been used extensively for anophthalmic socket reconstruction, volume augmentation, treatment of lower eyelid malposition as a posterior lamellar spacer graft, thyroid eye disease and cicatricial paralytic lower eyelid retraction to elevate the lower eyelid and support the tarsus. (Korn, Ophthalmology 2008).
• The dermis fat graft, composed of dermis and appended subcutaneous fat after the epidermis is removed, is typically harvested from the lower abdomen, periumbilical region, inner thigh, or gluteal region, where the incision is optimally concealed.
• Potential advantages of dermal fat grafting
• Dermis enhances vascularization and minimizes the risk of fat atrophy.
• Autologous tissue avoids infection transmission or allergic reaction.
• Size of graft is virtually unlimited.
• Adipose tissue can contribute to a higher success rate due to an antifibrotic or anti-inflammatory effect within the middle lamella of the eyelid.
• Can provide excellent cosmetic results and functional longevity
• Using DFG as a posterior lamellar spacer
• Site of harvest identified, and marked with an elliptical skin incision measuring at least 20mm in the long axis
• Local anesthetic infiltrated to raise the epidermis
• Epidermis is discarded after carefully dissection away from the dermis with a 15-blade or scissors, taking care to avoid removing dermis
• An average of a 20 x 20mm area of dermis and underlying fat is removed, with the fat component slightly wider inferiorly rather than narrowing down
• Close harvest site with 3-0 or 4-0 polyglactin buried interrupted sutures, followed by skin closure
• The lower lid middle lamella is dissected to completely release any cicatrix
• Dermis fat graft is placed with the dermis side posteriorly, and the fat portion internal, and sutured into position using 6-0 polyglactin sutures
• Chang et al. (Ophthal Plast Reconstr Surg 2011) found similar results in volume augmentation using AlloDerm versus dermis-fat spacer graft in a retrospective review of 8 patients with lower eyelid retraction using en-glove lysis of lower eyelid retractors.
• Potential complications of dermis fat grafting include inability to accurately predict the amount of graft to be harvested, fat graft atrophy, volume loss, fatty augmentation requiring debulking (in younger children), harvest site dehiscence.
• Tarsus autologous grafts
• Tarsus autologous grafts can be used as a posterior lamellar spacer for lower eyelid elevation. If harvested from the upper eyelid, 4 mm tarsal height from the margin should be preserved for upper eyelid integrity.
• Surgical technique
• Local anesthetic injected to pretarsal upper eyelid
• Tarsus horizontally incised 4 to 5 mm above the eyelid margin for horizontal distance of 16 mm or less
• Two 4 mm vertical tarsal incision are made at the end of the horizontal incision
• Levator aponeurosis, Muller muscle and conjunctiva are separated from the graft, which is then removed
• The graft is placed with the mucosa facing the globe centrally in the lower eyelid
• Lateral tarsal strip or similar procedure is performed to correct for horizontal laxity
• The corners of the graft are sutured to the lower eyelid tarsus or retractor with buried 6.0 Vicryl sutures.
• Malhotra et al. (Ophthal Plast Reconstr Surg 2005) was able to obtain a spacer 7mm in height in 9 eyelids for lower eyelid elevation.
• Autogenous auricular cartilage grafts
• The use of autogenous auricular cartilage for upper eyelid entropion can be useful for patients with a deficient tarsal plate given some of its unique properties.
• Robust enough to provide adequate support and protection
• Offers a functional anatomical similarity as the tarsus
• Surgical technique (Yaqub, Eye 1997)
• Make an incision on the medial surface of the pinna through the subcutaneous tissues and dissect the underlying auricular cartilage.
• A 15-blade is used to remove the necessary graft size based on the eyelid and removed
• The graft is cleaned and a curve is created to the graft to mimic the tarsal plate. This can be difficult.
• The graft is placed into the dissected pocket of the eyelid.
• If placement is in the upper eyelid, the levator aponeurosis is sutured to the upper 1/3 of the graft with interrupted 7-0 vicryl sutures but it is not sutured to Muller’s muscle.
• The skin is reclosed with incorporation of the levator aponeurosis with 7.0 vicryl sutures to create a skin-crease.
• Hard palate mucous membrane grafts
• Hard palate mucosal grafts can be used for reconstruction of the posterior lamella of the upper or lower eyelid.
• Advantages of using the hard palate graft
• A larger size can be obtained
• Has appropriate strength, flexibility and is easy to harvest
• Epithelium and mucus production are similar to conjunctiva
• Swamy et al. (Clin Experiment Ophthalmol 2008) used hard palate mucous membrane grafts in 147 eyelids undergoing surgical management of cicatricial entropion. 95% of patients had symptomatic improvement. Most common postoperative complications during an average 21 month follow-up period included excess keratin (29%), recurrence of cicatricial entropion (4.1%), punctate epithelial erosion (2.7%), graft shrinkage (0.7%) and donor site bleeding (2.0%).
• Amniotic membrane graft
• An amniotic membrane graft is a thick collagen layer over basement membrane with a single layer of epithelium that can proliferate and differentiate on ocular surfaces.
• Advantages of amniotic membrane grafting
• Well tolerated
• No serologic evidence of rejection
• Facilitates epithelialization
• Minimizes scarring and inflammation
• Ti et al. (Ophthalmology 2001) performed a grey-line lid split procedure with vertical anterior lamella repositioning in 19 patients with moderate to severe cicatricial entropion. The human amniotic graft was used to reconstruct the eyelid margin and cover the exposed tarsus. Functional success was achieved in 88% of eyelids (22/25) with epithelialization of the bare tarsus 2–3 weeks later. Only 1 case recurred 14 months after surgery.

• Undercorrection
• Overcorrection
• Recurrence of entropion: Address the appropriate etiology of entropion and stabilize ocular cicatrizing condition prior to surgery.
• Eyelid margin irregularities, contour abnormality
• Retraction
• Potential lid margin necrosis, eyelash loss, corneal dellen formation
• Pyogenic granuloma in tarsal rotation or tarsotomy procedures

• Vision loss
• Chronic discharge
• Trichiasis
• Corneal abrasions
• Corneal ulceration
• Corneal scarring and decreased vision
• Lagophthalmos
• Severe dry eye
• Recurrence of entropion
• Upper lid retraction
• Lid margin necrosis due to vascular compromise (marginal artery)

• Detailed wound care instructions (topical antiobiotic ointment to sutures, avoid strenuous activity that could cause bleeding)
• Return for significant bleeding under a graft
• Keep eye well-lubricated
• Topical corticosteroids can be useful to limit scar formation and recurrence.
• Follow-up for recurrence of entropion as tissues heal

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