Spastic Entropion

Etiology

• Spastic entropion is often accompanied by involutional entropion.
• Pre-existing lower eyelid laxity or irritation after ocular surgery can cause a muscle spasm in the orbicularis oculi muscle, producing a transient pretarsal orbicularis override leading to entropion.
• Ocular irritation from infection, inflammation, or traumatic causes

History

• Local irritation or infection after an ocular surgery or procedure can uncover asymptomatic involutional entropion.
• Patients might describe intermittent foreign-body sensation, tearing, irritation, redness, pain.
• Perception of eyelid margin inversion might or might not occur.

Clinical features

• Central and inferior punctate keratopathy might be seen on exam.
• Impaired movement on downgaze secondary to lower eyelid weakening of eyelid retractors
• Mild upper eyelid ptosis and mild preseptal swelling of lower eyelid

Testing

• Can be elicited by asking the patient to forcefully close the eyelids to induce an overriding orbicularis muscle
• Test of induced entropion:
  • Pinch the lower eyelid with the index finger and thumb to roll the skin over the tarsal edge.
• Release the eyelid to see whether an induced entropion occurs (Faria, Clin Ophthalmol 2013).
• The snap-back and horizontal eyelid laxity tests can help determine the presence of underlying involutional entropion.

• Elderly
• Acute inflammatory ocular conditions
• Preceding intraocular surgery: laser procedures, orbital injections, cataract surgery (Levine, Ann Ophthalmol 1992)

• Involutional entropion
• Congenital entropion
• Trichiasis without entropion

Natural history

• Will often resolve in a few weeks or months after onset
• Medical treatment can provide symptomatic relief during course of the disease.
• Can progress to involutional entropion

Medical therapy

• If spastic entropion is secondary to infection or local irritations, treatment of the underlying cause is critical, i.e., topical antibiotics, epilation of offending eyelashes.
• Conservative management with artificial tears, lubricating ointment, and eyelid taping of the eyelid margin away from the ocular surface can be beneficial.
• Chemodenervation of the preseptal orbicularis muscle with 1–3 doses of about 2.5 units botulinum toxin each can provide temporary or permanent relief.

Surgical therapy

• If lower eyelid entropion is persistent or symptomatic, consider surgical therapy (see involutional entropion section for surgical options).

Common treatment responses, follow-up strategies

• Patients undergoing botulinum toxin injection might require multiple injections after the duration of effect has worn off.
• Aggressive doses of botulinum toxin might result in iatrogenic ectropion in the setting of eyelid laxity.
• Persistence or recurrence of entropion might suggest the need to treat an underlying involutional entropion.

• In a 10-year follow up study by Cillino et al. (Eye 2010), the mean duration of effect of 10.6-unit injections of botulinum toxin was 13.7 weeks.
• A high efficacy rate with good safety profile was reported, with only 1/24 patients developing increased tearing after botulinum toxin injection.
• There were no complaints of ecchymosis, ptosis, diplopia, dry eye, or photophobia.

• Chronic discharge
• Trichiasis
• Corneal abrasions
• Corneal ulceration
• Corneal scarring and decreased vision
• One case has been reported of a patient with spastic entropion developing late-onset deep infectious keratitis after Descemet stripping endothelial keratoplasty with vent incisions (Hannush, Cornea 2011).
• Involutional entropion 

• Surgical correction of spastic entropion was reported as early as 1939 by Wheeler (Tran Am Ophthalmol Soc) with the use of orbicularis transplantation.
• Multiple surgical methods were subsequently reported, including shortening of the orbital fibers (Strampelli, Boll Ocul 1952), the Wies procedure (Wies, Trans Am Acad Ophthalmol Otolaryngol 1955), and cautery (Harbin, Arch Ophthalmol 1965).
• High success rates were reportedly achieved with injection of 80% alcohol into the orbicularis oculi to reduce spasm levels (Hubbard, Proc R Soc Med 1973).

1. Cillino S, Raimondi G, Guepratte N et al. Long-term efficacy of botulinum toxin A for treatment of blepharospasm, hemifacial spasm, and spastic entropion: a multicentre study using two drug-dose escalation indexes. Eye (Lond) 2010; 24: 600-607.
2. Faria ESSJ, de Paula Gomes Vieira M, Silva JV. Uncovering intermittent entropion. Clin Ophthalmol. 2013; 7: 385-388.
3. Hannush SB, Chew HF, Eagle RC, Jr. Late-onset deep infectious keratitis after descemet stripping endothelial keratoplasty with vent incisions. Cornea. 2011; 30: 229-232.
4. Harbin T. Correction of spastic entropion: an effective cautery technique. Arch Ophthalmol. 1965; 73: 514-515.
5. Hubbard IH, Kanski JJ. A simple treatment for spastic entropion. Proc R Soc Med. 1973; 66: 173-174.
6. Levine MR, Enlow MK, Terman S. Spastic entropion after cataract surgery. Ann Ophthalmol. 1992; 24: 195-198.
7. Strampelli B. [Shortening of the muscle by torsion of the orbital fibers in surgery of spastic entropion]. Boll Ocul. 1952; 31: 496-500.
8. Wheeler JM. Spastic Entropion Correction by Orbicularis Transplantation. Trans Am Ophthalmol Soc. 1938; 36: 157-162.
9. Wies FA. Spastic entropion. Trans Am Acad Ophthalmol Otolaryngol. 1955; 59: 503-506.